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Stoichiometric silicon carbide (SiC) thin films were grown using thermal chemical vapor deposition (TCVD) from the single source precursor 1,3,5-trisilacyclohexane (TSCH) on c-Si (100) substrates within an optimized substrate temperature window ranging from 650 to 850 °C. X-ray photoelectron spectroscopy (XPS) and Fourier transform infrared spectroscopy (FTIR) analyses revealed that the as-deposited films consisted of a Si-C matrix with a Si:C ratio of ~1:1. FTIR and photoluminescence (PL) spectrometry studies showed that films deposited ≥ 750 °C were defect- and H-free within the detection limit of the techniques used, while ellipsometry measurements yielded an as-grown SiC average refractive index of ~2.7, consistent with the reference value for the 3C-SiC phase. The exceptional quality of the films appears sufficient to overcome limitations associated with structural defects ranging from failure in high voltage, high temperature electronics to 2-D film growth. TSCH, a liquid at room temperature with good structural stability during transport and handling as well as high vapor pressure (~10 torr at 25 °C), provides a viable single source precursor for the growth of stoichiometric SiC without the need for post-deposition thermal treatment.

Increasingly precise control of polymer architectures generated by “Living” Anionic Ring-Opening Polymerization (Living AROP) is leading to a broad range of commercial advanced material applications, particularly in the area of siloxane macromers. While academic reports on such materials remain sparse, a significant portion of the global population interacts with them on a daily basis—in applications including medical devices, microelectronics, food packaging, synthetic leather, release coatings, and pigment dispersions. The primary driver of this increased utilization of siloxane macromers is their ability to incorporate the properties of silicones into organic structures in a balanced manner. Compared to organic polymers, the differentiating properties of silicones—low Tg, hydrophobicity, low surface energy, and high free molal space—logically lend themselves to applications in which low modulus, release, permeability to oxygen and moisture, and tactile interaction are desired. However, their mechanical, structural and processing properties have until recently precluded practical applications. This review presents applications of “Living” AROP derived polymers from the perspective of historical technology development. Applications in which products are produced on a commercial scale—defined as not only offered for sale, but sold on a recurrent basis—are emphasized. Hybrid polymers with intriguing nanoscale morphology and potential applications in photoresist, microcontact printing, biomimetic soft materials, and liquid crystals are also discussed. Previously unreported work by the authors is provided in the context of this review.

Latar belakang. Kesulitan dalam mencari penyebab demam berkepanjangan disebabkan oleh banyak faktor terutama karena penyebab yang beraneka ragam. Waktu serta tempat timbulnya penyakit juga turut berperan. Pengetahuan tentang etiologi dan karakteristik penyakit sangat diperlukan karena memudahkan para klinisi dalam menegakkan diagnosis demam berkepanjangan. Metode. Penelitian deskriptif retrospektif dilakukan untuk mengetahui etiologi dan karakteristik pasien demam berkepanjangan yang dirawat di RSCM. Populasi anak dengan keluhan demam berkepanjangan saat masuk diambil dari data rekam medis sejak Januari 2004 hingga Maret 2007. Hasil. Angka kejadian pasien demam berkepanjangan di RS Cipto Mangunkusumo 2% (100 pasien), sebagian besar laki-laki 59% dan perempuan 41% kasus. Penyebab terbanyak penyakit infeksi 80%, yaitu infeksi saluran kemih, demam tifoid, bakteremia, tuberkulosis serta otitis media. Sebagian besar pasien berusia di bawah dua tahun 46% kasus, memiliki status gizi kurang (75%). Kuman terbanyak yang ditemukan pada biakan darah, biakan urin dan biakan feses berturut turut Staphylococcus epidermidis, Escherichia coli, dan Escherichia coli patogen Kesimpulan. Kelompok penyakit infeksi merupakan penyebab terbanyak demam berkepanjangan pada seluruh kelompok umur. Anamnesis, pemeriksaan fisis serta pemeriksaan penunjang yang terarah merupakan kunci keberhasilan dalam mencari etiologi demam berkepanjangan.

In this paper we explore some mechanisms for constructing bivariate and multivariate beta and Kumaraswamy distributions. Specifically, we focus our attention on the Arnold-Ng (2011) eight parameter bivariate beta model. Several models in the literature are identified as special cases of this distribution including the Jones-OlkinLiu-Libby-Novick bivariate beta model, and certain Kotz and Nadarajah bivariate beta models among others. The utility of such models in constructing bivariate Kumaraswamy models is investigated. Structural properties of such derived models are studied. Parameter estimation for the models is also discussed. For illustrative purposes, a real life data set is considered to exhibit the applicability of these models in comparison with rival bivariate beta and Kumaraswamy models.

Scandia, Inc., is a commercial vessel management company located in the New York Metropolitan area and is part of a family of firms including Scandia Technical; International Tankers, Ltd.; Global Tankers, Ltd.; Sun Maritime S.A.;Adger Tankers AS; Leeward Tankers, Inc.; Manhattan Tankers, Ltd.; and Liuʼs Tankers, S.A. The companyʼs current market niche is the commercial management of chemical tankers serving the transatlantic market with a focus on the east and gulf coast of the United States and Northern Europe. This three-part case describes the commercial shipping industry as well as several mishaps that the company and its President, Chris Haas, have had to deal with including withdrawal of financial support by creditors, intercorporate firm conflict, and employee retention. Part A, which was published in the Fall 2010 issue, presented an overview of the commercial vessel industry and set the stage for Parts B and C where the firm’s operation is discussed.

Scandia, Inc., is a commercial vessel management company located in the New York Metropolitan area and is part of a family of firms including Scandia Technical; International Tankers, Ltd.; Global Tankers, Ltd.; Sun Maritime S.A.;Adger Tankers AS; Leeward Tankers, Inc.; Manhattan Tankers, Ltd.; and Liuʼs Tankers, S.A. The companyʼs current market niche is the commercial management of chemical tankers serving the transatlantic market with a focus on the east and gulf coast of the United States and Northern Europe. This three-part case describes the commercial shipping industry as well as several mishaps that the company and its President, Chris Haas, have had to deal with including withdrawal of financial support by creditors, intercorporate firm conflict, and employee retention. Part A presents an overview of the commercial vessel industry and sets the stage for Parts B and C (to be published in the Spring 2011 issue) where the firmʼs operation is discussed.

INTRODUCTION Urinary tract infections (UTIs) are common, affect men and women of all ages, and vary dramatically in their presentation and sequelae. They are a common cause of morbidity and can lead to significant mortality. New antimicrobial agents that achieve high urinary and tissue levels, that can be administered orally, and that are not nephrotoxic have significantly reduced the need for hospitalization for severe infection. Shorter-course therapy and prophylactic antimicrobial agents have reduced the morbidity and cost associated with recurrent cystitis in women. Intravesical instillation of aminoglycoside has been used empirically as prophylaxis and to treat bacilluria in spinal-cord-injured patients undergoing clean intermittent catheterization. METHODS In a prospective clinical trial performed in the urologic ward of Dr. Sardjito Hospital, yogyakarta, Indonesia, we studied 56 patients who has indwelling urethral catheter more than 4 days. Patients were divided into two groups. In group 1 (28 patients) one-time intravesical instillation of Netilmicin 25 mg was administred, and in group 2 (28 patients) none were given any treatment. Urinalysis was evaluated before and after instillation of Netilmicin. Statistical data and results were studied using descriptive statistics as median (minimum and maximum). To compare the response to treatment, Chi-Square test was used in two groups. Consequently, the data were analyzed using the SPSS 17 software. RESULTS Urinalysis were evaluated in two groups 4 days after intravesical instillation of 50 mg netilmicin. The patients we studied, the median age 59 years old (min. 29; max. 81). In the first group we found 22 (78,5 %) patients still without UTI, 6 (21,5 %) patients with UTI, in the second group we found 4 (14,3 %) still without UTI, 24 (85,7 %) patients with UTI. The difference was statistically significant (p=0.0001) CONCLUSIONS Intravesical instillation of netilmicin on patients with indwelliing urethral catheter were effective on preventing catheter-related UTI. Keywords : UTI, indwelling catheter, netilmicin, intravesical antibiotic instillation.

Background: Patients with heterozygous familial hypercholesterolemia (HeFH) are at high risk of major adverse cardiovascular events (MACE) and mortality. Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), including monoclonal antibodies (alirocumab, evolocumab) and small interfering RNA (inclisiran), substantially reduce lipid levels. This meta-analysis aimed to evaluate the efficacy of both types of PCSK9i specifically in patients with HeFH., Methods: A librarian-assisted systematic search of MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov was performed from 2013 to 2023. Randomized controlled trials of PCSK9i versus control in patients with HeFH were included. No language restrictions were applied. Cochrane Risk-of-Bias tool 2 was used to assess quality of evidence. Meta-analyses were performed using Cochrane ReviewManager. Outcomes included change in atherogenic lipids, MACE, and all-cause death., Results: Seven trials were included (N = 2196). Overall risk of bias was mostly low or with some concerns. Median follow-up was 24 weeks. PCSK9i had an uncertain effect on MACE (odds ratio [OR] 1.25, 95% confidence interval [CI] 0.69-2.26) and all-cause death (OR 2.47, 95% CI 0.33-18.26) due to the low event rate and short follow-up. However, PCSK9i significantly reduced low-density lipoprotein cholesterol (LDL-C) by 54% (95% CI 49-58), apolipoprotein B by 43% (95% CI 37-49), and lipoprotein(a) by 20% (95% CI 13-28)., Conclusions: In patients with HeFH, PCSK9i significantly reduced atherogenic lipids (LDL-C, apolipoprotein B, and lipoprotein[a]). Despite this, the effect on MACE or all-cause death was unclear. Larger-scale randomized controlled trials of longer duration are needed to validate whether this short-term reduction in lipid levels translates into a reduction in clinically meaningful outcomes., Competing Interests: Declarations. Funding: None to report. Conflict of interest: The authors have no financial or other conflicts of interest related to this work. Author contributions: MM and AB contributed to the study conception and design. The search strategy was designed and performed by all authors. The study selection, data extraction, and statistical analyses were performed by MM and AB. The first draft of the manuscript was written by MM and revised by AB. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Data availability: All data collected and analyzed for this study are included in the published article and the supplementary material. Code availability: Not applicable. Ethics approval: Not applicable. Consent to participate: Not applicable. Consent for publication: Not applicable., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Heterozygous familial hypercholesterolemia (HeFH) is a genetic condition that is associated with a high risk of atherosclerotic cardiovascular disease (ASCVD) due to elevated lipid levels. Proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody inhibitors have been shown to reduce low-density lipoprotein cholesterol (LDL-C) substantially. This study aimed to assess the real-world effectiveness of PCSK9 inhibitor therapy among patients with HeFH., Methods: Retrospective cohort study of patients with probable or definite HeFH on a PCSK9 inhibitor at a specialized lipid clinic between 2015 and 2022. The primary objective was the proportion of patients who attained a ≥50% reduction in LDL-C after 12 months of treatment., Results: In total, 141 patients were screened and 95 were included. Mean age was 63 years, 51% were female, and mean baseline LDL-C level was 4.0 mmol/L (155 mg/dL). A majority of patients (60%) had statin intolerance, and 73% were on ezetimibe. The most common PCSK9 inhibitor was evolocumab (94%). Overall, 74% of patients achieved a ≥50% reduction in LDL-C after 12 months of therapy. Mean LDL-C concentration decreased to 1.7 mmol/L (66 mg/dL) (approximately 59% reduction from baseline) after 12 months of follow-up but increased to 1.9 mmol/L (73 mg/dL) after ≥24 months of follow-up. Similar trends were observed in non-high-density lipoprotein cholesterol and apolipoprotein B. Lipoprotein(a) was significantly reduced by 45% over 12 months. Twelve percent of patients permanently discontinued therapy. Barriers to PCSK9i use were mostly related to cost., Conclusions: In a real-world cohort of HeFH patients, most of which were intolerant to statins, a high majority were able to achieve a ≥50% reduction in LDL-C after 12 months of PCSK9 inhibitor therapy (mean reduction of approximately 59%), which is similar to clinical trial data of patients with ASCVD. A significant reduction in non-high-density lipoprotein cholesterol, apolipoprotein B, and lipoprotein(a) were also observed., (© 2024 The Author(s). Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy published by Wiley Periodicals LLC on behalf of Pharmacotherapy Publications, Inc.)

Aims: The optimal antithrombotic therapy to balance the risk of thrombosis and bleeding in patients who undergo transcatheter aortic valve implantation (TAVI) is unknown. This systematic review/network meta-analysis of randomized controlled trials (RCTs) aimed to evaluate the efficacy and safety of different oral anticoagulant (OAC) and antiplatelet regimens in patients post-TAVI., Methods and Results: MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov were searched from inception to April 2023. Co-primary outcomes were all-cause death and major bleeding. We conducted Bayesian network meta-analyses to compare all interventions simultaneously. For each outcome, we generated odds ratios (ORs) with 95% credible intervals using a random-effects model with informative priors, and ranked interventions based on mean surface under the cumulative ranking curve. We included 11 RCTs (n = 6415), including 1 unpublished RCT. Three trials enrolled patients with an indication for an OAC. Overall risk of bias was low or with some concerns. Median age was 81 years. Median follow-up was 6 months. The combination of OAC plus single antiplatelet therapy (SAPT) increased the risk of all-cause death compared with dual antiplatelet therapy (DAPT) (OR 1.78, 95% credible interval 1.15-2.77). No other comparisons for all-cause death were significantly different. For major bleeding, SAPT reduced the risk compared with DAPT, direct-acting OAC, and OAC + SAPT (OR 0.20-0.40), and DAPT reduced the risk compared with OAC + SAPT. SAPT and DAPT ranked best for all-cause death, while SAPT ranked best for major bleeding., Conclusion: In post-TAVI patients, SAPT may provide the optimal balance of reducing thrombotic events while minimizing the risk of bleeding., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: In Canada, 2 guidelines provide guidance for the management of dyslipidemia. The Patients, Experience, Evidence, Research simplified lipid guidelines, intended for primary care practitioners, and the Canadian Cardiovascular Society guidelines, intended for all practitioners, are based on differing methodologies with distinct priorities and preferences. The disparate approaches may contribute to confusion among family practitioners and their co-managed patients, with the potential for compromised care, differing standards for training in the fundamentals of lipidology, and differing criteria that might be used in practice audits to evaluate quality of care., Methods: The Patients, Experience, Evidence, Research (PEER) recommendations were considered by primary authors of the Canadian Cardiovascular Society guideline to identify areas of concordance, discordance, or agreement with qualifications., Results: Discordance between the guidelines is greatest with respect to interpretation of the cholesterol profile, the implications of elevated triglyceride, the utility of apolipoprotein B and non-high-density lipoprotein-cholesterol measurements, the role of nonstatin medications, and the importance of assuring adherence and avoiding undertreatment through follow-up measurement of lipid profiles. The disparate importance attached to identification of patients with enhanced risk due to an elevated lipoprotein (a) level is also apparent., Conclusions: This comparison attempts to reconcile key principles of practice, to foster both high quality of care and fully informed patient-centred decision-making., (© 2024 The Authors.)

Background: The effect of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs) on major adverse cardiovascular events (MACE) in patients who undergo coronary artery bypass graft surgery is equivocal. This retrospective, population-based cohort study evaluated effect of exposure to an ACEI/ARB on MACE using linked administrative databases that included all cardiac revascularization procedures, hospitalizations, and prescriptions for the population of British Columbia, Canada., Methods and Results: All adults who underwent coronary artery bypass graft surgery between 2002 and 2020 were eligible. The primary outcome was time to MACE, defined as a composite of all-cause death, myocardial infarction, and ischemic stroke using Cox proportional hazards models with inverse probability treatment weighting. Included were 15 439 patients and 6191 (40%) were prescribed an ACEI/ARB. Mean age was 66 years, 83% were men, and 16% had heart failure (HF). Median exposure time was 40 months. Over the 5-year follow-up, 1623 MACE occurred. Impact of exposure was different for patients with and without HF ( P <0.0001 for interaction). After probability-weighting and adjustment for relevant covariates, exposure to ACEI/ARBs was associated with a lower hazard of MACE in patients with HF at 1 year (hazard ratio, 0.13 [95% CI, 0.09-0.19]) and 5 years (hazard ratio, 0.36 [95% CI, 0.30-0.44]). In patients without HF, ACEI/ARBs had a lower hazard of MACE at 1 year (hazard ratio, 0.35 [95% CI, 0.27-0.46]) and 5 years (hazard ratio, 0.66 [95% CI, 0.58-0.76])., Conclusions: In this population-based study, ACEI/ARBs were associated with a lower hazard of MACE in a cohort of patients post-coronary artery bypass graft surgery irrespective of HF status.

Introduction: Patients with atrial fibrillation (AF) often switch between oral anticoagulants (OACs). It can be hard to know why a patient has switched outside of a clinical setting. Medication attribute comparisons can suggest benefits. Consensus on terms and definitions is required for inferring OAC switch benefits. The objectives of the study were to generate consensus on a taxonomy of the potential benefits of OAC switching in patients with AF and apply the taxonomy to real-world data., Methods: Nine expert clinicians (seven clinical pharmacists, two cardiologists) with at least 3 years of clinical and research experience in AF participated in a Delphi process. The experts rated and commented on a proposed taxonomy on the potential benefits of OAC switching. After each Delphi round, ratings were analyzed with the RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness method. Median ratings, disagreement index, and comments were used to modify the taxonomy. The resulting taxonomy from the Delphi process was applied to a cohort of patients with AF who switched OACs in a population-based administrative health dataset from 1996 to 2019 in British Columbia, Canada., Results: The taxonomy was finalized in two Delphi rounds, reaching consensus on five switch benefit categories: safety, effectiveness, convenience, economic considerations, and drug interactions. Safety benefit (a switch that could lower the risk of adverse drug events) had three subcategories: major bleeding, intracranial hemorrhage (ICH), and gastrointestinal (GI) bleeding. Effectiveness benefit had four subcategories: stroke and systemic embolism (SSE), ischemic stroke, myocardial infarction (MI), and all-cause mortality. Real-world OAC switches revealed that more OAC switches had convenience (72.6%) and drug interaction (63.0%) benefits compared to effectiveness (SSE 22.0%, ischemic stroke 11.1%, MI 3.1%, all-cause mortality 10.1%), safety (major bleeding 24.3%, GI bleeding 10.6%, ICH 48.5%), and economic benefits (12.1%)., Conclusions: The Delphi-based taxonomy identified five criteria for the beneficial effects of OAC switching, aiding in characterizing real-world OAC switching., (© 2024. The Author(s), under exclusive licence to Springer Healthcare Ltd., part of Springer Nature.)

This study aims to provide practical insights for developing trauma-informed interaction strategies between service providers and participants in homeless service organizations (HSOs). Twelve providers and 17 participants were interviewed for a qualitative study on trauma-informed care (TIC) within an HSO. Thematic analysis revealed six themes regarding provider approaches to TIC interactions with participants: provide a sounding board, promote safety, foster understanding and respect, build relationships and trust, facilitate connection to services, and ensure flexibility in service provision. Participants noted three themes regarding their views of TIC interactions with providers: possess education and experience, build relationships and trust, and demonstrate supportive interpersonal styles. This study describes the application of TIC within an HSO, emphasizing the importance of supportive, positive interactions that promote understanding, respect, and trust. It highlights key factors in service provision. The findings expand our understanding of TIC implementation in HSOs and suggest areas for improvement., (© 2023 Wiley Periodicals LLC.)

Our objectives were to measure long-term adherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and to identify patient factors associated with adherence. Using linked, population-based administrative data from British Columbia, Canada, an incident cohort of adults prescribed OACs for AF was identified. We calculated the proportion of days covered (PDC) as a time-dependent covariate for each 90-day window from OAC initiation until the end of follow-up. Associations between patient attributes and adherence were assessed using generalized mixed effect linear regression models. 30,264 patients were included. Mean PDC was 0.69 (SD 0.28) over a median follow-up of 6.7 years. 54% of patients were non-adherent (PDC < 0.8). After controlling for confounders, factors positively associated with adherence were number of drug class switches, history of stroke or transient ischemic attack, history of vascular disease, time since initiation, and age. Age > 75 years at initiation, polypharmacy (among VKA users only), and receiving DOAC (vs. VKA) were negatively associated with adherence. PDC decreased over time for VKA users and increased for DOAC users. Over half of AF patients studied were, on average, nonadherent to OAC therapy and missed 32% of their doses. Several patient factors were associated with higher or lower adherence, and adherence to VKA declined during therapy while DOAC adherence increased slightly over time. To min im ize the risk stroke, adherence-supporting interventions are needed for all patients with AF, particularly those aged > 75 years, those with prior stroke or vascular disease, VKA users with polypharmacy, and DOAC recipients., (© 2023. The Author(s).)

Background: Three landmark trials on the use of acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease (CVD) were published in 2018. Since then, major clinical practice guidelines have been updated with recommendations against the routine use of ASA for primary CVD prevention, particularly in older adults. However, little is known about the uptake of this evidence into real world practice. The purpose of this study was to assess the change in ASA usage for primary prevention of CVD in older adults between 2017 and 2021., Methods: A retrospective cross-sectional study of ASA use for primary prevention in ambulatory older adults without known CVD in an urban Canadian city was conducted., Results: Seven hundred and fifty-six participants were included. The mean age was 78.9 years (standard deviation 7.9) and 64.8% were female. One hundred and thirty (17.2%) participants used ASA for primary prevention, including 20.3% in 2017, 17.0% in 2018, 21.8% in 2019, 16.3% in 2020, and 11.0% in 2021 ( p = .061). Female sex was associated with lower ASA use (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.29-0.68) and hypertension was associated with higher ASA use (OR 2.72, 95% CI 1.73-4.29)., Conclusions: Use of ASA for primary CVD prevention in older Canadians decreased between 2017 and 2021, suggesting an uptake of clinical trial data and practice guideline recommendations. Focusing on deprescribing of ASA for primary CVD prevention continues to be warranted, given the risks associated with ASA in this population., Competing Interests: CONFLICT OF INTEREST DISCLOSURES We have read and understood the Canadian Geriatrics Journal’s policy on disclosing conflicts of interest and declare that we have none., (© 2023 Author(s).)

Background: Adherence to secondary preventive pharmacotherapy after an acute coronary syndrome (ACS) is generally poor and is associated with recurrent cardiovascular events. Patients' beliefs about their medications are a strong predictor of intentional nonadherence., Methods: This prospective, observational study assessed adult patients' beliefs about their post-ACS medications, using the Beliefs About Medicines Questionnaire (BMQ), and adherence, using the Medication Adherence Report Scale (MARS-5) at St. Paul's Hospital in Vancouver, Canada during May-December, 2022. The BMQ and MARS-5 were administered in-hospital and at 4 weeks after discharge. Outcomes included difference in BMQ necessity-concerns differential (BMQ-NCD) from hospitalization to 4-week follow-up and factors associated with the BMQ-NCD., Results: Forty-seven participants completed the 4-week follow-up. The mean age was 64 years, and 83% were male. Most presented with a non-ST-segment-elevation ACS. No difference occurred in BMQ-NCD (7.3 vs 6.6, P  = 0.29) or MARS-5 scores from discharge to 4 weeks (22.8 vs 23.7, P  = 0.06); however, the BMQ specific-necessity subscale score decreased significantly (20.3 vs 18.8, P  = 0.002). South Asian and Middle Eastern ethnic origins, compared to European, were associated with a higher BMQ-NCD. Part-time employment and male sex were associated with a lower BMQ-NCD., Conclusions: Participants held favourable beliefs about their post-ACS medications, which were largely unchanged from hospitalization to 4 weeks postdischarge, except for beliefs about the necessity of taking their medications. Those of European descent, those with part-time employment, and males had the lowest BMQ-NCD. Self-reported adherence was high. Ongoing reassessment of patients' beliefs about the necessity of taking their post-ACS medications may be warranted to mitigate further decline in BMQ-NCD., (© 2023 The Authors.)

Competing Interests: The authors have no financial or other conflicts of interest related to this work.

Background: Oral anticoagulation (OAC) is recommended for most individuals with atrial fibrillation (AF), including those who are frail. Based on previous literature, those who are frail may be less likely to be prescribed OAC, and up to one-third may receive an inappropriate dose if prescribed a direct oral anticoagulant (DOAC). The objectives of this study were to determine the proportion of frail ambulatory older adults with AF who are prescribed OAC, compare the rates of OAC use across the frailty spectrum, assess the appropriateness of DOAC dosing, and identify if frailty and geriatric syndromes impact OAC prescribing patterns., Methods: Retrospective cross-sectional review of individuals with AF referred to an ambulatory clinic for older adults living with frailty and/or geriatric syndromes. Rockwood clinical frailty score of ≥4 was used to define frailty and DOAC appropriateness was assessed based on the Canadian Cardiovascular Society AF guidelines., Results: Two hundred and ten participants were included. The mean age was 84 years, 49% were female and the median frailty score was 5. Of the 185 participants who were frail, 82% were prescribed an OAC (83% with frailty score of 4, 85% with a frailty score of 5, and 78% with a frailty score of 6). Of those prescribed a DOAC, 70% received a guideline-approved dose., Conclusions: Over 80% of ambulatory older adults with frailty and AF were prescribed an OAC. However, of those prescribed a DOAC, 30% received an unapproved dose, suggesting more emphasis should be placed on initial and ongoing dosage selection., Competing Interests: CONFLICT OF INTEREST DISCLOSURES We have read and understood the Canadian Geriatrics Journal’s policy on disclosing conflicts of interest and declare the following interest: KM is the Editor-in-Chief of the Canadian Geriatrics Journal. JY received the Canadian Foundation of Pharmacy Innovation Fund Grant in 2021. JB, AB, MD, and CI have no conflicts of interest to declare., (© 2023 Author(s).)

Competing Interests: The authors declare no potential or actual conflict of interest with respect to research, authorship and/or publication of this article.

Background: Guideline-directed medical therapy (GDMT) reduces morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF). Use of GDMT is recommended in all adults with HFrEF, but it is potentially underutilized in patients with advanced age. This study sought to characterize use of GDMT in octogenarians and nonagenarians with HFrEF and identify barriers to initiation and uptitration., Methods: This retrospective cohort study included patients aged 80-99 years at 3 heart failure clinics in the Lower Mainland region of British Columbia, Canada. Patients with a left ventricular ejection fraction ≤ 40% and heart failure hospitalization < 12 months were included. Data were collected between September 2019 and August 2021, for up to 24 months from the initial clinic visit., Results: A total of 91 patients were included. The mean age was 85 years, and the mean left ventricular ejection fraction was 30%. About 50% of patients had New York Heart Association class II symptoms. Throughout the study follow-up period, approximately 91% of patients were on a beta-blocker, 72% were on a renin-angiotensin system (RAS) inhibitor, 31% were on a mineralocorticoid receptor antagonist (MRA), and 4% were on a sodium-glucose cotransporter 2 (SGLT2) inhibitor. The target dose was achieved in 19% of patients on a beta-blocker, 7% on an RAS inhibitor, 11% on an MRA, and 100% on an SGLT2 inhibitor. Frequent barriers to GDMT initiation and/or uptitration were renal dysfunction, hypotension, and hyperkalemia., Conclusions: The levels of use of RAS inhibitors and beta-blockers in patients aged 80-99 years with HFrEF were reasonable, whereas the levels of use of MRAs and SGLT2 inhibitors were low. Achievement of target doses of GDMT was rare, owing to common adverse effects., (© 2023 The Authors.)

Background: Pharmacologic management of heart failure with reduced ejection fraction (HFrEF) involves several medications. Decision aids informed by patient decisional needs and treatment preferences could assist in making HFrEF medication choices; however, these are largely unknown., Methods: We searched MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), without language restriction, for qualitative, quantitative, and mixed-method studies that included patients with HFrEF or clinicians providing HFrEF care, and reported data on decisional needs or treatment preferences applicable to HFrEF medications. We classified decisional needs using a modified version of the Ottawa Decision Support Framework (ODSF)., Results: From 3996 records, we included 16 reports describing 13 studies (n = 854). No study explicitly assessed ODSF decisional needs; however, 11 studies reported ODSF-classifiable data. Patients commonly reported having inadequate knowledge or information, and difficult decisional roles. No study systematically assessed treatment preferences, but 6 studies reported on attribute preferences. Reducing mortality and improving symptoms frequently were ranked as being important, whereas cost importance rankings varied, and adverse events generally were ranked as being less important., Conclusion: This scoping review identified key decisional needs regarding HFrEF medications, notably inadequate knowledge or information, and difficult decisional roles, which can readily be addressed by decision aids. Future studies should systematically explore the full scope of ODSF-based decisional needs in patients with HFrEF, along with relative preferences among treatment attributes to further inform development of individualized decision aids., (© 2022 The Authors.)

Patients with heart failure with reduced ejection fraction (HFrEF) often have concurrent chronic kidney disease (CKD), which can make initiating and titrating the 4 standard pharmacologic therapies a challenge. Drug dosing is often based on a calculation of the patient's creatine clearance or estimated glomerular filtration rate (eGFR), but it should also incorporate the trend in their renal function over time and the risk of toxicity of the drug. The presence of CKD in a patient should not preclude the use of a renin-angiotensin system inhibitor, although patients should be monitored frequently for worsening renal function and hyperkalemia. Sacubitril/valsartan is not recommended in patients with an eGFR < 30 mL/min per 1.73 m 2 . Of the 3 ß-blockers recommended in the management of HFrEF, only bisoprolol may accumulate in patients with renal impairment; however, patients should still be titrated to the target dose (10 mg daily) or the maximally tolerated dose, depending on their clinical response. The sodium-glucose cotransporter 2 inhibitors are effective at reducing adverse cardiovascular and renal outcomes in patients with HFrEF and CKD (eGFR ≥ 25 mL/min per 1.73 m 2 with dapagliflozin or ≥ 20 mL/min per 1.73 m 2 with empagliflozin), although declining kidney function is a risk, due to the osmotic diuretic effect. Finally, mineralocorticoid receptor antagonist therapy should be considered in all patients with HFrEF and an eGFR ≥ 30 mL/min per 1.73 m 2 . The starting dose should be low (eg, 6.25-12.5 mg daily or 12.5 mg every other day) and can be uptitrated based on the patient's renal function and serum potassium., (© 2022 The Authors.)

Warfarin's complex dosing is a significant barrier to measurement of its exposure in observational studies using population databases. Using population-based administrative data (1996-2019) from British Columbia, Canada, we developed a method based on statistical modeling (Random Effects Warfarin Days' Supply (REWarDS)) that involves fitting a random-effects linear regression model to patients' cumulative dosage over time for estimation of warfarin exposure. Model parameters included a minimal universally available set of variables from prescription records for estimation of patients' individualized average daily doses of warfarin. REWarDS estimates were validated against a reference standard (manual calculation of the daily dose using the free-text administration instructions entered by the dispensing pharmacist) and compared with alternative methods (fixed window, fixed tablet, defined daily dose, and reverse wait time distribution) using Pearson's correlation coefficient (r), the intraclass correlation coefficient, and the root mean squared error. REWarDS-estimated days' supply showed strong correlation and agreement with the reference standard (r = 0.90 (95% confidence interval (CI): 0.90, 0.90); intraclass correlation coefficient = 0.95 (95% CI: 0.94, 0.95); root mean squared error = 8.24 days) and performed better than all of the alternative methods. REWarDS-estimated days' supply was valid and more accurate than estimates from all other available methods. REWarDS is expected to confer optimal precision in studies measuring warfarin exposure using administrative data., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Competing Interests: Declaration of Conflicting Interests: The authors have no financial or other conflicts of interest related to this work.

Background: Conventional adherence summary measures do not capture the dynamic nature of adherence., Objectives: This study aims to characterize distinct long-term oral anticoagulant adherence trajectories and the factors associated with them in patients with atrial fibrillation., Methods: Adults with incident atrial fibrillation were identified using linked population-based administrative health data in British Columbia, Canada (1996-2019). Group-based trajectory modeling was used to model patients' 90-day proportions of days covered over time to identify distinct 5-year adherence trajectories. Multinomial regression analysis was used to assess the effect of various demographic and clinical factors on exhibiting each adherence trajectory., Results: The study cohort included 19,749 patients with AF (mean age: 70.6 ± 10.6 years), 56% male, mean CHA 2 DS 2 -VASc stroke risk score 2.8 ± 1.4. Group-based trajectory modeling identified 4 distinct oral anticoagulants adherence trajectories: "consistent adherence" (n = 14,631, 74% of the cohort), "rapid decline and discontinuation" (n = 2,327, 12%), "rapid decline and partial recovery" (n = 1,973, 10%), and "slow decline and discontinuation" (n = 819, 4%). Very few patient variables were found to be associated with specific adherence trajectories., Conclusions: There is heterogeneity among nonadherent patients in the rate and timing of decline in their medication taking. Clinical and demographic characteristics were found to be inadequate to predict patients' adherence trajectories. Insights from this study could be used to inform the design and timing of adherence interventions, and qualitative studies may be needed to better understand the psychosocial determinants and reasons for the behaviors reflected in the identified trajectories., Competing Interests: Funding Support and Author Disclosures This research was supported by Canadian Institutes of Health Research grant (FRN 168896). All inferences, opinions and conclusions drawn in this manuscript are those of the authors, and do not reflect the opinions or policies of the Data Steward(s). Dr Loewen’s research is also partially supported by the UBC David H MacDonald Professorship in Clinical Pharmacy (Vancouver, Canada). Dr Salmasi’s PhD studies are supported by the International Doctoral Fellowship from the University of British Columbia (Vancouver, Canada). Dr Andrade has received honoraria from Bayer, Biosense Webster, BMS Pfizer, Medtronic, and Servier; and has received grants from Baylis, and Medtronic. Dr Deyell has received honoraria from Pfizer, Servier, and Bayer. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Marine-derived omega-3 fatty acids, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), are a type of polyunsaturated fatty acids with many purported beneficial health effects including the prevention of atherosclerotic cardiovascular disease (ASCVD) events. Omega-3 fatty acid intake may be supplemented via dietary sources, as well as prescription or non-prescription products. Omega-3 fatty acids have been shown to reduce serum triglycerides, but there remains ongoing debate regarding the effect of omega-3 fatty acids on major adverse cardiovascular events in patients with established, or at risk of, ASCVD. Recent evidence from randomized, placebo-controlled trials has demonstrated that low-dose (1 g daily or less) omega-3 fatty acids (DHA and EPA) do not reduce cardiovascular events or death in patients with or without established ASCVD. Contrarily, the REDUCE-IT trial demonstrated that a purified form of EPA ethyl esters (icosapent ethyl) at 4 g daily reduced cardiovascular events and death in patients with ASCVD (or diabetes and multiple cardiovascular risk factors) and elevated triglycerides on background statin therapy. However, 4 g daily of omega-3 carboxylic acids (DHA and EPA) did not show a cardiovascular benefit in the STRENGTH trial, which enrolled a similar population. The explanation for this observed discrepancy remains a source of contention and discourse. For now, icosapent ethyl has the most compelling evidence to support a cardiovascular benefit and should be considered in select patients who meet the REDUCE-IT criteria. Furthermore, alternative versions of omega-3 fatty acids should not be considered equivalent to icosapent ethyl. Patients taking an omega-3 fatty acid supplement should be monitored for potential adverse effects, including gastrointestinal disorders or bleeding, in addition to a possible increased risk of atrial fibrillation., (© 2021 Pharmacotherapy Publications, Inc.)

Purpose: To identify randomized controlled trials that compared antiplatelet monotherapy to combination antiplatelet plus anticoagulant therapy and evaluated major adverse cardiovascular events (MACE) or major adverse limb events (MALE), death, or bleeding in patients with lower extremity peripheral artery disease (PAD)., Summary: A systematic search of MEDLINE, Embase, and CENTRAL databases revealed 5 trials. Two trials consisted of patients with stable PAD, while 3 trials examined patients with PAD post revascularization. Antiplatelet therapy was mostly aspirin (81-325 mg daily), and anticoagulation included rivaroxaban 2.5 mg twice daily or warfarin. Duration of follow-up ranged from 12 to 38 months. Two trials had low risk of bias, whereas 3 trials had high/unclear risk of bias. For patients with stable PAD, one trial showed that use of warfarin (or acenocoumarol) with antiplatelet therapy did not reduce MACE, MALE, or cardiovascular or all-cause death but increased the risk of life-threatening bleeding. A second trial demonstrated that low-dose rivaroxaban plus antiplatelet therapy lowered the risk of MACE and MALE, with no effect in preventing cardiovascular or all-cause death, but increased the risk of major bleeding. For patients with PAD post revascularization receiving warfarin and antiplatelet therapy, 2 trials showed no benefit in MACE or MALE but increased or similar rates of all-cause death and major bleeding. In a third trial, low-dose rivaroxaban plus aspirin reduced occurrence of the composite of MACE and MALE but increased major bleeding, with no effect on cardiovascular or all-cause death., Conclusion: Dual-pathway inhibition with low-dose rivaroxaban and aspirin reduced MACE and MALE in patients with stable or revascularized PAD, but net clinical benefit is questionable., (© American Society of Health-System Pharmacists 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To evaluate the evidence for common therapeutic controversies in the medical management of valvular heart disease (VHD)., Data Sources: A literature search of PubMed (inception to December 2020) was performed using the terms angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and aortic stenosis (AS); and adrenergic β-antagonists and aortic valve regurgitation (AR) or mitral stenosis (MS)., Study Selection and Data Extraction: Randomized controlled trials (RCTs) and meta-analyses conducted in humans and published in English that reported ≥1 clinical outcome were included., Data Synthesis: Nine articles were included: 3 RCTs and 1 meta-analysis for ACE inhibitors/ARBs in AS, 1 RCT for β-blockers in AR, and 4 RCTs for β-blockers in MS. Evidence suggests that ACE inhibitors/ARBs do not increase the risk of adverse outcomes in patients with AS but may delay valve replacement. β-Blockers do not appear to worsen outcomes in patients with chronic AR and may improve left-ventricular function in patients with a reduced ejection fraction. β-Blockers do not improve and may actually worsen exercise tolerance in patients with MS in sinus rhythm., Relevance to Patient Care and Clinical Practice: ACE inhibitors/ARBs and β-blockers can likely be safely used in patients with AS or AR, respectively, who have a compelling indication. There is insufficient evidence to recommend routine use of β-blockers in patients with MS without atrial fibrillation., Conclusions: Common beliefs about the medical treatment of VHD are not supported by high-quality data. There remains a need for larger-scale RCTs in the medical management of VHD.

The 2021 guidelines primary panel selected clinically relevant questions and produced updated recommendations, on the basis of important new findings that have emerged since the 2016 guidelines. In patients with clinical atherosclerosis, abdominal aortic aneurysm, most patients with diabetes or chronic kidney disease, and those with low-density lipoprotein cholesterol ≥ 5 mmol/L, statin therapy continues to be recommended. We have introduced the concept of lipid/lipoprotein treatment thresholds for intensifying lipid-lowering therapy with nonstatin agents, and have identified the secondary prevention patients who have been shown to derive the largest benefit from intensification of therapy with these agents. For all other patients, we emphasize risk assessment linked to lipid/lipoprotein evaluation to optimize clinical decision-making. Lipoprotein(a) measurement is now recommended once in a patient's lifetime, as part of initial lipid screening to assess cardiovascular risk. For any patient with triglycerides ˃ 1.5 mmol/L, either non-high-density lipoprotein cholesterol or apolipoprotein B are the preferred lipid parameter for screening, rather than low-density lipoprotein cholesterol. We provide updated recommendations regarding the role of coronary artery calcium scoring as a clinical decision tool to aid the decision to initiate statin therapy. There are new recommendations on the preventative care of women with hypertensive disorders of pregnancy. Health behaviour modification, including regular exercise and a heart-healthy diet, remain the cornerstone of cardiovascular disease prevention. These guidelines are intended to provide a platform for meaningful conversation and shared-decision making between patient and care provider, so that individual decisions can be made for risk screening, assessment, and treatment., (Copyright © 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Statement of conflicting interests: The authors have no financial or other conflicts of interest related to this work.

Pharmacists across Canada have varying degrees of ability to prescribe medications depending on their jurisdiction of licensure. The purpose of this study was to the evaluate attitudes, beliefs, and perceptions of independent pharmacist prescribing among health authority- and community-based pharmacists. This prospective, cross-sectional online survey assessed the perceptions of independent pharmacist prescribing of health authority and community pharmacists practising in northern British Columbia (BC), which was defined as within the geographical boundaries of Northern Health. Responses were analysed using descriptive statistics and a regression analysis. There were 45 respondents to the survey: 22 community pharmacists and 23 health authority pharmacists. Both community and health authority pharmacists held positive perceptions of independent pharmacist prescribing and did not identify any barriers to incorporating independent pharmacist prescribing into their practice. Respondents were highly likely to apply for independent pharmacist prescribing authority, if available. Pharmacists in BC are currently not able to independently prescribe schedule I medications. The provincial regulatory body has proposed a framework for a Certified Pharmacist Prescriber designation, which if approved would allow pharmacists to prescribe in collaborative practice settings. This study provides some insight into the perception of pharmacists in northern BC in pursuing this designation, which may be valuable for planning purposes in case of adoption of the framework. These results are also likely applicable to other non-urban practice settings in Canada. Pharmacists in northern BC perceived independent pharmacist prescribing positively and a high proportion were likely to apply for this authority if it were permitted via legislation.

Aims: The aim of this study was to synthesize the evidence on the effect of heart failure with reduced ejection fraction (HFrEF) pharmacotherapy on health-related quality of life (HRQoL)., Methods and Results: We searched MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform in June 2020. Randomized placebo-controlled trials evaluating contemporary HFrEF pharmacotherapy and reporting HRQoL as an outcome were included. Two reviewers independently assessed studies for eligibility, extracted data, and assessed risk of bias and GRADE certainty of evidence. The primary outcome was HRQoL at last available follow-up analysed using a random-effects model. We included 37 studies from 5770 identified articles. Risk of bias was low in 10 trials and high/unclear in 27 trials. High certainty evidence from meta-analyses demonstrated improved HRQoL over placebo with sodium-glucose co-transporter 2 (SGLT2) inhibitors [standardized mean difference (SMD) 0.16, 95% confidence interval (CI) 0.08-0.23] and intravenous iron (SMD 0.52, 95% CI 0.04-1.00). Furthermore, high certainty evidence from ≥1 landmark trial further supported improved HRQoL with angiotensin receptor blockers (ARBs) (SMD 0.09, 95% CI 0.02-0.17), ivabradine (SMD 0.14, 95% CI 0.04-0.23), hydralazine-nitrate (SMD 0.24, 95% CI 0.04-0.44) vs. placebo, and for angiotensin receptor-neprilysin inhibitor (ARNI) compared with an angiotensin-converting enzyme (ACE) inhibitor (SMD 0.09, 95% CI 0.02-0.17). Findings were inconclusive for ACE inhibitors, beta-blockers, digoxin, and oral iron based on low-to-moderate certainty evidence., Conclusion: ARBs, ARNIs, SGLT2 inhibitors, ivabradine, hydralazine-nitrate, and intravenous iron improved HRQoL in patients with HFrEF. These findings can be incorporated into discussions with patients to enable shared decision-making., (© 2021 European Society of Cardiology.)

Competing Interests: Declaration of Conflicting Interests:The authors have no real or potential financial conflicts of interest related to this work.

Despite advancements in medical and interventional therapy, patients with cardiovascular disease (CVD) continue to have residual risk for recurrent cardiovascular events. Colchicine has a unique antiinflammatory mechanism that has generated interest in its potential use as a secondary cardiovascular preventive therapy. The objective of this systematic review was to evaluate the evidence for long-term (6 months or more) colchicine therapy in patients with established CVD. A search of Medline and Embase from inception to February 2020 was performed. Included were randomized controlled trials (RCTs) or propensity score-matched observational studies that compared colchicine (at any dose) with placebo or no treatment. Outcomes of interest included any major adverse cardiovascular event, cardiovascular hospitalization, coronary artery restenosis, cardiovascular death, or all-cause death. Five RCTs were included. The dose of colchicine ranged from 0.5 mg/day to 0.6 mg twice/day, and follow-up ranged from ~6-36 months. Two trials (one double blind and one single blind) showed a reduction in composite outcomes of major adverse cardiovascular events. One study failed to demonstrate a benefit with colchicine in restenosis or recurrent ischemia after angioplasty; however, it was conducted before the routine use of modern percutaneous coronary intervention and medical therapies. In contrast, a more recent trial found that colchicine reduced the rate of in-stent restenosis in patients who received a bare metal stent. Finally, one trial in patients with heart failure with reduced ejection fraction did not observe a benefit in death or heart failure hospitalization with colchicine despite a reduction in inflammatory markers. No trial demonstrated a reduction in cardiovascular or all-cause death, and most trials showed an increase in the rate of diarrhea with colchicine. Overall, colchicine has demonstrated promising results for the secondary prevention of CVD; however, further studies are required to confirm these findings before colchicine can be routinely recommended in practice., (© 2020 Pharmacotherapy Publications, Inc.)

Background: Sacubitril/valsartan is a first-in-class angiotensin receptor-neprilysin inhibitor indicated in the management of heart failure with reduced ejection fraction, based on the results of the PARADIGM-HF trial. Practice-based studies are needed to validate its effect in real-world settings. Clinical pharmacists are ideally situated to assess and titrate sacubitril/valsartan., Objective: To evaluate the utilization, safety, and tolerability of sacubitril/valsartan in a multidisciplinary heart failure clinic, with assessment and titration by a clinical pharmacist or a nurse practitioner., Methods: A retrospective cohort study was conducted at a heart failure clinic in Abbotsford, Canada. Included were adult patients with heart failure who were currently or formerly taking sacubitril/valsartan. Data collected for the period October 2015 to February 2019 included patient characteristics, New York Heart Association (NYHA) classification, concurrent medications, sacubitril/valsartan dose, adverse effects, and discontinuation rate., Results: In total, 128 patients were included. Mean age was 70.1 years, 98 (77%) of the patients were men, and 79 (62%) had NYHA class 2 heart failure. The clinical pharmacist managed care for 78 (61%) of the patients, and the nurse practitioner managed care for 50 (39%). Forty-one (32%) of the patients met modified PARADIGM-HF inclusion criteria. Eighty-five (66%) of the patients achieved the target dose of sacubitril/valsartan, with similar proportions for the clinical pharmacist and nurse practitioner groups, over a mean of 2.2 clinic visits. Patients who achieved the sacubitril/valsartan target dose, relative to those who did not, were significantly younger and had higher mean systolic blood pressure at baseline. Twenty-nine percent of patients (35/119) had an improvement in NYHA classification from before initiation of sacubitril/valsartan to achievement of target or maximally tolerated dose. Eighty-five (66%) of the patients experienced an adverse effect, primarily hypotension, and 12 (9%) required a dose reduction. Only 9 (7%) patients discontinued therapy., Conclusions: This study demonstrates the real-world safety and tolerability of sacubitril/valsartan in the treatment of heart failure, and reinforces that clinical pharmacists can effectively assess and titrate medications in a multidisciplinary heart failure clinic., Competing Interests: Competing interests: None declared., (2020 Canadian Society of Hospital Pharmacists. All content in the Canadian Journal of Hospital Pharmacy is copyrighted by the Canadian Society of Hospital Pharmacy. In submitting their manuscripts, the authors transfer, assign, and otherwise convey all copyright ownership to CSHP.)

Low-dose acetylsalicylic acid (ASA) is recommended in patients with established cardiovascular disease. However, the role of ASA in those without cardiovascular disease (i.e., primary prevention) is less clear, which has led to discordance among Canadian guidelines. In 2018, 3 double-blind, randomized controlled trials were published that evaluated ASA 100 mg daily versus placebo in patients without established cardiovascular disease. In the ASPREE trial, ASA did not reduce the risk of all-cause death, dementia, or persistent physical disability in patients ≥70 years of age but increased the risk of major bleeding. In the ARRIVE trial, ASA failed to lower the risk of a composite of cardiovascular events but increased any gastrointestinal bleeding in patients at intermediate risk of cardiovascular disease. In the ASCEND trial, ASA significantly reduced the primary composite cardiovascular outcome in patients with diabetes for a number needed to treat of 91 over approximately 7.4 years. Yet major bleeding was increased with ASA for a number needed to harm of 112. Therefore, in most situations, ASA should not be recommended for primary cardiovascular prevention. However, there are additional indications for ASA beyond cardiovascular disease. Thus, a sequential algorithm was developed based on contemporary evidence to help pharmacists determine the suitability of ASA in their patients and play an active role in educating their patients about the potential benefits (or lack thereof) and risks of ASA. Can Pharm J (Ott) 2020;153:xx-xx., Competing Interests: Declaration of Conflicting Interests:The authors have no real or potential financial conflicts of interest related to this work., (© The Author(s) 2020.)

This report describes an episode of severe hypoglycemia in a 55-year-old woman with type 1 diabetes mellitus approximately 2 weeks after initiating sacubitril/valsartan for heart failure. She was receiving a continuous subcutaneous insulin infusion and denied any severe hypoglycemic events in the prior 13 years. She experienced a second hypoglycemic episode 1 week later. She subsequently reduced her insulin dose and continued on sacubitril/valsartan. Eight months later, she did not have any recurrent hypoglycemic episodes. Clinicians should be aware of this potential adverse effect and educate patients on concomitant insulin therapy to monitor for symptoms of hypoglycemia when initiating sacubitril/valsartan., (© 2020 Canadian Cardiovascular Society. Published by Elsevier Inc.)

Background: This study sought to characterize the real-world treatment of chronic noncancer pain (CNCP) in patients on opioid therapy in primary care., Methods: A retrospective cohort study from 2014-18 was conducted at a multidisciplinary primary care clinic in Chilliwack, British Columbia. Included were adults on daily opioid therapy for CNCP. Patients receiving palliative care or ≤1 visit were excluded. Outcomes of interest included use of opioid/nonopioid pharmacotherapy, number/frequency of visits and proportion of patients able to reduce/discontinue opioid therapy., Results: Seventy patients (mean age 53 years, 53% male, 51% back pain) were included. Median follow-up was 6 visits over 12 months. Sixty-two patients (89%) reduced their opioid dose, 6 patients had no change and 2 patients required a dose increase. Mean opioid dose was reduced from 183 to 70 mg morphine equivalents daily. Twenty-four patients (34%) discontinued opioid therapy, 6 patients (9%) transitioned to opioid agonist therapy and 6 patients (9%) breached their opioid treatment agreement. Nonopioid pharmacotherapy included nonsteroidal anti-inflammatory drugs (64%), gabapentinoids (63%), tricyclic antidepressants (56%) and nabilone (51%)., Discussion: Over half of patients were no longer on opioid therapy by the end of the study. Most patients had a disorder (e.g., back pain) for which opioids are generally not recommended. Overall mean opioid dose was reduced from baseline by approximately 60% over 1 year. Lack of access to specialized pain treatments may have accounted for high nonopioid pharmacotherapy usage., Conclusions: This study demonstrates that treatment of CNCP and opioid tapering can successfully be achieved in a primary care setting. Can Pharm J (Ott) 2020;153:xx-xx., Competing Interests: Declaration of Conflicting Interests:The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (© The Author(s) 2019.)

Competing Interests: Statement of Conflicting Interests:The authors have no financial or other conflicts of interest related to this work.

Background: Data suggest that patients who undergo coronary artery bypass grafting (CABG) have a lower rate of secondary preventive cardiovascular pharmacotherapy use compared with patients who undergo percutaneous coronary intervention (PCI). This study sought to assess the rate of use of preventive pharmacotherapy at discharge in patients who underwent CABG vs PCI post-acute coronary syndrome (ACS)., Methods: A prospective cohort study was conducted at St Paul's Hospital in Vancouver, Canada. Patients aged ≥ 18 years who presented with an ACS and underwent CABG or PCI between January and November 2018 were included. Data on preventive pharmacotherapy use and reasons for justified nonuse (eg, intolerance, contraindication) were collected., Results: A total of 275 patients were included. Mean age was 65 years, and 83% were male. Overall, 141 patients (51%) underwent CABG and 134 patients (49%) underwent PCI. All patients received acetylsalicylic acid, but more patients who underwent CABG received 325 mg (vs 80-81 mg) compared to PCI (25% vs 1%, P < 0.01). Use of P2Y12 inhibitors was higher in patients who underwent PCI (primarily ticagrelor) compared with patients who underwent CABG (primarily clopidogrel) (99% vs 26%, P < 0.01). All patients who underwent CABG received a β-blocker vs 96% of patients who underwent PCI ( P = 0.017). Use of angiotensin-modulating agents was higher in patients who underwent PCI (98% vs 65%, P < 0.01). Statin use was similar between groups (99% vs 99%, P = 0.96), but more patients who underwent PCI received maximum-dose therapy (89% vs 64%, P < 0.01)., Conclusions: Use of acetylsalicylic acid, β-blockers, and statins in patients post-ACS was high regardless of revascularization strategy, whereas P2Y12 inhibitors and angiotensin-modulating agents were underused in patients who underwent CABG even after adjusting for justified nonuse., (© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc.)

Competing Interests: Competing interests: None declared.

Background: In many jurisdictions, the pharmacist's role continues to evolve from drug distribution-based service delivery to expanded scopes of practice, including independent prescribing of medications., Objectives: To assess health authority-based pharmacists' attitudes, beliefs, and perceptions about independent prescribing, to determine how independent prescribing may affect their behaviour, and to identify perceived barriers and enablers to incorporating it into their practice., Methods: An anonymous, cross-sectional online survey of 677 health authority-based pharmacists employed by Lower Mainland Pharmacy Services in British Columbia collected information in the following domains: demographic characteristics; attitudes, beliefs, and perceptions regarding pharmacist prescribing; anticipated effect of pharmacist prescribing on behaviour; likelihood of applying for this authority, if granted; and barriers and enablers to applying for prescribing authority and incorporating prescribing into their practice. A multivariate regression analysis was performed., Results: A total of 266 pharmacists (39.3%) responded to the survey. Most respondents agreed that prescribing is important to the profession and relevant to their practice, and that it might enhance job satisfaction. Additionally, respondents agreed that they had the expertise to prescribe. Respondents perceived prescribing as having the potential to positively affect behaviour, including deprescribing, prescribing at time of discharge or transfer, and renewing medications. Enablers to applying for pharmacist prescribing authority included perceived positive impact on patient care and the profession, level of support from management and coworkers, and personal ability. No barriers were identified. About two-thirds of pharmacists indicated they would likely apply for prescribing authority if it were granted through legislation. Pharmacists with a clinical practice or research role were significantly more likely to apply to be a prescriber, whereas those with more than 10 years of experience were less likely to apply., Conclusions: In this study, health authority-based pharmacists held positive attitudes and beliefs about the value and impact of independent prescribing of medications on their practice and the profession. There were no perceived barriers to applying for prescribing authority or to incorporating prescribing into practice., Competing Interests: Competing interests: None declared.

Background: Pharmacists are now seeking to incorporate physical assessment (PA) into their practices. This trend prompted the creation, by the British Columbia Branch of the Canadian Society of Hospital Pharmacists, of a 30-h course specifically designed for practising pharmacists., Objective: To evaluate pharmacists' knowledge, skills, and confidence in performing PA after completing the course., Methods: All course participants were invited to complete 2 anonymous online surveys, immediately and 6 months after course completion., Results: Of the 218 participants, 82 (38%) responded to the survey administered immediately after the course, and 77 (35%) completed this survey in full. About half of the respondents (39/79 [49%]) reported use of PA on a real patient before taking the course. Lack of formal training and lack of comfort were the most frequently selected barriers to performing PA. All respondents (79/79) agreed that the course had improved their knowledge of PA, 96% (76/79) agreed that it had improved their skills, and 90% (71/79) agreed that it had improved their ability to care for patients. In addition, 61% (48/79) and 67% (53/79), respectively, agreed that they felt confident performing PA and intervening with regard to a patient's drug therapy on the basis of physical findings. Thirty-eight (17%) of the course participants completed the 6-month follow-up survey. In that survey, the most frequently selected barrier to performing PA was lack of time. Paired data, available for 23 respondents, showed a significant increase in use of PA on real patients over time ( p = 0.013 by χ 2 test). However, there was no significant improvement in confidence in performing PA or intervening on a patient's drug therapy on the basis of physical findings ( p > 0.05 by 2-sided t test). The primary limitation of this study was potential responder bias., Conclusions: A PA course designed for pharmacists improved participants' self-reported knowledge and skills, as well as self-perceived ability to care for patients. Six months after the course, two-thirds of respondents had used PA in practice. However, there was no improvement in confidence in performing such assessments or using the findings to intervene on a patient's drug therapy., Competing Interests: Competing interests: None declared.

Introduction: Patients' lack of knowledge is a key barrier to therapy adherence. We aimed to gather insights into atrial fibrillation (AF) patients' education needs from patient and clinician viewpoints., Methods: We conducted a qualitative descriptive study using purposive sampling and semi-structured interviews with AF patients and clinicians recruited from AF clinics. Data from patients and clinicians were analyzed independently and iteratively through inductive qualitative thematic analysis., Results: Eleven clinicians and 10 patients were interviewed. Three themes emerged from analysis of clinician data: (1) patients' knowledge gaps and misconceptions, (2) clinicians' experiences teaching AF patients, and (3) clinicians' suggestions for AF education programs. Four themes emerged from the patient data: (1) emotional appraisal of the disease, (2) information seeking behavior, (3) knowledge gaps, and (4) education preferences. A key finding was identification of the need for education that addresses patients' unjustified anxieties by emphasizing that AF is not fatal, and that many patients with AF live a normal life. Risk communication was identified as the most challenging aspect of AF education. In synthesizing our findings, we developed evidence-based recommendations for educational strategies for AF., Conclusion: We found that AF patients have many knowledge gaps and misconceptions, significant emotional education needs, and a positive attitude towards online and classroom education. In synthesizing our findings, we developed evidence-based recommendations which can inform the design of AF patient education programs and initiatives., (Copyright © 2018 Elsevier Ltd. All rights reserved.)