搜索结果：falls

Many tools have been developed to assess fall risk and support fall prevention for older adults, but the authors are unaware of any study that compares the performance of predictive algorithms based on major composite assessment tools and commonly used single assessment tools. This study compares the predictive performance of the algorithms for two composite fall risk assessment tools and four single fall risk assessment tools among community-dwelling Chinese older adults. A 12-month prospective study was conducted between April 2023 and June 2024 in Changsha, China. Two major composite assessment tools (Stopping Elderly Accidents, Deaths & Injuries [STEADI] and World Falls Guidelines [WFG] algorithms) and four single assessment tools (Stay Independent Brochure Questionnaire [SIB], Falls Efficacy Scale International [FES-I], Home Falls and Accidents Screening Tool [HOME FAST], and Timed Up and Go Test [TUGT]) were included. Primary performance measures included area under the receiver operating characteristic curves (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Among the 1,428 enrolled older adults, 1,237 participants completed the study. All ten algorithms from the two composite assessment tools showed notably low AUC (0.527-0.575), sensitivity (11.3-36.5%) and PPV (12.7-31.7%), but acceptably high specificity (78.9-96.2%) and NPV (87.2-92.9%) to predict both falls and fall-related injuries throughout the 12-month follow-up period. Among the ten algorithms, WFG algorithm 3 exhibited the best performance in predicting both falls (AUC = 0.573, 95% CI: 0.544, 0.600) and fall-related injuries (AUC = 0.575, 95% CI: 0.546, 0.602). Compared to five algorithms based on four single assessment tools, WFG algorithm 3 did not demonstrate significantly superior performance (p>0.05). The performances of the optimal algorithm in predicting 12-month falls and fall-related injuries among older adults from the two composite risk assessment tools were not better than those from four common single risk assessment tools.

Recent studies associate computed tomography (CT) measurements of the quadriceps femoris with fall risk. However, no study has examined the relationship between falls and each individual quadriceps component. This study longitudinally investigated the association between CT values and cross-sectional areas of individual quadriceps components and the occurrence of falls 1&#x2009;year later. Single-slice CT images of the right mid-thigh were obtained at the initial visit from 246 patients (Age: 77.4&#x2009;&#xb1;&#x2009;6.6, Male: 80) who returned for follow-up after 1&#x2009;year. The quadriceps femoris was segmented into the whole muscle, rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius. For each compartment, cross-sectional area and mean CT value (average pixel value within a segmented region, representing muscle quality) were calculated. Participants were categorized into fall and non-fall groups based on new falls during the one-year follow-up. Associations between baseline measurements and subsequent falls were analyzed. Among females in the fall group, CT values of the whole quadriceps femoris, vastus lateralis, and vastus intermedius were significantly lower (p&#x2009;<&#x2009;0.01, p&#x2009;<&#x2009;0.05, and p&#x2009;<&#x2009;0.01, respectively). Binary logistic regression analysis showed that among all CT values, only that of the vastus intermedius was a predictor of falls (p&#x2009;<&#x2009;0.01; odds ratio, 0.92; 95% confidence interval, 0.862-0.978). The cutoff value was 49.1 Hounsfield units. Cross-sectional area was not associated with falls, whereas the CT value of the vastus intermedius was significantly associated with fall occurrence. These findings suggest that the condition of the vastus intermedius may play an important role in fall risk.

Falls are the leading cause of facial fractures in the elderly, contributing to significant morbidity and mortality. This study aimed to identify the trends, epidemiology, characteristics, and outcomes of facial fractures in the elderly resulting from mechanical falls. The 2018 to 2020 NEDS HCUP database was queried for facial fracture encounters using the ICD-10 codes. Demographics, causes of injury, concomitant injuries, and cost data were evaluated. Multivariable logistic regression analysis was performed to ascertain the factors associated with facial fracture from etiology and mortality. Of 420,105 geriatric facial fractures, 320,209 (76%) resulted from falls. Fall-related facial fractures occurred in older patients (mean age, fall: 79&#xa0;y versus non-fall: 75&#xa0;y, P < 0.001). Mortality was lower following falls compared with non-fall mechanisms (fall: 2.2% versus non-fall: 4.3%, P < 0.001), though falls were associated with substantial morbidity, with 43.7% requiring discharge to skilled nursing facilities and 30.6% requiring hospital admission. Increasing age, higher injury severity score, skull vault, skull base, and occipital fractures independently predicted mortality (all P < 0.001). Injury severity score &#x2265;25 was associated with 9-fold increased odds of death (OR: 9.03, 95% CI: 7.98-10.20). Mechanical falls account for the majority of geriatric facial fractures and are associated with significant morbidity and mortality, particularly among older individuals with high injury severity and cranial fractures. These findings highlight the need for early risk stratification and targeted fall-prevention strategies to reduce adverse outcomes in the elderly. Findings may supplement a clinician's judgment in cases where the mechanism and severity of a patient's injuries are ill-defined.

Anticholinergic medications may exacerbate orthostatic blood pressure dysregulation in frail older adults. We aimed to investigate the association between anticholinergic burden (ACB) and orthostatic hypotension (OH)-related adverse clinical outcomes in prefrail and frail older adults. A cross-sectional analysis. Community-dwelling older adults aged &#x2265;65 years, totaling 1465 individuals, undergoing comprehensive geriatric assessment. Frailty was defined using the Fried phenotype. ACB was quantified using the Anticholinergic Cognitive Burden Scale and categorized as absent (ACB = 0) or present (ACB &#x2265;1). OH was defined as a &#x2265;20 mm Hg systolic or &#x2265;10 mm Hg diastolic blood pressure reduction within 3 minutes of standing. Among individuals with OH (n = 181), associations between ACB and adverse outcomes (falls, fractures, injuries, depressive symptoms, cognitive impairment, and dependency) were examined separately in prefrail and frail groups. OH prevalence increased progressively across frailty stages (robust 6.6%, prefrail 12.1%, frail 14.5%; P = .03). In prefrail individuals with OH, ACB &#x2265;1 was independently associated with dependency (odds ratio [OR], 3.50; 95% CI, 1.30-9.41; P = .01). In frail individuals with OH, ACB &#x2265;1 was independently associated with falls (OR, 2.39; 95% CI, 1.13-5.05; P = .02) and cognitive impairment (OR, 3.63; 95% CI, 1.63-8.07; P = .002). These associations remained consistent in sensitivity analyses. ACB is linked to frailty-stage-specific adverse outcomes in older adults with OH and may be associated with dependency in prefrailty as well as falls and cognitive impairment in frailty. Incorporating ACB assessment into medication review strategies may represent a modifiable target for mitigating vulnerability in older adults with OH.

The relationship between social participation and health-related outcomes remains underexplored among individuals with multiple sclerosis (MS). This study aimed to examine associations between social participation and self-reported outcomes, and to explore whether these relationships varied by age and sex. A total of 1162 adults with MS (mean age: 52.3 years, 80.6% female) completed an online survey. Social participation was assessed using the short form of the ability to participate in social roles and activities of the Quality of Life in Neurological Disorders. Outcomes included self-reported ambulation difficulty (Multiple Sclerosis Walking Scale-12), cognitive deficit (Perceived Deficits Questionnaire), fatigue (Modified Fatigue Impact Scale), dual-task difficulty (Dual-Task Impact on Daily Living Questionnaire), fear of falling (Fall Efficacy Scale-International), and recurrent falls (>1 fall). Linear and logistic regression models were used to examine the associations between social participation and self-reported outcomes. Greater social participation is associated with reduced fatigue (B [95% CI]&#x202f;=&#x202f;-2.04 [-2.38, -1.70]), ambulation difficulty (-1.79 [-2.19, -1.38]), cognitive deficit (-0.40 [-0.50, -0.30]), dual-task difficulty (-1.30 [-1.59, -1.01]), fear of falling (-0.75 [-0.91, -0.60]), and recurrent falls (OR [95% CI]&#x202f;=&#x202f;0.89 [0.83, 0.95]). Significant age and social participation interactions were observed for cognition, ambulation, and fatigue, with older adults showing smaller magnitudes of benefits from social participation. Only cognition showed significant sex and social participation interaction, with a stronger association among females than males with MS. This study supports the clinical relevance of social participation as a factor associated with health-related outcomes in people with MS.

This study aimed to characterise the epidemiology, clinical features and outcomes of adults with severe traumatic brain injury (sTBI) managed by emergency medical services (EMS) in New Zealand. Objectives included describing demographics, event and clinical characteristics, estimating national incidence, and 30-day mortality. This retrospective observational study analysed EMS data from the Aotearoa New Zealand Paramedic Care Collection (ANZPaCC) between 1 January 2020 and 31 December 2022. Patients aged &#x2265;16 years with head injury and a Glasgow Coma Scale score &#x2264;8 were included. Descriptive statistics and age-standardised incidence rates were calculated by sex, ethnicity, age, rurality and socio-economic deprivation. EMS attended 630 sTBI patients over 3 years; most were male (n=430, 68.3%) and of European/Other ethnicity (n=398, 63.2%). sTBI incidence was higher among M&#x101;ori than non-M&#x101;ori (44.5-68.7 versus 28.6-35.6 per 100,000 person-years). Younger adults (&#x2264;45 years) had the highest rates. sTBIs in urban areas (n=485, 77%) and the most deprived quintile (n=213, 33.8%) were over-represented. Falls (n=217, 34.4%) and road traffic incidents (n=196, 31.0%) were the leading mechanisms. Thirty-day mortality was 37.8% (n=238). EMS working diagnoses of sTBI provide a valuable perspective on patient needs at the point of injury, capturing cases that may be missed in hospital-based datasets yet still influence transport decisions, destination selection and tertiary healthcare capacity. The data indicate that sTBI disproportionately affects M&#x101;ori, younger adults, individuals living in socio-economically deprived areas and urban populations, highlighting health inequities and the need for targeted interventions, informed service planning and further research.

Distal radius fractures are common in older women, but the optimal treatment remains debated. We compared conservative treatment, volar locking plate fixation, and external fixation in women aged &#x2265;65 years with low-energy distal radius fractures, focusing on patient-reported outcomes (PROMs) and radiographic alignment. This retrospective cohort study included consecutive women aged &#x2265;65 years treated at a tertiary center between January 2019 and January 2024. Only low-energy mechanisms, such as falls from standing height, were included. Patients were grouped according to treatment received: conservative management (n=44), open reduction and internal fixation with a volar locking plate (ORIF; n=47), or external fixation (n=43). The primary endpoint was the PRWE total score at &#x2265;12 months. Secondary outcomes included QuickDASH, PRWE pain and function subscores, range of motion, grip strength, and radiographic parameters. A total of 134 women were analyzed. The primary outcome, PRWE total score, did not differ significantly across groups: 15.40&#xb1;6.71 after conservative treatment, 14.89&#xb1;5.55 after volar plating, and 17.08&#xb1;7.51 after external fixation (p=0.268). QuickDASH scores were 14.35&#xb1;7.21, 17.86&#xb1;6.57, and 15.44&#xb1;7.61, respectively (p=0.058). Grip strength as a percentage of the contralateral side was also similar (88.62&#xb1;5.85%, 90.09&#xb1;5.54%, and 91.02&#xb1;5.54%; p=0.139). Patients selected for operative treatment had better final radiographic alignment, including volar tilt (5.80&#xb1;2.79&#xb0;, 7.55&#xb1;1.57&#xb0;, and 7.07&#xb1;1.65&#xb0;; p<0.001) and radial height (9.73&#xb1;2.42 mm, 11.77&#xb1;1.91 mm, and 12.86&#xb1;1.91 mm; p<0.001). In women aged &#x2265;65 years with low-energy distal radius fractures, PRWE total score did not differ significantly across treatment pathways, despite better radiographic alignment in patients selected for operative treatment. Because treatment allocation was not randomized and baseline fracture morphology differed substantially between groups, these comparisons should be interpreted as descriptive observational findings after individualized treatment selection in routine practice. The absence of statistically significant differences in PROMs should not be interpreted as evidence of treatment equivalence or as a causal treatment effect.

To provide a practical guide on when to suspect endogenous hypercortisolism, how to use the overnight 1-mg dexamethasone suppression test (DST) for targeted case-finding, and which patients are most likely to benefit from treatment. This narrative review synthesizes evidence from clinical practice guidelines, prospective prevalence studies, randomized controlled trials, systematic reviews, and meta-analyses addressing the recognition, diagnosis, and management of endogenous hypercortisolism in patients with treatment-resistant type 2 diabetes (T2D), resistant hypertension, and adrenal incidentalomas. Confirmed endogenous hypercortisolism is found in 0.6%-3.4% of broader T2D cohorts after stepwise biochemical evaluation, but recent prospective studies-including CATALYST and MOMENTUM-report abnormal cortisol suppression in approximately one in four patients within selected high-risk groups. Mild autonomous cortisol secretion (MACS), defined as ACTH-independent cortisol production with post-dexamethasone serum cortisol >&#x2009;50&#x2009;nmol/L (>&#x2009;1.8&#x2009;&#x3bc;g/dL) in the absence of classic Cushingoid features, is associated with clinically meaningful increases in hypertension, T2D, visceral adiposity, and all-cause mortality. Routine screening of all patients with diabetes or hypertension is not recommended; testing should be reserved for those with multiple, progressive, or atypical cardiometabolic features, or with adrenal incidentalomas. Attention to test timing, drug interactions, and physiologic non-neoplastic hypercortisolism is essential for accurate interpretation. When etiology and laterality permit, surgical resection offers the best chance for durable remission. When surgery is not feasible, not curative, or declined, medical alternatives-including glucocorticoid-receptor antagonists (e.g., mifepristone) and steroidogenesis inhibitors (e.g., osilodrostat, ketoconazole)-can reduce cortisol activity or lower cortisol production, each with specific efficacy, tolerability, and safety considerations warranting endocrinologist involvement. As cortisol activity falls, glucose- and blood-pressure medications often require down-titration. Monitoring for adrenal insufficiency, cortisol withdrawal syndrome, and drug-specific adverse effects requires coordinated multidisciplinary follow-up. Through careful evaluation and targeted treatment, hypercortisolism can be recognized and managed as a modifiable contributor to cardiometabolic risk. Many people with type 2 diabetes or high blood pressure do not reach their treatment goals even when they take several medicines as prescribed. In some of these patients, the body produces too much of a hormone called cortisol (sometimes called the body's stress hormone). This can raise blood sugar and blood pressure, increase abdominal fat, speed up muscle and bone loss, and increase the risk of heart and blood vessel disease. Cortisol excess exists on a spectrum. Some patients have classic outward signs&#x2014;such as a rounded face, purple stretch marks, and severe muscle weakness&#x2014;that are easier to recognize. However, many others have no obvious physical changes and mainly have diabetes, high blood pressure, or other metabolic problems that remain difficult to control despite multiple medications. Without targeted testing, these patients often go undiagnosed. Not everyone with diabetes or high blood pressure needs to be tested for cortisol problems. However, if a patient has an incidental adrenal mass on imaging, or diabetes and hypertension that remain difficult to control despite several medicines&#x2014;especially when accompanied by unexplained weight gain, muscle weakness, or bones that break easily&#x2014;it is reasonable to consider excess cortisol as a possible cause and discuss testing with a clinician. A simple test called the overnight 1&#x2010;mg dexamethasone suppression test (DST) can help. Patients take a small pill (1&#x2009;mg dexamethasone) at night, and their cortisol levels are checked the next morning. If levels remain high, further testing is needed to confirm excess cortisol. It is important to rule out certain factors that can affect test accuracy&#x2014;including some medications (such as oestrogen&#x2010;containing pills), heavy alcohol use, and untreated sleep apnea&#x2014;and to interpret the test together with a health care professional. If confirmed, treatment can help. Options include surgery to remove an adrenal or pituitary tumour when present, or medicines that reduce cortisol production, reduce cortisol activity at the receptor level, or both. These treatments require specialist supervision and regular monitoring for side effects, including a temporary withdrawal reaction (such as fatigue, body aches, or low mood) that can occur as the body adjusts to lower cortisol. When cortisol is effectively reduced&#x2014;whether through lower production or by reducing its activity at the receptor level&#x2014;blood sugar and blood pressure often become easier to control, and some patients can reduce the number of medicines they take. Regular follow&#x2010;up with a care team is important to ensure the best results and to watch for side effects.

Sexual and gender minority (SGM) individuals are at increased risk of adverse neurological health outcomes. Despite this, risk factors and outcomes of SGM populations after traumatic brain injury (TBI) remain poorly characterized. Our study aimed to describe the epidemiology of TBI in SGM people and to compare TBI risk factors and outcomes, including the incidence of repetitive TBI, with those of non-SGM people with TBI. We conducted a retrospective chart review of adults presenting with TBI to a level I trauma center between 2019 and 2024. SGM patients were identified through the sexual orientation and gender identity SmartForm in Epic, and non-SGM patients were matched by year of presentation. Repetitive TBI was defined as subsequent presentation for head injury within 5 years of the index TBI. Among 509 patients (SGM: n = 238, non-SGM: n = 271), SGM patients were more likely to have a history of psychiatric illness (p < 0.0001) and previous TBI (i.e., prior to the index TBI of inclusion, p = 0.006). TBI severity by Glasgow Coma Scale did not differ across groups (p > 0.05), but SGM patients differed in injury mechanisms, with fewer ground-level falls (p = 0.01) and greater violence/assault (p = 0.04). There were differences in TBI outcomes, with fewer inpatient admissions for SGM patients (p = 0.004) and lower rates of in-hospital mortality (p = 0.014). The incidence of repetitive TBI was higher in the SGM group versus non-SGM group (39% vs. 15%, p < 0.0001). SGM people had 3.1 times higher odds of repetitive TBI compared with non-SGM people (95% confidence interval: 1.8-5.4, p < 0.0001), even after adjusting for age, sex assigned at birth, underlying psychiatric diagnosis, and history of prior TBI. Our findings of a higher prevalence of comorbid psychiatric illness, prior TBI, distinct TBI mechanisms, and higher repetitive TBI incidence among SGM patients underscore a distinct injury profile and the critical need to identify the reasons for these differences to improve outcomes.

Pharmacist involvement in the emergency department (ED) and early in a patient's hospital stay improves clinical outcomes and reduces medication errors. Because EDs are high-pressure settings with limited pharmacist staffing, pharmacists cannot review every patient. Instead, they must focus on identifying and prioritising patients who may be at risk of potential medication-related harm. To establish and prioritise consensus-based medication management criteria to identify patients with potential medication-related harm within the ED setting for early pharmacist review. We used Nominal Group Technique (NGT) methodology to rank the most important criteria for identifying whether a patient's presentation may be due to medication-related harm or whether they may be at risk of developing medication-related harm in the ED. Participants were purposively recruited ED clinicians including pharmacists, doctors and nurses who worked at the ED of either the Gold Coast University Hospital or Robina Hospital on the Gold Coast, Queensland, Australia, during May-June 2025. A total of 14 participants comprising six pharmacists, five nurses and three doctors participated in two 1-h NGT workshops. Participants ranked 12 criteria from a list of 34 during NGT Round 1. They subsequently ranked six criteria from the list of 12 during NGT Round 2. The weighted rankings of the criteria across both groups were combined to determine the top six criteria which were, in order from 1 to 6 (1&#x2009;=&#x2009;most relevant): (1) medication-related admission or thinks medicine responsible for admission; (2) bleeding and falls; (3) poor historian (unable to provide reliable history)/suspected non-adherence or poor compliance; (4) carbidopa/levodopa (entacapone), co-beneldopa; (5) unverified medicines; and (6) medicines requiring therapeutic drug monitoring/medicines with narrow therapeutic index. The first four criteria were ranked within the top six in both NGT workshops. This study has provided a concise list of six medication-related criteria that expert consensus agreed were the most important for prioritising patients with potential medication-related harm. This forms the basis for the development of information gathering strategies to be incorporated into clinicians' workflows early in patients' ED journey.

PurposeThe widely accepted position that clinicians are not obligated to provide interventions that are considered to be outside standards of care requires a "deeper dive" and in some cases, a revision. Relying solely on standards of care may be inadequate given the complexity of modern medical practice, which aims to improve quality through personalization and precision, and the reality that healthcare professionals do not always reach consensus on what constitutes standards of care under certain circumstances.Despite the increasing emphasis on evidence-based medicine expected to contribute to established standards of care practices, only about 10% of current medical practice is supported by high-level evidence. Intensive Care Unit (ICU) clinicians are often exhorted by patients and their surrogates to administer treatments or interventions that they deem to be outside accepted standards of care given the patients' clinical status. These clinicians and their teams must balance respect for patient autonomy with their duty to maximize the benefits and minimize the risks of the proposed intervention or treatment.Clinicians and ethicists can become entangled in conflicting ethical principles, uncertain of which to prioritize, and may rely on standards of care to guide both clinical and ethical decisions. However, standards of care are not as definitive as they may appear; they contain ambiguities and uncertainties. As illustrated by three anonymized cases, physicians must often go beyond guideline recommendations. They must critically evaluate and thoughtfully consider the intervention's applicability to the specific patient, balancing its potential benefits and harms, and negotiating a shared path forward, even if it falls outside established norms.