Clinical Outcomes with First-Line Chemotherapy in a Large Retrospective Study of Patients with Metastatic Pancreatic Cancer Treated in a US Community Oncology Setting.

BACKGROUND: The combination chemotherapy regimens of nab-paclitaxel plus gemcitabine (nab-p + G) and FOLFIRINOX (FFX) have each demonstrated improved survival compared with gemcitabine monotherapy in clinical trials for metastatic pancreatic cancer; however, limited comparative data exist. OBJECTIVE: The objective of this study was to compare patient characteristics and clinical outcomes including time to treatment failure and overall survival in patients with metastatic pancreatic cancer receiving first-line chemotherapy in the community. METHODS: We conducted a retrospective, multi-site, observational cohort study of patients with metastatic pancreatic cancer receiving first-line nab-p + G, FFX, or gemcitabine monotherapy between April 2013 and October 2015, using data from the iKnowMed electronic health record database. Patients on clinical trials or with other cancer diagnoses were excluded. Time to treatment failure and overall survival were assessed by Kaplan-Meier methods. RESULTS: Four hundred and eighty-six patients met selection criteria, 255 nab-p + G, 159 FFX, and 72 gemcitabine patients. Median age was 61, 68, and 73 years for FFX, nab-p + G, and gemcitabine patients, respectively (p < 0.01 for nab-p + G vs. FFX). Eastern Cooperative Oncology Group performance status of 0-1 was 91% for FFX, 77% for nab-p + G, and 68% for gemcitabine patients (p < 0.01 for nab-p + G vs. FFX). For the nab-p + G vs. FFX cohorts, respectively, time to treatment failure was 3.7 vs. 4.3 months (log-rank p = 0.25); and OS was 9.8 vs. 11.4 months (log-rank p = 0.38). Among patients with Eastern Cooperative Oncology Group performance status 0-1, time to treatment failure was 4.2 vs. 4.3 months (log-rank p = 0.47); and overall survival was 12.1 vs 11.4 months (log-rank p = 0.68). CONCLUSIONS: The nab-p + G patients were older and had worse performance status than FFX patients. Time to treatment failure and overall survival were not observed to be significantly different in first-line nab-p + G and FFX patients. Results were similar after stratifying by performance status.

Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults.

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic nonautomated office blood pressure (non-AOBP) readings ≥ 140 mm Hg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single-pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic non-AOBP to ≤ 60 mm Hg, especially in the presence of left ventricular hypertrophy. After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP lowering to < 140 mm Hg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed.

Does the association between adherence to statin medications and mortality depend on measurement approach? A retrospective cohort study.

BACKGROUND: The aim of this study was to examine the relationship between mortality and statin adherence using two different approaches to adherence measurement (summary versus repeated-measures). METHODS: A retrospective cohort study was conducted using administrative data from Saskatchewan, Canada between 1994 and 2008. Eligible individuals received a prescription for a statin following hospitalization for acute coronary syndrome (ACS). Adherence was measured using proportion of days covered (PDC) expressed either as: 1) a fixed summary measure, or 2) as a repeatedly measured covariate. Multivariable Cox-proportional hazards models were used to estimate the association between adherence and mortality. RESULTS: Among 9,051 individuals, optimal adherence (≥80%) modeled with a fixed summary measure was not associated with mortality benefits (adjusted HR 0.97, 95% CI 0.86 to 1.09, p = 0.60). In contrast, repeated-measures approach resulted in a significant 25% reduction in the risk of death (adjusted HR 0.75, 95% CI 0.67 to 0.85, p < 0.01). CONCLUSIONS: Unlike the summary measure, the repeated measures approach produces a significant reduction of all-cause mortality with optimal adherence. This effect may be a result of the repeated measures approach being more sensitive, or more prone to survival bias. Our findings clearly demonstrate the need to undertake (and report) multiple approaches when assessing the benefits of medication adherence.

Impact of primary platinum-free interval and BRCA1/2 mutation status on treatment and survival in patients with recurrent ovarian cancer.

OBJECTIVE: To understand the relationship between primary platinum-free interval (PFI), BRCA mutation status, and overall survival (OS) in patients with recurrent ovarian cancer receiving multiple lines of therapy in a multicenter, community-based, retrospective observational cohort study of adult patients with stage III-IV high-grade ovarian cancer. METHODS: Data were retrospectively obtained from the electronic health record (EHR) of a US community oncology network, including patient characteristics, subsequent treatments, primary PFI, and BRCA status. OS was analyzed by the Kaplan-Meier method, stratified by primary PFI and BRCA status. RESULTS: 750 patient charts were reviewed. BRCA testing status was known in 267 patients (16% BRCA mutation). Among patients with identified recurrent disease, 41% had a primary PFI <6months and 59% had a primary PFI ≥6months. Of second-line patients, 59% received third-line therapy, and 60% of third-line patients received fourth-line therapy within the period of observation. Median OS from the start of primary treatment for the entire population was 41.4months (95% CI, 39.0-48.3months). Median OS was significantly increased in patients with primary PFI ≥6months at second-line and third-line (P<0.0001 and P=0.002, respectively). Survival was observed to be increased among patients with BRCA mutations across multiple treatment lines, although this was not statistically significant. CONCLUSIONS: Patients with a primary PFI ≥6months demonstrated improved outcomes over multiple lines of therapy. BRCA status was known in 36% of patients, and those patients with a BRCA mutation demonstrated a trend toward delayed primary recurrence and improved clinical outcomes.

Bacillus Panophthalmitis with Posterior Extension to the Prechiasmatic Optic Nerve.

A rare case of Bacillus panophthlamitis with extension to the prechiasmatic optic nerve secondary to hematogenous spreading after intravenous drug use is presented. A 27-year-old man with a recent history of trauma to the left eye presented with severe left eye pain following a binge of intravenous drug use. Visual acuity (VA) was LP. On examination he had chemosis, proptosis, elevated intraocular pressure, and a complete hyphema. CT-scan identified preseptal swelling, but no evidence of any posterior extension of the anterior process or orbital fractures. Topical and systemic therapy were initiated. On follow-up clinical examination less than 12 hours after presentation he had signs of a keratitis with worsening ophthalmoplegia and repeat imaging demonstrated posterior extension to the prechiasmatic optic nerve. Shortly after the cornea ruptured with cultures growing Bacillus. The patient underwent enucleation and has had no further progression of infection. To the best of our knowledge, this is the first report of Bacillus panophthalmitis presenting with signs of trauma with posterior extension to the prechiasmatic optic nerve.

Hypertension Canada's 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension.

Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force provides annually updated, evidence-based recommendations to guide the diagnosis, assessment, prevention, and treatment of hypertension. This year, we present 4 new recommendations, as well as revisions to 2 previous recommendations. In the diagnosis and assessment of hypertension, automated office blood pressure, taken without patient-health provider interaction, is now recommended as the preferred method of measuring in-office blood pressure. Also, although a serum lipid panel remains part of the routine laboratory testing for patients with hypertension, fasting and nonfasting collections are now considered acceptable. For individuals with secondary hypertension arising from primary hyperaldosteronism, adrenal vein sampling is recommended for those who are candidates for potential adrenalectomy. With respect to the treatment of hypertension, a new recommendation that has been added is for increasing dietary potassium to reduce blood pressure in those who are not at high risk for hyperkalemia. Furthermore, in selected high-risk patients, intensive blood pressure reduction to a target systolic blood pressure ≤ 120 mm Hg should be considered to decrease the risk of cardiovascular events. Finally, in hypertensive individuals with uncomplicated, stable angina pectoris, either a ß-blocker or calcium channel blocker may be considered for initial therapy. The specific evidence and rationale underlying each of these recommendations are discussed. Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force will continue to provide annual updates.

Multiple-domain Versus Single-domain Measurements of Socioeconomic Status (SES) for Predicting Nonadherence to Statin Medications: An Observational Population-based Cohort Study.

INTRODUCTION: Low socioeconomic status (SES) should be a robust predictor of medication nonadherence because it shares key features with the theoretical origins of this phenomenon. However, population-based studies have demonstrated weak associations overall, possibly because SES is inadequately represented. We compared the performance of multiple versus single-domain measures of SES as predictors of statin adherence. METHODS: This retrospective cohort study used population-based administrative data mapped to area-level census information of individuals who received a statin medication following a hospitalization for coronary heart disease. One-year adherence was calculated by dividing the sum of all tablets dispensed by the total number of days in the observation period (365 d following the first statin dispensation). Logistic regression models were constructed and the relative impact of each SES measure was assessed by its adjusted odds ratio (OR) and improvement over the predictive accuracy of a reference model that included non-SES factors only. RESULTS: More than two thirds (ie, 68.8%; 6517/9478) of eligible individuals exhibited optimal adherence (ie, ≥80%). The estimated impact of SES on optimal adherence differed depending on the SES measure tested. The highest performing single-domain measure, household income (OR=0.75; 95% confidence interval, 0.63-0.90; model c-statistic improvement 0.5%, P=0.04) generated a similar result to the multiple-domain measure (adjusted OR=0.74; 95% confidence interval, 0.62-0.88; model c-statistic improvement 0.7%, P=0.01). CONCLUSION: Multidomain measurements of SES using administrative databases mapped to census data are not associated with better performance in predicting statin medication adherence compared with single-domain measures such as household income.

Residents' and attendings' perceptions of a night float system in an internal medicine program in Canada.

BACKGROUND: The Night Float system (NFS) is often used in residency training programs to meet work hour regulations. The purpose of this study was to examine resident and attendings' perceptions of the NFS on issues of resident learning, well-being, work, non-educational activities and the health care system (patient safety and quality of care, inter-professional teams, workload on attendings and costs of on-call coverage). METHODS: A survey questionnaire with closed and open-ended questions (26 residents and eight attendings in an Internal Medicine program), informal discussions with the program and moonlighting and financial data were collected. RESULTS AND DISCUSSION: The main findings included, (i) an overall congruency in opinions between resident and attendings across all mean comparisons, (ii) perceptions of improvement for most aspects of resident well-being (e.g. stress, fatigue) and work environment (e.g. supervision, support), (iii) a neutral effect on the resident learning environment, except resident opinions on an increase in opportunities for learning, (iv) perceptions of improved patient safety and quality of care despite worsened continuity of care, and (v) no increases in work-load on attendings or the health care system (cost-neutral call coverage). Patient safety, handovers and increased utilization of moonlighting opportunities need further exploration.

The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.

The Canadian Hypertension Education Program reviews the hypertension literature annually and provides detailed recommendations regarding hypertension diagnosis, assessment, prevention, and treatment. This report provides the updated evidence-based recommendations for 2015. This year, 4 new recommendations were added and 2 existing recommendations were modified. A revised algorithm for the diagnosis of hypertension is presented. Two major changes are proposed: (1) measurement using validated electronic (oscillometric) upper arm devices is preferred over auscultation for accurate office blood pressure measurement; (2) if the visit 1 mean blood pressure is increased but < 180/110 mm Hg, out-of-office blood pressure measurements using ambulatory blood pressure monitoring (preferably) or home blood pressure monitoring should be performed before visit 2 to rule out white coat hypertension, for which pharmacologic treatment is not recommended. A standardized ambulatory blood pressure monitoring protocol and an update on automated office blood pressure are also presented. Several other recommendations on accurate measurement of blood pressure and criteria for diagnosis of hypertension have been reorganized. Two other new recommendations refer to smoking cessation: (1) tobacco use status should be updated regularly and advice to quit smoking should be provided; and (2) advice in combination with pharmacotherapy for smoking cessation should be offered to all smokers. The following recommendations were modified: (1) renal artery stenosis should be primarily managed medically; and (2) renal artery angioplasty and stenting could be considered for patients with renal artery stenosis and complicated, uncontrolled hypertension. The rationale for these recommendation changes is discussed.

Dress and deportment of medical residents: formal or informal?

PURPOSE: Health care workers, including physicians, have adopted more casual dress. The appearance of a physician may influence patients' opinion of physician knowledge, competence and trustworthiness. We hypothesized that medical inpatients and outpatients would rate these attributes higher in residents who dressed and acted in a more formal manner. METHODS: Prospective cohort included both inpatients and outpatients. One hundred thirty three patients, aged 62.3 ± 16 years, 49% of whom were female, were surveyed. One of two male resident physicians approached each patient, ostensibly to obtain consent to a brief mini-mental status examination. The physician was dressed, and acted, either "formally" (F) or "informally" (I). Patients then completed a six item questionnaire, using a 5 point Likert scale, to assess their confidence in the resident. Total scores could be 6 to 30. Total scores were compared using one-way ANOVA. RESULTS: Patients' perceptions were high for both F and I: 25.5 ± 3.1 vs. 24.1 ± 3.0, respectively (p=0.013). This difference was driven by the "lab coat" question: patients generally preferred physicians to wear a lab coat (3.9 ± 1.0 vs. 2.8 ± 1.3, p < 0.0001). Responses to four of the other five questions were numerically, but not statistically, higher in F. There was no difference in preference between the two residents: 24.6 ± 2.8 vs. 24.9 ± 3.5, p=0.56. CONCLUSION: More formal dress and demeanor by residents leads to a modest, but significant, increase in patient perception of the resident's value. Wearing a white lab coat, in particular, has a positive effect.

The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.

Herein, updated evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in Canadian adults are detailed. For 2014, 3 existing recommendations were modified and 2 new recommendations were added. The following recommendations were modified: (1) the recommended sodium intake threshold was changed from ≤ 1500 mg (3.75 g of salt) to approximately 2000 mg (5 g of salt) per day; (2) a pharmacotherapy treatment initiation systolic blood pressure threshold of ≥ 160 mm Hg was added in very elderly (age ≥ 80 years) patients who do not have diabetes or target organ damage (systolic blood pressure target in this population remains at < 150 mm Hg); and (3) the target population recommended to receive low-dose acetylsalicylic acid therapy for primary prevention was narrowed from all patients with controlled hypertension to only those ≥ 50 years of age. The 2 new recommendations are: (1) advice to be cautious when lowering systolic blood pressure to target levels in patients with established coronary artery disease if diastolic blood pressure is ≤ 60 mm Hg because of concerns that myocardial ischemia might be exacerbated; and (2) the addition of glycated hemoglobin (A1c) in the diagnostic work-up of patients with newly diagnosed hypertension. The rationale for these recommendation changes is discussed. In addition, emerging data on blood pressure targets in stroke patients are discussed; these data did not lead to recommendation changes at this time. The Canadian Hypertension Education Program recommendations will continue to be updated annually.

Socioeconomic status and nonadherence to antihypertensive drugs: a systematic review and meta-analysis.

BACKGROUND: Although conventional wisdom suggests that low socioeconomic status (SES) is a robust predictor of medication nonadherence, the strength of this association remains unclear. OBJECTIVES: 1) To estimate the proportion of studies that identified SES as a potential risk indicator of nonadherence, 2) to describe the type of SES measurements, and 3) to quantify the association between SES and nonadherence to antihypertensive pharmacotherapy. METHODS: A systematic review and meta-analysis research design was used. We searched multiple electronic databases for studies in English or French examining nonadherence to antihypertensive medications measured by electronic prescription databases where explanatory factors were considered. Two authors independently assessed quality, described the SES measure(s), and recorded its association with nonadherence to antihypertensives. A random-effects model meta-analysis was performed, and heterogeneity was examined by using the I(2) statistic. RESULTS: Fifty-six studies with 4,780,293 subjects met the inclusion criteria. Twenty-four of these studies (43%) did not report any SES measures. When it was reported (n = 32), only seven (13%) examined more than one component but none performed a multidimensional assessment. Most of the studies relied on income or income-related measures (such as prescription-drug benefits or co-payments) (27 of 32 [84%]). Meta-analysis could be quantified in 40 cohorts reported in 30 studies. Overall, the pooled adjusted risk estimate for nonadherence according to SES (high vs. low) was 0.89 (95% confidence interval 0.87-0.92; I(2) = 95%; P < 0.001). Similar patterns were observed in all subgroups examined. CONCLUSIONS: Published studies have not found a strong association between low SES and nonadherence to antihypertensive medications. However, important limitations in the assessment of SES can be identified in virtually all studies. Future studies are required to ascertain whether a stronger association is observed when SES is determined by comprehensive measures.

Accuracy of drug store blood pressure monitors: an observational study.

OBJECTIVES: Publically accessible blood pressure monitors are widely used, but little information is available on their accuracy. We compared blood pressure readings of 17 drug store monitors with those obtained using a validated home monitor (Omron BP742CAN) and both with those taken at home using the Canadian Hypertension Education Program protocol. MATERIALS AND METHODS: Duplicate readings were taken using the drug store monitor (VitaStat, n=6, and PharmaSmart, n=11) on the left arm and the Omron on the right in three participants: two normal and one untreated hypertensive patient. We used Bland-Altman methods for comparison. We explored the correlation with average home blood pressure readings. RESULTS: Home average blood pressure for our three participants was 121±6/73±5, 106±6/62±4, and 142±8/81±7 mmHg. The mean systolic blood pressure difference (drug store-Omron) was -1.8±8.2 mmHg. Diastolic pressure difference was 1.7±5.6. Individual paired systolic differences varied from -19 to 14 mmHg. For the participant who required a large cuff, drug store systolic readings tended to be higher (4.1±6.7). In our three participants, drug store monitors as a group read higher than home systolic blood pressure: 7.5 [95% confidence interval (CI) 1.5-13.4], 1.2 (95% CI -4.0 to 6.4), and 1.0 (95% CI -2.5 to 4.4) mmHg. Diastolic blood pressure and heart rate differences were similar in magnitude. CONCLUSION: On average, drug store monitors recorded lower systolic blood pressures and higher diastolic blood pressures than a validated monitor, but the difference was neither statistically nor clinically significant. Single reading comparisons showed a much broader range. In three participants, drug store monitors did reflect the average home blood pressure.

The 2013 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2013. This year's update includes 2 new recommendations. First, among nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise does not adversely influence blood pressure (BP) (Grade D). Thus, such patients need not avoid this type of exercise for fear of increasing BP. Second, and separately, for very elderly patients with isolated systolic hypertension (age 80 years or older), the target for systolic BP should be < 150 mm Hg (Grade C) rather than < 140 mm Hg as recommended for younger patients. We also discuss 2 additional topics at length (the pharmacological treatment of mild hypertension and the possibility of a diastolic J curve in hypertensive patients with coronary artery disease). In light of several methodological limitations, a recent systematic review of 4 trials in patients with stage 1 uncomplicated hypertension did not lead to changes in management recommendations. In addition, because of a lack of prospective randomized data assessing diastolic BP thresholds in patients with coronary artery disease and hypertension, no recommendation to set a selective diastolic cut point for such patients could be affirmed. However, both of these issues will be examined on an ongoing basis, in particular as new evidence emerges.

Pharmacist intervention in cardiac rehabilitation: a randomized controlled trial.

PURPOSE: We aimed to determine to what extent a telephone-based pharmacist intervention would (a) be utilized by individuals not attending a traditional cardiac rehabilitation (CR) program and (b) facilitate adherence to cardiovascular medications. METHODS: We conducted a randomized, controlled open-label trial among patients eligible for CR in Saskatoon, Canada. Patients were invited to participate in telephone-based CR, regardless of participation in the formal program. Subjects in the intervention group were assessed by the CR pharmacist and received education and counseling on medication adherence. The primary endpoint was adherence to cardiovascular medication assessed by electronic filling records over a minimum of 6 months. Mean adherence was expected to reach 70% during the followup period. RESULTS: Patient recruitment was halted early because of low enrollment. Of the 95 patients randomized, 90% had also registered in the traditional CR program. During the followup period, 129 telephone interactions were performed (median, 2 calls), with every subject taking part in at least 1 interaction. Over the study period, the mean adherence to all recently initiated cardiovascular medications combined was 88.8% in the intervention group and 89.9% in the usual care group (P = .73). CONCLUSIONS: Participation in traditional CR programs does not appear to be influenced by the availability of telephone-based education and support. Furthermore, the high rate of adherence among the control group may suggest that CR programs are attracting "healthy adherers" who volunteer for such programs, while missing those with the greatest need for health care system resources.

Methylglyoxal mediates adipocyte proliferation by increasing phosphorylation of Akt1.

Methylglyoxal (MG) is a highly reactive metabolite physiologically presented in all biological systems. The effects of MG on diabetes and hypertension have been long recognized. In the present study, we investigated the potential role of MG in obesity, one of the most important factors to cause metabolic syndrome. An increased MG accumulation was observed in the adipose tissue of obese Zucker rats. Cell proliferation assay showed that 5-20 µM of MG stimulated the proliferation of 3T3-L1 cells. Further study suggested that accumulated-MG stimulated the phosphorylation of Akt1 and its targets including p21 and p27. The activated Akt1 then increased the activity of CDK2 and accelerated the cell cycle progression of 3T3-L1 cells. The effects of MG were efficiently reversed by advanced glycation end product (AGE) breaker alagebrium and Akt inhibitor SH-6. In summary, our study revealed a previously unrecognized effect of MG in stimulating adipogenesis by up-regulation of Akt signaling pathway and this mechanism might offer a new approach to explain the development of obesity.

Comparing health behaviours of internal medicine residents and medical students: an observational study.

PURPOSE: During residency, many physicians find it difficult to maintain a healthy lifestyle; however, there is little objective data available. In this study, residents' health behaviours and cardiovascular risk status were compared with those of medical students. METHODS: Medical residents (n=55, postgraduate years 1 to 4) were compared with medical students (n=62, years 1-4). The main dependent variable was the average number of steps per day (assessed using a pedometer) at work and leisure over three days, during which subjects were not on call or post-call. In addition, all subjects completed a three day food log. Frequency of vigorous exercise was assessed by a single question. Body mass index (BMI), waist circumference, blood pressure, total and high-density lipoprotein cholesterol, smoking habits and random blood glucose were measured, and Framingham Risk Score coronary artery disease 10 year probabilities (FRS) were calculated. RESULTS: Residents recorded 8344±3520 steps per day while students recorded 10703±3986 (p < 0.002). 35% of residents and 52% of students averaged more than 10,000 steps per day and senior residents took fewer steps than junior residents. Both groups frequently failed to achieve the recommended daily servings of fruits and vegetables; on average, 3.5±2.0 servings for residents and 5.4±2.2 for students (p < 0.0001). BMI and FRS were higher among the residents in comparison with the students. CONCLUSION: Medical residents at our institution appear less active and consume fewer servings of fruits and vegetables than undergraduate medical students. These differences are associated with higher BMI, waist circumference and cardiovascular risk.

Coding of heart failure diagnoses in Saskatchewan: a validation study of hospital discharge abstracts.

BACKGROUND: Validity of Heart Failure (HF) diagnoses from administrative records has not been extensively evaluated, especially with respect to small / unselected hospitals. OBJECTIVES: To determine the positive predictive value of a primary / most responsible diagnosis of HF among a general population of subjects discharged from Saskatchewan hospitals. METHODS: Using administrative health records from the Province of Saskatchewan, Canada, we identified subjects experiencing their first HF hospitalization between 1994 and 2003. From this cohort, we randomly selected 500 subjects for individual validation using Framingham and Carlson criteria. RESULTS: The 466 charts available for analysis, 74% (345/466) and 63.9% (298/466) of subjects met criteria for a clinical diagnosis of HF based on Framingham or Carlson criteria, respectively; 57.5% (268/466) met both criterion. Provincial hospitals (located in the largest urban centres) were associated with the highest proportion of confirmed HF diagnoses (87.8% by Framingham criteria) compared to progressively smaller hospitals (regional 77.9%; district 64.2%; and community 60.0%). Accuracy also differed when stratified by physician category. Cardiologists and internists were associated with the highest rates of confirmed diagnoses [(97.5% (39 / 40) and 85.0% (34 / 40)]) compared to general practitioners [(73.1% (95 / 130)]) and other physicians [(69.1% (177 / 256)]), by Framingham criteria. CONCLUSIONS: Hospital discharge abstracts indicating HF are frequently inaccurate. These findings have important implications for the epidemiologic study of HF as well as the clinical management of patients.

Vitamin D and hypertension in pregnancy.

PURPOSE: Vitamin D Deficiency is common, particularly in northern latitudes. We examined the association between vitamin D status and hypertension in late pregnancy. METHODS: A case-control study was conducted during two time periods: September-October, 2008, and January-March, 2009, in women near term. A case was defined as having two or more documented blood pressure readings above 140/90 (either/or) at any time during pregnancy (n=78). Controls had at least two blood pressure readings, with none above 140/90 during pregnancy (n=109). Serum 25-hydroxyvitamin D (25(OH)D) was measured in all participants. RESULTS: In the summer, 13% of controls and 29% of the cases had 25(OH) D levels < 50 nmol/L. During the winter, these numbers rose to 44% and 49% respectively. Both cases and controls were more likely to be vitamin D deficient in the winter (p=0.002). There was a negative correlation between BMI and 25(OH)D (r=-0.202, p=0.002). In univariate analysis, cases had lower 25(OH)D (p=0.046), but also higher body mass index, so that in multivariate analysis 25(OH)D status was no longer significant. There was no difference in mean oral daily vitamin D intake (dietary intake and supplements, 746 and 785 IU respectively). Controls gained less weight in pregnancy. There was a negative correlation between the highest blood pressure measured in pregnancy and 25(OH)D levels (r= -0.118; p=0.012). CONCLUSION: There is a high prevalence of vitamin D deficiency in pregnant women recruited in Saskatoon, Saskatchewan. Women with low circulating vitamin D concentrations are more likely to have hypertension.

Comparison of two oscillometric blood pressure monitors in subjects with atrial fibrillation.

OBJECTIVE: To compare blood pressure readings obtained with two commonly used oscillometric monitors: Omron HEM 711 AC (OM) and Welch-Allyn 52000 series NIBP/oximeter (WA) with mercury sphygmomanometers (Merc) in subjects with atrial fibrillation. METHODS: We recruited 51 hemodynamically stable subjects with atrial fibrillation. Fifty four subjects in normal sinus rhythm served as controls. Supine blood pressure readings in each arm were recorded simultaneously using one monitor and Merc. The second monitor then replaced the first and readings were repeated. Merc was then switched to the opposite arm, and both monitors retested. Apical heart rates were ascertained with a stethoscope. We used the averaged, same arm Merc readings as "gold standard". RESULTS: Automated blood pressure readings were obtained in all control subjects and in all but three of those with atrial fibrillation. Both monitors, and operators, noted a difference between apical and radial/brachial pulse rates: apical-recorded: Merc 6.1 + or - 15.0; OM 5.5 + or - 13.7; WA 10.0 + or - 21.2 beats per minute. Both monitors were accurate in controls: over 90% of readings were within 10 mmHg of averaged Merc, and both achieved European Hypertension Society standards. In subjects with atrial fibrillation, about one quarter of all oscillometric readings differed from Merc by more than 10 mmHg. Both falsely high and falsely low readings occurred, some up to 30 mmHg. There was no relation between accuracy and heart rate. CONCLUSIONS: Single blood pressure readings, taken with oscillometric monitors in subjects with atrial fibrillation differ, often markedly, from those taken manually. Health care professionals should record multiple readings manually, using validated instruments when making therapeutic decisions.