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Kelly Zarnke

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Papers by Kelly Zarnke

Barriers to Implementing Internist Recommendations for Perioperative Anticoagulation Management by Surgical Teams

Canadian Journal of General Internal Medicine

Introduction: In our center, half of all recommendations made by an internist about perioperative... more Introduction: In our center, half of all recommendations made by an internist about perioperative anticoagulation management are not followed by surgical team members. We aimed to understand the barriers to implementing perioperative anticoagulation recommendations.Methods: This was a prespecified analysis of interviews with surgical team members about individual- and systems-level drivers of missed perioperative anticoagulation recommendations. Interviews and analysis were guided by the Theoretical Domains Framework and the Consolidation Framework for Implementation Research.Results: We interviewed 16 surgical team members and 2 internists. Surgical team members intentionally did not follow recommendations about perioperative anticoagulation management when they felt that the bleeding risk outweighed the risk of thrombosis. This assessment of risk was driven by emotion and previous experience, even among participants who were familiar with perioperative literature.Conclusions: Deve...

Implications

The management of hypertension in Canada: a review of current

Venous Thromboembolism Prophylaxis in Obese Medical Patients: a Retrospective Cohort Study

THE ULUTAS MEDICAL JOURNAL, 2015

Background: Obese patients are 2-3 times more likely to develop venous thromboembolism (VTE), and... more Background: Obese patients are 2-3 times more likely to develop venous thromboembolism (VTE), and over 60% of VTE occurs in hospital. Our primary objective was to identify the incidence of objectively documented symptomatic VTE during hospitalization or up to ninety days post discharge. Our secondary objectives were to describe the prescribing patterns of VTE prophylaxis received in hospitalized obese medical patients (body mass index [BMI] ≥30 kg/m 2 ) as well as risk factors for VTE in obese patients. Method: A retrospective design was used look at obese patients admitted to a general medicine service at three tertiary care academic teaching hospitals in Calgary, AB, Canada from January 1, 2012 to December 31, 2012. VTE was identified based on clinical diagnosis and incidence was calculated. Results: There were 443 patients included in the analysis. The average age and BMI were 58.5 years and 41 kg/m 2 respectively, and 70.2% were males. The median length of stay in hospital was 7 days (IQR 4-13). A total of 122 patients (27.5%) of patients did not receive thromboprophylaxis during their hospitalization. Unfractionated heparin (UFH) was the most common agent prescribed (37.9%), and only seven patients received high-dose thromboprophylaxis. The median duration of prophylaxis was 6.5 days . Seven patients (1.6%) developed VTE (5 pulmonary embolism and 2 DVT) during the study period, and six of these patients received thromboprophylaxis. In terms of risk for VTE, the median Padua Prediction Score for the study group was 2 (IQR 1-3). There is very little literature on VTE prophylaxis and incidence of VTE in the obese medical patient. Given the low risk for and incidence of VTE in this study, particularly in the context of 27.5% of the study population not receiving thromboprophylaxis, there is a need for further research to evaluate the efficacy and safety of high dose thromboprophylaxis in the obese medical patient.

Amlodipine plus perindopril was better than atenolol plus bendroflumethiazide for reducing complications in hypertension

Evidence-based medicine, 2006

In patients 40 to 79 years of age with hypertension and ≥ 3 other cardiovascular (CV) risk factor... more In patients 40 to 79 years of age with hypertension and ≥ 3 other cardiovascular (CV) risk factors, is amlodipine plus perindopril more effective than atenolol plus bendroflumethiazide for reducing CV outcomes? M e t h o d s Design: Randomized controlled trial (Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm [ASCOT-BPLA]). Allocation: Concealed.* Blinding: Blinded (outcome assessors).* Follow-up period: Median 5.5 years. Setting: 686 family practices in the Nordic countries and 32 regional centers in the United Kingdom and Ireland. Patients: 19 257 patients 40 to 79 years of age (mean age 63 y, 77% men) who had hypertension and ≥ 3 other CV risk factors. Exclusion criteria included previous myocardial infarction (MI), currently treated angina, and a cerebrovascular event within the previous 3 months. Intervention: Amlodipine, 5 to 10 mg, adding perindopril, 4 to 8 mg as required (n = 9639), or atenolol, 50 to 100 mg, adding bendroflumethiazide, 1.25 to 2.5 mg, and potassium as required (n = 9618).

Diabetes During Diarrhea-Associated Hemolytic Uremic Syndrome: A systematic review and meta-analysis

Diabetes Care, 2005

OBJECTIVE—To quantify the incidence of diabetes during the acute phase of diarrhea-associated hem... more OBJECTIVE—To quantify the incidence of diabetes during the acute phase of diarrhea-associated hemolytic uremic syndrome (D+HUS) and to identify features associated with its development. RESEARCH DESIGN AND METHODS—A systematic review and meta-analysis of articles assessing diabetes during D+HUS was conducted. Relevant citations were identified from Medline, Embase, and Institute for Scientific Information Citation Index databases. Bibliographies of relevant articles were hand searched. All articles were independently reviewed for inclusion and data abstraction by two authors. RESULTS—Twenty-one studies from six countries were included. Only 2 studies reported a standard definition of diabetes; 14 defined diabetes as hyperglycemia requiring insulin. The incidence of diabetes during the acute phase of D+HUS could be quantified in a subset of 1,139 children from 13 studies (1966–1998, age 0.2–16 years) and ranged from 0 to 15%, with a pooled incidence of 3.2% (95% CI 1.3–5.1, random-ef...

The 2014 Canadian Hypertension Education Program Recommendations for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension

Canadian Journal of Cardiology, 2014

See page 500 for disclosure information. A version of the hypertension recommendations designed f... more

Steroid Use in the Perioperative Period

Rate-control versus conversion strategy in postoperative atrial fibrillation: trial design and pilot study results

Cardiac Electrophysiology Review, 2003

Atrial fibrillation (AF) remains a frequent complication of cardiac surgery. The optimal treatmen... more Atrial fibrillation (AF) remains a frequent complication of cardiac surgery. The optimal treatment strategy has not been established. Retrospective studies have suggested that a primary rate-control strategy may be equivalent to a strategy that restores sinus rhythm. Fifty patients with postoperative atrial fibrillation were randomly assigned to a strategy of antiarrhythmic therapy +/- electrical cardioversion or ventricular rate control. Anticoagulation with heparin overlapped with coumadin was administered to both arms. The primary endpoint of the study was time to conversion to sinus rhythm analyzed by the Kaplan-Meier method. The effects of strategy on hospital length of stay was examined as well as the incidence of recurrent AF. This study demonstrated no significant difference between an antiarrhythmic conversion strategy (n = 27) and a rate-control strategy (n = 23) in time to conversion to sinus rhythm (11.2 +/- 3.2 vs. 11.8 +/- 3.9 hours; p = 0.8). With Cox multivariate ana...

The Perioperative Surgical Home, Enhanced Recovery After Surgery and how integration of these models may improve care for medically complex patients

Canadian Journal of Surgery

Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve... more Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop int...

Estimated GFR and Incidence of Major Surgery: A Population-Based Cohort Study

American Journal of Kidney Diseases

How Attending Physician Preceptors Negotiate Their Complex Work Environment: A Collective Ethnography

Academic medicine : journal of the Association of American Medical Colleges, Dec 20, 2017

To generate an empiric, detailed, and updated view of the attending physician preceptor role and ... more To generate an empiric, detailed, and updated view of the attending physician preceptor role and its interface with the complex work environment. In 2013, the authors conducted a modified collective ethnography with observations of internal medicine medical teaching unit preceptors from two university hospitals in Canada. Eleven observers conducted 32 observations (99.5 hours) of 26 preceptors (30 observations [93.5 hours] of 24 preceptors were included in the analysis). An inductive thematic approach was used to analyze the data with further axial coding to identify connections between themes. Four individuals coded the main data set; differences were addressed through discussion to achieve consensus. Three elements or major themes of the preceptor role were identified: (1) competence or the execution of traditional physician competencies, (2) context or the extended medical teaching unit environment, and (3) conduct or the manner of acting or behaviors and attitudes in the role. M...

Predictors, Prognosis, and Management of New Clinically Important Atrial Fibrillation After Noncardiac Surgery: A Prospective Cohort Study

Anesthesia and analgesia, Jul 1, 2017

Despite the frequency of new clinically important atrial fibrillation (AF) after noncardiac surge... more Despite the frequency of new clinically important atrial fibrillation (AF) after noncardiac surgery and its increased association with the risk of stroke at 30 days, there are limited data informing their prediction, association with outcomes, and management. We used the data from the PeriOperative ISchemic Evaluation trial to determine, in patients undergoing noncardiac surgery, the association of new clinically important AF with 30-day outcomes, and to assess management of these patients. We also aimed to derive a clinical prediction rule for new clinically important AF in this population. We defined new clinically important AF as new AF that resulted in symptoms or required treatment. We recorded an electrocardiogram 6 to 12 hours postoperatively and on the 1st, 2nd, and 30th days after surgery. A total of 211 (2.5% [8351 patients]; 95% confidence interval, 2.2%-2.9%) patients developed new clinically important AF within 30 days of randomization (8140 did not develop new AF). AF ...

Hypertension Canada's 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension

Canadian Journal of Cardiology, 2017

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, asses... more 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

How stable are white-coat hyper- and normotensive effects over time?

Amer J Hypertens, 2000

and 41 (9.7%) were under irregular drug treatment. From the whole population, only 91 (21.5%) had... more and 41 (9.7%) were under irregular drug treatment. From the whole population, only 91 (21.5%) had controlled vs 332 (78.5%) uncontrolled BP, as follow: 121 (36.4%) in stage I, 123 (37.1%) in stage II and 88 (26.5%) in stage III. Forty-four patients (13.2%) had isolated systolic hypertension. Despite their stages, 53 out of the total population (12.5%) were undergone to ABPM, and 22 (41.5%) presented normal systolic and diastolic BP loads (Ͻ30%), and 31 (58.5%) intermediate or high BP loads (Ն30%). We conclude that: 1) In our Clinic, the rate of controlled hypertensive patients is 21.5%, in spite of the fact that 83.6% said that were taking medication. 2) Among the uncontrolled patients, 41.5% showed normal ABPM, becoming the true controlled population in 53.9%. 3) Would the study of hypertension control be underestimating the number of patients effectively controlled? 4) Would ABPM be a more accurated method to evaluate the hypertensive patients? Further studies have to be done to explain these aspects.

Antihypertensive persistence and drug class

The Canadian Journal of Cardiology, Jun 1, 2002

Noncompliance with antihypertensive therapy is a major problem that hinders successful hypertensi... more Noncompliance with antihypertensive therapy is a major problem that hinders successful hypertension management. To study antihypertensive drug persistence for hypertensive patients in routine clinical settings. Hypertensive patients were retrospectively studied (1994 through 1998) using databases managed by Saskatchewan Health. The study population (46,458 people) included all patients with an International Classification of Diseases-9 code of 401, 402, 403 or 404, or any four-digit code included in these categories, who received at least one antihypertensive therapy prescription during the first 4.5 years of the study and received no antihypertensive therapy 12 months before the dispensing of the first therapy. Prescriptions were placed into the following drug classes: angiotensin II antagonists, angiotensin-converting enzyme inhibitors, beta-blockers, calcium channel blockers and diuretics. Persistence was determined for four intervals in the patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s therapy at 180, 360, 540 and 720 days. Drug class had a statistically significant (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001) effect on persistence. Angiotensin II antagonists had the highest persistence followed by angiotensin-converting enzyme inhibitors, calcium channel blockers, beta-blockers and diuretics. Persistence decreased as the time interval increased. Females were significantly more persistent than males (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.005), and elderly patients were significantly more persistent than younger patients (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001) at each of the four time intervals. For angiotensin II antagonists, age and sex did not affect persistence. The consistently higher persistence associated with the use of angiotensin II antagonists may improve the management of hypertension.

Hypertension Canada’s 2016 CHEP Guidelines for Blood Pressure Measurement, Diagnosis and Assessment of Risk of Pediatric Hypertension

Canadian Journal of Cardiology, 2016

We present the inaugural evidence-based Canadian recommendations for the measurement of blood pre... more We present the inaugural evidence-based Canadian recommendations for the measurement of blood pressure in children, and the diagnosis and evaluation of pediatric hypertension. Rates of pediatric hypertension are increasing concomitant with increased rates of childhood obesity. With this there is growing awareness of the need to measure blood pressure in children. Consequently, the present recommendations have been developed to address an important gap and improve the clinical care of children. For 2016 a total of 15 recommendations are presented, these are categorized in a similar fashion to the existing adult recommendations. Specifically, we present recommendations on (1) accurate measurement of blood pressure in children; (2) criteria for diagnosis of hypertension in children; (3) assessment of overall cardiovascular risk in hypertensive children; (4) routine laboratory tests for the investigation of children with hypertension; (5) ambulatory blood pressure measurement in children; and, (6) role of echocardiography. We discuss the rationale for the recommendations and present additional supporting material for the clinician, including tables with standardized techniques for blood pressure measurement and determination of normative blood pressure values for children. Hypertension Canada's CHEP Guidelines Task Force will update the recommendations annually and develop future evidence-based recommendations to guide prevention and treatment of pediatric hypertension. guide.medlive.cn

The attributes of an effective teacher differ between the classroom and the clinical setting

Advances in Health Sciences Education, 2016

Most training programs use learners&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;a... more Most training programs use learners&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; subjective ratings of their teachers as the primary measure of teaching effectiveness. In a recent study we found that preclinical medical students&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; ratings of classroom teachers were associated with perceived charisma and physical attractiveness of the teacher, but not intellect. Here we explored whether the relationship between these variables and teaching effectiveness ratings holds in the clinical setting. We asked 27 Internal Medicine residents to rate teaching effectiveness of ten teachers with whom they had worked on a clinical rotation, in addition to rating each teacher&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s clinical skills, physical attractiveness, and charisma. We used linear regression to study the association between these explanatory variables and teaching effectiveness ratings. We found no association between rating of physical attractiveness and teaching effectiveness. Clinical skill and charisma were independently associated with rating of teaching effectiveness (regression coefficients [95 % confidence interval] 0.73 [0.60, 0.85], p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001 and 0.12 [0.01, 0.23], p = 0.03, respectively). The variables associated with effectiveness of classroom and clinical teachers differ, suggesting context specificity in teaching effectiveness ratings. Context specificity may be explained by differences in the exposure that learners have to teachers in the classroom versus clinical setting-so that raters in the clinical setting may base ratings upon observed behaviours rather than stereotype data. Alternatively, since subjective ratings of teaching effectiveness inevitably incorporate learners&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; context-specific needs, the attributes that make a teacher effective in one context may not meet the needs of learners in a different context.

The 2015 canadian hypertension education program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension

The Canadian journal of cardiology, 2015

The Canadian Hypertension Education Program reviews the hypertension literature annually and prov... more 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…

Risk prediction models for acute kidney injury following major noncardiac surgery: systematic review

Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, Jan 24, 2015

Acute kidney injury (AKI) is a serious complication of major noncardiac surgery. Risk prediction ... more Acute kidney injury (AKI) is a serious complication of major noncardiac surgery. Risk prediction models for AKI following noncardiac surgery may be useful for identifying high-risk patients to target with prevention strategies. We conducted a systematic review of risk prediction models for AKI following major noncardiac surgery. MEDLINE, EMBASE, BIOSIS Previews and Web of Science were searched for articles that (i) developed or validated a prediction model for AKI following major noncardiac surgery or (ii) assessed the impact of a model for predicting AKI following major noncardiac surgery that has been implemented in a clinical setting. We identified seven models from six articles that described a risk prediction model for AKI following major noncardiac surgeries. Three studies developed prediction models for AKI requiring renal replacement therapy following liver transplantation, three derived prediction models for AKI based on the Risk, Injury, Failure, Loss of kidney function, E...

Venous Thromboembolism Prophylaxis in Obese Medical Patients: a Retrospective Cohort Study

by Duane Bates, Kelly Zarnke, Elizabeth Mackay, and Peter Jamieson

THE ULUTAS MEDICAL JOURNAL, 2015

Barriers to Implementing Internist Recommendations for Perioperative Anticoagulation Management by Surgical Teams

Canadian Journal of General Internal Medicine

Introduction: In our center, half of all recommendations made by an internist about perioperative... more Introduction: In our center, half of all recommendations made by an internist about perioperative anticoagulation management are not followed by surgical team members. We aimed to understand the barriers to implementing perioperative anticoagulation recommendations.Methods: This was a prespecified analysis of interviews with surgical team members about individual- and systems-level drivers of missed perioperative anticoagulation recommendations. Interviews and analysis were guided by the Theoretical Domains Framework and the Consolidation Framework for Implementation Research.Results: We interviewed 16 surgical team members and 2 internists. Surgical team members intentionally did not follow recommendations about perioperative anticoagulation management when they felt that the bleeding risk outweighed the risk of thrombosis. This assessment of risk was driven by emotion and previous experience, even among participants who were familiar with perioperative literature.Conclusions: Deve...

Implications

The management of hypertension in Canada: a review of current

Venous Thromboembolism Prophylaxis in Obese Medical Patients: a Retrospective Cohort Study

THE ULUTAS MEDICAL JOURNAL, 2015

Background: Obese patients are 2-3 times more likely to develop venous thromboembolism (VTE), and... more Background: Obese patients are 2-3 times more likely to develop venous thromboembolism (VTE), and over 60% of VTE occurs in hospital. Our primary objective was to identify the incidence of objectively documented symptomatic VTE during hospitalization or up to ninety days post discharge. Our secondary objectives were to describe the prescribing patterns of VTE prophylaxis received in hospitalized obese medical patients (body mass index [BMI] ≥30 kg/m 2 ) as well as risk factors for VTE in obese patients. Method: A retrospective design was used look at obese patients admitted to a general medicine service at three tertiary care academic teaching hospitals in Calgary, AB, Canada from January 1, 2012 to December 31, 2012. VTE was identified based on clinical diagnosis and incidence was calculated. Results: There were 443 patients included in the analysis. The average age and BMI were 58.5 years and 41 kg/m 2 respectively, and 70.2% were males. The median length of stay in hospital was 7 days (IQR 4-13). A total of 122 patients (27.5%) of patients did not receive thromboprophylaxis during their hospitalization. Unfractionated heparin (UFH) was the most common agent prescribed (37.9%), and only seven patients received high-dose thromboprophylaxis. The median duration of prophylaxis was 6.5 days . Seven patients (1.6%) developed VTE (5 pulmonary embolism and 2 DVT) during the study period, and six of these patients received thromboprophylaxis. In terms of risk for VTE, the median Padua Prediction Score for the study group was 2 (IQR 1-3). There is very little literature on VTE prophylaxis and incidence of VTE in the obese medical patient. Given the low risk for and incidence of VTE in this study, particularly in the context of 27.5% of the study population not receiving thromboprophylaxis, there is a need for further research to evaluate the efficacy and safety of high dose thromboprophylaxis in the obese medical patient.

Amlodipine plus perindopril was better than atenolol plus bendroflumethiazide for reducing complications in hypertension

Evidence-based medicine, 2006

In patients 40 to 79 years of age with hypertension and ≥ 3 other cardiovascular (CV) risk factor... more In patients 40 to 79 years of age with hypertension and ≥ 3 other cardiovascular (CV) risk factors, is amlodipine plus perindopril more effective than atenolol plus bendroflumethiazide for reducing CV outcomes? M e t h o d s Design: Randomized controlled trial (Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm [ASCOT-BPLA]). Allocation: Concealed.* Blinding: Blinded (outcome assessors).* Follow-up period: Median 5.5 years. Setting: 686 family practices in the Nordic countries and 32 regional centers in the United Kingdom and Ireland. Patients: 19 257 patients 40 to 79 years of age (mean age 63 y, 77% men) who had hypertension and ≥ 3 other CV risk factors. Exclusion criteria included previous myocardial infarction (MI), currently treated angina, and a cerebrovascular event within the previous 3 months. Intervention: Amlodipine, 5 to 10 mg, adding perindopril, 4 to 8 mg as required (n = 9639), or atenolol, 50 to 100 mg, adding bendroflumethiazide, 1.25 to 2.5 mg, and potassium as required (n = 9618).

Diabetes During Diarrhea-Associated Hemolytic Uremic Syndrome: A systematic review and meta-analysis

Diabetes Care, 2005

OBJECTIVE—To quantify the incidence of diabetes during the acute phase of diarrhea-associated hem... more OBJECTIVE—To quantify the incidence of diabetes during the acute phase of diarrhea-associated hemolytic uremic syndrome (D+HUS) and to identify features associated with its development. RESEARCH DESIGN AND METHODS—A systematic review and meta-analysis of articles assessing diabetes during D+HUS was conducted. Relevant citations were identified from Medline, Embase, and Institute for Scientific Information Citation Index databases. Bibliographies of relevant articles were hand searched. All articles were independently reviewed for inclusion and data abstraction by two authors. RESULTS—Twenty-one studies from six countries were included. Only 2 studies reported a standard definition of diabetes; 14 defined diabetes as hyperglycemia requiring insulin. The incidence of diabetes during the acute phase of D+HUS could be quantified in a subset of 1,139 children from 13 studies (1966–1998, age 0.2–16 years) and ranged from 0 to 15%, with a pooled incidence of 3.2% (95% CI 1.3–5.1, random-ef...

The 2014 Canadian Hypertension Education Program Recommendations for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension

Canadian Journal of Cardiology, 2014

See page 500 for disclosure information. A version of the hypertension recommendations designed f... more

Steroid Use in the Perioperative Period

Rate-control versus conversion strategy in postoperative atrial fibrillation: trial design and pilot study results

Cardiac Electrophysiology Review, 2003

Atrial fibrillation (AF) remains a frequent complication of cardiac surgery. The optimal treatmen... more Atrial fibrillation (AF) remains a frequent complication of cardiac surgery. The optimal treatment strategy has not been established. Retrospective studies have suggested that a primary rate-control strategy may be equivalent to a strategy that restores sinus rhythm. Fifty patients with postoperative atrial fibrillation were randomly assigned to a strategy of antiarrhythmic therapy +/- electrical cardioversion or ventricular rate control. Anticoagulation with heparin overlapped with coumadin was administered to both arms. The primary endpoint of the study was time to conversion to sinus rhythm analyzed by the Kaplan-Meier method. The effects of strategy on hospital length of stay was examined as well as the incidence of recurrent AF. This study demonstrated no significant difference between an antiarrhythmic conversion strategy (n = 27) and a rate-control strategy (n = 23) in time to conversion to sinus rhythm (11.2 +/- 3.2 vs. 11.8 +/- 3.9 hours; p = 0.8). With Cox multivariate ana...

The Perioperative Surgical Home, Enhanced Recovery After Surgery and how integration of these models may improve care for medically complex patients

Canadian Journal of Surgery

Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve... more Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop int...

Estimated GFR and Incidence of Major Surgery: A Population-Based Cohort Study

American Journal of Kidney Diseases

How Attending Physician Preceptors Negotiate Their Complex Work Environment: A Collective Ethnography

Academic medicine : journal of the Association of American Medical Colleges, Dec 20, 2017

To generate an empiric, detailed, and updated view of the attending physician preceptor role and ... more To generate an empiric, detailed, and updated view of the attending physician preceptor role and its interface with the complex work environment. In 2013, the authors conducted a modified collective ethnography with observations of internal medicine medical teaching unit preceptors from two university hospitals in Canada. Eleven observers conducted 32 observations (99.5 hours) of 26 preceptors (30 observations [93.5 hours] of 24 preceptors were included in the analysis). An inductive thematic approach was used to analyze the data with further axial coding to identify connections between themes. Four individuals coded the main data set; differences were addressed through discussion to achieve consensus. Three elements or major themes of the preceptor role were identified: (1) competence or the execution of traditional physician competencies, (2) context or the extended medical teaching unit environment, and (3) conduct or the manner of acting or behaviors and attitudes in the role. M...

Predictors, Prognosis, and Management of New Clinically Important Atrial Fibrillation After Noncardiac Surgery: A Prospective Cohort Study

Anesthesia and analgesia, Jul 1, 2017

Despite the frequency of new clinically important atrial fibrillation (AF) after noncardiac surge... more Despite the frequency of new clinically important atrial fibrillation (AF) after noncardiac surgery and its increased association with the risk of stroke at 30 days, there are limited data informing their prediction, association with outcomes, and management. We used the data from the PeriOperative ISchemic Evaluation trial to determine, in patients undergoing noncardiac surgery, the association of new clinically important AF with 30-day outcomes, and to assess management of these patients. We also aimed to derive a clinical prediction rule for new clinically important AF in this population. We defined new clinically important AF as new AF that resulted in symptoms or required treatment. We recorded an electrocardiogram 6 to 12 hours postoperatively and on the 1st, 2nd, and 30th days after surgery. A total of 211 (2.5% [8351 patients]; 95% confidence interval, 2.2%-2.9%) patients developed new clinically important AF within 30 days of randomization (8140 did not develop new AF). AF ...

Hypertension Canada's 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension

Canadian Journal of Cardiology, 2017

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, asses... more 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

How stable are white-coat hyper- and normotensive effects over time?

Amer J Hypertens, 2000

and 41 (9.7%) were under irregular drug treatment. From the whole population, only 91 (21.5%) had... more and 41 (9.7%) were under irregular drug treatment. From the whole population, only 91 (21.5%) had controlled vs 332 (78.5%) uncontrolled BP, as follow: 121 (36.4%) in stage I, 123 (37.1%) in stage II and 88 (26.5%) in stage III. Forty-four patients (13.2%) had isolated systolic hypertension. Despite their stages, 53 out of the total population (12.5%) were undergone to ABPM, and 22 (41.5%) presented normal systolic and diastolic BP loads (Ͻ30%), and 31 (58.5%) intermediate or high BP loads (Ն30%). We conclude that: 1) In our Clinic, the rate of controlled hypertensive patients is 21.5%, in spite of the fact that 83.6% said that were taking medication. 2) Among the uncontrolled patients, 41.5% showed normal ABPM, becoming the true controlled population in 53.9%. 3) Would the study of hypertension control be underestimating the number of patients effectively controlled? 4) Would ABPM be a more accurated method to evaluate the hypertensive patients? Further studies have to be done to explain these aspects.

Antihypertensive persistence and drug class

The Canadian Journal of Cardiology, Jun 1, 2002

Noncompliance with antihypertensive therapy is a major problem that hinders successful hypertensi... more Noncompliance with antihypertensive therapy is a major problem that hinders successful hypertension management. To study antihypertensive drug persistence for hypertensive patients in routine clinical settings. Hypertensive patients were retrospectively studied (1994 through 1998) using databases managed by Saskatchewan Health. The study population (46,458 people) included all patients with an International Classification of Diseases-9 code of 401, 402, 403 or 404, or any four-digit code included in these categories, who received at least one antihypertensive therapy prescription during the first 4.5 years of the study and received no antihypertensive therapy 12 months before the dispensing of the first therapy. Prescriptions were placed into the following drug classes: angiotensin II antagonists, angiotensin-converting enzyme inhibitors, beta-blockers, calcium channel blockers and diuretics. Persistence was determined for four intervals in the patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s therapy at 180, 360, 540 and 720 days. Drug class had a statistically significant (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001) effect on persistence. Angiotensin II antagonists had the highest persistence followed by angiotensin-converting enzyme inhibitors, calcium channel blockers, beta-blockers and diuretics. Persistence decreased as the time interval increased. Females were significantly more persistent than males (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.005), and elderly patients were significantly more persistent than younger patients (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001) at each of the four time intervals. For angiotensin II antagonists, age and sex did not affect persistence. The consistently higher persistence associated with the use of angiotensin II antagonists may improve the management of hypertension.

Hypertension Canada’s 2016 CHEP Guidelines for Blood Pressure Measurement, Diagnosis and Assessment of Risk of Pediatric Hypertension

Canadian Journal of Cardiology, 2016

We present the inaugural evidence-based Canadian recommendations for the measurement of blood pre... more We present the inaugural evidence-based Canadian recommendations for the measurement of blood pressure in children, and the diagnosis and evaluation of pediatric hypertension. Rates of pediatric hypertension are increasing concomitant with increased rates of childhood obesity. With this there is growing awareness of the need to measure blood pressure in children. Consequently, the present recommendations have been developed to address an important gap and improve the clinical care of children. For 2016 a total of 15 recommendations are presented, these are categorized in a similar fashion to the existing adult recommendations. Specifically, we present recommendations on (1) accurate measurement of blood pressure in children; (2) criteria for diagnosis of hypertension in children; (3) assessment of overall cardiovascular risk in hypertensive children; (4) routine laboratory tests for the investigation of children with hypertension; (5) ambulatory blood pressure measurement in children; and, (6) role of echocardiography. We discuss the rationale for the recommendations and present additional supporting material for the clinician, including tables with standardized techniques for blood pressure measurement and determination of normative blood pressure values for children. Hypertension Canada's CHEP Guidelines Task Force will update the recommendations annually and develop future evidence-based recommendations to guide prevention and treatment of pediatric hypertension. guide.medlive.cn

The attributes of an effective teacher differ between the classroom and the clinical setting

Advances in Health Sciences Education, 2016

Most training programs use learners&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;a... more Most training programs use learners&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; subjective ratings of their teachers as the primary measure of teaching effectiveness. In a recent study we found that preclinical medical students&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; ratings of classroom teachers were associated with perceived charisma and physical attractiveness of the teacher, but not intellect. Here we explored whether the relationship between these variables and teaching effectiveness ratings holds in the clinical setting. We asked 27 Internal Medicine residents to rate teaching effectiveness of ten teachers with whom they had worked on a clinical rotation, in addition to rating each teacher&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s clinical skills, physical attractiveness, and charisma. We used linear regression to study the association between these explanatory variables and teaching effectiveness ratings. We found no association between rating of physical attractiveness and teaching effectiveness. Clinical skill and charisma were independently associated with rating of teaching effectiveness (regression coefficients [95 % confidence interval] 0.73 [0.60, 0.85], p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001 and 0.12 [0.01, 0.23], p = 0.03, respectively). The variables associated with effectiveness of classroom and clinical teachers differ, suggesting context specificity in teaching effectiveness ratings. Context specificity may be explained by differences in the exposure that learners have to teachers in the classroom versus clinical setting-so that raters in the clinical setting may base ratings upon observed behaviours rather than stereotype data. Alternatively, since subjective ratings of teaching effectiveness inevitably incorporate learners&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; context-specific needs, the attributes that make a teacher effective in one context may not meet the needs of learners in a different context.

The 2015 canadian hypertension education program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension

The Canadian journal of cardiology, 2015

The Canadian Hypertension Education Program reviews the hypertension literature annually and prov... more 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…

Risk prediction models for acute kidney injury following major noncardiac surgery: systematic review

Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, Jan 24, 2015

Acute kidney injury (AKI) is a serious complication of major noncardiac surgery. Risk prediction ... more Acute kidney injury (AKI) is a serious complication of major noncardiac surgery. Risk prediction models for AKI following noncardiac surgery may be useful for identifying high-risk patients to target with prevention strategies. We conducted a systematic review of risk prediction models for AKI following major noncardiac surgery. MEDLINE, EMBASE, BIOSIS Previews and Web of Science were searched for articles that (i) developed or validated a prediction model for AKI following major noncardiac surgery or (ii) assessed the impact of a model for predicting AKI following major noncardiac surgery that has been implemented in a clinical setting. We identified seven models from six articles that described a risk prediction model for AKI following major noncardiac surgeries. Three studies developed prediction models for AKI requiring renal replacement therapy following liver transplantation, three derived prediction models for AKI based on the Risk, Injury, Failure, Loss of kidney function, E...

Venous Thromboembolism Prophylaxis in Obese Medical Patients: a Retrospective Cohort Study

by Duane Bates, Kelly Zarnke, Elizabeth Mackay, and Peter Jamieson

THE ULUTAS MEDICAL JOURNAL, 2015