Care in the Home for the Management of Chronic Heart Failure: Systematic Review and Cost-Effectiveness Analysis.

BACKGROUND: The objective of this study was to determine the effect of care in the home (CHM) compared with usual care (UC) in patients with chronic heart failure (CHF) on clinical outcomes and healthcare use including a cost-effectiveness analysis. METHODS: A systematic literature search on MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, as well as Centre for Reviews and Dissemination was conducted to identify randomized controlled trials comparing CHM with UC in CHF. The randomized controlled trials meeting inclusion criteria were meta-analyzed by outcome, and the quality of evidence for each outcome was evaluated using Grading of Recommendations Assessment, Development, and Evaluation system. A cost-effectiveness model was developed to estimate costs and quality-adjusted life years. RESULTS: Six randomized controlled trials were identified from 1277 citations. Care in the home was predominately provided by a single health professional consisting of nurse-led education of varying duration and frequency. One study included pharmacist-led CHM. Care in the home showed a decreased risk for all-cause mortality and hospitalizations combined (risk ratio, 0.88; 95% confidence interval [CI], 0.80-0.97), but not all-cause mortality alone (risk ratio, 0.92; 95% CI, 0.81-1.04). Care in the home resulted in fewer hospitalizations (mean difference, -1.03; 95% CI, -1.53 to -0.53) and fewer emergency department visits (mean difference, -1.32; 95% CI, -1.87 to -0.77). Quality of life also improved with CHM delivered by nurses. Critical appraisal of the quality of evidence suggests uncertainty in the estimates for a number of outcomes. Care in the home resulted in a savings of $10,665 and a gain of 0.11 quality-adjusted life years compared with UC. CONCLUSIONS: In conclusion, the beneficial effect of CHM in CHF is by reducing mortality and hospitalizations combined. Care in the home in CHF seems to be more effective and less costly compared with UC.

Work-related mild-moderate traumatic brain injury and the construction industry.

BACKGROUND: Consequences of traumatic brain injury underscore the need to study high-risk groups. Few studies have investigated work-related traumatic brain injuries (WrTBIs) in the construction industry. OBJECTIVE: To examine WrTBIs in Ontario for the construction industry compared to other industries. METHODS: A retrospective study of individuals who sustained a WrTBI and had a clinical assessment as an outpatient at a hospital-based referral centre. Data were collected for a number of factors including demographic, injury and occupation and were analyzed according to the Person-Environment-Occupation (PEO) model. PARTICIPANTS: 435 individuals who sustained a WrTBI. RESULTS: There were 19.1% in the construction industry, 80.9% in other industries. Compared to other industries, individuals in the construction industry were more likely to be male, to not have attained post-secondary education, and experience multiple traumas. WrTBIs in the construction industry were commonly due to elevated work. The construction occupations involved included skilled workers and general labourers, and compared to other industries, WrTBIs occurred most often for those employed for a short duration in the construction industry. CONCLUSIONS: Construction industry workers experience serious WrTBIs that are amenable to prevention. Use of the PEO model increased our understanding of WrTBIs in the construction industry.

Window to the brain: Can retinopathy be used to assess cognitive function.

OBJECTIVE: Retinopathy status as a screening method to predict cognitive health is limited. The objective of this study was to examine the association between retinopathy and lowered cognitive performance in a Canadian First Nations population. METHODS: Eligible individuals were assessed by the Clock Drawing Test (CDT) and the Trail Making Test Parts A and B, which were combined into an executive function score (TMT-exec). Digital fundus photographs were taken for both eyes to assess retinopathy. Anthropometric, vascular and metabolic risk factors were assessed by interview, clinical examinations and blood tests. Carotid atherosclerosis was assessed by Doppler ultrasonography. RESULTS: Retinopathy was detected in 7.1% of the population. Individuals classified as having a previous history of cardiovascular disease, insulin resistance and diabetes were more likely to have retinopathy. No other cardiovascular risk factors were associated. In unadjusted analysis, there were no associations between retinopathy and lowered cognitive performance (CDT, odds ratio [OR]: 0.86, 95% confidence interval [CI]: 0.30­2.53; TMT-exec, OR: 1.79, 95% CI: 0.60­5.33). Multivariable adjusted analysis also showed no associations, although sample size may be limiting. CONCLUSIONS: Retinopathy was not associated with lowered cognitive performance. Associations for microvascular risk factors suggest a panel of cognitive tests is needed for future studies.

Work-related mild-moderate traumatic brain injuries due to falls.

OBJECTIVE: Workplace falls are a common cause of head injuries; however, detailed study of this is limited. The objective of the study was to examine the person, environment and occupation factors associated with work-related traumatic brain injuries (WrTBI) due to falls from elevation (FFE) and falls from the same level (FFSL). METHODS: This study is a retrospective chart review. Data was extracted from consecutive medical records of workers who sustained a head injury at work and were referred to the Toronto Rehabilitation Institute for clinical assessment. RESULTS: FFE were more likely to occur in men and result in multiple traumas, compared to FFSL. FFSL occurred more equally among men and women. Slippery conditions and placement of objects were common for WrTBI due to FFSL. Change in elevation was common for WrTBI due to FFE. WrTBI due to FFE most often occurred in trades, transport occupations and the construction industry, whereas WrTBI due to FFSL most often occurred in professional, management, skilled positions and the manufacturing industry. CONCLUSIONS: Types of falls resulting in brain injury and their mechanisms of injury vary across industries and occupations. The study provides information for more tailored workplace safety strategies and primary prevention across industries.

Examining occupational traumatic brain injury in Ontario.

OBJECTIVE: Occupational traumatic brain injuries disrupt the lives of workers and carry major economic repercussions. To date, there has been limited information on brain injuries that occur at work across injury severity levels in Canada. The aim of this study was to provide an overview of occupational traumatic brain injuries in Ontario, with a focus on the sex of the workers. METHODS: For this cross-sectional study, data from the Ontario Workplace Safety and Insurance Board were used. A retrospective chart review was conducted of over 1,500 claim files from the year 2004 with the diagnostic codes of concussion and intracranial injury. Severity was assessed according to data on days off work. RESULTS: The average age of those injured was 37.8 years. The breakdown by sex shows that 57.8% of claims for occupational traumatic brain injury involved males. The most common mechanism of injury was being "struck by or against", followed by "falls". Most of the occupational traumatic brain injuries were from the manufacturing, and government and related services sectors. The highest rate, however, was shown for transportation and storage (81.5/100,000), followed by government and related services (56.6/100,000) and primary industries (47/100,000). CONCLUSIONS: An examination of occupational traumatic brain injuries across a range of severities reveals a profile that is different from that associated with more severely injured workers: there were many more women in particular industries who were injured and more injuries involving being struck by an object. This paper provides data on key industries, mechanisms and contributing factors involved in work-related traumatic brain injury that result in claims to the Workplace Safety and Insurance Board.

Medical record review conduction model for improving interrater reliability of abstracting medical-related information.

Medical record review (MRR) is often used in clinical research and evaluation, yet there is limited literature regarding best practices in conducting a MRR, and there are few studies reporting interrater reliability (IRR) from MRR data. The aim of this research was twofold: (a) to develop a MRR abstraction tool and standardize the MRR process and (b) to examine the IRR from MRR data. This study introduces the MRR-Conduction Model, which was used to implement a MRR, and examines the IRR between two abstractors who collected preinjury medical and psychiatric, incident-related medical and postinjury head symptom information from the medical records of 47 neurologically injured workers. Results showed that the percentage agreement was > or =85% and the unweighted kappa statistic was > or =.60 for most variables, indicating substantial IRR. An effective and reliable MRR to abstract medical-related information requires planning and time. The MRR-Conduction Model is proposed to guide the process of creating a MRR.

Obesity and lowered cognitive performance in a Canadian First Nations population.

The association between obesity, other cardiovascular risk factors, and cognitive function in a Canadian First Nations population was investigated using a cross-sectional design. Eligible individuals were aged >/=18 years, without a history of stroke, nonpregnant, with First Nations status, and who had undergone cognitive function assessment by the Clock Drawing Test (CDT) and Trail Making Test Parts A and B. Parts A and B were combined into an Executive Function Score (TMT-exec). Hypertension, a previous history of cardiovascular disease, dyslipidemia, metabolic syndrome, insulin resistance, and the presence and duration of diabetes were examined in addition to obesity. In the case of TMT-exec only, obese individuals were at an approximately fourfold increased risk for lowered cognitive performance compared to those who were not obese in multivariable models (odds ratio (OR): 3.77, 95% confidence interval (CI): 1.46-9.72) whereas there was no effect for overweight individuals compared to those with a normal weight in unadjusted analysis. Those having an increased waist circumference also had 5 times the risk compared to those without an increased waist circumference (OR: 5.41, 95% CI: 1.83-15.99). Adjusted for age, sex, and insulin resistance, individuals having the metabolic syndrome were at an approximately fourfold increased risk compared to those without the metabolic syndrome (OR: 3.67, 95% CI: 1.34-10.07). No other cardiovascular risk factors were associated. Obesity and metabolic syndrome were associated with lowered cognitive performance. These results highlight the importance of studying the health effects of obesity beyond traditional disease endpoints, even in a relatively youthful population.

Etiology of hormone receptor-defined breast cancer: a systematic review of the literature.

Breast cancers classified by estrogen receptor (ER) and/or progesterone receptor (PR) expression have different clinical, pathologic, and molecular features. We examined existing evidence from the epidemiologic literature as to whether breast cancers stratified by hormone receptor status are also etiologically distinct diseases. Despite limited statistical power and nonstandardized receptor assays, in aggregate, the critically evaluated studies (n = 31) suggest that the etiology of hormone receptor-defined breast cancers may be heterogeneous. Reproduction-related exposures tended to be associated with increased risk of ER-positive but not ER-negative tumors. Nulliparity and delayed childbearing were more consistently associated with increased cancer risk for ER-positive than ER-negative tumors, and early menarche was more consistently associated with ER-positive/PR-positive than ER-negative/PR-negative tumors. Postmenopausal obesity was also more consistently associated with increased risk of hormone receptor-positive than hormone receptor-negative tumors, possibly reflecting increased estrogen synthesis in adipose stores and greater bioavailability. Published data are insufficient to suggest that exogenous estrogen use (oral contraceptives or hormone replacement therapy) increase risk of hormone-sensitive tumors. Risks associated with breast-feeding, alcohol consumption, cigarette smoking, family history of breast cancer, or premenopausal obesity did not differ by receptor status. Large population-based studies of determinants of hormone receptor-defined breast cancers defined using state-of-the-art quantitative immunostaining methods are needed to clarify the role of ER/PR expression in breast cancer etiology.

Loss of antigenicity in stored sections of breast cancer tissue microarrays.

Immunohistochemical characterization of tumor tissues in epidemiological studies is a promising approach to identify breast cancer subtypes with distinct etiology. The recent development of the tissue microarray (TMA) technique allows for standardized, rapid, and cost-effective immunohistochemical characterization of many cases, which is critical in epidemiological studies. Sectioning paraffin blocks at different times results in loss of material, which can be reduced by preparing many sections each time a block is cut. However, data suggest that staining intensity declines in whole sections prepared from conventional paraffin blocks with storage time, resulting in false-negative results. This problem would be accentuated in TMAs because of the limited tissue representation of each case. To evaluate this concern, we prepared a single TMA block from 125 invasive breast carcinomas collected in a population-based case-control study conducted in Poland and compared estrogen receptor (ER-alpha), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) expression in sections cut and stored for 6 months at room temperature with sections cut from the same TMA block and stained on the same day. Percentage of positive cases for stored versus fresh sections was similar for ER (59.0%) but significantly higher in fresh sections for PR (56.3% versus 64.1%, P = 0.01) and HER2 (45.5% versus 64.4%, P < 0.001). Among cases positive in both stored and fresh sections, the median percentage of immunoreactive cells was significantly reduced and the staining intensity was consistently lower in stored compared with fresh sections. We conclude that loss of immunoreactivity is an important problem in TMAs of breast cancer. Improved methods for sectioning TMAs and storing tissue sections aimed at reducing loss of immunoreactivity are critical for the use of TMAs in epidemiological studies.