Background:
In some jurisdictions, routine reporting of the estimated glomerular filtration rate (eGFR) has led to an increase in nephrology referrals and wait times.
Objective:
We describe the use ...of the Kidney Failure Risk Equation (KFRE) as part of a triage process for new nephrology referrals for patients with chronic kidney disease stages 3 to 5 in a Canadian province.
Design:
A quasi-experimental study design was used.
Setting:
This study took place in Manitoba, Canada.
Measurements:
Demographics, laboratory values, referral numbers, and wait times were compared between periods.
Methods:
In 2012, we adopted a risk-based cutoff of 3% over 5 years using the KFRE as a threshold for triage of new referrals. Referrals who did not meet other prespecified criteria (such as pregnancy, suspected glomerulonephritis, etc) and had a kidney failure risk of <3% over 5 years were returned to primary care with recommendations based on diabetes and hypertension guidelines. The average wait time and number of consults seen between the pretriage (January 1, 2011, to December 31, 2011) and posttriage period (January 1, 2013, to December 31, 2013) were compared using a general linear model.
Results:
In the pretriage period, the median number of referrals was 68/month (range: 44-76); this increased to 94/month (range: 61-147) in the posttriage period. In the posttriage period, 35% of referrals were booked as urgent, 31% as nonurgent, and 34% of referrals were not booked. The median wait times improved from 230 days (range: 126-355) in the pretriage period to 58 days (range: 48-69) in the posttriage period.
Limitations:
We do not have long-term follow-up on patients triaged as low risk. Our study may not be applicable to nephrology teams operating under capacity without wait lists. We did not collect detailed information on all referrals in the pretriage period, so any differences in our pretriage and posttriage patient groups may be unaccounted for.
Conclusions:
Our risk-based triage scheme is an effective health policy tool that led to improved wait times and access to care for patients at highest risk of progression to kidney failure.
The contemporary incidence and prevalence of thoracic aortic aneurysm and dissection (TAAD) remains understudied. Epidemiological research on TAAD has been limited by incomplete case identification ...within administrative data sources. The objectives of this study were to develop a case identification method and determine the incidence and prevalence of TAAD, based on data from Manitoba, Canada.
Hospital records and medical claims housed at the Manitoba Centre for Health Policy, and data from the Manitoba Thoracic Aortic Diseases Clinic were used to develop a case definition and identify patients with TAAD in Manitoba, Canada. The age-standardized incidence and prevalence of thoracic aortic disease was determined and stratified by sex from 1998 to 2016.
We identified 4264 patients with TAAD, of whom 63% were male. The age standardized incidence was 2 times higher in men, peaking at 42 cases per 100,000 in 2013. Although the overall incidence was lower in female patients, the number of incident cases increased 68% compared with 25% in male patients. In hospitalized patients, the incidence and prevalence of aneurysms increased over time, whereas the incidence of dissection and rupture has remained stable.
The use of a novel case identification method provided a more complete description of the epidemiology of TAAD. The incidence and prevalence of TAAD is rising, more so in female patients over time. These data support increased resource allocation to thoracic aortic diseases clinics to ensure appropriate monitoring, treatment, and follow-up for the growing number patients with thoracic aortic disease.
L’incidence et la prévalence contemporaines de l’anévrisme et de la dissection de l’aorte thoracique (ADAT) demeurent sous-étudiées. L’identification incomplète des cas dans les sources de données administratives limite la recherche épidémiologique sur l’ADAT. La présente étude visait à mettre au point une méthode d’identification des cas et à déterminer l’incidence et la prévalence de l’ADAT à partir de données provenant du Manitoba (Canada).
Les dossiers hospitaliers et les demandes de remboursements de frais médicaux conservés au Centre des politiques de santé du Manitoba de même que les données de la Manitoba Thoracic Aortic Diseases Clinic ont servi à définir les cas d’ADAT et à en faire la recension au Manitoba (Canada). L’incidence et la prévalence de la maladie de l’aorte thoracique normalisées selon l’âge ont été établies et stratifiées par sexe pour la période allant de 1998 à 2016.
Nous avons recensé 4 264 cas d’ADAT; dans 63 % d’entre eux, il s’agissait de patients de sexe masculin. L’incidence normalisée selon l’âge était deux fois plus élevée chez les hommes, culminant à 42 cas pour 100 000 individus en 2013. Même si l’incidence globale était inférieure chez les femmes, le nombre de nouveaux cas a augmenté de 68 %, comparativement à 25 % chez les hommes. Parmi les patients hospitalisés, l’incidence et la prévalence d’anévrismes ont augmenté au fil du temps, tandis que l’incidence de dissection et de rupture est demeurée stable.
La mise en œuvre d’une nouvelle méthode d’identification des cas a procuré une description plus complète de l’épidémiologie de l’ADAT. L’incidence et la prévalence de l’ADAT sont en hausse, et davantage chez les femmes au fil du temps. Ces données plaident en faveur de mesures permettant d’accroître les ressources cliniques en vue d’assurer la surveillance, le traitement et le suivi appropriés des patients, toujours plus nombreux, atteints de maladies de l’aorte thoracique.
Frailty is a risk factor for cardiovascular disease (CVD). Biomarkers have the potential to detect the early stages of frailty, such as pre-frailty. Myokines may act as biomarkers of frailty-related ...disease progression, as a decline in muscle health is a hallmark of the frailty phenotype. This study is a secondary analysis of 104 females 55 years of age or older with no previous history of CVD. Differences in systemic myokine concentrations based on frailty status and CVD risk profile were examined using a case-control design. Propensity matching identified two sets of 26 pairs with pre-frailty as the exposure variable in low or elevated CVD risk groups for a total 104 female participants. Frailty was assessed using the Fried Criteria (FC) and CVD risk was assessed using the Framingham Risk Score (FRS). Factorial ANOVA compared the main effects of frailty, CVD risk, and their interaction on the concentrations of 15 myokines. Differences were found when comparing elevated CVD risk status with low for the concentrations of EPO (384.76 ± 1046.07 vs. 206.63 ± 284.61 pg/mL, p = .001), FABP3 (2772.61 ± 3297.86 vs. 1693.31 ± 1019.34 pg/mL, p = .017), FGF21 (193.17 ± 521.09 vs. 70.18 ± 139.51 pg/mL, p = .010), IL-6 (1.73 ± 4.97 vs. 0.52 ± 0.89 pg/mL, p = .023), and IL-15 (2.62 ± 10.56 vs. 0.92 ± 1.25 pg/mL, p = .022). Pre-frail females had lower concentrations of fractalkine compared to robust (27.04 ± 20.60 vs. 103.62 ± 315.45 pg/mL, p = .004). Interaction effects between frailty status and CVD risk for FGF21 and OSM were identified. In elevated CVD risk, pre-frail females, concentrations of FGF21 and OSM were lower than that of elevated CVD risk, robust females (69.10 ± 62.86 vs. 317.24 ± 719.69, p = .011; 1.73 ± 2.32 vs. 24.43 ± 69.21, p = .018, respectively). These data identified specific biomarkers of CVD risk and biomarkers of frailty that are exacerbated with CVD risk.
•EPO, FABP3, IL-6, IL-15 and FGF-21 were different in females with elevated CVD risk.•Pre-frail females had lower fractalkine, compared to females who were robust.•Interactions between frailty status and CVD risk were found for FGF21 and OSM.•Specific myokines were found to be biomarkers of CVD risk and frailty.
Abstract Objective To analyze outcomes and predictors of functional survival (primary care home admission + mortality) and hospital readmission in patients aged 80 years and over who underwent ...surgical aortic valve replacement in Manitoba. Methods This was a retrospective cohort study of patients aged 80 years and over who underwent surgical aortic valve replacement with or without coronary artery bypass graft in Manitoba from 1995 to 2014. Data from The Manitoba Adult Cardiac Surgery database and The Manitoba Centre for Health Policy was used. Kaplan-Meier estimates of outcomes and Cox multivariate regression analysis of risk factors were performed. Survival was compared to the age and sex matched life expectancy. Results 1872 patients were aged 50 and over. 378 were 80 years and over, 55% (208) of which underwent concurrent coronary artery bypass grafting. Compared to younger cohorts, octogenarians had higher in-hospital mortality (8.5%, P<0.001), longer stays in intensive care units (47.2 hours, P<0.001) and in hospital (13 days, P<0.001). Median follow-up time was 5.2 years. At 1 and 5 years functional survival was 82.4%, 56.5% and freedom from any hospital readmission was 61.5%, and 28.4% respectively. Survival approximated their age and sex matched life expectancy at 1 (83.8%) and 5 (60.8%) years. Preoperative atrial fibrillation, peripheral vascular disease, female gender, postoperative acute kidney injury and blood transfusion were associated with adverse outcomes. Conclusion In eligible Octogenarians, surgical aortic valve replacement has acceptable 1 and 5 year functional survival and hospital readmission rates but significant perioperative mortality and morbidity.
To determine the independent and combined impact of preoperative physical activity and depressive symptoms with hospital length of stay (HLOS), and postoperative re-hospitalization and mortality in ...cardiac surgery patients.
A cohort study including 405 elective and in-house urgent cardiac surgery patients were analyzed preoperatively. Physical activity was assessed with the International Physical Activity Questionnaire to categorize patients as active and inactive. The Patient Health Questionnaire-9 was used to evaluate preoperative depressive symptoms and categorize patients as depressed and not depressed. Patients were separated into four groups: 1) Not depressed/active (n = 209), 2) Depressed/active (n = 48), 3) Not depressed/inactive (n = 101), and 4) Depressed/inactive (n = 47). Administrative data captured re-hospitalization and mortality data, and were combined into a composite endpoint. Models adjusted for demographics, comorbidities, and cardiac surgery type. Multiple imputation was used to impute missing values.
Preoperative physical activity behavior and depression were not associated with HLOS examined in isolation or when analyzed by the physical activity/depressive symptom groups. Physical inactivity (HR: 1.60, 95% CI 1.05 to 2.42; p = 0.03), but not depressive symptoms, was independently associated with the composite outcome. Freedom from the composite outcome were 76.1%, 87.5%, 68.0%, and 61.7% in the Not depressed/active, Depressed/active, Not depressed/inactive, and Depressed/inactive groups, respectively (P = 0.02). The Active/Depressed group had a lower risk of the composite outcome (HR: 0.35 95% CI 0.14 to 0.89; p = 0.03) compared to the other physical activity/depression groups.
Preoperative physical activity appears to be more important than depressive symptoms on short-term postoperative re-hospitalization and mortality.
Relapsed/refractory (r/r) acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) outcomes remain poor. A targeted cluster of differentiation (CD)33 × CD3 bispecific antibody, JNJ‐67571244, ...was assessed to identify the maximum tolerated dose (MTD), recommended phase II dose (RP2D), safety and tolerability, and preliminary clinical activity in patients with r/rAML or r/rMDS. This first‐in‐human, open‐label, phase I, dose‐escalation/dose‐expansion study included patients with r/rAML or r/rMDS who were ineligible for or had exhausted standard therapeutic options. JNJ‐67571244 was administered intravenously or subcutaneously using step‐up dosing until ≥1 discontinuation condition was met. Outcomes included safety/tolerability, preliminary clinical activity, and systemic pharmacokinetics and pharmacodynamics. The study was terminated after evaluating 10 dose‐escalation cohorts (n = 68) and before starting dose‐expansion. Overall, 11 (16.2%) patients experienced ≥1 dose‐limiting toxicity; all experienced ≥1 treatment‐emergent adverse event (TEAE; treatment related: 60 88.2%); and 64 (94.1%) experienced ≥1 TEAE of Grade ≥3 toxicity (treatment related: 28 41.2%). Although some patients had temporary disease burden reductions, no responses were seen. JNJ‐67571244 administration increased multiple cytokines, which coincided with incidence of cytokine release syndrome, infusion‐related reactions, and elevated liver function tests. A prolonged step‐up strategy was tested to improve tolerability, though this approach did not prevent hepatotoxicity. T‐cell activation following treatment suggested target engagement but did not correlate with clinical activity. Safely reaching the projected exposure level for JNJ‐67571244 efficacy was not achieved, thus MTD and RP2D were not determined.
Recently, anecdotal evidence suggested an increase in infective endocarditis (IE) in Manitoba driven by an increasing proportion of patients with intravenous drug use (IVDU)-associated endocarditis. ...This study aimed to characterize the observed changing incidence and epidemiology of IE.
This retrospective study evaluated consecutive patients >18 years old with an International Classification of Disease–10 diagnosis of IE who presented to a tertiary referral center in Winnipeg, Manitoba between January 1, 2004 and December 31, 2018. Data were obtained by individual review of paper and electronic medical records and entered into the Research Electronic Data Capture database. Mortality and hospital readmission data were acquired by linking Research Electronic Data Capture data to the Manitoba Centre for Health Policy, which prospectively maintains a comprehensive population-based health database.
A total of 612 cases of IE were identified. The incidence of IE increased from 2.03 per 100,000 in 2004 to 5.16 per 100,000 in 2018, with IVDU-associated cases increasing from 0.11 to 2.87 per 100,000. Left heart vegetations were most common in the non-IVDU group, whereas right-sided vegetations dominated in the IVDU group. All-cause mortality did not differ between IVDU and non-IVDU IE, despite a significantly younger age in patients with IVDU. The IVDU group showed a higher rate of endocarditis recurrence.
In this first study to examine the longitudinal incidence of IE in Manitoba, we showed that the incidence of IE has significantly increased over the last 15 years, with a contribution of IVDU-associated IE that has a high rate of mortality and disease recurrence.
Des données anecdotiques récentes montraient une augmentation de l’endocardite infectieuse (EI) au Manitoba attribuable à la proportion accrue de patients atteints d’une endocardite associée à l’usage de drogues par voie intraveineuse (UDVI). La présente étude avait pour but de caractériser les changements observés dans l’incidence et l’épidémiologie de l’EI.
Cette étude rétrospective a permis d’évaluer les patients consécutifs > 18 ans qui avaient un diagnostic d’EI conformément à la Classification internationale des maladies, 10e révision, et qui s’étaient présentés dans un centre d’aiguillage en soins tertiaires de Winnipeg, au Manitoba, entre le 1er janvier 2004 et le 31 décembre 2018. Nous avons obtenu les données par l’examen du dossier individuel et des dossiers médicaux électroniques de la base de données Research Electronic Data Capture. Nous avons obtenu les données sur la mortalité et les réadmissions à l’hôpital par la liaison des données de la Research Electronic Data Capture au Manitoba Centre for HealthPolicy, qui maintient de manière prospective une base de données exhaustive sur la santé de la population.
Nous avons trouvé un total de 612 cas d’EI. L’incidence de l’EI est passée de 2,03 par 100 000 en 2004 à 5,16 par 100 000 en 2018, et l’incidence des cas d’EI associée à l’UDVI, de 0,11 à 2,87 par 100 000. Les végétations du cœur gauche étaient plus fréquentes dans le groupe de patients atteints d’une EI non associée à l’UDVI, alors que les végétations du cœur droit dominaient dans le groupe de patients atteints d’une EI associée à l’UDVI. La mortalité toutes causes confondues ne différait pas entre les patients atteints d’une EI associée à l’UDVI ou non associée à l’UDVI, en dépit de l’âge significativement plus jeune des patients atteints d’une EI associée à l’UDVI. Le groupe de patients atteints d’une EI associée à l’UDVI montrait un taux plus élevé de récurrence de l’endocardite.
Dans cette première étude, qui portait sur l’incidence longitudinale de l’EI au Manitoba, nous avons montré que l’incidence de l’EI avait considérablement augmenté au cours des 15 dernières années, puisque l’EI associée à l’UDVI a contribué à l’augmentation du taux de mortalité et de récurrence de la maladie.
Background
Evidence regarding the incremental benefit of cardiac resynchronization therapy (CRT) with a defibrillator (CRT‐D) versus without (CRT‐P) in elderly patients with heart failure is limited. ...We compared mortality and cardiac hospitalisation between CRT‐D and CRT‐P in the elderly.
Methods
A retrospective chart review identified all consecutive patients with age ≥75 with CRT implantation over the last 10 years at a Canadian tertiary care cardiac centre. Kaplan‐Meier survival analyses and cumulative incidence curves were used to compare mortality and time to first cardiac hospitalisation, respectively, with CRT‐D versus CRT‐P over a 3 year period. Analyses were also repeated with propensity score matching based on age, sex, primary versus secondary prevention, date of implant, and Charlson Comorbidity Index.
Results
One hundred and seventy CRT patients were identified. A total of 128 received CRT‐D while 42 received CRT‐P. Median age was 79 (IQR 77‐81), and the majority were male (83%). CRT‐P patients had a higher burden of comorbidities (Charlson score 7, IQR 6‐8) than CRT‐D patients (Charlson score 5, IQR 5‐7; P < 0.001). There was no significant difference in survival between the two groups in an unmatched comparison (P = 0.69) and with a propensity score‐matched cohort (P = 0.91). Secondary prevention CRT‐D patients had a higher risk of hospitalisation compared to primary prevention CRT‐D patients; however, there was no significant difference in hospitalisation between the CRT‐D and CRT‐P groups.
Conclusion
This study suggests there is no significant difference in mortality or cardiac hospitalisation between CRT‐D and CRT‐P in elderly patients with heart failure.
Abstract Background Peripartum cardiomyopathy (PPCM) is a heterogeneous condition characterized by heart failure and left ventricular dysfunction (LVEF<45%) in the absence of an alternative cause and ...a previous diagnosis of cardiomyopathy. The Aboriginal population (Inuit, First Nations, Metis) of Canada often has barriers to healthcare, which can lead to delays in diagnosis and treatment. Our objectives are to describe PPCM in a Canadian population, and to determine if Canadian Aboriginal women have worse clinical outcomes than non-Aboriginal women. Methods A retrospective study was performed at a single tertiary care center, between 2008-2014. Demographics, symptoms of presentation, medical history, discharge medications, blood work, echocardiographic parameters and follow up information were collected. Results A total of 177 women were screened, and 23 were included in the study (52% were Aboriginal). Aboriginal women were found to have higher rates of gravidity and parity, and higher incidence of tobacco smoking than non-Aboriginal women, and were more likely to be discharged on diuretics. At diagnosis, Aboriginal women were more likely to have a lower LVEF (20% (IQR 15-23%) vs 40% (IQR 30-42%), p=0.02) and a more dilated LV (LVEDD 64mm (IQR 57-74mm) vs 54mm (IQR 50-57mm), p<0.01). Recovery rate, defined as LVEF>50%, was similar (46% in Aboriginal patients and 60% in non-Aboriginal patients). Conclusion Our findings support that Aboriginal women with PPCM are more likely to present with lower LVEF and a more dilated LV, as well, require more symptomatic management. This is the first description and contrast of PPCM between Aboriginal and non-Aboriginal Canadians.
Chronic kidney disease (CKD) is common in patients with type 2 diabetes mellitus (T2DM) and limits therapeutic options. Dipeptidyl peptidase-4 (DPP-4) inhibitors represent a novel class of oral ...glucose-lowering agents and are known to be safe and effective in the general population.
We searched Cochrane, EMBASE, and PubMed from the time of their inception until March 2015. We included randomized controlled trials analyzing the efficacy (change in hemoglobin A1C HbA1C) and safety of DPP-4 agents in individuals with reduced kidney function (estimated glomerular filtration rate <60 mL/min/1.73 m2). We extracted study characteristics, participants' baseline characteristics, and safety outcomes from eligible studies. We performed a random effects meta-analysis to summarize the change in HbA1C and the relative risk of cardiovascular events in patients with T2DM and CKD. We also collected data on hypoglycemia, other serious adverse events, and mortality.
We reviewed 12 studies with 4,403 patients with CKD and 239 on dialysis, finding a mean weighted decline in HbA1C of -0.48 (95% CI -0.61 to -0.35) with DPP-4 inhibitor therapy compared to placebo. DPP-4 inhibitors did not result in any additional adverse events, hypoglycemic episodes, or increased mortality. Restricting to studies with low risk of bias did not alter these findings.
DPP-4 inhibitors can lower HbA1C without increasing the risk of cardiovascular or other major adverse events in patients with CKD. Few studies reported critical adverse events such as heart failure and hypersensitivity. If compared with other oral antiglycemic drugs, the effect of DPP-4 inhibitors is limited; however, their low risk of hypoglycemia may favor their use in patients with CKD.
This systematic review of DPP-4 inhibitors in CKD suggests that they reduce HbA1C by about 0.5%. Furthermore, there was not any increase in the risk for significant adverse events. More research is needed to determine the safety and efficacy of DPP-4 inhibitors in CKD.
PDF
