Key Outcomes Of Interest Research Articles

Do nurse navigators bring about fewer patient hospitalisations?

Nurse navigators (NNs) coordinate patient care, improve care quality and potentially reduce healthcare resource use. The purpose of this paper is to undertake an evaluation of hospitalisation outcomes in a new NN programme in Queensland, Australia. A matched case-control study was performed. Patients under the care of the NNs were randomly selected ( n=100) and were matched to historical ( n=300) and concurrent ( n=300) comparison groups. The key outcomes of interest were the number and types of hospitalisations, length of hospital stay and number of intensive care unit days. Generalised linear and two-part models were used to determine significant differences in resources across groups. The control and NN groups were well matched on socio-economic characteristics, however, groups differed by major disease type and number/type of comorbidities. NN patients had high healthcare needs with 53 per cent having two comorbidities. In adjusted analyses, compared with the control groups, NN patients showed higher proportions of preventable hospitalisations over 12 months, similar days in intensive care and a smaller proportion had overnight stays in hospital. However, the NN patients had significantly more hospitalisations (mean: 6.0 for NN cases, 3.4 for historical group and 3.2 for concurrent group); and emergency visits. As many factors will affect hospitalisation rates beyond whether patients receive NN care, further research and longer follow-up is required. A matched case-control study provides a reasonable but insufficient design to compare the NN and non-NN exposed patient outcomes.

A meta-analysis comparing 48-week treatment outcomes of single and multi-tablet antiretroviral regimens for the treatment of people living with HIV

ObjectivesTo compare outcomes with single tablet regimens (STR) versus multi-tablet regimens (MTR) for human immunodeficiency virus (HIV) treatment using published data.DesignSystematic review and random-effects meta-analysis of literature on approved and investigational HIV regimens.MethodsThe research followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Single or un-blinded studies reporting a direct comparison between STR and MTR were eligible for the meta-analysis. Double-blinded studies were excluded due to lack of difference in pill burden between cohorts. The key outcomes of interest included: adherence rates/proportion meeting target, efficacy, safety/tolerability, non-clinical and economic outcomes.ResultsAfter screening 63 full-text articles and posters, 14 studies were eligible for the meta-analysis. The analysis showed that patients taking STR had improved outcomes over those taking MTR. Patients were significantly more adherent regardless of daily dosing frequency (odds ratio [OR]: 1.96, p < 0.001) and were more likely to achieve virological suppression (relative risk [RR]: 1.05, p = 0.002). There was a trend toward a lower discontinuation risk in the STR cohort, together with reported higher therapy satisfaction, better symptom control, improved health status, reduced healthcare resource utilization and demonstrated cost-effectiveness compared to MTR. There were no differences in CD4 cell count increase (at 48 weeks) or safety outcomes.ConclusionsThe findings of this study confirm previously reported preliminary findings of the advantages of STR over MTR for HIV treatment in adherence, therapy continuation, viral suppression, tolerability, quality of life improvement, cost-effectiveness and healthcare resource utilization.

282 Impact of Emergency Medical Services Vehicle Use by Acute Ischemic Stroke Patients on Functional Outcomes: An Observational Study

Previous studies have documented the impact of emergency medical services (EMS) vehicle use on speedy thrombolytic treatment, but not on patient functional outcomes. We assessed the association of EMS use with likelihood and timeliness of intravenous (IV) thrombolytic treatment and functional outcomes at discharge and 90 days. Prospective observational study using Get With The Guidelines Stroke data on AIS patients with cerebrovascular imaging evidence, discharged 4/2016 to 10/2017 from a non-profit hospital’s primary stroke center unit in Columbia, South Carolina. Key outcomes of interest were: National Institutes of Health Stroke Scale (NIHSS) change from arrival to discharge (continuous variable), discharge disposition (discharged to home versus otherwise), and 90-day modified Rankin Scale, mRS 0-1 versus otherwise, (ascertained by phone calls to patients discharged from 4/2018 to 8/2017 within 75-105 days of discharge using a standardized script, supplemented by medical record data on neurology follow-up visits). Multiple logistic and linear regression analyses were used as appropriate. Of 1,166 total AIS discharges, 328 were excluded (transfer patients or hospice assigned pre-admission). Among 838 study-eligible patients, 52.4% were black, 72.2% arrived by EMS, mean admission NIHSS (available for 96.7% of patients) was 6.8 (±7.3; median 4.0, range 0 - 37), mean stroke-relevant comorbidities per patient 3.7 (±1.9), alteplase received 114 (13.6%), and 92 expired or assigned to hospice. Mean door to imaging (DTI) time was 98.8 minutes (±151.0; median 49), and mean door to needle (DTN) time for IV alteplase recipients, 46.2 minutes (±31.2; median 38.0). In bivariate analyses, EMS arrivals were older (mean age 70 years versus 63.6 for other transport), more severe (mean NIHSS 8.3 (±7.7) versus 2.9 (±3.7), more likely to have contraindications to alteplase, and had worse discharge outcomes. Adjusted for demographic and other factors, EMS use was highly associated with stroke severity (adjusted odds 4.1 for moderate stroke (NIHSS 6-15) versus mild stroke (NIHSS 0-5), and 12.3 for severe stroke (NIHSS>15), p<0.001). Adjusted for stroke severity, comorbidities, endovascular treatment and other relevant factors as appropriate, EMS arrival (relative to other transport) was associated with: 5-fold higher odds of IV alteplase, 88.5 minutes lower DTI (p<0.01; 57% reduction), and, among severe stroke patients, 5.7 points better improvement in discharge NHISS over admission NIHSS (all p<0.001). Insurance status and race were not significant factors in alteplase use, DTI or DTN. Discharge disposition was not significantly associated with arrival mode. 90-day mRS was ascertained for 430 patients (59.2% of eligible, despite 87.1% of eligibles fully pursued per protocol). The study lacked statistical power to assess EMS impact on 90-day mRS, given the effect magnitude of stroke severity on both EMS use and 90-day outcomes. However, discharge NIHSS accurately predicted 90-day mRS, (adjusted beta 0.20; score ranges of the 2 scales, 0-37 versus 0-6; model R2 = 0.42), supporting that EMS use may produce better long-term outcomes in severe stroke patients. This study breaks new ground, documenting a positive impact of EMS use on functional outcomes in severe stroke. Given evidence of equitable care regardless of insurance status/race at the study center, findings may be generalizable despite being a single-center observational study.

Does natriuretic peptide monitoring improve outcomes in heart failure patients? A systematic review and meta-analysis

BackgroundCurrent guidelines do not support the use of serial natriuretic peptide (NP) monitoring for heart failure with preserved (HFpEF) or reduced ejection fraction (HFrEF) treatment, despite some studies showing benefit. We conducted an updated meta-analysis to address whether medical therapy in HFpEF or HFrEF should be titrated according to NP levels. MethodsMEDLINE, Scopus and Cochrane CENTRAL databases were searched for randomized controlled trials (RCTs) comparing NP versus guideline directed titration in HF patients through December 2017. The key outcomes of interest were mortality, HF hospitalizations and all-cause hospitalizations. Risk ratios and 95% confidence intervals were pooled using random effects model. Sub-group analyses were performed for type of NP used, average age and acute or chronic HF. ResultsEighteen trials including 5116 patients were included. Meta-analysis showed no significant difference between the NP-guided arm versus guideline directed titration in all-cause mortality (RR = 0.91 [0.81, 1.03]; p = 0.13), HF hospitalizations (RR = 0.81 [0.65, 1.01]; p = 0.06), and all cause hospitalizations (RR = 0.93 [0.86, 1.01]; p = 0.09). The results were consistent upon subgroup analysis by biomarker type (NT-proBNP or BNP) and type of heart failure (acute or chronic and HFrEF or HFpEF). Sub-group analysis suggested that NP-guided treatment was associated with decreased all-cause hospitalizations in patients younger than 72 years of age. ConclusionThe available evidence suggests that NP-guided therapy provides no additional benefit over guideline directed therapy in terms of all-cause mortality and HF-related hospitalizations in acute or chronic HF patients, regardless of their ejection fraction.

Assessing psychological inflexibility in university students: Development and validation of the acceptance and action questionnaire for university students (AAQ-US)

This study sought to develop and validate a domain-specific measure of psychological inflexibility for university students, the acceptance and action questionnaire for university students (AAQ-US). Generic versions of the AAQ tend to not be as sensitive to changes in campus-specific functioning —a key outcome of interest in this population. An online survey was conducted with 425 undergraduate students. Psychometric analyses led to the refinement of a 12-item, single factor scale with strong internal consistency. Evidence for convergent validity was found with moderate to large correlations between the AAQ-US and measures of academic outcomes, mental health, and psychological inflexibility. The AAQ-US was a stronger predictor of academic outcomes than the AAQ-II (a general measure of psychological inflexibility) whereas the AAQ-II was more strongly related to mental health outcomes than the AAQ-US. Incremental validity for the AAQ-US was found for predicting both academic and mental health outcomes while controlling for the AAQ-II, though effects were stronger for academic outcomes. Overall, results indicate that the AAQ-US is a reliable and valid measure of psychological inflexibility among university students and may be particularly relevant in the context of academic outcomes.

Commentary on Stewart et al. (2017): Stimulants and marijuana-the potential value in studying substance co-use.

Commentary on Stewart et al. (2017): Stimulants and marijuana-the potential value in studying substance co-use.

Longditudinal Study of Type-2 Diabetics – Do the morbidly obese really have better outcomes?

ABSTRACT&#x0D; BackgroundDiabetes continues to utilise 10% of the NHS budget and have considerable impact on people’s lives. Abertawe bro Morganwyg Health board identified diabetes and obesity as a strategic priorities. Working in collaboration with SAIL and We Predict ABM identified this as an area for which greater insights could be gained from linked data. Type-2 diabetes is not easily identified through ICD-10 and READ codes but if new diabetics can be identified through linked data and followed up over time local areas can understand the progression locally, which populations are at risk of serious outcomes and where interventions may be made.&#x0D; ObjectivesTo identify newly diagnosed type-2 diabetics and matched controls in order to produce and analyse difference to the key outcomes of interest – death, retinopathy, myocardial infarction, CVD, CKD and amputation. In addition to produce sub group analysis – including by age group, gender, BMI and deprivation.&#x0D; ApproachA stakeholder group of GPs, managers, NHS analysts and SAIL employees were consulted. Several approaches to define and identify newly diagnosed type 2 diabetics were considered. The final algorithm consisted of a combination of 227 linked primary and secondary care codes. All 635,552 patients in the historical data set were eligible for inclusion. Suitable matched controls (patients who did not have a Type-2 Diabetes diagnosis matched based on Gender and Age Group) were identified, and allocated a synthetic ‘date of diagnosis’ or date of entry into ‘study’. The ‘cases’ and controls were then followed up to each of the key outcomes of interest for as long as data was available (in some cases 20 years). Using ‘R’ relevant analysis including survival curves were produced. After feedback to key stakeholders different approaches to presenting (visualising) the outputs were developed. Finally all the statistics and visualisation was automated.&#x0D; Results 47,848 people were identified with a new a diagnosis of diabetes. Large differences in mortality were clearly evident in people with diabetes in ABM HB – for example 10 years in middle aged men when diagnosed with diabetes compared to those who were not.&#x0D; There were some surprising results where people with higher BMIs appeared to have better outcomes when compared to groups of people in similar categories but with lower BMI. However this finding was not consistent - there was a difference in micro vascular and macro vascular outcomes.

Health facility and skilled birth deliveries among poor women with Jamkesmas health insurance in Indonesia: a mixed-methods study

BackgroundThe growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement. As part of Indonesia’s strategy to achieve the goal of UHC, large investments have been made to increase health access for the poor, resulting in the implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jamkesmas program. In the backdrop of Indonesia’s aspiration to reach UHC is the high rate of maternal mortality that disproportionally affects poor women. The objective of this study was to evaluate the association of health facility and skilled birth deliveries among poor women with and without Jamkesmas and explore perceived barriers to health insurance membership and maternal health service utilization.MethodsWe used a mixed-methods design. Utilizing data from the 2012 Indonesian Demographic and Health Survey (n = 45,607), secondary analysis using propensity score matching was performed on key outcomes of interest: health facility delivery (HFD) and skilled birth delivery (SBD). In-depth interviews (n = 51) were conducted in the provinces of Jakarta and Banten among poor women, midwives, and government representatives. Thematic framework analysis was performed on qualitative data to explore perceived barriers.ResultsIn 2012, 63.0% of women did not have health insurance; 19.1% had Jamkesmas. Poor women with Jamkesmas were 19% (OR = 1.19 [1.03–1.37]) more likely to have HFD and 17% (OR = 1.17 [1.01–1.35]) more likely to have SBD compared to poor women without insurance. Qualitative interviews highlighted key issues, including: lack of proper documentation for health insurance registration; the preference of pregnant women to deliver in their parents’ village; the use of traditional birth attendants; distance to health facilities; shortage of qualified health providers; overcrowded health facilities; and lack of health facility accreditation.ConclusionsPoor women with Jamkesmas membership had a modest increase in HFD and SBD. These findings are consistent with economic theory that health insurance coverage can reduce financial barriers to care and increase service uptake. However, factors such as socio-cultural beliefs, accessibility, and quality of care are important elements that need to be addressed as part of the national UHC agenda to improve maternal health services in Indonesia.

Using Elite Athletes to Promote Drug Abstinence: Evaluation of a Single-Session School-Based Drug Use Prevention Program Delivered by Junior Hockey Players

ABSTRACTSchool-based substance use prevention programs are a common method to approaching drug use in youths. Project SOS is a single-session drug prevention program developed by police officers and delivered by elite junior hockey players to students in grades 6 and 7. The current study evaluates the effects of Project SOS at achieving its objectives of educating youths about the consequences and dangers of illicit drugs, and changing attitudes with respect to drug use. Results highlight some promising findings, although few significant differences were seen from pretest to posttest on key outcomes of interest. Recommendations for adapting the program using evidence-based strategies are provided.

Everolimus-eluting bioresorbable vascular scaffolds versus second generation drug-eluting stents for percutaneous treatment of chronic total coronary occlusions: Technical and procedural outcomes from the GHOST-CTO registry.

We aimed at comparing the acute performance of bioresorbable scaffolds (BRS) and second-generation drug-eluting stents (DES) for the treatment of chronic total occlusions (CTO). There is a lack of knowledge regarding the use of BRS in CTO. Key outcomes of interest were technical and procedural success. Technical success was defined as successful stent delivery and implantation, postprocedural residual diameter stenosis <30% within the treated segment, and restoration of thrombolysis in myocardial infarction (TIMI) grade 3 flow. Procedural success was defined as technical success with no in-hospital major adverse cardiac events (MACE). Between May 2013 and May 2014, 32 patients underwent CTO percutaneous coronary intervention (PCI) with the Absorb BRS (Abbott Vascular, Santa Clara, CA) and were compared with a historical control group of 54 patients who had undergone CTO PCI with second-generation DES. Baseline characteristics were similar between the BRS and DES groups, with the exception of a larger mean reference vessel diameter in the BRS group (2.92±0.34 vs 2.50±0.68; P<0.001). Technical success was less likely to be achieved in the BRS group compared with the DES group (78.1% vs 96.3%, P=0.012). Procedural success rates were 78.1% and 94.4% in the BRS and DES group, respectively (P = 0.035). Compared with second-generation DES for PCI of CTO lesions, BRS were associated with lower rates of technical and procedural success. © 2016 Wiley Periodicals, Inc.

Ketamine-propofol combination (ketofol) vs propofol for procedural sedation and analgesia: systematic review and meta-analysis

ObjectiveThis meta-analysis of trials was conducted to evaluate the analgesic and side effects of ketamine-propofol combination (ketofol) in comparison to propofol in procedural sedation and analgesia (PSA). MethodsMedline, EMBASE, Scopus, CINHAL, and Cochrane Central Register of Controlled Trials were searched for clinical trial. The administration complications were the key outcomes of interest. ResultEighteen clinical trials that met our criteria were included in the analysis. Pooling of data showed that ketofol is significantly effective for reduction of respiratory complication and with relative risk (RR) of 0.31 in 14 trials (95% confidence interval [CI], 0.47-0.7; P = .001). Ketofol was also effective in reducing cardiovascular complications with hypotension RR of 0.11 in 9 trials (95% CI, 0.17-0.97; P = .04) and bradycardia RR of 0.47 in 8 trials (95% CI, 0.28-0.72; P = .008). The present study also showed that the summary of RR for psychomimetic complications was 1.95 in 13 trials were (95% CI, 0.79-4.81; P = .15) and for muscle rigidity was 0.52 for 2 trials (95% CI, 0.06-4.67; P = .56), and both were insignificant. In regard to nausea and vomiting, the RR was 1.23 in 12 trials (95% CI, 0.39-3.88; P = .72) and insignificant. ConclusionThis meta-analysis demonstrates good safety profile in cardiorespiratory problems and comparable rate of other complications with propofol in adult procedural sedation and analgesia.

Locking plate versus non-locking plate in open-wedge high tibial osteotomy: a meta-analysis.

The purpose of this study was to conduct a meta-analysis to determine whether the locking plate or non-locking plate results in better opening-wedge high tibial osteotomy (OWHTO) outcomes. The MEDLINE, EMBASE, COCHRANE, and KOREAMED register databases were searched for studies. The eligibility criteria for inclusion in the review were studies that compared the locking plate with the non-locking plate for OWHTO, and those that provided clear descriptions of surgical techniques and outcomes. The key outcomes of interest were union rate, correction loss angle, correction loss rate, and full weight-bearing starting point. The statistical software "RevMan" was used in statistical analysis. Five studies were included in the meta-analysis. Among their reported results, there were no differences in the incidence of union [risk ratio (RR)=1.01, p=0.34], non-locking plate was associated with lower incidence of correction maintenance (RR=1.13, p=0.0006) and greater angle of correction loss [mean difference (MD)=-2.06, p<0.00001], and locking plate was associated with a significant improvement in Knee society score and function score (MD=5.77, p<0.0001; MD=7.50, p=0.0005). Locking plate provides better clinical outcomes and reduced correction loss rates and angles as compared to non-locking plate for fixation with OWHTO. IV.

Influence of patient medication information format on comprehension and application of medication information: A randomized, controlled experiment

ObjectiveTo examine patients’ comprehension and application of alternative versions of patient medication information handouts for a fictitious drug, and whether patient characteristics influence patients’ ability to understand the handouts. MethodsA web-based experiment was conducted in which 1397 adults with rheumatoid arthritis, ankylosing spondylitis, or plaque psoriasis were randomly assigned to one of three conditions: (1) a one-page “Bubbles” format; (2) a one-page “Over-The-Counter” (OTC) format; and (3) a four-page document modeled after MedGuides used in 2009 which served as the control arm. Comprehension and application of information in the handouts were the key outcomes of interest. ResultsParticipants who viewed either the Bubbles or OTC formats had greater comprehension than participants who viewed the MedGuide, but did not have better application scores. No significant differences were noted between the Bubbles and OTC formats. Patient characteristics did not moderate the results. ConclusionBoth formats resulted in better comprehension than the MedGuide format used in the study. Practice implicationsResults provide valuable information on how to design patient information to improve patients’ understanding of the risks and benefits of the drugs they are prescribed. Results could be extended to inform the content of other types of patient education materials.

How Does Homestead Food Production Improve Child Nutrition? Path Analysis of the AAMA Project in Nepal

The Action Against Malnutrition through Agriculture (AAMA) Project is an Enhanced Homestead Food Production Project implemented by Helen Keller International and local partners in Far Western Nepal that combined a nutrition‐sensitive agriculture intervention with behavior change communication to improve nutrition and health. Data from a cross‐sectional endline survey were used to measure variables along HKI's hypothesized Program Impact Pathway (PIP), from inputs through key outcomes of interest, including child growth and maternal and child hemoglobin. Survey respondents included mothers with children aged 12‐48 months at the time of the interview (n=2614). We used path analysis to assess the relative contribu&lt;a name=”_GoBack”&gt;&lt;/a&gt;tion of specific mechanisms of effect on nutrition and health as outlined in the PIP. The hypothesized model for height‐for‐age z‐score fit the data well (χ²(19)=55.8, p&lt;0.001; RMSEA=0.027; CFI=0.945), while the model for child hemoglobin (χ²(20)=297.7, p&lt;0.001; RMSEA=0.073, CFI=0.913) was a moderate fit, and some models did not achieve adequate fit. Agricultural inputs is the program component with the strongest path in the model (β=0.022, p&lt;0.001). Areas of weak association and poor model fit may be attributed to weaknesses in measurement, intervention fidelity, and contextual factors unaccounted for in the PIP. These findings guide program improvements by highlighting areas for enhancements in program design, implementation or evaluation.

Use of antibiotics in patients with Crohn's disease: a systematic review and meta-analysis.

Some studies have suggested that antibiotic treatment might be efficient for patients with active Crohn's disease (CD). However, the results are conflicting. The aim of this study was to summarize the available evidence on the efficacy of antibiotics, especially ciprofloxacin, in treating patients with CD. A literature search was conducted on the PubMed, Medline, Web of Science and Excerpta Medica Database (EMBASE) for manuscripts published until March 2014. Randomized controlled trials that mainly evaluated the efficacy of antibiotic treatment in patients with CD using clinical remission or response as the key outcome of interest were included. Intention-to-treat analyses were used to evaluate the relative risk (RR) and 95% confidence intervals (CI). In all, 15 randomized placebo-controlled clinical trials involving 1407 participants were included in the meta-analysis. A pooled analysis revealed that compared with placebo, antibiotics benefited CD patients to a certain extent (RR 1.33, 95% CI 1.17-1.51, P < 0.00001). The random-effects model showed that there was no significant difference between patients treated with ciprofloxacin and placebo (combined RR 1.35, 95% CI 0.92-1.97, P = 0.12). However, ciprofloxacin exhibited significant clinical benefits in patients with perianal fistulas (RR 1.64, 95% CI 1.16-2.32, P = 0.005). The utility of antibiotics was beneficial for patients with CD. Nevertheless, subgroup analyses indicated that treatment with ciprofloxacin alone was significantly efficient for CD patients with perianal fistulas.

PIH5 - The Efficacy of Oximes in Acute Human Organophosphorus Poisoning; An Updated Meta-Analysis

The present study iims to meta-analyze clinical trials evaluating the efficacy of oximes on organophosphorus (OP) poisoning treatment. PubMed, Scopus, Google Scholar, and clinicaltials. gov were searched for studies investigating the effects of oximes in the treatment of OP poisoning. Mortality, intermediate syndrome, intensive care unit (ICU) admission rate, hospital stay duration, and intubation rate were the key outcomes of interest. Data were searched in the time period of 1966 through December 2013. Thirteen studies (eleven clinical trials and two historical cohorts) that met our criteria were included in the analysis. Pooling of data showed that relative risk (RR) of need for intubation in OP poisoning for eight included trials comparing oximes with placebo was 1.27 with 95% CI= 0.73 to 2.23 (P= 0.4). RR of only one observational study was 1.57 (95% CI= 0.79 to 3.2, P>0.05). The summary of RR for mortality rate in 9 studies was 0.38 (95% CI= 0.65 to 2.97, P= 0.41) and for one observational study was 1.33 (95% CI= 0.54 to 3.29, P>0.05). The RR for ICU admission rate in OP poisoning for three trials comparing oximes to placebo was2.12 with 95% CI= 0.89 to 5.03 (P= 0.09). For only one observational study, RR was 0.81 (95% CI= 0.49 to 1.25, P>0.05). For intermediate syndrome, while the RR of only trial comparing oximes with placebo was 1.89 (95% CI= 1.27 to 2.91, P<0.05), for only one observational study, it was 1.43 (95% CI= 0.7 to 2.96, P>0.05). For hospital stay duration, the RR of four studies was 0.75 with 95% CI = -0.51 to 1.99. According to these data, oximes beneficence in OP poisoning is unclear and there is possible increase in incidence of intermediate syndrome.

The burden of hospitalised fall‐related injury in community‐dwelling older people in Victoria: a database study

To estimate the burden of hospitalised fall-related injury in community-dwelling older people in Victoria. We analysed fall-related, person-identifying hospital discharge data and patient-level hospital treatment costs for community-dwelling older people aged 65+ years from Victoria between 1 July 2005 and 30 June 2008, inclusive. Key outcomes of interest were length of stay (LOS)/episode, cumulative LOS (CLOS)/patient and inpatient costs. The burden of hospitalised fall-related injury in community-dwelling older people aged 65+ years in Victoria was 284,781 hospital bed days in 2005-06, rising to 310,031 hospital bed days in 2007-08. Seventy-one per cent of episodes were multiday. One in 15 acute care episodes was a high LOS outlier and 14% of patients had ≥1 episode classified as high LOS outlier. The median CLOS/patient was nine days (interquartile range 2-27). The annual costs of inpatient care, in June 2009 prices, for fall-related injury in community-dwelling people aged 65+ years in Victoria rose from $213 million in 2005-06 to $237 million in 2007-08. The burden of hospitalised fall-related injury in community-dwelling older women, people aged 85+ years and those with comorbidity was considerable. The burden of hospitalised fall-related injury in community-dwelling older people aged 65+ years in Victoria is significantly more than previously projected. Importantly, this study identifies that women, patients with comorbidity and those aged 85+ years account for a considerable proportion of this burden. A corresponding increase in falls prevention effort is required to ensure that the burden is properly addressed.

Meta-analysis of the outcomes of intramedullary nailing and plate fixation of humeral shaft fractures

ObjectiveThe purpose of this study is to compare the outcomes of intramedullary nailing and plate fixation in the treatment of humeral shaft fractures using meta-analysis. MethodsPubMed, MEDLINE, EMBASE, the Cochrane Controlled Clinical Trials Register (CCTR) databases were searched for studies that investigated the efficacy of intramedullary nailing and plate fixation in the management of humeral shaft fractures. Delayed healing rate, nonunion, postoperative infection and radial nerve paralysis were key outcomes of interest. Data were searched within the time period of July 1990 through September 2012. The statistical software RevMan 5.0 was used to analyze the statistical significance of the results. ResultsTotal 459 cases of patients in 10 literature, including 231 cases of plate group and 228 cases of the intramedullary nailing groups were collected. The results of meta-analysis showed that delayed healing rate of humeral shaft fractures was lower in plate fixation compared with intramedullary nailing (RR = 2.64, 95% CI (1.08, 6.49), P < 0.05). No statistically significant difference in nonunion, postoperative infections, radial nerve paralysis and other complications was identified between nailing and plate fixation groups (P > 0.05). ConclusionsIn general, the effect size of intramedullary nailing may be comparable to that of plate fixation in the terms of nonunion, postoperative infections, radial nerve paralysis. The only slightly difference was identified in the event of delayed healing rate.

Induction of clinical response and remission of inflammatory bowel disease by use of herbal medicines: A meta-analysis

To evaluate the efficacy and tolerability of herbal medicines in inflammatory bowel disease (IBD) by conducting a meta-analysis. Electronic databases were searched for studies investigating efficacy and/or tolerability of herbal medicines in the management of different types of IBD. The search terms were: "herb" or "plant" or "herbal" and "inflammatory bowel disease". Data were collected from 1966 to 2013 (up to Feb). The "clinical response", "clinical remission", "endoscopic response", "endoscopic remission", "histological response", "histological remission", "relapse", "any adverse events", and "serious adverse events" were the key outcomes of interest. We used the Mantel-Haenszel, Rothman-Boice method for fixed effects and DerSimonian-Laird method for random-effects. For subgroup analyses, we separated the studies by type of IBD and type of herbal medicine to determine confounding factors and reliability. Seven placebo controlled clinical trials met our criteria and were included (474 patients). Comparison of herbal medicine with placebo yielded a significant RR of 2.07 (95%CI: 1.41-3.03, P = 0.0002) for clinical remission; a significant RR of 2.59 (95%CI: 1.24-5.42, P = 0.01) for clinical response; a non-significant RR of 1.33 (95%CI: 0.93-1.9, P = 0.12) for endoscopic remission; a non-significant RR of 1.69 (95%CI: 0.69-5.04) for endoscopic response; a non-significant RR of 0.64 (95%CI: 0.25-1.81) for histological remission; a non-significant RR of 0.86 (95%CI: 0.55-1.55) for histological response; a non-significant RR of 0.95 (95%CI: 0.52-1.73) for relapse; a non-significant RR of 0.89 (95%CI: 0.75-1.06, P = 0.2) for any adverse events; and a non-significant RR of 0.97 (95%CI: 0.37-2.56, P = 0.96) for serious adverse events. The results showed that herbal medicines may safely induce clinical response and remission in patients with IBD without significant effects on endoscopic and histological outcomes, but the number of studies is limited to make a strong conclusion.

Lifecourse factors and likelihood of rural practice and emigration: a survey of Ghanaian medical students

Health worker shortages and maldistribution have important implications for the capacity of health systems. Ghana has one of the highest physician emigration rates in the world, and over 75% of those who remain work in Ghana's two largest cities. The aim of this study was to investigate the contribution of experiential factors across Ghanaian medical students' lifespans on intent to practice in a rural area and intent to emigrate. All fourth year medical students in Ghana were surveyed on demographics, rural and international experience, and future career plans. Key outcomes of interest were students' stated likelihood of practicing in a deprived rural area or emigrating after graduation. Lifecourse predictors of interest were parental socioeconomic status, gender, relationship status, rural and international living experience, and school of study. Bivariate and multivariate logistic regression were used to estimate associations between predictors and outcomes of interest. Of 310 eligible students, 307 (99%) participated in the survey. Of these, 228 were Ghanaian and the focus of this analysis. It was found that 131 (57.5%) were willing to work in a deprived area in Ghana and 148 (64.9%) had considered emigrating after graduation. In the multivariate regression models, willingness to work in a deprived area was predicted by male gender (OR: 2.31, 95%CI: 1.23-4.35), having lived in a rural area but never lived abroad (OR: 2.77, 95%CI: 1.08-7.13), and low parental professional and educational status (OR: 2.33, 95%CI: 1.23-4.43). Consideration of emigration was predicted by having lived abroad but never in a rural area (OR: 3.39, 95%CI: 1.15-9.97). A sub-set of 80 individuals (35%) reported that they were willing to work in a deprived area in Ghana but also considering emigration. These subjects were more likely to be male. Students with parents of a lower socioeconomic class, those with rural experience, and those without international experience are more likely to stay in Ghana and are also more likely to work in a deprived area after graduation. Selective admissions policies based on lifecourse factors combined with exposure to rural practice in medical school may have a role in increasing the number of rural physicians.