Heart failure (HF) is a complex disease which is growing to be a significant cause of morbidity and mortality leading to increased cost of chronic care and hospitalization. In the DAPA-HF study, the sodium-glucose co-transporter 2 inhibitor (SGLT-2i) dapagliflozin was shown to reduce the risk of worsening HF and death in patients with HF with reduced ejection fraction (HFrEF). Our goal was to conduct an audit in a tertiary referral centre at University Hospital Galway (UHG) to identify patients with HFrEF who fulfil the eligibility criteria for SGLT-2i therapy, as seen in the DAPA-HF study. We also sought to identify patients with Type 2 Diabetes Mellitus (T2DM) in our HFrEF cohort who are potential candidates for improvement of glycaemic control with SGLT-2i therapy according to the ADA-EASD Guidelines.
Methodology
A retrospective audit was conducted on 129 patients with HFrEF attending the specialist-led heart failure clinic at UHG between January and March 2020. Demographic, clinical, biochemical and medication data were collected from medical charts and our local digital database:EVOLVE® and CVWeb®. Patients had to meet the DAPA-HF inclusion criteria to be deemed eligible for dapagliflozin therapy.
Results
Table 1 summarises the baseline clinical data and table 2 summarises the list of medical therapy at our centre. Of note, the 129 patients in our study represented a more elderly cohort compared to the DAPA-HF study population. Only 49/129 (38%) of our HFrEF patients were eligible for SGLT-2i therapy based on the DAPA-HF inclusion criteria. This is primarily due to the higher than expected percentage of patients in our cohort who were asymptomatic (34.9%) and who had low NT-proBNP levels (29.6%). 16/129 (12.4%) had severe CKD with an eGFR <30 ml/min/1.73 m2. There were only 26/129 (20.2%) patients with T2DM of which 6 patients were already on SGLT-2i. The majority had ischemic cardiomyopathy (69%) with concomitant risk factors and (30.8%) had poor glycaemic control.
Conclusion
This study shows a lower than expected number of patients in our centre who would have been included in the DAPA-HF trial. This could be because many patients in this cohort were already on optimal HF treatment, many being asymptomatic and had low NT-proBNP levels. Some patients were also ineligible for SGLT-2i because of Stage 4 CKD. One-third of the diabetic patients in this HFrEF cohort were not at target HbA1C range and according to the ADA-EASD Guidelines, all these patients should have SGLT-2i added to intensify glycaemic control. Lately, the Canadian Heart Society have updated their guidelines with a strong recommendation to introduce SGLT-2i in diabetics with ischemic cardiomyopathy despite adequate glycaemic control for cardiovascular benefits. SGLT-2i represents an important, but underutilized therapeutic option by cardiologists, likely due to the lack of familiarity on its use. This study reveals that SGLT-2i prescription could potentially increase in HFrEF patients with or without T2DM as guidelines will soon be updated based on robust evidence from large-scale clinical trials and when prescribers become aware of the indication for primary prevention of heart failure hospitalization and death.
Abstract Since 2005, the American Red Cross (ARC) Hemovigilance Program has systematically evaluated adverse reactions and complications after blood donation and transfusion, which has led to improvements in safety for both donors and patients. After establishing baseline estimates of the risk of transfusion reactions such as transfusion-related acute lung injury (TRALI) and sepsis from bacterially contaminated platelet components, the program has demonstrated that the preventive measures that were implemented to reduce their occurrence were effective. 1–4 Reports of transfusion-transmitted infections, most commonly babesiosis linked to RBC components, have identified the need for targeted interventions. 5 The program has also described the spectrum of adverse reactions experienced by healthy volunteers after whole blood or apheresis donation, including systemic (e.g., vasovagal), phlebotomy-related, and other complications. 6,7 The information about donor reactions has led to several initiatives to reduce the already low rates of complications among the most susceptible groups and improve the donors’ experience. 8,9 In this report, we present annual data on donation and transfusion complications in the ARC in 2007 and discuss the strengths and limitations of our national hemovigilance program.
In preliminary studies, we demonstrated that an on-line application of Gauss’ area formula (SketchAndCalc™) measured percentage areas of 20 segments under a computer-generated normal distribution curve (−3.0 standard deviations (SD) to +3.0 SD) with accuracy and precision (Pearson's correlation of measured areas with corresponding theoretical areas r[20]=0.9962 (p<0.0001)). Thus, we used SketchAndCalc™ to quantify percentages of microcytes (50-80 fL) and macrocytes (110-200 fL) in archived AHA histogram images in women with previously untreated iron-deficiency anemia (IDA) and previously untreated hemochromatosis.
Although medical factors such as hypertension and coagulopathy have been identified that are associated with hemorrhage after renal biopsy, little is known about the role of technical factors. The purpose of our study was to examine the effects of biopsy needle direction on renal biopsy specimen adequacy and bleeding complications.Two hundred and forty-two patients who had undergone ultrasound-guided renal biopsies were included. A printout of the ultrasound picture taken at the time of the biopsy was used to measure the biopsy angle ("angle of attack" [AOA]) and to determine if the biopsy needle was aimed at the upper or lower pole and if the medulla was targeted or avoided.Of the 3 groups of biopsy angle, an AOA of between 50°-70° yielded the most glomeruli per core (P = .001) and the fewest inadequate specimens (4% vs 15% for > 70°, and 9% for < 50°, P = .038). Biopsy directed at a pole vs an interpolar region resulted in fewer inadequate specimens (8% vs 23%, P = .005), while biopsies that were medulla-avoiding resulted in fewer inadequate specimens (5% vs 16%, P = .004) and markedly reduced bleeding complications (12% vs 46%, P < .001) compared to biopsies where the medulla was entered.An AOA of approximately 60°, aiming at the poles, and avoiding the medulla were each associated with fewer inadequate biopsies and bleeding complications. While biopsy of the medulla is necessary for some diagnoses, the increased bleeding risk emphasizes the need for communication between nephrologist, pathologist, and radiologist.
We sought to evaluate the hypothesis that the relatively high HFE C282Y allele frequency in White persons in central Alabama (0.0896) is due to a predominance of persons of Irish and Scots descent, and is not attributable to Native American ancestry common in this geographic area.Eighty evaluable hemochromatosis probands with C282Y homozygosity and 319 White controls reported countries of ancestry of their grandparents. Frequencies of country of ancestry reports were tabulated. The reports were also converted to scores that reflect proportional countries of ancestry in individuals. Using the scores, we computed aggregate country of ancestry indices as estimates of group ancestry composition. Results were compared to those of European populations with C282Y allele frequencies >0.0800.The respective frequencies of "British Isles" and Scotland reports were significantly greater in hemochromatosis probands than in controls. The respective frequencies of "Europe Not British Isles," Italy, and Poland reports were significantly greater in controls. Aggregate "British Isles" and Scotland indices were significantly greater in hemochromatosis probands. The "Europe Not British Isles" index was significantly greater in controls. Approximately one-quarter of hemochromatosis probands and controls reported "Native American" ancestry; the corresponding country of ancestry index was not significantly different in probands and controls. C282Y frequencies >0.0800 were reported from England, Ireland, Scotland, Wales, Brittany, and Denmark.The present results indicate that hemochromatosis probands with C282Y homozygosity in central Alabama report significantly different countries of ancestry than control subjects. It is unlikely that Native American ancestry is associated with an enrichment of hemochromatosis among adult probands. British Isles ancestry, not exclusively Irish and Scots ancestries, likely accounts for the relatively high C282Y frequency in White persons in central Alabama.
A critical feature of any continuing medical education (CME) program is the inclusion of a needs assessment for its target audience. This assessment must identify both perceived and unperceived needs, so as to best capture the entire spectrum of learning opportunities for the group.We describe the process developed by the Canadian Society of Nephrology (CSN) to enhance the educational effectiveness of its Annual General Meeting program.The design of this study is the analysis of a survey questionnaire and of the Canadian Organ Replacement Registry (CORR) database.We surveyed members of the CSN and analyzed patient data from CORR aggregated by center.We tabulated votes in the survey by topic. We assessed the extent to which centers achieved CSN guideline targets on the clinical management of patients on dialysis.Perceived needs: a CSN panel constructed a list of topics, which was amplified by the inclusion of topics based on members' text responses to open-ended questions during previous iterations of this process. CSN members specified their top five choices, using an online survey instrument. Unperceived needs: an expert panel determined achievable thresholds for a number of quality metrics associated with dialysis. The quality metrics were identified from CSN guidelines. Using patient data in the CORR database, we generated center-specific performance estimates for each quality metric and constructed ratios comparing the performance of each center with the achievable threshold. We triangulated the results of the two assessments.The response rate for the perceived needs assessment survey was 16 %. This assessment identified "Primary and Secondary Glomerulonephritis" as the non-dialysis topics and "Infectious Complications of Dialysis Access" and "Volume Status and Hypertension on Dialysis" as the dialysis topics with the highest perceived learning needs. In the unperceived needs assessment, "Vascular Access Type" and "Vascular Access Monitoring" were identified as having the highest learning needs. Triangulation identified "Vascular Access Type" and "Vascular Access Monitoring" as high needs topics.Perceived needs assessment: Some topics were much more general than others, which could have led to over-selection. The response rate of 16 % limits the robustness of generalization to the membership as a whole or to all meeting attendees. Unperceived needs assessment: The assessment was limited by the data that CORR actually collects; many aspects of general nephrology practice, including glomerulonephritis, are not covered. The level of evidence underlying the various guidelines was variable, and in some cases, poor. A validated approach to data analysis in this area is lacking.To our knowledge, this is the first published example of a needs assessment for a nephrology CME event that considers both the perceived and unperceived needs of the membership. The results of this exercise are currently being used to assist in the development of a more responsive CME program.Un aspect crucial de tout programme d’enseignement médical continu (EMC) est l’inclusion d’une évaluation des besoins de la clientèle cible. Cet examen se doit de permettre l’identification tant des besoins perçus que des besoins non perçus afin de mieux cerner les occasions d’apprentissage pour le groupe.Cet article fait la description de la démarche mise au point par la Société de Néphrologie du Canada (SNC) dans le cadre du programme de son assemblée générale annuelle. Cette démarche vise accroître l’efficacité de la formation.On a procédé à l’analyse des réponses obtenues lors d’une enquête auprès des membres ainsi qu’à la consultation des métadonnées du Registre Canadien des Insuffisances et des Transplantations d’Organes (RCITO).Le sondage a été mené auprès des membres de la SCN et on a procédé à l’examen des données du RCITO cumulées dans chaque centre de soins.La compilation des réponses au sondage a été effectuée par catégories. Nous avons également évalué dans quelle mesure avaient été atteints les objectifs d’orientation fixés par les lignes directrices de la SCN quant à la conduite du traitement clinique des patients sous dialyse.Un premier volet s’attardait à définir les besoins perçus. Pour ce faire, le comité de la SCN a dressé une liste de thèmes. Cette liste s’est par la suite allongée avec l’ajout de sujets tirés des réponses des membres aux questions ouvertes colligées lors des versions antérieures du sondage. Les membres de la SCN ont spécifié les cinq thèmes qu’ils jugeaient les plus importants par le biais d’un instrument de sondage en ligne. Un second volet se penchait sur les besoins non perçus. Dans ce deuxième cas, un groupe d’experts a déterminé les seuils réalisables pour un certain nombre de paramètres de la qualité associés à la dialyse. L’identification de ces paramètres était tirée des lignes directrices de la SCN. À l’aide des données des patients contenues dans le RCITO, une appréciation de la performance de chaque centre de soins a été produite pour chacun des paramètres identifiés. Des ratios ont ensuite été construits en comparant la performance de chaque centre de soins avec le seuil réalisable établi précédemment. De plus, les résultats des deux analyses ont été triangulés.Le taux de réponse pour le sondage sur l’analyse des besoins perçus a été de 16 %. Cet examen a permis d’identifier les besoins perçus à considérer en matière de formation pour les futurs néphrologues. Du côté des sujets non reliés directement à la dialyse elle-même, on retrouve la glomérulonéphrite primaire et secondaire ainsi que les complications infectieuses liées au cathéter. Quant aux sujets directement reliés à la dialyse, on a pu identifier la volémie et l’hypertension en dialyse. En ce qui concerne les besoins non perçus, le type d’accès vasculaire et la surveillance de celui-ci ont été identifiés comme étant des sujets important à couvrir lors de la formation. Ces deux derniers sujets sont également ressortis comme très importants à considérer dans les besoins de formation lors de la triangulation des résultats.Dans le cas des besoins perçus, certains sujets étaient de nature très générale et ceci pourrait avoir conduit à une sélection excessive. Qui plus est, le très faible taux de réponse limite la robustesse d’une généralisation des résultats à tous les membres ayant participé à l’assemblée. Du côté des besoins non perçus, l’analyse est limitée par les données du RCITO où plusieurs aspects de la pratique générale en néphrologie, notamment la prise en charge de la glomérulonéphrite, ne sont pas couverts. Le degré d’éléments probants sous-jacent les différents principes directeurs s’est avéré variable et dans certains cas, médiocre. Une approche validée face à l’analyse des données dans ce domaine est manquante.À notre connaissance, cette enquête constitue la première analyse publiée des besoins, réalisée lors d’un événement d’EMC en néphrologie, qui prend en considération les besoins perçus et non perçus de ses membres. Les résultats de cet exercice sont actuellement utilisés dans le développement d’un programme d’EMC mieux adapté.
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