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Background: Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head. Methods: This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression. Results: The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%-99.6%), specificity was 20.3% (95% CI 19.1%-21.5%) and negative predictive value was 99.8% (95% CI 99.2%-99.9%). Interpretation: We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755., As populations age, emergency departments are managing a growing number of older adults who fall. (1-3) Falling on level ground is the most common cause of traumatic intracranial bleeding. (4-6) [...]

Objective. This project aimed to develop a virtual intervention for vertebral fractures (VIVA) to implement the international recommendations for the nonpharmacological management of osteoporotic vertebral fractures and to test its acceptability and usability. Methods. VIVA was developed in accordance with integrated knowledge translation principles and was informed by the Behavioral Change Wheel, the Theoretical Domains Framework, and the affordability, practicability, effectiveness and cost-effectiveness, acceptability, side effects/safety, and equity (APEASE) criteria. The development of the prototype of VIVA involved 3 steps: understanding target behaviors, identifying intervention options, and identifying content and implementation options. The VIVA prototype was delivered to 9 participants to assess its acceptability and usability. Results. VIVA includes 7 1-on-1 virtual sessions delivered by a physical therapist over 5 weeks. Each session lasts 45 minutes and is divided in 3 parts: education, training, and behavioral support/goal setting. Four main themes emerged from the acceptability evaluation: perceived improvements in pain, increased self-confidence, satisfaction with 1-on-1 sessions and resources, and ease of use. All of the participants believed that VIVA was very useful and were very satisfied with the 1-on-1 sessions. Four participants found the information received very easy to practice, 4 found it easy to practice, and 1 found it somewhat difficult to practice. Five participants were satisfied with the supporting resources, and 4 were very satisfied. Potential for statistically significant improvements was observed in participants' ability to make concrete plans about when, how, where, and how often to exercise. Conclusion. VIVA was acceptable and usable to the participants, who perceived improvements in pain and self-confidence. Impact. The virtual implementation of the recommendations for the nonpharmacological management of vertebral fractures showed high acceptability and usability. Future trials will implement the recommendations on a larger scale to evaluate their effectiveness. Keywords: Education, Fragility Fractures, Osteoporosis, Rehabilitation, Spine, Introduction Osteoporotic vertebral fracture (VF) is the most common type of fracture in people with osteoporosis. (1-3) One in 5 women with an incident VF will experience another one within [...]

Contexte: Au Canada, plus de 2 millions de personnes vivent avec l'osteoporose, une maladie qui accroTt le risque de fracture, ce qui fait augmenter la morbidite et la mortalite, et entraTne une perte de qualite de vie et d'autonomie. La presente actualisation des lignes directrices vise a accompagner les professionnelles et professionnels de la sante au Canada dans la prestation de soins visant a optimiser la sante osseuse et a prevenir les fractures chez les femmes menopausees et les hommes de 50 ans et plus. Methodes: Le present document fournit une actualisation des lignes directrices de pratique clinique de 2010 d'Osteoporose Canada sur le diagnostic et la prise en charge de l'osteoporose au pays. Nous avons utilise l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) et effectue l'assurance de la qualite conformement aux normes de qualite et de presentation des rapports de la grille AGREE II (Appraisal of Guidelines for Research & Evaluation). Les medecins de premier recours et les patientes et patients partenaires ont ete representes a tous les niveaux des comites et des groupes ayant participe a l'elaboration des lignes directrices, et ont participe a toutes les etapes du processus pour garantir la pertinence des informations pour les futurs utilisateurs et utilisatrices. Le processus de gestion des interets concurrents a ete entame avant l'elaboration des lignes directrices et s'est poursuivi sur toute sa duree, selon les principes du Reseau international en matiere de lignes directrices. Dans la formulation des recommandations, nous avons tenu compte des avantages et des risques, des valeurs et preferences de la patientele, des ressources, de l'equite, de l'acceptabilite et de la faisabilite; la force de chacune des recommandations a ete determinee en fonction du cadre GRADE. Recommandations: Les 25 recommandations et les 10 enonces de bonne pratique sont repartis en sections: activite physique, alimentation, evaluation du risque de fracture, instauration du traitement, interventions pharmacologiques, duree et sequence du traitement, et monitorage. La prise en charge de l'osteoporose devrait se fonder sur le risque de fracture, etabli au moyen d'une evaluation clinique realisee avec un outil d'evaluation du risque de fracture valide. L'activite physique, l'alimentation et la pharmacotherapie sont des elements essentiels a la strategie de prevention des fractures, qui devraient etre personnalises. Interpretation: Les presentes lignes directrices ont pour but d'outiller les professionnelles et professionnels de la sante et la patientele afin qu'ensemble ils puissent parler de l'importance de la sante osseuse et du risque de fracture tout au long de la vie adulte avancee. La detection et la prise en charge efficace de la fragilite osseuse peuvent contribuer a reduire les fractures et a preserver la mobilite, l'autonomie et la qualite de vie., Le risque de fracture augmente avec l'age, en raison du declin de la robustesse squelettique et de l'augmentation du risque de chute. Au Canada, plus de 2 millions de personnes [...]

Background: In Canada, more than 2 million people live with osteoporosis, a disease that increases the risk for fractures, which result in excess mortality and morbidity, decreased quality of life and loss of autonomy. This guideline update is intended to assist Canadian health care professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal females and in males aged 50 years and older. Methods: This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and quality assurance as per Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards. Primary care physicians and patient partners were represented at all levels of the guideline committees and groups, and participated throughout the entire process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the guideline development, informed by the Guideline International Network principles. We considered benefits and harms, patient values and preferences, resources, equity, acceptability and feasibility when developing recommendations; the strength of each recommendation was assigned according to the GRADE framework. Recommendations: The 25 recommendations and 10 good practice statements are grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. The management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool. Exercise, nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized. Interpretation: The aim of this guideline is to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk throughout older adulthood. Identification and appropriate management of skeletal fragility can reduce fractures, and preserve mobility, autonomy and quality of life., Fracture risk increases with advancing age, as a result of declining skeletal strength and increased risk of falling. In Canada, more than 2 million people live with osteoporosis. (1) Every [...]

Objectives: The population is aging and falls are a common reason for emergency department visits. Appropriate imaging in this population is important. The objectives of this study were to estimate the prevalence of cervical spine injury and identify factors associated with cervical spine injuries in adults ≥ 65 years after low-level falls. Methods: This was a pre-specified sub-study of a prospective observational cohort study of intracranial bleeding in emergency patients ≥ 65 years presenting after low-level falls. The primary outcome was cervical spine injury. The risk factors of interest were Glasgow coma scale (GCS) < 15, head injury, neck pain, age, and frailty defined as Clinical Frailty Scale ≥ 5. Multivariable logistic regression was used to measure the strength of association between risk factors and cervical spine injury. A descriptive analysis of absence of significant risk factors was performed to determine patients who may not require imaging. Results: There were 4308 adults ≥ 65 who sustained low-level falls with mean age of 82.0 (standard deviation ± 8.8) years and 1538 (35.7%) were male; 23 [0.5% (95% confidence interval (CI) 0.3–0.8%)] were diagnosed with cervical spine injuries. The adjusted odds ratios and 95% CIs were 1.3 (0.5–3.2) for GCS < 15, 5.3 (1.7–26.7) for head injury, 13.0 (5.7–31.2) for new neck pain, 1.4 (1.0–1.8) for 5-year increase in age, and 1.1 (0.4–2.9) for frailty. Head injury or neck pain identified all 23 cervical spine injuries. Management was a rigid collar in 19/23 (82.6%) patients and none had surgery. Conclusions: In emergency patients ≥ 65 years presenting after a low-level fall, head injury, neck pain, and older age were associated with the diagnosis of cervical spine injury. There were no cervical spine injuries in those without head injury or neck pain. Patients with no head injury or neck pain may not require cervical spine imaging.

Background. Regular exercise is advocated in osteoporosis guidelines to prevent fractures. Few studies have evaluated the effect of exercise on functional performance, posture, and other outcomes that are important to patients after vertebral fractures. Objective. This pilot study will explore the effect of home exercise versus control on functional performance, posture, and patient-reported outcome measures. Design. This study was a parallel 2-arm pilot feasibility trial with 1:1 randomization to exercise or attentional control groups. Setting. This study took place in 5 Canadian and 2 Australian academic or community hospitals/centers. Participants. This study included 141 women [greater than or equal to]65 years of age with radiographically confirmed vertebral fractures. Intervention. A physical therapist delivered exercise and behavioral counseling in 6 home visits over 8 months and monthly calls. Participants were to exercise [greater than or equal to]3 times weekly. Controls received equal attention. Measurements. Functional performance, posture, quality of life, pain, and behavior-change outcomes were assessed at baseline and after 6 (questionnaires only) and 12 months. Adherence to exercise was assessed by calendar diary. All t tests examined between-group mean differences (MD) in change from baseline in intention-to-treat and per-protocol analyses. Results. There was a small effect of exercise on 5 times sit-to-stand test versus control (MD = -1.58 [95% CI = -3.09 to -0.07], intention-to-treat; MD = -1.49 [95% CI = -3.12 to 0.16], per-protocol). There were no other major or statistically significant MDs for any other measured outcomes after follow-up. Adherence declined over time. Limitations. Treatment effects on variables may have been underestimated due to multiple comparisons and underpowered analyses. Conclusions. Our exploratory estimate of the effect of exercise on functional leg muscle strength was consistent in direction and magnitude with other trials in individuals with vertebral fractures. Declining adherence to home exercise suggests that strategies to enhance long-term adherence might be important in future confirmatory trials., Osteoporotic vertebral fractures are associated with significant health and economic burden worldwide (1,2) and can lead to functional decline, (3) pain, (4) reduced quality of life, (5) hospitalization, (6) and [...]

BACKGROUND: The Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening QualitY) intervention was designed to improve primary care teamwork and promote optimal aging. We evaluated the effectiveness of Health TAPESTRY in attaining goals of older adults (e.g., physical activity, productivity, social connection, medical status) and other outcomes. METHODS: We conducted a pragmatic randomized controlled trial between January and October 2015 in a primary care practice in Hamilton, Ontario. Older adults were randomized (1:1) to Health TAPESTRY (n = 158) or control (n = 154). Trained community volunteers gathered information on people's goals, needs and risks in their homes, using electronic forms. Interprofessional primary care teams reviewed summaries and addressed issues. Participants reported goal attainment (primary outcome), self-efficacy, quality of life, optimal aging, social support, empowerment, physical activity, falls, and access to and comprehensiveness of the health system. We determined use of health care resources through chart audit. RESULTS: There were no differences between groups in goal attainment or many other patient-reported outcome and experience assessments at 6 months. More primary care visits took place in the intervention versus control group over 6 months (mean [+ or -] standard deviation [SD] 4.93 [+ or -] 3.86 v. 3.50 [+ or -] 3.53; difference of 1.52 [95% confidence interval (CI) 0.84 to 2.19]). The odds of having 1 or more hospital admission were lower for the intervention group (odds ratio [OR] 0.44 [95% CI 0.20 to 0.95]). INTERPRETATION: Health TAPESTRY did not improve the primary outcome of goal attainment but showed signals of shifting care from reactive to active preventive care. Further evaluation will help in understanding effective components, costs and consequences of the intervention. Trial registration: ClinicalTrials.gov, no. NCT02283723, Countries with well-functioning primary care systems have realized better health outcomes and health equity. (1,2) Health care systems worldwide are rearranging primary care to be proactive versus reactive, to focus [...]

Les Lignes directrices de pratique clinique 2010 pour le diagnostic et le traitement de I'osteoporose au Canada (1) portaient sur les soins aux adultes vivant dans la communaute. Cependant, le [...]

The 2010 clinical practice guideline for the diagnosis and management of osteoporosis in Canada (1) focused on the care of adults living in the community. However, the fracture rate for [...]

Background. Our goal is to conduct a multicenter randomized controlled trial (RCT) to investigate whether exercise can reduce incident fractures compared with no intervention among women aged [greater than or equal to] 65 years with a vertebral fracture. Objectives. This pilot study will determine the feasibility of recruitment, retention, and adherence for the proposed trial. Design. The proposed RCT will be a pilot feasibility study with 1:1 randomization to exercise or attentional control groups. Setting. Five Canadian sites (1 community hospital partnered with an academic center and 4 academic hospitals or centers affiliated with an academic center) and 2 Australian centers (1 academic hospital and 1 center for community primary care, geriatric, and rehabilitation services). Participants. One hundred sixty women aged [greater than or equal to] 65 years with vertebral fracture at 5 Canadian and 2 Australian centers will be recruited. Intervention. The Build Better Bones With Exercise (B3E) intervention includes exercise and behavioral counseling, delivered by a physical therapist in 6 home visits over 8 months, and monthly calls; participants are to exercise [greater than or equal to] 3 times weekly. Controls will receive equal attention. Measurements. Primary outcomes will include recruitment, retention, and adherence. Adherence to exercise will be assessed via calendar diary. Secondary outcomes will include physical function (lower extremity strength, mobility, and balance), posture, and falls. Additional secondary outcomes will include quality of life, pain, fall self-efficacy, behavior change variables, intervention cost, fractures, and adverse events. Analyses of feasibility objectives will be descriptive or based on estimates with 95% confidence intervals, where feasibility will be assessed relative to a priori criteria. Differences in secondary outcomes will be evaluated in intention-to-treat analyses via independent Student t tests, chi-square tests, or logistic regression. The Bonferroni method will be used to adjust the level of significance for secondary outcomes so the overall alpha level is .05. Limitations. No assessment of bone mineral density will be conducted. The proposed definitive trial will require a large sample size. Conclusions. The viability of a large-scale exercise trial in women with vertebral fractures will be evaluated, as well as the effects of a home exercise program on important secondary outcomes., Osteoporotic fractures create a substantial human and economic burden. (1) Vertebral fractures are a common consequence of osteoporosis that can cause pain and are associated with increased mortality. (2) One [...]

Since the publication of the Osteoporosis Canada guidelines in 2002, there has been a paradigm shift in the prevention and treatment of osteoporosis and fractures. (1,2) The focus now is [...]

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 (adjust ed 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. Une version francaise de ce resume est disponible a l'adresse www.cmaj.ca/cgi/content/full/cmaj.081720/DC1, 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 [...]

ABSTRACT In 2002, Osteoporosis Canada published clinical practice guidelines for the diagnosis and management of osteoporosis. The current paper supplements that guideline and provides a review and synthesis of the [...]

Abstract Background: Human parathyroid hormone (hPTH)(1-34) was approved in 2004 for the treatment of severe osteoporosis. Members of the Osteoporosis Canada clinical guidelines committee conducted a systematic review of randomized [...]

In 2002, Osteoporosis Canada published clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. (1) At the time, there was considerable evidence for the use of anti-resorptive [...]

Osteoporotic vertebral compression fractures (VCFs) represent a significant diagnostic and management challenge for primary care physicians (PCPs), and they are likely to become an increasingly important health issue for many [...]

This article presents a case study of an elderly woman with subacute delirium associated with systemic lupus erythematosus. After several weeks of treatment with prednisone, a corticosteroid, the neuropsychiatric manifestations diminished, the patient regained lost weight, and she resumed daily activities without residual cognitive difficulty.

A cross-sectional chart review for the month 5/99 has been carried out for four long-term care facilities to find out whether dosing guidelines based on creatinine clearance (Ccr) for renally excreted medications are being applied when drugs are prescribed for long-term care residents. It was found that renal function is often overlooked when these medications are prescribed for this population. Approximately one in three prescriptions was found inappropriate for the calculated Ccr for the patient.

Aortic or iliac graft infection is a serious complication in vascular surgery, which carries significant risks for the patient's limb and life and requires complex treatment. We report a patient who presented sepsis due to a previous ilio(common iliac)-femoral(profunda femoris) graft infection. Taking into account that the superficial femoral and popliteal arteries were occluded (no suitable target vessel, except for the distal profunda femoral) and the fact that he presented methicillin-resistant Staphylococcus aureus–positive blood cultures, the patient was scheduled for excision of the contaminated graft and in situ reconstruction. Along with the femoral vein, a segment of the adjacent occluded superficial femoral artery was used after eversion endarterectomy to ensure adequate homograft length to perform the bypass. To our knowledge, this is the first report of this technique which can be particularly useful in similar settings.

RÉSUMÉ:Les outils cliniques employés dans les établissements de soins peuvent fournir des informations pronostiques importantes aux professionnels de la santé. Dans cette étude observationnelle prospective d’un an, nous avons examiné l’association entre les scores au Short Performance Physical Battery (SPPB), d’une part, et les consultations à l’urgence et les hospitalisations au cours de l’étude, d’autre part. Au total, 191 patients ayant été nouvellement référés à une clinique gériatrique externe de Hamilton (Ontario) ont été contactés, et parmi eux, 120 pris part à l’étude. Le SPPB et d’autres évaluations ont été réalisés dans le cadre de consultations de routine. Les dossiers médicaux électroniques ont été examinés pour déterminer le nombre de consultations à l’urgence et d’hospitalisations dans l’année qui a suivi l’évaluation de base. Des analyses de régression logistique ont été utilisées pour identifier des prédicteurs des consultations à l’urgence et des hospitalisations. Le score moyen au SPPB dans la cohorte étudiée (moyenne d’âge = 80,6 ans, écart-type = 6,3 ans ; 53 % de femmes) était de 6,3 (écart-type = 3,2). Au cours de cette période d’un an, le score au SPPB était associé au nombre de consultations à l’urgence [RR = 0,90 (0,78–1,03)] et d’hospitalisations [RR = 0,84 (0,72–0,97)], après ajustement pour l’âge, le sexe et les comorbidités.ABSTRACT:Tools applied at the point of care can provide valuable prognostic information for practitioners. In this one-year, prospective observational study, we examined the association of the short performance physical battery (SPPB) and one-year emergency department (ED) visits and hospitalizations. Overall, 191 new referrals attending an outpatient geriatric clinic in Hamilton, Ontario, were approached, and 120 were enrolled. SPPB and other assessments were completed during the routine clinical visit. ED visits and hospitalizations within one year of the baseline assessment were abstracted from electronic medical records. Logistic regression analyses were used to determine ED visits and hospitalization predictors. The mean SPPB score in the study cohort (mean age 80.6, SD 6.3 years; 53% female) was 6.3 (SD 3.2). SPPB score was associated with a one-year ED visit (OR = 0.90 [0.78–1.03]) and hospitalization (OR = 0.84 [0.72–0.97]) after adjusting for age, sex, and co-morbidities.

Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications.

Critical limb ischemia (CLI) often results from multilevel occlusive disease. There are occasions where a patent profunda femoral artery (PFA) is the only target artery that can be used as outflow during reconstruction to bypass aortoiliac disease (AOID), with no further option for infrainguinal revascularization. We aim to report results of the use of PFA as the sole target vessel for the treatment of these patients.

ABSTRACTIntroduction: Chemotherapy induced nausea and vomiting (CINV) are major side effects of chemotherapy and a great burden to patients’ quality of life. Serotonin and substance P are the major neurotransmitters involved in the pathophysiology of CINV, but in spite of new antiemetics no completely effective regime exists for its prevention or treatment.Areas covered: In this review the authors provide a detailed description of granisetron’s chemistry pharmacokinetics, pharmacodynamics, toxicity and a brief review of clinical trials involving granisetron and the management of CINV. We searched reviews, meta-analysis and randomized controlled trials (Medline, Embase and article reference lists).Expert opinion: According to current literature, granisetron 2 mg orally or 0,01mg/kg (1 mg) intravenously per day, co-administered with dexamethasone and NK-1 antagonists is the recommended regime for highly emetogenic chemotherapy. In the future the role of transdermal and subcutaneous formulations against delayed CINV will be clarified and probably enhance patients’ convenience.

RÉSUMÉLes résidents en soins de longue durée (SLD) ont souvent besoin de soins en réadaptation pour maintenir ou améliorer leur état physique fonctionnel. L’objectif de cet examen de portée était de décrire l’envergure des publications concernant la réadaptation physique en SLD jusqu’à ce jour, avec une emphase sur les types d’interventions en réadaptation qui ont été évaluées, ainsi que sur les mesures de résultats utilisées et les outils déterminant l’admissibilité au service. Une recherche structurée a été réalisée dans six bases de données sous licence et dans la littérature grise. Deux analystes ont identifié 381 articles qui ont été triés en utilisant un formulaire qui avait préalablement été testé dans un essai pilote, et les données de ces articles ont été extraites. La plupart des interventions avaient été réalisées et évaluées au niveau des résidents, et consistaient fréquemment en des programmes d’exercices à plusieurs composantes dispensés par du personnel de recherche et des physiothérapeutes. Les mesures les plus couramment rapportées étaient basées sur la performance, les activités de la vie quotidienne et l’humeur. Une lacune importante a été identifiée concernant les connaissances sur la réadaptation en lien avec des objectifs qui soient pertinents pour les résidents, tels que la qualité de vie. Dans les études à venir, il serait important que les caractéristiques des résidents en SLD soit représentatives de la complexité de l’état de santé de cette population; la durée de leur séjour devrait aussi être incluse et différenciée. Les études d’intervention devraient aussi explorer des méthodes de prestation de soins qui soient réalistes et soutenables. Le développement d’outils pour favoriser une meilleure détermination de l’admissibilité aux services est aussi nécessaire pour assurer l’égalité en matière de soins en réadaptation dans l’ensemble du secteur des SLD.

The adoption of cluster randomized trials (CRTs) with the stratified design is currently gaining widespread interest. In the stratified design, clusters are first grouped into two or more strata and then randomized into treatment groups within each stratum. In this study, we evaluated the performance of several commonly used methods for analyzing continuous data from stratified CRTs.

Background:Many medications used in older adults have strong anticholinergic (ACH) properties, which may increase the risk of falls and fractures. Use of these medications was identified in a population-based Canadian cohort. Objective:To identify the fall and fracture risk associated with ACH medication use. Methods:Data collection and analysis were conducted at baseline, year 5, and year 10. Cross-sectional analyses were performed to examine associations between ACH medication use and falls. Time-dependent Cox regression was used to examine time to first nontraumatic fracture. Finally, change in bone mineral density (BMD) over 10 years was compared in ACH medication users versus nonusers. Results:Strongly ACH medications were used by 618 of 7753 participants (8.0%) at study baseline, 592 (9.5%) at year 5, and 334 (7.7%) at year 10. Unadjusted ACH medication use was associated with falls at baseline (odds ratio = 1.50; 95% CI = 1.14-1.98; P= 0.004), but the association was no longer significant after covariate adjustment. Similar results occurred at years 5 and 10. ACH medication use was associated with increased incident fracture risk before (hazard ratio = 1.22; CI = 1.13-1.32; P< 0.001) but not after covariate adjustment. Mean (SD) change in femoral neck BMD T-score over 10 years, in those using ACH medications at both years 0 and 5, was −0.60 (0.63) in ACH users versus −0.49 (0.45) in nonusers (P= 0.041), but this was not significant after covariate adjustment. Conclusions:ACH medications were not found to be independently associated with an increased risk of falling, fractures, or BMD loss. Rather, factors associated with ACH medication use explained the apparent associations.

The collected works οf Hippocrates include a wealth of references to emergencies and acute conditions; if the physician could treat these, he would be considered superior to his colleagues. Works most relevant to current Emergency Medicine are presented. They indicate Hippocrates’ remarkable insight and attention to the value of close observation, meticulous clinical examination, and prognosis. Hippocrates and his followers disdained mystery and were not satisfied until they had discovered a rational cause to diseases. They assigned great significance to distressing signs and symptoms – the famous Hippocratic face, the breathing pattern, pain, seizures, opisthotonus – pointing to a fatal outcome, which they reported to their patient. The principles of treatment of emergencies, such as angina, haemorrhage, empyema, ileus, shoulder dislocations and head injuries, are astonishingly similar to the ones used nowadays.

RÉSUMÉIl y a eu peu d’études qui se concentrent sur les chutes chez les clients qui reçoivent des soins à domicile (SD) avec des conditions neurologiques. Cette étude a identifié les facteurs qui accroissent le risque de chutes chez les clients SD sans histoire récente de telles chutes, et a exploré si les profils de risque variaient parmi les personnes atteintes de démence ou le parkinsonisme, par rapport à celles sans conditions neurologiques sélectionnés. Une étude de cohorte rétrospective a été utilisée, et l’analyse des données provenant de clients SD communautaires de l’Ontario a été menée sur un échantillon de clients ambulatoires atteints de démence, de parkinsonisme, ou d’aucune des conditions neurologiques sélectionnées. Les données ont été obtenues à partir de l’instrument d’évaluation des résidents en soins à domicile (IERSD-SD). Dans l’analyse multivariée, le résultat utilisé était de savoir si les clients ont tombé au cours du suivi. Une démarche instable était un fort prédicteur des chutes dans les trois groupes. Le parkinsonisme co-morbide a prédit plus fortement les chutes dans le groupe de démence. Les clients qui ont montré la limite intacte à la déficience cognitive légère étaient plus susceptibles de se sont trouvés dans les groupes de parkinsonisme et de comparaison. Les chances de tomber étaient plus élevées pour les clients avec la limite intacte à la déficience cognitive légère qui également faisaient partie des groupes de la maladie de Parkinson et de comparaison.

ABSTRACTIn vitroand in vivostudies and evidence from human tumors have long implicated Rho GTPase signaling in the formation and dissemination of a range of cancers. Recently next generation sequencing has identified direct mutations of Rho GTPases in human cancers. Moreover, the effects of ablating genes encoding Rho GTPases and their regulators in mouse models, or through pharmacological inhibition, strongly suggests that targeting Rho GTPase signaling could constitute an effective treatment. In this review we will explore the various ways in which Rho signaling can be deregulated in human cancers.

Proton pump inhibitors (PPIs) are a commonly prescribed class of medications. Their use has been associated with an increased rate of fractures, most notably hip fractures. However, there does not seem to be a clear association between PPI use and bone mineral density measurements, assessed by dual X-ray absorptiometry. The mechanism by which PPI use increases the risk of fractures remains unclear. This review will summarize the current evidence on this topic.

RÉSUMÉCette étude décrit les tendances de prescrire avant et après la mise en œuvre d'une stratégie provinciale visant à améliorer la prévention de l'ostéoporose et de la fracture dans les foyers de soins de longue durée (SLD) de l'Ontario. Les données ont été obtenues à partir d'une pharmacie qui a fourni pour 10 centres de SLD en 2007 et 166 foyers en 2012. Nos analyses ont utilisés la régression linéaire multiple et pondérée pour examiner les changements dans les niveaux ou les taux de prescriptions dans les établissements pour la vitamine D, le calcium et les médicaments pour l'ostéoporose de 2007 à 2012. Après cinq ans, l'augmentation des taux estimés pour la prescription de vitamine D, calcium et les médicaments pour l'ostéoporose, respectivement, était de 38,2 pour cent, 4 pour cent et 0,2 pour cent. Bien que l'étude n'a pas évalué la causalité, les résultats suggèrent que les activités à grande échelle dans le transfert des connaissances ont effectué des taux ameliorés de la prescription de vitamine D, bien que des efforts continus sont nécessaires pour cibler les foyers don’t les capacités de traduire les connaissances en pratique sont faibles.

The purpose of this study was to explore nurses' perceptions of their current practices related to administering pain medications to long-term care (LTC) residents. A cross-sectional survey design was used, including both quantitative and open-ended questions. Data were collected from 165 nurses (59% response rate) at nine LTC homes in southern Ontario, Canada. The majority (85%) felt that the medication administration system was adequate to help them manage residents' pain and 98% felt comfortable administering narcotics. In deciding to administer a narcotic, nurses were influenced by pain assessments, physician orders, diagnosis, past history, effectiveness of non-narcotics and fear of making dosage miscalculations or developing addictions. Finally, most nurses stated that they trusted the physicians and pharmacists to ensure orders were safe. These findings highlight nurses' perceptions of managing pain medications in LTC and related areas where continuing education initiatives for nurses are needed.

Decreased physical activity levels are an increasing concern, specifically for the aging population. Older adults (>65 years) are able to achieve health benefits from participating in a regular exercise program based on studies done in younger community-dwelling older adults. There is less research investigating the efficacy of exercise for improving physical function among the older adult population in assisted living settings. This study investigated using a treadmill with a harness system, to engage older adults in aerobic exercise. The primary objective of the study was to assess the feasibility of a large trial by evaluating the recruitment and short-term retention rate of older adults with limited mobility. Secondary objectives were to determine whether older adults could achieve the frequency, intensity, and duration of aerobic exercise recommended by the American College of Sports Medicine.

R?SUM?Objectif :Les objectifs de cette ?tude ?taient double : (1) d?explorer les obstacles ? la gestion de la douleur et ceux associ?s ? la mise en ?uvre d?un programme de gestion de la douleur en soins de longue dur?e (SLD) et (2) de d?velopper une approche interprofessionelle afin d?am?liorer la gestion de la douleur en soins de longue dur?e.M?thodes :Une ?tude de cas a inclus tous les deux ?l?ments, quantitatifs et qualitatifs. Nous avons recueilli des donn?es sur deux sites LTC ? l?aide de sept groupes de discussion pour les infirmi?res autoris?es, fournisseurs de soins non r?glement?s, et m?decins, et 10 entretiens avec des autres groupes de fournisseurs de soins de sant?, l?administration et des r?sidents. Nous avons examin? les documents et administr? un sondage ? court aux participants ? l??tude pour ?valuer les perceptions des obstacles ? la gestion de la douleur.R?sultats :Les r?sultats ont r?v?l? des obstacles ? la gestion efficace de la douleur au niveau des soins de longue dur?e des r?sidents et des familles, des fournisseurs de soins de sant?, et des syst?mes de sant?. Nous avons ensuite ?labor? un mod?le ? six niveaux, avec les interventions propos?es pour surmonter ces obstacles.Conclusions :Ce mod?le peut guider le d?veloppement d?approches novatrices pour am?liorer la gestion de la douleur dans les ?tablissements de soins de longue dur?e.

Most low-trauma fractures occur among women with osteopenic bone mineral density (BMD), a population considered to have moderate absolute fracture risk. Our purpose was to refine the fracture risk prediction in women with osteopenic BMD to determine the subgroups at lowest and highest risk.

Normative data for the SF-36 measure of health-related quality of life (HRQOL) exist for those over 25 years of age, based on data from the population-based Canadian Multicentre Osteoporosis Study (CaMos). CaMos recently recruited a sample of young Canadians aged between 16 and 24 years. The purpose of this study was to develop normative SF-36 data for this age group. After direct standardization to the Canadian population, means, standard deviations (SD), 95% confidence intervals and percentage at floor and ceiling were produced for the eight domain and two summary scores of the SF-36. Domains are scored from 0 (poor) to 100 (excellent). Summary scores are standardized to a mean of 50, with scores over 50 representing better than average and below 50 poorer than average function. Separate analyses were completed for men and women, and for those 16–19 years and 20–24 years. The 1,001 community-based participants consisted of 474 men and 527 women from nine CaMos centres across Canada. Mean Physical Component Summary scores were 53.9 (SD=6.9) and 53.3 (SD=5.7) for young men and women, respectively. The equivalent Mental Component Summary scores were 49.3 (SD=9.7) and 48.8 (SD=8.9). In general, men scored somewhat higher than women, and younger (16–19 years) women scored higher than older (20–24 years) women, although the differences were small. HRQOL is good in this cohort of young Canadians. Both men and women scored somewhat better on physically than mentally oriented domains. In general, Canadian scores were similar to those of the US, while a comparable Swedish sample scored higher than both countries on most domains. Results underscore the importance of taking country, age and gender into consideration when using normative data. Des données normatives sur la qualité de vie liée à la santé (QVLS) dans le questionnaire sur l’état de santé SF-36 existent déjà pour les personnes de plus de 25 ans grâce aux données représentatives de l’Étude canadienne multicentrique sur l’ostéoporose (CaMos). La CaMos a recruté récemment un échantillon de jeunes Canadiens âgés de 16 à 24 ans. Le but de notre étude était d’élaborer des données normatives SF-36 pour ce groupe d’âge. Après avoir effectué une standardisation directe à partir de la population canadienne, nous avons calculé les moyennes, les écarts-types (ET), les intervalles de confiance de 95% et le pourcentage minimum et maximum pour les huit domaines et les deux notes globales du SF-36. Les domaines sont notés de 0 (mauvais) à 100 (excellent). Les notes globales sont standardisées selon une moyenne de 50, les notes de plus de 50 indiquant des fonctions supérieures à la moyenne, et les notes de moins de 50, des fonctions inférieures à la moyenne. Nous avons analysé séparément les hommes des femmes, et le groupe des 16 à 19 ans de celui des 20 à 24 ans. Les 1 001 participants sélectionnés dans la communauté comprenaient 474 hommes et 527 femmes des neuf centres CaMos du Canada. Les notes globales moyennes pour la composante santé physique étaient de 53,9 (ET=6,9) et de 53,3 (ET=5,7) pour les jeunes hommes et les jeunes femmes, respectivement. Les notes équivalentes pour la composante santé mentale étaient de 49,3 (ET=9,7) et de 48,8 (ET=8,9). En général, les hommes ont obtenu des notes un peu meilleures que celles des femmes, et les femmes plus jeunes (16 à 19 ans), de meilleures notes que leurs aînées (20 à 24 ans), mais ces différences étaient faibles. La QVLS est bonne dans cette cohorte de jeunes Canadiens. Tant les hommes que les femmes ont obtenu des notes un peu meilleures pour la santé physique que pour la santé mentale. En général, les notes canadiennes étaient semblables à celles des États-Unis, mais un échantillon suédois comparable a obtenu des notes plus élevées que ces deux pays dans la plupart des domaines. Ces résultats soulignent l’importance de tenir compte du pays, de l’âge et du sexe lorsqu’on utilise des données normatives.

Objectives: To determine (a) adherence rates at 6, 9 and 18 months amongst patients receiving teriparatide treatment for severe osteoporosis and (b) causes of therapy discontinuation and the effect of teriparatide on bone mineral density (BMD) in adherent and nonadherent patients at different time intervals.Methods: A retrospective chart review of 111 patients receiving teriparatide from September 2004 to June 2007 was performed. Patients’ self-reports were used to record adherence and causes of nonadherence at 6, 9 and 18 months. BMDs for all patients were measured using the same DXA scanner at baseline and follow up.Results: Of 111 participants, 17 were male (mean age 60 years) and 94 were female (mean age 69 years). Of these, 12 did not initiate therapy and 4 were lost to follow up. Reported adherence was 89.6% at 6 months, 87.6% at 9 months and 74.7% at 18 months. Causes of nonadherence included cost (n= 4), no benefit (n= 1) and adverse events (n= 8). Common adverse events were leg cramps (n= 9), headache (n= 5) and myalgia (n= 4). Mean spine and femur BMD changes were 3.30% and 0.67% at 4—9 months respectively, and 5.39% and 0.77% at 10—18 months respectively.Conclusion: Adherence to teriparatide was almost 90% at 9 months and decreased to 75% at 18 months. Adverse events led to nonadherence in 20% of patients. Those who were nonadherent had lower baseline BMD values than those who were adherent. Changes in BMD at the lumbar spine were greater than changes observed at the femoral neck.

The article focuses on the vertebral compression fractures (VCFs) among older adults in Canada. It claims that VCFs are the hallmark of osteoporosis, yet two-thirds of them remain undiagnosed and untreated. It discusses the adverse outcomes of VCFs. It suggests that strategies to increase clinical diagnosis of VCF include assessment of clinical risk factors and screening patients at risk with dual energy X-ray absorptiometry (DXA).

Background and aims:Previous studies suggest that depression increases risk of falls, low bone mineral density, and fractures. Our aim was to evaluate whether depressive symptomatology alone predicts 5-year clinical fracture risk in older adults. Methods:In this secondary analysis of a community-based, prospective cohort study including 4175 women and 1652 men in Canada, depressive symptomatology was assessed at baseline by the mental health inventory-5 (MHI-5) and the mental component score (MCS) of the short form 36 questionnaire (SF-36). Fracture events were assessed annually for five years; all reported incident fragility fractures were confirmed radiographically. Results:Depressive symptomatology did not predict time to first fracture in men (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.45–1.65) or women (HR 1.09, 95% CI 0.86–1.39). Results were similar after controlling for potential confounders. Depressive symptoms were not significantly associated with baseline bone mineral density at the lumbar spine or femoral neck. Women with depressive symptoms were more likely to report falls in the previous month (odds ratio [OR] 1.52, 95% CI 1.12–2.06, p=0.01). This association did not achieve statistical significance in men (OR 1.71, 95% CI 0.96–3.04, p=0.07). Conclusion:In this large, community cohort, depressive symptomatology did not predict five-year risk of clinical fracture. Further research is needed to determine if individuals with major depressive disorder (MDD) are at higher fracture risk and whether neuroendocrine or hormonal dysregulation might contribute to such risk in MDD.

Patients with cystic fibrosis (CF) are at risk for early bone loss, and demonstrate increased risks for vertebral fractures and kyphosis. A multicenter, randomized, controlled trial was conducted to assess the efficacy, tolerability, and safety of therapy with oral alendronate (FOSAMAX; Merck; Whitehouse Station, NJ) in adults with CF and low bone mass.

We systematically reviewed the literature to determine whether low socioeconomic status is associated with severe hypoglycemia in individuals with type 1 diabetes in developed countries.