Effect of combined GLP-1 analogue and bupropion/naltrexone on weight loss: a retrospective cohort study.

OBJECTIVE: Little is known about the effect of a multi-drug weight loss strategy in obesity treatment, particularly combining bupropion/naltrexone and glucagon-like peptide 1 (GLP-1) analogue. The purpose of this study was to evaluate if there are any additive effects of prescribing bupropion/naltrexone on top of GLP-1 analogue as weight loss therapy. METHODS: This was a retrospective cohort study of adult patients with a body mass index (BMI) ≥ 30 kg/m2 prescribed GLP-1 analogue therapy at an obesity specialist clinic in Vancouver, Canada. We compared a 6 and 12-month change in total body weight loss (TBWL) for those receiving monotherapy from the initiation of GLP-1 analogue therapy with those receiving combination therapy from the initiation of bupropion/naltrexone added-on therapy. Patients prescribed combination therapy were stratified into responder (loss of ≥ 5% TBWL) and non-responder (TBWL < 5%) subgroups based on initial response to the GLP-1 analogue alone for any amount of time. RESULTS: The mean weight loss among patients prescribed GLP-1 analogue monotherapy at 12 months was 11.42 kg, SD 9.95 (9.6% TBWL). There was no significant difference between these two treatment strategies overall (HR 0.88, 95% CI 0.68 to 1.14, p = 0.35). However, when stratified by response to initial GLP analogue therapy, the addition of bupropion/naltrexone was associated with a statistically significant reduction in weight in both the responder (4.3% TBWL (p < 0.01)) and non-responder groups (4.0% TBWL (p < 0.01)). CONCLUSIONS: GLP-1 analogues are an effective treatment for weight loss, and the addition of bupropion/naltrexone is associated with greater weight loss including in patients who are initially non-responsive to GLP-1 analogues.

Adiposity and the role of diverse social supports: an observational, gender-sensitive study using the baseline Canadian Longitudinal Study on Aging.

OBJECTIVE: To quantify associations between four types of social support and measured adiposity among women and men. DESIGN: The cross-sectional sample from the Canadian Longitudinal Study on Aging (CLSA, 2012-2015). Height, weight and waist circumference (WC) were clinically measured, and perceived availability of informational, tangible, emotional and belonging social supports was self-reported. SETTING: Canada. PARTICIPANTS: 28 779 adults aged 45-85 years from the CLSA. RESULTS: All social support types were associated with WC and BMI among women but not among men. Women reporting the lowest informational support had significantly higher mean BMI (28·84 kg/m2 (95 % CI 28·63, 29·05)) and WC (90·81 cm (95 % CI 90·31, 91·30)) compared with women reporting maximum support (respectively, 28·09 kg/m2 (95 % CI 27·88, 28·30) and 88·92 cm (95 % CI 88·43, 89·4)). Women's abdominal obesity was associated with low levels of informational, emotional and belonging support, and women's general obesity with informational and emotional support. Notably, informational and emotional support were associated with both obesity outcomes independent of other supports among women. Only a low level of informational support was significantly independently associated with higher odds of obesity among men. CONCLUSIONS: Our study provides novel insights into gender-specific associations between different types of social support and adiposity. Prospective studies are needed to further investigate potential causality of these associations between the specific social supports and future weight status, especially among women.

Impact of language barriers on stroke care and outcomes.

BACKGROUND AND PURPOSE: Language barriers may lead to poor quality of care, particularly for conditions like acute stroke for which diagnosis and treatment decision making rely on taking an accurate patient history. The purpose of this study was to determine the impact of patient language barriers on quality of stroke care and clinical outcomes. METHODS: This retrospective cohort study used data from the Registry of the Canadian Stroke Network. All Ontario patients who were admitted with acute stroke or transient ischemic attack between July 2003 and March 2008 were selected. Mortality, stroke outcomes, in-hospital complications, quality of care, and disposition were compared between those without (n=12 787) and with (n=1506) language barriers, which was defined based on the patient's preferred language. Hierarchical multivariable regression models determined the effect of language barriers, independent of baseline covariates. RESULTS: Patients with language barriers had better 7-day mortality than those without (7.0% versus 9.2%; OR, 0.69; 95% CI, 0.57-0.82; P<0.001). However, they were more likely to be discharged with a moderate-to-severe neurological deficit (65.9% versus 51.5%; OR, 1.25; 95% CI, 1.15-1.35). In-hospital complication rates did not differ, and quality of care indicators generally favored patients with language barriers. CONCLUSIONS: Patients who had language barriers had reduced mortality and better performance on some quality of care measures. These differences existed despite adjustment for many potential confounders, including ethnicity, prognostic factors, and stroke characteristics.

Sex differences in health behavior change after premature acute coronary syndrome.

BACKGROUND: Limited information is available on the health behavior profile of patients with premature acute coronary syndrome (ACS). The purpose of this study is to desribe the health bahvior of young patients with ACS at the baseline and 1 year post-ACS and examine sex differences. METHODS: GENESIS-PRAXY is a prospective cohort study of adults (18-55 years old) hospitalized with ACS from 26 centers located in Canada, United States, and Switzerland. Data on diet, physical activity, smoking, alcohol consumption, and recreational drug use were collected through self-administered questionnaires at baseline and 1 year post-ACS. RESULTS: Our analysis included 740 patients with complete data. At baseline, the health behavior profile of young patients with ACS was worse than that of the general population. Men had a lower fruit and vegetable intake, consumed alcohol more, and used recreational drugs more than women. Conversely, fewer men than women were smokers (34% vs 42%). At 1 year post-ACS, the proportion of those consuming ≥5 daily servings of fruits and vegetables increased modestly (+5% vs +1%, for men vs women) but remained lower than the general population. Among women, the prevalence of smoking remained about twice as high as the general population. Recreational drug use also remained higher than in the general population. CONCLUSIONS: Despite small improvements at 1 year post-ACS, the health behavior profile of young patients remained worse than that of the general population. Greater efforts to improve health behaviors post-ACS among young patients are needed, and a sex-based approach may be required to ensure successful behavioral changes.

Potential factors associated with fruit and vegetable intake after premature acute coronary syndrome: a prospective cohort study.

Studies on dietary changes and their associated factors are limited, particularly with respect to younger cardiovascular patients. Our objective was to evaluate the factors associated with fruit and vegetable intake among adults with premature acute coronary syndrome (ACS) 1 year after the event. We used data from GENESIS-PRAXY, a multicentre prospective study of adults aged 18-55 years, hospitalised for ACS. Participants were 704 adults from 24 centres in Canada, 1 in USA and 1 in Switzerland. Data were collected through questionnaires and chart reviews at baseline and 1 year post-ACS. Fruit and vegetable intake was low among adults with premature ACS, and remained suboptimal at 1 year post-ACS, with only 21% meeting the minimum recommendations of at least 5 daily servings. The findings suggest that patient lifestyle characteristics, such as the number of hours spent at work and baseline intake are factors that may be associated with the intake of fruits and vegetables. More research is needed to assess effective strategies to increase fruit and vegetable intake among patients with premature ACS so that they meet dietary recommendations.

Implementation of a home blood pressure monitoring program for the management of hypertensive disorders of pregnancy, an observational study in British Columbia, Canada.

Background: COVID-19 pandemic has influenced health care delivery. We conducted an observational study to understand how obstetric medicine (ObM) physicians utilized home blood pressure monitoring (HBPM) to manage hypertension in pregnancy. Methods: Pregnant participants with risk factors or diagnosis of hypertensive disorders of pregnancy (HDP) were enrolled, May 2020-December 2021, and provided with validated home blood pressure (BP) monitor. ObM physicians completed questionnaires to elicit how home BP readings were interpreted to manage HDP. Results: We enrolled 103 people: 44 antepartum patients (33.5 ± 5 years, gestational age of 24 ± 5 weeks); 59 postpartum patients (35 ± 6 years, enrolled 6 ± 4 days post-partum). ObM physicians used range of home BP readings (70%) for management of HDP. Conclusions: HBPM to manage HDP is acceptable and can be used to manage hypertension during pregnancy. Further studies are needed to assess the generalizability of our findings and the safety of HBPM reliance alone in management of HDP.

Differences in Physician Burnout by Specialty: A Cross-Sectional Survey.

BACKGROUND: The prevalence of physician burnout increased notably during the COVID-19 pandemic, but whether measures of burnout differed based on physician specialty is unknown. The authors sought to determine the prevalence of burnout, worklife conflict, and intention to quit among physicians from different specialties. METHODS: This is a cross-sectional online survey of physicians working at 2 urban hospitals in Vancouver, Canada, from August to October 2021. Responses were categorized by specialty (including surgical and nonsurgical), and data about whether physicians provided frontline patient care during COVID-19 were also included. Physician burnout was measured using the Maslach Burnout Inventory. Responses were categorized by specialty (including surgical and nonsurgical), and data about whether physicians provided frontline patient care during COVID-19 were also included. RESULTS: The survey response rate was 42% (209/498). The overall prevalence of burnout was 69%. Burnout was not significantly different by specialty or between frontline COVID-19 specialties compared with other specialties. Physicians in surgical specialties were more likely to report work-life conflict than those in nonsurgical specialties (p = 0.012). Differences in intention to quit among specialties were not statistically significant. CONCLUSION: During the COVID-19 pandemic, physician burnout was high across physicians, without significant differences between specialties, highlighting the need to support all physicians.

Population Trends of New Prescriptions for Antihyperglycemics and Antihypertensives Between 2014 and 2022.

BACKGROUND: In the wake of pandemic-related health decline and health care disruptions, there are concerns that previous gains for cardiovascular risk factors may have stalled or reversed. Population-level excess burden of drug-treated diabetes and hypertension during the pandemic compared with baseline is not well characterized. We evaluated the change in incident prescription claims for antihyperglycemics and antihypertensives before versus during the pandemic. METHODS AND RESULTS: In this retrospective, serial, cross-sectional, population-based study, we used interrupted time series analyses to examine changes in the age- and sex-standardized monthly rate of incident prescriptions for antihyperglycemics and antihypertensives in patients aged ≥66 years in Ontario, Canada, before the pandemic (April 2014 to March 2020) compared with during the pandemic (July 2020 to November 2022). Incident claim was defined as the first prescription filled for any medication in these classes. The characteristics of patients with incident prescriptions of antihyperglycemics (n=151 888) or antihypertensives (n=368 123) before the pandemic were comparable with their pandemic counterparts (antihyperglycemics, n=97 015; antihypertensives, n=146 524). Before the pandemic, monthly rates of incident prescriptions were decreasing (-0.03 per 10 000 individuals [95% CI, -0.04 to -0.01] for antihyperglycemics; -0.14 [95% CI, -0.18 to -0.10] for antihypertensives). After July 2020, monthly rates increased (postinterruption trend 0.31 per 10 000 individuals [95% CI, 0.28-0.34] for antihyperglycemics; 0.19 [95% CI, 0.14-0.23] for antihypertensives). CONCLUSIONS: Population-level increases in new antihyperglycemic and antihypertensive prescriptions during the pandemic reversed prepandemic declines and were sustained for >2 years. Our findings are concerning for current and future cardiovascular health.

Risk factors, quality of care and prognosis in South Asian, East Asian and White patients with stroke.

BACKGROUND: Stroke has emerged as a significant and escalating health problem for Asian populations. We compared risk factors, quality of care and risk of death or recurrent stroke in South Asian, East Asian and White patients with acute ischemic and hemorrhagic stroke. METHODS: Retrospective analysis was performed on consecutive patients with ischemic stroke or intracerebral hemorrhage admitted to 12 stroke centers in Ontario, Canada (July 2003-March 2008) and included in the Registry of the Canadian Stroke Network database. The database was linked to population-based administrative databases to determine one-year risk of death or recurrent stroke. RESULTS: The study included 253 South Asian, 513 East Asian and 8231 White patients. East Asian patients were more likely to present with intracerebral hemorrhage (30%) compared to South Asian (17%) or White patients (15%) (p<0.001). Time from stroke to hospital arrival was similarly poor with delays >2 hours for more than two thirds of patients in all ethnic groups. Processes of stroke care, including thrombolysis, diagnostic imaging, antithrombotic medications, and rehabilitation services were similar among ethnic groups. Risk of death or recurrent stroke at one year after ischemic stroke was similar for patients who were White (27.6%), East Asian (24.7%, aHR 0.97, 95% CI 0.78-1.21 vs. White), or South Asian (21.9%, aHR 0.91, 95% CI 0.67-1.24 vs. White). Although risk of death or recurrent stroke at one year after intracerebral hemorrhage was higher in East Asian (35.5%) and White patients (47.9%) compared to South Asian patients (30.2%) (p=0.002), these differences disappeared after adjustment for age, sex, stroke severity and comorbid conditions (aHR 0.89 [0.67-1.19] for East Asian vs White and 0.99 [0.54-1.81] for South Asian vs. White). CONCLUSION: After stratification by stroke type, stroke care and outcomes are similar across ethnic groups in Ontario. Enhanced health promotion is needed to reduce delays to hospital for all ethnic groups.

Outcomes following percutaneous coronary intervention and coronary artery bypass grafting surgery in Chinese, South Asian and White patients with acute myocardial infarction: administrative data analysis.

BACKGROUND: Little is known on whether there are ethnic differences in outcomes following percutaneous coronary intervention (PCI) and coronary artery bypass grafting surgery (CABG) after acute myocardial infarction (AMI). We compared 30-day and long-term mortality, recurrent AMI, and congestive heart failure in South Asian, Chinese and White patients with AMI who underwent PCI and CABG. METHODS: Hospital administrative data in British Columbia (BC), Canada were linked to the BC Cardiac Registry to identify all patients with AMI who underwent PCI (n = 4729) or CABG (n = 1687) (1999-2003). Ethnicity was determined from validated surname algorithms. Logistic regression for 30-day mortality and Cox proportional-hazards models were adjusted for age, sex, socio-economic status, severity of coronary disease, comorbid conditions, time from AMI to a revascularization procedure and distance to the nearest hospital. RESULTS: Following PCI, Chinese had higher short-term mortality (Odds Ratio (OR): 2.36, 95% CI: 1.12-5.00; p = 0.02), and South Asians had a higher risk for recurrent AMI (OR: 1.34, 95% CI: 1.08-1.67, p = 0.007) and heart failure (OR 1.81, 95% CI: 1.00-3.29, p = 0.05) compared to White patients. Risk of heart failure was higher in South Asian patients who underwent CABG compared to White patients (OR (95% CI) = 2.06 (0.92-4.61), p = 0.08). There were no significant differences in mortality following CABG between groups. CONCLUSIONS: Chinese and South Asian patients with AMI and PCI or CABG had worse outcomes compared to their White counterparts. Further studies are needed to confirm these findings and investigate potential underlying causes.

Sex Differences in Ambulatory Blood Pressure Levels and Subtypes in a Large Italian Community Cohort.

BACKGROUND: Sex differences in blood pressure control are recognized. We systematically investigated sex differences in specific components of ambulatory blood pressure (ABP), including variability, day-night changes, morning surge, and hypertension types. METHODS: We analyzed ABPs of 52 911 participants (45.6% male, 54.4% female, 37.0% treated for hypertension) visiting 860 Italian community pharmacies. Sex differences in ABP levels and patterns were evaluated in the whole group and 4 risk groups (antihypertensive-treated patients, patients with diabetes, dyslipidemia, or cardiovascular disease). RESULTS: Average 24-hour, day-time, and night-time blood pressure values were consistently higher in males than females (P<0.001). Variability in ABP was higher in females, except during the night. Nondippers and an abnormal morning surge were more common among males (odds ratio and 95% CI, 1.282 [1.230-1.335] and 1.244 [1.159-1.335]; P<0.001). The prevalence of 24-hour and masked hypertension was higher in males (odds ratio and 95% CI, 2.093 [2.019-2.170] and 1.347 [1.283-1.415]; P<0.001) and that of white-coat hypertension in females (0.719 [0.684-0.755]; P<0.001). Ambulatory heart rate mean values were higher (P<0.001) in females. Day-time HR variability was higher and night-time heart rate variability lower in females (P<0.001). Sex differences in ABP levels and patterns detected in the whole population were replicated in all risk groups, except for the prevalence of abnormal morning surge (between sexes difference in antihypertensive-treated participants only). CONCLUSIONS: Females show better ABP control than males, but with an increased blood pressure variability and a greater prevalence of white-coat hypertension. These findings support tailored management of hypertension. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03781401.

Characterizing Hypertension Specialist Care in Canada: A National Survey.

Background: The hypertension specialist often receives referrals of patients with young-onset, severe, difficult-to-control hypertension, patients with hypertensive emergencies, and patients with secondary causes of hypertension. Specialist hypertension care compliments primary care for these complex patients and contributes to an overall hypertension control strategy. The objective of this study was to characterize hypertension centres and the practice patterns of Canadian hypertension specialists. Methods: Adult hypertension specialists across Canada were surveyed to describe hypertension centres and specialist practice in Canada, including the following: the patient population managed by hypertension specialists; details on how care is provided; practice pattern variations; and differences in access to specialized hypertension resources across the country. Results: The survey response rate was 73.5% from 25 hypertension centres. Most respondents were nephrologists and general internal medicine specialists. Hypertension centres saw between 50 and 2500 patients yearly. A mean of 17% (± 15%) of patients were referred from the emergency department and a mean of 52% (± 24%) were referred from primary care. Most centres had access to specialized testing (adrenal vein sampling, level 1 sleep studies, autonomic testing) and advanced therapies for resistant hypertension (renal denervation). Considerable heterogeneity was present in the target blood pressure in young people with low cardiovascular risk and in the diagnostic algorithms for investigating secondary causes of hypertension. Conclusions: These results summarize the current state of hypertension specialist care and highlight opportunities for further collaboration among hypertension specialists, including standardization of the approach to specialist care for patients with hypertension.

Contexte: Le spécialiste de l'hypertension reçoit souvent des patients orientés pour une hypertension sévère, d'apparition précoce et difficile à maîtriser, pour une urgence hypertensive ou pour des causes secondaires de l'hypertension. Les soins spécialisés de l'hypertension complètent les soins primaires pour ces cas complexes et font partie d'une stratégie globale de maîtrise de l'hypertension. Cette étude avait pour objectif de caractériser les centres de traitement de l'hypertension et les habitudes de pratique des spécialistes canadiens qui traitent l'hypertension. Méthodologie: Un sondage a été mené auprès de spécialistes de l'hypertension adulte de l'ensemble du Canada afin de décrire les centres de traitement de l'hypertension et la pratique des spécialistes au Canada, notamment les éléments suivants : la population de patients prise en charge par des spécialistes de l'hypertension, les renseignements sur la façon dont les soins sont prodigués, les variations dans les habitudes de pratique ainsi que les différences relatives à l'accès aux ressources spécialisées en hypertension à l'échelle du pays. Résultats: Le taux de réponse au sondage a été de 73,5 % dans 25 centres de l'hypertension. La plupart des répondants étaient des néphrologues et des spécialistes en médecine interne générale. Les centres de l'hypertension recevaient entre 50 et 2500 patients par année. En moyenne, 17 % (± 15 %) des patients provenaient du service des urgences et 52 % (± 24 %) provenaient d'une unité de soins primaires. La plupart des centres avaient accès à des tests spécialisés (prélèvements veineux surrénaliens, études du sommeil de niveau 1, tests autonomes) et à des traitements avancés pour l'hypertension résistante (dénervation rénale). Une hétérogénéité considérable a été constatée en ce qui concerne la pression artérielle cible chez les jeunes présentant un faible risque cardiovasculaire et les algorithmes diagnostiques pour étudier les causes secondaires de l'hypertension. Conclusions: Ces résultats résument la situation actuelle des soins spécialisés de l'hypertension et font ressortir des occasions d'accroître la collaboration entre les spécialistes de l'hypertension, notamment en ce qui concerne une normalisation de l'approche des soins spécialisés pour les patients hypertendus.

Addressing global disparities in blood pressure control: perspectives of the International Society of Hypertension.

ABSTRACT: Raised blood pressure (BP) is the leading cause of preventable death in the world. Yet, its global prevalence is increasing, and it remains poorly detected, treated, and controlled in both high- and low-resource settings. From the perspective of members of the International Society of Hypertension based in all regions, we reflect on the past, present, and future of hypertension care, highlighting key challenges and opportunities, which are often region-specific. We report that most countries failed to show sufficient improvements in BP control rates over the past three decades, with greater improvements mainly seen in some high-income countries, also reflected in substantial reductions in the burden of cardiovascular disease and deaths. Globally, there are significant inequities and disparities based on resources, sociodemographic environment, and race with subsequent disproportionate hypertension-related outcomes. Additional unique challenges in specific regions include conflict, wars, migration, unemployment, rapid urbanization, extremely limited funding, pollution, COVID-19-related restrictions and inequalities, obesity, and excessive salt and alcohol intake. Immediate action is needed to address suboptimal hypertension care and related disparities on a global scale. We propose a Global Hypertension Care Taskforce including multiple stakeholders and societies to identify and implement actions in reducing inequities, addressing social, commercial, and environmental determinants, and strengthening health systems implement a well-designed customized quality-of-care improvement framework.

Virtual management of hypertension: lessons from the COVID-19 pandemic-International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension.

The coronavirus disease 2019 pandemic caused an unprecedented shift from in person care to delivering healthcare remotely. To limit infectious spread, patients and providers rapidly adopted distant evaluation with online or telephone-based diagnosis and management of hypertension. It is likely that virtual care of chronic diseases including hypertension will continue in some form into the future. The purpose of the International Society of Hypertension's (ISH) position paper is to provide practical guidance on the virtual management of hypertension to improve its diagnosis and blood pressure control based on the currently available evidence and international experts' opinion for nonpregnant adults. Virtual care represents the provision of healthcare services at a distance with communication conducted between healthcare providers, healthcare users and their circle of care. This statement provides consensus guidance on: selecting blood pressure monitoring devices, accurate home blood pressure assessments, delivering patient education virtually, health behavior modification, medication adjustment and long-term virtual monitoring. We further provide recommendations on modalities for the virtual assessment and management of hypertension across the spectrum of resource availability and patient ability.