Emergency medical services use by stroke patients: a population-based study

Objectives

Emergency medical services (EMS) use by stroke patients varies from 38% to 65%. In an epidemiological study, we determined the proportion of stroke patients who used EMS, hypothesizing that demographics, stroke severity, stroke type, and location at stroke onset would be associated with EMS use.

Methods

Stroke and transient ischemic attack patients were identified in a population of 1.3 million in the Cincinnati area in 1999. Patient charts and EMS records were abstracted by research nurses and reviewed by study physicians. The proportion of EMS users was computed. Logistic regression was used to test for associations with EMS use.

Results

Of 3949 strokes, we excluded strokes/transient ischemic attacks that occurred in the hospital (n = 283), out of town (n = 10), during EMS transport (n = 2), and at unknown locations (n = 73). Patients with unknown EMS use (n = 301); those with missing estimated stroke severity (n = 174), prestroke disability (n = 78), race (n = 3), and stroke type (n = 3); and those younger than 18 years (n = 14) were also excluded. The remaining 3008 patients had a mean age of 74 years, 17% were black, and 45% were men. Emergency medical services was used by 1532 (50.9%) patients. Age, prestroke disability, stroke severity, hemorrhagic stroke, and stroke at work were associated with EMS use. Race, sex, and prior stroke were not associated with EMS use.

Conclusion

Half of stroke patients used EMS in our population-based study. Older patients; those with greater prestroke disability, more severe stroke, and hemorrhagic stroke; and those having stroke at work were more likely to use EMS.     

Patterns of use of emergency medical transport: a population-based study

The objective of this study was to characterize population-based emergency medical service (EMS) use rates and examine some of the factors associated with usage of prehospital services. The design was a population-based observational study with multiple regression analysis. Transports reported by prehospital services to the Kentucky Emergency Medical Services Information System from Kentucky counties in which all EMS units submit computerized data was the data source. There were 102,321 emergent transports reported. The overall rate of use of EMS transports was 51.7 +/- 24.1/1,000/year, but the rate varied between different communities (range 11 to 139/1,000/year). Rate of use was highest in those older than 65 (178.5 +/- 84.2/1,000/year), with the rate increasing exponentially with increasing age in this age group. Reasons for transport were age dependent. There was an association between increasing poverty level and use of EMS. In addition, the absence of 911 service (odds ratio [OR] 1.18, 95% confidence interval [CI; 1.14,1.22]) and the absence of a hospital in the county (OR 1.27, 95% CI [1.24,1.30]) were also associated with increasing rates of ambulance use. Rates of use of EMS are most dependent on age and cause, but use is also correlated with increasing levels of poverty. Wide variations in use between communities suggests that point estimates using one community may over- or underestimate EMS usage.     

Out-of-hospital cardiac arrest in the elderly: A large-scale population-based study

BackgroundThere is little information on elderly people who suffer from out-of-hospital cardiac arrest (OHCA).AimTo determine 30-day mortality and neurological outcome in elderly patients with OHCA.MethodsOHCA patients ≥70 years of age who were registered in the Swedish Cardiopulmonary Resuscitation Register between 1990 and 2013 were included and divided into three age categories (70–79, 80–89, and ≥90 years). Multiple logistic regression analyses were performed to identify independent predictors of 30-day survival.ResultsAltogether, 36,605 cases were included in the study. Thirty-day survival was 6.7% in patients aged 70–79 years, 4.4% in patients aged 80–89 years, and 2.4% in those over 90 years. For patients with witnessed OHCA of cardiac aetiology found in a shockable rhythm, survival was higher: 20%, 15%, and 11%, respectively. In 30-day survivors, the distribution according to the cerebral performance categories (CPC) score at discharge from hospital was similar in the three age groups. In multivariate analysis, in patients over 70 years of age, the following factors were associated with increased chance of 30-day survival: younger age, OHCA outside the home, witnessed OHCA, CPR before arrival of EMS, shockable first-recorded rhythm, and short emergency response time.ConclusionsAdvanced age is an independent predictor of mortality in OHCA patients over 70 years of age. However, even in patients above 90 years of age, defined subsets with a survival rate of more than 10% exist. In survivors, the neurological outcome remains similar regardless of age.     

Emergency medical technician treatment of hypoglycemia without transport

Objectives

We examine the safety and efficacy of emergency medical technicians (EMTs) providing treatment to stable hypoglycemic patients without transport or paramedic involvement, which is currently beyond their scope of practice.

Methods

All hypoglycemic patients treated in the field without transport for 12 months were included. We used a patient follow-up survey to compare the outcomes of EMT and paramedic-treated patients on the occurrence of repeat hypoglycemic episodes, 911 calls, and/or in-hospital reevaluation within 48 hours; patients' adhering to the provided instructions; and patient satisfaction.

Results

Of 402 cases identified, we were able to contact and survey 203 (51%). There were no statistically significant differences for any of the outcome measures studied. Patients treated by EMTs (110) and paramedics (93) had 8 (7%) and 7 (8%) episodes of repeat hypoglycemia, 3 (3%) and 5 (5%) repeat 911 calls, and 9 (8%) and 10 (11%) hospital evaluations, respectively.

Conclusions

Emergency medical technicians performed comparably with paramedics treating hypoglycemia without transport.     

Chronic pain among community-dwelling elderly: a population-based clinical study

Objective: To present the occurrence, characteristics, etiology, interference, and medication of chronic pain among the elderly living independently at home. Design/setting: A total of 460 subjects in three cohorts aged 75, 80 and 85 years respectively received visits by communal home-care department nurses for a cross-sectional survey. Of them, 175 had chronic (duration ≥ 3 months) pain with an average intensity of ≥ 4/10 and/or ≥ moderate interference in daily life. Main outcome measures: Clinical assessment was performed for consenting subjects to define the location, intensity, etiology, type, interference and medications of chronic pain. Results: According to home visits, elderly people with chronic pain rated their health and mobility worse and felt sadder, lonelier and more tired than those without chronic pain. A geriatrician made clinical assessments for 106 patients with chronic pain in 2009–2013. Of them, 66 had three, 35 had two and 5 had one pain condition. The worst pain was musculoskeletal in 88 (83%) of patients. Pain was pure nociceptive in 61 (58%), pure neuropathic in 9 (8%), combined nociceptive and neuropathic pain in 34 (32%), and idiopathic in 2 (2%) patients. On a numerical rating scale from 0 to 10, the mean and maximal intensity of the worst pain was 5.7 and 7.7, respectively, while the mean pain interference was 5.9. Mean pain intensity and maximal pain intensity decreased by age. Duration of pain was longer than 5 years in 51 (48%) patients. Regular pain medication was used by 82 (77%) patients, most commonly paracetamol or NSAIDs. Although pain limited the lives of the elderly with chronic pain, they were as satisfied with their lives as those without chronic pain. Conclusions: Elderly people in our study often suffered from chronic pain, mostly musculoskeletal pain, and the origin of pain was neuropathic in up to 40% of these cases. However, elderly people with chronic pain rarely used the medications specifically for neuropathic pain. Based on increased loneliness, sadness and tiredness, as well as decreased subjective health and mobility, the quality of life was decreased among those with chronic pain compared with those without pain.

• Key Points

• It is known that chronic pain is one of the most common reasons for general practice consultations and is more common in women than men.

• In our study using detailed clinical examinations, up to 40% of patients with chronic pain in cohorts aged 75, 80 and 85 years suffered from neuropathic pain.

• However, only a few elderly people with chronic pain used medications specifically for chronic pain, which may be due to side effects or non-willingness to experiment with these drugs.

• Elderly people with chronic pain rated their health and mobility to be worse and felt sadder, lonelier and more tired but were not less satisfied with their lives than those without chronic pain.

     

Diabetes and automobile crashes in the elderly. A population-based case-control study.

OBJECTIVE: The aim of this study was to estimate the association between diabetes and its complications and at-fault automobile crashes among older drivers. RESEARCH DESIGN AND METHODS: This was a population-based case-control study. Case subjects were drivers aged > or = 65 years who had been involved in a crash during 1996 in which they were at fault. Two control groups were selected: 1) crash-involved not-at-fault subjects and 2) non-crash-involved subjects. Telephone interviewers collected information on demographic characteristics, driving habits, diabetes sequelae and treatment, other chronic medical conditions, and visual function. RESULTS: Overall, there was no association between diabetes and at-fault crash involvement. The adjusted odds ratio (OR) for diabetes was 1.1 (CI 0.7-1.9) when case subjects were compared with either control group. However, the adjusted OR for diabetes was 2.5 (0.9-7.2) among subjects who had been involved in a crash in the 4 years preceding 1996, while it was only 0.9 (0.5-1.7) among those who had not. There was no evidence of an association between treatment modalities and at-fault crash involvement. Case subjects were, although not significantly (P = 0.25), more likely (OR 2.4) to report neuropathy compared with both control groups, and retinopathy was not associated with increased crash risk. CONCLUSIONS: This study provides no evidence that older drivers with diabetes are at increased risk for automobile crashes. There remains the possibility that those with diabetes who have more severe disease or have had multiple crashes are at increased risk.     

Direct medical costs in patients with Alzheimer's disease in Taiwan: A population-based study

Background: Alzheimer's disease (AD) has the potential to become a major health concern and associated health care costs may become a significant economic burden on society.Objective: The aim of this study was to estimate the direct medical costs attributable to AD in patients aged ≥60 years in Taiwan from 2000 through 2002 and to explore the correlation of these costs with patients' age and sex.Methods: This study was based on the National Health Insurance Research Database of Taiwan's National Health Insurance (NHI) program. The NHI program insures >98% of the 23 million inhabitants of Taiwan. Detailed data were extracted from a random sample of 0.2% of inpatient and 5% of outpatient recipients with AD (International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 331.0) who were aged ≥60 years and who received inpatient or outpatient services with claims from January 1, 2000, to December 31, 2002. Duplicate charges for a specific patient and diagnoses of other types of dementia were excluded from this study.Results: A total of 69,780 patients were found to have a diagnosis of AD. The direct medical costs for outpatients were estimated at US $1.2 million in 2000, US $1.9 million in 2001, and US $2.3 million in 2002; the costs for inpatient care were estimated at US $670,000 in 2000, US $2.4 million in 2001, and US $3.2 million in 2002. The total direct medical costs were estimated at US $1.86 million in 2000, US $4.24 million in 2001, and US $5.48 million in 2002. The increase of total direct medical costs was not significantly correlated with patients' age or sex.Conclusions: From 2000 through 2002, the direct medical costs of AD increased annually in Taiwan among patients with AD aged ≥60 years. No significant correlation was found between increased total direct medical costs and sex or age. The cost estimate presented here has implications for future decision making about reallocating medical resources for treating AD in Taiwan.     

Causes of strain affecting relatives of Swedish oldest elderly. A population-based study

We examined determinants of carer strain in a random sample of 170 relative of dependent elderly persons in Sweden aged 80 years or more. These persons were interviewed at home by means of the Sickness Impact Profile (SIP). Carer strain was assessed in interviews with carers who bore the main responsibility for care of an elderly relative. The response rate was 92%. Multiple logistic regression showed that cohabitation of carer and recipient was the sociodemographic variable most significantly associated with various stress factors and consequences or manifestations of stress; strain connected with ADL assistance given to the elderly person, strain arising from the elderly person's uncooperative or recalcitrant attitude or behaviour, worsening of the elderly-carer relationship, and encroachment on the carer's social life. Correlations between strain and various categories of physical and mental impairment were much lower, and in some respects were even negative. We conclude that support programs for relatives caring for dependent elderly persons should aim primarily at creating continuous relief for the carers and improving their opportunities for contact with other people generally.     

Urbanization and place of death for the elderly: a 10-year population-based study

OBJECTIVES: To explore the association between the place of death and the level of urbanization within the communities where the elderly were residing at the time of their death. METHODS: A retrospective, population-based, cross-sectional study set in Taiwan, involving a total of 697,814 eligible deaths occurred between 1995 and 2004, among elderly people (aged 65 years or above). RESULTS: After adjusting for other factors, the multilevel logistic regression analyses showed that home death was associated with lower levels of urbanization; as compared with participants living in the highest urbanization level (level 1), the respective adjusted odds of dying at home were 1.600, 2.769, 3.774, 4.481, 4.003 and 4.717 times for those living in the areas from the second highest to the lowest urbanization levels (levels 2-7). CONCLUSIONS: After adjusting for other socio-demographic, clinical and healthcare factors, the place of death has a significant association with the level of urbanization among the elderly.     

军队干体所老年人轻度认知功能损害的患病率调查

INTRODUCTIONMildcognitiveimpairment（MCI）isconsideredtobeatransitionalstagebetweenagingandAlzheimerdisease（AD），whichisanewfocusinclinicalresearchofAD犤１－８犦．MCIisbelievedtobeahigh－riskconditionforthedevelopmentofADandhasbeenproposedasanosologicalentity犤３－８犦．However，theepidemiologyofMCIisnotwellknowninChina．ThisstudywasdesignedtodeterminetheprevalenceofMCIinanelderlypopulation．MATERIALSANDMETHODSMaterialsAlltheveteranssanatoriumsinShijiazhuangcitywereinves…     

Emergency medical support units to critical care transport teams in Iraq

Early in the author's deployment in the United States Air Force to southern Iraq, his unit was exposed to the first of many mass casualties sent to his Expeditionary Medical Support System unit. Within minutes of the injured military members' arrival, the four-bed evaluation station was transformed into an open bay trauma room where patients were treated and supported until they could be evacuated to more definitive care. Patients were transitioned with awe-inspiring speed and professionalism to Critical Care Air Transport teams for care during aeromedical evacuation. The lessons learned from the frequency of these events are valuable to any similar transport case with critically ill and injured patients.     

Emergency medical services: Brazil

Emergency medical services in Brazil have been created to offer first aid, primary medical treatment, basic life support, stabilization and rapid transfer to the closest appropriate hospital and advanced life support. Pre-hospital emergency care in Brazil is divided into permanent and mobile services. Permanent care is provided by the pre-hospital network (basic health units, family health program, specialized clinics, diagnosis and therapy services, non-hospital emergency care units). The mobile medical services include: mobile emergency care service, fire department and private services. Emergency hospital care units (emergency departments) are classified into general and reference units. Details of these services are described.     

Relationship between migraine, blood pressure and carotid thickness. A population-based study in the elderly

The relationship between migraine and blood pressure is controversial. We studied the association between migraine and blood pressure in a population-based sample of elderly patients. Participants were 1373 subjects 59-71 years of age. Lifetime migraine was diagnosed according to the International Headache Society criteria by a headache specialist. Blood pressure was measured as well as the carotid intima-media thickness (IMT) which is a good marker of the long-term exposure to high blood pressure. Migraine during life was diagnosed in 140 participants. Mean systolic blood pressure was lower in subjects with migraine than in those without headache (128 mmHg vs. 137 mmHg). There was a significant trend of decreasing frequency of migraine with increasing blood pressure and also with increasing IMT. In this study, migraine was associated with lower levels of blood pressure and with smaller values of carotid wall thickness.     

Emergency medical services transport of patients with headache: Mode of arrival may indicate serious etiology

Objective. To determine whether mode of arrival is associated with seriousness of etiology and use of diagnostic testing in patients treated in the emergency department for headache. Methods. This observational, retrospective study was conducted by consecutive review of the records of patients presenting to the emergency department with a chief complaint of headache from December 1994 through May 1995. Patients with altered mental status or seizures were excluded. Mode of arrival was classified as either by EMS or other (e.g., private vehicle). Patients with a final diagnosis of meningitis, intracranial hemorrhage, or central nervous system tumor were classified as having serious causes, whereas those with headache due to migraine, tension headache, or headache that was otherwise unspecified were classified as nonserious. The use of diagnostic studies, such as lumbar puncture or CT scan, and their results, was recorded. Patients were included in the category of patients having serious intracranial pathology even if the diagnosis was delayed. Statistical analysis was performed using the Yates-corrected chi-square test, and by determining odds ratios (ORs) with 95% confidence intervals. Results. For 967 patients presenting with a chief complaint of headache, 837 charts were included in the analysis. A total of 102 patients arrived by EMS, and 735 arrived by other means. Patients arriving by EMS had a higher rate of serious cause of headache than did those arriving by other means (OR = 18.5, p < 0.0001). EMS patients tended to undergo additional diagnostic testing (OR = 4.4, p < 0.001), and those tests were more likely to be abnormal than for those arriving by other means (OR = 9.4, p < 0.0001). Males had a somewhat higher rate of serious diagnosis (OR = 2.6, p < 0.05). Conclusions. In this EMS system, patients with headache who arrive by EMS are more likely to have serious causes. Mode of arrival may be of use to the clinician in assessing risk of serious illness among patients with headache. Whether this observation represents an element of self-triage or a combination of other factors remains to be determined.     

Need for urgent medical care in a Jerusalem neighborhood: a population-based study

We conducted a population-based survey of an urban community in Jerusalem to estimate the incidence of urgent and emergency medical events and to characterize the response of the populace to various medical episodes. We found deficiencies in the ability of the population to identify an urgent event, resulting in long delays in seeking professional care, as well as inappropriate choice of source of care, in a substantial proportion of subjects. These deficiencies can and should be corrected by inexpensive educational programs.     

Bereavement grief: A population-based foundational evidence study

Information is needed on the incidence and prevalence of bereavement grief, and factors associated with severe or prolonged grief. Among 1,208 representative Canadian adults, 96% had experienced bereavement grief and 78% were actively grieving at interview. Grief levels were higher among women, Protestants, and Catholics, when the death was under 2 years previously, when a spouse, parent, or child had died, and when the perceived death quality was lower. This study reveals the importance of good deaths; they are essential for dying people and also those who mourn their deaths.     

A longitudinal population-based study of prothrombotic factors in elderly subjects with atrial fibrillation: the Rotterdam Study 1990–1999

BACKGROUND: A prothrombotic or hypercoagulable state in atrial fibrillation may contribute to stroke and thromboembolism. Results of longitudinal population-based studies in elderly people with atrial fibrillation are not yet available. METHODS: In the Rotterdam Study, a population-based prospective cohort study, 162 participants with atrial fibrillation at baseline, aged 55 years and over, were matched for age and gender with 324 people in sinus rhythm. Associations were examined between three coagulation factors and the risk of total and cardiac mortality and stroke. Hazard rate ratios were calculated with 95% confidence intervals using Cox's proportional hazards model, adjusted for potential confounders. RESULTS: Plasma von Willebrand factor was, age- and gender-adjusted, associated with cardiac mortality in the total population (relative risk 1.16; 1.06-1.27, per 10 IU dL(-1) increase), but statistical significance was lost after additional adjustments. A strong association (1.27; 1.08-1.50, per 5-unit increase) was found between soluble P-selectin (sP-sel) and cardiac mortality in atrial fibrillation patients but not in participants in sinus rhythm. Furthermore, the expected association between fibrinogen and cardiac mortality was observed only in those in sinus rhythm (2.60; 1.69-4.01, per unit increase), and not in atrial fibrillation. No associations were found between coagulation factors and stroke. CONCLUSIONS: In this population-based study, plasma levels of sP-sel predicted clinical adverse outcomes in atrial fibrillation, suggesting a role of platelets in the prothrombotic state associated with atrial fibrillation. Fibrinogen was a risk factor of cardiac and all-cause mortality in sinus rhythm, but not in atrial fibrillation.