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.

Home Blood Pressure Telemonitoring Technology for Patients With Asymptomatic Elevated Blood Pressure Discharged From the Emergency Department: Pilot Study.

BACKGROUND: Hypertension affects 1 in 5 Canadians and is the leading cause of morbidity and mortality globally. Hypertension control is declining due to multiple factors including lack of access to primary care. Consequently, patients with hypertension frequently visit the emergency department (ED) due to high blood pressure (BP). Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring Blood Pressure is a pilot project that implements and evaluates a comprehensive home blood pressure telemonitoring (HBPT) and physician case management protocol designed as a postdischarge management strategy to support patients with asymptomatic elevated BP as they transition from the ED to home. OBJECTIVE: Our objective was to conduct a feasibility study of an HBPT program for patients with asymptomatic elevated BP discharged from the ED. METHODS: Patients discharged from an urban, tertiary care hospital ED with asymptomatic elevated BP were recruited in Vancouver, British Columbia, Canada, and provided with HBPT technology for 3 months of monitoring post discharge and referred to specialist hypertension clinics. Participants monitored their BP twice in the morning and evenings and tele-transmitted readings via Bluetooth Sensor each day using an app. A monitoring clinician received these data and monitored the patient's condition daily and adjusted antihypertensive medications. Feasibility outcomes included eligibility, recruitment, adherence to monitoring, and retention rates. Secondary outcomes included proportion of those who were defined as having hypertension post-ED visits, changes in mean BP, overall BP control, medication adherence, changes to antihypertensive medications, quality of life, and end user experience at 3 months. RESULTS: A total of 46 multiethnic patients (mean age 63, SD 17 years, 69%, n=32 women) found to have severe hypertension (mean 191, SD 23/mean 100, SD 14 mm Hg) in the ED were recruited, initiated on HBPT with hypertension specialist physician referral and followed up for 3 months. Eligibility and recruitment rates were 40% (56/139) and 88% (49/56), respectively. The proportion of participants that completed ≥80% of home BP measurements at 1 and 3 months were 67% (31/46) and 41% (19/46), respectively. The proportion of individuals who achieved home systolic BP and diastolic BP control at 3 months was 71.4% (30/42) and 85.7% (36/42) respectively. Mean home systolic and diastolic BP improved by -13/-5 mm Hg after initiation of HBPT to the end of the study. Patients were prescribed 1 additional antihypertensive medication. No differences in medication adherence from enrollment to 3 months were noted. Most patients (76%, 25/33) were highly satisfied with the HBPT program and 76% (25/33) found digital health tools easy to use. CONCLUSIONS: HBPT intervention is a feasible postdischarge management strategy and can be beneficial in supporting patients with asymptomatic elevated BP from the ED. A randomized trial is underway to evaluate the efficacy of this intervention on BP control.

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.

Effect of an Exercise and Nutrition Program on Quality of Life in Patients With Atrial Fibrillation: The Atrial Fibrillation Lifestyle Project (ALP).

Background: Studies of separate exercise and weight loss interventions have reported improvements in quality of life (QoL) or reduction in atrial fibrillation (AF) burden. We investigated the impact of a structured exercise, nutrition, and risk-factor-modification program on QoL and AF burden. Methods: In this trial, 81 successive patients with body mass index > 27 kg/m2 and nonpermanent AF were randomized to an intervention (n = 41) or control group (n = 40). The intervention consisted of cardiovascular risk management and a 6-month nutrition and exercise program, followed by a 6-month maintenance program. All participants received usual AF care. The primary end-point was QoL at 6 and 12 months. Results: At 6 months, we observed improved QoL among patients in the intervention group, relative to that among control-group patients (intervention (I) n = 34, control (C) n = 38) in the 36-item Short Form Survey Instrument scores on the subscales of vitality (I: 13.2 ± 20.4; C: 1.0 ± 14.9, P < 0.001), social functioning (I: 14.7 ± 24.1; C: 2.4 ± 21.2, P = 0.018), emotional well-being (I: 5.5 ± 14.1 ; C: -1.0 ± 13.3, P = 0.017), and general health perceptions (I: 8.1 ± 12.3; C: 2.7 ± 13.3, P = 0.009). At the 6-month follow-up, improvement in the scores on the subscales of vitality (P = 0.021) and emotional well-being (P = 0.036) remained significant. The burden of AF as measured by Holter monitor and Toronto AF symptom score was not significantly changed. Conclusions: A structured exercise and nutrition program resulted in significant sustained improvements in QoL, without reduction in AF burden. This type of program may provide an additional treatment for people with impaired QoL due to AF.

Introduction: Des études sur des interventions distinctes d'exercice et de perte de poids ont montré des améliorations de la qualité de vie (QdV) ou la réduction du fardeau de la fibrillation auriculaire (FA). Nous avons examiné les répercussions d'un programme structuré d'exercice, d'alimentation et de modification des facteurs de risque sur la QdV et le fardeau de la FA. Méthodes: Dans le présent essai, nous avons réparti de façon aléatoire 81 patients successifs dont l'indice de masse corporelle était > 27 kg/m2 et la FA était non permanente à une intervention (n = 41) ou à un groupe témoin (n = 40). L'intervention a consisté en la prise en charge du risque cardiovasculaire et un programme d'alimentation et d'exercice de six mois, et a été suivie d'un programme de maintien de six mois. Tous les participants ont reçu les soins usuels relatifs à la FA. Le principal critère d'évaluation était la QdV après six mois et 12 mois. Résultats: Après six mois, nous avons observé la QdV chez les patients du groupe d'intervention par rapport à celle des patients du groupe témoin (intervention [I] n = 34, témoin [C] n = 38) selon les scores de la version abrégée du questionnaire de 36 items aux sous-échelles sur la vitalité (I : 13,2 ± 20,4; C : 1,0 ± 14,9, P < 0,001), le fonctionnement social (I : 14,7 ± 24,1; C : 2,4 ± 21,2, P = 0,018), le bien-être émotionnel (I : 5,5 ± 14,1 ; C : ­1,0 ± 13,3, P = 0,017), et les perceptions de la santé générale (I : 8,1 ± 12,3; C : 2,7 ± 13,3, P = 0,009). Au suivi après six mois, l'amélioration des scores aux sous-échelles sur la vitalité (P = 0,021) et le bien-être émotionnel (P = 0,036) demeurait significative. Le fardeau de la FA selon le moniteur Holter et le score selon la Toronto Atrial Fibrillation Severity Scale n'avait pas changé de façon significative. Conclusions: Un programme structuré d'exercice et d'alimentation a donné lieu à des améliorations significatives et soutenues de la QdV, sans réduire le fardeau de la FA. Ce type de programme peut constituer un traitement supplémentaire aux personnes qui connaissent une diminution de leur QdV en raison de la FA.

Hypertension Canada's 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children.

Hypertension Canada's 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.

Early Warning Scores to Predict Noncritical Events Overnight in Hospitalized Medical Patients: A Prospective Case Cohort Study.

BACKGROUND: Physicians are often called to evaluate patients overnight with varying levels of clinical deterioration. Early warning scores predict critical clinical deterioration in patients; however, it is unknown whether they are able to reliably predict which patients will need to be seen overnight and whether these patients will require further resource use. METHODS: A prospective case cohort study of 522 patient nights in a single tertiary care hospital in Vancouver, British Columbia, Canada, was conducted to assess the ability of Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS) to predict patients who will need to be seen overnight by physicians and will require other healthcare resources. Prediction ability was assessed using area under the receiver operating characteristic curve and logistic regression models. RESULTS: The MEWS and NEWS both significantly predicted which patients needed to be seen overnight, and area under the receiver operating characteristic curves (95% confidence interval) for MEWS and NEWS were 0.72 (0.66-0.78) and 0.69 (0.63-0.76), respectively. Odds ratios (95% confidence interval) for MEWS and NEWS predicting need to be seen overnight were 1.52 (1.34-1.73) and 1.22 (1.14-1.31), respectively. CONCLUSIONS: Both MEWS and NEWS have fair ability to predict patients who will need to be seen overnight. This may be useful for improving handover and resource allocation for overnight care.

Structured patient handoff on an internal medicine ward: A cluster randomized control trial.

BACKGROUND: The effect of a multi-faceted handoff strategy in a high volume internal medicine inpatient setting on process and patient outcomes has not been clearly established. We set out to determine if a multi-faceted handoff intervention consisting of education, standardized handoff procedures, including fixed time and location for face-to-face handoff would result in improved rates of handoff compared with usual practice. We also evaluated resident satisfaction, health resource utilization and clinical outcomes. METHODS: This was a cluster randomized controlled trial in a large academic tertiary care center with 18 inpatient internal medicine ward teams from January-April 2013. We randomized nine inpatient teams to an intervention where they received an education session standardizing who and how to handoff patients, with practice and feedback from facilitators. The control group of 9 teams continued usual non-standardized handoffs. The primary process outcome was the rate of patients handed over per 1000 patient nights. Other process outcomes included perceptions of inadequate handoff by overnight physicians, resource utilization overnight and hospital length of stay. Clinical outcomes included medical errors, frequency of patients requiring higher level of care overnight, and in-hospital mortality. RESULTS: The intervention group demonstrated a significant increase in the rate of patients handed over to the overnight physician (62.90/1000 person-nights vs. 46.86/1000 person-nights, p = 0.002). There was no significant difference in other process outcomes except resource utilization was increased in the intervention group (26.35/1000 person-days vs. 17.57/1000 person-days, p-value = 0.01). There was no significant difference between groups in medical errors (4.8% vs. 4.1%), need for higher level of care or in hospital mortality. Limitations include a dependence of accurate record keeping by the overnight physician, the possibility of cross-contamination in the handoff process, analysis at the cluster level and an overall low number of clinical events. CONCLUSIONS: Implementation of a multi-faceted resident handoff intervention did not result in a significant improvement in patient safety although did improve number of patients handed off. Novel methods to improve handoff need to be explored. TRIAL REGISTRATION: Registered at ClinicalTrials.gov: NCT01796756.

Who to handover: a case-control study of a novel scoring system to prioritise handover of internal medicine inpatients.

BACKGROUND: Handover of patients between care providers is a critical event in patient care. There is, however, little evidence to guide the handover process, including determining which patients to handover. AIM: Compare the ability of gestalt-based handover with two structured scores, the modified early warning score (MEWS) and our novel iHAND clinical decision support system, to predict which patients will be assessed by a physician overnight. METHODS: This case-control study included 90 inpatients, comprising 32 patients assessed overnight (cases) and 58 patients not assessed overnight (controls) at a teaching hospital in British Columbia, Canada (May 2012). Gestalt, MEWS and iHAND scores were analysed against patients seen overnight using logistic regression and receiver-operating characteristic (ROC) curves. RESULTS: Neither current gestalt-based handover practice (odds ratio (OR) 1.50, 95% CI 0.89 to 3.83) nor MEWS (OR 0.96, 95% CI 0.75 to 1.24, area under the ROC curve (AUC) 0.61, 95% CI 0.49 to 0.73) were significantly associated with need to be seen overnight. The iHAND score was associated with need to be seen (OR 1.93, 95% CI 1.24 to 3.02, AUC 0.70, 95% CI 0.60 to 0.81). CONCLUSIONS: The iHAND score had moderate ability to predict which patients required assessment overnight, while MEWS score and current gestalt approach correlated poorly, suggesting the iHAND score may help prioritisation of patients likely to be seen overnight for handover.

Origins and functional diversification of salinity-responsive Na(+) , K(+) ATPase α1 paralogs in salmonids.

The Salmoniform whole-genome duplication is hypothesized to have facilitated the evolution of anadromy, but little is known about the contribution of paralogs from this event to the physiological performance traits required for anadromy, such as salinity tolerance. Here, we determined when two candidate, salinity-responsive paralogs of the Na(+) , K(+) ATPase α subunit (α1a and α1b) evolved and studied their evolutionary trajectories and tissue-specific expression patterns. We found that these paralogs arose during a small-scale duplication event prior to the Salmoniform, but after the teleost, whole-genome duplication. The 'freshwater paralog' (α1a) is primarily expressed in the gills of Salmoniformes and an unduplicated freshwater sister species (Esox lucius) and experienced positive selection in the freshwater ancestor of Salmoniformes and Esociformes. Contrary to our predictions, the 'saltwater paralog' (α1b), which is more widely expressed than α1a, did not experience positive selection during the evolution of anadromy in the Coregoninae and Salmonine. To determine whether parallel mutations in Na(+) , K(+) ATPase α1 may contribute to salinity tolerance in other fishes, we studied independently evolved salinity-responsive Na(+) , K(+) ATPase α1 paralogs in Anabas testudineus and Oreochromis mossambicus. We found that a quarter of the mutations occurring between salmonid α1a and α1b in functionally important sites also evolved in parallel in at least one of these species. Together, these data argue that paralogs contributing to salinity tolerance evolved prior to the Salmoniform whole-genome duplication and that strong selection and/or functional constraints have led to parallel evolution in salinity-responsive Na(+) , K(+) ATPase α1 paralogs in fishes.

Conservation genomics of Atlantic salmon: variation in gene expression between and within regions of the Bay of Fundy.

Due to difficulties in identifying important within-species biodiversity for effective species management and conservation, the use of multiple complementary sources of information is required to identify and assess the designation of conservation units based on the degree of variation among populations within a species. In this study, we combined estimates of microsatellite and transcriptomic variation to assess the population structure and potential for adaptive variation of threatened Atlantic salmon, Salmo salar, among rivers in the Bay of Fundy. In general, population structure identified by genetic differentiation was consistent with the patterns of variation in gene expression, although there was not a strong correlation between neutral genetic variation and variation in gene expression. Both data sets provided clear indication of strong regional differentiation between rivers located within the inner Bay of Fundy relative to rivers located within the outer Bay of Fundy or the Southern Upland region, and there was also support for more refined population structure. Both data sets indicated that Atlantic salmon populations from the inner and outer Bay of Fundy reflect unique genetic lineages, with some evidence of population differentiation between regions of the inner Bay of Fundy, and between individual rivers within a region. Consistency of the microarray data across 2 years helped to validate the use of this technique as a useful tool in assessment of variation among wild populations for species conservation.