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Rationale: The use of “pro re nata” (PRN) medication in patients with behavioral and psychological symptoms of dementia (BPSD) is common but may be a source of inappropriate medication administration. Objective: To identify trends in the administration of PRN medications to inpatients with BPSD. Methods: Retrospective chart audits were completed on inpatients with dementia who had PRN medications prescribed for aggression, agitation, or insomnia. Data collected included age, sex, time of day, day of week, medication used, and dementia diagnosis. Additionally, data regarding administration of ranged doses and concurrent use with regularly prescribed medications of the same class were collected. Results: A total of 170 inpatients with dementia were included. Over 50 346 bed days, 4000 PRNs were administered. Individuals were more likely to receive a PRN if they were younger, shortly after shift change, in the evening, or during the weekend. If a ranged dose is provided they are more likely to receive the higher dose. If they are receiving regularly scheduled medication from the same class, there is risk of double dosing.

To determine whether the reported clinical presentation of tension pneumothorax differs between patients who are breathing unassisted versus receiving assisted ventilation.Animal studies suggest that the pathophysiology and physical signs of tension pneumothorax differ by subject ventilatory status.We searched electronic databases through to October 15, 2013 for observational studies and case reports/series reporting clinical manifestations of tension pneumothorax. Two physicians independently extracted clinical manifestations reported at diagnosis.We identified 5 cohort studies (n = 310 patients) and 156 case series/reports of 183 cases of tension pneumothorax (n = 86 breathing unassisted, n = 97 receiving assisted ventilation). Hypoxia was reported among 43 (50.0%) cases of tension pneumothorax who were breathing unassisted versus 89 (91.8%) receiving assisted ventilation (P0.001). Pulmonary dysfunction progressed to respiratory arrest in 9.3% of cases breathing unassisted. As compared to cases who were breathing unassisted, the adjusted odds of hypotension and cardiac arrest were 12.6 (95% confidence interval, 5.8-27.5) and 17.7 (95% confidence interval, 4.0-78.4) times higher among cases receiving assisted ventilation. One cohort study reported that none of the patients with tension pneumothorax who were breathing unassisted versus 39.6% of those receiving assisted ventilation presented without an arterial pulse. In contrast to cases breathing unassisted, the majority (70.4%) of those receiving assisted ventilation who experienced hypotension or cardiac arrest developed these signs within minutes of clinical presentation.The reported clinical presentation of tension pneumothorax depends on the ventilatory status of the patient. This may have implications for improving the diagnosis and treatment of this life-threatening disorder.

Background Despite a lack of randomized trial evidence, clinicians often suggest that women use a brassiere to reduce poststernotomy pain and discomfort. We tested the effect of women's use of a special (compression) undergarment after sternotomy on pain, discomfort, and functional status. Methods Women (n = 481) having first-time sternotomy in 1 of 10 Canadian centers were randomized to receive the intervention or usual care. Pain and discomfort data (using numeric rating scales) were collected in person while participants were hospitalized. Thereafter, pain, discomfort, and functional status data (using Health Assessment Questionnaire) were collected by standardized telephone interview until 12 postoperative weeks. Results Overall, and until at least 6 weeks postoperatively, fewer women in the intervention than usual care group reported having incision and breast pain and discomfort. Breast pain scores were lower in the intervention than the usual care group at 2 weeks postoperatively ( P = .04), and over time (OR 0.65 [95% CI 0.45-0.94], P = .02). For women discharged within 14 postoperative days, post hoc analyses revealed intervention group patients had a significantly reduced likelihood of breast pain (OR 0.46 [95% CI 0.32-0.66], P P = .01) but not incision pain (OR 0.99 [95% CI 0.72-1.37], P = .95) or discomfort (OR 0.77 [95% CI 0.55-1.02], P = .06). There was no difference between groups in functional status. The effects were not influenced by age or brassiere size. Conclusions Using a supportive undergarment during the early postoperative reduces breast pain. This finding is amplified and extends to include a reduction in breast discomfort, when women are discharged within 14 postoperative days.

Objective Ordinal scales often generate scores with skewed data distributions. The optimal method of analyzing such data is not entirely clear. The objective was to compare four statistical multivariable strategies for analyzing skewed health-related quality of life (HRQOL) outcome data. HRQOL data were collected at 1 year following catheterization using the Seattle Angina Questionnaire (SAQ), a disease-specific quality of life and symptom rating scale. Study Design and Setting In this methodological study, four regression models were constructed. The first model used linear regression. The second and third models used logistic regression with two different cutpoints and the fourth model used ordinal regression. To compare the results of these four models, odds ratios, 95% confidence intervals, and 95% confidence interval widths (i.e., ratios of upper to lower confidence interval endpoints) were assessed. Results Relative to the two logistic regression analysis, the linear regression model and the ordinal regression model produced more stable parameter estimates with smaller confidence interval widths. Conclusion A combination of analysis results from both of these models (adjusted SAQ scores and odds ratios) provides the most comprehensive interpretation of the data.

Surnames have the potential to accurately identify ancestral origins as they are passed on from generation to generation. In this study, we developed and validated a Chinese surname list to define Chinese ethnicity.We conducted a literature review, a panel review, and a telephone survey in a randomly selected sample from a Canadian city in 2003 to develop a Chinese surname list. The list was then validated to data from the Canadian Community Health Survey. Both surveys collected information on self-reported ethnicity and surname.Of the 112,452 people analyzed in the Canadian Community Health Survey, 1.6% were self-reported as Chinese. This was similar to the 1.5% identified by the surname list. Compared with self-reported Chinese ethnicity (reference standard), the surname list had 77.7% sensitivity, 80.5% positive predictive value, 99.7% specificity, and 99.6% negative predictive value. When stratifying by sex and marital status, the positive predictive value was 78.9% for married women and 83.6% for never married women.The Chinese surname list appears to be valid in identifying Chinese ethnicity. The validity may depend on the geographic origins and Chinese dialects in given populations.

Background: The optimal population rate of cardiac catheterization is unknown. One potential way to determine it would be to examine whether there is a population rate beyond which the yield of high-risk coronary artery disease (CAD) does not rise. Methods: Using a detailed clinical registry that captures all patients undergoing cardiac catheterization in Alberta, we determined annual population rates of cardiac catheterization and the corresponding yield of cases of high-risk CAD in each of Alberta9s 17 health regions from 1995 to 2002. Least squares linear regression analysis and hierarchical modelling methods were then used to assess the linear relation between catheterization rates and rates of high-risk CAD. Results: The age-adjusted average rate of cardiac catheterization among men ranged from 404.9 to 638.1 per 100 000 population aged over 20 years. Among women, the average rate ranged from 171.8 to 314.0 per 100 000. For both sexes, increased regional rates of catheterization were associated with a linearly increasing yield of high-risk CAD, with no evidence of a plateau in yield when more procedures were performed. One additional case of high-risk CAD was identified for every 2.5 additional cardiac catheterization procedures performed among men, and for every 3.7 additional procedures performed among women. Interpretation: The increasing yield of patients with high-risk CAD associated with increased regional population rates of cardiac catheterization, together with the absence of a plateau in yield, suggests that Alberta9s population rates of cardiac catheterization are suboptimal to detect people with high-risk CAD.

Background Clinicians who work with women poststernotomy often suggest that they wear a supportive brassiere to ameliorate pain, discomfort, and potential wound complications. There is no empirical evidence that supports this practice. Methods Despite methodological challenges, a clinical trial is currently underway to investigate the efficacy of early use of a novel undergarment after sternotomy. Women (N = 430) having first time sternotomy in 9 Canadian centers will be randomized to receive either the usual care of the institution or early use of a novel undergarment. Follow-up is planned over 12 postoperative weeks. Coprimary outcomes are pain, discomfort, and return to function. Wound healing is a secondary outcome. An economic evaluation substudy is also underway. Conclusions The WREST Study is a unique ongoing trial examining the efficacy of a novel undergarment in reducing women's pain and enhancing their comfort and return to function. The findings of the trial and its economic substudy will enable health care providers to make rational evidence-based clinical decisions regarding women's early care after sternotomy.

Objective. Many consider smoking to be a personal choice for which individuals should be held accountable. We assessed whether there is any evidence of bias against smokers in cardiac care decision-making by determining whether smokers were as likely as non-smokers to undergo revascularization procedures after cardiac catheterization. Design. Prospective cohort study. Subjects and setting. All patients undergoing cardiac catheterization in Alberta, Canada. Main measures. Patients were categorized as current smokers, former smokers, or never smokers, and then compared for their risk-adjusted likelihood of undergoing revascularization procedures (percutaneous coronary intervention or coronary artery bypass grafting) after cardiac catheterization. Results. Among 20406 patients undergoing catheterization, 25.4% were current smokers at the time of catheterization, 36.6% were former smokers, and 38.0% had never smoked. When compared with never smokers (reference group), the hazard ratio for undergoing any revascularization procedure after catheterization was 0.98 (95% CI 0.93–1.03) for current smokers and 0.98 (0.94–1.03) for former smokers. The hazard ratio for undergoing coronary artery bypass grafting was 1.09 (1.00–1.19) for current smokers and 1.00 (0.93–1.08) for former smokers. For percutaneous coronary intervention, the hazard ratios were 0.93 (0.87–0.99) for current smokers and 1.00 (0.94–1.06) for former smokers. Conclusion. Despite potential for discrimination on the basis of smoking status, current and former smokers undergoing cardiac catheterization in Alberta, Canada were as likely to undergo revascularization procedures as catheterization patients who had never smoked.

Dr. Stuart McGill provided an insightful commentary on the issues surrounding the usefulness of reliable clinical tests in the management of patients with spinal pain conditions. In this response, we will address the points raised in the commentary and provide a rationale for the use of reliable tests in the development of clinical decision guides.

OBJECTIVE—Women with ischemic heart disease have poorer outcomes than men and are suggested to have greater risk associated with diabetes. We evaluated the prognosis associated with diabetes, in analyses stratified by sex, to determine whether similar differences are seen in a large unselected cohort of patients. RESEARCH DESIGN AND METHODS—Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), a clinical data collection and follow-up initiative capturing all patients undergoing cardiac catheterization in Alberta, Canada, the relative significance of diabetes on long-term survival in 13,152 men and 4,249 women was evaluated in patients presenting with or without myocardial infarction and according to first treatment received. RESULTS—The 1-year mortality rates were 4.7% and 6.8% in men and women (P < 0.001), 4.1% and 7.4% in nondiabetic and diabetic men (P < 0.001), and 5.8% and 9.6% in nondiabetic and diabetic women, respectively (P < 0.001). The risk-adjusted Cox proportional hazard ratios associated with diabetes in myocardial infarction were 1.03 in men and 1.20 in women. The diabetes hazard ratios for percutaneous coronary intervention were 1.28 in men and 1.40 in women, 1.23 in men and 1.32 in women for bypass surgery, and 1.26 in men and 1.31 in women for medical therapy (P = NS for all diabetes hazard ratio comparisons between men and women). CONCLUSIONS—Hazard ratios quantifying the adverse prognosis associated with diabetes in patients undergoing angiography are consistently higher among women than men, but the differences across sexes are not statistically significant. These slight sex differences noted in the APPROACH registry are similar to previously reported findings and may be clinically important.

Health researchers commonly use logistic regression when profiling health providers. Data from the patients treated by the providers are used to construct models predicting the expected number of outcomes for providers and the ratio of observed to expected outcomes (O/E ratio) used as a risk-adjusted measure of provider performance. Typically, when calculating the standard deviation (SD) of O/E ratios, only O is treated as a random variable. We used the propagation of errors (Pe) to derive a SD estimate that accounted for variability in O and the estimate of E. Using data previously used to profile Canadian cardiac surgery providers, we compared Pe-SD estimates with typical SD (SDT) estimates. The SDT estimates and confidence intervals were always larger than the Pe estimates, most notably when one or more providers treated a large proportion of the patients. This was confirmed using computer simulations. SDT estimates should be abandoned in favor of more sophisticated estimates.

This waitlist-controlled study examined the timing of changes during Mindfulness-Based Cancer Recovery (MBCR), and explored sequential mediated effects through enhanced mindfulness and emotion regulation (ER) in a cancer population.Patients were recruited from the MBCR program waitlist and were either registered for immediate participation (n = 135) or waiting for the next program to begin (n = 76). Participants completed self-report measures of stress symptoms, mood disturbance, mindfulness, and ER (rumination, worry, and experiential avoidance) pre-, mid- and post-MBCR or waiting period.There was a relatively early effect of MBCR on observing, nonjudging, rumination, and worry. All other measures changed later. Early changes in present-focused nonjudgmental awareness, rumination, and worry mediated the effect of MBCR on mindfulness skills such as nonreactivity later on.The constructs of mindfulness and ER may overlap and changes may be mutually facilitative during MBCR. The study informs our understanding of mindfulness and ER as mechanisms of mindfulness-based interventions.

Cardiovascular disease (CVD) is a leading cause of mortality in rheumatoid arthritis (RA). This study systematically reviewed and appraised guidelines and quality indicators (QIs) pertaining to CVD risk management in patients with RA.Four electronic medical databases (Medline, Embase, CINAHL, and Web of Science) and gray literature publications were searched using terms and keywords pertaining to guidelines, QIs, RA, and CVD (RA and general population literature searched). Abstracts were screened for inclusion and rated using the Appraisal of Guidelines for Research and Evaluation II instrument independently by 2 of 3 reviewers.In total, 16,064 abstracts were screened and 808 underwent full-text review. A total of 17 guidelines and 3 QI sets published between 2008 and 2013 were included. A number of consistent themes emerged, including the increased CV risk faced by RA patients and the need to address modifiable risk factors on a regular basis. The role of the multidisciplinary team in risk optimization was also highlighted. Ten guidelines provided recommendations for CVD prevention in patients with RA. Unfortunately, most recommendations lacked the specificity required to determine adherence to the recommendation. Only 4 RA-specific CVD QIs were identified (1 general comorbidity screening, formal CVD risk estimation, exercise, and minimizing steroid use).Regular screening for CVD risk factors is an important part of care in patients with RA. Unfortunately, existing RA-specific CVD QIs do not adequately address risk factor management, and existing guideline recommendations lack specificity for measurement and use in quality improvement initiatives.

The quantity of subarachnoid (SAH) and intraventricular hemorrhage (IVH) occurring in the setting of a ruptured cerebral aneurysm is strongly associated with subsequent complications and poor outcomes. We randomly allocated aneurysmal SAH patients with a modified Fisher score of 4, who had been treated with endovascular coil embolization and ventricular drainage, to receive either 2 mg intraventricular tissue plasminogen activator (TPA) every 12 h (maximum 10 mg) or placebo. Computed tomography scans were performed 12, 48, and 72 h after administration. Primary outcomes included feasibility (enrollment and consent rates), safety (assessed by prospectively screening for complications), and rate of intracranial blood clearance (measured using sequential IVH, modified Graeb, and SAH sum scores). Secondary outcomes included angiographic vasospasm, delayed cerebral ischemia, need for ventriculoperitoneal shunting, and 6-month neurological outcomes. Seventy-seven patients were screened, 17 were eligible, and 12 were randomized. The consent rate was 87 %. There were no cases of new intracranial hemorrhage complicating use of TPA. Models fit using generalized estimating equations demonstrated more rapid reduction in IVH volume (p = 0.009), modified Graeb score (p

Objective To derive a clinical decision guide (CDG) to identify patients best suited for cervical diagnostic facet joint blocks. Design Prospective cohort study. Setting Pain management center. Participants Consecutive patients with neck pain (N=125) referred to an interventional pain management center were approached to participate. Interventions Subjects underwent a standardized testing protocol, performed by a physiotherapist, prior to receiving diagnostic facet joint blocks. All subjects received the reference standard diagnostic facet joint block protocol, namely controlled medial branch blocks (MBBs). The physicians performing the MBBs were blinded to the local anesthetic used and findings of the clinical tests. Main Outcome Measures Multivariate regression analyses were performed in the derivation of the CDGs. Sensitivity, specificity, positive and negative likelihood ratios, and 95% confidence intervals (CIs) were calculated for the index tests and CDGs. Results A CDG involving the findings of the manual spinal examination (MSE), palpation for segmental tenderness (PST), and extension-rotation (ER) test demonstrated a specificity of 84% (95% CI, 77–90) and a positive likelihood ratio of 4.94 (95% CI, 2.8–8.2). Sensitivity of the PST and MSE were 94% (95% CI, 90–98) and 92% (95% CI, 88–97), respectively. Negative findings on the PST were associated with a negative likelihood ratio of .08 (95% CI, .03–.24). Conclusions MSE, PST, and ER may be useful tests in identifying patients suitable for diagnostic facet joint blocks. Further research is needed to validate the CDGs prior to their routine use in clinical practice.

Background Studies of survival of patients with multivessel coronary artery disease (MVD) in the prestent era suggested that outcomes after coronary artery bypass surgery (CABG) are similar to those after percutaneous coronary intervention (PCI) in subsets of coronary severity. The purpose of this study of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) was to examine the association between treatment and survival up to 5 years in patients with MVD enrolled from 1995 through 1998. Methods and Results Data on patient characteristics were obtained at the time of the initial coronary angiography. Survival was determined through data linkage to the provincial Bureau of Vital Statistics. Risk-adjusted hazard ratios were calculated to compare different treatments. In the 11,661 patients with MVD, CABG was the initial therapy in 3782, PCI in 3540, and medical therapy in 4339. Cumulative 5-year survival was 91.4% with CABG, 91.9% with PCI, and 82.9% with medical therapy (P

Purpose: The association between radiotherapy for gynecological carcinoma and sexual dysfunction is well established. Regular vaginal dilation is widely recommended to these women as a way for them to maintain vaginal health and good sexual functioning. However, the compliance rate with this recommendation is low. The purpose of this study was to test the effectiveness of a group psychoeducational program based on the “information-motivation–behavioral skills” model of behavior change in increasing the rate of compliance. Methods and Materials: Thirty-two women with Stage I or II cervical or endometrial carcinoma who were being treated with radiotherapy were randomized and received either the experimental group program or the control intervention that consisted of written information and brief counseling. Outcome measures included global sexual health, knowledge about sexuality and cancer, fears about sexuality after cancer, and vaginal dilation compliance. Results: Younger women attending the experimental program (44.4%) were significantly more likely to follow recommendations for vaginal dilation than those who received the control intervention (5.6%). Women, regardless of age, who received the experimental intervention reported less fear about sex after cancer treatment. The older women who received the experimental intervention gained more sexual knowledge. There was no evidence that the experimental intervention improved global sexual health. Conclusions: This is the first controlled study to provide evidence of an intervention’s effectiveness 1. in increasing women’s vaginal dilation following radiotherapy for gynecological carcinoma and 2. in reducing their fears about sex after cancer. Most women, particularly younger women, are unlikely to follow the recommendation to dilate unless they are given assistance in overcoming their fears and taught behavioral skills.

BACKGROUND Vitamin D deficiency and insufficiency are prevalent worldwide, but relatively few studies have examined vitamin D status in working populations. AIMS To assess the prevalence of vitamin D deficiency and insufficiency in Canadian workers and investigate risk factors in this population. METHODS A cross-sectional study using data from a health programme enrolling workers mostly from Northern Alberta, Canada. As part of the programme, volunteers were invited to complete a lifestyle questionnaire. Blood was taken to determine plasma 25-hydroxyvitamin D (25(OH)D) levels. Logistic and linear regressions were used to investigate the relationships between individual characteristics and vitamin D status. RESULTS Between October 2007 and December 2012, 6101 eligible workers enrolled in the health programme. The prevalence of vitamin D deficiency (plasma 25(OH)D, levels

To compare the diagnostic accuracy of computed tomographic angiography (CTA) with digital subtraction angiography (DSA) for blunt cerebrovascular injury (BCVI) detection in trauma patients.Controversy exists as to whether the diagnostic performance of CTA compares favorably with the reference-standard, DSA.We searched electronic databases (1950 to May 22, 2012), article bibliographies, conference proceedings (2008-2011), and clinical trial registries for studies comparing the accuracy of CTA with DSA for BCVI detection in trauma patients. Pooled estimates of sensitivity, specificity, and positive and negative likelihood ratios were calculated using bivariate random effects models.Eight studies that examined 5704 carotid or vertebral arteries in 1426 trauma patients met inclusion criteria. The pooled sensitivity and specificity for BCVI detection with CTA versus DSA was 66% (95% CI, 49%-79%; I = 80.4%) and 97% (95% CI, 91%-99%; I = 94.6%), respectively. Corresponding pooled positive and negative likelihood ratios were 20.0 (95% CI, 6.9-58.4; I = 87.7%) and 0.35 (95% CI, 0.22-0.56; I = 74.9%), respectively. Although pooled sensitivity varied with the number of available CT slices, the training of interpreting radiologists, and in a pattern suggestive of differences in diagnostic threshold for judging CTA positivity, it remained 80% or less among studies that used scanners with 16 or more slices per rotation and where the CTA was read by neuroradiologists.Existing evidence suggests that the diagnostic performance of CTA varies considerably across studies, likely due to an implicit variation in diagnostic threshold across trauma centers. Moreover, although CTA appears to lack sensitivity to adequately rule out BCVI, it may be useful to rule in BCVI among trauma patients with a high pretest probability of injury.

Background— Contrast-induced acute kidney injury (CI-AKI) has been associated with mortality, although it has been suggested this association may be attributable to confounding. We performed a systematic review and meta-analysis to characterize the associations between CI-AKI and subsequent clinical outcomes. Methods and Results— We identified studies using MEDLINE (1950 to June 2011) and Embase (1980 to June 2011), manual bibliographic searches, and contact with experts. We included observational studies that characterized outcomes among patients with and without AKI (based on changes in serum creatinine) after coronary angiography. Eligible studies reported at least 1 of mortality, cardiovascular events, end-stage renal disease, or length of hospital stay. Thirty-nine observational studies met inclusion criteria. Of 34 studies reporting mortality (including 139 603 participants), 33 reported an increased risk of death in those with CI-AKI, although the effect size varied between studies ( I 2 =93.5%). Between-study heterogeneity was partially explained by whether adjustment for confounding features was performed (11 studies without adjustment; pooled crude risk ratio, 8.19; 95% confidence interval, 4.30–15.60; I 2 =77.3% versus 23 studies with adjustment; pooled adjusted risk ratio, 2.39; 95% confidence interval, 1.98–2.90; I 2 =88.3%). CI-AKI was consistently associated with an increased risk of cardiovascular events in 14 studies, end-stage renal disease in 3 studies, and prolonged hospitalization in 11 studies. Conclusions— CI-AKI is associated with an increased risk of mortality, cardiovascular events, renal failure, and prolonged hospitalization. However, the association between CI-AKI and mortality is strongly confounded by baseline clinical characteristics that simultaneously predispose to both kidney injury and mortality, and the risk attributable to CI-AKI is much lower than that reported from unadjusted studies.

We have devised a new scoring system using visual analogue scales (VAS) to determine the functional outcome in 15 patients with 20 displaced intra-articular calcaneal fractures, confirmed by CT. The average follow-up was 19 months. A VAS was completed separately by the patient, the surgeon and an independent assessor. It showed satisfactory agreement between observers and strong correlations with a General Health Survey (SF36), a pain scale (McGill Pain Questionnaire) and a disease-specific, historical scale for calcaneal fractures (the Rowe score).

Importance Reported prevalence rates of chronic rhinosinusitis (CRS) range from 1% to 12% worldwide. To facilitate appropriate health service delivery and resource allocation, it is important to improve the estimated burden of CRS to the health care system. Objectives To assess the prevalence and incidence of diagnosed CRS in Alberta, Canada, from the perspective of the health care system and to evaluate the 10-year temporal trend and geographic variation of diagnosed CRS. Design, Setting, and Participants From provincial-wide physicians’ claim data, a CRS cohort was identified using a validated case definition. The population at the midpoint (2008-2009) of the study period (2 925 930) was used as the reference. The crude as well as age- and sex-standardized incidence and prevalence rates were calculated. The age-specific incidence and prevalence by sex were also assessed in each study year. Small-area variation analysis was conducted using extremal quotient, weighted coefficient of variation, χ 2 statistic, systematic component of variation, and empirical Bayes variance estimate. Results Of the 2 925 930 individuals in the study at midpoint (2008-2009), 1 451 261 (49.6%) were women, and the mean (SD) age was 45 (17) years. From fiscal year 2004-2005 to fiscal year 2013-2014, the mean age- and sex-standardized incidence of diagnosed CRS was 2.5 (range, 2.3-2.7) per 1000 population. The estimated prevalence based on age-specific incidence varied between 18.8 (95% CI, 18.7-18.9) and 23.3 (95% CI, 23.1-23.5) per 1000 population during 2004-2005 to 2013-2014, and no obvious growing trend was found. There was high geographic variation in the diagnosed incidence and prevalence of CRS (mean systematic component of variation, 19.4 and 12.3, respectively). Conclusions and Relevance Although the incidence and prevalence rates of diagnosed CRS were lower compared with earlier published estimates obtained from population-based survey analysis, outcomes from this study may more accurately reflect the disease burden of CRS to the health care system. Given that the prevalence of CRS within a single province is expected to be uniformly distributed, the large geographic variation in diagnosed CRS indicates a potential gap in quality of care and justifies further investigation into the reasons for the variation.

Objective. In addition to the need for good measurement tools in occupational therapy, there is a need for the tools to be used knowledgeably. The purpose of this article is to investigate the usefulness of the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) for both descriptive (diagnostic) and evaluative (change over time) purposes. Method. The typical profile of subtest scores for children with mild motor problems revealed that certain subtests of the BOTMP may be better indicators of motor problems for these children than others. An analysis also was performed to compare the use of raw (point) scores with standard (age-adjusted) scores in evaluating change. Results. Four subtests that provide a greater degree of discrimination between children with and without motor problems were identified. Raw (points) scores were found to provide a more valid measure of change over time than standard (age-related) scores. Conclusion. We recommend that, for clinical use, the BOTMP subtest standard scores be used for diagnostic purposes and that the raw scores be used for evaluative purposes.

Objective To measure the intra- and interrater reliability of select standardized clinical tests used for the assessment of patients with axial neck pain referred for diagnostic facet joint blocks. Design Single-group, repeated-measures study. Setting Tertiary interventional pain management center. Participants Consecutive patients with persistent neck pain, referred to a tertiary interventional pain management center, were approached to participate. Fifty-six patients consented to participate in the study. Interventions Subjects underwent a standardized clinical testing protocol, performed by 2 physiotherapists, before receiving diagnostic facet joint blocks. Subjects were examined twice by 1 assessor for the determination of the intrarater reliability of the testing protocol, and again by a second assessor for determination of interrater reliability. Main Outcome Measures Intraclass correlation coefficients (ICCs), kappa coefficients, and 95% confidence intervals were calculated to determine the intra- and interrater reliability for cervical range of motion (ROM; 6 directions), extension-rotation (ER) test, manual spinal examination (MSE), and palpation for paraspinal tenderness (PST) from C2 through C7. Results For intrarater reliability, kappa coefficients ranged from .51 to .88 for the ER test, MSE, and PST, and ICCs ranged from .91 to .97 for ROM. For interrater reliability, kappa coefficients ranged from .74 to .96 for the ER test, MSE, and PST, and ICCs ranged from .90 to .95 for ROM. Conclusions The standardized clinical tests exhibited moderate to substantial reliability in patients with axial neck pain referred for diagnostic facet joint blocks. The data justify the incorporation of these tests into a clinical prediction model to screen patients before referral for diagnostic facet blocks.

Background It has been suggested that more-complex fibrillation requires higher energy shocks to terminate. Furthermore, animal studies have demonstrated that shock timing also plays a role. The objective of this study was to test these assertions in a clinical context. Methods Near- and far-field electrograms were collected during defibrillation threshold testing. Fibrillation complexity was measured by quantifying the organization in the signals with wavelet-based methods, scaling exponent, and cross-correlation analysis. Receiver operator characteristic curves were used to determine predictive value. The effect of the phase at which defibrillation shocks were applied was also determined. Results No measure was able to classify whether a particular shock would be successful. All performed very poorly. Shock timing played no role in defibrillation outcome. Conclusions Signal organization of a local electrogram and phase of shock delivery do not relate to minimum defibrillation shock energy immediately after ventricular fibrillation onset.

Context Older patients with coronary artery disease often experience depressive symptoms and are vulnerable to developing cognitive impairment. Whether depressive symptoms increase their risk of cognitive decline is unknown. Objectives To examine the association between the stability of depressive symptoms and cognitive decline for 30 months among patients undergoing coronary angiography and to explore whether any observed associations were modified by the presence of the apolipoprotein E (APOE)e4 allele. Design Cohort study. Setting Urban tertiary care hospital serving southern Alberta. Participants Three hundred fifty patients 60 years or older (73.7% male) undergoing nonemergent catheterization (October 27, 2003, through February 28, 2007) without prior revascularization. We compared a baseline measure of depressive symptoms (Geriatric Depression Scale score≥5) with a dynamic measure capturing change from baseline to 12 months. Main Outcome Measures Mean change in domain (z scores for attention/executive function, learning/memory, and verbal fluency) and global (raw Mini-Mental State Examination) cognitive scores from baseline to 6, 12, and 30 months and from 12 to 30 months. Results In adjusted models, participants with persistent depressive symptoms (at baseline and≥1follow-up visit) showed significantly greater declines at 30 months in attention/executive function (mean z score change,−0.22), learning/memory (−0.19), verbal fluency (−0.18), and global cognition (mean Mini-Mental State Examination [MMSE] score change,−0.99) compared with participants with no or baseline-only depressive symptoms. Persistent depressive symptoms were associated with significantly greater declines in all cognitive measures from 12 to 30 months after adjusting for sociodemographic and clinical factors. For global cognition, a significantly greater decline was evident for patients with persistent depressive symptoms and the APOEe4 allele (mean MMSE score change,−2.93 [95% CI,−4.40 to−1.45]). Conclusions Depressive symptoms persist in some patients with coronary artery disease, placing them at a greater risk for cognitive decline. Whether this decline is additionally modified by the presence of APOEe4 requires further investigation.

Summary The objective of this study was to develop and validate coding algorithms for epilepsy using ICD-coded inpatient claims, physician claims, and emergency room (ER) visits. 720/2049 charts from 2003 and 1533/3252 charts from 2006 were randomly selected for review from 13 neurologists’ practices as the “gold standard” for diagnosis. Epilepsy status in each chart was determined by 2 trained physicians. The optimal algorithm to identify epilepsy cases was developed by linking the reviewed charts with three administrative databases (ICD 9 and 10 data from 2000 to 2008) including hospital discharges, ER visits and physician claims in a Canadian health region. Accepting chart review data as the gold standard, we calculated sensitivity, specificity, positive, and negative predictive value for each ICD-9 and ICD-10 administrative data algorithm (case definitions). Of 18 algorithms assessed, the most accurate algorithm to identify epilepsy cases was “2 physician claims or 1 hospitalization in 2 years coded” (ICD-9 345 or G40/G41) and the most sensitive algorithm was “1 physician clam or 1 hospitalization or 1 ER visit in 2 years.” Accurate and sensitive case definitions are available for research requiring the identification of epilepsy cases in administrative health data.

Vasovagal syncope is a common problem associated with a poor quality of life, which improves when the frequency of syncope is reduced. Effective pharmacological therapies for vasovagal syncope have been elusive. Midodrine is a pro-drug whose primary metabolite is an alpha-1 adrenoreceptor agonist. A few studies have suggested that it may be beneficial in syncope, but all have had significant methodological limitations. A placebo-controlled clinical trial of midodrine for the prevention of vasovagal syncope is needed. The prevention of syncope trial IV (POST 4) is a multicenter, international, randomized, placebo-controlled study of midodrine in the prevention of vasovagal syncope. The primary end point is the time to first recurrence of syncope. Patients will be randomized 1:1 to receive midodrine 10–30 mg/day or matching placebo, and followed for 1 year. Secondary end points include syncope frequency, presyncope, and quality of life. Primary analysis will be performed with an intention-to-treat approach, with a secondary on-treatment analysis. A total sample size of 112, split equally between the two groups, achieves 85 % power to detect a 50 % relative risk reduction when the event rates are 55 and 27.5 % in the placebo and midodrine arms. Allowing for 20 % dropout, we propose to enroll 140 patients. POST 4 is registered with http://www.clinicaltrials.gov (NCT01456481). This study will be the first adequately powered trial to determine whether midodrine is effective in preventing vasovagal syncope. If it is effective, then midodrine may become the first-line pharmacological therapy for this condition.

BackgroundThere is variation in cardiac catheterization utilization across jurisdictions. Previous work from Alberta, Canada, showed no evidence of a plateau in the yield of high-risk disease at cardiac catheterization rates as high as 600 per 100,000 population suggesting that the optimal rate is higher. This work aims 1) To determine if a previously demonstrated linear relationship between the yield of high-risk coronary disease and cardiac catheterization rates persists with contemporary data and 2) to explore whether the linear relationship exists in other jurisdictions.MethodsDetailed clinical information on all patients undergoing cardiac catheterization in 3 Canadian provinces was available through the Alberta Provincial Project for Outcomes Assessment in Coronary Heart (APPROACH) disease and partner initiatives in British Columbia and Nova Scotia. Population rates of catheterization and high-risk coronary disease detection for each health region in these three provinces, and age-adjusted rates produced using direct standardization. A mixed effects regression analysis was performed to assess the relationship between catheterization rate and high-risk coronary disease detection.ResultsIn the contemporary Alberta data, we found a linear relationship between the population catheterization rate and the high-risk yield. Although the yield was slightly less in time period 2 (2002-2006) than in time period 1(1995-2001), there was no statistical evidence of a plateau. The linear relationship between catheterization rate and high-risk yield was similarly demonstrated in British Columbia and Nova Scotia and appears to extend, without a plateau in yield, to rates over 800 procedures per 100,000 population.ConclusionsOur study demonstrates a consistent finding, over time and across jurisdictions, of linearly increasing detection of high-risk CAD as population rates of cardiac catheterization increase. This internationally-relevant finding can inform country-level planning of invasive cardiac care services.

Controlling escalating costs of hip (THA) and knee arthroplasty (TKA) without compromising quality of care has created the need for innovative system reorganization to inform sustainable solutions.The purpose of this study was to inform estimates of the value of THA and TKA by determining: (1) the data sources data required to obtain costs across the care continuum; (2) the data required for different analytical perspectives; and (3) the relative costs across the continuum of care.Within the context of a pragmatic randomized controlled trial comparing alternative care pathways, we captured healthcare resource use: (1) 12 months before surgery; (2) inpatient; (3) acute recovery; and (4) long-term recovery 3 and 12 months postsurgery. We established a standardized costing model to reflect both the healthcare payer and patient perspectives.Multiple data sources from regional health authorities, administrative databases, and patient questionnaire were required to estimate costs across the care continuum. Inpatient and acute care costs were approximately 60% of the total with the remaining 40% incurred 12 months presurgery and 12 months postsurgery. Regional health authorities bear close to 60%, and patient costs are approximately 30% of the mean total costs, most of which were incurred after the acute inpatient stay.To fully understand the value of an orthopaedic intervention such as THA and TKA, a broader perspective than one limited to the payer should be considered using a standardized measurement framework over a relevant time horizon and from multiple viewpoints to reflect the substantial patient burden and support sustainable improvement over the care continuum.Level III, economic and decision analyses study. See Guidelines for Authors for a complete description of levels of evidence.

Background In order to reduce the delays encountered through patient transfer, regional care models have been developed that directly transport subsets of acute myocardial infarction (AMI) patients to hospitals with percutaneous coronary intervention (PCI) facilities. Calgary is a Canadian city that implemented this type of model in 2004. Methods The study population included 9768 AMI patients admitted to Calgary hospitals between 1997 and 2007. Administrative data were used to define patients who were directly admitted to the PCI hospital and those transferred there after initial admission to a hospital without specialized cardiac care. The differences in clinical characteristics and mortality trends of patients grouped by hospital delivery site and transfer practice are described. Results The proportion of patients directly admitted to a PCI hospital has increased with the implementation of a regional care model. Among patients admitted to non-PCI facilities, the patients who are transferred are younger, more likely to be male, have a shorter length of stay, and have lower proportions of several comorbid conditions. The risk-adjusted in-hospital mortality odds ratio for patients who received care at the PCI hospital postmodel relative to those treated at non-PCI hospitals premodel was 0.38 (95% confidence interval, 0.31-0.47). The corresponding adjusted odds ratio was 0.60 (0.47-0.76). Conclusions Our results suggest changing care over time and trends toward improved outcomes. Patients' clinical characteristics appear to play a major role in the decision to transfer. Avoidance of the risk treatment paradox through refinement of regional transfer protocols ought to be a priority.

Dietary patterns, rather than intakes of specific foods or nutrients, may influence risk of endometrial cancer (EC). This population-based case-control study in Canada (2002-2006) included incident EC cases (n = 506) from the Alberta Cancer Registry and controls frequency age-matched to cases (n = 981). Past-year dietary patterns were defined using factor analysis of food frequency questionnaire data. Logistic regression was used to estimate EC risk within quartiles of dietary patterns. Three patterns (sweets, meat, plants) explained 23% of the variance in the dietary data. In multivariable models, EC risk was significantly reduced by 30% for women in the highest quartile of the healthier plants pattern (OR = 0.70, 95% CI 0.50-0.98, P trend = 0.02). When stratified by body mass index (BMI; kg/m(2)), risk was further reduced among overweight or obese women with a BMI ≥25 (OR = 0.57, 95% CI 0.39-0.83; P trend = 0.004). EC was not associated with the less healthy sweets and meat patterns. However, risk was modestly, but not significantly, elevated for higher intakes of the meat pattern among overweight or obese women. A mostly plant-based dietary pattern may reduce EC risk. Recommendations for risk reduction should focus on maintaining a healthy weight and the role of diet should be studied further.

The aim of the study was to assess the use of the centre-edge (CE) angle in the assessment of pincer femoro-acetabular impingement (FAI) for reliability and predictability in the diagnosis.Between 2004 and 2008, 55 patients underwent surgical treatment for FAI. A control group of 30 was identified among patients attending the emergency department with normal radiographs. Radiographs were assessed by two independent observers both before and after the operation. Nine patients with trauma were excluded. The magnetic resonance arthrogram reports of the remaining 46 patients were assessed for pincer FAI. Nineteen patients were identified and underwent repeat radiographic assessment. All underwent surgical dislocation of hip (SDH), acetabular, with/without femoral osteochondroplasty. Acetabular depth and version were also assessed. The intraclass correlation (ICC) was used to assess reliability of the CE angle. The paired t test and independent groups t test were used to assess the difference between the pincer FAI group, both pre-op and post-op and against controls.The control and pincer groups were similar in demographics (p=0.1769). Coxa profunda was present in 14 patients with eight also having retroverted acetabuli. Of the rest two had retroverted acetabuli and one protrusio. The mean CE angle in the control group was 31.4°, in the pre-op pincer group 46.2° and in the post-op pincer group 38.3°. The ICC for intra-observer correlation was 0.977 and 0.992 pre-op and 0.986 and 0.974 post-op. The ICC for inter-observer correlation was 0.960 and 0.957 pre-op and 0.979 and 0.967 post-op.The p value was0.001 between the controls, the pre-op and post-op pincer groups. The test characteristics using the CE angle ≥ 40 is a reasonably good predictor of FAI, with a sensitivity of 84.2% and a specificity of 100%.The pincer FAI can be reliably assessed with the CE angle and can be predicted in patients presenting with FAI.

Background The effectiveness of various solutions instilled into the central venous catheter lumens after each hemodialysis session (catheter locking solutions) to decrease the risk of catheter malfunction and bacteremia in patients undergoing hemodialysis is unknown. Methods We randomly assigned 225 patients undergoing long-term hemodialysis in whom a central venous catheter had been newly inserted to a catheter-locking regimen of heparin (5000 U per milliliter) three times per week or recombinant tissue plasminogen activator (rt-PA) (1 mg in each lumen) substituted for heparin at the midweek session (with heparin used in the other two sessions). The primary outcome was catheter malfunction, and the secondary outcome was catheter-related bacteremia. The treatment period was 6 months; treatment assignments were concealed from the patients, investigators, and trial personnel. Results A catheter malfunction occurred in 40 of the 115 patients assigned to heparin only (34.8%) and 22 of the 110 patients assigned to rt-PA (20.0%) — an increase in the risk of catheter malfunction by a factor of almost 2 among patients treated with heparin only as compared with those treated with rt-PA once weekly (hazard ratio, 1.91; 95% confidence interval [CI], 1.13 to 3.22; P = 0.02). Catheter-related bacteremia occurred in 15 patients (13.0%) assigned to heparin only, as compared with 5 (4.5%) assigned to rt-PA (corresponding to 1.37 and 0.40 episodes per 1000 patient-days in the heparin and rt-PA groups, respectively; P = 0.02). The risk of bacteremia from any cause was higher in the heparin group than in the rt-PA group by a factor of 3 (hazard ratio, 3.30; 95% CI, 1.18 to 9.22; P = 0.02). The risk of adverse events, including bleeding, was similar in the two groups. Conclusions The use of rt-PA instead of heparin once weekly, as compared with the use of heparin three times a week, as a locking solution for central venous catheters significantly reduced the incidence of catheter malfunction and bacteremia. (Funded by Hoffmann–La Roche; Current Controlled Trials number, ISRCTN35253449.)

Background— Acute kidney injury (AKI) is associated with early mortality after percutaneous coronary revascularization procedures, but its prognostic relevance to long-term clinical outcomes remains controversial. Methods and Results— We conducted a retrospective study of 14 782 adults who received coronary angiography in the province of Alberta, Canada, between 2004 and 2006. AKI was identified on the basis of changes in serum creatinine concentration within 7 days of the procedure according to AKI Network criteria. The associations between AKI and long-term outcomes, including mortality, end-stage renal disease, and cardiovascular and renal hospitalizations, were studied with the use of Cox regression of multiple failure times. The adjusted risk of death increased with increasing severity of AKI; compared with no AKI, the adjusted hazard ratio for death was 2.00 (95% confidence interval, 1.69 to 2.36) with stage 1 AKI and 3.72 (95% confidence interval, 2.92 to 4.76) with stage 2 or 3 AKI. The adjusted risk of end-stage renal disease requiring renal replacement therapy also increased according to the severity of AKI (hazard ratio, 4.15 [95% confidence interval, 2.32 to 7.42] and 11.74 [95% confidence interval, 6.38 to 21.59], respectively), as did the risks of subsequent hospitalizations for heart failure and acute renal failure. Conclusions— These findings inform the controversy surrounding AKI after angiography, demonstrating that it is a significant risk factor for long-term mortality, end-stage renal disease, and hospitalization for cardiovascular and renal events after coronary angiography.

This prospective observational study of 499 patients with hip resurfacing and 255 patients with total hip arthroplasty compared outcomes for 2 years. We used propensity scores to identify matched cohorts of 118 patients with hip resurfacing and 118 patients with total hip arthroplasty. We used these cohorts to compare improvements in the Western Ontario and McMaster University (WOMAC) osteoarthritis index and Medical Outcomes Short-Form 36 physical function component (SF-36 PF) scores at 3 months and at 1 and 2 years postsurgery. Both groups demonstrated significant improvements from baseline in WOMAC and SF-36 PF. Improvements in SF-36 PF were greater for patients with hip resurfacing than for patients with total hip arthroplasty 1 and 2 years postsurgery; improvements in WOMAC were similar for both groups. The clinical significance of this observation needs further investigation.

Background Whether the benefits observed with cardiac resynchronization therapy (CRT) are similar in patients with versus those without atrial fibrillation (AF) is unclear. Furthermore, whether patients with AF receiving CRT should undergo atrioventricular nodal (AVN) ablation remains uncertain. Objective The purpose of this study was to compare outcomes in patients with and those without AF receiving CRT and to evaluate the influence of AVN ablation on outcomes in patients with AF. Methods A systematic review and meta-analysis was performed. Outcomes included death, CRT nonresponse, and changes in left ventricular (LV) remodeling, quality of life (QoL), and 6-minute hall walk distance (6MWD). Results Twenty-three observational studies were included and followed a total of 7,495 CRT recipients, 25.5% with AF, for a mean of 33 months. AF was associated with an increased risk of nonresponse to CRT (34.5% vs 26.7%; pooled relative risk [RR] 1.32; 95% confidence interval [CI] 1.12, 1.55; P = .001)) and all-cause mortality (10.8% vs 7.1% per year, pooled RR 1.50, 95% CI 1.08, 2.09; P = .015). The presence of AF was also associated with less improvement in QoL, 6-minute hall walk distance, and LV end-systolic volume but not LV ejection fraction. Among patients with AF, AVN ablation appeared favorable with a lower risk of clinical nonresponse (RR 0.40; 95% CI 0.28, 0.58; P Conclusion The benefits of CRT appear to be attenuated in patients with AF. The presence of AF is associated with an increased risk of clinical nonresponse and death than in patients without AF. AVN ablation may improve CRT outcomes in patients with AF.

Background Previous studies evaluated cardiac procedure use and outcome over the short term, with relatively few Asian patients included. Objectives To determine the likelihood of undergoing percutaneous coronary intervention and coronary artery bypass grafting, and survival during 10.5 years of follow-up after coronary angiography among South Asian, Chinese and other Canadian patients. Methods Using prospective cohort study data from two large Canadian provinces, 3061 South Asian, 1473 Chinese and 77,314 other Canadian patients with angiographically proven coronary artery disease from 1995 to 2004 were assessed, and their revascularization and mortality rates during 10.5 years of follow-up were determined. Results Compared with other Canadian patients, South Asian and Chinese patients were slightly less likely to undergo revascularization (risk-adjusted HR 0.94, 95% CI 0.90 to 0.98 for South Asian patients; and HR 0.94, 95% CI 0.88 to 1.00 for Chinese patients). However, South Asian patients underwent coronary artery bypass grafting (HR 1.00, 95% CI 0.94 to 1.07) and Chinese patients underwent percutaneous coronary intervention (HR 0.96, 95% CI 0.89 to 1.04) as frequently as other Canadian patients. Although the 30-day mortality rate was similar across the three ethnic groups, the mortality rate in the follow-up period was significantly lower for South Asian patients (HR 0.76, 95% CI 0.61 to 0.95) and marginally lower for Chinese patients (HR 0.80, 95% CI 0.60 to 1.07) compared with other Canadian patients. Conclusions South Asian and Chinese patients used revascularization slightly less but had better survival outcomes than other Canadian patients. The factors underlying the better outcomes for South Asian and Chinese patients warrant further study.

The Clinical Observations of Motor and Postural Skills (COMPS) is a screening tool for children with motor incoordination. A study of reliability (test-retest, interrater, and internal consistency) and construct validity with 132 children, both with and without developmental coordination disorder, is reported here. Test-retest reliability over 2 weeks was high: .92 for a group of 48 children. Interrater reliability for occupational therapists experienced in pediatrics was also excellent: .87 for a group of 72 children. Internal consistency of the COMPS was high, particularly when one of the seven items (Schilder’s arm extension) was deleted. The test discriminates well between children with and without motor problems and has many properties of a good screening test.

Although test-retest reliability of the Southern California Postrotary Nystagmus Test (SCPNT) with normal children is reported in the literature as high, there is more variability in response and lower reliability when the lest is used with learning or motor disabled children. As part of another study, 69 children (aged 5 to 9 years) with motor coordination problems were administered the SCPNT on multiple occasions. Test-retest reliability ranged from .64 to .79 (ICC) when the same tester administered both tests, but was very low when different testers were used (.12 and .17). There was no difference in test-retest reliability between children who had an average degree of excursion and those with barely perceptible excursion. Implications for the use of the test are discussed.

Controversy surrounds the use of sensory integration (SI) treatment for children with motor difficulties and learning disabilities. The efficacy of 75 sessions of individual SI therapy was compared to equal amounts of individual tutoring with 29 subjects, ages 5-9 years. Assessments by people blind to group assignment occurred at pre-test and after 6 and 12 months of treatment, using academic, motor and behavioral measures. Non significant differences were noted between the two treatment groups after 6 or 12 months of treatment. The fact that the SI group improved as much in reading and other academic measures as the tutoring group who received extensive work in those areas supports the theory that SI may be as effective as tutoring in improving academic functioning. Tutoring, however, was effective as SI in improving motor functioning, which was unexpected.

Although obstructive sleep apnoea (OSA) has been linked to insulin resistance and glucose intolerance, it is unclear whether there is an independent association between OSA and diabetes mellitus (DM) and whether all patients with OSA are at risk. The objective of this study was to determine the association between OSA and DM in a large cohort of patients referred for sleep diagnostic testing.A cross-sectional analysis of participants in a clinic-based study was conducted between July 2005 and August 2007. DM was defined by self-report and concurrent use of diabetic medications (oral hypoglycaemics and/or insulin). Sensitivity analysis was performed using a validated administrative definition of diabetes. OSA was defined by the respiratory disturbance index (RDI) using polysomnography or ambulatory monitoring. Severe OSA was defined as an RDIor = 30/h. Subjective sleepiness was defined as an Epworth Sleepiness Scale scoreor = 10.Complete data were available for 2149 patients. The prevalence of DM increased with increasing OSA severity (p0.001). Severe OSA was associated with DM following adjustment for patient demographics, weight and neck circumference (odds ratio (OR) 2.18; 95% CI 1.22 to 3.89; p0.01). Following a stratified analysis, this relationship was observed exclusively in sleepy patients (OR 2.59 (95% CI 1.35 to 4.97) vs 1.16 (95% CI 0.31 to 4.37) in non-sleepy patients).Severe OSA is independently associated with DM in patients who report excessive sleepiness. Future studies investigating the impact of OSA treatment on DM may wish to focus on this patient population.

Background Observational outcome studies of patients with obstructive sleep apnea (OSA) require adjustment for co-morbidity to produce valid results. The aim of this study was to evaluate whether the combination of administrative data and self-reported data provided a more complete estimate of co-morbidity among patients referred for sleep diagnostic testing. Methods A retrospective observational study of 2149 patients referred for sleep diagnostic testing in Calgary, Canada. Self-reported co-morbidity was obtained with a questionnaire; administrative data and validated algorithms (when available) were also used to define the presence of these co-morbid conditions within a two-year period prior to sleep testing. Results Patient self-report of co-morbid conditions had varying levels of agreement with those derived from administrative data, ranging from substantial agreement for diabetes (κ = 0.79) to poor agreement for cardiac arrhythmia (κ = 0.14). The enhanced measure of co-morbidity using either self-report or administrative data had face validity, and provided clinically meaningful trends in the prevalence of co-morbidity among this population. Conclusion An enhanced measure of co-morbidity using self-report and administrative data can provide a more complete measure of the co-morbidity among patients with OSA when agreement between the two sources is poor. This methodology will aid in the adjustment of these coexisting conditions in observational studies in this area.

Background:The Alberta Hip and Knee Replacement Project developed a new evidence-based clinical pathway (NCP) for total hip (THR) and knee (TKR) replacement. The aim was to facilitate the delivery of services in a timely and cost-effective manner while achieving the highest quality of care for the patient across the full continuum of care from patient referral to an orthopedic surgeon through surgery, recovery, and rehabilitation. The purpose of this article is to provide an overview of the study design, rationale, and execution of this project as a model for health technology assessment based on comparative effectiveness of alternative clinical pathways.Methods:A pragmatic randomized controlled trial study design was used to evaluate the NCP compared with the standard of care (SOC) for these procedures. The pragmatic study design was selected as a rigorous approach to produce high quality evidence suitable for informing decisions between relevant interventions in real clinical practice. The NCP was evaluated in three of the nine regional health authorities (RHAs) in Alberta with dedicated central intake clinics offering multidisciplinary care teams, constituting 80 percent of THR and TKR surgeries performed annually in Alberta. Patients were identified in the offices of twenty orthopedic surgeons who routinely performed THR or TKR surgeries. Evaluation outcome measures were based on the six dimensions of the Alberta Quality Matrix for Health (AQMH): acceptability, accessibility, appropriateness, effectiveness, efficiency and safety. Data were collected prospectively through patient self-completed questionnaires at baseline and 3 and 12 months after surgery, ambulatory and inpatient chart reviews, and electronic administrative data.Results:The trial design was successful in establishing similar groups for rigorous evaluation. Of the 4,985 patients invited to participate, 69 percent of patients consented. A total of 3,434 patients were randomized: 1,712 to SOC and 1,722 to the NCP. The baseline characteristics of patients in the two study arms, including demographics, comorbidity as measured by CDS and exposure to pain medications, and health-related quality of life, as measured by Western Ontario and McMaster Universities Osteoarthritis Index and Short Form-36, were similar.Conclusions:The Alberta Hip and Knee Replacement Project demonstrates the feasibility and advantages of applying a pragmatic randomized controlled trial to ascertain comparative effectiveness. This is a model for health technology assessment that incorporates how clinical pathways can be effectively evaluated.