Objective To update the evidence-based recommendations for the prevention and management of hypertension in adults. Options and outcomes For lifestyle and pharmacological interventions, evidence was ...preferentially reviewed from randomized controlled trials and systematic reviews of trials. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease. Evidence A Cochrane collaboration librarian conducted an independent MEDLINE search from 2006 to August 2007 to update the 2007 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence. Recommendations For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium intake to less than 100 mmol/day (and 65 mmol/day to 100 mmol/day in hypertensive patients); perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m2 to 24.9 kg/m2 ) and waist circumference (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and one that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin-converting enzyme (ACE) inhibitors (in nonblack patients), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered for initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. Other agents appropriate for firstline therapy for isolated systolic hypertension include long-acting dihydropyridine CCBs or ARBs. In patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension but who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered. Validation All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.
Abstract Background The risk of hospital readmission in acute kidney injury survivors is not well understood. We estimated the proportion of acute kidney injury patients who were rehospitalized ...within 30 days and identified characteristics associated with hospital readmission. Methods We conducted a population-based study of patients who survived a hospitalization complicated by acute kidney injury from 2003-2013 in Ontario, Canada. The primary outcome was 30-day hospital readmission. We used a propensity score model to match patients with and without acute kidney injury, and a Cox proportional hazards model with death as a competing risk to identify predictors of 30-day readmission. Results We identified 156,690 patients who were discharged from 197 hospitals after an episode of acute kidney injury. In the subsequent 30 days, 27,457 (18%) patients were readmitted; 15,988 (10%) visited the emergency department and 7480 (5%) died. We successfully matched 111,778 patients with acute kidney injury 1:1 to patients without acute kidney injury. The likelihood of 30-day readmission was higher in acute kidney injury patients than those without acute kidney injury (hazard ratio HR 1.53; 95% confidence interval CI, 1.50-1.57). Factors most strongly associated with 30-day rehospitalization were the number of hospitalizations in the preceding year (adjusted HR 1.45 for ≥2 hospitalizations; 95% CI, 1.40-1.51) and receipt of inpatient chemotherapy (adjusted HR 1.44; 95% CI, 1.32-1.58). Conclusions One in 5 patients who survive a hospitalization complicated by acute kidney injury is readmitted in the next 30 days. Better strategies are needed to identify and care for acute kidney injury survivors in the community.
ABSTRACT BACKGROUND Despite the fact that many older adults receive home or long-term care services, the effect of these care settings on hospital readmission is often overlooked. Efforts to reduce ...hospital readmissions, including capacity planning and targeting of interventions, require clear data on the frequency of and risk factors for readmission among different populations of older adults. METHODS We identified all adults older than 65 years discharged from an unplanned medical hospital stay in Ontario between April 2008 and December 2015. We defined 2 preadmission care settings (community, long-term care) and 3 discharge care settings (community, home care, long-term care) and used multinomial regression to estimate associations with 30-day readmission (and death as a competing risk). RESULTS We identified 701 527 individuals (mean age 78.4 yr), of whom 414 302 (59.1%) started in and returned to the community. Overall, 88 305 in dividuals (12.6%) were re admitted within 30 days, but this proportion varied by care setting combination. Relative to individuals returning to the community, those discharged to the community with home care (adjusted odds ratio OR 1.43, 95% confidence interval CI 1.39–1.46) and those returning to long-term care (adjusted OR 1.35, 95% CI 1.27–1.43) had a greater risk of readmission, whereas those newly admitted to long-term care had a lower risk of readmission (adjusted OR 0.68, 95% CI 0.63–0.72). INTERPRETATION In Ontario, about 40% of older people were discharged from hospital to either home care or long-term care. These discharge settings, as well as whether an individual was admitted to hospital from long-term care, have important implications for understanding 30-day readmission rates. System planning and efforts to reduce readmission among older adults should take into account care settings at both admission and discharge.
Measuring the cost of adverse events in hospital Lapointe-Shaw, Lauren, MD PhD; Bell, Chaim M., MD PhD
Canadian Medical Association journal (CMAJ),
08/2019, Letnik:
191, Številka:
32
Journal Article
Subspecialization in glaucoma surgery Campbell, Robert J; Bell, Chaim M; Gill, Sudeep S ...
Ophthalmology (Rochester, Minn.),
11/2012, Letnik:
119, Številka:
11
Journal Article
Recenzirano
To evaluate trends in glaucoma surgery subspecialization.
Population-based analysis of incisional glaucoma surgery and laser trabeculoplasty practice patterns among all ophthalmologists in Ontario, ...Canada, from 1995 through 2010.
All ophthalmologists in Ontario, Canada, providing universal health care for the provincial population of approximately 12 million.
The province of Ontario provides government-funded universal health care insurance to all citizens through the Ontario Health Insurance Plan (OHIP). Anonymized physician services data were obtained from the OHIP database, which has excellent accuracy for procedure performance.
Proportion of ophthalmologists providing incisional glaucoma surgery and laser trabeculoplasty and the distribution of these surgical and laser procedures among ophthalmologists.
Between 1995 and 2010, the median number of ophthalmologists in Ontario was 427 (35.1 per 1 million population), ranging from 417 to 453 (32.9-40.3 per 1 million population). The percentage of ophthalmologists providing incisional glaucoma surgery dropped from 35% in 1995 to 19% in 2010, a 47% decline. Over the same period, the mean number of incisional glaucoma surgeries performed per surgeon doubled, and the percentage of incisional glaucoma operations provided by high-volume surgeons rose from 23% to 59%. The percentage of ophthalmologists performing laser trabeculoplasty was relatively stable (48% in 1995 to 50% in 2010).
Over the past 16 years, the proportion of ophthalmologists providing incisional glaucoma surgery has declined significantly. At the same time, the proportion of incisional glaucoma surgery provided by high-volume glaucoma surgeons has more than doubled. These trends will have important implications for stakeholders from policy makers and hospitals to academic departments and residency education programs.
To evaluate the association between dementia and postoperative outcomes of older adults with hip fractures.
Population-based, retrospective cohort study.
Province of Ontario, Canada.
All individuals ...with hip fractures who underwent hip fracture surgery in Ontario, Canada between April 1, 2003 and March 31, 2010 were identified. Physician-diagnosed dementia, prior to hip fracture, was identified using a diagnostic algorithm in the administrative databases.
The preoperative characteristics of older adults with and without dementia were compared separately for individuals admitted to hospital from community or long-term care (LTC). Multivariable regression was used to compare postoperative health service utilization, time with LTC admission, and mortality for individuals with and without dementia.
A total of 45,602 older adults had hip fractures and individuals with dementia accounted for 23.9% and 83.5% of all hip fractures from the community and LTC settings, respectively. Compared with those without dementia, individuals with dementia were less likely to be admitted to rehabilitation facilities. Among community-dwelling older adults, dementia was associated with an increased risk of LTC admission hazard ratio (HR) = 2.49, 95% confidence interval (CI): 2.38-2.61, P < .0001. Dementia was also associated with a higher mortality for older adults from community (HR = 1.47, 95% CI: 1.41-1.52, P < .0001) and LTC (HR = 1.10; 95% CI: 1.02-1.18, P = .005) settings.
Dementia is common among older adults with hip fractures and associated with poor prognosis following hip fracture surgery. Specialized services targeting the growing number of older adults with dementia may help to prevent hip fractures and optimize postoperative care for this vulnerable population.
Background Readmissions following hospital discharge among maintenance dialysis patients are common, potentially modifiable, and costly. Compared with patients receiving in-center hemodialysis (HD), ...patients receiving peritoneal dialysis (PD) have fewer routine dialysis clinic encounters and as a result may be more susceptible to a hospital readmission following discharge. Study Design Population-based retrospective-cohort observational study. Settings & Participants Patients treated with maintenance dialysis who were discharged following an acute-care hospitalization during January 1, 2003, to December 31, 2013, across 164 acute-care hospitals in Ontario, Canada. For those with multiple hospitalizations, we randomly selected a single hospitalization as the index hospitalization. Predictor Dialysis modality PD or in-center HD. Propensity scores were used to match each patient on PD therapy to 2 patients on in-center HD therapy to ensure that baseline indicators of health were similar between the 2 groups. Outcome All-cause 30-day readmission following the index hospital discharge. Results 28,026 dialysis patients were included in the study. 4,013 PD patients were matched to 8,026 in-center HD patients. Among the matched cohort, 30-day readmission rates were 7.1 (95% CI, 6.6-7.6) per 1,000 person-days for patients on PD therapy and 6.0 (95% CI, 5.7-6.3) per 1,000 person-days for patients on in-center HD therapy. The risk for a 30-day readmission among patients on PD therapy was higher compared with those on in-center HD therapy (adjusted HR, 1.19; 95% CI, 1.08-1.31). The primary results were consistent across several key prespecified subgroups. Limitations Lack of information for the frequency of nephrology physician encounters following discharge from the hospital in both the PD and in-center HD cohorts. Limited validation of International Classification of Diseases, Tenth Revision codes. Conclusions The risk for 30-day readmission is higher for patients on home-based PD compared to in-center HD therapy. Interventions to improve transitions in care between the inpatient and outpatient settings are needed, particularly for patients on PD therapy.
Use of multiple, concurrent drug therapies, often referred to as polypharmacy, is a concern in the long term care (LTC) setting, where frail older adults are particularly at risk for adverse events. ...We quantified the scope of this practice by exploring variation in the use of nine or more drug therapies across LTC homes.
Cross-sectional analysis of LTC home census data.
All LTC homes in Ontario, Canada.
A total of 64,394 LTC residents aged 66 years and older residing in 589 LTC homes in the fall of 2005.
Facility-level rates of polypharmacy were compared with rates of use of Beers criteria and antipsychotic drug therapies. Multivariate logistic regression models were used to assess predictors of polypharmacy across residents and LTC homes.
Nine or more drug therapies were dispensed concurrently to 10,007 (15.5%) of LTC home residents. Compared with those dispensed fewer drugs, residents receiving 9 or more drug therapies were more likely to have multiple comorbidities. There was threefold variation in polypharmacy rates across homes (26.2% versus 7.9%) and facility-level rates of polypharmacy were modestly correlated with rates of use of Beers criteria drugs (r = 0.27, P < .001) and antipsychotic drug therapies (r = 0.16, P < .001). Controlling for resident factors, those living in LTC homes with high polypharmacy rates were more likely to receive 9 or more drug therapies (odds ratio 1.9, 95% confidence interval 1.7-2.0).
Residents in Ontario LTC homes commonly received nine or more concurrent drug therapies, particularly residents with multiple chronic conditions. The threefold variation in rate across homes suggests a role for this measure in guiding drug review at the facility level.
Abstract Background Sodium polystyrene sulfonate (Kayexalate; Sanofi-Aventis, Paris, France) is a cation-exchange resin routinely used in the management of hyperkalemia. However, its use has been ...associated with colonic necrosis and other fatal gastrointestinal adverse events. Although the addition of sorbitol to sodium polystyrene sulfonate preparations was previously believed to be the cause of gastrointestinal injury, recent reports have suggested that sodium polystyrene sulfonate itself may be toxic. Our objective was to systematically review case reports of adverse gastrointestinal events associated with sodium polystyrene sulfonate use. Methods MEDLINE (1948 to July 2011), EMBASE (1980 to July 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (1993 to July 27, 2011), bibliographies of identified articles, and websites of relevant drug agencies and professional associations in the United States and Canada were reviewed to identify eligible reports of adverse gastrointestinal events associated with sodium polystyrene sulfonate use. Causality criteria of the World Health Organization causality assessment system were applied to each report. Results Thirty reports describing 58 cases (41 preparations containing sorbitol and 17 preparations without sorbitol) of adverse events were identified. The colon was the most common site of injury (n = 44; 76%), and transmural necrosis (n = 36; 62%) was the most common histopathologic lesion reported. Mortality was reported in 33% of these cases due to gastrointestinal injury. Conclusions Sodium polystyrene sulfonate use, both with and without sorbitol, may be associated with fatal gastrointestinal injury. Physicians must be cognizant of the risk of these adverse events when prescribing this therapy for the management of hyperkalemia.
Echocardiography is important for the diagnosis of infective endocarditis (IE), for which transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE).
A systematic ...review and meta-analysis of observational studies was performed with the objective of evaluating diagnostic properties of TTE, with transesophageal findings of IE as the reference standard in patients with suspected IE.
The literature search yielded 377 unique articles, of which 16 met the inclusion criteria. The 16 studies included 2,807 patients, of whom 793 (28%) had vegetations on TEE. For detecting vegetations, harmonic TTE had sensitivity of 61% (95% CI, 45%-75%) and specificity of 94% (95% CI, 85%-98%) with a negative likelihood ratio (NLR) of 0.42 (95% CI, 0.26-0.61). NLR for harmonic TTE can be improved by including only patients without prosthetic valves (NLR = 0.36; 95% CI, 0.22-0.55) or by having strict criteria for conclusively negative results on TTE (NLR = 0.17; 95% CI, 0.10-0.28). In the setting of patients without prosthetic valves, harmonic TTE had likelihood ratios of 0.14 (95% CI, 0.09-0.23) for a conclusively negative result, 0.66 (95% CI, 0.53-0.81) for an indeterminate result, and 14.60 (95% CI, 3.37-70.40) for a positive result.
Modern harmonic TTE still has the potential to miss many vegetations detected on TEE. When limited to patients without prosthetic valves, a conclusively negative TTE under optimal view greatly decreases likelihood of IE. All other transthoracic results are not useful for ruling out IE, and subsequent TEE is almost always required.
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