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1.
Manon Choinière Judy Watt-Watson J. Charles Victor Roger J.F. Baskett Jean S. Bussières Michel Carrier Jennifer Cogan Judy Costello Christopher Feindel Marie-Claude Guertin Mélanie Racine Marie-Christine Taillefer 《CMAJ》2014,186(7):E213-E223
Background:
Persistent postoperative pain continues to be an underrecognized complication. We examined the prevalence of and risk factors for this type of pain after cardiac surgery.Methods:
We enrolled patients scheduled for coronary artery bypass grafting or valve replacement, or both, from Feb. 8, 2005, to Sept. 1, 2009. Validated measures were used to assess (a) preoperative anxiety and depression, tendency to catastrophize in the face of pain, health-related quality of life and presence of persistent pain; (b) pain intensity and interference in the first postoperative week; and (c) presence and intensity of persistent postoperative pain at 3, 6, 12 and 24 months after surgery. The primary outcome was the presence of persistent postoperative pain during 24 months of follow-up.Results:
A total of 1247 patients completed the preoperative assessment. Follow-up retention rates at 3 and 24 months were 84% and 78%, respectively. The prevalence of persistent postoperative pain decreased significantly over time, from 40.1% at 3 months to 22.1% at 6 months, 16.5% at 12 months and 9.5% at 24 months; the pain was rated as moderate to severe in 3.6% at 24 months. Acute postoperative pain predicted both the presence and severity of persistent postoperative pain. The more intense the pain during the first week after surgery and the more it interfered with functioning, the more likely the patients were to report persistent postoperative pain. Pre-existing persistent pain and increased preoperative anxiety also predicted the presence of persistent postoperative pain.Interpretation:
Persistent postoperative pain of nonanginal origin after cardiac surgery affected a substantial proportion of the study population. Future research is needed to determine whether interventions to modify certain risk factors, such as preoperative anxiety and the severity of pain before and immediately after surgery, may help to minimize or prevent persistent postoperative pain.Postoperative pain that persists beyond the normal time for tissue healing (> 3 mo) is increasingly recognized as an important complication after various types of surgery and can have serious consequences on patients’ daily living.1–3 Cardiac surgeries, such as coronary artery bypass grafting (CABG) and valve replacement, rank among the most frequently performed interventions worldwide.4 They aim to improve survival and quality of life by reducing symptoms, including anginal pain. However, persistent postoperative pain of nonanginal origin has been reported in 7% to 60% of patients following these surgeries.5–23 Such variability is common in other types of major surgery and is due mainly to differences in the definition of persistent postoperative pain, study design, data collection methods and duration of follow-up.1–3,24Few prospective cohort studies have examined the exact time course of persistent postoperative pain after cardiac surgery, and follow-up has always been limited to a year or less.9,14,25 Factors that put patients at risk of this type of problem are poorly understood.26 Studies have reported inconsistent results regarding the contribution of age, sex, body mass index, preoperative angina, surgical technique, grafting site, postoperative complications or level of opioid consumption after surgery.5–7,9,13,14,16–19,21–23,25,27 Only 1 study investigated the role of chronic nonanginal pain before surgery as a contributing factor;21 5 others prospectively assessed the association between persistent postoperative pain and acute pain intensity in the first postoperative week but reported conflicting results.13,14,21,22,25 All of the above studies were carried out in a single hospital and included relatively small samples. None of the studies examined the contribution of psychological factors such as levels of anxiety and depression before cardiac surgery, although these factors have been shown to influence acute or persistent postoperative pain in other types of surgery.1,24,28,29We conducted a prospective multicentre cohort study (the CARD-PAIN study) to determine the prevalence of persistent postoperative pain of nonanginal origin up to 24 months after cardiac surgery and to identify risk factors for the presence and severity of the condition. 相似文献2.
Naveen Poonai Gina Bhullar Kangrui Lin Adam Papini David Mainprize Jocelyn Howard John Teefy Michelle Bale Cindy Langford Rodrick Lim Larry Stitt Michael J. Rieder Samina Ali 《CMAJ》2014,186(18):1358-1363
Background:
Recent warnings from Health Canada regarding codeine for children have led to increased use of nonsteroidal anti-inflammatory drugs and morphine for common injuries such as fractures. Our objective was to determine whether morphine administered orally has superior efficacy to ibuprofen in fracture-related pain.Methods:
We used a parallel group, randomized, blinded superiority design. Children who presented to the emergency department with an uncomplicated extremity fracture were randomly assigned to receive either morphine (0.5 mg/kg orally) or ibuprofen (10 mg/kg) for 24 hours after discharge. Our primary outcome was the change in pain score using the Faces Pain Scale — Revised (FPS-R). Participants were asked to record pain scores immediately before and 30 minutes after receiving each dose.Results:
We analyzed data from 66 participants in the morphine group and 68 participants in the ibuprofen group. For both morphine and ibuprofen, we found a reduction in pain scores (mean pre–post difference ± standard deviation for dose 1: morphine 1.5 ± 1.2, ibuprofen 1.3 ± 1.0, between-group difference [δ] 0.2 [95% confidence interval (CI) −0.2 to 0.6]; dose 2: morphine 1.3 ± 1.3, ibuprofen 1.3 ± 0.9, δ 0 [95% CI −0.4 to 0.4]; dose 3: morphine 1.3 ± 1.4, ibuprofen 1.4 ± 1.1, δ −0.1 [95% CI −0.7 to 0.4]; and dose 4: morphine 1.5 ± 1.4, ibuprofen 1.1 ± 1.2, δ 0.4 [95% CI −0.2 to 1.1]). We found no significant differences in the change in pain scores between morphine and ibuprofen between groups at any of the 4 time points (p = 0.6). Participants in the morphine group had significantly more adverse effects than those in the ibuprofen group (56.1% v. 30.9%, p < 0.01).Interpretation:
We found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen. However, morphine was associated with a significantly greater number of adverse effects. Our results suggest that ibuprofen remains safe and effective for outpatient pain management in children with uncomplicated fractures. Trial registration: ClinicalTrials.gov, no. .There is ample evidence that analgesia is underused, NCT016907801 underprescribed,2 delayed in its administration2 and suboptimally dosed 3 in clinical settings. Children are particularly susceptible to suboptimal pain management4 and are less likely to receive opioid analgesia.5 Untreated pain in childhood has been reported to lead to short-term problems such as slower healing6 and to long-term issues such as anxiety, needle phobia,7 hyperesthesia8 and fear of medical care.9 The American Academy of Pediatrics has reaffirmed its advocacy for the appropriate use of analgesia for children with acute pain.10Fractures constitute between 10% and 25% of all injuries.11 The most severe pain after an injury occurs within the first 48 hours, with more than 80% of children showing compromise in at least 1 functional area.12 Low rates of analgesia have been reported after discharge from hospital.13 A recently improved understanding of the pharmacogenomics of codeine has raised significant concerns about its safety,14,15 and has led to a Food and Drug Administration boxed warning16 and a Health Canada advisory17 against its use. Although ibuprofen has been cited as the most common agent used by caregivers to treat musculoskeletal pain,12,13 there are concerns that its use as monotherapy may lead to inadequate pain management.6,18 Evidence suggests that orally administered morphine13 and other opioids are increasingly being prescribed.19 However, evidence for the oral administration of morphine in acute pain management is limited.20,21 Thus, additional studies are needed to address this gap in knowledge and provide a scientific basis for outpatient analgesic choices in children. Our objective was to assess if orally administered morphine is superior to ibuprofen in relieving pain in children with nonoperative fractures. 相似文献3.
Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months 总被引:1,自引:0,他引:1
Meghan B. Azad Theodore Konya Heather Maughan David S. Guttman Catherine J. Field Radha S. Chari Malcolm R. Sears Allan B. Becker James A. Scott Anita L. Kozyrskyj 《CMAJ》2013,185(5):385-394
Background:
The gut microbiota is essential to human health throughout life, yet the acquisition and development of this microbial community during infancy remains poorly understood. Meanwhile, there is increasing concern over rising rates of cesarean delivery and insufficient exclusive breastfeeding of infants in developed countries. In this article, we characterize the gut microbiota of healthy Canadian infants and describe the influence of cesarean delivery and formula feeding.Methods:
We included a subset of 24 term infants from the Canadian Healthy Infant Longitudinal Development (CHILD) birth cohort. Mode of delivery was obtained from medical records, and mothers were asked to report on infant diet and medication use. Fecal samples were collected at 4 months of age, and we characterized the microbiota composition using high-throughput DNA sequencing.Results:
We observed high variability in the profiles of fecal microbiota among the infants. The profiles were generally dominated by Actinobacteria (mainly the genus Bifidobacterium) and Firmicutes (with diverse representation from numerous genera). Compared with breastfed infants, formula-fed infants had increased richness of species, with overrepresentation of Clostridium difficile. Escherichia–Shigella and Bacteroides species were underrepresented in infants born by cesarean delivery. Infants born by elective cesarean delivery had particularly low bacterial richness and diversity.Interpretation:
These findings advance our understanding of the gut microbiota in healthy infants. They also provide new evidence for the effects of delivery mode and infant diet as determinants of this essential microbial community in early life.The human body harbours trillions of microbes, known collectively as the “human microbiome.” By far the highest density of commensal bacteria is found in the digestive tract, where resident microbes outnumber host cells by at least 10 to 1. Gut bacteria play a fundamental role in human health by promoting intestinal homeostasis, stimulating development of the immune system, providing protection against pathogens, and contributing to the processing of nutrients and harvesting of energy.1,2 The disruption of the gut microbiota has been linked to an increasing number of diseases, including inflammatory bowel disease, necrotizing enterocolitis, diabetes, obesity, cancer, allergies and asthma.1 Despite this evidence and a growing appreciation for the integral role of the gut microbiota in lifelong health, relatively little is known about the acquisition and development of this complex microbial community during infancy.3Two of the best-studied determinants of the gut microbiota during infancy are mode of delivery and exposure to breast milk.4,5 Cesarean delivery perturbs normal colonization of the infant gut by preventing exposure to maternal microbes, whereas breastfeeding promotes a “healthy” gut microbiota by providing selective metabolic substrates for beneficial bacteria.3,5 Despite recommendations from the World Health Organization,6 the rate of cesarean delivery has continued to rise in developed countries and rates of breastfeeding decrease substantially within the first few months of life.7,8 In Canada, more than 1 in 4 newborns are born by cesarean delivery, and less than 15% of infants are exclusively breastfed for the recommended duration of 6 months.9,10 In some parts of the world, elective cesarean deliveries are performed by maternal request, often because of apprehension about pain during childbirth, and sometimes for patient–physician convenience.11The potential long-term consequences of decisions regarding mode of delivery and infant diet are not to be underestimated. Infants born by cesarean delivery are at increased risk of asthma, obesity and type 1 diabetes,12 whereas breastfeeding is variably protective against these and other disorders.13 These long-term health consequences may be partially attributable to disruption of the gut microbiota.12,14Historically, the gut microbiota has been studied with the use of culture-based methodologies to examine individual organisms. However, up to 80% of intestinal microbes cannot be grown in culture.3,15 New technology using culture-independent DNA sequencing enables comprehensive detection of intestinal microbes and permits simultaneous characterization of entire microbial communities. Multinational consortia have been established to characterize the “normal” adult microbiome using these exciting new methods;16 however, these methods have been underused in infant studies. Because early colonization may have long-lasting effects on health, infant studies are vital.3,4 Among the few studies of infant gut microbiota using DNA sequencing, most were conducted in restricted populations, such as infants delivered vaginally,17 infants born by cesarean delivery who were formula-fed18 or preterm infants with necrotizing enterocolitis.19Thus, the gut microbiota is essential to human health, yet the acquisition and development of this microbial community during infancy remains poorly understood.3 In the current study, we address this gap in knowledge using new sequencing technology and detailed exposure assessments20 of healthy Canadian infants selected from a national birth cohort to provide representative, comprehensive profiles of gut microbiota according to mode of delivery and infant diet. 相似文献4.
Adam T. Hancock Christian D. Mallen Sara Muller John Belcher Edward Roddy Toby Helliwell Samantha L. Hider 《CMAJ》2014,186(13):E495-E501
Background:
Polymyalgia rheumatica is one of the most common inflammatory rheumatologic conditions in older adults. Other inflammatory rheumatologic disorders are associated with an excess risk of vascular disease. We investigated whether polymyalgia rheumatica is associated with an increased risk of vascular events.Methods:
We used the General Practice Research Database to identify patients with a diagnosis of incident polymyalgia rheumatica between Jan. 1, 1987, and Dec. 31, 1999. Patients were matched by age, sex and practice with up to 5 patients without polymyalgia rheumatica. Patients were followed until their first vascular event (cardiovascular, cerebrovascular, peripheral vascular) or the end of available records (May 2011). All participants were free of vascular disease before the diagnosis of polymyalgia rheumatica (or matched date). We used Cox regression models to compare time to first vascular event in patients with and without polymyalgia rheumatica.Results:
A total of 3249 patients with polymyalgia rheumatica and 12 735 patients without were included in the final sample. Over a median follow-up period of 7.8 (interquartile range 3.3–12.4) years, the rate of vascular events was higher among patients with polymyalgia rheumatica than among those without (36.1 v. 12.2 per 1000 person-years; adjusted hazard ratio 2.6, 95% confidence interval 2.4–2.9). The increased risk of a vascular event was similar for each vascular disease end point. The magnitude of risk was higher in early disease and in patients younger than 60 years at diagnosis.Interpretation:
Patients with polymyalgia rheumatica have an increased risk of vascular events. This risk is greatest in the youngest age groups. As with other forms of inflammatory arthritis, patients with polymyalgia rheumatica should have their vascular risk factors identified and actively managed to reduce this excess risk.Inflammatory rheumatologic disorders such as rheumatoid arthritis,1,2 systemic lupus erythematosus,2,3 gout,4 psoriatic arthritis2,5 and ankylosing spondylitis2,6 are associated with an increased risk of vascular disease, especially cardiovascular disease, leading to substantial morbidity and premature death.2–6 Recognition of this excess vascular risk has led to management guidelines advocating screening for and management of vascular risk factors.7–9Polymyalgia rheumatica is one of the most common inflammatory rheumatologic conditions in older adults,10 with a lifetime risk of 2.4% for women and 1.7% for men.11 To date, evidence regarding the risk of vascular disease in patients with polymyalgia rheumatica is unclear. There are a number of biologically plausible mechanisms between polymyalgia rheumatica and vascular disease. These include the inflammatory burden of the disease,12,13 the association of the disease with giant cell arteritis (causing an inflammatory vasculopathy, which may lead to subclinical arteritis, stenosis or aneurysms),14 and the adverse effects of long-term corticosteroid treatment (e.g., diabetes, hypertension and dyslipidemia).15,16 Paradoxically, however, use of corticosteroids in patients with polymyalgia rheumatica may actually decrease vascular risk by controlling inflammation.17 A recent systematic review concluded that although some evidence exists to support an association between vascular disease and polymyalgia rheumatica,18 the existing literature presents conflicting results, with some studies reporting an excess risk of vascular disease19,20 and vascular death,21,22 and others reporting no association.23–26 Most current studies are limited by poor methodologic quality and small samples, and are based on secondary care cohorts, who may have more severe disease, yet most patients with polymyalgia rheumatica receive treatment exclusively in primary care.27The General Practice Research Database (GPRD), based in the United Kingdom, is a large electronic system for primary care records. It has been used as a data source for previous studies,28 including studies on the association of inflammatory conditions with vascular disease29 and on the epidemiology of polymyalgia rheumatica in the UK.30 The aim of the current study was to examine the association between polymyalgia rheumatica and vascular disease in a primary care population. 相似文献5.
Ian Williamson Jane Vennik Anthony Harnden Merryn Voysey Rafael Perera Sadie Kelly Guiqing Yao James Raftery David Mant Paul Little 《CMAJ》2015,187(13):961-969
Background:Otitis media with effusion is a common problem that lacks an evidence-based nonsurgical treatment option. We assessed the clinical effectiveness of treatment with a nasal balloon device in a primary care setting.Methods:We conducted an open, pragmatic randomized controlled trial set in 43 family practices in the United Kingdom. Children aged 4–11 years with a recent history of ear symptoms and otitis media with effusion in 1 or both ears, confirmed by tympanometry, were allocated to receive either autoinflation 3 times daily for 1–3 months plus usual care or usual care alone. Clearance of middle-ear fluid at 1 and 3 months was assessed by experts masked to allocation.Results:Of 320 children enrolled, those receiving autoinflation were more likely than controls to have normal tympanograms at 1 month (47.3% [62/131] v. 35.6% [47/132]; adjusted relative risk [RR] 1.36, 95% confidence interval [CI] 0.99 to 1.88) and at 3 months (49.6% [62/125] v. 38.3% [46/120]; adjusted RR 1.37, 95% CI 1.03 to 1.83; number needed to treat = 9). Autoinflation produced greater improvements in ear-related quality of life (adjusted between-group difference in change from baseline in OMQ-14 [an ear-related measure of quality of life] score −0.42, 95% CI −0.63 to −0.22). Compliance was 89% at 1 month and 80% at 3 months. Adverse events were mild, infrequent and comparable between groups.Interpretation:Autoinflation in children aged 4–11 years with otitis media with effusion is feasible in primary care and effective both in clearing effusions and improving symptoms and ear-related child and parent quality of life. Trial registration: ISRCTN, No. 55208702.Otitis media with effusion, also known as glue ear, is an accumulation of fluid in the middle ear, without symptoms or signs of an acute ear infection. It is often associated with viral infection.1–3 The prevalence rises to 46% in children aged 4–5 years,4 when hearing difficulty, other ear-related symptoms and broader developmental concerns often bring the condition to medical attention.3,5,6 Middle-ear fluid is associated with conductive hearing losses of about 15–45 dB HL.7 Resolution is clinically unpredictable,8–10 with about a third of cases showing recurrence.11 In the United Kingdom, about 200 000 children with the condition are seen annually in primary care.12,13 Research suggests some children seen in primary care are as badly affected as those seen in hospital.7,9,14,15 In the United States, there were 2.2 million diagnosed episodes in 2004, costing an estimated $4.0 billion.16 Rates of ventilation tube surgery show variability between countries,17–19 with a declining trend in the UK.20Initial clinical management consists of reasonable temporizing or delay before considering surgery.13 Unfortunately, all available medical treatments for otitis media with effusion such as antibiotics, antihistamines, decongestants and intranasal steroids are ineffective and have unwanted effects, and therefore cannot be recommended.21–23 Not only are antibiotics ineffective, but resistance to them poses a major threat to public health.24,25 Although surgery is effective for a carefully selected minority,13,26,27 a simple low-cost, nonsurgical treatment option could benefit a much larger group of symptomatic children, with the purpose of addressing legitimate clinical concerns without incurring excessive delays.Autoinflation using a nasal balloon device is a low-cost intervention with the potential to be used more widely in primary care, but current evidence of its effectiveness is limited to several small hospital-based trials28 that found a higher rate of tympanometric resolution of ear fluid at 1 month.29–31 Evidence of feasibility and effectiveness of autoinflation to inform wider clinical use is lacking.13,28 Thus we report here the findings of a large pragmatic trial of the clinical effectiveness of nasal balloon autoinflation in a spectrum of children with clinically confirmed otitis media with effusion identified from primary care. 相似文献
6.
Mark J. Eisenberg Jonathan Afilalo Patrick R. Lawler Michal Abrahamowicz Hugues Richard Louise Pilote 《CMAJ》2011,183(4):430-436
Background
Patients exposed to low-dose ionizing radiation from cardiac imaging and therapeutic procedures after acute myocardial infarction may be at increased risk of cancer.Methods
Using an administrative database, we selected a cohort of patients who had an acute myocardial infarction between April 1996 and March 2006 and no history of cancer. We documented all cardiac imaging and therapeutic procedures involving low-dose ionizing radiation. The primary outcome was risk of cancer. Statistical analyses were performed using a time-dependent Cox model adjusted for age, sex and exposure to low-dose ionizing radiation from noncardiac imaging to account for work-up of cancer.Results
Of the 82 861 patients included in the cohort, 77% underwent at least one cardiac imaging or therapeutic procedure involving low-dose ionizing radiation in the first year after acute myocardial infarction. The cumulative exposure to radiation from cardiac procedures was 5.3 milliSieverts (mSv) per patient-year, of which 84% occurred during the first year after acute myocardial infarction. A total of 12 020 incident cancers were diagnosed during the follow-up period. There was a dose-dependent relation between exposure to radiation from cardiac procedures and subsequent risk of cancer. For every 10 mSv of low-dose ionizing radiation, there was a 3% increase in the risk of age- and sex-adjusted cancer over a mean follow-up period of five years (hazard ratio 1.003 per milliSievert, 95% confidence interval 1.002–1.004).Interpretation
Exposure to low-dose ionizing radiation from cardiac imaging and therapeutic procedures after acute myocardial infarction is associated with an increased risk of cancer.Studies involving atomic bomb survivors have documented an increased incidence of malignant neoplasm related to the radiation exposure.1–4 Survivors who were farther from the epicentre of the blast had a lower incidence of cancer, whereas those who were closer had a higher incidence.5 Similar risk estimates have been reported among workers in nuclear plants.6 However, little is known about the relation between exposure to low-dose ionizing radiation from medical procedures and the risk of cancer.In the past six decades since the atomic bomb explosions, most individuals worldwide have had minimal exposure to ionizing radiation. However, the recent increase in the use of medical imaging and therapeutic procedures involving low-dose ionizing radiation has led to a growing concern that individual patients may be at increased risk of cancer.7–12 Whereas strict regulatory control is placed on occupational exposure at work sites, no such control exists among patients who are exposed to such radiation.13–16It is not only the frequency of these procedures that is increasing. Newer types of imaging procedures are using higher doses of low-dose ionizing radiation than those used with more traditional procedures.8,11 Among patients being evaluated for coronary artery disease, for example, coronary computed tomography is increasingly being used. This test may be used in addition to other tests such as nuclear scans, coronary angiography and percutaneous coronary intervention, each of which exposes the patient to low-dose ionizing radiation.12,17–21 Imaging procedures provide information that can be used to predict the prognosis of patients with coronary artery disease. Since such predictions do not necessarily translate into better clinical outcomes,8,12 the prognostic value obtained from imaging procedures using low-dose ionizing radiation needs to be balanced against the potential for risk.Authors of several studies have estimated that the risk of cancer is not negligible among patients exposed to low-dose ionizing radiation.22–27 To our knowledge, none of these studies directly linked cumulative exposure and cancer risk. We examined a cohort of patients who had acute myocardial infarction and measured the association between low-dose ionizing radiation from cardiac imaging and therapeutic procedures and the risk of cancer. 相似文献7.
Mark A. Ware Tongtong Wang Stan Shapiro Ann Robinson Thierry Ducruet Thao Huynh Ann Gamsa Gary J. Bennett Jean-Paul Collet 《CMAJ》2010,182(14):E694-E701
Background
Chronic neuropathic pain affects 1%–2% of the adult population and is often refractory to standard pharmacologic treatment. Patients with chronic pain have reported using smoked cannabis to relieve pain, improve sleep and improve mood.Methods
Adults with post-traumatic or postsurgical neuropathic pain were randomly assigned to receive cannabis at four potencies (0%, 2.5%, 6% and 9.4% tetrahydrocannabinol) over four 14-day periods in a crossover trial. Participants inhaled a single 25-mg dose through a pipe three times daily for the first five days in each cycle, followed by a nine-day washout period. Daily average pain intensity was measured using an 11-point numeric rating scale. We recorded effects on mood, sleep and quality of life, as well as adverse events.Results
We recruited 23 participants (mean age 45.4 [standard deviation 12.3] years, 12 women [52%]), of whom 21 completed the trial. The average daily pain intensity, measured on the 11-point numeric rating scale, was lower on the prespecified primary contrast of 9.4% v. 0% tetrahydrocannabinol (5.4 v. 6.1, respectively; difference = 0.7, 95% confidence interval [CI] 0.02–1.4). Preparations with intermediate potency yielded intermediate but nonsignificant degrees of relief. Participants receiving 9.4% tetrahydrocannabinol reported improved ability to fall asleep (easier, p = 0.001; faster, p < 0.001; more drowsy, p = 0.003) and improved quality of sleep (less wakefulness, p = 0.01) relative to 0% tetrahydrocannabinol. We found no differences in mood or quality of life. The most common drug-related adverse events during the period when participants received 9.4% tetrahydrocannabinol were headache, dry eyes, burning sensation in areas of neuropathic pain, dizziness, numbness and cough.Conclusion
A single inhalation of 25 mg of 9.4% tetrahydrocannabinol herbal cannabis three times daily for five days reduced the intensity of pain, improved sleep and was well tolerated. Further long-term safety and efficacy studies are indicated. (International Standard Randomised Controlled Trial Register no. ISRCTN68314063)Chronic neuropathic pain has a prevalence of 1%–2%,1 and treatment options are limited.2 Pharmacotherapy includes anticonvulsants, antidepressants, opioids and local anesthetics,3,4 but responses vary and side effects limit compliance.Cannabis sativa has been used to treat pain since the third millennium BC.5 An endogenous pain-processing system has been identified, mediated by endogenous cannabinoid ligands acting on specific cannabinoid receptors.6 These findings, coupled with anecdotal evidence of the analgesic effects of smoked cannabis,7 support a reconsideration of cannabinoid agents as analgesics.Oral cannabinoids such as tetrahydrocannabinol, cannabidiol and nabilone have, alone and in combination, shown efficacy in central8,9 and peripheral10 neuropathic pain, rheumatoid arthritis11 and fibromyalgia.12The analgesic effects of smoked cannabis remain controversial, although it is used by 10%–15% of patients with chronic noncancer pain13 and multiple sclerosis.14 Clinical trials are needed to evaluate these effects, given that the risks and benefits of inhaled cannabinoids may differ from oral agents. To date, three small clinical trials of the analgesic efficacy of smoked cannabis have been reported.15–17 All studies were conducted in residential laboratories, and participants smoked multiple doses of the drug at each time point. No study adequately reported data related to adverse events.We conducted a clinical trial using a standardized single-dose delivery system to explore further the safety and efficacy of smoked cannabis in outpatients with chronic neuropathic pain. 相似文献8.
Gilaad G. Kaplan Elijah Dixon Remo Panaccione Andrew Fong Li Chen Mieczyslaw Szyszkowicz Amanda Wheeler Anthony MacLean W. Donald Buie Terry Leung Steven J. Heitman Paul J. Villeneuve 《CMAJ》2009,181(9):591-597
Background
The pathogenesis of appendicitis is unclear. We evaluated whether exposure to air pollution was associated with an increased incidence of appendicitis.Methods
We identified 5191 adults who had been admitted to hospital with appendicitis between Apr. 1, 1999, and Dec. 31, 2006. The air pollutants studied were ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, and suspended particulate matter of less than 10 μ and less than 2.5 μ in diameter. We estimated the odds of appendicitis relative to short-term increases in concentrations of selected pollutants, alone and in combination, after controlling for temperature and relative humidity as well as the effects of age, sex and season.Results
An increase in the interquartile range of the 5-day average of ozone was associated with appendicitis (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.03–1.25). In summer (July–August), the effects were most pronounced for ozone (OR 1.32, 95% CI 1.10–1.57), sulfur dioxide (OR 1.30, 95% CI 1.03–1.63), nitrogen dioxide (OR 1.76, 95% CI 1.20–2.58), carbon monoxide (OR 1.35, 95% CI 1.01–1.80) and particulate matter less than 10 μ in diameter (OR 1.20, 95% CI 1.05–1.38). We observed a significant effect of the air pollutants in the summer months among men but not among women (e.g., OR for increase in the 5-day average of nitrogen dioxide 2.05, 95% CI 1.21–3.47, among men and 1.48, 95% CI 0.85–2.59, among women). The double-pollutant model of exposure to ozone and nitrogen dioxide in the summer months was associated with attenuation of the effects of ozone (OR 1.22, 95% CI 1.01–1.48) and nitrogen dioxide (OR 1.48, 95% CI 0.97–2.24).Interpretation
Our findings suggest that some cases of appendicitis may be triggered by short-term exposure to air pollution. If these findings are confirmed, measures to improve air quality may help to decrease rates of appendicitis.Appendicitis was introduced into the medical vernacular in 1886.1 Since then, the prevailing theory of its pathogenesis implicated an obstruction of the appendiceal orifice by a fecalith or lymphoid hyperplasia.2 However, this notion does not completely account for variations in incidence observed by age,3,4 sex,3,4 ethnic background,3,4 family history,5 temporal–spatial clustering6 and seasonality,3,4 nor does it completely explain the trends in incidence of appendicitis in developed and developing nations.3,7,8The incidence of appendicitis increased dramatically in industrialized nations in the 19th century and in the early part of the 20th century.1 Without explanation, it decreased in the middle and latter part of the 20th century.3 The decrease coincided with legislation to improve air quality. For example, after the United States Clean Air Act was passed in 1970,9 the incidence of appendicitis decreased by 14.6% from 1970 to 1984.3 Likewise, a 36% drop in incidence was reported in the United Kingdom between 1975 and 199410 after legislation was passed in 1956 and 1968 to improve air quality and in the 1970s to control industrial sources of air pollution. Furthermore, appendicitis is less common in developing nations; however, as these countries become more industrialized, the incidence of appendicitis has been increasing.7Air pollution is known to be a risk factor for multiple conditions, to exacerbate disease states and to increase all-cause mortality.11 It has a direct effect on pulmonary diseases such as asthma11 and on nonpulmonary diseases including myocardial infarction, stroke and cancer.11–13 Inflammation induced by exposure to air pollution contributes to some adverse health effects.14–17 Similar to the effects of air pollution, a proinflammatory response has been associated with appendicitis.18–20We conducted a case–crossover study involving a population-based cohort of patients admitted to hospital with appendicitis to determine whether short-term increases in concentrations of selected air pollutants were associated with hospital admission because of appendicitis. 相似文献9.
Stefan B?sner J?rg Haasenritter Annette Becker Konstantinos Karatolios Paul Vaucher Baris Gencer Lilli Herzig Monika Heinzel-Gutenbrunner Juergen R. Schaefer Maren Abu Hani Heidi Keller Andreas C. S?nnichsen Erika Baum Norbert Donner-Banzhoff 《CMAJ》2010,182(12):1295-1300
Background
Chest pain can be caused by various conditions, with life-threatening cardiac disease being of greatest concern. Prediction scores to rule out coronary artery disease have been developed for use in emergency settings. We developed and validated a simple prediction rule for use in primary care.Methods
We conducted a cross-sectional diagnostic study in 74 primary care practices in Germany. Primary care physicians recruited all consecutive patients who presented with chest pain (n = 1249) and recorded symptoms and findings for each patient (derivation cohort). An independent expert panel reviewed follow-up data obtained at six weeks and six months on symptoms, investigations, hospital admissions and medications to determine the presence or absence of coronary artery disease. Adjusted odds ratios of relevant variables were used to develop a prediction rule. We calculated measures of diagnostic accuracy for different cut-off values for the prediction scores using data derived from another prospective primary care study (validation cohort).Results
The prediction rule contained five determinants (age/sex, known vascular disease, patient assumes pain is of cardiac origin, pain is worse during exercise, and pain is not reproducible by palpation), with the score ranging from 0 to 5 points. The area under the curve (receiver operating characteristic curve) was 0.87 (95% confidence interval [CI] 0.83–0.91) for the derivation cohort and 0.90 (95% CI 0.87–0.93) for the validation cohort. The best overall discrimination was with a cut-off value of 3 (positive result 3–5 points; negative result ≤ 2 points), which had a sensitivity of 87.1% (95% CI 79.9%–94.2%) and a specificity of 80.8% (77.6%–83.9%).Interpretation
The prediction rule for coronary artery disease in primary care proved to be robust in the validation cohort. It can help to rule out coronary artery disease in patients presenting with chest pain in primary care.Chest pain is common. Studies have shown a lifetime prevalence of 20% to 40% in the general population.1 Its prevalence in primary care ranges from 0.7% to 2.7% depending on inclusion criteria and country,2–4 with coronary artery disease being the underlying cause in about 12% of primary care patients.1,5 General practitioners are challenged to identify serious cardiac disease reliably and also protect patients from unnecessary investigations and hospital admissions. Because electrocardiography and the cardiac troponin test are of limited value in primary care,6,7 history taking and physical examination remain the main diagnostic tools.Most published studies on the diagnostic accuracy of signs and symptoms for acute coronary events have been conducted in high-prevalence settings such as hospital emergency departments.8–10 Predictive scores have also been developed for use in emergency departments, mainly for the diagnosis of acute coronary syndromes.11–13 To what degree these apply in primary care is unknown.14–16A clinical prediction score to rule out coronary artery disease in general practice has been developed.17 However, it did not perform well when validated externally. The aim of our study was to develop a simple, valid and usable prediction score based on signs and symptoms to help primary care physicians rule out coronary artery disease in patients presenting with chest pain. 相似文献10.
11.
Background:
Many hospitals have adopted smoke-free policies on their property. We examined the consequences of such polices at two Canadian tertiary acute-care hospitals.Methods:
We conducted a qualitative study using ethnographic techniques over a six-month period. Participants (n = 186) shared their perspectives on and experiences with tobacco dependence and managing the use of tobacco, as well as their impressions of the smoke-free policy. We interviewed inpatients individually from eight wards (n = 82), key policy-makers (n = 9) and support staff (n = 14) and held 16 focus groups with health care providers and ward staff (n = 81). We also reviewed ward documents relating to tobacco dependence and looked at smoking-related activities on hospital property.Results:
Noncompliance with the policy and exposure to secondhand smoke were ongoing concerns. Peoples’ impressions of the use of tobacco varied, including divergent opinions as to whether such use was a bad habit or an addiction. Treatment for tobacco dependence and the management of symptoms of withdrawal were offered inconsistently. Participants voiced concerns over patient safety and leaving the ward to smoke.Interpretation:
Policies mandating smoke-free hospital property have important consequences beyond noncompliance, including concerns over patient safety and disruptions to care. Without adequately available and accessible support for withdrawal from tobacco, patients will continue to face personal risk when they leave hospital property to smoke.Canadian cities and provinces have passed smoking bans with the goal of reducing people’s exposure to secondhand smoke in workplaces, public spaces and on the property adjacent to public buildings.1,2 In response, Canadian health authorities and hospitals began implementing policies mandating smoke-free hospital property, with the goals of reducing the exposure of workers, patients and visitors to tobacco smoke while delivering a public health message about the dangers of smoking.2–5 An additional anticipated outcome was the reduced use of tobacco among patients and staff. The impetuses for adopting smoke-free policies include public support for such legislation and the potential for litigation for exposure to second-hand smoke.2,4Tobacco use is a modifiable risk factor associated with a variety of cancers, cardiovascular diseases and respiratory conditions.6–11 Patients in hospital who use tobacco tend to have more surgical complications and exacerbations of acute and chronic health conditions than patients who do not use tobacco.6–11 Any policy aimed at reducing exposure to tobacco in hospitals is well supported by evidence, as is the integration of interventions targetting tobacco dependence.12 Unfortunately, most of the nearly five million Canadians who smoke will receive suboptimal treatment,13 as the routine provision of interventions for tobacco dependence in hospital settings is not a practice norm.14–16 In smoke-free hospitals, two studies suggest minimal support is offered for withdrawal, 17,18 and one reports an increased use of nicotine-replacement therapy after the implementation of the smoke-free policy.19Assessments of the effectiveness of smoke-free policies for hospital property tend to focus on noncompliance and related issues of enforcement.17,20,21 Although evidence of noncompliance and litter on hospital property2,17,20 implies ongoing exposure to tobacco smoke, half of the participating hospital sites in one study reported less exposure to tobacco smoke within hospital buildings and on the property.18 In addition, there is evidence to suggest some decline in smoking among staff.18,19,21,22We sought to determine the consequences of policies mandating smoke-free hospital property in two Canadian acute-care hospitals by eliciting lived experiences of the people faced with enacting the policies: patients and health care providers. In addition, we elicited stories from hospital support staff and administrators regarding the policies. 相似文献12.
Mélanie Drolet Marc Brisson Kenneth E. Schmader Myron J. Levin Robert Johnson Michael N. Oxman David Patrick Caty Blanchette James A. Mansi 《CMAJ》2010,182(16):1731-1736
Background
Vaccination against herpes zoster is being considered in many countries. We conducted a multicentre prospective study to describe the impact of herpes zoster and postherpetic neuralgia on health-related quality of life.Methods
From October 2005 to July 2006, 261 outpatients aged 50 years or older with herpes zoster were recruited from the clinical practices of 83 physicians within 14 days after rash onset. The Zoster Brief Pain Inventory was used to measure severity of pain and interference with activities of daily living because of pain. The EuroQol EQ-5D assessment tool was used to measure quality of life. These outcomes were assessed at recruitment and on days 7, 14, 21, 30, 60, 90, 120, 150 and 180 following recruitment.Results
Acute herpes zoster interfered in all health domains, especially sleep (64% of participants), enjoyment of life (58%) and general activities (53%). The median duration of pain was 32.5 days. The median duration of interference with activities of daily living because of pain varied between 27 and 30 days. Overall, 24% of the participants had postherpetic neuralgia (pain for more than 90 days after rash onset). Anxiety and depression, enjoyment of life, mood and sleep were most frequently affected during the postherpetic neuralgia period. The mean EQ-5D score was 0.59 at enrolment and remained at 0.67 at all follow-up points among participants who reported clinically significant pain.Interpretation
These data support the need for preventive strategies and additional early intervention to reduce the burden of herpes zoster and postherpetic neuralgia.Herpes zoster, which is characterized by dermatomal pain and vesicular rash,1,2 results from reactivation of the varicella-zoster virus.3,4 The average lifetime risk of herpes zoster in developed countries is estimated to be about 30%5–7 and increases with increasing life expectancy. The most common complication of herpes zoster, and one of the most challenging to treat, is postherpetic neuralgia, a painful condition often defined as pain persisting for more than 90 days after rash onset.8 According to this definition, postherpetic neuralgia is estimated to occur in 8%–27% of people with herpes zoster overall.9–14 The risk of postherpetic neuralgia increases markedly with age.15The Shingles Prevention Study, a randomized double-blind placebo-controlled trial, showed that a live-attenuated varicella-zoster virus vaccine was safe and effective in preventing herpes zoster and postherpetic neuralgia among people 60 years of age and older.13 Given these promising results, policy-makers and clinicians are being asked to make recommendations regarding the use and funding of the herpes zoster vaccine. To do this, evidence on the burden of herpes zoster from the patient’s perspective is required. The only data available on the impact of herpes zoster on health-related quality of life comes from two short-term studies.16,17 Clinical reports and cross-sectional surveys18–20 have also suggested that postherpetic neuralgia can profoundly impair quality of life. However, no study followed a cohort of patients with newly diagnosed herpes zoster for a sufficient period to assess postherpetic neuralgia and describe the associated impact on quality of life.We undertook a multicentre prospective study to describe the impact of herpes zoster and postherpetic neuralgia on health-related quality of life. 相似文献13.
Nancy Babio Estefanía Toledo Ramón Estruch Emilio Ros Miguel A. Martínez-González Olga Casta?er Mònica Bulló Dolores Corella Fernando Arós Enrique Gómez-Gracia Valentina Ruiz-Gutiérrez Miquel Fiol José Lapetra Rosa M. Lamuela-Raventos Lluís Serra-Majem Xavier Pintó Josep Basora José V. Sorlí Jordi Salas-Salvadó 《CMAJ》2014,186(17):E649-E657
Background:
Little evidence exists on the effect of an energy-unrestricted healthy diet on metabolic syndrome. We evaluated the long-term effect of Mediterranean diets ad libitum on the incidence or reversion of metabolic syndrome.Methods:
We performed a secondary analysis of the PREDIMED trial — a multicentre, randomized trial done between October 2003 and December 2010 that involved men and women (age 55–80 yr) at high risk for cardiovascular disease. Participants were randomly assigned to 1 of 3 dietary interventions: a Mediterranean diet supplemented with extra-virgin olive oil, a Mediterranean diet supplemented with nuts or advice on following a low-fat diet (the control group). The interventions did not include increased physical activity or weight loss as a goal. We analyzed available data from 5801 participants. We determined the effect of diet on incidence and reversion of metabolic syndrome using Cox regression analysis to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).Results:
Over 4.8 years of follow-up, metabolic syndrome developed in 960 (50.0%) of the 1919 participants who did not have the condition at baseline. The risk of developing metabolic syndrome did not differ between participants assigned to the control diet and those assigned to either of the Mediterranean diets (control v. olive oil HR 1.10, 95% CI 0.94–1.30, p = 0.231; control v. nuts HR 1.08, 95% CI 0.92–1.27, p = 0.3). Reversion occurred in 958 (28.2%) of the 3392 participants who had metabolic syndrome at baseline. Compared with the control group, participants on either Mediterranean diet were more likely to undergo reversion (control v. olive oil HR 1.35, 95% CI 1.15–1.58, p < 0.001; control v. nuts HR 1.28, 95% CI 1.08–1.51, p < 0.001). Participants in the group receiving olive oil supplementation showed significant decreases in both central obesity and high fasting glucose (p = 0.02); participants in the group supplemented with nuts showed a significant decrease in central obesity.Interpretation:
A Mediterranean diet supplemented with either extra virgin olive oil or nuts is not associated with the onset of metabolic syndrome, but such diets are more likely to cause reversion of the condition. An energy-unrestricted Mediterranean diet may be useful in reducing the risks of central obesity and hyperglycemia in people at high risk of cardiovascular disease. Trial registration: ClinicalTrials.gov, no. ISRCTN35739639.Metabolic syndrome is a cluster of 3 or more related cardiometabolic risk factors: central obesity (determined by waist circumference), hypertension, hypertriglyceridemia, low plasma high-density lipoprotein (HDL) cholesterol levels and hyperglycemia. Having the syndrome increases a person’s risk for type 2 diabetes and cardiovascular disease.1,2 In addition, the condition is associated with increased morbidity and all-cause mortality.1,3–5 The worldwide prevalence of metabolic syndrome in adults approaches 25%6–8 and increases with age,7 especially among women,8,9 making it an important public health issue.Several studies have shown that lifestyle modifications,10 such as increased physical activity,11 adherence to a healthy diet12,13 or weight loss,14–16 are associated with reversion of the metabolic syndrome and its components. However, little information exists as to whether changes in the overall dietary pattern without weight loss might also be effective in preventing and managing the condition.The Mediterranean diet is recognized as one of the healthiest dietary patterns. It has shown benefits in patients with cardiovascular disease17,18 and in the prevention and treatment of related conditions, such as diabetes,19–21 hypertension22,23 and metabolic syndrome.24Several cross-sectional25–29 and prospective30–32 epidemiologic studies have suggested an inverse association between adherence to the Mediterranean diet and the prevalence or incidence of metabolic syndrome. Evidence from clinical trials has shown that an energy-restricted Mediterranean diet33 or adopting a Mediterranean diet after weight loss34 has a beneficial effect on metabolic syndrome. However, these studies did not determine whether the effect could be attributed to the weight loss or to the diets themselves.Seminal data from the PREDIMED (PREvención con DIeta MEDiterránea) study suggested that adherence to a Mediterranean diet supplemented with nuts reversed metabolic syndrome more so than advice to follow a low-fat diet.35 However, the report was based on data from only 1224 participants followed for 1 year. We have analyzed the data from the final PREDIMED cohort after a median follow-up of 4.8 years to determine the long-term effects of a Mediterranean diet on metabolic syndrome. 相似文献14.
Chun-Sick Eom Christie Y. Jeon Ju-Won Lim Eun-Geol Cho Sang Min Park Kang-Sook Lee 《CMAJ》2011,183(3):310-319
Background
Observational studies and randomized controlled trials have yielded inconsistent findings about the association between the use of acid-suppressive drugs and the risk of pneumonia. We performed a systematic review and meta-analysis to summarize this association.Methods
We searched three electronic databases (MEDLINE [PubMed], Embase and the Cochrane Library) from inception to Aug. 28, 2009. Two evaluators independently extracted data. Because of heterogeneity, we used random-effects meta-analysis to obtain pooled estimates of effect.Results
We identified 31 studies: five case–control studies, three cohort studies and 23 randomized controlled trials. A meta-analysis of the eight observational studies showed that the overall risk of pneumonia was higher among people using proton pump inhibitors (adjusted odds ratio [OR] 1.27, 95% confidence interval [CI] 1.11–1.46, I2 90.5%) and histamine2 receptor antagonists (adjusted OR 1.22, 95% CI 1.09–1.36, I2 0.0%). In the randomized controlled trials, use of histamine2 receptor antagonists was associated with an elevated risk of hospital-acquired pneumonia (relative risk 1.22, 95% CI 1.01–1.48, I2 30.6%).Interpretation
Use of a proton pump inhibitor or histamine2 receptor antagonist may be associated with an increased risk of both community- and hospital-acquired pneumonia. Given these potential adverse effects, clinicians should use caution in prescribing acid-suppressive drugs for patients at risk.Recently, the medical literature has paid considerable attention to unrecognized adverse effects of commonly used medications and their potential public health impact.1 One group of medications in widespread use is acid-suppressive drugs, which represent the second leading category of medication worldwide, with sales totalling US$26.9 billion in 2005.2Over the past 40 years, the development of potent acid-suppressive drugs, including proton pump inhibitors, has led to considerable improvements in the treatment of acid-related disorders of the upper gastrointestinal tract.3 Experts have generally viewed proton pump inhibitors as safe.4 However, potential complications such as gastrointestinal neoplasia, malabsorption of nutrients and increased susceptibility to infection have caused concern.5Of special interest is the possibility that acid-suppressive drugs could increase susceptibility to respiratory infections because these drugs increase gastric pH, thus allowing bacterial colonization.6,7 Several previous studies have shown that treatment with acid-suppressive drugs might be associated with an increased risk of respiratory tract infections8 and community-acquired pneumonia in adults6,7 and children.9 However, the association between use of acid-suppressive drugs and risk of pneumonia has been inconsistent.10–13Given the widespread use of proton pump inhibitors and histamine2 receptor antagonists, clarifying the potential impact of acid-suppressive therapy on the risk of pneumonia is of great importance to public health.14 Previous meta-analyses have focused on the role of acid-suppressive drugs in preventing stress ulcer,11,13,15 but none have examined pneumonia as the primary outcome.The aim of this study was to summarize the association between the use of acid-suppressive drugs and the risk of pneumonia in observational studies and randomized controlled trials. 相似文献15.
Background:Head injuries have been associated with subsequent suicide among military personnel, but outcomes after a concussion in the community are uncertain. We assessed the long-term risk of suicide after concussions occurring on weekends or weekdays in the community.Methods:We performed a longitudinal cohort analysis of adults with diagnosis of a concussion in Ontario, Canada, from Apr. 1, 1992, to Mar. 31, 2012 (a 20-yr period), excluding severe cases that resulted in hospital admission. The primary outcome was the long-term risk of suicide after a weekend or weekday concussion.Results:We identified 235 110 patients with a concussion. Their mean age was 41 years, 52% were men, and most (86%) lived in an urban location. A total of 667 subsequent suicides occurred over a median follow-up of 9.3 years, equivalent to 31 deaths per 100 000 patients annually or 3 times the population norm. Weekend concussions were associated with a one-third further increased risk of suicide compared with weekday concussions (relative risk 1.36, 95% confidence interval 1.14–1.64). The increased risk applied regardless of patients’ demographic characteristics, was independent of past psychiatric conditions, became accentuated with time and exceeded the risk among military personnel. Half of these patients had visited a physician in the last week of life.Interpretation:Adults with a diagnosis of concussion had an increased long-term risk of suicide, particularly after concussions on weekends. Greater attention to the long-term care of patients after a concussion in the community might save lives because deaths from suicide can be prevented.Suicide is a leading cause of death in both military and community settings.1 During 2010, 3951 suicide deaths occurred in Canada2 and 38 364 in the United States.3 The frequency of attempted suicide is about 25 times higher, and the financial costs in the US equate to about US$40 billion annually.4 The losses from suicide in Canada are comparable to those in other countries when adjusted for population size.5 Suicide deaths can be devastating to surviving family and friends.6 Suicide in the community is almost always related to a psychiatric illness (e.g., depression, substance abuse), whereas suicide in the military is sometimes linked to a concussion from combat injury.7–10Concussion is the most common brain injury in young adults and is defined as a transient disturbance of mental function caused by acute trauma.11 About 4 million concussion cases occur in the US each year, equivalent to a rate of about 1 per 1000 adults annually;12 direct Canadian data are not available. The majority lead to self-limited symptoms, and only a small proportion have a protracted course.13 However, the frequency of depression after concussion can be high,14,15 and traumatic brain injury in the military has been associated with subsequent suicide.8,16 Severe head trauma resulting in admission to hospital has also been associated with an increased risk of suicide, whereas mild concussion in ambulatory adults is an uncertain risk factor.17–20The aim of this study was to determine whether concussion was associated with an increased long-term risk of suicide and, if so, whether the day of the concussion (weekend v. weekday) could be used to identify patients at further increased risk. The severity and mechanism of injury may differ by day of the week because recreational injuries are more common on weekends and occupational injuries are more common on weekdays.21–27 The risk of a second concussion, use of protective safeguards, propensity to seek care, subsequent oversight, sense of responsibility and other nuances may also differ for concussions acquired from weekend recreation rather than weekday work.28–31 Medical care on weekends may also be limited because of shortfalls in staffing.32 相似文献
16.
Clare L. Atzema Peter C. Austin Thao Huynh Ansar Hassan Maria Chiu Julie T. Wang Jack V. Tu 《CMAJ》2011,183(13):1482-1491
Background:
Coronary artery disease is the most common cause of death in the Western world, and being married decreases the risk of death from cardiovascular causes. We aimed to determine whether marital status was a predictor of the duration of chest pain endured by patients with acute myocardial infarction before they sought care and whether the patient’s sex modified the effect.Methods:
We conducted a retrospective, population-based cohort analysis of patients with acute myocardial infarction admitted to 96 acute care hospitals in Ontario, Canada, from April 2004 to March 2005. We excluded patients who did not experience chest pain. Using multivariable regression analyses, we assessed marital status in relation to delayed presentation to hospital (more than six hours from onset of pain), both overall and stratified by sex. In patients who reported the exact duration of chest pain, we assessed the effect of marital status on the delay in seeking care.Results:
Among 4403 eligible patients with acute myocardial infarction, the mean age was 67.3 (standard deviation 13.6) years, and 1486 (33.7%) were women. Almost half (2037 or 46.3%) presented to a hospital within two hours, and 3240 (73.6%) presented within six hours. Overall, 75.3% (2317/3079) of married patients, 67.9% (188/277) of single patients, 68.5% (189/276) of divorced patients and 70.8% (546/771) of widowed patients presented within six hours of the onset of chest pain. Being married was associated with lower odds of delayed presentation (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.30–0.71, p < 0.001) relative to being single. Among men, the OR was 0.35 (95% CI 0.21–0.59, p < 0.001), whereas among women the effect of marital status was not significant (OR 1.36, 95% CI 0.49–3.73, p = 0.55).Interpretation:
Among men experiencing acute myocardial infarction with chest pain, being married was associated with significantly earlier presentation for care, a benefit that was not observed for married women. Earlier presentation for medical care appears to be one reason for the observed lower risk of cardiovascular death among married men, relative to their single counterparts.Marriage has long been known to offer health benefits1,2 and is associated with a lower risk of death3,4 relative to people who are not married. The effect is more pronounced among men than among women.5,6 However, the specific mechanisms responsible for the lower rate of cardiovascular deaths in married persons7 are not known.Effective, time-sensitive therapy for acute myocardial infarction is available,8,9 and delays in the emergency department and for in-hospital components of care have been substantially reduced over the past few decades.10,11 In contrast, patients’ delay in seeking care for acute myocardial infarction has shown little improvement over time,12,13 despite intensive campaigns to raise public awareness.14,15 Patients’ delay remains by far the largest component of the overall delay between onset of symptoms and receipt of therapy.16 No study has examined the effect of marital status on patients’ delay, and only a few small studies have examined predictors of this component of delay by sex.17,18We examined the effect of marital status, a social factor, on the time from onset of chest pain to arrival in an emergency department or hospital, in a population-based cohort of patients with acute myocardial infarction. We hypothesized that being married or in a common-law relationship would be associated with less delay, because we surmised that a spouse would encourage earlier pursuit of medical care, either directly or indirectly (i.e., even if the spouse was not physically present during the symptoms, his or her existence might spur the patient to seek care earlier). We hypothesized that wives would be more likely than husbands to assume the caregiver role and that the beneficial effect of marriage would therefore be stronger among men than among women. 相似文献17.
18.
George Ioannidis Alexandra Papaioannou Wilma M. Hopman Noori Akhtar-Danesh Tassos Anastassiades Laura Pickard Courtney C. Kennedy Jerilynn C. Prior Wojciech P. Olszynski Kenneth S. Davison David Goltzman Lehana Thabane Amiran Gafni Emmanuel A. Papadimitropoulos Jacques P. Brown Robert G. Josse David A. Hanley Jonathan D. Adachi 《CMAJ》2009,181(5):265-271
Background
Fractures have largely been assessed by their impact on quality of life or health care costs. We conducted this study to evaluate the relation between fractures and mortality.Methods
A total of 7753 randomly selected people (2187 men and 5566 women) aged 50 years and older from across Canada participated in a 5-year observational cohort study. Incident fractures were identified on the basis of validated self-report and were classified by type (vertebral, pelvic, forearm or wrist, rib, hip and “other”). We subdivided fracture groups by the year in which the fracture occurred during follow-up; those occurring in the fourth and fifth years were grouped together. We examined the relation between the time of the incident fracture and death.Results
Compared with participants who had no fracture during follow-up, those who had a vertebral fracture in the second year were at increased risk of death (adjusted hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.1–6.6); also at risk were those who had a hip fracture during the first year (adjusted HR 3.2, 95% CI 1.4–7.4). Among women, the risk of death was increased for those with a vertebral fracture during the first year (adjusted HR 3.7, 95% CI 1.1–12.8) or the second year of follow-up (adjusted HR 3.2, 95% CI 1.2–8.1). The risk of death was also increased among women with hip fracture during the first year of follow-up (adjusted HR 3.0, 95% CI 1.0–8.7).Interpretation
Vertebral and hip fractures are associated with an increased risk of death. Interventions that reduce the incidence of these fractures need to be implemented to improve survival.Osteoporosis-related fractures are a major health concern, affecting a growing number of individuals worldwide. The burden of fracture has largely been assessed by the impact on health-related quality of life and health care costs.1,2 Fractures can also be associated with death. However, trials that have examined the relation between fractures and mortality have had limitations that may influence their results and the generalizability of the studies, including small samples,3,4 the examination of only 1 type of fracture,4–10 the inclusion of only women,8,11 the enrolment of participants from specific areas (i.e., hospitals or certain geographic regions),3,4,7,8,10,12 the nonrandom selection of participants3–11 and the lack of statistical adjustment for confounding factors that may influence mortality.3,5–7,12We evaluated the relation between incident fractures and mortality over a 5-year period in a cohort of men and women 50 years of age and older. In addition, we examined whether other characteristics of participants were risk factors for death. 相似文献19.
Shoo K. Lee Khalid Aziz Nalini Singhal Catherine M. Cronin Andrew James David S.C. Lee Derek Matthew Arne Ohlsson Koravangattu Sankaran Mary Seshia Anne Synnes Robin Walker Robin Whyte Joanne Langley Ying C. MacNab Bonnie Stevens Peter von Dadelszen 《CMAJ》2009,181(8):469-476