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OBJECTIVE: Ischemic cardiovascular disease is the leading cause of death in Canada. In ST elevation myocardial infarction (STEMI), time to reperfusion is a key determinant in reducing morbidity and mortality with percutaneous coronary intervention (PCI) being the preferred reperfusion strategy. Where PCI is available, delays to definitive care include times to electrocardiogram (ECG) diagnosis and cardiovascular laboratory access. In 2004, the Cardiac Care Network of Ontario recommended implementation of an emergency department (ED) protocol to reduce reperfusion time by transporting patients with STEMI directly to the nearest catheterization laboratory. The model was implemented in Frontenac County in April 2005. The objective of this study was to assess the effectiveness of a protocol for rapid access to PCI in reducing door-to-balloon times in STEMI. METHODS: Two 1-year periods before and after implementation of a rapid access to PCI protocol (ending March 2005 and June 2006, respectively) were studied. Administrative databases were used to identify all subjects with STEMI who were transported by regional emergency medical services (EMS) and received emergent PCI. The primary outcome measure was time from ED arrival to first balloon inflation (door-to-balloon time). Times are presented as medians and interquartile ranges (IQRs). Statistical comparisons were made using the Mann-Whitney U test and presented graphically with Kaplan-Meier curves. RESULTS: Patients transported under the rapid access protocol (n = 39) were compared with historical controls (n = 42). Median door-to-balloon time was reduced from 87 minutes (IQR 67-108) preprotocol to 62 minutes (IQR 40-80) postprotocol (p < 0.001). CONCLUSION: In our region, implementation of an EMS protocol for rapid access to PCI significantly reduced time to reperfusion for patients with STEMI. [ABSTRACT FROM AUTHOR]

This report describes the occurrence of pneumonitis in a young male immediately after inhalation of aerosolized chemicals subsequent to motor vehicle airbag deployment. The clinical presentation was one of mild shortness of breath associated with bilateral alveolar infiltrates on chest radiology. Not previously described, this diagnosis should be considered in the differential of pulmonary infiltrates in motor vehicle crash patients. [ABSTRACT FROM AUTHOR]

Objective: Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes.Research Design and Methods: A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient's visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both.Results: Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA1c (A1C) with feedback + reminders (deltaA1C 0.6%, final A1C 7.46%) were significantly better than control (deltaA1C 0.2%, final A1C 7.84%, P < 0.02); changes were smaller with feedback only and reminders only (P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P < 0.001).Conclusions: Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings. [ABSTRACT FROM AUTHOR]

Objective: Age, BMI, and race/ethnicity are used in National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and American Diabetes Association (ADA) guidelines to prompt screening for pre-diabetes and diabetes, but cutoffs have not been evaluated rigorously.Research Design and Methods: Random plasma glucose (RPG) was measured and 75-g oral glucose tolerance tests were performed in 1,139 individuals without known diabetes. Screening performance was assessed by logistic regression and area under the receiver operating characteristic curve (AROC).Results: NIDDK/ADA indicators age >45 years and BMI >25 kg/m(2) provided significant detection of both diabetes and dysglycemia (both AROCs 0.63), but screening was better with continuous-variable models of age, BMI, and race and better still with models of age, BMI, race, sex, and family history (AROC 0.78 and 0.72). However, screening was even better with RPG alone (AROCs 0.81 and 0.72). RPG >125 mg/dl could be used to prompt further evaluation with an OGTT.Conclusions: Use of age, BMI, and race/ethnicity in guidelines for screening to detect diabetes and pre-diabetes may be less important than evaluation of RPG. RPG should be investigated further as a convenient, inexpensive screen with good predictive utility. [ABSTRACT FROM AUTHOR]

Objective: To describe the associations between the socioeconomic status of emergency department (ED) users and age, sex, and acuity of medical conditions to better understand users' common characteristics, and to better meet primary and ambulatory health care needs., Design: A retrospective, observational, population-based analysis. A rigorous proxy of socioeconomic status was applied using census-based methods to calculate a relative deprivation index., Setting: Ontario., Participants: All Ontario ED visits for the fiscal year April 1, 2008, to March 31, 2009, from the National Ambulatory Care Reporting System data set., Main Outcome Measures: Emergency department visits were ranked into deprivation quintiles, and associations between deprivation and age, sex, acuity at triage, and association with a primary care physician were investigated., Results: More than 25% of ED visits in Ontario were from the most deprived population; almost half of those (12.3%) were for conditions of low acuity. Age profiles indicated that a large contribution to low-acuity ED visits was made by young adults (aged 20 to 30 years) from the most deprived population. For the highest-volume ED in Ontario, 94 of the 499 ED visits per day were for low-acuity patients from the most deprived population. Most of the highest volume EDs in Ontario (more than 200 ED visits per day) follow this trend., Conclusion: Overall input into EDs might be reduced by providing accessible and appropriate primary health care resources in catchment areas of EDs with high rates of low-acuity ED visits, particularly for young adults from the most deprived segment of the population.

Background: Medication history forms completed by patients are an essential part of the medication reconciliation process., Objective: In a crossover prospective study, investigators compared the accuracy and acceptability of a "fill-in-the blank" medication history form (USUAL) to a customized form (CUSTOM) that contained a checklist of the 44 most frequently prescribed diabetes clinic medications., Methods: The content of both forms was compared to a "gold-standard" medication list compiled by a clinical pharmacist who conducted a medication history and reviewed pharmacy profiles and medical chart. Subject preference and time to complete the forms were also determined. Accurate was defined as complete and correct (name, dose, and frequency) relative to the gold standard., Results: A total of 77 subjects completed both forms. Complete list accuracy was poor; there was no difference in the accuracy between CUSTOM (6.5%) and USUAL (9.1%) (odds ratio [OR], 0.33; P = 0.62). Out of a total of 648 medications, subjects accurately listed 43.7% of medications on CUSTOM and 45.5% on USUAL (OR, 0.88; P = 0.41). The 44 medications on the checklist were more than twice as likely to be accurately reported using CUSTOM than with USUAL (OR, 2.1; P = 0.0002). More subjects preferred CUSTOM (65.7%) compared with USUAL (32.8%, P = 0.007)., Conclusion: Medication self-report is very poor, and few subjects created an accurate list on either form. Subjects were more likely to report the drugs on the checklist using CUSTOM than when they used USUAL; however, there was no difference in the overall accuracy between CUSTOM and USUAL.

Objective: Prompt detection of infectious disease outbreaks and rapid introduction of mitigation strategies is a primary concern for public health, emergency and security management organizations. Traditional surveillance methods rely on astute clinical detection and reporting of disease or laboratory confirmation. Although effective, these methods are slow, dependent on physician compliance and delay timely, effective intervention. To address these issues, syndromic surveillance programs have been integrated into the health care system at the earliest points of access; in Ontario, these points are primary care providers, emergency departments (ED), and Telehealth Ontario. This study explores the role of Telehealth Ontario, a telephone helpline, as an early warning system for detection of gastrointestinal (GI) illness., Methods: Retrospective time-series analysis of the National Ambulatory Care Reporting System (NACRS) ED discharges and Telehealth Ontario data for GI illness from June 1, 2004 to March 31, 2006., Results: Telehealth Ontario recorded 184,904 calls and the NACRS registered 34,499 ED visits for GI illness. The Spearman rank correlation coefficient was calculated to be 0.90 (p < 0.0001). Time-series analysis resulted in significant correlation at lag (weekly) 0 indicating that increases in Telehealth Ontario call volume correlate with increases in NACRS data for GI illness., Conclusion: Telehealth Ontario call volume fluctuation reflects directly on ED GI visit data on a provincial basis. Telehealth Ontario GI call complaints are a timely, novel and representative data stream that shows promise for integration into a real-time syndromic surveillance system for detection of unexpected events.

A major challenge for large scale, multi-site research studies is the time-sensitive tracking of numerous subjects, samples and results through multiple encounters and processes, by many team members in several different locations. This may be compounded by collaborations with other studies to share samples, data collection and subjects. The Screening for Impaired Glucose Tolerance (SIGT) study has met this challenge by developing a secure, informatics system with web and client server interfaces.

Background: A key opportunity for continuing diabetes care is to assure outpatient follow-up after hospitalization. To delineate patterns and factors associated with having an ambulatory care visit, we examined immediate postdischarge follow-up among a cohort of urban, hospitalized patients with diabetes mellitus., Methods: Retrospective study of 658 inpatients of a municipal hospital. Primary data sources were inpatient surveys and electronic records., Results: Patients were stratified into outpatient follow-up (69%), acute care follow-up (15%), and those with no follow-up (16%); differences between groups were detected for age (P =.02), percentage discharged with insulin (P =.03), and percentage receiving a full discount for care (P<.001). Among patients with a postdischarge visit, 43% were seen in our specialty diabetes clinic, and 26% in a primary care site. Adjusted analyses showed any follow-up visit significantly decreased with having to pay for care. The odds of coming to the Diabetes Clinic increased if patients were discharged with insulin, had new-onset diabetes, or had a direct referral., Conclusions: In this patient cohort, most individuals accomplished a postdischarge visit, but a substantial percentage had an acute care visit or no documented follow-up. New efforts need to be devised to track patients after discharge to assure care is achieved, especially in this patient population particularly vulnerable to diabetes.

Some investigators have speculated that structural brain alterations observed in some psychiatric patients might be related to increased limbic-hypothalamic-pituitary-adrenal axis (LHPA) activity. To explore this hypothesis, we prospectively studied 166 research volunteers (19 patients with research diagnostic criteria (RDC) major depression, 9 patients with RDC bipolar depression, 45 patients with RDC schizophrenia, and 94 RDC normal controls), examining the relationship between magnetic resonance image-determined ventricular-to-brain ratio (VBR) and indices of LHPA axis function (cerebrospinal fluid (CSF) corticotropin-releasing factor (CRF), CSF adrenocorticotropic hormone (ACTH), and 24-hour urinary-free cortisol secretion). We observed no significant differences in mean VBR among the three patient groups and the normal control volunteers. Of the indices of LHPA activity, only CSF CRF concentrations distinguished the four subject groups, with CSF CRF being significantly elevated in the more severely depressed major depression patients. Indices of LHPA activity were not significantly correlated with VBR in any of the three patient groups or in the normal volunteers. These preliminary results suggest that VBR is not highly associated with alterations in LHPA activity, at least as determined cross-sectionally. Further longitudinal studies with reference to diagnostic subtypes, severity, symptom profiles, and more specific neuroanatomic regions may allow the elucidation of possible relationships between LHPA pathology and structural brain alterations.