Search

Introduction: People with chronic medical conditions often take medications that improve long‐term outcomes but which can be harmful during acute illness. Guidelines recommend that healthcare providers offer instructions to temporarily stop these medications when patients are sick (i.e., sick days). We describe the experiences of patients managing sick days and of healthcare providers providing sick day guidance to their patients. Methods: We undertook a qualitative descriptive study. We purposively sampled patients and healthcare providers from across Canada. Adult patients were eligible if they took at least two medications for diabetes, heart disease, high blood pressure and/or kidney disease. Healthcare providers were eligible if they were practising in a community setting with at least 1 year of experience. Data were collected using virtual focus groups and individual phone interviews conducted in English. Team members analyzed transcripts using conventional content analysis. Results: We interviewed 48 participants (20 patients and 28 healthcare providers). Most patients were between 50 and 64 years of age and identified their health status as 'good'. Most healthcare providers were between 45 and 54 years of age and the majority practised as pharmacists in urban areas. We identified three overarching themes that summarize the experiences of patients and healthcare providers, largely suggesting a broad spectrum in approaches to managing sick days: Individualized Communication, Tailored Sick Day Practices, and Variation in Knowledge of Sick Day Practices and Relevant Resources. Conclusion: It is important to understand the perspectives of both patients and healthcare providers with respect to the management of sick days. This understanding can be used to improve care and outcomes for people living with chronic conditions during sick days. Patient or Public Contribution: Two patient partners were involved from proposal development to the dissemination of our findings, including manuscript development. Both patient partners took part in team meetings and contributed to team decision‐making. Patient partners also participated in data analysis by reviewing codes and theme development. Furthermore, patients living with various chronic conditions and healthcare providers participated in focus groups and individual interviews. [ABSTRACT FROM AUTHOR]

Background: People with kidney failure receiving dialysis (CKD‐G5D) are more likely to undergo surgery and experience poorer postoperative outcomes than those without kidney failure. In this scoping review, we aimed to systematically identify and summarize perioperative strategies, protocols, pathways, and interventions that have been studied or implemented for people with CKD‐G5D. Methods: We searched MEDLINE, EMBASE, CINAHL Plus, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials registry (inception to February 2020), in addition to an extensive grey literature search, for sources that reported on a perioperative strategy to guide management for people with CKD‐G5D. We summarized the overall study characteristics and perioperative management strategies and identified evidence gaps based on surgery type and perioperative domain. Publication trends over time were assessed, stratified by surgery type and study design. Results: We included 183 studies; the most common study design was a randomized controlled trial (27%), with 67% of publications focused on either kidney transplantation or dialysis vascular access. Transplant‐related studies often focused on fluid and volume management strategies and risk stratification, whereas dialysis vascular access studies focused most often on imaging. The number of publications increased over time, across all surgery types, though driven by non‐randomized study designs. Conclusions: Despite many current gaps in perioperative research for patients with CKD‐G5D, evidence generation supporting perioperative management is increasing, with recent growth driven primarily by non‐randomized studies. Our review may inform organization of evidence‐based strategies into perioperative care pathways where evidence is available while also highlighting gaps that future perioperative research can address. [ABSTRACT FROM AUTHOR]

Low estradiol status is associated with increased cardiovascular risk. We sought to determine the association between heart rate variability (HRV), a marker of cardiovascular risk, at baseline and in response to stressor as a function of menopausal status, menstrual cycle phase and estradiol level. Forty‐one healthy women (13 postmenopausal, 28 premenopausal) were studied. Eleven premenopausal women were additionally studied in the high and low estradiol phases of the menstrual cycle. HRV was calculated by spectral power analysis (low Frequency (LF), high frequency (HF) and LF:HF) at baseline and in response to graded Angiotensin II (AngII) infusion. The primary outcomes were differences in HRV at baseline and in response to AngII. Compared to premenopausal women in the low estradiol phase, postmenopausal women demonstrated lower baseline LF (p = 0.01) and HF (p < 0.001) measures, which were not significant after adjustment for age and BMI. In response to AngII, a decrease in cardioprotective HRV (ΔHF = −0.43 ± 0.46 ln ms2, p = 0.005 vs. baseline) was observed in postmenopausal women versus premenopausal women. Baseline HRV parameters did not differ by menstrual phase in premenopausal women. During the low estradiol phase, no differences were observed in the HRV response to AngII challenge. In contrast, women in the high estradiol phase were unable to maintain HRV (ΔLF = −0.07 ± 0.46 ln ms2, p = 0.048 response vs. baseline, ΔHF = −0.33 ± 0.74 ln ms2, p = 0.048 response vs. baseline). No association was observed between any measure of HRV and estradiol level. Menopausal status and the high estradiol phase in premenopausal women were associated with reduced HRV, a marker of cardiovascular risk. Understanding the role of estradiol in the modulation of cardiac autonomic tone may help guide risk reduction strategies in women. [ABSTRACT FROM AUTHOR]

Abstract: Cardiovascular disease has been identified as one of the late complications of cancer therapy. The purpose of this study was to quantify the long‐term risk of cardiovascular mortality among lymphoma survivors relative to that of the general population. A systematic review and meta‐analysis were conducted. Articles were identified in November 2016 by searching EMBASE, MEDLINE, and CINAHL databases. Observational studies were included if they assessed cardiovascular mortality in patients with lymphoma who survived for at least 5 years from time of diagnosis or if they had a median follow‐up of 10 years. A pooled standardized mortality ratio (SMR) was estimated using a DerSimonian and Laird random‐effects model. The Q and I2 statistics were used to assess heterogeneity. Funnel plots and Begg's and Egger's tests were used to evaluate publication bias. Of the 7450 articles screened, 27 studies were included in the systematic review representing 46 829 Hodgkin and 14 764 non‐Hodgkin lymphoma survivors. The pooled number of deaths attributable to cardiovascular disease among Hodgkin and non‐Hodgkin disease was estimated to be 7.31 (95% CI: 5.29‐10.10; I2 = 95.4%) and 5.35 (95% CI: 2.55‐11.24; I2 = 94.0%) times that of the general population, respectively. This association was greater among Hodgkin lymphoma survivors treated before the age of 21 (pooled SMR = 13.43; 95% CI: 9.22‐19.57; I2 = 78.9%). There was a high degree of heterogeneity and a high risk of bias due to confounding in this body of literature. Lymphoma survivors have an increased risk of fatal cardiovascular events compared to the general population and should be targeted for cardiovascular screening and prevention campaigns. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) is associated with high morbidity and mortality and consumes substantial health-care resources, particularly when renal replacement therapy is required. Randomized controlled trials (RCTs) have not identified the optimal mode of renal replacement for AKI in terms of clinically relevant endpoints such as patient survival or recovery of renal function. As for other complex health interventions, the costs and consequences of AKI treatment are relevant to health-care providers and decision makers aiming to maximize health outcomes despite fixed health resources. Studies from several different centers suggest that continuous renal replacement therapy (CRRT) is more costly than intermittent hemodialysis and less economically attractive than even intensive intermittent dialysis. On the other hand, while the incremental costs of providing CRRT are significant, they remain relatively small compared with the projected costs of providing chronic dialysis to survivors who do not recover renal function. Even small differences in the risk of chronic dialysis in survivors are likely to determine the economic attractiveness of the different types of renal replacement therapies. To clarify the true incremental cost-effectiveness of these therapies, future RCTs should collect data on long-term survival, the need for chronic dialysis, and detailed information on costs. [ABSTRACT FROM AUTHOR]

Findings from observational studies have established that the arteriovenous fistula (AVF) is the preferred form of vascular access for chronic hemodialysis. Unfortunately, in a subset of patients with end-stage renal disease, an AVF cannot be placed or fails to mature. In these patients an alternate form of vascular access, either an arteriovenous graft (AVG) or central venous catheter (CVC) must be selected. In this review we discuss the findings and limitations of studies examining the effect of access type (AVG or CVC) on clinical endpoints including mortality, quality of life, occurrence of infections, as well as the impact of the different access types on resource requirements. Specifically, we examine whether findings from previous studies are valid and applicable to patients for whom an AVF is not possible, and outline the need for future randomized clinical trials addressing this question. [ABSTRACT FROM AUTHOR]

Background Administrative data have limited sensitivity for case finding of atrial fibrillation/atrial flutter (AF/AFL). Linkage with clinical repositories of interpreted ECGs may enhance diagnostic yield of AF/AFL. Methods and Results We retrieved 369 ECGs from the institutional Marquette Universal System for Electrocardiography (MUSE) repository as validation samples, with rhythm coded as AF (n=49), AFL (n=50), or other competing rhythm diagnoses (n=270). With blinded, duplicate review of ECGs as the reference comparison, we compared multiple MUSE coding definitions for identifying AF/AFL. We tested the agreement between MUSE diagnosis and reference comparison, and calculated the sensitivity and specificity. Using a data set linking clinical registries, administrative data, and the MUSE repository (n=11 662), we assessed the incremental diagnostic yield of AF/AFL by incorporating ECG data to administrative data-based algorithms. The agreement between MUSE diagnosis and reference comparison depended on the coding definitions applied, with the Cohen κ ranging from 0.57 to 0.75. Sensitivity ranged from 60.6% to 79.1%, and specificity ranged from 93.2% to 98.0%. A coding definition with AF/AFL appearing in the first 3 ECG statements had the highest sensitivity (79.1%), with little loss of specificity (94.5%). Compared with the algorithms with only administrative data, incorporating ECG data increased the diagnostic yield of preexisting AF/AFL by 14.5% and incident AF/AFL by 7.5% to 16.1%. Conclusions Routine ECG interpretation using MUSE coding is highly specific and moderately sensitive for AF/AFL detection. Inclusion of MUSE ECG data in AF/AFL case identification algorithms can identify cases missed using administrative data-based algorithms alone.