A Scoping Review of Risk Factors of Hypertensive Disorders of Pregnancy in Black Women Living in High-Income Countries: An Intersectional Approach

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are maternity-related increases in blood pressure (eg, gestational hypertension, preeclampsia, and eclampsia). Compared with women of other races in high-income countries, Black women have a comparatively higher risk of an HDP. Intersectionality helps to provide a deeper understanding of the multifactorial identities that affect health outcomes in this high-risk population.

OBJECTIVE

In this review, we sought to explore the literature on HDP risk factors in Black women living in high-income countries and to assess the interaction of these risk factors using the conceptual framework of intersectionality.

METHODS

We conducted this review using the Arksey and O'Malley methodology with enhancements from Levac and colleagues. Published articles in English on HDP risk factors with a sample of not less than 10% of Black women in high-income countries were included. Six databases, theses, and dissertations were searched from January 2000 to July 2021. A thematic analysis was used to summarize the results.

RESULTS

A final total of 36 studies were included from the 15 480 studies retrieved; 4 key themes of HDP risks were identified: (1) biological; (2) individual traditional; (3) race and ethnicity, geographical location, and immigration status; and (4) gender related. These intersectional HDP risk factors intersect to increase the risk of HDP among Black women living in high-income countries.

CONCLUSION

Upstream approaches are recommended to lower the risks of HDP in this population.

Community- and Patient-Partner Engagement in Women's Cardiovascular Disease Research: A Rapid Review of the Evidence

The primary objective of this rapid review is to describe community-partner and patient-partner engagement in women's cardiovascular disease (CVD) research. Secondary objectives are to: (i) describe the phase of the research in which community and patient partners were engaged; (ii) define the level of engagement at each research phase; and (iii) make recommendations for future engagement of community and/or patient partners in women's CVD research. Rapid review guidelines recommended by the Cochrane Rapid Reviews Methods Group and Tricco et al. were used to search 5 databases using medical subject headings (MeSH) and/or keywords. Participants included women (cis and trans) aged > 18 years who had ischemic heart disease, heart failure, or stroke. A risk of bias assessment was not undertaken. Findings are summarized and/or clustered as community-based participatory research, or patient-oriented and/or patient-partner research. Our search yielded 39,998 titles and abstracts. Of these, 35 were included in a final narrative synthesis, comprising data from 474 community and/or patient partners, including 417 (88%) women. Over 85% of community partners collaborated in the design and/or planning and implementation of women's CVD research; most originated in the US; only one originated in Canada. Most patient-oriented and patient-partner research originated in Canada. However, less than 50% of patient partners collaborated in any phase of research. Sex, gender, race, and ethnicity were rarely reported. Results suggest negligible community and inadequate patient-oriented and/or patient-partner engagement in women's CVD research in Canada. Improved CVD outcomes for women may be achieved with better community- and patient-partner collaboration across all phases of research, genders, race, and ethnicities.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 8: Knowledge Gaps and Status of Existing Research Programs in Canada

Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women.

Impact of Sex and Gender on Metabolic Syndrome in Adults: A Retrospective Cohort Study From the Canadian Primary Care Sentinel Surveillance Network

OBJECTIVE

Metabolic syndrome (MetS), a cluster of 5 interconnected factors, is the main contributor to cardiovascular disease. Although sex- and gender-related elements have been linked to MetS and its components, this association has not been explored among Canadians with or without MetS. In this study, we aimed to identify sex and gender differences in characteristics of MetS in the Canadian population.

METHODS

This retrospective cohort study used data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) database. The CPCSSN contains de-identified electronic health records of >1.5 million Canadians (2010-2019). Individuals 35 to 75 years of age who had a primary care encounter formed the study sample (N=37,813). Multiple logistic regression models were used to estimate adjusted odds ratios for sex and gender differences among Canadians with and without MetS, which was the primary outcome variable.

RESULTS

The estimated prevalence of MetS was 41.9%. The risk of developing MetS was significantly lower among females compared with males (odds ratio 0.73, 95% confidence interval 0.70 to 0.76). However, the risk was higher in females who used antidepressants (odds ratio 1.53, 95% confidence interval 1.42 to 1.65). An equal distribution of deprivation indexes was observed between males and females with MetS, with risk slightly higher for those with material deprivation. Females were found to be the most socially deprived.

CONCLUSIONS

This study provides important sex- and gender-specific differences in MetS among Canadians. Targeting sex- and gender-specific risk factors could assist in reversing the trend of adverse cardiovascular outcomes associated with MetS.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations

This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.

Providing compassionate care in a virtual context: Qualitative exploration of Canadian primary care nurses' experiences

Objective

Virtual care presents a promising opportunity to create new communication channels and increase access to healthcare. However, concerns have been raised around the potential for unintended emotional distances created through virtual care environments that could strain patient-provider relationships. While compassionate care is an enabler of emotional connectivity and a core tenant of nursing, little is known about whether or how nurses have adapted their compassion skills into virtual interactions. These concerns are particularly relevant in primary care, where there is a focus on relational continuity (i.e. relationship-based, longitudinal care) and a broad uptake of virtual care. The aim of this study was to explore the meaning of compassionate virtual care and to uncover how nurses operationalized compassionate care through virtual interactions in primary care.

Methods

We used a qualitative interpretive descriptive lens to conduct semistructured interviews with primary care nurses (Ontario, Canada) who had provided virtual care (i.e. video visits, remote patient monitoring, or asynchronous messaging). We used a thematic approach to analyze the data.

Results

We interviewed 18 nurse practitioners and two registered nurses. Participants described how: (1) compassionate care was central to nursing practice, (2) compassionate care was evolving through virtual nurse-patient interaction, and (3) nurses balanced practice with patients' expectations while providing virtual compassionate care.

Conclusions

There is an opportunity to better align nurses' understanding and operationalization of compassionate care in virtual primary care contexts. Exploring how compassionate care is operationalized in primary care settings is a necessary first step to building compassionate competencies across the nursing profession to support the continued virtual evolution of health service delivery.

Retraction speed and chronic poststernotomy pain: A randomized controlled trial

OBJECTIVES

Approximately 30% of patients develop chronic poststernotomy pain (CPSP) following cardiac surgery with sternal retraction. Risk factors have been described but no causal determinants identified. Investigators hypothesized that opening the sternum slowly would impart less force (and thereby less nerve/tissue damage) and translate to a reduced incidence of CPSP. The main objectives were to determine whether or not slower sternal retraction would reduce the incidence of CPSP and improve health-related quality of life.

METHODS

Patients undergoing coronary artery bypass graft surgery were recruited to this randomized controlled trial. Patients were randomized to slow or standard retraction (ie, sternum opened over 15 minutes vs 30 seconds, respectively). Although the anesthesiologist and surgeon were aware of the randomization, the patients, assessors, and postoperative nursing staff remained blinded. Sternotomy pain and analgesics were measured in hospital. At 3, 6, and 12 months postoperatively, all patients completed the Medical Outcomes Survey Short Form and reported on CPSP and complications requiring rehospitalization. Thirty-day rehospitalizations and mortality were recorded.

RESULTS

In total, 326 patients consented to participate and 313 were randomized to slow (n = 159) versus standard retraction (n = 154). No clinically relevant differences were detected in acute pain, analgesic consumption, or the incidence of CPSP or health-related quality of life. Although the slow group had significantly more hospitalizations at 3 and 12 months postoperatively, the reasons were unrelated to retraction speed. No differences were observed in 30-day rehospitalizations or mortality.

CONCLUSIONS

All outcomes were consistent with previous reports, but no clinically significant differences were observed with retraction speed.

Health locus of control and self-management behaviours among individuals with ischaemic heart disease: protocol for a scoping review

INTRODUCTION

Ischaemic heart disease is a significant cause of morbidity and mortality worldwide. Self-management is a way to reduce the risk associated with ischaemic heart disease; however, some individuals may not have the ability or willingness to engage in self-management behaviours. One approach to identify an individual's readiness and capacity to engage in self-management behaviours is to assess their health locus of control. Based on the Individual and Family Self-Management Theory, this review's objectives are to describe: (1) how health locus of control affects the process of engaging in self-management behaviours, (2) impacts of health locus of control on outcomes associated with self-management behaviours and (3) potential contextual variations in the relationship between health locus of control and self-management behaviours.

METHODS AND ANALYSIS

The scoping review will be guided by the Joanna Briggs Institute methodological framework. A comprehensive search will encompass seven electronic databases (Ovid Medline, CINAHL, EMBASE, APA PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus) and grey literature sources (ProQuest Dissertations, ClinicalTrials.gov). Collaborative efforts with library experts will inform our search strategies, building on insights from previous reviews centred on self-management and ischaemic heart disease. Two review authors will independently conduct the screening and data extraction processes; discrepancies will be resolved through consensus or discussion with a third review author. The review will include English studies from database inception, focusing on the health locus of control among adults with ischaemic heart disease. Findings will be presented graphically and tabularly, together with a narrative description.

ETHICS AND DISSEMINATION

We will collect data from published and grey literature, meaning ethical approval is not necessary. Findings will be published in peer-reviewed journals and presented at academic conferences.

REGISTRATION DETAILS

Open Science Framework (https://doi.org/10.17605/OSF.IO/B4A6F).

Exploring the Lived Experience of Self-Management Practices of Indigenous Men, Women, and Two Spirited Individuals Living with Type 2 Diabetes in Canada, the USA, Australia, and New Zealand: A Scoping Review

BACKGROUND

Indigenous men, women and two-spirted individuals have been significantly impacted by type 2 diabetes mellitus (T2DM) and its complications. It is believed that T2DM in Indigenous Peoples is a direct result of colonization and the introduction of changes to traditional Indigenous ways of knowing, being and living.

OBJECTIVES

The broader question will guide the aim of this scoping review: What is currently known about the lived experience of self-managing diabetes in Indigenous men, women and 2S individuals living with T2DM in Canada, USA, Australia and New Zealand? Specific objectives of this scoping review include 1) to explore the lived experience of self-management practices of Indigenous men, women, and two spirited individuals living with T2DM and 2) to describe how self-management experiences, differ from physical, emotional, mental, and spiritual perspectives.

METHODS

A total of six databases were searched and included Ovid Medline, Embase, PsychINFO, CINAHL, Cochrane, and the Native Health Database. An example of keywords searched included self-management, Indigenous, Type 2 Diabetes Mellitus. A total of 37 articles were included in the synthesis of results and the four quadrants of the Medicine Wheel were used to organize and interpret data.

RESULTS

The use of culture within self-management practices was important for Indigenous Peoples. Demographic data was collected for many of the studies including sex and gender characteristics, however only a small number of studies discussed the influence of sex and gender on outcomes.

CONCLUSIONS

Results inform future Indigenous diabetes education and health care service delivery and future research.

Mental health and well-being of unpaid caregivers: a cross-sectional survey protocol

INTRODUCTION

Unpaid caregiving, care provided by family/friends, is a public health issue of increasing importance. COVID-19 worsened the mental health conditions of unpaid caregivers, increasing substance/drug use and early development of chronic disease. The impact of the intersections of race and ethnicity, sex, age and gender along with unpaid care work and caregivers' health and well-being is unknown. The aim of this study is to describe the inequities of caregiver well-being across the intersections of race and ethnicity, sex, age and gender using a cross-sectional survey design.

METHODS AND ANALYSIS

We are collaborating with unpaid caregivers and community organisations to recruit a non-probability sample of unpaid caregivers over 18 years of age (n=525). Recruitment will focus on a target sample of 305 South Asian, Chinese and Black people living in Canada, who represent 60% of the Canadian racial and ethnic populations. The following surveys will be combined into one survey: Participant Demographic Form, Caregiver Well-Being Index, interRAI Self-report of Carer Needs and the GENESIS (GENdEr and Sex DetermInantS of Cardiovascular Disease: From Bench to Beyond-Premature Acute Coronary Syndrome) PRAXY Questionnaire. Sample characteristics will be summarised using descriptive statistics. The scores from the Caregiver Well-Being Index will be dichotomised into fair/poor and good/excellent. A two-stage analytical strategy will be undertaken using logistic regression to model fair/poor well-being and good/excellent well-being according to the following axes of difference set a priori: sex, race and ethnicity, gender identity, age, gender relations, gender roles and institutionalised gender. The first stage of analysis will model the main effects of each factor and in the second stage of analysis, interaction terms will be added to each model.

ETHICS AND DISSEMINATION

The University of Toronto's Health Sciences Research Ethics Board granted approval on 9 August 2022 (protocol number: 42609). Knowledge will be disseminated in pamphlets/infographics/email listservs/newsletters and journal articles, conference presentation and public forums, social media and through the study website.

TRIAL REGISTRATION NUMBER

This is registered in the Open Sciences Framework with a Registration DOI as follows: https://doi.org/10.17605/OSF.IO/PB9TD.

Peer-support interventions for women with cardiovascular disease: protocol for synthesising the literature using an evidence map

INTRODUCTION

The leading cause of death for women is cardiovascular disease (CVD), including ischaemic heart disease, stroke and heart failure. Previous literature suggests peer support interventions improve self-reported recovery, hope and empowerment in other patient populations, but the evidence for peer support interventions in women with CVD is unknown. The aim of this study is to describe peer support interventions for women with CVD using an evidence map. Specific objectives are to: (1) provide an overview of peer support interventions used in women with ischaemic heart disease, stroke and heart failure, (2) identify gaps in primary studies where new or better studies are needed and (3) describe knowledge gaps where complete systematic reviews are required.

METHODS AND ANALYSIS

We are building on previous experience and expertise in knowledge synthesis using methods described by the Evidence for Policy and Practice Information (EPPI) and the Coordinating Centre at the Institute of Education. Seven databases will be searched from inception: CINAHL, Embase, MEDLINE, APA PsycINFO, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials, and Scopus. We will also conduct grey literature searches for registered clinical trials, dissertations and theses, and conference abstracts. Inclusion and exclusion criteria will be kept broad, and studies will be included if they discuss a peer support intervention and include women, independent of the research design. No date or language limits will be applied to the searches. Qualitative findings will be summarised narratively, and quantitative analyses will be performed using R.

ETHICS AND DISSEMINATION

The University of Toronto's Research Ethics Board granted approval on 28 April 2022 (Protocol #42608). Bubble plots (ie, weighted scatter plots), geographical heat/choropleth maps and infographics will be used to illustrate peer support intervention elements by category of CVD. Knowledge dissemination will include publication, presentation/public forums and social media.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Connecting the Dots: Structural Racism, Intersectionality, and Cardiovascular Health Outcomes for African, Caribbean, and Black Mothers

African, Caribbean, and Black (ACB) women globally experience health inequities that impact on their cardiovascular health outcomes during the perinatal period, and for years after. Aside from being at a high risk of having and dying from hypertensive disorders of pregnancy, ACB women who survive face a lifelong risk of cardiovascular disease years after the diagnosis. Racism as a determinant of health intersects with gender, societal structures, and immigration status to contribute to cardiovascular health and access to quality health care services for ACB women. Equitable policies and culturally appropriate programs are needed to improve the cardiovascular health of ACB women.

Building Capacity for Patient-Oriented Research: Utilizing Decision Aids to Translate Evidence into Practice, Policy and Outcomes

BACKGROUND

The aim of this project was to engage with patient partners to translate knowledge about the decision aids and develop a scaling-up strategy for wider effects and reach.

METHOD

This project was guided by the World Health Organization and IDEAS (Integrate, Design, Assess and Share) frameworks for design thinking (e.g., ideating creative strategies), dissemination (e.g., sharing locally and widely) and scalability.

RESULTS

We engaged 132 stakeholders in six webinars, had 321 total page views of the decision aids and conducted 16 interviews to determine revisions to the design of the decision aids before scalability.

CONCLUSION

Patient-partner collaborations assisted with design thinking, dissemination and scalability.

Patient engagement partnerships in clinical trials (PEP-CT): protocol for the systematic development and testing of patient partner and investigator decision aids

INTRODUCTION

Building capacity to improve sex/gender knowledge and strengthen patient engagement in clinical trials requires training and support. The overall goal of this 2-year project is to refine, translate and evaluate two web-based open-access patient and investigator decision aids aimed to improve patient engagement partnerships in clinical trials.

METHODS AND ANALYSIS

Two decision aids were designed in Phase 1 of this programme of research and this protocol describes a subsequent sequential phased approach to refine/translate (Phase 2A) and conduct alpha/usability (Phase 2B) and beta/field (Phase 3) testing. Decision aid development is guided by the International Patient Decision Aid Standards, User-Centred Design, Ottawa Decision-Support Framework and the Ottawa Model of Research Use. We have integrated patient-oriented research methods by engaging patient partners across all phases of our programme of research. Decision aids will first be refined and then translated to French (Phase 2A). Eight iterative cycles of semistructured interviews with 40 participants (20 patient partners and 20 investigators) will be conducted to determine usability (Phase 2B). A pragmatic pre/post pilot study design will then be implemented for field/beta testing using another purposive sample of 80 English-speaking and French-speaking participants (40 patients and 40 investigators). The samples are purposive to ensure an equal representation of English-speaking and French-speaking participants and an equal representation of men and women. Since sex and/or gender differences in utilisation and effectiveness of decision aids have not been previously reported, Phase 3 outcomes will be reported for the total sample and separately for men and women.

ETHICS AND DISSEMINATION

Ethics approval has been granted from the University of Toronto (41109, 28 September 2021). Informed consent will be obtained from participants. Dissemination will include co-authored publications, conference presentations, educational national public forums, fact sheets/newsletters, social media sharing and videos/webinars.

Biological and sociocultural determinants of increased blood pressure among women with a history of gestational diabetes mellitus in rural China: a retrospective cohort study

OBJECTIVES

Gestational diabetes mellitus (GDM) increases the risk of hypertension and cardiovascular events among mothers later in life. This risk has not been well recognised by healthcare professionals in rural China. Our objectives were to (1) describe the proportion of rural women with increased blood pressure and a history of GDM; and (2) explore the biological and sociocultural factors associated with increased blood pressure.

DESIGN

A retrospective cohort study using data from a cross-sectional survey.

SETTING

Data were collected in two county-level hospitals in the central south of China between November 2017 and June 2018.

PARTICIPANTS

Postpartum women aged >18 years with a history of GDM (N=397).

METHODS

Biological and sociocultural variables were examined. We used bivariate analyses to examine the associations between time since delivery and 2-hour postload glucose, and logistic regression to determine the biological and sociocultural factors associated with increased postpartum blood pressure.

RESULTS

Approximately 20% (n=78) of women had increased blood pressure, defined as a systolic blood pressure ≥130 mm Hg and/or a diastolic blood pressure ≥85 mm Hg. The biological factors of advanced age, family history of hypertension and abnormal 2-hour postload plasma glucose levels were positively associated with increased blood pressure (p<0.05). General self-efficacy was the only sociocultural factor negatively associated with increased blood pressure (p<0.05).

CONCLUSIONS

One in five rural Chinese postpartum women with a history of GDM were found to have increased blood pressure. Biological and sociocultural factors were associated with increased postpartum blood pressure; women with lower general self-efficacy were more likely to have increased blood pressure. Disseminating knowledge about the high risk of developing increased blood pressure among women with prior GDM in rural China is indicated. Diabetes prevention programmes could consider adding general self-efficacy promotion strategies in this population.

Intramuscular ossifying metastasis from oesophageal carcinoma, with a pattern distinct from myositis ossificans - A case report

Muscle metastasis is uncommon. We present second reported case of ossifying metastasis from oesophageal carcinoma and review the literature. Our case highlights the different patterns of ossification in muscle, which is essential to make the diagnosis of myositis ossificans, a "don't touch lesion" in contrast to muscle metastasis or tumour, that needs oncological management.

“Her Heart Matters”—Making Visible the Cardiac Pain Experiences of Women with Physical Disabilities and Heart Disease: A Qualitative Study

Background

Women with physical disabilities are faced with challenges in many aspects of life—education, work, income, relationships, as well as their general health. These women are at a greater risk of developing heart disease. This study aimed to explore the cardiac pain experiences of women with physical disabilities and heart disease within a Canadian healthcare context.

Methods

In this qualitative study, 8 women with physical disabilities and heart disease from across Canada were interviewed. They were asked about their pre-, peri-, and post-diagnostic experiences in the Canadian healthcare system. Transcripts of the interviews were analyzed using a hermeneutic phenomenological approach inspired by Ricoeur.

Results

Two main themes were uncovered in the analysis of the transcripts, as follows: (i) the diagnostic journey; and (ii) life with cardiac symptoms and a disability. The women indicated that they had experienced difficulties in utilizing the Canadian healthcare system prior to receiving a cardiac diagnosis, including long waitlists, expensive and unreliable transport, issues with accessibility, and dealing with providers’ attitudinal barriers regarding disability. Receiving a diagnosis was challenging due to poor relationships with healthcare providers; however, having a same-sex provider seemed essential to receiving adequate care. Self-managing a disability and heart disease had significant physical and psychological impact, which was lightened by financial and social supports, modified lifestyle choices, and self-advocacy.

Conclusions

Women with physical disabilities are often forgotten in discussions encompassing equity and inclusion. The participants’ experiences offer insight into what changes are needed within the Canadian healthcare system in order to improve outcomes for these women.

The Canadian Women’s Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women — Chapter 4: Sex- and Gender-Unique Disparities: CVD Across the Lifespan of a Woman

Women have unique sex- and gender-related risk factors for cardiovascular disease (CVD) that can present or evolve over their lifespan. Pregnancy-associated conditions, polycystic ovarian syndrome, and menopause can increase a woman’s risk of CVD. Women are at greater risk for autoimmune rheumatic disorders, which play a role in the predisposition and pathogenesis of CVD. The influence of traditional CVD risk factors (eg, smoking, hypertension, diabetes, obesity, physical inactivity, depression, anxiety, and family history) is greater in women than men. Finally, there are sex differences in the response to treatments for CVD risk and comorbid disease processes. In this Atlas chapter we review sex- and gender-unique CVD risk factors that can occur across a woman’s lifespan, with the aim to reduce knowledge gaps and guide the development of optimal strategies for awareness and treatment.

Predictors of one year chronic post-surgical pain trajectories following thoracic surgery

PURPOSE

Chronic post-surgical pain (CPSP) is a highly prevalent complication following thoracic surgery. This is a prospective cohort study that aims to describe the pain trajectories of patients undergoing thoracic surgery beginning preoperatively and up to 1 year after surgery METHODS: Two hundred and seventy nine patients undergoing elective thoracic surgery were enrolled. Participants filled out a preoperative questionnaire containing questions about their sociodemographic information, comorbidities as well as several psychological and pain-related statuses. They were then followed-up during their immediate postoperative period and at the three, six and 12 month time-points to track their postoperative pain, complications and pain-related outcomes. Growth mixture modeling was used to construct pain trajectories.

RESULTS

The first trajectory is characterized by 185 patients (78.1%) with mild pain intensity across the 12 month period. The second is characterized by 32 patients (7.5%) with moderate pain intensity immediately after surgery which decreases markedly by 3 months and remains low at the 12 month follow-up. The final trajectory is characterized by 20 patients (8.4%) with moderate pain intensity immediately after surgery which persists at 12 months. Patients with moderate to severe postoperative pain intensity were much more likely to develop CPSP compared to patients with mild pain intensity. Initial pain intensity levels immediately following surgery as well as levels of pain catastrophizing at baseline were predicting pain trajectory membership. None of the surgical or anesthetic-related variables were significantly associated with pain trajectory membership.

CONCLUSION

Patients who undergo thoracic surgery can have postoperative pain that follows one of the three different types of trajectories. Higher levels of immediate postoperative pain and preoperative pain catastrophizing were associated with moderately severe CPSP.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women-Chapter 2: Scope of the Problem

Background

This Atlas chapter summarizes the epidemiology of cardiovascular disease (CVD) in women in Canada, discusses sex and gender disparities, and examines the intersectionality between sex and other factors that play a prominent role in CVD outcomes in women, including gender, indigenous identity, ethnic variation, disability, and socioeconomic status.

Methods

CVD is the leading cause of premature death in Canadian women. Coronary artery disease, including myocardial infarction, and followed by stroke, accounts for the majority of CVD-related deaths in Canadian women. The majority of emergency department visits and hospitalizations by women are due to coronary artery disease, heart failure, and stroke. The effect of traditional cardiovascular risk factors and their association with increasing cardiovascular morbidity is unique in this group.

Results

Indigenous women in Canada experience increased CVD, linked to colonization and subsequent social, economic, and political challenges. Women from particular racial and ethnic backgrounds (ie, South Asian, Afro-Caribbean, Hispanic, and Chinese North American women) have greater CVD risk factors, and CVD risk in East Asian women increases with duration of stay in Canada.

Conclusions

Canadians living in northern, rural, remote, and on-reserve residences experience greater CVD morbidity, mortality, and risk factors. An increase in CVD risk among Canadian women has been linked with a background of lower socioeconomic status, and women with disabilities have an increased risk of adverse cardiac events.

Primary and Secondary Cardiovascular Prevention Among First Nations Peoples With Type 2 Diabetes in Canada: Findings From the FORGE AHEAD Program

Background

First Nations (FN) peoples in Canada face spiraling rates of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). Data on the extent of CVD risk-factor management in FN peoples with T2DM in Canada are scarce.

Methods

A T2DM registry with data from 7 FN communities in Canada was utilized to identify individuals eligible for primary and secondary CVD prevention. Proportions of individuals meeting clinical practice guideline-specified targets (hemoglobin A1c ≤7.0%; blood pressure ≤130/80 mm Hg; low-density lipoprotein ≤2 mmol/L) were calculated. Prescription of recommended cardioprotective medications (antithrombotic medication, lipid-lowering agents, renin-angiotensin-aldosterone system inhibitors, and beta-blockers) among those with CVD was assessed. χ² tests were employed to evaluate differences between CVD prevention groups and sexes.

Results

Of the 2098 individuals in the registry, 18% had documented CVD (female: male = 1.12). Overall, <10% met all 3 clinical practice guideline targets. Attainment of hemoglobin A1c and blood pressure targets was comparable between primary and secondary CVD prevention groups, with<50% achieving targets. A greater proportion of the secondary prevention group met low-density lipoprotein targets compared to those without CVD (61.6% vs 40.9%, P < 0.01). In the secondary prevention group, beta-blockers were prescribed to only 20%, and <60% were prescribed antithrombotics, lipid-lowering medications, or agents targeting the renin-angiotensin-aldosterone system; <2% were prescribed medications from all 4 classes of cardioprotective medications.

Conclusions

Primary and secondary CVD prevention recommendations for individuals with T2DM are not being met for an alarmingly high proportion of FN peoples. These findings serve as an urgent call for proactive measures to reduce CVD events and related mortality in this high-risk population.

Patient Engagement Partnerships in Clinical Trials: Development of Patient Partner and Investigator Decision Aids

BACKGROUND

A 2017 systematic review suggested patient engagement in clinical trials has been limited, with little active engagement in trial design or data analysis, interpretation or dissemination. Additionally, there remains limited sex/gender reporting in clinical trial research.

OBJECTIVES

The overall goal of this project was to disseminate sex/gender knowledge and build capacity for patient engagement in clinical trials. Specific objectives were to (1) create capacity and identify opportunities for patient engagement in clinical trials and sponsor- or investigator-led activities (e.g. clinical trial design and conduct); and (2) enhance new/early investigator sex/gender knowledge and skills related to patient-oriented research (POR).

METHODS

We used the Canadian Institutes of Health Research Strategy for Patient-Oriented Research (SPOR) Capacity Development Framework and the SPOR Patient Engagement Framework to guide three phases of this project: (1) conduct a scoping review using methods described by the Evidence for Policy and Practice Information (EPPI) and the Coordinating Centre at the Institute of Education (Phase 1); (2) host a 1-day POR consultation workshop (Phase 2); and (3) deliver a new/early investigator POR training day (Phase 3). Six electronic databases (CINAHL, MEDLINE, EMBASE, PsychInfo, the Cochrane Library, and AMED) were searched from 1996 using keywords and Medical Subject Heading (MeSH) terms in accordance with the International Association for Public Participation (IAP2) and the search criteria in the bibliographic databases. Standard approaches were used to search the grey literature.

RESULTS

A total of 79 studies and over 150 websites were subject to data abstraction by team members, capturing information on sex/gender and SPOR's patient engagement guiding principles of inclusiveness, support, mutual respect, and co-building. Results were presented to 32 key stakeholders at the consultation workshop and input was sought on next steps using nominal group techniques. Based on the plethora of existing POR resources, relevant POR information from the scoping review was collated into two decision aids (patient and investigator) to determine readiness to engage with/as a patient partner in a clinical trial. The decision aids were presented at a POR training day with 88 new/early investigators, clinicians, patient partners and decision makers. The decision aids showed 'good' usability, assessed using the System Usability Scale (SUS). Attendees thought the decision aids were engaging, they increased their understanding of sex/gender, patient engagement and POR, and they would recommend them to others. POR principles and practices were integrated across all phases of the project. Patient partners (1) identified research priorities/search terms; (2) collected/analyzed data; (3) designed the patient partner decision aid; and (4) disseminated the results through presentation.

CONCLUSION

Our digital patient partner and investigator decision aids are the first to provide information technology to deliver sex/gender, POR knowledge, and decision support beyond the traditional decision aids used for health screening and/or treatment decisions. The decision aids have the potential to make a significant contribution to Canada's Strategy for POR and support the collaborative efforts of patients and investigators to build a sustainable, accessible and equitable health care system.

A Smartphone App (mDASHNa-CC) to Support Healthy Diet and Hypertension Control for Chinese Canadian Seniors: Protocol for Design, Usability and Feasibility Testing

BACKGROUND

This proposed study aims to translate the Dietary Approach to Stop Hypertension with Sodium (Na) Reduction for Chinese Canadians (DASHNa-CC), a classroom-based, antihypertensive, dietary educational intervention, to an innovative smartphone app (mDASHNa-CC). This study will enable Chinese Canadian seniors to access antihypertensive dietary interventions anytime, regardless of where they are. It is hypothesized that senior Chinese Canadians will be satisfied with their experiences using the mDASHNa-CC app and that the use of this app could lead to a decrease in their blood pressure and improvement in their health-related quality of life.

OBJECTIVE

The goal of this study is to design and test the usability and feasibility of a smartphone-based dietary educational app to support a healthy diet and hypertension control for Chinese Canadian seniors.

METHODS

A mixed-method two-phase design will be used. The study will be conducted in a Chinese immigrant community in Toronto, Ontario, Canada. Chinese Canadian seniors, who are at least 65 years old, self-identified as Chinese, living in Canada, and with elevated blood pressure, will be recruited. In Phase I, we will design and test the usability of the app using a user-centered approach. In Phase II, we will test the feasibility of the app, including implementation (primary outcomes of accrual and attrition rates, technical issues, acceptability of the app, and adherence to the intervention) and preliminary effectiveness (secondary outcomes of systolic and diastolic blood pressure, weight, waist circumference, health-related quality of life, and health service utilization), using a pilot, two-group, randomized controlled trial with a sample size of 60 participants in a Chinese Canadian community.

RESULTS

The study is supported by the Startup Research Grant from Nipissing University, Canada. The research ethics application is under review by a university research ethics review board.

CONCLUSIONS

The study results will make several contributions to the existing literature, including illustrating the rigorous design and testing of smartphone app technology for hypertension self-management in the community, exploring an approach to incorporating traditional medicine into chronic illness management in minority communities and promoting equal access to current technology among minority immigrant senior groups.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03988894; https://clinicaltrials.gov/ct2/show/NCT03988894.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/15545.

Predicting the periodic risk of anthrax in livestock in Victoria, Australia, using meteorological data

Cases of anthrax in livestock are infrequently and irregularly reported in the state of Victoria, Australia; however, their impact on individual livestock, farming communities and the government agencies tasked with containing these outbreaks is high. This infrequency has been anecdotally associated with differences in annual and local weather patterns. In this study, we used historical anthrax cases and meteorological data from weather stations throughout Victoria to train a generalized linear mixed effects model to predict the daily odds of a case of anthrax occurring in each shire in the coming 30 days. Meteorological variables were transformed to deviations from the mean values for temperature or cumulative values for rainfall in the shire across all years. Shire was incorporated as a random effect to account for meteorological variation between shires. The model incorporated a post hoc weighting for the frequency of historic cases within each shire and the spatial contribution of each shire to the recently redefined Australian Anthrax Belt. Our model reveals that anthrax cases were associated with drier summer conditions (OR 0.96 (95% CI 0.95-0.97) and OR 0.98 (95% CI 0.97-0.99) for every mm increase in rainfall during September and December, respectively) and cooler than average spring (OR 0.20 (95% CI 0.11-0.52) for every °C increase in minimum daily temperature during November and warmer than average summer temperatures (OR 1.45 (95% CI 1.29-1.61) for every °C increase in maximum daily temperature during January. Cases were also preceded by a 40-day period of cooler, drier temperatures (OR 0.5 (95% CI 0.27-0.74) for every °C increase in maximum daily temperature and OR 0.96 (95% CI 0.95-0.97) for every mm increase in rainfall followed by a warmer than average minimum (or nightly) temperature 10 days immediately before the case (OR 1.46 (95% CI 1.35-1.58) for every °C increase in maximum daily temperature). These coefficients of this training model were then applied daily to meteorological data for each shire, and output of these models was presented as a choropleth and timeline plot in a Shiny web application. The application builds on previous spatial modelling and provides Victorian agencies with a tool to engage at-risk farmers and guide discussions towards anthrax control. This application can contribute to the wider rejuvenation of anthrax knowledge and control in Victoria and corroborates the anecdote that increased odds of disease can be linked to meteorological events.

Development and usability testing of HEARTPA♀N: protocol for a mixed methods strategy to develop an integrated smartphone and web-based intervention for women with cardiac pain

INTRODUCTION

More women experience cardiac pain related to coronary artery disease and cardiac procedures compared with men. The overall goal of this programme of research is to develop an integrated smartphone and web-based intervention (HEARTPA♀N) to help women recognise and self-manage cardiac pain.

METHODS AND ANALYSIS

This protocol outlines the mixed methods strategy used for the development of the HEARTPA♀N content/core feature set (phase 2A), usability testing (phase 2B) and evaluation with a pilot randomised controlled trial (RCT) (phase 3). We are using the individual and family self-management theory, mobile device functionality and pervasive information architecture of mHealth interventions, and following a sequential phased approach recommended by the Medical Research Council to develop HEARTPA♀N. The phase 3 pilot RCT will enable us to refine the prototype, inform the methodology and calculate the sample size for a larger multisite RCT (phase 4, future work). Patient partners have been actively involved in setting the HEARTPA♀N research agenda, including defining patient-reported outcome measures for the pilot RCT: pain and health-related quality of life (HRQoL). As such, the guidelines for Inclusion of Patient-Reported Outcomes in Clinical Trial Protocols (SPIRIT-PRO) are used to report the protocol for the pilot RCT (phase 3). Quantitative data (eg, demographic and clinical information) will be summarised using descriptive statistics (phases 2AB and 3) and a content analysis will be used to identify themes (phase 2AB). A process evaluation will be used to assess the feasibility of the implementation of the intervention and a preliminary efficacy evaluation will be undertaken focusing on the outcomes of pain and HRQoL (phase 3).

ETHICS AND DISSEMINATION

Ethics approval was obtained from the University of Toronto (36415; 26 November 2018). We will disseminate knowledge of HEARTPA♀N through publication, conference presentation and national public forums (Café Scientifique), and through fact sheets, tweets and webinars.

TRIAL REGISTRATION NUMBER

NCT03800082.

Experiences of informal caregivers after cardiac surgery: a systematic integrated review of qualitative and quantitative studies

OBJECTIVES

To provide a comprehensive synthesis of informal caregivers' experiences of caring for a significant other following discharge from cardiac surgery.

DESIGN

Systematic integrated review without meta-analysis.

DATA SOURCES

A bibliographic search for publications indexed in six databases (Cochrane Library, CINAHL, MEDLINE, EMBASE, AMED and PsycINFO), including a scan of grey literature sources (GreyNet International, Google Scholar, Web of Science, WorldCat and the Clinical Trials Registry) was conducted in October 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they described views and perspectives of informal caregivers of cardiac surgery patients (non-intervention studies (qualitative and quantitative)), and the effectiveness of interventions to evaluate support programme for informal caregivers of cardiac surgery patients (intervention studies).

RESULTS

Of the 4912 articles identified in searches, 42 primary research studies were included in a narrative synthesis with 5292 participants, including 3231 (62%) caregivers of whom 2557 (79%) were women. The median sample size across studies was 96 (range 6-734). Three major themes emerged from the qualitative study data: (1) caregiver information needs; (2) caregiver work challenges and (3) caregivers adaption to recovery. Across the observational studies (n=22), similar themes were found. The trend across seven intervention studies focused on caregiver information needs related to patient disease management and symptom monitoring, and support for caregivers to reduce symptoms of emotional distress.

CONCLUSION

Informal caregivers want to assist in the care of their significant others after hospital discharge postcardiac surgery. However, caregivers feel insecure and overwhelmed and they lack clear/concise discharge information and follow-up support during the early at-home recovery period. The burden of caregiving has been recognised and reported since the early 1990s, but there remains a limited number of studies that assesses the effectiveness of caregiver interventions.

PROSPERO REGISTRATION NUMBER

CRD42018096590.

Prosthetic fungal infections: poor prognosis with bacterial co-infection

AIMS

The aims of this study were to report the efficacy of revision surgery for patients with co-infective bacterial and fungal prosthetic joint infections (PJIs) presenting to a single institution, and to identify prognostic factors that would guide management.

PATIENTS AND METHODS

A total of 1189 patients with a PJI were managed in our bone infection service between 2006 and 2015; 22 (1.85%) with co-infective bacterial and fungal PJI were included in the study. There were nine women and 13 men, with a mean age at the time of diagnosis of 64.5 years (47 to 83). Their mean BMI was 30.9 kg/m² (24 to 42). We retrospectively reviewed the outcomes of these PJIs, after eight total hip arthroplasties and 14 total knee arthroplasties. The mean clinical follow-up was 4.1 years (1.4 to 8.8).

RESULTS

The median number of risk factors for PJI was 5.5 (interquartile range (IQR) 3.25 to 7.25). All seven patients who initially underwent debridement and implant retention (DAIR) had a recurrent infection that led to a staged revision. All 22 patients underwent the first of a two-stage revision. None of the nine patients with negative tissue cultures at the second stage had a recurrent infection. The rate of recurrent infection was significantly higher in the presence of multidrug-resistant bacteria (p = 0.007), a higher C-reactive protein (CRP) at the time of presentation (p = 0.032), and a higher number of co-infective bacterial organisms (p = 0.041). The overall rate of eradication of infection after two and five years was 50% (95% confidence interval (CI) 32.9 to 75.9) and 38.9% (95% CI 22.6 to 67), respectively.

CONCLUSION

The risk of failure to eradicate infection with the requirement of amputation associated with this diagnosis is much higher than in patients with PJI without bacterial and fungal co-infection, and this risk is heightened when the fungal organism is joined by polymicrobial and multidrug-resistant bacterial organisms. Cite this article: Bone Joint J 2019;101-B:582-588.

Mechanisms of failure and survival of total femoral endoprosthetic replacements

AIMS

The aim of this study was to evaluate the prosthesis characteristics and associated conditions that may modify the survival of total femoral endoprosthetic replacements (TFEPR).

PATIENTS AND METHODS

In all, 81 patients treated with TFEPR from 1976 to 2017 were retrospectively evaluated and failures were categorized according to the Henderson classification. There were 38 female patients (47%) and 43 male patients (53%) with a mean age at diagnosis of 43 years (12 to 86). The mean follow-up time was 10.3 years (0 to 31.7). A survival analysis was performed followed by univariate and multivariate Cox regression to identify independent implant survival factors.

RESULTS

The revision-free survival of the implant was 71% at five years and 63.3% at ten years. Three prostheses reached 15 years without revision. The mean Musculoskeletal Tumor Society score in the group was 26 (23 to 28). The mechanisms of failure were infection in 18%, structural failures in 6%, tumour progression in 5%, aseptic loosening in 2%, and soft-tissue failures in 1%. Prostheses used for primary reconstruction after oncological resections had lower infection rates than revision implants (8% vs 25%; p = 0.001). The rates of infection in silver-coated and non-silver-coated prosthesis were similar (17.4% vs 19.%; p = 0.869). The incidence of hip dislocation was 10%. Rotating hinge prosthesis had a lower failure rate than fixed hinge prosthesis (5.3% vs 11%). After Cox regression, the independent factors associated with failures were the history of previous operations (hazard ratio (HR) 3.7; p = 0.041), and the associated arthroplasty of the proximal tibia (HR 3.8; p = 0.034). At last follow-up, 11 patients (13%) required amputation.

CONCLUSION

TFEPR offers a reliable reconstruction option for massive bone loss of the femur, with a good survival when the prosthesis is used as a primary implant. The use of a rotating hinge at the knee and dual mobility bearing at the hip may be adequate to reduce the risk of mechanical and soft-tissue failures. Infection remains the main concern and there is insufficient evidence to support the routine use of silver-coated endoprosthesis. Cite this article: Bone Joint J 2019;101-B:522-528.

Toward a phenomic analysis of chronic postsurgical pain following cardiac surgery

Background: Despite the same surgical approach, up to 40% of patients develop chronic postsurgical pain (CPSP) following cardiac surgery, whereas the rest are chronic pain free. This variability suggests that CPSP is controlled partially through genetics, but the genes for CPSP are largely unknown.

Aims: The aim of this study was to identify potential CPSP phenotypes by comparing patients who developed CPSP following cardiac surgery vs. those who did not.

Methods: A research ethics board–approved, cross-sectional study of post–cardiac surgery pain was conducted at Toronto General Hospital from 2011 to 2015. Patients were recruited to complete a short survey of chronic pain scores and the Short-Form McGill Pain Questionnaire–2. A subset of patients completed a longer survey of eight validated pain phenotyping questionnaires and/or four psychophysical assessments. All surveys and psychophysical testing were conducted after surgery. Patients were stratified by presence of chronic pain and groups were compared using descriptive statistics.

Results: Six hundred forty-three patients completed the short form survey. The mean postsurgery assessment time was 41.5 (SD = ±25.1) months. Over a quarter (27.8%) reported CPSP at the chest as a consequence of their surgery. Of patients reporting CPSP, 46.6% reported mild pain (0–3), 35.8% reported moderate pain (4–7), and 17.6% reported severe pain (7–10) in accordance with the numerical rating scale. Patients with moderate and/or severe CPSP were younger, had a greater body mass index, and had higher anxiety sensitivity, pain catastrophizing, and somatization scores.

Conclusions: Chronic pain levels after cardiac surgery are associated with anxiety, catastrophizing, and sensory abnormalities in body parts outside the field innervated by injured nerves, indicating the presence of widespread central sensitization to incoming sensory inputs from intact nerves.

Long-term outcomes after an initial experience of computer-navigated resection of primary pelvic and sacral bone tumours

Aims

The aim of this study was to investigate the local recurrence rate at an extended follow-up in patients following navigated resection of primary pelvic and sacral tumours.

Patients and Methods

This prospective cohort study comprised 23 consecutive patients (nine female, 14 male) who underwent resection of a primary pelvic or sacral tumour, using computer navigation, between 2010 and 2012. The mean age of the patients at the time of presentation was 51 years (10 to 77). The rates of local recurrence and mortality were calculated using the Kaplan–Meier method.

Results

Bone resection margins were all clear and there were no bony recurrences. At a mean follow-up for all patients of 59 months (12 to 93), eight patients (34.8%) developed soft-tissue local recurrence, with a cumulative rate of local recurrence at six-years of 35.1% (95% confidence interval (CI) 19.3 to 58.1). The cumulative all-cause rate of mortality at six-years was 26.1% (95% CI 12.7 to 49.1).

Conclusion

Despite the positive early experience with navigated-assisted resection, local recurrence rates remain high. With increasing knowledge of the size of soft-tissue margins required to reduce local recurrence and the close proximity of native structures in the pelvis, we advise against compromising resection to preserve function, and encourage surgeons to reduce local recurrence by prioritizing wide resection margins of the tumour. Cite this article: Bone Joint J 2019;101-B:484–490.

Self-management and blood pressure control in China: a community-based multicentre cross-sectional study

OBJECTIVES

This study explored the relationship between self-management and blood pressure (BP) control in China.

DESIGN

A cross-sectional study.

SETTING

Eight community health centres from four cities in the Northeast (Shenyang), Northwest (Xi'an), Southwest (Chengdu) and South (Changsha) of China.

PARTICIPANTS

A total of 873 adults with hypertension, including 360 men and 513 women. Hypertension was defined as systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg.

OUTCOME MEASUREMENTS

BP control was the primary outcome variable. This was categorised as good control if individuals with hypertension reduced their BP to <140/90 mm Hg, otherwise, it was categorised as poor control. Secondary outcomes included self-management, defined as: (1) context or condition-specific factors or physical/social environments (eg, age, sex, marital status, education, personal income and health insurance) and (2) process or knowledge/beliefs, self-regulation skills/abilities and social facilitation (eg, treatment, diet, exercise and risk factor management). Data were analysed using logistic regression models using SPSS V.20.

RESULTS

A total of 67.1% (n=586) participants had poor BP control. Limited outpatient care benefits in mainly rural residents (OR 2.26, 95% CI 1.06 to 4.81) and longer disease duration (OR 1.03, 95% CI 1.01 to 1.04) were associated with poor BP control. Self-management practices reduced the odds of having poor BP control (OR 0.98, 95% CI 0.97 to 0.99).

CONCLUSIONS

The individual and family self-management theory can serve as an effective theory for understanding the key contexts, processes and outcomes essential for BP control in China. Future research should evaluate the effect of a self-management intervention (eg, self-monitoring, medication adherence, regular and routine doctor visits, and social supports) for BP control in China using a multisite cluster randomised controlled trial. Sex and gender difference, cost and patient-reported outcomes should also be examined.

Prognostic factors for local recurrence in extremity-located giant cell tumours of bone with pathological fracture

AIMS

The aim of this paper was to investigate the prognostic factors for local recurrence in patients with pathological fracture through giant cell tumours of bone (GCTB).

PATIENTS AND METHODS

A total of 107 patients presenting with fractures through GCTB treated at our institution (Royal Orthopaedic Hospital, Birmingham, United Kingdom) between 1995 and 2016 were retrospectively studied. Of these patients, 57 were female (53%) and 50 were male (47%).The mean age at diagnosis was 33 years (14 to 86). A univariate analysis was performed, followed by multivariate analysis to identify risk factors based on the treatment and clinical characteristics.

RESULTS

The initial surgical treatment was curettage with or without adjuvants in 55 patients (51%), en bloc resection with or without reconstruction in 45 patients (42%), and neoadjuvant denosumab, followed by resection (n = 3, 3%) or curettage (n = 4, 4%). The choice of treatment depended on tumour location, Campanacci tumour staging, intra-articular involvement, and fracture displacement. Neoadjuvant denosumab was used only in fractures through Campanacci stage 3 tumours. Local recurrence occurred in 28 patients (25%). Surgery more than six weeks after the fracture did not affect the risk of recurrence in any of the groups. In Campanacci stage 3 tumours not treated with denosumab, en bloc resection had lower local recurrences (13%), compared with curettage (39%). In tumours classified as Campanacci 2, intralesional curettage and en bloc resections had similar recurrence rates (21% and 24%, respectively). After univariate analysis, the type of surgical intervention, location, and the use of denosumab were independent factors predicting local recurrence. Further surgery was required 33% more often after intralesional curettage in comparison with resections (mean 1.59, 0 to 5 vs 1.06, 0 to 3 operations). All patients treated with denosumab followed by intralesional curettage developed local recurrence.

CONCLUSION

In patients with pathological fractures through GCTB not treated with denosumab, en bloc resection offers lower risks of local recurrence in tumours classified as Campanacci stage 3. Curettage or resections are both similar options in terms of the risk of local recurrence for tumours classified as Campanacci stage 2. The benefits of denosumab followed by intralesional curettage in these patients still remains unclear.

Self-Management of Cardiac Pain in Women: A Meta-Summary of the Qualitative Literature

Symptom recognition and self-management is instrumental in reducing the number of deaths related to coronary artery disease (CAD) in women. The purpose of this study was to synthesize qualitative research evidence on the self-management of cardiac pain and associated symptoms in women. Seven databases were systematically searched, and the concepts of the Individual and Family Self-Management Theory were used as the framework for data extraction and analysis. Search strategies yielded 22,402 citations, from which 35 qualitative studies were included in a final meta-summary, comprising data from 769 participants, including 437 (57%) women. The available literature focused cardiac pain self-management from a binary sex and gender perspective. Ethnicity was indicated in 19 (54%) studies. Results support individualized intervention strategies that promote goal setting and action planning, management of physical and emotional responses, and social facilitation provided through social support.

Association between self-perceived pain sensitivity and pain intensity after cardiac surgery

Background and purpose

Cardiac surgical pain remains a clinical challenge affecting about 40% of individuals in the first six months post-cardiac surgery, and continues up to two years after surgery for about 15–20%. Self-perceived sensitivity to pain may help to identify individuals at risk for persistent cardiac surgical pain to optimize health care responses. The purpose of this study was to assess the relationship between self-perceived pain sensitivity assessed by the Pain Sensitivity Questionnaire (PSQ) and postoperative worst pain intensity up to 12 months after cardiac surgery. Sex differences in baseline characteristics and the PSQ scores were also assessed.

Methods

This study was performed among 416 individuals (23% women) scheduled for elective coronary artery bypass graft and/or valve surgery between March 2012 and September 2013. A secondary data-analysis was utilized to explore the relationship between preoperative PSQ scores and worst pain intensity rated preoperatively, across postoperative Days 1–4, at 2 weeks, and at 1, 3, 6, and 12 months post-surgery. Linear mixed model analyses were performed to estimate changes in pain intensity during 1-year follow-up.

Results

The mean (±standard deviation) PSQ-total score was 3.3±1.4, with similar scores in men and women. The PSQ-total score was significantly associated with higher worst pain intensity ratings adjusted for participant characteristics (p=0.001).

Conclusion

Use of the PSQ before surgery may predict cardiac surgical pain intensity. However, previous evidence is limited and not consistent, and more research is needed to substantiate our results.