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Maeder MT, Rickli H, Brenner R, Scheler E, Buser M. [Therapy of Heart Failure with Reduced Ejection Fraction: What's New in the 2021 Guidelines?]. Praxis (Bern 1994) 2022; 111:445-456. [PMID: 35673837 DOI: 10.1024/1661-8157/a003876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Therapy of Heart Failure with Reduced Ejection Fraction: What's New in the 2021 Guidelines? Abstract. The spectrum of treatment options for patients with heart failure with reduced ejection fraction (HFrEF) has substantially expanded over the last years. The 2021 guidelines of the European Society of Cardiology propose a new treatment algorithm for patients with HFrEF and define the role of the currently available drugs, interventions and devices in this context. The new standard is a basic therapy consisting of four drugs with different mechanisms of action for all patients with HFrEF: an angiotensin-converting enzyme inhibitor, a betablocker, a mineralocorticoid antagonist, and a sodium glucose co-transporter-2 inhibitor. Additional drugs and/or interventions/devices are indicated depending on the response to the four-drug basic therapy (which has to be up-titrated to the maximally tolerated doses) and the clinical phenotype. In the present article, we discuss the available drugs and devices, their role in the proposed HFrEF treatment algorithm and clinically relevant practical aspects.
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Affiliation(s)
- Micha T Maeder
- Klinik für Kardiologie, Kantonsspital St. Gallen, St. Gallen, Schweiz
| | - Hans Rickli
- Klinik für Kardiologie, Kantonsspital St. Gallen, St. Gallen, Schweiz
| | - Roman Brenner
- Klinik für Kardiologie, Kantonsspital St. Gallen, St. Gallen, Schweiz
| | - Eva Scheler
- Klinik für Kardiologie, Kantonsspital St. Gallen, St. Gallen, Schweiz
| | - Marc Buser
- Klinik für Kardiologie, Kantonsspital St. Gallen, St. Gallen, Schweiz
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Blanchette V, Patry J, Brousseau-Foley M. Adequacy Between Canadian Clinical Guidelines and Recommendations Compared With International Guidelines for the Management of Diabetic Foot Ulcers. Can J Diabetes 2021; 45:761-767.e12. [PMID: 34052133 DOI: 10.1016/j.jcjd.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/21/2021] [Accepted: 03/19/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Although quality of care in the prevention and management of diabetic foot ulceration (DFU) has improved with the use of comprehensive evidence-based clinical practice guidelines, disparities between national and international guidelines have been demonstrated in one study conducted in Western Pacific regions. Although there are challenges of systematic implementation of evidence-based care in some clinical settings, their applications have demonstrated positive outcomes on DFU-associated burdens in many countries. The aim of this study was to review and evaluate 3 Canadian clinical practice guidelines and recommendations (CPGRs) in comparison with the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines. METHODS Extraction of all 85 recommendations from the IWGDF guidelines was performed and 3 independent investigators used a rating recommendations adequacy method with descriptive statistics. The Appraisal of Guidelines REsearch & Evaluation (AGREE) II instrument was used for quality appraisal and reliability scores were noted using intraclass correlation coefficients. RESULTS The Wounds Canada CPGR had the higher adequacy with the IWGDF guidelines. However, its development method was poor to fair. The Registered Nurses' Association of Ontario CPGR was superior for its development and implementation strategies, but major gaps were found in all chapters. The Diabetes Canada CPGR obtained a good quality appraisal evaluation, but was not dedicated exclusively to DFU and some important recommendations were absent. Reliability scores of AGREE II were good between investigators (p<0.0001). Some disparities were noted between Canadian and international recommendations. CONCLUSIONS Some disparities were noted, future orientations for development should include various health-care professionals involved in the team approach, patient-oriented research, recommendations published along with their level of evidence and strength of recommendations (such as with the Grading of Recommendations, Assessment, Development and Evaluations system) and implementation strategies to enhance evidence-based practice in Canada.
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Affiliation(s)
- Virginie Blanchette
- Department of Physical Activity Sciences and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada; Centre de recherche du Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec, Canada.
| | - Jérôme Patry
- Department of Physical Activity Sciences and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada; Centre de recherche du Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec, Canada; Faculty of Medicine, Family Medicine and Emergency Medicine Department, Université Laval, Québec, Canada
| | - Magali Brousseau-Foley
- Department of Physical Activity Sciences and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada; Faculty of Medicine, Centre intégré universitaire de santé et de services sociaux de la Mauricie et du Centre-du-Québec affiliated with Université de Montréal, Trois-Rivières Family Medicine University Clinic, Trois-Rivières, Québec, Canada
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Abstract
This paper discusses the current state of knowledge and practice for diagnosing fetal alcohol spectrum disorder (FASD). The strengths and challenges of different models of diagnosis are compared. Some models require a team approach for evaluation, while other approaches assume that a clinician in his or her office provides a diagnosis based on a review of the patient's medical and social history, behaviour, and physical examination. The author reviews the emergence of new information from recent advances in genetics, imaging, and electrophysiology that has the potential to lead to changes in practice and improved reliability of an FASD diagnosis.
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Affiliation(s)
- Albert E Chudley
- Department of Pediatrics and Child Health and Department of Biochemistry and Medical Genetics, Max Rady College of Medicine, Rady Faculty of Heath Sciences, University of Manitoba, and the Children's Hospital, Winnipeg, MB R3A 1R9, Canada.,Department of Pediatrics and Child Health and Department of Biochemistry and Medical Genetics, Max Rady College of Medicine, Rady Faculty of Heath Sciences, University of Manitoba, and the Children's Hospital, Winnipeg, MB R3A 1R9, Canada
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Hamelin AL, Yan JW, Stiell IG. Emergency Department Management of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State in Adults: National Survey of Attitudes and Practice. Can J Diabetes 2017; 42:229-236. [PMID: 28734951 DOI: 10.1016/j.jcjd.2017.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/11/2017] [Accepted: 05/15/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES In 2013, the Canadian Diabetes Association, now Diabetes Canada, published national clinical practice guidelines for the effective management of diabetic ketoacidosis and hyperosmolar hyperglycemic states in adults. We sought to determine emergency physician compliance rates and attitudes toward these guidelines and to identify potential barriers to their use in Canadian emergency departments. METHODS An online survey consisting of questions related to the awareness and use of the Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada was distributed to 500 randomly selected members of the Canadian Association of Emergency Physicians. Also included in the survey were 3 clinical vignettes to assess adherence rates to the guidelines. RESULTS The survey response rate was 62.2% (311 of 500). The majority of physicians reported the guidelines to be useful (83.6%); 54.6% of respondents were familiar with the guidelines, and 54.7% claimed to use them in clinical practice. The most frequently reported barrier to guideline implementation was a lack of education (56.0%). The clinical vignettes demonstrated respondent variability in fluid administration and sodium bicarbonate administration, as well as some variability in insulin and potassium administration. CONCLUSIONS Although Canadian emergency physicians were generally supportive of the guidelines, many were unaware that these guidelines existed, and barriers to their implementation were reported. These results suggest the need to improve knowledge translation strategies across Canadian emergency departments to standardize management of diabetic ketoacidosis and hyperosmolar hyperglycemic states and support the highest quality of patient care, as well as to ensure that future guidelines include management strategies applicable to the emergency department setting.
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Affiliation(s)
| | - Justin W Yan
- The Division of Emergency Medicine, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada; Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ian G Stiell
- The University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Grenier J, Goodman SG, Leiter LA, Langer A, Teoh H, Bhatt DL, Cheng AYY, Tan MK, Ransom T, Connelly KA, Yan AT. Blood Pressure Management in Adults With Type 2 Diabetes: Insights From the Diabetes Mellitus Status in Canada (DM-SCAN) Survey. Can J Diabetes 2017; 42:130-137. [PMID: 28552652 DOI: 10.1016/j.jcjd.2017.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/02/2017] [Accepted: 01/11/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Optimal treatment of blood pressure (BP) and other cardiovascular risk factors, including hyperglycemia, is integral to diabetes management. There are limited data from the primary care setting concerning the contemporary and comprehensive management of type 2 diabetes and other cardiovascular risk factors in relation to guideline-recommended BP target achievement. METHODS The Diabetes Mellitus Status in Canada (DM-SCAN) survey included 5172 ambulatory patients with type 2 diabetes. Data were collected on patient demographics, medical histories, medication usage, BP levels and laboratory investigations. We stratified the study population based on their attainment of the BP target recommended by the Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada and the Canadian Hypertension Education Program (<130/80 mmHg) and compared patient clinical characteristics and treatments. RESULTS Of the 5145 patients with available BP data, 36% achieved the BP target. Prevalence of smoking, known coronary artery disease, retinopathy, neuropathy and nephropathy were similar in the groups with BP 130/80 mmHg or higher and BP 130/80 mmHg or lower. Patients with BP 130/80 mmHg or higher were taking more antihypertensive agents and were more likely to be taking angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers, diuretics and calcium channel blockers. They also had significantly higher glycated hemoglobin and low-density lipoprotein-cholesterol levels. Overall, these patients were also less likely to achieve guideline-recommended glycemic and lipid targets. CONCLUSIONS Only about one-third of patients with diabetes achieved the target BP of below 130/80 mmHg. Patients with BP 130/80 mmHg or higher were also less likely to achieve optimal guideline-recommended glycated hemoglobin and low-density lipoprotein-cholesterol targets. Improved comprehensive management of all risk factors in patients with diabetes is warranted.
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Affiliation(s)
- Jasmine Grenier
- Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Shaun G Goodman
- Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Lawrence A Leiter
- University of Toronto, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, St Michael's Hospital, Toronto, Ontario, Canada
| | - Anatoly Langer
- University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Hwee Teoh
- Division of Endocrinology and Metabolism, St Michael's Hospital, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, United States
| | - Alice Y Y Cheng
- University of Toronto, Toronto, Ontario, Canada; The Credit Valley Hospital and St Michael's Hospital, Toronto, Ontario, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Thomas Ransom
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kim A Connelly
- Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Yan
- Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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Alexander PE, Li SA, Tonelli M, Guyatt G. Canadian Primary Care Physicians' Attitudes Toward Understanding Clinical Practice Guidelines for Diabetes Screening. Can J Diabetes 2016; 40:580-585. [PMID: 27590082 DOI: 10.1016/j.jcjd.2016.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 05/18/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The Canadian Task Force on Preventive Health Care (CTFPHC) produces guidelines for Canadian physicians regarding screening and prevention. To better appreciate the barriers to and facilitators of guideline adherence, we sought to explore physicians' views of guidelines in general and their understanding of this CTFPHC diabetes screening guideline in particular because they pertain to screening and positive treatment. METHODS We included Canadian physicians (N=10) who agreed to be interviewed regarding their use of guidelines as part of practice, focusing on the CTFPHC 2012 diabetes screening guideline. Individual semistructured interviews explored primary care physicians' experiences and perspectives on the use, relevance and feasibility of guidelines as part of practice, approaches to screening for diabetes, and suggestions for improving guidelines. RESULTS Overall, physicians recognized the need for guidelines and the benefits of using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods in the guideline development process. Physicians also noted several barriers to guideline adherence, including the lack of opportunity for physicians to provide input during guideline formulation, insufficient guidance on interpreting GRADE's weak or conditional recommendations, and feasibility issues concerning using risk calculators. The predominant challenge raised by physicians was the unclear guidance for pharmacologic interventions; all respondents were unclear about the guidelines' implicit assumption that screen-positive patients would be treated with statins and aspirin (ASA). CONCLUSIONS These interviews suggest the need for greater clarity in guideline recommendations, including clarification of the quality of evidence ratings and the strength of recommendation grading. Our low participation rate raises the issue of representativeness; replication in samples with greater willingness to participate would be desirable.
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Affiliation(s)
- Paul E Alexander
- Health Research Methods (HRM), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
| | - Shelly-Anne Li
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Marcello Tonelli
- Departments of Health Research and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University Health Sciences Centre, Hamilton, Ontario, Canada
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Savaskan E, Baumgartner M, Georgescu D, Hafner M, Hasemann W, Kressig RW, Popp J, Rohrbach E, Schmid R, Verloo H. [Not Available]. Praxis (Bern 1994) 2016; 105:941-952. [PMID: 27524166 DOI: 10.1024/1661-8157/a002433] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Zusammenfassung. Delir ist ein ätiologisch unspezifisches hirnorganisches Syndrom, das im Alter und vor allem bei Demenz häufiger vorkommt. Der akute Beginn, starke Fluktuationen im klinischen Bild und die multifaktorielle Genese erfordern einen interprofessionellen und interdisziplinären Ansatz in der Diagnostik und Therapie. Die vorliegenden Empfehlungen sollen den aktuellen Stand des Wissens in diesem Bereich abbilden und dabei die wissenschaftliche Evidenz, aber auch die klinische Erfahrung berücksichtigen. Sie sind das Ergebnis der Zusammenarbeit einer Expertengruppe der Schweizerischen Gesellschaft für Alterspsychiatrie und -psychotherapie (SGAP), der Schweizerischen Fachgesellschaft für Geriatrie (SFGG), des Schweizerischen Berufsverbands der Pflegefachfrauen und Pflegefachmänner (SBK) und des Schweizerischen Vereins für Pflegewissenschaft (VfP). Präventive und nicht-pharmakologische Interventionen sind sehr wichtig und sollten vorbeugend und begleitend angeboten werden. Bei richtiger Indikation und unter Berücksichtigung von möglichen Interaktionen und Nebenwirkungen ist die konsequente Durchführung der pharmakologischen Therapie oft notwendig. Die Förderung des interdisziplinären Managements des Delirs ist ein wichtiges Anliegen der Empfehlungen.
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Affiliation(s)
- Egemen Savaskan
- 1 Schweizerische Gesellschaft für Alterspsychiatrie und -Psychotherapie (SGAP)
- 2 Klinik für Alterspsychiatrie, Psychiatrische Universitätsklinik Zürich
| | | | - Dan Georgescu
- 1 Schweizerische Gesellschaft für Alterspsychiatrie und -Psychotherapie (SGAP)
- 4 Bereich Alters- und Neuropsychiatrie, Psychiatrische Dienste Aargau AG
| | - Martina Hafner
- 5 Schweizerische Fachgesellschaft für Geriatrie (SFGG)
- 6 Universitäre Altersmedizin und Rehabilitation, Felix Platter Spital Basel
| | - Wolfgang Hasemann
- 7 Schweizerischer Verein für Pflegewissenschaft (VfP)
- 8 Basel Dementia und Delirium Management Program, Universitätsspital Basel
| | - Reto W Kressig
- 5 Schweizerische Fachgesellschaft für Geriatrie (SFGG)
- 6 Universitäre Altersmedizin und Rehabilitation, Felix Platter Spital Basel
| | - Julius Popp
- 9 Centre Hospitalier Universitaire Vaudois (CHUV)
| | - Erich Rohrbach
- 10 Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachmänner (SBK)
| | - Ruth Schmid
- 10 Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachmänner (SBK)
| | - Henk Verloo
- 9 Centre Hospitalier Universitaire Vaudois (CHUV)
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Abstract
Most common heart valve diseases in western industrialized nations are the aortic valve stenosis and the mitral valve regurgitation. More seldom are a regurgitation of the aortic valve and mitral valve stenosis. Even more seldom are heart valve diseases of the Tricuspid and the pulmonary valve. The only curative therapy in severe heart valve disease is a surgical intervention. The timing is crucial for the outcome. Especially in asymptomatic patients it's difficult to find the right point of time for intervention due to missing realization of the health status. In 2013, the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC) published guidelines according to the therapy in heart valve disease. Here we want to summarize the recommendations of these guidelines in regards of timing of the surgical intervention.
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Affiliation(s)
| | - Diana Reser
- Klinik für Herz- und Gefässchirurgie, Universitätsspital Zürich
| | - Martin Czerny
- Klinik für Herz- und Gefässchirurgie, Universitätsspital Zürich
| | - Volkmar Falk
- Klinik für Herz- und Gefässchirurgie, Universitätsspital Zürich
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