Carotid Plaque Score is Associated with 10-year Major Adverse Cardiovascular Events in Low-Intermediate Risk Patients Referred to a General Cardiology Community Clinic.

AIMS: Atherosclerotic carotid plaque assessments have not been integrated into routine clinical practice due to the time-consuming nature of both imaging and measurements. Plaque score, Rotterdam method, is simple, quick, and only requires 4-6 B-mode ultrasound images. The aim was to assess the benefit of plaque score in a community cardiology clinic to identify patients at risk for major adverse cardiovascular events (MACE). METHODS AND RESULTS: Patients ≥40 years presenting for risk assessment were given a carotid ultrasound. Exclusions included a history of vascular disease or MACE and being >75 years. Kaplan-Meier curves and hazard ratios were performed. The left and right common carotid artery (CCA), bulb, and internal carotid artery (ICA) were given 1 point per segment if plaque present (plaque score 0 to 6). Administrative data holdings at ICES were used for 10-year event follow-up. Of 8,472 patients, 60% were females (n = 5,121). Plaque was more prevalent in males (64% vs 53.9%; P <0.0001). The 10-year MACE cumulative incidence estimate was 6.37% with 276 events (males 6.9 % vs females 6.0%; P = 0.004). Having both maximal CCA IMT <1.00 mm and plaque score = 0, was associated with less events. A plaque score <2 was associated with a low 10-year event rate (4.1%) compared to 2-4 (8.7%) and 5-6 (20%). CONCLUSION: A plaque score ≥2 can re-stratify low-intermediate risk patients to a higher risk for events. Plaque score may be used as a quick assessment in a cardiology office to guide treatment management of patients.

New obesity treatment: Fasting, exercise and low carb diet - The NOT-FED study.

INTRODUCTION: Due to high rates of obesity in Canada, weight loss is an important primary care challenge. Recent innovations in strategies include intermittent fasting and low-carbohydrate diets, with limited research in a rural setting. METHODS: This prospective 1-year observational study provided patients in Sioux Lookout, Northwestern Ontario with information on fasting and low-carbohydrate diets. Patients were recommended to attend every 3 months for measurements of weight, waist circumference, body mass index (BMI) and blood pressure. Initial and 6-month bloodwork included A1c and Lipids. A survey of health status and diet was administered at 6 months. RESULTS: Of the 94 initial registrants, 36 participants completed 1 year and achieved a 9% weight loss and an 8.6% decrease in BMI and waist circumference. Most participants were female with an average age of 60 years. Clinically insignificant changes in blood pressure and serology were observed. Participants reported few side effects and good compliance with intermittent fasting, averaging 15 h/day, 6 days/week. As in other dietary studies, the dropout rate was high at 62%. CONCLUSION: This low-resource initiative was successful in assisting self-selected patients at a rural primary care clinic to achieve significant weight loss at 1-year. This approach is practical and is fertile ground for ongoing research.

Introduction: En raison du taux élevé d'obésité au Canada, la perte pondérale est un énorme défi en première ligne. Les récentes innovations stratégiques incluent le jeûne intermittent et les régimes faibles en glucides, qui ont fait l'objet de peu de recherche dans les contextes ruraux. Méthodologie: Cette étude prospective d'observation d'un an a fourni aux patients de Sioux Lookout, du Nord-Ouest de l'Ontario de l'information sur le jeûne et les régimes faibles en glucides. On recommandait aux patients de se présenter tous les 3 mois pour mesurer le poids, le tour de taille, l'IMC et la tension artérielle. Les analyses sanguines initiales et à 6 mois comptaient les taux d'HbA1C et de lipides. Un sondage sur l'état de santé et le régime alimentaire était administré à 6 mois. Résultats: Sur les 94 personnes initialement inscrites, 36 participants ont terminé l'étude d'un an et ont perdu 9 % de leur poids et ont réduit l'IMC et le tour de taille de 8,6 %. La plupart des participants étaient de sexe féminin et l'âge moyen était de 60 ans. Des variations significatives sur le plan clinique de la tension artérielle et de la sérologie ont été observées. Les participants ont signalé peu d'effets indésirables et ont bien observé le jeûne intermittent, en moyenne pendant 15 heures/jour, 6 jours sur 7. Tout comme dans les autres études sur les régimes alimentaires, le taux d'abandons était élevé, à 62 %. Conclusion: Cette initiative nécessitant peu de ressources a réussi à aider les patients volontaires recrutés dans une clinique rurale de première ligne à perdre significativement de poids à un an. Cette approche est pratique et est un terreau fertile pour la recherche qui continue. Mots-clés: diabète, obésité, régimes faibles en glucides, jeûne intermittent.

Intermittent fasting and weight loss: Systematic review.

OBJECTIVE: To examine the evidence for intermittent fasting (IF), an alternative to calorie-restricted diets, in treating obesity, an important health concern in Canada with few effective office-based treatment strategies. DATA SOURCES: A MEDLINE and EMBASE search from January 1, 2000, to July 1, 2019, yielded 1200 results using the key words fasting, time restricted feeding, meal skipping, alternate day fasting, intermittent fasting, and reduced meal frequency. STUDY SELECTION: Forty-one articles describing 27 trials addressed weight loss in overweight and obese patients: 18 small randomized controlled trials (level I evidence) and 9 trials comparing weight after IF to baseline weight with no control group (level II evidence). Studies were often of short duration (2 to 26 weeks) with low enrolment (10 to 244 participants); 2 were of 1-year duration. Protocols varied, with only 5 studies including patients with type 2 diabetes. SYNTHESIS: All 27 IF trials found weight loss of 0.8% to 13.0% of baseline weight with no serious adverse events. Twelve studies comparing IF to calorie restriction found equivalent results. The 5 studies that included patients with type 2 diabetes documented improved glycemic control. CONCLUSION: Intermittent fasting shows promise for the treatment of obesity. To date, the studies have been small and of short duration. Longer-term research is needed to understand the sustainable role IF can play in weight loss.

Cesarean Delivery and Vaginal Birth After Cesarean Delivery Rates in a First Nations Community-Based Obstetrical Program in Northwestern Ontario.

OBJECTIVE: To examine rates of cesarean delivery (CD) and vaginal birth after cesarean delivery (VBAC) and the patient profile in a community-based obstetrical practice. METHODS: Retrospective data from 2012 to 2017 for the Sioux Lookout Meno Ya Win Health Centre (SLMHC) were compared to data from the 30 hospitals providing the same level of services (Maternity 1b: maternity care by family physicians/midwives with CD and VBAC capacity) and Ontario. SLMHC VBAC patients were then compared to the general SLMC obstetrical population. Data included maternal age, parity, comorbidities, CD, VBAC, neonatal birth weight, and Apgar scores. RESULTS: The SLMHC obstetrical population differed from comparable obstetrical programs, with significantly higher rates of alcohol, tobacco, and opioid use and a higher prevalence of diabetes. CD rates were significantly lower (25% vs. 28%), and women delivering at SLMHC chose a trial of labour after CD almost twice as often (46% vs. 27%), resulting in a significantly higher VBAC rate (31% vs. 16%). Patients in the VBAC population differed from the general SLMHC obstetrical population, being older (7 years) and of greater parity. The neonates of VBAC patients had equivalent Apgar scores but lower rates of macrosomia and lower birth weights, although the average VBAC birth weight at 3346 g was equivalent to the provincial average. CONCLUSION: The SLMHC obstetrical program has lower CD and higher VBAC rates than expected, despite prevalent risk factors typically associated with CD. Our study demonstrates that VBAC can be safely performed in well-screened and monitored patients in a rural setting with emergency CD capacity.

Prevalence of chronic kidney disease and cardiovascular comorbidities in adults in First Nations communities in northwest Ontario: a retrospective observational study.

BACKGROUND: The prevalence of adult chronic kidney disease and cardiovascular comorbidities in Canadian Indigenous communities is largely unknown. We conducted a study to document the prevalence of chronic kidney disease and concurrent diabetes mellitus, hypertension and dyslipidemia in a First Nations population in northwest Ontario. METHODS: In this observational study, we used retrospective data collected from regional electronic medical records of 16 170 adults (age ≥ 18 yr) from 26 First Nations communities in northwest Ontario from May 2014 to May 2017. Demographic and laboratory data included age, gender, prescribed medications, estimated glomerular filtration rate, urine albumin:creatinine ratio, low-density lipoprotein cholesterol (LDL-C) level and glycated hemoglobin (HbA1c) concentration. We identified patients with diabetes by an HbA1c concentration of 6.5% or higher, or the use of a diabetic medication, those with dyslipidemia by an elevated LDL-C level (≥ 2.0 mmol/L) or use of lipid-lowering medication, and those with hypertension by use of antihypertensive medication. RESULTS: Of the 16 170 adults residing in the communities, 5224 unique patients (32.3%) had renal testing (albumin:creatinine ratio and/or estimated glomerular filtration rate). The age-adjusted prevalence of chronic kidney disease was 14.5%, and the prevalence of stage 3-5 chronic kidney disease (estimated glomerular filtration rate < 60 mL/min) was 7.0%. Most patients with chronic kidney disease (1487 [80.0%]) had at least 1 cardiovascular comorbidity. A total of 1332 patients (71.6%) had diabetes, 1313 (70.6%) had dyslipidemia, and 1098 (59.1%) had hypertension; all 3 comorbidities were present in 716 patients (38.5%). INTERPRETATION: We document a high prevalence of advanced chronic kidney disease in this First Nations population, 7.0%, double the rate in the general population. High rates of cardiovascular comorbidities were also common in these patients with chronic kidney disease, which places them at increased risk for cardiovascular disease.