Diabetic patients with prior specialist care have better glycaemic control than those with prior primary care

OBJECTIVE: To compare glycaemic control, as reflected in the A1c level, of diabetic patients with primary care vs. with specialist care. METHODS: The study used administrative data from eastern Ontario, Canada, and a database containing the results of all A1c tests from this region between 1 September 1999 and 1 September 2000. To avoid referral bias, diabetic patients with an index specialist visit were selected and separated into those with exclusively primary care previously (n = 974) and those with prior specialist care (n = 3533). We compared A1c levels measured within 30 days of the index visit and hence attributable to the prior care. To control for confounding between the groups, both multiple linear regression and propensity score-based matching were used. RESULTS: After controlling for confounders, patients with prior specialist care had significantly lower A1c levels (P < 0.0001). Other predictors of lower A1c included older age, shorter diabetes duration, rural residence and higher neighbourhood income. In propensity score-matched cohorts, the A1c level was 8.3 +/- 2.0% with prior primary care vs. 7.9 +/- 1.6% with prior specialist care (P < 0.0001). CONCLUSIONS: Specialist care prior to the index visit was associated with a lower A1c level than prior primary care. This difference would result in reductions in diabetes complications for patients with ongoing specialist care.     

Entropy score, patent ductus arteriosus (PDA), and cardiopulmonary bypass (CPB): ligation of PDA on CPB can compromise cerebral blood flow

A patent ductus arteriosus (PDA) is often present in patients undergoing correction of congenital heart disease. It is well appreciated that during cardiopulmonary bypass (CPB), a PDA steals arterial inflow into pulmonary circulation, and may lead to systemic hypoperfusion, excessive pulmonary blood flow (PBF) and distention of the left heart. Therefore, PDA is preferably ligated before initiation of CPB. We describe acute decreases of arterial blood pressure and entropy score with the initiation of CPB and immediate increase in entropy score following the PDA ligation in a child undergoing intracardiac repair of ventricular septal defect and right ventricular infundibular stenosis. The observation strongly indicates that a PDA steals arterial inflow into pulmonary circulation and if the PDA is dissected and ligated on CPB or its ligation on CPB is delayed the cerebral perfusion is potentially compromised.     

Surname lists to identify South Asian and Chinese ethnicity from secondary data in Ontario,Canada: a validation study

Background  

Surname lists are useful for identifying cohorts of ethnic minority patients from secondary data sources. This study sought to develop and validate lists to identify people of South Asian and Chinese origin.     

Long-term impact of bariatric surgery on glycemic control and glucose-lowering therapy for people with type 2 diabetes: population-based cohort study

BackgroundRandomized controlled trials (RCTs) have demonstrated that bariatric surgery improves glycemic control among people with diabetes. However, evidence from RCTs may not be generalizable to real-world clinical care with unselected patients in routine clinical practice.ObjectivesTo examine long-term glycemic control and glucose-lowering drug regimens following bariatric surgery for people with type 2 diabetes (T2D) in unselected patients in routine clinical practice.SettingPopulation-based cohort study using linked routinely collected real-world data from Ontario, Canada.MethodsIndividuals with T2D who were assessed for bariatric surgery at any referral center in the province between February 2010 and November 2016 were identified and divided into those who received surgery within 2 years of the initial assessment and those who did not.ResultsThere were 3674 people who had bariatric surgery and 1335 who did not. By 2 years, people who had undergone surgery had a significantly lower HbA1C (6.3 ± 1.2 % versus 7.8 ± 1.8 %, P < .0001), and this difference persisted at 3, 4, 5, and 6 years. Even by 6 years, half of those who had undergone surgery remained on no glucose-lowering drugs, and they were nearly 6 times less likely to be on insulin than those who had not undergone surgery.ConclusionsIn real-world clinical care, bariatric surgery was associated with large and sustained improvements in glycemic control.     

Investigation of angioedema associated with the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers.

BACKGROUND: Angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) are known to cause angioedema. OBJECTIVE: To evaluate the time to onset of angioedema and the subsequent episodes of angioedema in patients initially experiencing ACE-I- or ARB-induced angioedema. METHODS: A manual medical record review was conducted on 64 patients with a diagnosis of urticaria, angioedema, or anaphylaxis as a result of taking an ACE-I or ARB. Data recorded included demographic characteristics; time to onset of symptoms; concomitant medication use; laboratory test results; recurrent episodes of angioedema, urticaria, or anaphylaxis; and morbidity and mortality. RESULTS: The mean age of patients with angioedema was 60.2 years (age range, 32-92 years). Women (60%) and African Americans (69%) were affected more commonly. The primary location for angioedema was the lips and tongue. Sixty-one of 64 patients developed at least one episode of angioedema as the result of taking an ACE-I, and 3 patients had angioedema associated with an ARB. The mean time to onset of angioedema after initiation of therapy in 51 patients was 1.8 years, with 13 patients (25%) presenting within the first month and 6 patients (12%) developing angioedema in the first week. No patients required a tracheostomy or died. Also, none of the 6 patients, whose angioedema was attributed to an ACE-I who then received an ARB, developed recurrent angioedema in more than 8.1 patient-years of follow-up. CONCLUSIONS: Angioedema attributable to an ACE-I or ARB resolves on discontinued use of the medication. It most commonly affects women and African Americans and did so in the first month of treatment in 25% of patients. Physicians should be aware but not deterred necessarily from recommending an ARB in patients with ACE-I-induced angioedema because of the benefits of control of hypertension or reducing albuminuria in selected patients.