Inhibit progression of coronary artery calcification with vitamin K in hemodialysis patients (the iPACK-HD study): a randomized, placebo-controlled multi-center, pilot trial.

BACKGROUND: Vitamin K activates matrix Gla protein (MGP), a key inhibitor of vascular calcification. There is a high prevalence of sub-clinical vitamin K deficiency in patients with end-stage kidney disease. METHODS: A parallel randomized placebo-controlled pilot trial was designed to determine whether 10 mg of phylloquinone thrice weekly versus placebo modifies coronary artery calcification progression over 12 months in patients requiring hemodialysis with a coronary artery calcium score (CAC) ≥30 Agatston Units (ClinicalTrials.gov identifier NCT01528800). The primary outcome was feasibility (recruitment rate, compliance with study medication, study completion and adherence overall to study protocol). CAC score was used to assess calcification at baseline and 12 months. Secondary objectives were to explore the impact of phylloquinone on vitamin K-related biomarkers (phylloquinone, dephospho-uncarboxylated MGP and the Gla-osteocalcin to Glu-osteocalcin ratio) and events of clinical interest. RESULTS: A total of 86 patients with a CAC score ≥30 Agatston Units were randomized to either 10 mg of phylloquinone or a matching placebo three times per week. In all, 69 participants (80%) completed the trial. Recruitment rate (4.4 participants/month) and medication compliance (96%) met pre-defined feasibility criteria of ≥4.17 and ≥90%, respectively. Patients randomized to phylloquinone for 12 months had significantly reduced levels of dephospho-uncarboxylated MGP (86% reduction) and increased levels of phylloquinone and Gla-osteocalcin to Glu-osteocalcin ratio compared with placebo. There was no difference in the absolute or relative progression of coronary artery calcification between groups. CONCLUSION: We demonstrated that phylloquinone treatment improves vitamin K status and that a fully powered randomized trial may be feasible.

The Effect of Sex on Door-to-Balloon Time in Patients Presenting With ST-Elevation Myocardial Infarction and Referred for Primary Percutaneous Coronary Intervention: A Systematic Review.

Timely reperfusion using primary percutaneous coronary intervention (pPCI) is the cornerstone of acute ST-elevation myocardial infarction (STEMI) management. We conducted a systematic review to examine the effect of sex on door-to-balloon (D2B) time and symptom-to-balloon (S2B) time. We observed longer D2B times and S2B times in female patients presenting with STEMI and referred for pPCI when compared to male patients. Future work is required to try and elucidate and mitigate sex-based front-line treatment delays for female STEMI patients.

The Effect of Transcatheter Mitral Valve Repair on Short-Term Mortality in Patients With Chronic Kidney Disease - A Systematic Review and Meta-Analysis.

Transcatheter Mitral Valve Repair (TMVr) offers clinically significant benefit to select symptomatic patients with severe mitral regurgitation (MR). We conducted a systematic review and meta-analysis of clinical trials and observational studies to identify the effect of pre-procedural Chronic Kidney disease (CKD) on short-term mortality in TMVr. We found CKD is a predictor of 30-day mortality in patients undergoing TMVr. Specifically, a GFR < 30 mL/min conveys a significant increase in 30-day mortality. This is significant for patient selection, prognostication, as well as identifies an area of need for further research. SUMMARY FOR ANNOTATED TABLE OF CONTENTS: A systematic review and meta-analysis looking at short-term mortality in patients undergoing Transcatheter Mitral Valve Repair with chronic kidney disease. Findings show severe renal disease is associated with increased 30-day mortality.

Statin Use is Associated With Insulin Resistance in Participants of the Canadian Multicentre Osteoporosis Study.

CONTEXT: Statins have been linked to the development of diabetes and atherosclerotic plaque calcification in patients with cardiac disease. OBJECTIVE: To determine the association between statin use and statin characteristics and insulin resistance and abdominal aortic calcification (AAC) in participants of the Canadian Multicentre Osteoporosis Study (CaMos). DESIGN: Observational study. SETTING: General community. PARTICIPANTS: Nondiabetic participants of the Kingston CaMos site. INTERVENTION: Insulin resistance and AAC in statin users and nonstatin users were compared with and without the inclusion of a propensity score (PS) to be on a statin. The covariates of hypertension, sex, body mass index, smoking, kidney stones, and age that were included in the PS were selected based on clinical judgment confirmed by the statistical analysis of a difference between statin users and nonstatin users. MAIN OUTCOME MEASURES: Insulin resistance measured by the homeostasis model assessment (HOMA-IR) and AAC assessed on lateral spine radiographs using the Framingham methodology. RESULTS: Using a general linear model, statin use was associated with higher levels of HOMA-IR after stratified PS adjustment (ß = 1.52, [1.18-1.95], P < 0.01). Hydrophilic statin users (n = 9) and lipophilic statins users (n = 30) had higher HOMA-IR compared to nonstatin users (n = 125) ([ß = 2.29, (1.43-3.68), P < 0.001] and [ß = 1.36, (1.04-1.78), P < 0.05]), respectively, in general linear models after stratified PS adjustment. Statin use was associated with AAC without stratifying by PS in the Wilcoxon test, but was no longer significant when stratified by PS. CONCLUSIONS: Statins, widely prescribed drugs to lower cholesterol, may have unintended consequences related to glucose homeostasis that could be relevant in healthy aging.

Canada-wide mixed methods analysis evaluating the reasons for inappropriate emergency department presentation in patients with a history of atrial fibrillation: the multicentre AF-ED trial.

OBJECTIVES: The primary objective of this study was to ascertain the reasons for emergency department (ED) attendance among patients with a history of atrial fibrillation (AF). DESIGN: Appropriate ED attendance was defined by the requirement for an electrical or chemical cardioversion and/or an attendance resulting in hospitalisation or administration of intravenous medications for ventricular rate control. Quantitative and qualitative responses were recorded and analysed using descriptive statistics and content analysis, respectively. Random effects logistic regression was performed to estimate the OR of inappropriate ED attendance based on clinically relevant patient characteristics. PARTICIPANTS: Participants ≥18 years with a documented history of AF were approached in one of eight centres partaking in the study across Canada (Ontario, Nova Scotia, Alberta and British Columbia). RESULTS: Of the 356 patients enrolled (67±13, 45% female), the majority (271/356, 76%) had inappropriate reasons for presentation and did not require urgent ED treatment. Approximately 50% of patients(172/356, 48%) were driven to the ED due to symptoms, while the remainder presented on the basis of general fear or anxiety (67/356, 19%) or prior medical advice (117/356, 33%). Random effects logistic regression analysis showed that patients with a history of congestive heart failure were significantly more likely to seek urgent care for appropriate reasons (p=0.03). Likewise, symptom-related concerns for ED presentation were significantly less likely to result in inappropriate visitation (p=0.02). When patients were surveyed on alternatives to ED care, the highest proportion of responses among both groups was in favour of specialised rapid assessment outpatient clinics (186/356, 52%). Qualitative content analysis confirmed these results. CONCLUSIONS: Improved education focused on symptom management and alleviating disease-related anxiety as well as the institution of rapid access arrhythmias clinics may reduce the need for unnecessary healthcare utilisation in the ED and subsequent hospitalisation. TRIAL REGISTRATION NUMBER: NCT03127085.

Phosphorus Consumption Within 1 Hour Prior to Blood Work and Associated Serum Levels of Phosphate, Calcium, and PTH in Adult Patients Receiving Hemodialysis Treatment.

BACKGROUND: While dietary intake is known to influence serum markers of chronic kidney disease-mineral and bone disorder (CKD-MBD), the effects of recent food and beverage intake, particularly phosphorus consumption on these serum markers (phosphate, calcium, and parathyroid hormone [PTH]), are unknown in hemodialysis patients. An understanding of these effects could have direct and important implications on the management of CKD-MBD. OBJECTIVE: To determine whether serum phosphate, calcium, and PTH levels were higher in hemodialysis patients who had consumed dietary phosphorus within 1 hour prior to their routine dialysis-related blood work (non-phosphorus-fasted) compared with patients who did not (phosphorus-fasted). DESIGN: Observational, cross-sectional study. SETTING: Kingston Health Sciences Center-Kingston General Hospital Site and its affiliated satellite hemodialysis units. PATIENTS: Two hundred fifty-four adult patients receiving outpatient hemodialysis treatment for end-stage kidney disease were recruited. MEASUREMENTS: The main measurements for this study included an assessment of dietary phosphorus intake as well as serum phosphate, calcium, PTH, albumin, Kt/V, and urea reduction ratio. METHODS: A direct patient interview was performed to assess dietary phosphorus intake within 1 hour prior to routine dialysis-related blood work. The Canadian Nutrient File was then used to estimate dietary phosphorus based on the specific foods and beverages (including portion sizes and brands where applicable) identified in the interview. Serum measures of phosphate, PTH, calcium, albumin, and dialysis adequacy (Kt/V and urea reduction ratio) were obtained from participants' routine dialysis-related blood work. RESULTS: Non-phosphorus-fasted participants had nonsignificantly higher serum PTH levels compared to phosphorus-fasted participants (61.2 ± 64.7 vs 47.9 ± 39.7, P = .05). Non-phosphorus-fasted participants with PTH levels at the Kidney Disease Improving Global Outcomes (KDIGO) "target" (between 15 and 60 pmol/L) had significantly higher serum phosphate levels relative to phosphorus-fasted participants (1.6 ± 0.3 vs 1.4 ± 0.4, P = .006). In non-phosphorus-fasted participants, there was a nonsignificant association between the number of items containing inorganic phosphate additives and higher levels of serum phosphate and lower levels of serum calcium. LIMITATIONS: Some limitations include the cross-sectional nature of this study, self-reporting biases and estimates (as opposed to direct measurements) related to the dietary assessment, and the use of single (and not serial) assessments of serum measures. CONCLUSIONS: Dietary phosphorus intake in close proximity to blood work may contribute to subtle alterations in some key serum CKD-MBD parameters in adult outpatient hemodialysis patients but may not meaningfully alter CKD-MBD management.

CONTEXTE: Alors que l'alimentation est connue pour influencer les marqueurs sériques des troubles minéraux et osseux associés à l'insuffisance rénale chronique (TMO-IRC), les effets d'une consommation récente de nourriture et de boisson, particulièrement de phosphore, sur ces mêmes marqueurs sériques (phosphate, calcium et hormone parathyroïde [PTH]), demeurent inconnus chez les patients hémodialysés. Une meilleure connaissance de ces effets pourrait avoir une influence majeure et directe sur la prise en charge des TMO-IRC. OBJECTIF: Déterminer si les taux sériques de phosphate, de calcium et de PTH sont plus élevés chez les patients hémodialysés ayant consommé des aliments contenant du phosphore dans l'heure précédant les analyses sanguines de routine liées à la dialyse (analyse sanguine de routine), lorsque comparés aux taux des patients n'en ayant pas consommé (patients à jeun). TYPE D'ÉTUDE: Une étude transversale observationnelle. CADRE: Le Kingston Health Sciences Centre, sur le site de l'hôpital général de Kingston, et ses unités satellites d'hémodialyse. SUJETS: L'étude porte sur 244 patients adultes atteints d'insuffisance rénale terminale et recevant des traitements ambulatoires d'hémodialyse. MESURES: Les principales mesures incluaient l'évaluation de l'apport en phosphore alimentaire, la mesure des taux sériques de phosphate, de calcium, de PTH et d'albumine, de même que le Kt/V et le taux de réduction de l'urée. MÉTHODOLOGIE: Les patients ont été questionnés sur leur consommation de phosphore dans les heures précédant l'analyse sanguine de routine liée à la dialyse. Le Fichier canadien des éléments nutritifs a par la suite été employé pour estimer la quantité de phosphore alimentaire selon les aliments et les boissons consommés (portions et marque du produit, lorsque disponibles). Les mesures sériques de phosphate, de PTH, de calcium et d'albumine, de même que l'efficacité de la dialyse (Kt/V et taux de réduction de l'urée) ont été obtenues par les analyses sanguines de routine. RÉSULTATS: Les participants qui avaient consommé du phosphore n'ont pas présenté un taux de PTH sérique plus élevé que les patients à jeun (61,2 ± 64,7 contre 47,9 ± 39,7; P = 0,05). Les sujets ayant consommé du phosphore et dont les taux de PTH sériques se situaient dans la « cible ¼ du KDIGO (Kidney Disease Improving Global Outcomes), soit entre 15 et 60 pmol/L, présentaient des taux de phosphate sérique significativement plus élevés que les sujets à jeun (1,6 ± 0,3 contre 1,4 ± 0,4; P = .006). En outre, chez les patients ayant consommé du phosphore, une association non significative a été observée entre le nombre d'aliments contenant des additifs phosphatés inorganiques qui avaient été consommés et des taux sériques plus élevés en phosphate et plus faibles en calcium. LIMITES: La nature transversale de l'étude, de possibles biais et estimations dus à l'auto-évaluation des apports alimentaires (par rapport à une mesure directe) et le recours à des mesures uniques (et non en série) pour les analyses sanguines constituent les limites. CONCLUSION: La consommation de phosphore alimentaire dans les heures précédant l'analyse sanguine est susceptible d'introduire de légères altérations pour certains paramètres sériques clés du TMO-IRC chez les adultes recevant des traitements ambulatoires d'hémodialyse, sans toutefois altérer la gestion du TMO-IRC de façon significative.

Differences in lumbopelvic control and occupational behaviours in female nurses with and without a recent history of low back pain due to back injury.

Low back pain is highly prevalent in nurses. This study aimed to determine which physical fitness, physical activity (PA) and biomechanical characteristics most clearly distinguish between nurses with [recently injured (RInj)] and without [not recently injured (NRInj)] a recent back injury. Twenty-seven (8 RInj, 19 NRInj) female nurses completed questionnaires (pain, work, PA), physical fitness, biomechanical and low back discomfort measures, and wore an accelerometer for one work shift. Relative to NRInj nurses, RInj nurses exhibited reduced lumbopelvic control (41.4% more displayed a moderate loss of frontal plane position), less active occupational behaviours (less moderate PA; less patient lifts performed alone; more sitting and less standing time) and more than two times higher low back discomfort scores. Despite no physical fitness differences, the lumbopelvic control, occupational behaviours and discomfort measures differed between nurses with and without recent back injuries. It is unclear whether poor lumbopelvic control is causal or adaptive in RInj nurses and may require further investigation. Practitioner Summary: It is unclear which personal modifiable factors are most clearly associated with low back pain in nurses. Lumbopelvic control was the only performance-based measure to distinguish between nurses with and without recent back injuries. Future research may investigate whether reduced lumbopelvic control is causal or adaptive in recently injured nurses.