Benchmarks for acute stroke care delivery.

OBJECTIVE: Despite widespread interest in many jurisdictions in monitoring and improving the quality of stroke care delivery, benchmarks for most stroke performance indicators have not been established. The objective of this study was to develop data-derived benchmarks for acute stroke quality indicators. DESIGN: Nine key acute stroke quality indicators were selected from the Canadian Stroke Best Practice Performance Measures Manual. PARTICIPANTS: A population-based retrospective sample of patients discharged from 142 hospitals in Ontario, Canada, between 1 April 2008 and 31 March 2009 (N = 3191) was used to calculate hospital rates of performance and benchmarks. INTERVENTION: The Achievable Benchmark of Care (ABC™) methodology was used to create benchmarks based on the performance of the upper 15% of patients in the top-performing hospitals. MAIN OUTCOME MEASURES: Benchmarks were calculated for rates of neuroimaging, carotid imaging, stroke unit admission, dysphasia screening and administration of stroke-related medications. RESULTS: The following benchmarks were derived: neuroimaging within 24 h, 98%; admission to a stroke unit, 77%; thrombolysis among patients arriving within 2.5 h, 59%; carotid imaging, 93%; dysphagia screening, 88%; antithrombotic therapy, 98%; anticoagulation for atrial fibrillation, 94%; antihypertensive therapy, 92% and lipid-lowering therapy, 77%. ABC™ acute stroke care benchmarks achieve or exceed the consensus-based targets required by Accreditation Canada, with the exception of dysphagia screening. CONCLUSIONS: Benchmarks for nine hospital-based acute stroke care quality indicators have been established. These can be used in the development of standards for quality improvement initiatives.

Mood and the menstrual cycle.

BACKGROUND: Premenstrual mood symptoms are considered common in women, but such prevailing attitudes are shaped by social expectations about gender, emotionality and hormonal influences. There are few prospective, community studies of women reporting mood data from all phases of the menstrual cycle (MC). We aimed (i) to analyze daily mood data over 6 months for MC phase cyclicity and (ii) to compare MC phase influences on a woman's daily mood with that attributable to key alternate explanatory variables (physical health, perceived stress and social support). METHOD: A random sample of Canadian women aged 18-40 years collected mood and health data daily over 6 months, using telemetry, producing 395 complete MCs for analysis. RESULTS: Only half the individual mood items showed any MC phase association; these links were either with the menses phase alone or the menses plus the premenstrual phase. With one exception, the association was not solely premenstrual. The menses-follicular-luteal MC division gave similar results. Less than 0.5% of the women's individual periodogram records for each mood item showed MC entrainment. Physical health, perceived stress and social support were much stronger predictors of mood (p < 0.0001 in each case) than MC phase. CONCLUSIONS: The results of this study do not support the widespread idea of specific premenstrual dysphoria in women. Daily physical health status, perceived stress and social support explain daily mood better than MC phase.

Factors associated with the sexual assault of students: an exploratory study of victims treated at hospital-based sexual assault treatment centers.

Research suggests that students experience high levels of sexual assault, but studies addressing how they differ in their experiences from other sexual assault victims are virtually nonexistent. To address this gap, information was collected from consecutive individuals, aged 16 years or older, presenting to one of 7 hospital-based sexual assault treatment centers in Ontario from 2005 to 2007. Of the 882 victims seen during the study period, 32% were students. Relative to other sexual assault victims, students were more likely to be aged 16 to 18 years and 19 to 24 years versus 25 years and older. They were more likely to be living alone, with family of origin, a partner or spouse, or a nonrelative than on the street or in a shelter or institution. They were also more likely to report having consumed over-the-counter medication in the 72 hours prior to examination. Student victims were less likely than nonstudent victims to report having a disability and having used street drugs. Implications for research, education, and practice are discussed.

Reinitiation of anticoagulation after warfarin-associated intracranial hemorrhage and mortality risk: the Best Practice for Reinitiating Anticoagulation Therapy After Intracranial Bleeding (BRAIN) study.

BACKGROUND: While warfarin-related intracranial hemorrhage (ICH) occurs in 0.25%-1.1% patients per year, little is known about the practice and outcomes of anticoagulant reinitiation. METHODS: We studied a cohort of consecutive patients with warfarin-related ICH (intracerebral or subarachnoid) admitted to 13 stroke centres in the Registry of the Canadian Stroke Network between July 2003 and March 2008. We examined patterns of warfarin reinitiation and variables associated with 30-day and 1-year outcomes. RESULTS: Among the 284 patients studied (mean age 74 ± 12 years), warfarin was restarted in-hospital in 91 patients (32%). Factors associated with restarting warfarin were lower stroke severity (adjusted odds ratio [aOR] 2.07, 95% confidence interval [CI]; 1.20-3.57, P = 0.009) or presence of valve prosthesis (aOR 3.07, 95% CI; 1.29-7.27, P = 0.011). Mortality rates were not higher in those who restarted warfarin in-hospital: 31.9% vs 54.4% (30-day, P < 0.001) and 48% vs 61% (1-year, P = 0.04), and bleeding was not increased. Multivariable predictors of mortality included initial international normalized ratio > 3.0 (aOR, 3.28 [30-day, P < 0.001] and 3.32 [1-year, P = 0.003]), greater stroke severity (aOR, 6.04 [30-day] and 4.22 [1-year]; both P < 0.001), and intraventricular hemorrhage (aOR, 2.19 [30-day; P = 0.03] and 2.04 [1-year; P = 0.04]). In selected patients who reinitiated warfarin, there was no increase in 30-day (aOR, 0.49; P = 0.03) or 1-year mortality (aOR, 0.79; P = 0.43). CONCLUSIONS: In selected patients at high thrombosis risk, reinitiation of warfarin after ICH did not confer increased mortality or bleeding events.

Drug-facilitated sexual assault in Ontario, Canada: toxicological and DNA findings.

The purpose of this study was to determine which persons reporting sexual assault to a hospital-based treatment centre may have been covertly drugged and to provide information about whether a sexual assault may have occurred. Each consecutive adolescent and adult presenting at a sexual assault treatment centre was screened for drug-facilitated sexual assault (DFSA). Urine was collected and tested for central nervous system active drugs. Oral, vaginal, and/or rectal swabs were tested for male DNA. Unexpected drugs were defined as those not reported as having been voluntarily consumed within the previous 72 h. Positive swabs for unexpected DNA were determined by whether the person reported having had consensual intercourse in the previous week. A total of 184 of 882 eligible participants met suspected DFSA criteria. Mean age was 25.8 years (SD=8.5), 96.2% were female and 64.7% White. Urine samples were positive for drugs in 44.9% of cases, alcohol in 12.9%, and both drugs and alcohol in 18.0%. The drugs found on toxicological screening were unexpected in 87 of the 135 (64.4%) cases with a positive drug finding and included cannabinoids (40.2%), cocaine (32.2%), amphetamines (13.8%), MDMA (9.2%), ketamine (2.3%), and GHB (1.1%). Male DNA was unexpected in 30 (46.9%) of 64 cases where it was found. Among those persons presenting to a sexual assault treatment centre with a suspicion of DFSA, the presence of unexpected drugs and male DNA was common, lending support for their contention that they had been intentionally drugged and sexually assaulted. Most unexpected drugs found were not those typically described as 'date rape drugs'.

Women's perceptions of influences on their mood.

AIMS: Knowledge of prevailing community ideas about mood determination can guide research about variability in mood. A random sample of urban Canadian women, aged 18-40 years (n = 507), was asked to compare the relative importance of three specified domains (physical health, social support, stress) as influences on their mood and then to list additional life experiences they considered important. They also rated the frequency and recurrence patterns (cyclicity) of their daily positive and negative moods. RESULTS: More women reported a positive overall mood than negative mood. Of three domains studied, social support was listed as the greatest influence on positive mood and stress on negative mood in the bivariate tests. More frequent moods (both positive and negative) were more likely to be viewed as recurrent or cyclical. Patterns of influence for positive mood differed from those for negative mood. Multivariate modeling found that women reporting frequent positive mood were more often North American and employed full-time and likely to consider stress or lack of stress was unimportant as an influence on positive mood. The only factors in the model associated with frequent negative mood were the perception of physical health and stress as important influences on negative mood. Less than 5% cited menstrual cycle phase as an influence. CONCLUSIONS: These subjective data suggest that women perceived a wide range of external, usually interpersonal, influences as relevant to their mood, however menstrual cycle was rarely mentioned. Perceptions of influences on mood are statistically related to frequency of moods. In addition, ethnicity and paid employment are independently associated with positive mood.

Factors associated with suspected drug-facilitated sexual assault.

BACKGROUND: There has been little systematic investigation of widespread reports of drugging and sexual assault. We sought to determine the prevalence of and factors associated with suspected drug-facilitated sexual assault. METHODS: Between June 2005 and March 2007, a total of 977 consecutive sexual assault victims underwent screening for suspected drugging at 7 hospital-based sexual assault treatment centres. We defined victims of drug-facilitated sexual assault as those who presented to a centre within about 72 hours of being assaulted and who provided at least 1 valid reason for suspecting that she or he had been drugged and sexually assaulted. We used logistic regression modelling to compare victims of suspected drug-facilitated sexual assault with other sexual assault victims, controlling for covariates. RESULTS: In total, 882 victims were eligible for inclusion in the study. Of these, 855 (96.9%) were women, and 184 (20.9%) met the criteria for suspected drug-facilitated sexual assault. Compared with other victims, victims of drug-facilitated sexual assault were more likely to have presented to a large urban centre for care (odds ratio [OR] 2.31, 95% confidence interval [CI] 1.47-3.65), to be employed (OR 1.92, 95% CI 1.34-2.76), to have consumed over-the-counter medications (OR 3.97, 95% CI 2.47-6.38) and street drugs (OR 1.71, 95% CI 1.12-2.62) in the 72 hours before being examined and to have used alcohol before the assault (OR 4.00, 95% CI 2.53-6.32). INTERPRETATION: Suspected drug-facilitated sexual assault is a common problem. Sexual assault services should be tailored to meet the needs of those experiencing this type of victimization.