Validity of Home Blood Pressure Devices Sold in Canada.

Background: Measurement of home blood pressure is an important tool for the management of hypertension. However, the validity of home devices is of concern. The Recommended Blood Pressure Devices Program of Hypertension Canada reviews and recommends blood pressure devices using international validation standards. We sought to determine the proportion of Hypertension Canada-recommended devices available for purchase in pharmacies and online. Methods: We visited 16 community pharmacies in the Edmonton area to record the blood pressure devices they sold. We also reviewed the 50 most popular devices from online retailers (Amazon, Walmart, Best Buy, and Canadian Tire). All devices were referenced against the Recommended Blood Pressure Device Program of Hypertension Canada (www.hypertension.ca/bpdevices) to determine if the models were recommended. Results: We reviewed 170 devices. Of those sold in pharmacies, 61 of 68 (89.7%) were Hypertension Canada-recommended devices, whereas online retailers had only 46 of 102 (45.1%) recommended devices; P < 0.001. Conclusions: Most blood pressure devices sold in pharmacies are Hypertension Canada recommended, in contrast to less than one-half from online retailers. The lack of validation of many home blood pressure devices could have important clinical implications, leading to over- or undertreatment of hypertension. Clinicians should advise patients on the importance of home blood pressure device validation and direct them to resources such as Hypertension Canada (https://hypertension.ca/public/recommended-devices) for guidance.

Contexte: La mesure de la pression artérielle au domicile est un outil important dans la prise en charge de l'hypertension. Or, il semble que les appareils utilisés à la maison à cette fin ne soient pas toujours des dispositifs validés. Dans le cadre de son Programme de recommandation d'appareils de mesure de la pression artérielle, Hypertension Canada analyse et recommande des tensiomètres selon des normes de validation internationales. Nous avons donc cherché à déterminer la proportion des tensiomètres recommandés par Hypertension Canada qu'il est possible d'acheter dans les pharmacies et en ligne. Méthodologie: Nous avons rendu visite à 16 pharmacies communautaires dans la région d'Edmonton pour recenser les tensiomètres qui y étaient vendus. Nous avons également analysé les 50 tensiomètres les plus vendus par des détaillants en ligne (Amazon, Walmart, Best Buy et Canadian Tire). Nous avons vérifié si chacun des modèles faisait partie de la liste des appareils recommandés par Hypertension Canada (www.hypertension.ca/bpdevices). Résultats: Nous avons passé en revue 170 appareils. Dans les pharmacies, 61 appareils sur 68 (89,7 %) étaient recommandés par Hypertension Canada, alors qu'en ligne, cette proportion n'était que de 46 sur 102 (45,1 %); p < 0,001. Conclusions: La plupart des tensiomètres vendus dans les pharmacies sont recommandés par Hypertension Canada, contrairement à moins de la moitié de ceux qui sont vendus en ligne. L'absence de validation pour de nombreux tensiomètres pourrait avoir d'importantes conséquences cliniques, menant à un traitement excessif ou insuffisant de l'hypertension. Les cliniciens doivent informer les patients de l'importance d'utiliser un tensiomètre validé à la maison et les orienter vers des ressources comme Hypertension Canada (https://hypertension.ca/public/recommended-devices) pour guider leur choix.

Pharmacological Treatment of Heart Failure: Recent Advances.

BACKGROUND: Heart failure is a clinical condition with high mortality and morbidity that occurs when the heart is unable to pump enough blood to meet the metabolic demands of the body. The pharmacological management of heart failure has been revolutionized over the past decade with novel treatments. OBJECTIVE: The aim of the review is to highlight the recent pharmacological advances in the management of heart failure. RESULTS: Sodium-glucose cotransporter-2 inhibitor (SGLT2i), iron carboxymaltose, finerenone, omecamtiv mecarbil, and vericiguat have been shown to reduce hospitalization for heart failure. However, only SGLT2i, vericiguat, and omecamtiv mecarbil have been shown to reduce cardiovascular death. Finerenone has been shown to reduce cardiovascular events and renal adverse outcomes in patients with diabetes and kidney disease. Currently, only SGLT2i has been studied in patients beyond the heart failure with reduced ejection fraction population. CONCLUSION: The current quadruple therapy in the treatment of heart failure has demonstrated a reduction in the hospitalization of patients and a decrease in mortality associated with the condition. Individualized heart failure therapy research have shown some benefit in select heart failure patients. Further research on novel therapies will help improve heart failure patient outcomes.

Sector-Based Regression Strategies to Reduce Refractive Error-Associated Glaucoma Diagnostic Bias When Using OCT and OCT Angiography.

Purpose: This cross-sectional study aimed to investigate the sectoral variance of optical coherence tomography (OCT) and OCT angiography (OCTA) glaucoma diagnostic parameters across eyes with varying degrees of refractive error. Methods: Healthy participants, including individuals with axial ametropia, enrolled in the Hong Kong FAMILY cohort were imaged using the Avanti/AngioVue OCT/OCTA system. The OCT and OCTA parameters obtained include peripapillary nerve fiber layer thickness (NFLT), peripapillary nerve fiber layer plexus capillary density (NFLP-CD), and macular ganglion cell complex thickness (GCCT). Sectoral measurements of NFLT, NFLP-CD, and GCCT were based on sectors and hemispheres. Results: A total of 1339 eyes from 791 participants were stratified based on spherical equivalent refraction: high myopia (<-6 D), low myopia (-6 D to -1 D), emmetropia (-1 D to 1 D), and hyperopia (>1 D). Multivariable broken stick regression models, accounting for age, sex, and signal strength, showed that all NFLT sectors except temporally, the inferior GCCT hemisphere, and half of the NFLP-CD sectors were more affected by ametropia-related covariates than the corresponding global parameters. As expected, the false-positive rates in those sectors were elevated. Finally, sector-specific axial length (AL) and spherical equivalent (SE) adjustments helped reduce the elevated false-positive rates. Conclusions: The effect of optical magnification is even more prominent among sectors than the global parameters. AL- and SE-based adjustments should be individualized to each sector to mitigate this magnification bias effectively. Translational Relevance: Identifying sectoral differences among diagnostic parameters and adopting these sector-based adjustments into commercial OCT systems will hopefully reduce false-positive rates related to refractive error.

Practical Pharmacological Treatment of Heart Failure: Does Ejection Fraction Matter Anymore?

Heart failure (HF) is a complex clinical syndrome involving structural and/or functional abnormalities of the heart. Heart failure is often classified based on left ventricular ejection fraction, which serves as a predictor of mortality. The majority of the data supporting disease-modifying pharmacological therapies are from patients with reduced ejection fraction (less than 40%). However, with the recent results from the sodium glucose cotransporter-2 inhibitor trials, there is renewed interest in identifying potential beneficial pharmacological therapies. This review focuses on and includes pharmacological HF therapies across the spectrum of ejection fraction, providing an overview of the novel trials. We also examined the effects of the treatments on mortality, hospitalization, functional status, and biomarker levels to further investigate the interplay between ejection fraction and HF.

A photovoice study on community pharmacists' roles and lived experiences during the COVID-19 pandemic.

BACKGROUND: Community pharmacists were the face of the health response to the unprecedented COVID-19 pandemic. Their pivotal role during the pandemic has been widely recognized, as they adapted to continue to provide a higher level of care to their patients. OBJECTIVE: The objective of this study was to gain a deeper understanding of frontline pharmacists' lived experiences of the COVID-19 pandemic and its impact on their roles. METHODS: Photovoice, a visual research method that uses participant-generated photographs to articulate their experiences, was used with semi-structured interviews to explore pharmacists' lived experiences. Frontline community pharmacists who provided direct patient care during the COVID-19 pandemic in Alberta, Canada were recruited. Participants were asked to provide 3-5 photos that reflected on how they see themselves as a pharmacist and/or represents what they do as a pharmacist. Data analysis incorporated content, thematic and visual analysis and was facilitated using NVivo software. A published conceptual framework model was used as the foundation of the analysis with care taken to include new concepts. Ethics approval was obtained from the University of Alberta health research ethics board. RESULTS: Interviews were conducted with 21 participants and they 71 photos. This study advanced the conceptual framework model presented in a scoping review, of what was made visible (pharmacists' information, public health, and medication management roles) and what was invisible but made visible by the pandemic (pharmacists' leadership roles). It was revealed through the reflective nature of this study the important leadership role pharmacists have in their communities. CONCLUSIONS: This study highlighted the work of community pharmacists responding to the COVID-19 pandemic through their information, public health, medication management, and leadership roles. Their experiences also made visible the cost their work had on them as they did more to adapt and continually respond as the pandemic evolved. Pharmacists recognized their role as leaders in their practice and communities.

SGLT2 Inhibitors: The Next Blockbuster Multifaceted Drug?

Sodium glucose cotransporter 2 inhibitor (SGLT2i) is a class of drugs that were originally intended for decreasing blood glucose in diabetes. However, recent trials have shown that there are other beneficial effects. Major clinical trials involving SGLT2i medications from 2015 to 2022 were reviewed using PUBMED search. Recent major SGLT2i landmark trials have demonstrated benefits for cardiovascular disease (reduce major adverse cardiovascular events (heart attack, stroke, cardiovascular death), hospitalization for heart failure, all-cause death), and renal disease (delay the onset of dialysis) regardless of diabetic status. The consistent cardiorenal benefits observed in major landmark trials have resulted in the rapid adoption of SGLT2i therapy not only in diabetes guidelines but also cardiovascular and renal guidelines.

OCTA biomarkers in adults aged 50 and above: a prospective and cross-sectional community-based study.

BACKGROUND/AIMS: To assess the normative values and parameters of optical coherence tomography angiography (OCTA) influencing the best corrected visual acuity (BCVA) in adults aged 50 and above. METHODS: This was a prospective cross-sectional study from an eye screening programme in Hong Kong for 4188 citizens aged 50 and above. Images were analysed using a validated quantification software calculating vessel density and capillary perfusion density (CPD), along with other OCTA parameters, such as the foveal avascular zone area (FAZ) and circularity. OCTA data was collected from May 2019 to December 2020, including a total of 4188 healthy eyes from 4188 subjects. RESULTS: Mean superficial vessel density (MSVD) was 14.48 ± 3.60 mm- 1, while the mean capillary perfusion density (MCPD) was 0.41 ± 0.06. Multivariate analysis revealed ageing (ß = 0.321, p < 0.001), being male (ß=-0.089, p < 0.001), having a high body mass index (BMI) (ß = 0.039, p = 0.006), high FAZ area and low FAZ circularity (ß = 0.039 and - 0.034, p = 0.01 and 0.024 respectively), low MSVD in the outer ring (ß=-0.513, p < 0.001), specifically in the nasal and temporal outer quadrants (ß = -0.226 and - 0.259, p < 0.001 for both), and low MCPD in the outer superior quadrant (ß= -0.123, p = 0.016) being independently associated with BCVA. CONCLUSION: High FAZ area and low FAZ circularity, low MSVD in the outer ring, specifically the nasal and temporal outer quadrants, and low MCPD in the outer superior quadrant can be used as biomarkers in predicting a low visual acuity in adults aged 50 and above.

Regression-Based Strategies to Reduce Refractive Error-Associated Glaucoma Diagnostic Bias When Using OCT and OCT Angiography.

Purpose: The purpose of this study was to correct refractive error-associated bias in optical coherence tomography (OCT) and OCT angiography (OCTA) glaucoma diagnostic parameters. Methods: OCT and OCTA imaging were obtained from participants in the Hong Kong FAMILY cohort. The Avanti/AngioVue OCT/OCTA system was used to measure the peripapillary nerve fiber layer thickness (NFLT), peripapillary nerve fiber layer plexus capillary density (NFLP-CD), macular ganglion cell complex thickness (GCCT), and macular superficial vascular complex vascular density (SVC-VD). Healthy eyes, including ones with axial ametropia, were enrolled for analysis. Results: A total of 1346 eyes from 792 participants were divided into 4 subgroups: high myopia (<-6D), low myopia (-6D to -1D), emmetropia (-1D to 1D), and hyperopia (>1D). After accounting for age, sex, and signal strength, multivariable regression showed strong dependence in most models for NFLT, GCCT, and NFLP-CD on axial eye length (AL), spherical equivalent (SE) refraction, and apparent optic disc diameter (DD). Optical analysis indicated that AL-related transverse optical magnification variations predominated over anatomic variations and were responsible for these trends. Compared to the emmetropic group, the false positive rates were significantly (Chi-square test P < 0.003) elevated in both myopia groups for NFLT, NFLP-CD, and GCCT. Regression-based adjustment of these diagnostic parameters with AL or SE significantly (McNemar test P < 0.03) reduced the elevated false positive rates. Conclusions: Myopic eyes are biased to have lower NFLT, GCCT, and NFLP-CD measurements. AL- and SE-based adjustments were effective in mitigating this bias. Translational Relevance: Adoption of these adjustments into commercial OCT systems may reduce false positive rates related to refractive error.

Novel Drugs for Diabetes Also Have Dramatic Benefits on Hard Outcomes of Heart and Kidney Disease.

BACKGROUND: Diabetes is a major risk factor for developing cardiovascular disease. Patients with both diabetes and cardiovascular disease have even higher mortality. The convergence of cardiology and diabetology therapy is an important step in treating patients and advancing research. RESULTS: Major landmark trials and meta-analyses involving Sodium Glucose Cotransporter 2 inhibitors have shown dramatic clinical cardiorenal benefits in patients both with and without type 2 diabetes. In type 2 diabetes patients, Glucagon-like peptide-1 receptor agonists have been shown to improve major cardiac outcomes. CONCLUSION: This hot topic of research and clinical use of glucose lowering drugs intersects the fields of cardiovascular, renal, and diabetic medicine. The numerous cardiorenal benefits have led to the rapid adoption in clinical guidelines of these glucose lowering drugs in patients with Type 2 diabetes, cardiovascular disease, or renal disease.

Incorporating Optical Coherence Tomography Macula Scans Enhances Cost-effectiveness of Fundus Photography-Based Screening for Diabetic Macular Edema.

OBJECTIVE: To compare four screening strategies for diabetic macular edema (DME). RESEARCH DESIGN AND METHODS: Patients attending diabetic retinopathy screening were recruited and received macular optical coherence tomography (OCT), in addition to visual acuity (VA) and fundus photography (FP) assessments, as part of the standard protocol. Two retina specialists provided the reference grading by independently assessing each subject's screened data for DME. The current standard protocol (strategy A) was compared for sensitivity, specificity, quality-adjusted life-year (QALY) gained, and incremental cost-effectiveness ratio (ICER) with three alternative candidate protocols using a simulation model with the same subjects. In strategy B, macular hemorrhage or microaneurysm on FP were removed as surrogate markers for possible DME. Strategy C used best-corrected instead of habitual/pinhole VA and added central subfield thickness (CST) >290 µm on OCT in suspected cases as a confirmation marker for possible DME. Strategy D used CST >290 µm OCT in all subjects as a surrogate marker for suspected DME. RESULTS: We recruited 2,277 subjects (mean age 62.80 ± 11.75 years, 43.7% male). The sensitivities and specificities were 40.95% and 86.60%, 22.86% and 95.63%, 32.38% and 100%, and 74.47% and 98.34% for strategies A, B, C, and D, respectively. The costs (in U.S. dollars) of each QALY gained for strategies A, B, C, and D were $7,447.50, $8,428.70, $5,992.30, and $4,113.50, respectively. CONCLUSIONS: The high false-positive rate of the current protocol generates unnecessary referrals, which are inconvenient for patients and costly for society. Incorporating universal OCT for screening DME can reduce false-positive results by eightfold, while improving sensitivity and long-term cost-effectiveness.

Does the COVID-19 Pandemic Spell the End for the Direct Ophthalmoscope?

Despite advances in ophthalmic diagnostics, the direct ophthalmoscope remains a key clinical skill taught to medical students and is the tool of choice for retina examination among non-ophthalmic physicians. However, in recent years viable alternatives have become available. The coronavirus disease 2019 (COVID-19) pandemic has forced a major re-thinking in medical education worldwide. In this commentary, we examined the current merits and limitations of the direct ophthalmoscope in both the clinical sense and in the context of infection control. Furthermore, we compared the direct ophthalmoscope with alternatives, including commercially available portable non-mydriatic fundus cameras, that would allow a change in focus during ophthalmic teaching. We concluded that the latter will better prepare our medical students for the age of telemedicine and deep-learning systems. While the COVID-19 pandemic will not be the sole reason for the 'death' of the direct ophthalmoscope, the global situation will inevitably serve to expedite long overdue changes in our teaching of ophthalmic skills to non-ophthalmic physicians.

Prevalence and Causes of Visual Impairment and Blindness among Adult Chinese in Hong Kong - The Hong Kong Eye Study.

PURPOSE: To investigate the prevalence, associations, and causes of visual impairment and blindness in the adult population of Hong Kong. METHODS: This cross-sectional population-based study included 2018 (870, 43% male) randomly selected adults with a mean age 52 ± 16 years (range 18-90 years) in Hong Kong. Each participant underwent comprehensive ophthalmic examinations. Presenting visual acuity (PVA) and best-corrected visual acuity (BCVA) of each eye was recorded. Prevalence of visual impairment and blindness was calculated using both World Health Organization (WHO) and United States (US) definitions, based on BCVA and PVA. RESULTS: Visual acuity measurements were available for 1952 (96.8%) participants. The prevalence of visual impairment, based on BCVA value, using WHO and US definition, was 1.0 ± 0.1% and 2.7 ± 0.4%, respectively. The prevalence of visual impairment, based on PVA value, was 5.1 ± 0.5% and 14.0 ± 0.8%, using WHO and US definition, respectively. Multivariate analysis demonstrated the presence of visual impairment (PVA, WHO definition) increased significantly with older age (odds ratio 1.039, P < .001) and thinner central cornea thickness (odds ratio 0.994, P = .014), but not significantly associated with other socioeconomic, systemic or ocular parameters after adjusting for age and central corneal thickness. Under-correction of refractive error was the most common reason for presenting visual impairment. Causes of impaired BCVA were cataract (37%), age-related macular degeneration (26%), diabetic macular edema (11%), glaucoma (11%), epiretinal membrane (5%), and unknown (11%). CONCLUSION: The prevalence of visual impairment in Hong Kong increased significantly with older age and thinner central corneal thickness. The major causes for impairment were under-correction of refractive error, cataract, and age-related macular degeneration.

A Serial Cross-Sectional Analysis of the Prevalence, Risk Factors and Geographic Variations of Reduced Visual Acuity in Primary and Secondary Students from 2000 to 2017 in Hong Kong.

Background: We would like to investigate the prevalence trend, potential risk factors and geographic features of reduced visual acuity (VA) in primary and secondary schoolchildren of Hong Kong. Methods: This was a serial cross-sectional study using historical data of schoolchildren aged 6 to 15 years from the annual health checks conducted at Student Health Service Centers across Hong Kong, for the school years of 2000/2001 to 2016/2017. Results: The prevalence of reduced VA increased from 49.23% (95% CI, 48.99-49.47) in 2000/2001 to 54.34% (95% CI, 54.10-54.58) in 2011/2012 but decreased to 51.42% (95% CI, 51.17-51.66) in 2016/2017. Girls were less susceptible than boys at age 6-7 (and in grade primary 1-2), but more susceptible at older ages. The prevalence in junior grades increased while the risk effect of grade reduced over the past 17 years. Geographic variation on the risk for reduced VA existed and spatial autocorrelation was positive. The difference in prevalence of reduced VA between Hong Kong and mainland China has decreased in recent years. Cross-border students living in mainland China were associated with a lower risk for reduced VA. Conclusions: Further study was proposed to investigate the environmental association between students living in and outside Hong Kong with the prevalence of reduced VA. Multi-level research should also be conducted to investigate the influence of compositional and contextual factors on the prevalence of reduced VA.

Macular Vessel Density Measured With Optical Coherence Tomography Angiography and Its Associations in a Large Population-Based Study.

Purpose: We investigate macular perfusion and the systemic and ocular associations in a population-based setting. Methods: In this cross-sectional study, 2018 adults residing in Hong Kong underwent detailed ophthalmic examinations after consenting to participate. Macular perfusion was measured with optical coherence tomography angiography (OCTA) using the split-spectrum amplitude decorrelation angiography algorithm. The parafoveal flow index and vessel area density were quantified using automated custom-built software. Results: Of the 2018 participants, the OCTA measurements were available for 1940, and 1631 (84.1%) had good quality scans. The right eyes of these 1631 participants (43.1% men) were included for final analysis. Mean age was 49.8 years (range, 18-92 years). Mean global macular vessel density was 47.3% and 55.1% for the superficial and deep retinal layers, respectively. In multivariate analysis, lower superficial vessel density remained significantly associated with lower signal strength index (SSI; P < 0.001, standardized ß = 0.607) and male sex (P < 0.001, ß = 0.162), and borderline associated with older age (P = 0.09, ß = -0.045) and longer axial length (AL; P = 0.09, ß = -0.037), while lower deep layer vessel density was significantly associated with lower SSI (P < 0.001, standardized ß = 0.667), longer AL (P < 0.001, ß = -0.097), and higher creatinine (P < 0.001, ß = -0.072). Conclusions: This large population-based study provided normative OCTA data of macular vessel density and demonstrated that a lower superficial retinal vessel density was significantly associated with lower SSI and male sex, while a lower deep layer retinal vessel density was significantly associated with lower SSI, longer AL, and higher level of creatinine. These associations must be considered when interpreting clinical quantitative OCTA data.