Lead, cadmium and aluminum in Canadian infant formulae, oral electrolytes and glucose solutions

Lead (Pb), cadmium (Cd) and aluminum (Al) were determined in 437 individual samples of infant formulae, oral electrolytes and 5% glucose solutions available in Canada. In the electrolytes, Cd and Pb concentrations were all below 0.01 and 0.041 ng g−1, respectively. In the 5% glucose solutions, Pb and Cd levels averaged 0.01 and 0.09 ng g−1, respectively. Reported on an as-consumed basis, Pb levels in milk- and soya-based formulae averaged 0.90 and 1.45 ng g−1, respectively, while Cd levels averaged 0.23 and 1.18 ng g−1, respectively Average Al levels on an as-consumed basis were 440 ng g−1 (range 10–3400 ng g−1) in milk-based formulae and 730 ng g−1 (range 230–1100 ng g−1) in soy-based formulae. Al concentrations increased in the following order: plain formula < low-iron formula < iron-supplemented formula < casein hydrolysate formula ≈ premature formula ≤ soy formula. For example, in the powdered formulae, average Al concentrations were 18 ng g−1 for plain milk-based, 37 ng g−1 for low-iron, 128 ng g−1 for iron supplemented, 462 ng g−1 for lactose-free, 518 ng g−1 for hypoallergenic and 619 ng g−1 for soy-based formula. Al concentrations, as-consumed, increased with decreasing levels of concentration: powder < concentrated liquid < ready-to-use. Formulae stored in glass bottles contained between 100 and 300 ng g−1 more Al than the same formulae stored in cans. The source of the increased Al did not appear to be the glass itself, because most electrolytes and glucose solutions, also stored in glass, contained less than 8 ng g−1 Al. Corresponding differences in Pb and Cd levels were not observed. Al concentrations varied substantially among manufacturers; however, all manufacturers were able to produce plain milk-based formulae containing less than 50 ng g−1 Al, i.e. within the range of Al concentrations found in human milk. Next to soya-based and hypoallergenic formulae, premature formulae contained among the highest concentrations of Al, ranging 851–909 ng g−1 from one manufacturer and 365–461 ng g−1 from another

Factors Influencing the Prescription of Cardiovascular Preventive Therapies in Patients with Peripheral Arterial Disease.

BACKGROUND:Guidelines recommend that patients with peripheral arterial disease should be medically treated to reduce the occurrence of serious cardiovascular events. Despite these recommendations, studies conducted in the early 2000s reported that medical therapies for secondary cardiovascular prevention are not given systematically to patients with peripheral arterial disease (PAD). We identified factors associated with the prescription of preventive therapies in patients with symptomatic PAD. METHODS AND FINDINGS:Consecutive patients with symptomatic peripheral arterial disease (n = 362) treated between 2008 and 2010 in one tertiary care center (CHU de Quebec, Canada) were considered. Data were collected from the medical charts. The main outcome was the combined prescription of three therapies: 1) statins, 2) antiplatelets, 3) angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers. The mean age was 70 years and 43% had a pre-existing coronary artery disease. Antiplatelet therapy was the most prescribed drug (83%). A total of 52% of the patients received the three combined therapies. Less than 10% of patients had a known contraindication to one class of medication. Having at least three cardiovascular risk factors (Odds Ratio (OR) = 4.51; 95% CI: 2.76-7.37) was the factor most strongly associated with the prescription of the combined therapies. Pre-existing coronary artery disease (OR = 2.28; 95% CI: 1.43-3.65) and history of peripheral vascular surgery (OR = 2.30; 95% CI: 1.37-3.86) were two factors independently associated with the prescription of the combined therapies. However, peripheral arterial disease patients with chronic critical limb ischemia were less likely to receive the combined therapies (OR = 0.53; 95% CI: 0.32-0.87) than those with claudication. The retrospective nature of this study, not allowing for an exhaustive report of the contraindication to medication prescription, is the main limitation. CONCLUSION:About half of the patients with peripheral arterial disease were not optimally managed. Patients with multiple cardiovascular risk factors were more likely to receive the combined therapies. We still need to better understand the barriers and facilitators to the application of the guidelines

Epidemiology and prognostic implications of panic disorder and generalized anxiety disorder in patients with coronary artery disease: rationale and design for a longitudinal cohort study

Background: Anxiety is associated with poorer prognosis in patients with coronary artery disease (CAD). Due to their severity and chronic course, anxiety disorders, particularly generalized anxiety disorder (GAD) and panic disorder (PD), are of considerable interest and clinical importance in this population. This study has two main objectives: (1) to estimate the prevalence and incidence of GAD and PD in patients with CAD over a 2-year period and (2) to prospectively assess the association between PD or GAD and adverse cardiac events, treatment adherence, CAD-related health behaviors, quality of life and psychological distress.Design/Method: This is a longitudinal cohort study in which 3610 participants will be recruited following a CAD-related revascularization procedure. They will complete an interview and questionnaires at 5 time points over a 2-year period (baseline and follow-ups after 3, 6, 12 and 24 months). The presence of PD or GAD, adherence to recommended treatments, health behaviors, quality of life and psychological distress will be assessed at each time point. Data regarding mortality and adverse cardiac events will be collected with a combination of interviews and review of medical files.Discussion: This study will provide essential information on the prevalence and incidence of anxiety disorders in &#13; patients with CAD and on the consequences of these comorbidities. Such data is necessary in order to develop clear clinical recommendations for the management of PD and GAD in patients with CAD. This will help improve the prognosis of patients suffering from both conditions

Barriers and facilitators to implementing Decision Boxes in primary healthcare teams to facilitate shared decisionmaking: a study protocol

Abstract Background Decision Boxes are summaries of the most important benefits and harms of health interventions provided to clinicians before they meet the patient, to prepare them to help patients make informed and value-based decisions. Our objective is to explore the barriers and facilitators to using Decision Boxes in clinical practice, more precisely factors stemming from (1) the Decision Boxes themselves, (2) the primary healthcare team (PHT), and (3) the primary care practice environment. Methods/design A two-phase mixed methods study will be conducted. Eight Decision Boxes relevant to primary care, and written in both English and in French, will be hosted on a website together with a tutorial to introduce the Decision Box. The Decision Boxes will be delivered as weekly emails over a span of eight weeks to clinicians of PHTs (family physicians, residents and nurses) in five primary care clinics located across two Canadian provinces. Using a web-questionnaire, clinicians will rate each Decision Box with the Information Assessment Method (cognitive impacts, relevance, usefulness, expected benefits) and with a questionnaire based on the Theory of Planned Behavior to study the determinants of clinicians’ intention to use what they learned from that Decision Box in their patient encounter (attitude, social norm, perceived behavioral control). Web-log data will be used to monitor clinicians’ access to the website. Following the 8-week intervention, we will conduct semi-structured group interviews with clinicians and individual interviews with clinic administrators to explore contextual factors influencing the use of the Decision Boxes. Data collected from questionnaires, focus groups and individual interviews will be combined to identify factors potentially influencing implementation of Decision Boxes in clinical practice by clinicians of PHTs. Conclusions This project will allow tailoring of Decision Boxes and their delivery to overcome the specific barriers identified by clinicians of PHTs to improve the implementation of shared decision making in this setting.</p

Prescription of the recommended therapy.

<p>ACEI, angiotensin-converting-enzyme inhibitor; ARB, angiotensin receptor blocker; CAD, coronary artery disease; PAD, peripheral arterial disease.</p

Patient’s demographics and clinical characteristics (n = 362).

<p>Patient’s demographics and clinical characteristics (n = 362).</p

Factors associated with the prescription of the recommended therapies in multivariate analysis.

<p>Factors associated with the prescription of the recommended therapies in multivariate analysis.</p