Blood pressure targets in the very old: development of a tool in a geriatric day hospital.

PROBLEM ADDRESSED: Canadian hypertension guidelines do not address blood pressure (BP) targets in the very old (older than 85 years of age), making BP management in this group difficult. OBJECTIVE OF PROGRAM: To develop a BP target tool and implementation process in order to facilitate management of BP in the very old at the Bruyère Continuing Care Geriatric Day Hospital in Ottawa, Ont. PROGRAM DESCRIPTION: A BP target tool and implementation process were developed to target, monitor, and communicate BP goals within the care team, to the patient and family, and to other prescribers. An audit was conducted of the first 10 weeks of the tool's implementation and illustrated good use with areas for improvement noted. CONCLUSION: The development and use of a BP target tool increased prescriber consistency and confidence in managing BP in the very old. The tool filled a gap in the absence of guidelines specific to BP management in the very old. The BP target tool has implications for practice, as well as for the training of health care professionals involved in treating and monitoring BP in very old patients.

Improving care after hip fracture: the fracture? Think osteoporosis (FTOP) program.

BACKGROUND: Hip fractures are a common and serious consequence of osteoporosis, and hip fracture patients are at high risk for recurrence. Appropriate pharmacotherapy reduces this risk and is associated with reduced mortality after hip fracture, but a care gap exists for fracture prevention in these patients. This evaluation determined rates of osteoporosis treatment and bone mineral density (BMD) testing in hip fracture patients following discharge from a rehabilitation unit. METHODS: A prospective cohort study of hip fracture patients aged ≥ 50 on an inpatient rehabilitation unit in 2008 and 2011. Patients were seen by a nurse specialist, and encouraged to see their family physician for further assessment and treatment. Physicians were sent a letter indicating the need to follow up with their patient. Patients were contacted following discharge from hospital to determine treatment rates. RESULTS: Of 310 eligible hip fracture patients admitted to the rehabilitation unit in the years studied, 207 patients were reached post-discharge and provided data. Of patients who were not previously taking osteoporosis medication, 59% of patients from the 2008 cohort, and 42% of patients from the 2011 cohort had osteoporosis treatment initiated by six months following discharge. By 2 months following discharge, 46% of patients in the 2008 cohort had a new BMD performed or scheduled, while this was true for 14% of patients from the 2011 cohort. 35% of patients in 2011 had not seen their family physician by 2 months following discharge. CONCLUSIONS: Rates for osteoporosis treatment and BMD testing were higher than those reported in the literature for patients not enrolled in case manager programs. BMD testing declined from 2008 to 2011. Lower treatment rates may be due to concerns regarding reports of possible association between bisphosphonate use and atypical fractures. Improving rates of patient follow-up with family physicians will be important for increasing hip fracture treatment rates after discharge.

Working in interprofessional primary health care teams: what do pharmacists do?

BACKGROUND: Interprofessional teams are forming in primary health care. Little is known about how health care professional roles and routines develop in this environment. OBJECTIVES: This article describes the evolving routines of pharmacists working in new interprofessional teams, their perceptions of their roles, and perceptions of other providers toward the pharmacist role. METHODS: Ethnographic methods were used. Qualitative data derived from practice documents, field notes from practice activity and provider-patient interaction observations, and transcripts from interviews with patients and practice staff were analyzed in an exploratory manner using a constant comparative approach and immersion/crystallization. For this article, data pertaining to the role of pharmacists comprised a case study subanalysis. RESULTS: Two typologies emerged with some pharmacists found to be (1) physician oriented: responding to physician requests for drug information and other projects, and others found to be (2) working at multiple levels of interaction: providing patient-centered care, provider education/information, and initiating system-level interventions to improve drug therapy. CONCLUSIONS: Pharmacist routines and their own perception of their roles differed across interprofessional teams. Differences could be attributed to different educational background, philosophy of practice or characteristics of individual pharmacists, and also affected by leadership and communication within family health teams (FHTs). FHT leaders wanting to include a pharmacist to improve medication therapy should demonstrate leadership and vision by articulating needs and hiring a pharmacist with matching knowledge, skills, and qualities. A similar, generic approach may be useful to determine the need for and roles of any health care professional joining the team.

Assessing the potential adverse consequences of supplemental calcium on cardiovascular outcomes: should we change our approach to bone health?

OBJECTIVE: To assess cardiovascular risks associated with supplemental calcium use to assist clinicians with evidence-based recommendations for patients who have, or who are at risk for, osteoporosis or osteopenia. DATA SOURCES: Literature was accessed through December 2011 using MEDLINE, Cochrane Library, and International Pharmaceutical Abstracts using the terms calcium compounds and cardiovascular disease. In addition, reference citations from the publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: All English-language articles were evaluated. Randomized controlled trials, observational studies, and meta-analyses were included. DATA SYNTHESIS: While supplemental calcium and vitamin D have been demonstrated to improve bone mineral density and decrease the risk of fractures, there have been recent reports that calcium supplements may increase the risk for cardiovascular events. Nine clinical trials and/or meta-analyses were reviewed; 3 documented increases in cardiovascular risk associated with calcium supplements, and 6 did not. No studies were designed to assess cardiovascular outcomes as primary end points. Balancing the evidence from these analyses with the results of randomized controlled trials assessing the effect of calcium on fracture prevention suggests that the benefits of calcium outweigh the cardiovascular risk. CONCLUSIONS: At this time, there is no cause to change routine practice surrounding supplemental calcium use in patients who have, or are at risk for, osteoporosis or osteopenia.

Phase II study of erlotinib in recurrent or metastatic endometrial cancer: NCIC IND-148.

PURPOSE: Epidermal growth factor receptor (EGFR) overexpression is common in endometrial cancers and may have a major role in tumor growth and progression. Erlotinib is an orally active, selective inhibitor of EGFR tyrosine kinase activity. PATIENTS AND METHODS: A multinomial design two-stage phase II study was performed to evaluate single-agent activity of erlotinib in women with advanced endometrial cancer with recurrent or metastatic disease who were chemotherapy naïve and had received up to one line of prior hormonal therapy. Erlotinib was administered at daily dose of 150 mg. Archival tumor tissue was analyzed for EGFR expression by immunohistochemistry (IHC) and gene amplification by fluorescent in situ hybridization (FISH). Mutational status of EGFR was determined in responders. RESULTS: Thirty-two of 34 entered patients are assessable for response. Treatment was well tolerated and severe toxicity infrequent, with the only grade 4 toxicity being an elevation of transaminases (AST). There were four confirmed partial responses (PRs; 12.5%; 95% CI, 3.5% to 29%) lasting 2 to 36 months. Fifteen patients had stable disease (SD), with median duration of 3.7 months (range, 2 to 12 months). EGFR expression was analyzed in thirty patients; 19 were positive, nine were negative, and two were not assessable. Of the 19 patients who were EGFR positive, three had PR (16%), seven SD, and eight progressive disease, and one was not assessable. No mutations were identified in responders. FISH showed no correlation of response with gene amplification. CONCLUSION: Erlotinib is well tolerated with an overall objective response rate of 12.5%. Molecular analysis did not identify EGFR mutations in responders or correlation of response with gene amplification.

Transcriptional co-operativity between distant retinoic acid response elements in regulation of Cyp26A1 inducibility.

Cyp26A1 encodes an RA (retinoic acid)-catabolizing CYP (cytochrome P450) protein that plays a critical role in regulating RA distribution in vivo. Cyp26A1 expression is inducible by RA, and the locus has previously been shown to contain a RARE (RA response element), R1, within the minimal promoter [Loudig, Babichuk, White, Abu-Abed, Mueller and Petkovich (2000) Mol. Endocrinol. 14, 1483-1497]. In the present study, we report the identification of a second functional RARE (R2) located 2.0 kb upstream of the Cyp26A1 transcriptional start site. Constructs containing murine sequences encompassing both R1 and R2 showed that these elements work together to generate higher transcriptional activity upon treatment with RA than those containing R1 alone. Inclusion of R2 also dramatically enhanced the sensitivity of reporter constructs to RA, as even treatment with 10(-8) M RA resulted in a 5-fold induction of reporter activity. Mutational analysis identified R2 as the functional element responsible for the increased RA inducibility of promoter constructs. The element was shown to bind RARgamma (RA receptor gamma)/RXRalpha (retinoid X receptor alpha) heterodimers in vitro, and inclusion of nuclear receptors in transfections boosted the transcriptional response. A construct containing both R1 and R2 was used to generate a stable luciferase reporter cell line that can be used as a tool to identify factors regulating Cyp26A1 expression. The analysis of R1 and R2 has led to the proposal that the two elements work synergistically to provide a maximal response to RA and that R2 is an upstream enhancer.