This study aimed to identify stroke patients at high risk of repeated falls upon discharge from the hospital. The researchers recruited 122 independently mobile stroke patients being discharged from the hospital and assessed their balance, functioning, mood and attention both at discharge and 12 months later. Of the 115 patients with 12-month follow-up data, 63 experienced at least one fall and 48 experienced repeated falls in the first year. Through statistical analysis, the researchers identified that patients who experienced near-falls in the hospital and had poor upper limb function were most likely to experience repeated falls, with 70% specificity and 60% sensitivity. This study helps address the lack of knowledge around predicting future fall risk in stroke patients at the time of hospital discharge.
The document discusses important considerations for anesthetic choice in elderly patients undergoing surgery. Older patients are at higher risk of complications and mortality compared to younger patients. Even minor physiologic disturbances during surgery can have serious consequences for frail elderly patients with limited reserve. The choice of anesthetic regimen and agents can help minimize risks. For example, etomidate is preferred over propofol for induction due to lower risk of hypotension in older patients. Careful preoperative evaluation and avoidance of complications is important for optimizing outcomes in elderly surgical patients.
Inter society consensus for the management of peripheral arterial disease (tasc)Jonathan Campos
This document summarizes the key findings of the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). It discusses the prevalence of peripheral arterial disease (PAD), finding that PAD affects approximately 3-10% of the general population but is asymptomatic in around 75% of cases. The ratio of asymptomatic to symptomatic PAD is estimated to be between 3:1 and 4:1. Symptomatic PAD presents mainly as intermittent claudication. The document also outlines the grading system used to rate the strength of recommendations.
Complication Rates Following Open Reduction and Internal Fixation of Ankle Fr...Ortopedia Chiapas
This study analyzed data from 57,183 patients in California who underwent open reduction and internal fixation surgery for ankle fractures between 1995-2005 to determine short and intermediate-term complication rates. The overall short-term complication rate was low, below 2% for most outcomes. However, open fractures, older age, diabetes, and peripheral vascular disease significantly increased short-term complication risks. The intermediate fracture reoperation rate was also low at below 1% at 1 and 5 years. Trimalleolar fractures and open fractures significantly predicted higher reoperation risks. Hospital procedure volume did not significantly impact complication rates.
The study evaluated practices around informed consent for surgery at a hospital in Pakistan. It found that consent was often taken by nurses for elective surgeries and residents for emergencies, rather than surgeons. Patients were usually not well informed about risks and complications. While most patients were told the type of anesthesia, very few were told about anesthesia risks. Consent was often signed by family rather than patients. Overall, current practices did not adequately inform patients or respect patient autonomy, indicating a need for improved informed consent procedures.
HRV in trauma patients during prehospital transportRachel Russo, MD
1) The study found that prehospital heart rate variability (HRV), specifically standard deviation of normal-to-normal R-R intervals (SDNN), predicted patients with a base excess ≤-6, those requiring life-saving procedures, and those classified as seriously injured better than routine trauma criteria or vital signs.
2) When used alone as a triage tool, SDNN had a sensitivity of 80%, specificity of 75%, and accuracy of 76% for predicting life-saving interventions, outperforming other prehospital measures.
3) Incorporating SDNN into trauma triage criteria models improved prediction of outcomes compared to models without SDNN, better discriminating patients who were seriously or minimally injured
Geriatric Oncology
1. Relationship between aging and cancer
2. Constructs of frailty and multimorbidity
3. Evidence for geriatric assessment in older adults living with cancer
The document discusses important considerations for anesthetic choice in elderly patients undergoing surgery. Older patients are at higher risk of complications and mortality compared to younger patients. Even minor physiologic disturbances during surgery can have serious consequences for frail elderly patients with limited reserve. The choice of anesthetic regimen and agents can help minimize risks. For example, etomidate is preferred over propofol for induction due to lower risk of hypotension in older patients. Careful preoperative evaluation and avoidance of complications is important for optimizing outcomes in elderly surgical patients.
Inter society consensus for the management of peripheral arterial disease (tasc)Jonathan Campos
This document summarizes the key findings of the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). It discusses the prevalence of peripheral arterial disease (PAD), finding that PAD affects approximately 3-10% of the general population but is asymptomatic in around 75% of cases. The ratio of asymptomatic to symptomatic PAD is estimated to be between 3:1 and 4:1. Symptomatic PAD presents mainly as intermittent claudication. The document also outlines the grading system used to rate the strength of recommendations.
Complication Rates Following Open Reduction and Internal Fixation of Ankle Fr...Ortopedia Chiapas
This study analyzed data from 57,183 patients in California who underwent open reduction and internal fixation surgery for ankle fractures between 1995-2005 to determine short and intermediate-term complication rates. The overall short-term complication rate was low, below 2% for most outcomes. However, open fractures, older age, diabetes, and peripheral vascular disease significantly increased short-term complication risks. The intermediate fracture reoperation rate was also low at below 1% at 1 and 5 years. Trimalleolar fractures and open fractures significantly predicted higher reoperation risks. Hospital procedure volume did not significantly impact complication rates.
The study evaluated practices around informed consent for surgery at a hospital in Pakistan. It found that consent was often taken by nurses for elective surgeries and residents for emergencies, rather than surgeons. Patients were usually not well informed about risks and complications. While most patients were told the type of anesthesia, very few were told about anesthesia risks. Consent was often signed by family rather than patients. Overall, current practices did not adequately inform patients or respect patient autonomy, indicating a need for improved informed consent procedures.
HRV in trauma patients during prehospital transportRachel Russo, MD
1) The study found that prehospital heart rate variability (HRV), specifically standard deviation of normal-to-normal R-R intervals (SDNN), predicted patients with a base excess ≤-6, those requiring life-saving procedures, and those classified as seriously injured better than routine trauma criteria or vital signs.
2) When used alone as a triage tool, SDNN had a sensitivity of 80%, specificity of 75%, and accuracy of 76% for predicting life-saving interventions, outperforming other prehospital measures.
3) Incorporating SDNN into trauma triage criteria models improved prediction of outcomes compared to models without SDNN, better discriminating patients who were seriously or minimally injured
Geriatric Oncology
1. Relationship between aging and cancer
2. Constructs of frailty and multimorbidity
3. Evidence for geriatric assessment in older adults living with cancer
This study evaluated 25 patients with late onset congenital aqueductal stenosis hydrocephalus. The patients ranged from 5-64 years old and most were male. Common presenting symptoms were headache, visual disturbances, and gait disturbances. MRI and CT scans showed dilated ventricles. All patients underwent ventriculoperitoneal shunt placement. Most patients (80%) improved after surgery, while some developed complications like subdural hematomas. Late onset aqueductal stenosis hydrocephalus can present in adulthood and proper diagnosis through imaging and treatment with shunts can improve outcomes.
- The median delay from first consultation to radiation simulation for cervical cancer patients was 55 days. Longer delays did not correlate with increased tumor progression. However, one in four patients received blood transfusions or were hospitalized while waiting, and some required emergency brachytherapy due to bleeding. Though delays did not definitively increase progression in this study, the long wait times highlighted issues in access to timely radiation treatment for cervical cancer patients.
This study analyzed data from the California Patient Discharge Database between 2005-2013 to determine rates of subsequent major amputation after initial minor amputation due to peripheral artery disease (PAD) and/or diabetes mellitus (DM). Patients with combined PAD/DM had the highest rates of major amputation (6.3%) and repeat minor amputation (16%) compared to those with DM or PAD alone. The median time to major amputation was 12.9 months, with no significant differences between groups. Mortality rates were also highest in the PAD/DM group at 49%. Revascularization before subsequent amputation was associated with lower risk of limb loss.
The emerging field of oncogeriatrics, or geriatric oncology, deals with management of cancer in older people. This presentation introduces the area and reviews the evidence base. It also explains how cancer presents and behaves differently in older people.
Circulation 2015-criterios de jones reviewgisa_legal
This document revises the Jones criteria for diagnosing acute rheumatic fever to better align with current evidence and international guidelines. It recognizes that acute rheumatic fever remains a serious health problem globally. The revisions define high-risk populations, acknowledge variability in clinical presentation among these groups, and include Doppler echocardiography as a tool for diagnosing cardiac involvement even without overt symptoms. This represents the first major revision to the Jones criteria by the American Heart Association in over 20 years and applies their classification system for recommendations and evidence levels.
This document discusses guidelines for a clinical practice guideline on perioperative care. It summarizes discussions between guideline writing committees on how to address controversies surrounding certain clinical trials. Specifically, it was agreed that the controversial DECREASE trials led by Poldermans would be excluded from systematic reviews and recommendations. Nonretracted publications from these trials could be cited but not used as the basis for recommendations. The committees aimed to balance transparency with the availability of new evidence in developing their guidelines.
This document provides an updated clinical practice guideline from the American Society of Clinical Oncology and the American Society of Hematology on the use of erythropoiesis-stimulating agents (ESAs) in adult patients with cancer. The guideline committee reviewed new data published between 2007 and 2010. For patients with chemotherapy-induced anemia and a hemoglobin level under 10g/dL, the committee recommends discussing the potential harms and benefits of ESAs or red blood cell transfusions with patients. The risks and benefits of each option should contribute to shared decisions. The committee cautions against ESA use in other circumstances and provides other recommendations, such as administering ESAs at the lowest effective dose.
This document contains summaries of multiple studies that have found associations between red blood cell transfusions and negative health outcomes in critically ill and surgical patients. Specifically:
- 42 of 45 observational studies found that the risks of red blood cell transfusions outweighed the benefits for adult intensive care unit, trauma and surgical patients. Transfusions were associated with increased mortality, infections, multi-organ dysfunction and acute respiratory distress syndrome.
- Pooled analyses found odds ratios of 1.7 for mortality, 1.8 for infections, and 2.5 for acute respiratory distress syndrome in patients who received red blood cell transfusions.
- Transfusions appeared to have dose-dependent relationships with negative outcomes, with each additional unit
This document discusses cancer in older adults and the use of comprehensive geriatric assessment (CGA) to evaluate older cancer patients. It makes three key points:
1. CGA can help oncologists define "elderly" cancer patients and evaluate them for treatment. Factors like frailty, comorbidities, and functional status are more important than age alone.
2. CGA has prognostic value, as it can identify risk factors for toxicity from chemotherapy and predict patient outcomes. Frail older patients have higher risks of adverse events.
3. CGA tools have been developed that use factors like frailty, blood pressure, liver/kidney function to predict risks of severe toxicity and categorize
This study developed a preoperative risk model to predict the occurrence of postoperative pneumonia in patients undergoing coronary artery bypass grafting (CABG). Researchers analyzed data on over 16,000 CABG patients from 33 hospitals. Postoperative pneumonia occurred in 3.3% of patients. The final model identified 17 preoperative factors that were significantly associated with increased risk of pneumonia, including demographics, laboratory values, comorbid diseases, pulmonary function, and cardiac function/anatomy. The model had good discrimination (C-statistic of 0.74) and performed well in validation analyses. This risk model can help provide individualized risk estimates and identify opportunities to reduce preoperative pneumonia risk.
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
This literature review covers three topics: pneumonia, lung cancer, and pulmonary fibrosis. For pneumonia, it summarizes that the declines in childhood pneumonia hospitalizations observed after the introduction of PCV7 vaccines were sustained over a decade. It also found substantial reductions in adult pneumonia hospitalizations. For lung cancer, it discusses findings from several large randomized controlled trials that low-dose CT screening detects more early-stage lung cancers compared to chest radiography and tends to result in a stage shift toward earlier diagnoses. For pulmonary fibrosis, it reviews that the natural history can vary significantly, from complete resolution to progressive fibrosis leading to respiratory failure.
This document proposes a new 5-stage classification system (A-E) for cardiogenic shock to improve communication and help guide treatment. Stage A is "at risk" for shock, stage B is "beginning" shock, stage C is "classic" shock with hypoperfusion, stage D means initial interventions did not restore stability despite 30 minutes of observation, and stage E is "extremis" with cardiovascular collapse. The goal is to have a simple, clinically applicable system that can be used across care settings and potentially help identify patients most likely to benefit from different treatments.
This study analyzed 1,145 patients who underwent ERCP at a regional hospital in Mexico from 2002-2011. The complication rate was 2.1%, with hemorrhage being the most common complication at 1.2%. Precut/sphincterotomy was found to increase the risk of complications by 1.4 times compared to those without. The study concluded the complication rate was similar to other reports but could be reduced by only performing ERCP for therapeutic purposes and by highly qualified endoscopists.
This document presents the 2012 World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease. An international panel of experts developed evidence-based guidelines to standardize the identification of rheumatic heart disease using echocardiography. The guidelines define three categories - 'definite RHD', 'borderline RHD', and 'normal'. Criteria for 'definite RHD' include pathological mitral or aortic regurgitation accompanied by specific morphological changes to the valves. 'Borderline RHD' includes minor abnormalities that do not meet criteria for 'definite RHD'. The standardized criteria aim to allow consistent identification of rheumatic heart disease globally to facilitate screening and secondary prophylaxis programs.
Cerebrovascular stroke recurrence among critically ill patients (2)Alexander Decker
This document summarizes a study on risk factors, frequency, and severity of recurrent cerebrovascular stroke among critically ill patients admitted to intensive care units at a university hospital in Egypt. The study aimed to identify risk factors for recurrent stroke and examine recurrence intervals, frequency, and severity. Medical records of 80 patients admitted with recurrent stroke over 6 months were analyzed. Results found the majority had hypertension and diabetes as comorbidities. 30% experienced recurrence 2-5 years after initial stroke. Over 36% of cases were severe, with a mean severity score of 19.17 out of 42. The study concluded uncontrolled risk factors like age, gender, medical noncompliance and lifestyle factors like smoking contributed to recurrent strokes of varying severity.
This document discusses acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in resource-limited settings. It presents a case study of a 12-year-old girl diagnosed with ARF in The Gambia. Key challenges in diagnosis and management of ARF and RHD in these settings include limited access to investigations like echocardiography and lack of specialists. The Jones criteria for diagnosing ARF may be too insensitive for high-prevalence areas. Management involves bed rest, antibiotics, aspirin, and follow-up care, though access can be limited. RHD is a major cause of heart disease worldwide and often presents with severe disease due to limited care access.
This document provides guidelines from the American Diabetes Association and European Association for the Study of Diabetes on the management of hyperglycemia in type 2 diabetes. It recommends a patient-centered approach that considers individual patient needs and preferences. Glycemic targets should aim to lower HbA1c levels to <7% but must be tailored based on factors like disease duration, comorbidities, and risks of hypoglycemia. The guidelines emphasize shared decision-making between clinicians and patients and choosing therapies based on each drug's efficacy, safety profile, costs and patient lifestyle.
El documento proporciona especificaciones técnicas para cables monopolares de media tensión (MV) de 90°C para 5kV, 15kV y 35kV. Describe los componentes de los cables, incluidos el conductor, blindajes, aislamiento y chaqueta exterior. Incluye tablas con los diámetros, pesos y otras características para diferentes calibres de cable.
Este documento describe un curso de protecciones de subestaciones. Explica que el objetivo es enseñar a electricistas a interpretar correctamente el funcionamiento de las protecciones durante fallas en un sistema eléctrico de potencia. También cubre los diferentes tipos de fallas que pueden ocurrir, como cortocircuitos, y los sistemas de protección como fusibles y relevadores para proteger adecuadamente el sistema.
This study evaluated 25 patients with late onset congenital aqueductal stenosis hydrocephalus. The patients ranged from 5-64 years old and most were male. Common presenting symptoms were headache, visual disturbances, and gait disturbances. MRI and CT scans showed dilated ventricles. All patients underwent ventriculoperitoneal shunt placement. Most patients (80%) improved after surgery, while some developed complications like subdural hematomas. Late onset aqueductal stenosis hydrocephalus can present in adulthood and proper diagnosis through imaging and treatment with shunts can improve outcomes.
- The median delay from first consultation to radiation simulation for cervical cancer patients was 55 days. Longer delays did not correlate with increased tumor progression. However, one in four patients received blood transfusions or were hospitalized while waiting, and some required emergency brachytherapy due to bleeding. Though delays did not definitively increase progression in this study, the long wait times highlighted issues in access to timely radiation treatment for cervical cancer patients.
This study analyzed data from the California Patient Discharge Database between 2005-2013 to determine rates of subsequent major amputation after initial minor amputation due to peripheral artery disease (PAD) and/or diabetes mellitus (DM). Patients with combined PAD/DM had the highest rates of major amputation (6.3%) and repeat minor amputation (16%) compared to those with DM or PAD alone. The median time to major amputation was 12.9 months, with no significant differences between groups. Mortality rates were also highest in the PAD/DM group at 49%. Revascularization before subsequent amputation was associated with lower risk of limb loss.
The emerging field of oncogeriatrics, or geriatric oncology, deals with management of cancer in older people. This presentation introduces the area and reviews the evidence base. It also explains how cancer presents and behaves differently in older people.
Circulation 2015-criterios de jones reviewgisa_legal
This document revises the Jones criteria for diagnosing acute rheumatic fever to better align with current evidence and international guidelines. It recognizes that acute rheumatic fever remains a serious health problem globally. The revisions define high-risk populations, acknowledge variability in clinical presentation among these groups, and include Doppler echocardiography as a tool for diagnosing cardiac involvement even without overt symptoms. This represents the first major revision to the Jones criteria by the American Heart Association in over 20 years and applies their classification system for recommendations and evidence levels.
This document discusses guidelines for a clinical practice guideline on perioperative care. It summarizes discussions between guideline writing committees on how to address controversies surrounding certain clinical trials. Specifically, it was agreed that the controversial DECREASE trials led by Poldermans would be excluded from systematic reviews and recommendations. Nonretracted publications from these trials could be cited but not used as the basis for recommendations. The committees aimed to balance transparency with the availability of new evidence in developing their guidelines.
This document provides an updated clinical practice guideline from the American Society of Clinical Oncology and the American Society of Hematology on the use of erythropoiesis-stimulating agents (ESAs) in adult patients with cancer. The guideline committee reviewed new data published between 2007 and 2010. For patients with chemotherapy-induced anemia and a hemoglobin level under 10g/dL, the committee recommends discussing the potential harms and benefits of ESAs or red blood cell transfusions with patients. The risks and benefits of each option should contribute to shared decisions. The committee cautions against ESA use in other circumstances and provides other recommendations, such as administering ESAs at the lowest effective dose.
This document contains summaries of multiple studies that have found associations between red blood cell transfusions and negative health outcomes in critically ill and surgical patients. Specifically:
- 42 of 45 observational studies found that the risks of red blood cell transfusions outweighed the benefits for adult intensive care unit, trauma and surgical patients. Transfusions were associated with increased mortality, infections, multi-organ dysfunction and acute respiratory distress syndrome.
- Pooled analyses found odds ratios of 1.7 for mortality, 1.8 for infections, and 2.5 for acute respiratory distress syndrome in patients who received red blood cell transfusions.
- Transfusions appeared to have dose-dependent relationships with negative outcomes, with each additional unit
This document discusses cancer in older adults and the use of comprehensive geriatric assessment (CGA) to evaluate older cancer patients. It makes three key points:
1. CGA can help oncologists define "elderly" cancer patients and evaluate them for treatment. Factors like frailty, comorbidities, and functional status are more important than age alone.
2. CGA has prognostic value, as it can identify risk factors for toxicity from chemotherapy and predict patient outcomes. Frail older patients have higher risks of adverse events.
3. CGA tools have been developed that use factors like frailty, blood pressure, liver/kidney function to predict risks of severe toxicity and categorize
This study developed a preoperative risk model to predict the occurrence of postoperative pneumonia in patients undergoing coronary artery bypass grafting (CABG). Researchers analyzed data on over 16,000 CABG patients from 33 hospitals. Postoperative pneumonia occurred in 3.3% of patients. The final model identified 17 preoperative factors that were significantly associated with increased risk of pneumonia, including demographics, laboratory values, comorbid diseases, pulmonary function, and cardiac function/anatomy. The model had good discrimination (C-statistic of 0.74) and performed well in validation analyses. This risk model can help provide individualized risk estimates and identify opportunities to reduce preoperative pneumonia risk.
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
This literature review covers three topics: pneumonia, lung cancer, and pulmonary fibrosis. For pneumonia, it summarizes that the declines in childhood pneumonia hospitalizations observed after the introduction of PCV7 vaccines were sustained over a decade. It also found substantial reductions in adult pneumonia hospitalizations. For lung cancer, it discusses findings from several large randomized controlled trials that low-dose CT screening detects more early-stage lung cancers compared to chest radiography and tends to result in a stage shift toward earlier diagnoses. For pulmonary fibrosis, it reviews that the natural history can vary significantly, from complete resolution to progressive fibrosis leading to respiratory failure.
This document proposes a new 5-stage classification system (A-E) for cardiogenic shock to improve communication and help guide treatment. Stage A is "at risk" for shock, stage B is "beginning" shock, stage C is "classic" shock with hypoperfusion, stage D means initial interventions did not restore stability despite 30 minutes of observation, and stage E is "extremis" with cardiovascular collapse. The goal is to have a simple, clinically applicable system that can be used across care settings and potentially help identify patients most likely to benefit from different treatments.
This study analyzed 1,145 patients who underwent ERCP at a regional hospital in Mexico from 2002-2011. The complication rate was 2.1%, with hemorrhage being the most common complication at 1.2%. Precut/sphincterotomy was found to increase the risk of complications by 1.4 times compared to those without. The study concluded the complication rate was similar to other reports but could be reduced by only performing ERCP for therapeutic purposes and by highly qualified endoscopists.
This document presents the 2012 World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease. An international panel of experts developed evidence-based guidelines to standardize the identification of rheumatic heart disease using echocardiography. The guidelines define three categories - 'definite RHD', 'borderline RHD', and 'normal'. Criteria for 'definite RHD' include pathological mitral or aortic regurgitation accompanied by specific morphological changes to the valves. 'Borderline RHD' includes minor abnormalities that do not meet criteria for 'definite RHD'. The standardized criteria aim to allow consistent identification of rheumatic heart disease globally to facilitate screening and secondary prophylaxis programs.
Cerebrovascular stroke recurrence among critically ill patients (2)Alexander Decker
This document summarizes a study on risk factors, frequency, and severity of recurrent cerebrovascular stroke among critically ill patients admitted to intensive care units at a university hospital in Egypt. The study aimed to identify risk factors for recurrent stroke and examine recurrence intervals, frequency, and severity. Medical records of 80 patients admitted with recurrent stroke over 6 months were analyzed. Results found the majority had hypertension and diabetes as comorbidities. 30% experienced recurrence 2-5 years after initial stroke. Over 36% of cases were severe, with a mean severity score of 19.17 out of 42. The study concluded uncontrolled risk factors like age, gender, medical noncompliance and lifestyle factors like smoking contributed to recurrent strokes of varying severity.
This document discusses acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in resource-limited settings. It presents a case study of a 12-year-old girl diagnosed with ARF in The Gambia. Key challenges in diagnosis and management of ARF and RHD in these settings include limited access to investigations like echocardiography and lack of specialists. The Jones criteria for diagnosing ARF may be too insensitive for high-prevalence areas. Management involves bed rest, antibiotics, aspirin, and follow-up care, though access can be limited. RHD is a major cause of heart disease worldwide and often presents with severe disease due to limited care access.
This document provides guidelines from the American Diabetes Association and European Association for the Study of Diabetes on the management of hyperglycemia in type 2 diabetes. It recommends a patient-centered approach that considers individual patient needs and preferences. Glycemic targets should aim to lower HbA1c levels to <7% but must be tailored based on factors like disease duration, comorbidities, and risks of hypoglycemia. The guidelines emphasize shared decision-making between clinicians and patients and choosing therapies based on each drug's efficacy, safety profile, costs and patient lifestyle.
El documento proporciona especificaciones técnicas para cables monopolares de media tensión (MV) de 90°C para 5kV, 15kV y 35kV. Describe los componentes de los cables, incluidos el conductor, blindajes, aislamiento y chaqueta exterior. Incluye tablas con los diámetros, pesos y otras características para diferentes calibres de cable.
Este documento describe un curso de protecciones de subestaciones. Explica que el objetivo es enseñar a electricistas a interpretar correctamente el funcionamiento de las protecciones durante fallas en un sistema eléctrico de potencia. También cubre los diferentes tipos de fallas que pueden ocurrir, como cortocircuitos, y los sistemas de protección como fusibles y relevadores para proteger adecuadamente el sistema.
Differentiating trigeminal neuropathy from trigeminal neuralgiaDr P Deepak
1. This case involves a 26-year-old female with left-sided facial pain in the trigeminal distribution along with a history of chronic migraines, depression, and hypothyroidism.
2. Based on her pain characteristics, triggers, and physical exam findings, she most likely has atypical facial pain secondary to trigeminal neuropathic pain rather than classic trigeminal neuralgia.
3. It is important to differentiate the two conditions, as trigeminal neurolysis could worsen trigeminal neuropathy pain. She will undergo nerve blocks and be considered for additional procedures depending on response. Managing her transformed migraine and multiple medications will also be important.
This document summarizes research on the epidemiology of alcoholic liver disease (ALD). It finds that heavy alcohol consumption significantly increases the risk of developing ALD, especially cirrhosis of the liver. The risk is determined by both the quantity of alcohol consumed over time as well as gender and ethnic differences. While cirrhosis mortality rates have declined in some countries since the 1970s due to decreased consumption and increased treatment, heavy drinking remains strongly associated with higher rates of liver disease.
This document summarizes evidence from multiple clinical trials evaluating the use of thrombolysis/tissue plasminogen activator (tPA) for acute ischemic stroke. It discusses trials showing small benefits for functional outcomes with tPA if given within 3 hours, as well as increased risks of intracranial hemorrhage. Later trials found no clear benefits for tPA between 3-6 hours. Overall, tPA for acute stroke provides only modest benefits for a small proportion of patients, but is also associated with significant risks.
Comparison of clinical, radiological and outcome characteristics of ischemic ...MIMS Hospital
Here is the latest publication from the department of Neurology in the Journal of Neurology Research, titled, ’Comparison of Clinical, Radiological and Outcome Characteristics of Ischemic Strokes in Different Vascular Territories’ authored by Ashraf V Valappila, c, Dhanya T Janardhanana, Praveenkumar Raghunatha, Abdulla Cherayakkatb, Girija ASa
1. In patients with critical bleeding requiring massive transfusion, institutions should develop massive transfusion protocols that include guidelines for the dose, timing, and ratios of blood component transfusions.
2. Key parameters that should be measured early and frequently include temperature, acid-base status, calcium, hemoglobin, platelet count, coagulation factors, and fibrinogen level.
3. While specific transfusion ratios are uncertain, suggested doses of blood components in massive transfusion are 15 mL/kg of fresh frozen plasma, one adult therapeutic dose of platelets, and 3-4 grams of cryoprecipitate.
This document provides an overview of the pathophysiology of ischemic stroke. It defines stroke and classifies it, discusses the concept of the ischemic penumbra where tissue is at risk of infarction, and outlines the molecular mechanisms and cascade of injury that occurs during ischemia, including edema, microvascular thrombosis, programmed cell death, and necrosis. It notes that the penumbra exists as a dynamic region where tissue has the potential for recovery if blood flow is restored in a sufficient timeframe.
Este documento trata sobre líneas de transmisión y distribución de energía eléctrica. Presenta los autores y temario del documento. Explica los elementos de un sistema de energía eléctrico incluyendo generación, transmisión, distribución y carga. También describe las fuentes de energía renovables como hidráulica, solar, eólica y biomasa, y no renovables como carbón, petróleo y gas natural.
This study reviewed data on 215 young adults aged 18-45 admitted with ischemic stroke or transient ischemic attack (TIA) to a university hospital stroke center between 2005-2010.
The results showed:
- High rates of traditional vascular risk factors like hypertension (20%), diabetes (11%), dyslipidemia (38%), and smoking (34%).
- Extensive diagnostic testing including blood tests, echocardiograms, vessel imaging found relevant abnormalities in 136 of 203 patients on angiography and detected the likely stroke cause in nearly 90% of patients.
- Common causes were cardioembolism (47%), including 17% with patent foramen ovale, and arterial lesions in the middle cerebral artery (23%),
Blood products topic is very important for Medical students as they have to know which blood product will be much beneficial to patients when they go into clinical practice. This PPT provides all of them.
Blood components preparation and therapeutic uses finalglobalsoin
This document discusses the preparation of blood components and their therapeutic uses. It begins by explaining how whole blood can be separated into components like red blood cells, platelets, and plasma to provide targeted replacement therapies. It then provides a brief history of developments in blood transfusion medicine. The rest of the document details the various blood components that can be prepared including packed red cells, platelet-rich plasma, platelet concentrates, fresh frozen plasma, and cryoprecipitate. It describes the preparation methods, storage, indications, and dosages for each component.
This document provides an overview of the evaluation and treatment of acute ischemic stroke. Key points include:
- The treatment window for intravenous recombinant tissue-type plasminogen activator (rtPA) has been expanded to within 4.5 hours of symptom onset. Faster administration of reperfusion therapies results in better outcomes.
- For patients who are ineligible for intravenous rtPA but have moderate to severe strokes, endovascular therapy should be considered if treatment can begin within 6 hours of symptom onset.
- Effective emergent evaluation requires organized systems that maximize the speed of patient assessment and administration of appropriate therapies like intravenous rtPA and endovascular procedures.
1) Intravenous thrombolysis (IVT) with alteplase remains the standard treatment for acute ischemic stroke within 4.5 hours of symptom onset. Pivotal clinical trials in 1995 and 2008 demonstrated that IVT can reduce disability and is safe, with about a 7% risk of symptomatic intracranial hemorrhage.
2) Real-world data from registries show that IVT results in functional independence for 40-45% of patients at 3 months, and is effective in patients over 80 years old. Faster treatment times are associated with better outcomes.
3) Current research aims to increase the number of patients treated by overcoming some contraindications to IVT, and to
Stroke thrombolysis Dr Sanjay Jaiswal,consultant nerologist,Jaiswal Hospital ...Sanjay Jaiswal
We are presenting our personal experience regarding thrombolytic therepy in ac ischaemic stroke patients at jaiswal hospital and neuro institute ,kota,Rajasthan,INDIA
Unanswered questions in thrombolytic therapy for acute ischemic stroke. 2013Javier Pacheco Paternina
This document discusses unanswered questions regarding thrombolytic therapy for acute ischemic stroke. It begins by providing background on stroke incidence and efforts to treat patients promptly. The introduction outlines key unanswered questions such as the optimal time window for tissue plasminogen activator treatment and whether other agents or endovascular therapies could further extend the time window. The document then reviews landmark studies on intravenous thrombolysis and the established 3-hour time window as well as efforts to extend the window. It also discusses other pharmacologic and mechanical treatment options and their respective time windows.
This document discusses the management of acute ischemic stroke. It notes that stroke is an emergency condition that may be treatable through interventions aimed at restoring blood flow and interrupting the ischemic cascade. The major challenges are determining if an intervention is effective and what constitutes a significant effect size to justify approval. Four main targets of intervention are discussed: restoring blood flow within a therapeutic window, interfering with the ischemic cascade, lowering metabolic demand, and preventing recurrent events. The mechanism of stroke must be determined to guide treatment, such as whether thrombolysis may be appropriate. General principles of management include monitoring, imaging studies, and controlling factors like blood pressure, blood sugar, and temperature.
This document summarizes a study that evaluated the effect of substance use on the occurrence and severity of systemic inflammatory response syndrome (SIRS) following trauma. The study found that patients positive for alcohol had more occurrences of SIRS and more severe SIRS than other substance users. Patients positive for cannabis had less severe SIRS than other substance users. Substance use may increase the risk of poor SIRS-related outcomes like sepsis and organ failure after trauma.
The document proposes implementing color-coordinated fall risk identifiers for patients at risk of falls at the Manhattan VA Hospital to potentially decrease falls. It reviews literature finding single interventions like signs or bracelets are less effective than multiple reminders. The proposal is to randomly assign patients scoring high on the Morse Fall Scale to either bright yellow socks/bracelets or a red dot outside their room. Incidences of falls will be compared over 3 months between the two groups to evaluate if color-coordinated identifiers reduce falls more than the current program.
The document summarizes the process undertaken by an international task force to update the definitions of sepsis and septic shock. The task force concluded that previous definitions had limitations and needed reexamination based on advances in understanding the pathobiology of sepsis. The task force developed new definitions of sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock was defined as a subset of sepsis with profound circulatory and metabolic abnormalities associated with high mortality. The task force also established new clinical criteria for identifying sepsis and septic shock in patients aimed at facilitating earlier recognition and management.
The document presents new consensus definitions for sepsis and septic shock developed by an international task force. Key changes include:
- Sepsis is now defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, rather than being triggered by systemic inflammation.
- Septic shock is a subset of sepsis with profound circulatory and metabolic abnormalities at higher risk of mortality than sepsis alone. It can be identified by vasopressor need and hyperlactatemia in the absence of hypovolemia.
- A quickSOFA score of 2 or more is recommended to help identify patients with suspected infection at greater risk of poor outcomes in out-of-hospital and emergency department settings.
This document provides an introduction to the field of epidemiology. It defines epidemiology as the study of disease occurrence and distribution in human populations and the factors that influence these. Key points made include that epidemiological studies examine disease outcomes in relation to the population at risk, draw conclusions by making comparisons between groups, and aim to identify risk factors and monitor disease trends over time. However, the text stresses the importance of ensuring comparisons are not biased by unequal ascertainment of cases or exposures.
632 0713 - ferreyro bl - predictive score for estimating cancer after venou...Debourdeau Phil
This study developed a clinical predictive score to estimate cancer risk after venous thromboembolism (VTE). Researchers analyzed data from 540 patients diagnosed with new VTE. During the 1-year follow up, 26.4% developed cancer or died. Multivariable models were used to identify predictors of cancer alone and cancer/death. The final scores included previous VTE, recent surgery, comorbidities for cancer risk, and age, albumin, comorbidities, previous VTE, recent surgery for cancer/death risk. The scores had good discrimination for risk stratification with areas under the curve of 0.75-0.79 for cancer and 0.71-0.72 for cancer/death.
The Third International Consensus Definitions for Sepsis and Septic Shock (Se...Willian Rojas
The task force updated the definitions of sepsis and septic shock based on advances in understanding the pathobiology of sepsis. Sepsis is now defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction can be identified clinically as a Sequential Organ Failure Assessment (SOFA) score of 2 points or greater. Septic shock is defined as a subset of sepsis with profound circulatory and metabolic abnormalities associated with higher mortality than sepsis alone, and can be identified by vasopressor need and hyperlactatemia in the absence of hypovolemia. The task force also proposed new clinical criteria called quickSOFA to help rapidly identify patients with suspected infection who are at higher risk of poor outcomes
The task force updated the definitions of sepsis and septic shock based on advances in understanding the pathobiology of sepsis. Sepsis is now defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction can be identified clinically as a SOFA score of 2 points or higher. Septic shock is defined as a subset of sepsis with profound circulatory and metabolic abnormalities requiring vasopressors to maintain blood pressure and with lactate above 2 mmol/L. The task force also proposed new clinical criteria called qSOFA to help identify patients with suspected infection who are likely to have poor outcomes typical of sepsis.
The third international consensus definitions for sepsis and septic shock (se...Daniela Botero Echeverri
The document summarizes the process undertaken by an international task force to update the definitions of sepsis and septic shock based on advances in understanding of the pathobiology of sepsis since the prior definitions from 2001. The task force developed new definitions of sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection, and of septic shock as a subset of sepsis with profound circulatory and metabolic abnormalities. Clinical criteria including changes in SOFA scores and vasopressor requirements were recommended to operationalize the new definitions in practice.
The document presents new consensus definitions for sepsis and septic shock developed by an international task force. It summarizes limitations of previous definitions, which focused excessively on inflammation and lacked specificity. The task force developed updated definitions and clinical criteria through meetings, literature reviews, and consultation with international societies. The new definition of sepsis is "life-threatening organ dysfunction caused by a dysregulated host response to infection." Septic shock is defined as a subset of sepsis involving profound circulatory and metabolic abnormalities associated with higher mortality. Clinical criteria including changes in SOFA scores and vital signs were also developed to facilitate earlier recognition of at-risk patients. The task force aims to provide more consistency for research and management of sepsis.
Vascular repair after firearm injury is associated with increased morbidity a...anomwiradana
This study analyzed data from 648,662 patients with firearm injuries between 1993-2014 using the National Inpatient Sample database. The key findings were:
1) 9.9% (63,973) of firearm injuries involved a concurrent vascular repair, with these patients more likely to be younger, male, black, on Medicaid, and have lower income.
2) Patients undergoing vascular repair had higher injury severity scores and were more likely to have abdomen/pelvis or extremity injuries from assault.
3) Patients undergoing vascular repair had higher rates of in-hospital mortality (5.51% vs 1.98%), acute renal failure, venous thromboembolic events, pulmonary complications, cardiac complications, sepsis
Basic epidemiology and surveillance for nursesnemata55
presentation is basic introduction to epidemiology and foundation for infection control surveillance for nurses .it also give information and knowledge about the types of surveillance and how to conduct it in hospital setting
18Falls in The Long-Term Care SettingsNayaris ReyeAnastaciaShadelb
1
8
Falls in The Long-Term Care Settings
Nayaris Reyes
Florida National University
June 12, 2021
Brief Literature Review
The elderly in the long-term care facilities are typically predisposed to falling and might fall for various reasons. Some predisposing factors might be related to unsteady balance and gait, poor vision, weak muscles, dementia, and medications. In addition, various medical conditions, including stroke, low blood pressure, brain disorders, and poorly managed epilepsy, might increase older people's risk for falls (Golmakani et al., 2014). Therefore, several studies have been conducted to evaluate the efficacy of multi-factorial interventions on the occurrence of falls in long-term care settings, including psycho-geriatric nursing home patients. Based on the clinical study, it was concluded that various multi-factorial interventions used in preventing falls such as a general medical assessment emphasizing falls, specific fall risk evaluation devices, assessing medication intake, fall history, and mobility, using protective and assistive aids play a significant role in reducing the incidence of falls among the elderly (Ungar et al., 2013). Accordingly, it was evident that fall prevention, usually geared towards psycho-geriatric patients in a long-term care facility, is possible and efficient in minimizing falls among older people.
Other researchers carried out a study in developing a fall prevention program for the aged patients in long-term care entities, especially those at risk of falling, by increasing caregiving expertise or skills and motivating staff members. From the analysis, exercise programs encompassing warm-up, muscle reinforcement, especially in the lower extremities, and proprioceptive neuromuscular expedition are used in increasing motivation and caregiving skills (Donath et al., 2016). Another research conducted to evaluate the statistics of falls among the elderly found out that falls are the leading cause of injury-interrelated visits to emergency facilities in the U.S. They are also the primary etiology of accidental deaths in persons aged 60 and above. From the analysis, falls might be markers of diminishing function and poor health and are significantly attributable to morbidity.
To assess the risk factors related with falls among the older people in the long-term care facilities, it was realized that more than 25% of facility-dwelling older individuals and 60% of nursing home residents fall yearly (Pfortmueller et al., 2014). Various risk factors linked to their falls are medication use, increasing age, sensory deficits, and cognitive impairment. Studies depict that older persons who have fallen must undergo a thorough clinical evaluation (within the facilities) to analyze the preventive strategies further. This will aid in determining and treating the underlying cause of their falls, return them to baseline function, and minimize the likelihood of recurrent falls (Karlsson et al., 20 ...
Final PaperThis Final Paper involves the critical review and ana.docxssuser454af01
Final Paper
This Final Paper involves the critical review and analysis of a published epidemiological research study, using the epidemiological concepts covered in Modules 1–6. You do not choose your own study; your Instructor will provide the research study to review and analyze. The audience for this 5–8 page scholarly paper is other epidemiological researchers.
The Final Paper must include, but is not limited to, the following:
Part I. Study Summary (2–3 pages)
(Note: this summary must be in your own words)
· The study objective/research question
· Primary exposure(s) and outcome(s) of interest
· Identification of study design
· Description of study population and the sampling/selection process
· Description of the statistical analysis used and the primary measures of association reported
· Identification of potential confounders (if any) and the technique used to minimize them or analyze their effects
· Identification of potential effect modifiers (if any) and the technique used to analyze their effects
· Summary of major study results
Part II. Critical Analysis (3–5 pages)
· Discussion of random error and how it might have affected the results
· Explanation of possible selection bias and how it might have affected the results, including a discussion of the size and direction of any possible bias
· Explanation of possible misclassification (information) bias and how it might have affected the results, including a discussion of the size and direction of any possible bias
· Evaluation of the other limitations of the study
· Critique of the discussion section of the paper and whether it adequately addresses the strengths and limitations of the study
· Description of the potential generalizability of the study results
· Critique of the authors’ conclusions and whether or not they are appropriate given the study findings
· Descriptions of future studies that would be appropriate given the study findings
Original Contribution
Physical Activity, Sedentary Behavior, and Cause-Specific Mortality in Black and
White Adults in the Southern Community Cohort Study
Charles E. Matthews*, Sarah S. Cohen, Jay H. Fowke, Xijing Han, Qian Xiao, Maciej S. Buchowski,
Margaret K. Hargreaves, Lisa B. Signorello, and William J. Blot
* Correspondence to Dr. Charles E. Matthews, Nutritional Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer
Institute, 9609 Medical Center Drive, Room 6E340, MSC 9704, Bethesda, MD 20892-9704 (e-mail: [email protected]).
Initially submitted November 15, 2013; accepted for publication May 6, 2014.
There is limited evidence demonstrating the benefits of physical activity with regard to mortality risk or the harms
associated with sedentary behavior in black adults, so we examined the relationships between these health behav-
iors and cause-specific mortality in a prospective study that had a large proportion of black adults. Participants
(40–79 years of age) enrolled in the Southern Community ...
This document discusses descriptive and cross-sectional studies. It outlines the steps in the scientific method and differentiates between observational and experimental studies. Descriptive studies examine health status based on routine data to describe disease patterns without testing hypotheses. Cross-sectional studies can test hypotheses by including study and control groups to examine prevalence and potential causative factors. The document discusses the types, uses, advantages, and disadvantages of descriptive and cross-sectional studies, and outlines the steps to carry out a cross-sectional study.
Cardiology manscript from medical schoolKate Moreng
This study examined risk factor management (RFM) adherence and outcomes among 2,498 acute myocardial infarction (AMI) patients. At 1 month post-discharge, patients reported their recall of receiving RFM instructions and adherence levels, which were categorized as poor, partial, careful, or very careful. Very careful adherence was most common for medication adherence (94%). Patients reporting poor adherence were 58% more likely to report angina at 1 year compared to very careful adherence. However, RFM adherence was not associated with quality of life, physical functioning, rehospitalization, or mortality. While discharge instructions aim to improve post-AMI prognosis, greater research is needed on how adherence impacts outcomes.
This study examined whether systemic inflammatory response syndrome (SIRS) scores can predict length of stay in the intensive care unit (ICU) for patients with acute life-threatening injuries. The researchers conducted a retrospective chart review of 246 patients admitted to the ICU of a Level 1 trauma center between 1998-2007. They found that higher SIRS scores on admission and white race were predictive of longer ICU stays. Injury severity scores were also predictive of length of stay. SIRS scores measure the body's inflammatory response and can be assessed at the bedside, providing critical care nurses with an easy tool to help estimate ICU length of stay and prioritize care.
Number of Pages 4 (Double Spaced)Number of sources 8Writi.docxcherishwinsland
Number of Pages: 4 (Double Spaced)
Number of sources: 8
Writing Style: APA
Type of document: Coursework
Category: Healthcare
Order Instructions:
Comprehensive Article Review
Caverly, T.J., Fagerlin, A, & Wiener, R.S. (2018, January 22). Comparison of observed harms and expected mortality benefit for persons in the Veterans Health Affairs Lung Cancer Screening Demonstration Project. JAMA Internal Medicine.
1. What research questions are addressed in this study and what is their purpose (5 points)?
2. What type of research design was used (experimental, quasi-experimental, correlational) in this study and what led you to your decision (5 points)?
3. Are the instruments in this study valid and reliable, why or why not (10 points)?
4. Discuss the specific results of each of the ANCOVAs (analysis of covariance) done in this study. What was the purpose of"each" of the ANCOVAs? What was the covariate in each and why did they do an ANCOVA in each case (5 points)?
5. In the Tables, results are presented, Please explain the tables and summarize the results (15 points).
6. Explain, in simple language, any significant results of this study (25 points)?
7. Identify and discuss any threats to internal and/or external validity in this study (10 points).
8. If you could redesign this study correcting anything you have found wrong with the research, what would you correct and how would you do it (20 points)?
Opinion
EDITORIAL
Reducing Harms in Lung Cancer Screening
Bach to the Future
Michael ln cze, MD, MSEd: Rita F. Redberg, MD, MSc
TbeUS PreventativeServices Task Force cmrcntly recom mends si:;ree ning (grade Brecommendation)for lung canc er witha nnuallow-dose computed tomo graph}' for high-risk in dividuals ages55 to 80 years, defined as those having greate r
gLblefor LCS using the Bach risk tool,11 a vaJidatcd risk model usingsex,age, smokingduration, durationof abstinence from smoking and number of cigarettes smoked per day as inpu ts.
The asto undingly high ratesof false-pos itiveresults in the low
=Related attid e
than a 30 pack-year cumula tivesmoking historyand h av• ing quit with in the past 15 years.1 The evide nce to sup
est risk quintiles (eg, 2221false-positive resul ts per lung ca n cer death averted and a NNS of nearly 5600 in quintile1), as well as extremelylow ratesoflungcancerincidencein the low est-risk groups, confirm trends illustrated in previous stud
port thisrecommendation overwhelminglycomes rrom the Na
tional Lung CancerScreenfngTrial(NL ST). While3 other large randomized clinical trials failed to show any mortality ben efit tolung cancer screening (LCS), the NLST demonstrateda 20% reduction in lungcan ce r mortality,a lo ng with a 6.7% re duction in .ill-ca use mortality, when compared with an an nual chest radiograph, witb a number needed toscreen (NNS} of256to prevent I lung-cancerassociated death over3years.-2 5 Real-worldapplication ofLCS has been particularly .
A cohort study involves following a group of people over time to examine how a particular exposure affects the occurrence of a disease or health condition. The presentation defines a cohort study, discusses the steps involved in conducting one, and outlines methods for analyzing cohort data. Key points include that a cohort study starts with a population at risk, measures characteristics at baseline, follows the population over time to compare event rates between exposed and unexposed groups, and can provide direct estimates of risk and rate of disease occurrence over time.
1. Age and Ageing 2008; 37: 270–276 The Author 2008. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi:10.1093/ageing/afn066 All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Predicting people with stroke at risk of falls
A. ASHBURN1 , D. HYNDMAN1 , R. PICKERING2 , L. YARDLEY3 , S. HARRIS2
1 School of Health Professions and Rehabilitation Science, University of Southampton, UK
2
Medical Statistics, School of Medicine, University of Southampton, UK
3 School of Psychology, University of Southampton, UK
Address correspondence to: Ann Ashburn. Tel: +44 (0)023 8079 6469; Fax: +44 (0)023 8079 4340. Email:
A.M.Ashburn@soton.ac.uk
Abstract
Background: falls are common following a stroke, but knowledge about predicting future fallers is lacking.
Objective: to identify, at discharge from hospital, those who are most at risk of repeated falls.
Methods: consecutively hospitalised people with stroke (independently mobile prior to stroke and with intact gross cognitive
function) were recruited. Subjects completed a battery of tests (balance, function, mood and attention) within 2 weeks of
leaving hospital and at 12 months post hospital discharge.
Results: 122 participants (mean age 70.2 years) were recruited. Fall status at 12 months was available for 115 participants and
of those, 63 [55%; 95% confidence interval (CI) 46–64] experienced one or more falls, 48 (42%; 95% CI 33–51) experienced
repeated falls, and 62 (54%) experienced near-falls. All variables available at discharge were screened as potential predictors
of falling. Six variables emerged [near-falling in hospital, Rivermead leg and trunk score, Rivermead upper limb score, Berg
Balance score, mean functional reach, and the Nottingham extended activities of daily living (NEADL) score]. A score of
near-falls in hospital and upper limb function was the best predictor with 70% specificity and 60% sensitivity.
Conclusion: participants who were unstable (near-falls) in hospital with poor upper limb function (unable to save themselves)
were most at risk of falls.
Keywords: stroke, falls, prediction, elderly
Background small number of fallers seek professional assistance after an
event [13].
Although widely reported that one-third of the general In contrast to the general older population, previous falls
older population will fall in any 1 year [1], predicting falls and multiple medications are less important in predicting
among the elderly has been demonstrated as complex, falls among people with acute strokes, as a stroke itself
and no single tool is suitable for all situations [2]. People changes the individual’s state dramatically [9]. Factors such
who have suffered a stroke are at an even higher risk as greater body sway, inability to walk, visuo-spatial deficits
of falling than people among the general population [3–6] and apraxia and use of sedatives [9, 14–16], have been
but fewer researchers have attempted to develop specific associated with falls in the acute stage. In community
predictive tools. Estimates of fall frequency among the dwelling people, the number of impairments has not been
stroke population vary but Tutuarima et al. [3, 7] and Nyberg related to falls [17] but balance problems, particularly while
and Gustafson [8, 9] suggested that between 14 and 39% of performing complex tasks such as dressing, have been
people with stroke have had one or more falls during their strongly linked [18]. Hyndman et al. [10] found no significant
hospital stay and approximately three-fourths of individuals difference between the characteristics of their community-
with stroke have fallen in the 6 months following discharge based faller and non-faller groups with stroke, but subgroup
from hospital [4]. Findings from a more recent study have analysis of repeat fallers showed a trend to greater mobility
shown that fall rates remained as high as 50% among deficits, and statistically significant reduced arm function and
community dwelling people with stroke [10]. Minor injuries ADL abilities in comparison to those who did not report
(cuts and bruises) have been found to occur in about 20% any instability. Mackintosh et al. [6] also reported reduced
of falls [11] and approximately 37 hip fractures have been mobility and poorer balance among recurrent fallers with
reported per 1,000 stroke person-years; 84% of which stroke in the community. Based on these and other studies,
would have resulted from a fall [12]. Interestingly, only a it has now been well established that fall prediction should
270
2. People with stroke at risk of falls
focus on repeat fallers, as recurrent falls are more likely to community by asking them to keep a diary of falls events
lead to injury, and exploration of fall risk among one-off (recording falls as and when they occurred) in addition to
fallers can be misleading [4, 6, 10]. regular reminder telephone calls and letters. We defined a
Despite the knowledge that fall risk following a fall as an event that results in a person coming to rest
stroke increases significantly after discharge from hospital, unintentionally on the ground or other lower level, not as a
researchers have only recently started focusing their attention result of a major intrinsic event or overwhelming hazard [22].
on the community [6, 16]. The few researchers who have Participants were classed as repeat fallers if they experienced
assessed risk at the point of leaving hospital have recruited two or more falls during the 12-month follow up period, and
participants from specialist stroke rehabilitation units with as single fallers if they experienced one fall. A near-fall was
strict entry criteria, thereby excluding a large proportion who defined as an occasion on which an individual felt that they
were older or more severely affected [6, 16]. Small sample were about to fall, but did not actually fall [21].
sizes [6], the retrospective nature of the fall report and the Descriptive statistics were used to describe the recruited
inclusion of single fallers in the analysis [16] have further sample, and falling rates were estimated with 95% confidence
limited the generalisablity of these study findings. Hence, intervals (95% CI) produced using the Wilson method
there is still a lack of knowledge about predicting future within CIA [23]. The statistical analysis of prediction was
fallers with a stroke at the point of discharge from hospital. carried out in SPSS. In an initial screening all potential
The purpose of this study was to address that knowledge gap. predictors available at or before the time of discharge to the
community were compared between groups reporting repeat
Methods and non-repeat falling at the 12-month follow up. Continuous
variables were compared using t-tests; ordinal scales and
Ethical approval for the study was obtained from the non-normally distributed variables using Mann–Whitney U
Southampton and South West Hampshire Local Research tests; and binary and categorical variables using chi-squared
Ethics Committee, Ethical approval No: 095/02. tests. Variables that achieved significance at the 10% level
Consecutively hospitalised patients with a stroke in the were examined in a logistic regression of repeat falling
Southampton area were identified and recruited at the point
on their own and controlled for the other variables. The
of discharge from hospital. Those who were independently
importance of each variable was assessed with likelihood
mobile prior to the stroke and were able to give informed
ratio tests, and odds ratios (OR) are presented with 95% CI.
consent (passed a test of gross cognitive function) [19] were
Forwards selection was used to select the most important
eligible for recruitment. Demographic data (age, gender, time
predictors of repeat falling. Variables were selected if they
in hospital, side of lesion and Oxford Stroke Classification of
contributed significantly (up to the 15% level—though in
cerebral infarct [20]) were documented for each participant.
practice the selected variables were also significant at the
Information on impaired vision, hearing, and musculoskeletal
5% level). Predictive scores based on the selected variables
and vestibular deficits, history of previous strokes and other
and on all variables emerging from the initial screening were
neurological conditions was also recorded.
created using regression estimates. The accuracy of individual
Study participants completed tests of balance, function,
variables and the two predictive scores was examined using
mood and attention in their homes within 2 weeks of being
sensitivity, specificity, positive and negative predictive values
discharged from hospital to the community and at 12 months
at cut-points chosen to optimise sensitivity and specificity,
post-discharge from hospital. The teststhat were identified as
important in a previous study by the authors [10] were: Berg and 95% CI were presented. Receiver operating characteristic
Balance Scale, Nottingham Extended ADL Scale, Rivermead (ROC) curves and area under the curve (AUC) statistics are
Motor Assessment, a screen for unilateral visual neglect, four presented, the closer an ROC curve is to the top left hand
subtests of the Test for Every day Attention (TEA),0 test of corner representing 100% accurate prediction, the better the
attention, and the Hospital Anxiety and Depression Scale. prediction attainable from the variable in question.
The tests were carried out in participants’ homes by the main
assessor who was kept blind to their fall status. Results
A second independent assessor collected information
about falls using more than one procedure. Retrospective Out of 512 people identified for the study, 323 (63%)
fall data was collected from participants and their relatives were ineligible for a variety of reasons including death,
within the first 2 weeks of admission to hospital (recall about unconfirmed diagnosis, withholding of medical consent,
fall history prior to hospital admission), within 2 weeks of cognitive impairment, not discharged from hospital in time,
discharge from hospital to community (recall about falls in and discharged from hospital to a nursing home. Of the 189
hospital) and at 12 months post-discharge from hospital to eligible people approached to enter the study, 64 (34%) failed
the community using questions about fall events based on to reply or declined the invitation, 3 withdrew shortly after
the interview schedule developed by Stack and Ashburn [21]. enrollment, leaving 122 data sets for analysis. Information
Information about falls experienced in hospital was also about fall status at the 12-months follow up was available
sought from staff and accident records. Prospective fall for 115 participants and of them, 63 (55%; 95% CI 46–64)
data were collected when participants had returned to the experienced one or more falls; 48 (42%; 95% CI 33–51)
271
3. A. Ashburn et al.
experienced repeated falls; and 62 (54%) experienced near- between onset of stroke and the visit at the time of discharge
falls. We defined stroke types in our sample using the from hospital of 10–330 days (Table 1).
Oxford Community Stroke Project Classification (OCSP) All variables available at the time of discharge were
(Table 1). Partial anterior circulation infarct (PACI) was the considered in the screening for predictors of repeat falling,
most frequently occurring lesion; only six people with a total and seven potential predictors emerged (a history of near-
anterior circulation infarct (TACI) took part; and three were falling in hospital, and six tests of movement or function:
not classified. No major differences were apparent between Rivermead leg and trunk score, Rivermead upper limb score,
repeat and non-repeat fallers (Table 1): there was a wide age Rivermead total score, Berg Balance score, mean functional
range (21–92); more male than female participants; an even reach, and Nottingham extended ADL score—see Table 1
distribution of left and right hemisphere infarctions (one for selected results from the screening). Rivermead total
participant had both hemispheres affected); the majority of score was not included in the logistic regression modelling
participants had a first ever stroke; and a large range of time as it duplicates information in the leg and trunk and upper
Table 1. Characteristics of the sample at point of discharge to the community figures are number (%)
unless stated otherwise
Non-repeat faller Repeat faller
Variable (n = 67a ) (n = 48a ) Pb
..................................................................................................................
Age in years Mean (SD) 69.7 (13.3) 70.7 (11.0) 0.696 (t)
Minimum to maximum 21–92 46–91
Gender Male (%) 46 (69%) 31 (65%) 0.210 (χ2 )
Female (%) 21 (31%) 17 (35%)
Previous stroke 11 (16%) 8 (17%) 0.972 (χ2 )
c
OCSP classification TACI (%) 4 (6%) 2 (4%) 0.389 (χ2 )
PACI (%) 31 (46%) 15 (31%)
POCI (%) 13 (19% 12 (25%)
LACI (%) 11 (16%) 15 (31%)
PICH (%) 6 (9%) 3 (6%)
Not classified (%) 2 (3%) 1 (2%)
Side of infarction Right (%) 35 (52%) 22 (46%) 0.448 (χ2 )
Left (%) 31 (46%) 26 (54%)
Both (%) 1 (2%) 0
Time since stroke in days Mean (SD) 75.7 (54.6) 83.4 (59.7) 0.384 (MW)
Median (minimum to maximum) 59.0 (10–268) 69.5 (23–330)
Living status before the stroke Alone 17 (25%) 12 (25%) 0.815 (χ2 )
Partner 45 (67%) 32 (67%)
Family friends 4 (6%) 4 (8%)
Residential home 1 (1%) 0
Number of falls in year before onset Mean (median) 0.4 (0) 0.6 (0) 0.119 (MW)
Minimum to maximum 0–6 0–6
Number of falls in hospital Mean (median) 0.5 (0) 0.9 (0) 0.225 (MW)
Minimum to maximum 0–6 0–6
History of near-falls in hospital 11 (16%) 19 (40%) 0.005 (χ2 )
Rivermead leg and trunk Mean (SD) 7.8 (2.6) 7.2 (2.3) 0.054 (MW)
Minimum to maximum 0–10 1–10
Rivermead upper limb Mean (SD) 11.2 (4.6) 9.6 (4.2) 0.012 (MW)
Minimum to maximum 0–15 1–15
Rivermead gross function Mean (SD) 9.0 (2.8) 8.4 (2.3) 0.175 (MW)
Minimum to maximum 1–13 1–13
Rivermead total score Mean (SD) 28.0 (8.6) 25.2 (7.6) 0.020 (MW)
Minimum to maximum 1–38 3–38
Berg Balance Mean (SD) 41.2 (15.2) 37.5 (11.7) 0.016 (MW)
Minimum to maximum 5–56 7–56
Mean functional reach (cm) Mean (SD) 20.7 (12.8) 16.8 (9.3) 0.055 (MW)
Minimum to maximum 0–53 0–35
Nottingham extended ADL Mean (SD) 26.3 (15.6) 12.0 (11.8) 0.074 (MW)
Minimum to maximum 1–63 2–49
a Upto three missing values on some of the variables in the table.
b P values from several tests (t, from t-test; MW, from Mann–Whitney U test; χ2 , from chi-squared test).
c OCSP, Oxford Community Stroke Project Classification; TACI, total anterior circulation infarcts; PACI, partial anterior circulation
infarcts; POCI, posterior circulation infarcts; LACI, lacunar infarcts; PICH, primary intracerebral haemorrhage.
272
4. People with stroke at risk of falls
limb sub-scores, although its accuracy of prediction of repeat variables were not important in the controlled analysis or they
falling on its own is considered in Table 3. The logistic models duplicated predictive power obtainable from other variables.
were fitted to the 110 participants who had known fall status Forwards selection amongst the six variables resulted
and information on the six remaining variables emerging in a predictive score based on a history of near-falling
from the screening. In Table 2 it can be seen that a history in hospital and Rivermead upper limb score (predictive
of near-falling in hospital achieved highest significance of score: 0.293 + 1.290 × hospital near falls [Yes] −0.094 ×
these, and the Rivermead upper limb score, mean functional Rivermead upper limb). By choosing an optimal cut-point
reach and the Nottingham extended ADL were also close to of −0.4114, sensitivity—the proportion of participants who
significance when considered on their own. In the presence fell repeatedly and were predicted to do so—was 60%;
of the other selected variables, a history of near-falling in and specificity—the proportion of participants who had
zero or one fall and were predicted not to repeat fall—was
hospital remained highly significant, with Rivermead upper
70% (Table 3). These were achieved with positive predictive
limb score also close to significance. The OR for history of
value—the proportion of those who were predicted to
near-falling in hospital (unadjusted OR = 3.27, adjusted OR fall repeatedly and actually did so—of 59%; and negative
= 4.14) is a measure of the increased risk of repeated falling in predictive value—the proportion of those who were
this group. For the other variables the OR indicate that when predicted not to fall repeatedly and did not do so—of
considered on their own with unit improvement in the test in 71%. All six selected variables were also included in a logistic
question, the risk of repeat falling decreases since all are scaled regression to see whether the other variables, though not
in the direction of higher values indicating better function. statistically significant, might improve prediction (predictive
Two of the OR (those for the Rivermead leg and trunk and score: −0.455 + 1.421 × hospital near falls [Yes] + 0.149 ×
Berg Balance scores) became greater than 1.0 after adjusting Rivermead leg and trunk −0.119 × Rivermead upper limb
for the other selected variables, indicating greater risk of + 0.024 × Berg Balance −0.046 × mean functional reach
falling with better movement. This reflects the fact that these −0.012 × Nottingham extended ADL). Including all six,
Table 2. Adjusted and unadjusted odds ratios of repeat falling for variables selected from screening.
Models fitted to patients with data available for the six variables (n = 110)
Unadjusted Adjusteda
Variable Odds ratio (95% CI) P Odds ratio (95% CI) P
............................................................................................................
History of near-falling in hospital 3.27 (1.36, 7.90) 0.007 4.14 (1.57, 10.91) 0.003
Rivermead leg and trunkb 0.90 (0.77, 1.06) 0.209 1.16 (0.85, 1.59) 0.345
Rivermead upper limbb 0.92 (0.84, 1.00) 0.052 0.89 (0.78, 1.01) 0.059
Berg Balanceb 0.98 (0.95, 1.01) 0.199 1.02 (0.95, 1.10) 0.507
Mean functional reachb 0.97 (0.94, 1.01) 0.085 0.96 (0.89, 1.03) 0.202
Nottingham extended ADLb 0.97 (0.95, 1.00) 0.063 0.99 (0.95, 1.03) 0.558
a Adjusted for all of the other variables in the table.
b Odds ratio represents the increase in risk per unit increase in the variable.
Table 3. Sensitivity, specificity, positive and negative predictive values at optimal cut-points for individual variables
and predictive scores of repeat falling. Values are numbers (%; 95% CI)
Positive predictive Negative predictive
Variable Cut-pointa Sensitivity Specificity value value
................................................................................................................................
Score based on history of ≥ −0.4114 29/48 (60%; 46–73) 47/67 (70%; 58–80) 29/49 (59%; 45–72) 47/66 (71%; 59–81)
near falling in hospital and
Rivermead upper limb
Score based on the six ≥ −0.3731 29/45 (64%; 50–77) 45/65 (69%; 57–79) 29/49 (59%; 45–72) 45/61 (74%; 62–83)
variables
Number of falls in hospital ≥2 11/48 (23%; 13–37) 59/67 (88%; 78–94) 11/21 (52%; 32–72) 59/96 (61%; 51–71)
History of near-falling in Near faller 19/48 (40%; 27–54) 56/67 (84%; 73–91) 19/30 (63%; 46–78) 56/85 (66%; 55–75)
hospital
Rivermead leg and trunk ≤9.5 43/48 (90%; 78–95) 22/67 (33%; 23–45) 43/88 (49%; 39–59) 22/27 (81%; 63–92)
Rivermead upper limb ≤11.5 32/48 (67%; 53–78) 41/67 (61%; 49–72) 32/58 (55%; 42–67) 41/57 (72%; 59–82)
Rivermead total ≤28.5 33/48 (69%; 55–80) 36/67 (54%; 42–65) 33/66 (50%; 38–62) 36/51 (71%; 57–81)
Berg balance ≤48.5 41/48 (85%; 73–93) 33/67 (49%; 38–61) 41/75 (55%; 43–65) 33/40 (83%; 68–91)
Mean functional reach ≤21.5 31/45 (69%; 54–80) 35/65 (54%; 42–65) 31/61 (51%; 39–63) 35/49 (71%; 58–82)
Nottingham extended ADL ≤24.5 32/48 (67%; 53–78) 32/67 (48%; 36–60) 32/67 (48%; 36–60) 32/48 (67%; 53–78)
a Values in the range predict repeat falling.
273
5. A. Ashburn et al.
sensitivity was increased to 64% at the cost of slightly lower on the ROC curve for the number of actual falls in hospital
specificity of 69%. which is close to the diagonal line indicating no predictive
In Table 3 we also examine the predictive power of the power, an impression confirmed by its low AUC statistic
variables that emerged from the initial screening individually. (AUC = 0.556). The number of actual falls in hospital did
No variable gave sensitivity and specificity simultaneously not emerge from the initial screening, but has been plotted in
greater than 70% at the cut-points chosen. Near-falling Figure 1c for comparison with the predictive power of history
achieved higher specificity (84%) at the cost of lower of near-falling in hospital and because it has recently been
sensitivity. The Rivermead upper limb score achieved a suggested as a potential predictor of subsequent falling [6]. In
reasonable level of sensitivity (67%), but with relatively low Figure 1d the ROC curve for the Rivermead upper limb score
specificity. Considering all the potential predictors examined is shown. The points representing the optimal cut-points for
in Table 3, the best combinations of sensitivity and specificity the two predictive scores are slightly closer to the upper left
was achieved by the two scores with specificity of predicting hand corner of the plot (the point of perfect prediction) than
repeat falling of about 70%, and sensitivity of about 60%. those for the individual variables; nevertheless, it is clear
The ROC curves for the two predictive scores are shown that it is not possible to predict subsequent falling with high
in Figure 1a and b (the optimal cut-points shown in Table 3 sensitivity and specificity simultaneously.
are indicated by asterisks). The accuracy of prediction for
history of near-falling in hospital is not displayed as an ROC
Discussion
curve because only one cut-point is possible as it is binary. In Previous researchers in falls among the general older
Figure 1c the sensitivity and specificity for history of near- population [1] and stroke communities [9, 24] have high-
falling in hospital is indicated by an asterisk superimposed lighted the difficulties of developing a single predictive tool
(a) score based on history of near falling
in hospital and the Rivermead upper (b) score based on the six selected variables
limb score (AUC=0.694) (AUC=0.712)
1 1
.9 .9
.8 .8
>=-0.41 .7 >=-0.37
.7
*
Sensitivity
*
Sensitivity
.6 .6
.5 .5
.4 .4
.3 .3
.2 .2
.1 .1
0 0
0 .1 .2 .3 .4 .5 .6 .7 .8 .9 1 0 .1 .2 .3 .4 .5 .6 .7 .8 .9 1
1 - Specificity 1 - Specificity
(c) number of actual falls in hospital (d) Rivermead upper limb score
(AUC=0.556) (AUC=0.635)
1 1
.9 .9
.8 .8
<=11.5
.7 .7
*
Sensitivity
Sensitivity
.6 .6
near faller
.5 .5
in hospital
.4 .4
*
.3 .3
.2 .2
.1 .1
0 0
0 .1 .2 .3 .4 .5 .6 .7 .8 .9 1 0 .1 .2 .3 .4 .5 .6 .7 .8 .9 1
1 - Specificity 1 - Specificity
Figure 1. ROC curves of the prediction of repeat falling of scores based on history of near-falling and Rivermead upper limb score,
on the six selected variables, actual falls in hospital, and Rivermead upper limb score. Optimal cut-points shown with *.
274
6. People with stroke at risk of falls
owing to the wide range of factors associated with falls (e.g. Our recommendations for clinical practice are that, in the
fall history, impaired balance, altered mood and cognition), absence of conclusive evidence at the point of discharge, all
the varying profiles relating to environmental status (living people with stroke have to be considered as being at a risk of
in the community, hospital or supported housing) and the falls but that those who have been unsteady in hospital and
problems with validating fall events [2, 25, 26]. These fea- have upper limb impairments may be at greater risk. Tests of
tures may explain why in this study the sensitivity (60%) instability and upper limb movements are part of standard
and specificity (70%) of the two risk factors we identified therapy programmes and take a few minutes to administer
for predicting future falls were not simultaneously high. The although this may vary depending on stroke severity. These
experience of near-falling in hospital was associated with two assessments could be shared with colleagues following a
an increased risk of falling post discharge, surprisingly to a simple training. Individuals with stroke should be encouraged
greater extent than experiencing an actual fall in hospital. The to report both falls and near-falls (whilst in hospital and in
other variable that stood out was the Rivermead upper limb the community) so that management programmes can be
score. These findings suggest that individuals who showed implemented. Communication about falls requires careful
signs of instability (near-falls) and were unable to save them- questioning (using the fall interview schedule) in order to
selves from falling (poor upper limb function) were most identify fall-related circumstances [21].
at risk of falls after discharge from hospital. In a previous Research challenges in the future include the validation
study Hyndman et al. [10] found that repeat fallers had worse of predictive tools for fall risk among people with stroke
upper limb function in comparison to non-repeat fallers, and a systematic review of quality studies of prediction
and non-fallers who experienced near-falls saved themselves in this group. Increased understanding is needed of the
from actually falling by using their arms. Frequency of actual circumstances surroundings falls and the way individuals
falls during the hospital stay was not identified as a predictor save themselves or fall as this will form the basis of the
in this study, possibly due to hospital policies that stipulate development of interventions (exercises and strategies) and
careful monitoring to avoid fall events. Instability was there- subsequent evaluation of managing safe functional mobility.
fore identified through near-falls. In contrast, Mackintosh
et al. [6] from Australia found a link between the recurrent
falls of participants during their stay in a rehabilitation hospi-
tal, poor balance control and future falls in the community. Key points
• We were unable to make accurate predictions of falling
The nature of rehabilitation is to encourage independence
and mobility, opening up situations where fall events can in the 12 months following discharge to the community
occur [8] and this may also explain why there was a higher from the information available in this study at the time of
percentage of falls (42%) during the hospital stay in Mackin- discharge.
• Near-falls in hospital and poor upper limb function at time
tosh’s study [6] than this study (34%) which was based in a
typical UK District General Hospital. of discharge from hospital were the two best predictors of
The findings from this study need to be validated in a new repeated falls in the first 12 months following discharge
sample before recommendations can be made for clinical to the community among people with stroke who had
practice. Caution should be taken as the sensitivity (60%) passed a screen for gross cognitive impairment and who
and specificity (70%) were below the level recommended were independently mobile prior to their stroke.
• Individuals should be encouraged to report both falls and
by Oliver et al. [25] as high predictive value (70% for both
simultaneously). Although a systematic review of predictive near-falls.
tools of fall risk among the general older population
found some with good validity and reliability, none could
be recommended for implementation in all settings or
Conflicts of interest
for all sub-populations [26]. Crossing the boundaries into None
community settings in this study may have added to the
difficulties of finding a predictive tool; what influences a Funding
fall in the acute setting may be very different to that in
the community. We chose to predict those at a risk of This work was funded by The Stroke Association
falls at the point of leaving hospital as this is the natural
time for clinicians to initiate services for individuals with
stroke in the community. The interpretation of our findings References
must also be placed in the context of our non-inclusive
1. Campbell AJ, Robertson MC, Gardener MM. Elderly people
sample. We required participants to recall falls and near-falls who fall: identifying and managing the causes. Br J Hosp Med
so we screened individuals for gross cognitive impairment. 1999; 54: 520–3.
We selected those who were independently mobile prior 2. Scott V, Votova K, Scanlan A et al. Multifactorial and functional
to stroke and returning to the community, to avoid the mobility assessment tool for fall risk among older adults in
influence of previous immobility and institutional restrictions community, home-support, long-term and acute settings. Age
on subsequent falls. Ageing 2007; 36: 130–9.
275
7. A. Ashburn et al.
3. Tutuarima JA, de Haan RJ, Limburg M. Number of nursing 16. Andersson AG, Kamwendo K, Seiger A et al. How to identify
staff and falls: a case-control study on falls by stroke patients potential fallers in a stroke unit: validity indexes of four test
in acute care settings. J Adv Nurs 1993; 18: 1101–5. methods. J Rehabil Med 2006; 38: 186–91.
4. Forster A, Young J. Incidence and consequences of falls due 17. Yates YS, Lai SM, Duncan BW et al. Falls in community
to stroke: a systematic inquiry. Br Med J 1995; 311: 83–6. dwelling stroke survivors: an accumulated impairments model.
5. Jorgensen L, Engstad T, Bjarne K et al. Higher incidence of falls J Rehabil Res Dev 2002; 39: 385–94.
in log-term stroke survivors than population controls. Stroke 18. Lamb SE, Ferrucci L, Volapto S et al. For Women’s Health &
2002; 33: 542–7. Ageing Study Risk factors for falling in home-dwelling older
6. Mackintosh S, Hill K, Dodd K et al. Balance score and a history women with stroke. Stroke 2003; 34: 494–500.
of falls in hospital predict recurrent falls in the 6 months 19. Sheil A, Wilson B. A.Performance of stroke patients on the
following stroke rehabilitation. Arch Phys Med Rehabil 2006; Middlesex Elderly Assessment of Mental State. Clin Rehabil
87: 1583–9. 1992; 6: 283–9.
7. Tutuarima JA, van der Meulen JHP, de Haan RJ et al. Risk 20. Bamford J, Sandercock P, Dennis M et al. Classification and
factors for falls of hospitalized stroke patients. Stroke 1997; natural history of clinically identifiable subtypes of cerebral
28: 297–301. infarction. Lancet 1991; 337: 1521–6.
8. Nyberg L, Gustafson Y. Patient falls in stroke rehabilitation. A 21. Stack E, Ashburn A. Fall events described by people with
challenge to rehabilitation strategies. Stroke 1995; 26: 838–42. Parkinson’s disease: implications for clinical interviewing and
9. Nyberg L, Gustafson Y. Fall prediction index for patients in the research agenda. Physiother Res Int 1999; 4: 190–200.
stroke rehabilitation. Stroke 1997; 28: 716–21. 22. Clark R, Lord S, Webster I. Clinical parameters associated with
10. Hyndman D, Ashburn A, Stack E. Fall events among people falls in an elderly population. Gerontology 1993; 39: 117–23.
with stroke living in the community: circumstances of falls 23. Altman DG, Machin D, Bryant TN et al. Statistics with
and characteristics of fallers. Arch Phys Med Rehabil 2002; 83: Confidence, 2nd edition. London: BMJ Books, 2000.
165–70. 24. Smith J, Forster A, Young J. Use of the STRATIFY falls
11. Stein J, Viramontes BE, Kerrigan DC. Fall-related Injuries in risk assessment in patients recovering from acute stroke. Age
anticoagulated stroke patients during inpatient rehabilitation. Ageing 2006; 35: 138–43.
Arch Phys Med Rehabil 1995; 76: 840–3. 25. Oliver D, Daly F, Martin F et al. Risk factors and risk assessment
12. Ramnemark A, Nyberg L, Borsson B et al. Fractures after tools for falls in hospital in-patients: a systematic review. Age
stroke. Osteoporos Int 1998; 8: 92–5. Ageing 2004; 33: 122–30.
13. Mackintosh SFH, Hill K, Dodd KJ et al. Falls and injury 26. Oliver D. Prevention of falls in hospital inpatients. Agendas
prevention should be part of every stroke rehabilitation plan. for research and practice. Age Ageing 2004; 33: 328–30.
Clin Rehabil 2005; 19: 441–51.
14. Nyberg L, Gustafson Y. Using the Downton Index to predict Received 30 August 2007; accepted in revised form 3 March
those prone to falls in stroke rehabilitation. Stroke 1996; 27: 2008
1821–8.
15. Hyndman D, Ashburn A. People with stroke living in the
community: an investigation into the relationship between
attention, balance and falls. Clin Rehabil 2002; 16: 228.
276