A comparison between different patient groups for diabetes management during phases of the COVID-19 pandemic: a retrospective cohort study in Ontario, Canada.

BACKGROUND: With the onset of the COVID-19 pandemic and the large uptake in virtual care in primary care in Canada, the care of patients with type 2 diabetes has been greatly affected. This includes decreased in-person visits, laboratory testing and in-person assessments such as blood pressure (BP). No studies have investigated if these changes persisted with pandemic progression, and it is unclear if shifts impacted patient groups uniformly. The purpose of this paper was to examine changes in diabetes care pre, early, and later pandemic across different patient groups. METHODS: A repeated cross-sectional design with an open cohort was used to investigate diabetes care in adults with type 2 diabetes for a 6-month interval from March 14 to September 13 over three consecutive years: 2019 (pre-pandemic period), 2020 (early pandemic period), and 2021 (later pandemic period). Data for this study were abstracted from the University of Toronto Practice-Based Research Network (UTOPIAN) Data Safe Haven, a primary care electronic medical records database in Ontario, Canada. Changes in diabetes care, which included primary care total visits, in-person visits, hemoglobin A1c (HbA1c) testing, and BP measurements were evaluated across the phases of the pandemic. Difference in diabetes care across patient groups, including age, sex, income quintile, prior HbA1c levels, and prior BP levels, were assessed. RESULTS: A total of 39,401 adults with type 2 diabetes were included in the study. Compared to the 6-month pre-pandemic period, having any in-person visits decreased significantly early pandemic (OR = 0.079 (0.076-0.082)), with a partial recovery later pandemic (OR = 0.162 (95% CI: 0.157-0.169). Compared to the pre-pandemic period, there was a significant decrease early pandemic for total visits (OR = 0.486 (95% CI: 0.470-0.503)), HbA1c testing (OR = 0.401 (95% CI: 0.389-0.413)), and BP measurement (OR = 0.121 (95% CI: 0.116-0.125)), with partial recovery later pandemic. CONCLUSIONS: All measures of diabetes care were substantially decreased early pandemic, with a partial recovery later pandemic across all patient groups. With the increase in virtual care due to the COVID-19 pandemic, diabetes care has been negatively impacted over 1-year after pandemic onset.

Benefits and risks of antihypertensive medications in the elderly.

Hypertension is highly prevalent in older age and accounts for a large proportion of cardiovascular (CV) morbidity and mortality worldwide. Isolated systolic hypertension is more common in the elderly than younger adults and associated with poor outcomes such as cerebrovascular disease and acute coronary events. International guidelines are inconsistent in providing recommendations on optimal blood pressure targets in hypertensive elderly patients as a result of the limited evidence in this population. Evidence from clinical trials supports the use of antihypertensive drugs in hypertensive elderly patients due to benefits in reducing CV disease and mortality. However, elderly participants in these trials may not be typical of elderly patients seen in routine clinical practice, and the potential risks associated with use of antihypertensive drugs in the elderly are not as well studied as younger participants. Therefore, the purpose of this review was to provide a comprehensive summary of the benefits and risks of the use of antihypertensive drugs in elderly patients (aged ≥65 years), highlighting landmark clinical trials and observational studies. We will focus on specific outcomes relating to the benefits and risks of these medications in hypertensive elderly patients, such as CV disease, cognitive decline, dementia, orthostatic hypotension, falls, fractures, cancer and diabetes, in order to provide an update of the most relevant and current evidence to help inform clinical decision-making.

The medial column Synthes Midfoot Fusion Bolt is associated with unacceptable rates of failure in corrective fusion for Charcot deformity: Results from a consecutive case series.

Charcot neuro-osteoarthropathy (CN) of the midfoot presents a major reconstructive challenge for the foot and ankle surgeon. The Synthes 6 mm Midfoot Fusion Bolt is both designed and recommended for patients who have a deformity of the medial column of the foot due to CN. We present the results from the first nine patients (ten feet) on which we attempted to perform fusion of the medial column using this bolt. Six feet had concurrent hindfoot fusion using a retrograde nail. Satisfactory correction of deformity of the medial column was achieved in all patients. The mean correction of calcaneal pitch was from 6° (-15° to +18°) pre-operatively to 16° (7° to 23°) post-operatively; the mean Meary angle from 26° (3° to 46°) to 1° (1° to 2°); and the mean talometatarsal angle on dorsoplantar radiographs from 27° (1° to 48°) to 1° (1° to 3°). However, in all but two feet, at least one joint failed to fuse. The bolt migrated in six feet, all of which showed progressive radiographic osteolysis, which was considered to indicate loosening. Four of these feet have undergone a revision procedure, with good radiological evidence of fusion. The medial column bolt provided satisfactory correction of the deformity but failed to provide adequate fixation for fusion in CN deformities in the foot. In its present form, we cannot recommend the routine use of this bolt.

The risk of falls on initiation of antihypertensive drugs in the elderly.

SUMMARY: Antihypertensive drugs are associated with an immediate increased falls risk in elderly patients which was significant during the first 14 days after receiving a thiazide diuretic, angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, calcium channel blocker, or beta-adrenergic blocker. Fall prevention strategies during this period may prevent fall-related injuries. INTRODUCTION: The purpose of this study is to evaluate if initiation of the common antihypertensive drugs is associated with the occurrence of falls. METHODS: This population-based self-controlled case series study used healthcare administrative databases to identify new users of antihypertensive drugs in the elderly aged 66 and older living in Ontario, Canada who suffered a fall from April 1, 2000 to March 31, 2009. The risk period was the first 45 days following antihypertensive therapy initiation, further subdivided into 0-14 and 15-44 days with control periods before and after treatment in a 450-day observation period. We calculated the relative incidence (incidence rate ratio, IRR), defined as the rate of falls in the risk period compared to falls rate in the control periods. RESULTS: Of the 543,572 new users of antihypertensive drugs among community-dwelling elderly, 8,893 experienced an injurious fall that required hospital care during the observation period. New users had a 69 % increased risk of having an injurious fall during the first 45 days following antihypertensive treatment (IRR = 1.69; 95 % CI, 1.57-1.81). This finding was consistent for thiazide diuretics, angiotensin-converting enzyme inhibitors, calcium channel blockers, and beta-adrenergic blockers but not angiotensin II receptor antagonists. There was also an increased falls risk during the first 14 days of antihypertensive drug initiation (IRR = 1.94; 95 % CI, 1.75-2.16), which was consistent for all antihypertensive drug classes. CONCLUSIONS: This study suggests that initiation of antihypertensive drugs is a risk factor for falls in the elderly. Fall prevention strategies during this period may reduce injuries.

Urinary growth hormone: a screening test for growth hormone sufficiency.

OBJECTIVES: The majority of short statured children referred for serum GH testing prove to be GH sufficient. The purpose of our study was to evaluate urinary growth hormone (uGH) as a screening test for GH sufficiency. PATIENTS: We studied (i) short statured children previously diagnosed as GH sufficient (n = 44) or GH deficient (n = 41) (peak serum GH > or = 8 micrograms/l or < 8 micrograms/l, respectively); (ii) short children undergoing serum GH stimulation tests (n = 23, test group); (iii) normal statured children (n = 45, control group). DESIGN: Three separate overnight urine collections were obtained in all groups. GH injections in GH deficient subjects were discontinued 4 days prior to urine collection. MEASUREMENTS: uGH concentrations were measured using a chemiluminescence immunoassay. Overnight uGH was expressed in several ways (overnight excretion and overnight excretion corrected for body surface area, time and creatinine). Receiver operator curves (ROC) were constructed from the data obtained in the GH sufficient and deficient subjects. Sensitivity and specificity were then determined for various urinary cut-offs. These cutoffs were validated in turn in the test group by comparison of the predicted with the observed GH status. RESULTS: The GH deficient group had the lowest GH output with respect to overnight uGH, overnight uGH/m2, overnight uGH/h and overnight uGH/creatinine when compared with the GH sufficient and control groups (P = 0.0001). Overnight uGH/m2 data gave the greatest area under the ROC curve. At 100% specificity (no GH deficient subjects), it had the highest sensitivity, 63.6% (49.2-78.0% CI) at a cut-off of 2.3 ng/m2 (63.6% of GH sufficient subjects had uGH levels > 2.3 ng/m2). When this and other cut-offs were applied to the test group, we found consistency between the observed and predicted numbers of GH sufficient and deficient subjects. CONCLUSIONS: We conclude that urinary GH is a useful test for the diagnosis of GH sufficiency as defined by serum criteria and can be used to reduce significantly the number of serum stimulation tests.

Physiological doses of [Ile5]- and [Val5]-Angiotensin II fail to increase plasma catecholamines at the peak pressor response in rats.

Pressor responses to [Ile5]-Angiotensin II and [Val5]-Angiotensin II were measured following single intravenous doses of 0.0075, 0.075, 0.375, 0.75 and 7.5 micrograms/kg b.w. in anesthetised rats. [Val5]-Angiotensin II was significantly (10 per cent) more potent than [Ile5]-angiotensin II when log dose was plotted against the increase in carotid arterial pressure. Doses of 0.075 microgram/kg b.w. or more of each of the two peptides gave a full pressor response within 30 seconds. However, only at the highest and, probably, nonphysiological dose of [Ile5]-Angiotensin II (7.5 micrograms/kg b.w.) was there a significant increase in noradrenaline and adrenaline concentrations measured using a radioenzymatic assay. [Val5]-Angiotensin II was more potent than [Ile5]-Angiotensin II insofar as plasma noradrenaline increased significantly (p < 0.05) following doses of 0.75 and 7.5 micrograms/kg b.w.; adrenaline at the higher dose only. Plasma dopamine was unresponsive to both peptides.

Angiotensin II-mediated catecholamine release during the pressor response in rats.

Angiotensin II (ANG II)-mediated catecholamine release and its possible contribution to the pressor response was assessed in baroreceptor-denervated rats. Neonatal male Sprague-Dawley rats were injected with the sympatholytic drug, guanethidine monosulphate (50 mg/kg s.c., 6 days/week) for 40 days. Plasma catecholamine concentrations were measured using a 3H-radioenzymatic assay as follows: (a) before and 30 s after the injection of saline or ANG II (79.3 pmol/kg i.v.), at the peak of the pressor response, then 50 s and 80 s thereafter, in guanethidine-treated (GUAN) and saline-injected (SHAM) rats, and (b) before and after adrenalectomy (ADX), following the same time-sequence for ANG II as in (a). Peak pressor responses to graded doses of ANG II (6.6, 26.4, 53.0 and 79.3 pmol/kg i.v.) were measured in GUAN+ADX and ADX rats. Destruction of peripheral sympathetic nerves was confirmed by measurements of plasma noradrenaline (NA), adrenaline (AD) and dopamine (DA) concentrations and by changes in pressor responses and heart rates following i.v. doses of tyramine. ANG II induced significantly (P < 0.05) greater pressor responses in GUAN+ADX rats than in ADX rats, especially after the 53.0 and 79.3 pmol/kg doses. Plasma AD concentrations increased within seconds after the pressor response to ANG II in both GUAN and SHAM rats but there was no change in plasma NA or DA concentrations (P < 0.05). ANG-II-mediated AD release from the adrenal medulla may contribute to the overall pressor action of the peptide. The vasculature became more sensitive to ANG II at a time when NA and DA depletion occurred following sympathectomy and/or adrenalectomy. This heightened sensitivity to ANG II was not due to a decrease in circulating ANG II in sympathectomized rats because even though plasma renin activity fell from 6.54 +/- 0.52 to 3.77 +/- 0.26 ng ANG I/ml per h it remained within the normal range.