Universal access – but when? Treating the right patient at the right time: Access to electrophysiology services in Canada

The Canadian Cardiovascular Society Access to Care Working Group has published a series of commentaries on access to cardiovascular care in Canada. The present article reviews the evidence for timely access to electrophysiology services. Using the best available evidence along with expert consensus by the Canadian Heart Rhythm Society, the panel proposed a series of benchmarks for access to the full scope of electrophysiology services, from initial consultation through to operative procedures. The proposed benchmarks are presented herein.     

Universal access: But when? Treating the right patient at the right time: Access to cardiac rehabilitation

The Canadian Cardiovascular Society formed an Access to Care Working Group ('Working Group') in the spring of 2004. The mandate of the group was to use the best science and information to establish reasonable triage categories and safe wait times for access to common cardiovascular services and procedures. The present commentary presents the rationale for benchmarks for cardiac rehabilitation (CR) services. The Working Group's search for evidence included: a full literature review of the efficacy of CR, and the factors affecting access and referral to CR; a review of existing guidelines for access to CR; and a national survey of 14 CR programs across Canada undertaken in May 2005 to solicit information on referral to, and wait times for, CR. The Working Group also reviewed the results of The Ontario Cardiac Rehabilitation Pilot Project (2002) undertaken by the Cardiac Care Network of Ontario, which reported the average and median wait times for CR. Some international agencies have formulated their own guidelines relating to the optimal wait time for the onset of CR. However, due to the limited amount of supporting literature, these guidelines have generally been formed as consensus statements. The Canadian national survey showed that few programs had guidelines for individual programs. The Cardiac Care Network of Ontario pilot project reported that the average and median times from a cardiac event to the intake into CR were 99 and 70 days, respectively. The national survey of sampled CR programs also revealed quite remarkable differences across programs in terms of the length of time between first contact to first attendance and to commencement of exercise. Programs that required a stress test before program initiation had the longest wait for exercise initiation. Some patients need to be seen within a very short time frame to prevent a marked deterioration in their medical or psychological state. In some cases, early intervention and advocacy may reduce the risk of loss of employment. Or, there may be profound disturbances in the patient's family as a result of the cardiac event. For other patient groups, preferable wait times vary from one to 30 days, and acceptable wait times vary from seven to 60 days. All cardiovascular disease patients require core aspects of CR services. Patients who would derive benefit from formal CR programs should be provided the opportunity, given the proven efficacy and cost effectiveness of CR.     

Methotrexate treatment in juvenile idiopathic arthritis: when is the right time to stop?

OBJECTIVES: To investigate whether prolonged methotrexate (MTX) treatment after induction of remission influences the subsequent duration of remission in patients with juvenile idiopathic arthritis (JIA), and to analyse the usefulness of myeloid related proteins 8 and 14 (MRP8/MRP14) as predictive markers for the stability of remission at the time when MTX is withdrawn. METHODS: Twenty five patients with oligoarticular and polyarticular JIA who received MTX to induce remission were followed up. MTX treatment was stopped after a mean of 3.8 months (group 1) or 12.6 months (group 2) after remission was documented. Differences in the number of relapses between these groups were looked for. Additionally, MRP8/MRP14 were analysed by ELISA in 22 patients. RESULTS: No difference was found in the number of relapses between patients with prolonged or early discontinued MTX treatment. Patients who were in stable remission had significantly lower MRP levels when MTX was discontinued than patients with relapses. With a cut off point for MRP8/MRP14 at 250 ng/ml, sensitivity and specificity were 100% and 70%, respectively. CONCLUSION: Longer duration of MTX treatment after induction of remission does not generally improve the status of remission in patients with JIA. Residual synovial inflammation seems to influence the rate of relapses after discontinuation of MTX treatment. MRP8/MRP14 indicate residual activity even in the absence of other laboratory or clinical signs of continuing inflammation. Normal serum concentrations of MRP8/MRP14 in clinical inactive arthritis may help to identify patients in whom MTX can be safely withdrawn after remission is achieved.     

Treating mild hypercholesterolemia in the absence of overt cardiovascular disease: If,when, and why?

Summary Cohort data define a range of cholesterol concentrations (160–200 mg/dl), which is desirable in terms of public health. Cholesterol-lowering treatment leading to a serum cholesterol in this range is favorable for coronary heart disease prevention and safe in terms of noncardiovascular mortality. In individuals with moderate cholesterol elevation and without other coronary risk factors, the physician should encourage a healthy lifestyle and give prudent nutritional advice. Detection of asymptomatic cardiovascular disease by noninvasive methods might be used to identify individuals with mild hypercholesterolemia, but nevertheless at high risk for ischemic accidents. The aim of lipid-lowering treatment is to improve life expectancy through reduction of a major cause of premature death.     

Efforts to reduce sodium intake in Canada: why, what, and when?

This review addresses the rationale for lowering dietary sodium intake in Canada and recent progress in this direction. Data from trials involving moderate and sustained (≥ 4 weeks) reductions in sodium intake demonstrated significant dose-dependent effects on blood pressure (BP) with larger effects in hypertensive individuals. Average sodium intake in Canada (approximately 3500 mg per day) is well above currently recommended intake targets (≤ 1500 mg per day). Approximately one-eighth of sodium intake is a natural component of food, with the remainder added by food industries (approximately 3/4) or at home (approximately 1/8). Modelling results suggest that lowering Canadian sodium intake to near recommended levels would reduce hypertension prevalence by approximately 30%, prevent approximately 15,500 cardiovascular events per year, and yield savings of approximately CAD$2 billion per year. These estimates do not include the potential additional benefits of long-term sodium restriction on BP, nor BP-independent effects. Actions to facilitate lower sodium intakes in Canada included dietary intake recommendations, mandatory nutritional labelling, a national intake survey, and recommendations of a Government-appointed Sodium Working Group (SWG) that aims to reduce Canadian intakes below 2300 mg per day by 2016. SWG strategies included voluntary reductions in sodium added by food industries, increased education, and research. However, the SWG has recently been disbanded, its responsibilities passed to a Federal-Provincial-Territorial Committee and to a new Food Regulatory Advisory Committee, and the significance for implementing recommendations is unclear. Health care practitioners are encouraged to promote lower dietary sodium intake in their patients and to advocate continued Government efforts to reduce the sodium content of the Canadian food supply.     

Essential,but at what risk? A prospective study on central venous access in patients with haematological malignancies

Aims: Central venous catheters (CVC) are integral to modern haematology practice; however, they are associated with a range of complications. This prospective study aimed to determine the rate of CVC‐related complications and risk factors in haematology patients, who are vulnerable because of their underlying pathology and treatments. Methods: All inpatients that had a non‐tunnelled CVC inserted in a 14‐month period in the haematology ward at St Vincent's Hospital were enrolled. Complications (immediate and late), demographics, type of device, insertion technique and duration of dwell, were examined using multivariate analysis. Results: One hundred and seventy‐four CVC in 84 patients were recorded, representing 3016 catheter‐days. At least one complication was found in 43 (24.7%) patients. Immediate complications occurred in 13 (7.5%) insertions, with a higher rate in those inserted after ≥2 attempts compared with one (P= 0.02). Catheter‐related bloodstream infection occurred at a rate of 7.6 per 1000 catheter‐days, with acute lymphoblastic leukaemia associated with a higher rate (P= 0.02), and subclavian vein CVC had a lower rate compared with other locations (P < 0.01). Thrombosis was found in seven (4.0%) patients, with subclavian CVC carrying an increased risk (P= 0.02). Conclusions: This prospective observational study found almost a quarter of haematology patients experience a CVC‐related complication. An association was found with a number of attempts at insertion and immediate complications; other risk factors included anatomical location, underlying disease and duration of catheterisation. The relatively high complication rate, compared with reports of non‐haematology patients, highlights the need to improve CVC management, a vital part of care for this population.     

Heparin induced thrombocytopenia: how to manage when the patient is pregnant?

Immune mediated heparin induced thrombocytopenia (HIT) remains the most common anti-body mediated, drug-induced thrombocytopenic disorder, and a leading cause of morbidity and mortality. Management of HIT in pregnant women remains uncertain. In this article, HIT in general, and special conditions and management issues in pregnant women discussed and the related literature reviewed.     

Transplants for leukemia in relapse: when is the best time?

Transplantation of hematopoietic cells to treat acute leukemia can offer disease control and extended survival for a sizeable fraction of patients, but because alternative approaches may also be effective, the decision about transplant timing remains uncertain. For those transplanted in first complete remission (CR1), outcomes are the best, but some fraction of those might have had extended leukemia-free survival in the absence of a transplant. In later remission, outcomes are variable but promising-and markedly better than any nontransplant approach. Risks of relapse may differ based on the depth of remission, measurable minimal residual disease (MRD), or patient's performance status.     

Colonoscopy screening in the elderly: when to stop?

OBJECTIVES: The age to begin colorectal cancer (CRC) screening is based on the risk of neoplasia and is published in screening guidelines. The age to stop screening is unknown but should be based, in part, on the same principle. The purpose of this study was to establish whether the prevalence of neoplasia detected by colonoscopy diminished with advancing age, to warrant ceasing colonoscopic screening. METHODS: The endoscopic and pathology reports of all asymptomatic subjects undergoing colonoscopy for the purpose of CRC screening or an evaluation of abdominal pain or change in bowel habits between 1997 and 2000 were reviewed. A multivariate logistic regression analysis was used to assess the effect of age, gender, and indication for examination on the prevalence of neoplasia, as well as on having more than two adenomas, advanced adenomas (tubulovillous, villous, severe dysplasia, or size > or = 1 cm), and invasive cancers. RESULTS: A total of 915 patients were included. Of these, 50% were male, with a mean age of 65 yr (range 50-100). Neoplasia peaked in the seventh decade, with a fall thereafter (p = 0.009). Numerous adenomas, advanced adenomas, and invasive cancers increased with age. The yield for overall neoplasia, advanced adenomas, and more than two adenomas was higher in the screening group than in the symptomatic group. More invasive cancers were found in the symptomatic group compared with the asymptomatic group, but this did not achieve statistical significance (4 vs 1, p = 0.44). CONCLUSIONS: The prevalence of advanced neoplasia continues to increase with age. Subjects undergoing colonoscopy for screening had a greater risk for neoplasia than did subjects with symptoms. There is no decline in yield of advanced neoplasia to justify stopping screening colonoscopy in the elderly.     

Nutritional support in the severely compromised motility patient: when and how?

The management of CIPO remains difficult and requires a multidisciplinary approach. In adult patients with CIPO on HPN, the 10-year survival rate was 68%. Long-term HPN dependence does not seem to be associated with a significant increase in mortality and morbidity. HPN could be a safe and efficient approach to the management of intestinal failure caused by CIPO, with restoring oral intake and lowering hospitalization frequency as major goals of treatment.