Resistant or difficult-to-control hypertension is a problem that may affect as many as 13% of all persons with hypertension. It is estimated that more than 6 million (22.6%) of adults in Canada have ...hypertension, but less than two-thirds have it adequately controlled despite conventional strategies for treatment. Uncontrolled hypertension may arise from nonadherence to medication, selection of suboptimal treatment regimens and/or the presence of unidentified secondary causes. It is frustrating for both the patient and treating physician. Here, Kline et al discuss the diagnosis and disease-specific treatment for primary aldosteronism.
Hypertension Canada’s 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health ...care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.
Les lignes directrices 2020 d’Hypertension Canada pour la prévention, le diagnostic, l'évaluation des risques et le traitement de l'hypertension chez l’adulte et l’enfant fournissent aux professionnels de la santé et aux patients des conseils complets et fondés sur des données probantes. Hypertension Canada élabore ces lignes directrices en utilisant une méthodologie rigoureuse, en atténuant soigneusement le risque de partialité dans notre processus. Tous les projets de recommandations sont soumis à une évaluation critique par des experts en méthodologie, sans partialité, afin d'en garantir la qualité. Notre panel de lignes directrices est diversifié, comprenant de multiples groupes de professionnels de la santé (soins infirmiers, pharmacie, universitaire et médecins), et a travaillé de concert avec des experts en soins primaires et d’experts en mise en œuvre pour garantir une utilisation optimale. Les lignes directrices 2020 comprennent de nouvelles orientations sur la gestion de l'hypertension résistante et la prise en charge de l'hypertension chez les femmes qui planifient une grossesse.
Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and ...pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines are introduced, and 1 existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke is revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed.
Chaque année Hypertension Canada publie une mise à jour de ses lignes directrices fondées sur des données probantes relatives au diagnostic, à l'évaluation, à la prévention et au traitement de l'hypertension chez l'adulte et l'enfant. Cette année, les lignes directrices applicables aux adultes et aux enfants sont combinées en un seul document. Les nouvelles lignes directrices 2018 portant précisément sur l'hypertension pendant la grossesse sont publiées séparément. Pour 2018, cinq nouvelles lignes directrices sont présentées, et une ligne directrice existante portant sur les seuils et les cibles de pression artérielle dans le contexte de la thrombolyse dans un cas d'accident vasculaire cérébral ischémique aigu est révisée. L'utilisation de tensiomètres-bracelets validés pour l'estimation de la pression artérielle chez les personnes dont le bras a une circonférence élevée est à présent incluse. Des indications sont données pour les mesures de la pression artérielle dans le cadre d'un suivi à l'aide de méthodes normalisées et de dispositifs électroniques (oscillométriques) positionnés au niveau du bras chez les personnes hypertendues, ainsi que de la surveillance de la pression artérielle ambulatoire ou à domicile chez les personnes sujettes au « syndrome de la blouse blanche ». Nous recommandons notamment de procéder à une évaluation du risque cardiovasculaire global de toutes les personnes atteintes d'hypertension afin de les inciter à adopter de saines habitudes de vie permettant d’abaisser leur pression artérielle. Enfin, chez les personnes atteintes d'insuffisance cardiaque (présentant une fraction d'éjection < 40 %) qui sont symptomatiques malgré un traitement de cette affection à des doses appropriées et conforme aux lignes directrices, il est recommandé d'utiliser une association de médicaments inhibiteurs des récepteurs de l'angiotensine et de la néprilysine au lieu d’un inhibiteur de l’enzyme de conversion de l'angiotensine ou d'un antagoniste des récepteurs de l'angiotensine en monothérapie. Les données probantes et la justification qui sous-tendent chacune de ces lignes directrices sont analysées.
Endocrine hypertension, particularly primary aldosteronism (PA), was previously considered to account for less than 1% of all hypertension and was suspected only when patients presented with ...spontaneous hypokalemia. However, the last 20 years of PA research has now clearly shown that PA is not a rarity, but rather, may account for up to 13% of unselected hypertensive individuals and between 10% and 20% of those with resistant hypertension. Most of these patients do not have spontaneous hypokalemia. The population prevalence of PA likely far exceeds actual detection rates in routine clinical care. As PA represents one of the most common, potentially reversible causes of hypertension, and is associated with significant cardiovascular complications over the long term, it is clear that a pragmatic strategy for targeted case detection in primary care is needed.
Adrenal gland infarction resulting from adrenal vein thrombosis is an infrequently recognised entity with a limited differential diagnosis. When bilateral, it can result in acute life-threatening ...adrenal failure. Heparin-induced thrombocytopenia (HIT) is an antibody-mediated, prothrombotic state that represents an important cause of adrenal vein thrombosis leading to associated infarction. Sometimes, the clinical picture of HIT—including the presence of HIT antibodies—occurs despite absence of proximate heparin exposure (‘spontaneous HIT syndrome’). We report a case of nearly missed adrenal failure secondary to bilateral adrenal infarction that evolved during the second week following knee arthroplasty (a known trigger of spontaneous HIT syndrome). The combination of bilateral adrenal infarction, thrombocytopenia and presence of platelet-activating HIT antibodies not explainable by preceding heparin exposure led to a diagnosis of postknee arthroplasty spontaneous HIT syndrome. The case also highlights the clinical and laboratory findings associated with rapidly progressive acute adrenal failure.
Pantoprazole-induced acute interstitial nephritis Klassen, Sheila; Krepinsky, Joan C; Prebtani, Ally P H
Canadian Medical Association journal (CMAJ),
2013-Jan-08, 2013-01-08, 20130108, Letnik:
185, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Acute interstitial nephritis induced by pantoprazole was first reported in 2004.3 From that report until January 2012, according to the World Health Organization's Uppsala Monitoring Centre ...(www.who-umc.org), there have been 87 cases of pantoprazole causing acute renal failure. In Canada, there have been 10 spontaneously reported cases of tubulointerstitial nephritis induced by proton pump inhibitors since 1965.4 In a retrospective case review, however, Geevasinga and colleagues found 90 cases of acute renal failure associated with proton pump inhibitors over a 14-year span at a single institution, 5 suggesting that this complication may not be as infrequent as previously thought. Possible reasons for the discrepancy between the number of cases found in retrospective studies and those spontaneously reported are physicians not knowing that these drugs can cause acute interstitial nephritis and variability in the clinical presentation of the condition. Gallium-67 imaging has been proposed to help differentiate between acute tubular necrosis and acute interstitial nephritis. Both disease processes may present similarly, with nonspecific symptoms. However, the distinction between the two is important. There is definitive management for acute interstitial nephritis, whereas the management of acute tubular necrosis is mainly supportive care. In a nuclear medicine study that reviewed 500 gallium-67 images, 5.6% of patients showed abnormal uptake at 48 hours.6 Of these patients, 18% had acute interstitial nephritis and 2% had acute tubular necrosis. However, glomerulonephritis, pyelonephritis, chronic interstitial nephritis and normal kidneys have shown false-positive results with this technique. 6 The usefulness of gallium-67 imaging remains controversial; this technique may be useful in patients who have a good pretest likelihood of acute interstitial nephritis and who are too ill to tolerate renal biopsy. The most important aspect of treating acute interstitial nephritis is timely discontinuation of the offending agent. Removal of the trigger prevents further interstitial inflammation and tubular damage, with possible full recovery of renal function in 3-18 months. The role of steroids in treating acute interstitial nephritis is controversial. Although the results of several small trials suggest that patients given prednisone have better renal recovery, there have not been any large trials showing clear benefit. Methylprednisolone pulses given intravenously (250-500 mg/d for 3- 4 d), followed by a tapering course of prednisone (0.5-1 mg/kg daily) over 4-6 weeks has been suggested.2,7 The most recent retrospective multicentre study examining steroid use in druginduced acute interstitial nephritis confirmed by biopsy found that patients not given steroid therapy (n = 9) had significantly higher creatinine levels at the end of the follow-up period than patients who had received treatment (n = 52).7 In addition, patients who stopped taking the offending drug and began steroid treatment more than 7 days after the onset of renal failure had a 6- fold increased risk of chronic renal disease.7 A similar retrospective study involving 60 patients did not show improved recovery of renal function with corticosteroids, although there was a delay of 3-4 weeks after the onset of renal failure before steroid treatment began.8 A substantial proportion of patients in both groups had elevated creatinine levels at follow-up.8 Interestingly, a case study noted that despite continuing pantoprazole in a patient with acute interstitial nephritis, a 2-month course of high-dose prednisone therapy with tapering eradicated inflammatory infiltrates on renal biopsy.9 The authors also noted that the histologic appearance did not change on subsequent biopsy at 3 months after pantoprazole had been withdrawn and prednisone continued at 20 mg/d.9
Reducing the Risk of Developing Diabetes Prebtani, Ally P.H.; Bajaj, Harpreet S.; Goldenberg, Ronald ...
Canadian journal of diabetes,
April 2018, 2018-Apr, 2018-04-00, 20180401, Letnik:
42
Journal Article
Members of the College of Physicians and Surgeons of Ontario Endocrinology and Metabolism Peer Review Network have been involved in a quality improvement project to help standardize the peer ...assessment of physicians practicing in endocrinology and metabolism. This has included developing state-of-the-art summaries of common endocrine problems by Canadian experts in endocrinology and metabolism. These tools have been developed in response to the educational needs, as identified by peer reviewers, of practicing endocrinologists in Ontario. These pedagogical tools aim not only to standardize the documentation of the clinical performance of endocrinologists but also to make the process more transparent and to improve the quality of patient care in Ontario. This article summarizes the project and also provides the tools developed for the endocrinology and metabolism section of the College of Physicians and Surgeons of Ontario.
A rare case is provided of a 74 year old man who presented with ascites of unknown etiology. CT scan of the abdomen revealed extensive omental caking, and omental biopsy cytogenetics showed findings ...in keeping with a diagnosis of desmoplastic small round cell tumour (DSRCT). This case is unique in that it involves a significantly older patient, negative WT1 immunohistochemical staining, and negative cytology. Despite repeated paracenteses and fluid management, the patient died in hospital secondary to renal complications.
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