Safety and feasibility of single use cholecystoscopy for guiding laser or mechanical cholelithotripsy, and mechanical cholelithotomy.

PURPOSE Patients with acute calculus cholecystitis and contraindications to cholecystectomy receive cholecystostomy drainage catheters, many of which remain in place until end of life. This study aims to assess safety, feasibility, and early clinical outcomes of percutaneous cholecystoscopy using the LithoVue endoscope, laser/mechanical cholelithotripsy, and mechanical cholelithotomy for management of symptomatic cholelithiasis. METHODS This was a single-institute retrospective analysis of 17 patients with acute calculus cholecystitis who had contraindications to cholecystectomy, underwent cholecystostomy catheter placement between 2015 and 2017, and stone removal between 2017 and 2018. The LithoVue 7.7- 9.5 F endoscope was used in combination with laser/mechanical cholelithotripsy, mechanical retrograde, and balloon-assisted anterograde cholelithotomy to remove gallstones and common bile duct stones. Surgical contraindications ranged from cardiopulmonary disease to morbid obesity to neoplastic processes. Timing and number of interventions, as well as technical and clinical successes, were assessed. RESULTS The median time interval from cholecystostomy catheter placement to cholelithotripsy was 58 days, after an average of 2 tube exchange procedures. Technical and clinical success were achieved in all patients (stone-free gallbladder and cholecystostomy tube removal). On average, three sessions of cholecystoscopy and laser and mechanical cholelithotripsy were required for complete gallstone extraction. The mean interval time between the first cholelithotripsy session and removal of cholecystostomy was 71.8±60.8 days. There were neither major nor minor procedure-related complications. CONCLUSION Percutaneous cholecystoscopy using the LithoVue endoscope, in combination with laser/ mechanical cholelithotripsy and mechanical cholelithotomy, is feasible, safe, well-tolerated, and was able to remove the cholecystostomy tube in the patients with contraindication to cholecystectomy.

Surgical resection, radiotherapy and percutaneous thermal ablation for treatment of stage 1 non-small cell lung cancer: protocol for a systematic review and network meta-analysis.

INTRODUCTION: Non-small cell lung cancer (NSCLC) makes up the majority of lung cancer cases. Currently, surgical resection is the gold standard of treatment. However, as patients are becoming medically more complex presenting with advanced disease, minimally invasive image-guided percutaneous ablations are gaining popularity. Therefore, comparison of surgical, ablative and second-line external beam therapies will help clinicians, as management of NSCLC changes. We will conduct a meta-analysis, reviewing literature investigating these therapies in adult patients diagnosed with stage 1 NSCLC, with neither hilar nor mediastinal nodal involvement, confirmed either through cytology or histology regardless of type. METHODS AND ANALYSIS: We will search electronic databases (MEDLINE, Embase, Web of Science, Scopus, ClinicalTrials.gov, Cochrane) from their inception to January 2021 to identify randomised controlled trials (RCTs), cluster RCTs and cohort studies comparing survival and clinical outcomes between any two interventions (lobectomy, wedge resection, video-assisted thoracoscopic surgery/robot-assisted thoracoscopic surgery, radiofrequency ablation, microwave ablation, cryoablation and consolidated radiation therapies (external beam radiation therapy, stereotactic body radiation therapy, and 3D conformal radiation therapy). The primary outcomes will include cancer-specific survival, lung disease-free survival, locoregional recurrence, death, toxicity and non-target organ injury. We will also search published and unpublished studies in trial registries and will review references of included studies for possible inclusion. Risk of bias will be assessed using tools developed by the Cochrane collaboration. Two reviewers will independently assess the eligibility of studies and conduct the corresponding risk of bias assessments. For each outcome, given enough studies, we will conduct a network meta-analysis. Finally, we will use the Confidence in Network Meta-Analysis tool to assess quality of the evidence for each of the primary outcomes. ETHICS AND DISSEMINATION: We aim to share our findings through high-impact peer review. As interventional techniques become more popular, it will be important for providers in multidisciplinary teams caring for these patients to receive continuing medical education related to these interventions. Data will be made available to readers. PROSPERO REGISTRATION NUMBER: CRD42021276629.

Safety of Deep Brain Stimulation Lead Placement on Patients Requiring Anticlotting Therapies.

BACKGROUND: Limited studies exist to support the safety of performing neuromodulation surgeries in patients whose anticlotting medication has been held. Here, we assess the safety of performing deep brain stimulation (DBS) in this patient population. METHODS: All consecutive DBS patients who underwent lead and battery placement/revision at our institution between 2011 and 2020 were included in this Institutional Review Board-approved prospective outcomes database. We retrospectively recorded adverse events occurring within 90 days of surgery. RESULTS: The study included 226 patients who underwent 381 lead placements in 267 surgeries. Of the 267 surgeries included in this study, 176 (66%) were performed on patients not on anticoagulants and 89 (33%) cases were on patients on 1 drug. Two (0.7%) cases involved a patient taking 2 drugs. A total of 49 adverse events were seen. Thirteen occurred in patients taking anticoagulants. There was no difference in adverse event rate between patients on anticlotting medication and those not (χ2 [1] = 1.523, P = 0.2171). No clot-related sequelae occurred in any patient. Three hemorrhages occurred, all in patients not on anticoagulants. CONCLUSIONS: We found no increased risk of complications in patients routinely on anticlotting medication undergoing DBS lead placement. We show that our protocol was successful in balancing increased risks of bleeding and of thromboembolic events in this patient group.

Occipital Nerve Stimulation Attenuates Neuronal Firing Response to Mechanical Stimuli in the Ventral Posteromedial Thalamus of a Rodent Model of Chronic Migraine.

BACKGROUND: Chronic migraine (CM) is a highly debilitating disease, and many patients remain refractory to medicinal therapy. Given the convergent nature of neuronal networks in the ventral posteromedial nucleus (VPM) and the evidence of sensitization of pain circuitry in this disease, we hypothesize CM rats will have increased VPM neuronal firing, which can be attenuated using occipital nerve stimulation (ONS). OBJECTIVE: To determine whether VPM firing frequency differs between CM and sham rats, and whether ONS significantly alters firing rates during the application of mechanical stimuli. METHODS: Fourteen male Sprague-Dawley rats were infused with inflammatory media once daily through an epidural cannula for 2 wk to induce a CM state. Sham animals (n = 6) underwent cannula surgery but received no inflammatory media. ONS electrodes were implanted bilaterally and single-unit recordings were performed in the VPM of anesthetized rats during mechanical stimulation of the face and forepaw in the presence and absence of ONS. RESULTS: CM rats had significantly higher neuronal firing rates (P < .001) and bursting activity (P < .01) in response to mechanical stimuli when compared to shams. ONS significantly reduced neuronal firing in the VPM of CM rats during the application of 0.8 g (P = .04), 4.0 g (P = .04), and 15.0 g (P = .02) Von Frey filaments. ONS reduced bursting activity in CM rats during the 4.0 and 15 g filaments (P < .05). No significant changes in bursting activity or firing frequency were noted in sham animals during ONS. CONCLUSION: We demonstrate that neuronal spike frequencies and bursting activity in the VPM are increased in an animal model of CM compared to shams. Our results suggest that the mechanism of ONS may involve attenuation of neurons in the VPM of CM rats during the application of mechanical stimuli.

A Comparison of Unilateral Deep Brain Stimulation (DBS), Simultaneous Bilateral DBS, and Staged Bilateral DBS Lead Accuracies.

BACKGROUND: Accuracy of lead placement within the brain can affect the outcome of deep brain stimulation (DBS) surgery. Whether performing unilateral lead implantation, simultaneous bilateral lead implantation, or staged bilateral lead implantation affects accuracy has not yet been assessed. We compare lead placement errors to evaluate whether one approach affords greater lead accuracy. METHODS: We retrospectively reviewed 205 leads placed in 125 DBS surgeries. The accuracy of lead placement, defined by differences in x, y, and z coordinates and error vector magnitudes, was compared between three surgery groups: unilateral leads, bilateral leads placed simultaneously, and bilateral leads placed in staged surgeries. We also compared accuracies between first and second leads within each bilateral cohort and between second leads of the bilateral cohorts. Finally, we examined the effect of target and age on accuracy. RESULTS: The accuracy of lead placement was comparable among unilateral, simultaneous bilateral, and staged bilateral leads. Timing of placement of the second lead in bilateral cases was not found to affect accuracy. The mean number of microelectrode trajectories was greater for first leads in simultaneous bilateral DBS (p = 0.032). No significant correlation between either age or target and accuracy was found. CONCLUSION: Although there may be other important reasons for performing DBS in a staged fashion, our study finds that neither laterality nor timing of second lead placement, patient age, or target site have significant impact on DBS lead accuracy, a finding that indicates with appropriate approach selection based on patient factors, accuracy does not have to be significantly compromised.

Radiologic-pathologic analysis of quantitative 3D tumour enhancement on contrast-enhanced MR imaging: a study of ROI placement.

OBJECTIVES: To investigate the influence of region-of-interest (ROI) placement on 3D tumour enhancement [Quantitative European Association for the Study of the Liver (qEASL)] in hepatocellular carcinoma (HCC) patients treated with transcatheter arterial chemoembolization (TACE). METHODS: Phase 1: 40 HCC patients had nine ROIs placed by one reader using systematic techniques (3 ipsilateral to the lesion, 3 contralateral to the lesion, and 3 dispersed throughout the liver) and qEASL variance was measured. Intra-class correlations were computed. Phase 2: 15 HCC patients with histosegmentation were selected. Six ROIs were systematically placed by AC (3 ROIs ipsilateral and 3 ROIs contralateral to the lesion). Three ROIs were placed by 2 radiologists. qEASL values were compared to histopathology by Pearson's correlation, linear regression, and median difference. RESULTS: Phase 1: The dispersed method (abandoned in phase 2) had low consistency and high variance. Phase 2: qEASL correlated strongly with pathology in systematic methods [Pearson's correlation coefficient = 0.886 (ipsilateral) and 0.727 (contralateral)] and in clinical methods (0.625 and 0.879). However, ipsilateral placement matched best with pathology (median difference: 5.4 %; correlation: 0.89; regression CI: [0.904, 0.1409]). CONCLUSIONS: qEASL is a robust method with comparable values among tested placements. Ipsilateral placement showed high consistency and better pathological correlation. KEY POINTS: Ipsilateral and contralateral ROI placement produces high consistency and low variance. Both ROI placement methods produce qEASL values that correlate well with histopathology. Ipsilateral ROI placement produces best correlation to pathology along with high consistency.

Transthoracic needle aspiration: the past, present and future.

Transthoracic needle aspiration (TTNA) has been used to diagnose disease in the lung for many decades. Thanks to advances in technology and cytopathology, the diagnostic power, accuracy, safety, and efficacy of TTNA are constantly improving. The transition from fluoroscopy to computed tomography (CT) has yielded better visualization, and ability to enhance sophistication of tools used to biopsy. In addition, needles are being refined for obtaining better biopsy samples and increased capabilities. Because of the minimally invasive nature of TTNA, it is becoming a strong alternative to surgical intervention. In the future, these developments will continue and TTNA will become more efficient, and potentially open a door to personalized medicine. However, there are complications due to this procedure, which include pneumothorax, hemorrhage, air embolism, and others which are very rare. Probability of complication increases when patients are older, have significant past medical history, have larger lesions, and are uncooperative during procedure. Indications, contraindications, and other considerations should be contemplated before a patient is elected for TTNA.

Elevation in cardiovascular disease risk in South Asians is mediated by differences in visceral adipose tissue.

South Asians have a higher risk for cardiovascular disease (CVD) that remains largely unexplained. We hypothesized that the increased CVD risk in South Asians compared to Europeans is mediated through higher levels of visceral adipose tissue (VAT) in South Asians compared to total body fat and subcutaneous abdominal adipose tissue (SAT). South Asians (207) and Europeans (201) underwent assessment for demographics, body fat, and risk factors. Linear regression models were created by sex for each risk factor to explore mediation effects of total body fat, SAT, and VAT adjusted for age, income, smoking, and BMI (menopausal status for women). Mediation was based on changes in the ethnicity ß coefficient due to additional adjustment for our adipose variable of interest and the Sobel test for mediation. South Asians had worse lipid, glucose, insulin, and C-reactive protein (CRP) levels than Europeans after adjusting for confounders. Most of these differences remained even after further adjustment by either total body fat or SAT. In contrast, VAT attenuated the ethnic differences in risk factors by 16%-52%. After adjusting for VAT, there were no longer ethnic differences in total cholesterol (TC), LDL-C, TC/HDL-C, glucose, and diastolic blood pressure (BP) in men, and in HDL-C, triglycerides (TG), TC/HDL-C, and homeostasis model (HOMA) in women, and VAT was a significant mediator for these risk factors. Higher levels of risk factors for CVD in South Asians are predominantly because of the unique phenotype of South Asians having greater VAT than Europeans even at the same BMI.

The 2011 Canadian Hypertension Education Program recommendations for the management of hypertension: blood pressure measurement, diagnosis, assessment of risk, and therapy.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2011. The major guideline changes this year are: (1) a recommendation was made for using comparative risk analogies when communicating a patient's cardiovascular risk; (2) diagnostic testing issues for renal artery stenosis were discussed; (3) recommendations were added for the management of hypertension during the acute phase of stroke; (4) people with hypertension and diabetes are now considered high risk for cardiovascular events if they have elevated urinary albumin excretion, overt kidney disease, cardiovascular disease, or the presence of other cardiovascular risk factors; (5) the combination of an angiotensin-converting enzyme (ACE) inhibitor and a dihydropyridine calcium channel blocker (CCB) is preferred over the combination of an ACE inhibitor and a thiazide diuretic in persons with diabetes and hypertension; and (6) a recommendation was made to coordinate with pharmacists to improve antihypertensive medication adherence. We also discussed the recent analyses that examined the association between angiotensin II receptor blockers (ARBs) and cancer.

Hypertension in diabetes: a call to action.

The Canadian Hypertension Education Program, Blood Pressure Canada, Canadian Hypertension Society, Heart and Stroke Foundation of Canada, Canadian Diabetes Association, College of Family Physicians of Canada, Canadian Pharmacists Association and the Canadian Council of Cardiovascular Nurses call on Canadian health care professionals to redouble efforts to help patients achieve treatment targets (blood pressure less than 130 mmHg systolic and less than 80 mmHg diastolic) in people with diabetes. Treatment of high blood pressure in people with diabetes results in large reductions in death and disability within a short period of time and needs to be a therapeutic priority. Achieving blood pressure targets requires sustained lifestyle modification, and three or more drugs including a diuretic are often required. Antihypertensive treatment in people with diabetes is one of the few medical treatments estimated to reduce overall health costs. The cost of treatment is less than the cost of complications prevented. Blood pressure needs to be assessed at all visits and home blood pressure assessment is encouraged. Management strategies need to include assessment and management of cardiovascular risks including smoking, unhealthy eating, physical inactivity, abdominal obesity, dyslipidemia as well as dysglycemia. The risks and benefits of acetylsalicylic acid in primary prevention of cardiovascular disease are uncertain in people with hypertension and diabetes. Intensive individualized lifestyle modification is recommended to prevent and treat hypertension, dyslipidemia, dysglycemia and other vascular risks in people with diabetes.

Immigration presents a potential increased risk for atherosclerosis.

OBJECTIVE: Immigrants in Western countries tend to have a greater risk for cardiovascular disease (CVD) than those in their home country, but it is unclear if immigrants are at increased risk for CVD compared to non-immigrants in their new country. The purpose of this study was to determine the independent association of time since immigration with sub-clinical atherosclerosis in immigrants of Chinese, European and South Asian origin. METHODS: A total of 460 immigrants and 158 non-immigrants of Chinese, European and South Asian origin without pre-diagnosed CVD were assessed for sub-clinical atherosclerosis by carotid artery ultrasound scan, socio-demographics, CVD risk factors and lifestyle factors. Time since immigration in years was used as a measure of exposure. RESULTS: Participants who immigrated > or =30 years ago had a greater intima-media thickness (IMT) of the carotid artery compared to non-immigrants, and immigrants of < or =20 years. Time since immigration was associated with IMT, plaque area and IMT+plaque area. After adjustment for age, sex, ethnicity, income, education, family history of CVD and diabetes, smoking, physical activity, body mass index, visceral adipose tissue, lipids, insulin, glucose and blood pressure, time since immigration was significantly associated with IMT. For every ten years since immigration there was a 2% increase in IMT in addition to the 7% increase for every 10 years of age. CONCLUSIONS: Immigration was associated with an increased burden of sub-clinical atherosclerosis that surpassed that of non-immigrants. This burden increased over time independent of other risk factors. Immigrants represent a high-risk group for which targeted interventions are needed.

The 2006 Canadian Hypertension Education Program recommendations for the management of hypertension: Part I--Blood pressure measurement, diagnosis and assessment of risk.

OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with high blood pressure. OPTIONS AND OUTCOMES: For persons in whom a high blood pressure value is recorded, a diagnosis of hypertension is dependent on the appropriate measurement of blood pressure, the level of the blood pressure elevation, the approach used to monitor blood pressure (office, ambulatory or home/self), and the duration of follow-up. In addition, the presence of cardiovascular risk factors and target organ damage should be assessed to determine the urgency, intensity and type of treatment. For persons diagnosed as having hypertension, estimating the overall risk of adverse cardiovascular outcomes requires an assessment for other vascular risk factors and hypertensive target organ damage. EVIDENCE: MEDLINE searches were conducted from November 2004 to October 2005 to update the 2005 recommendations. Reference lists were scanned, experts were polled, and the personal files of the authors and subgroup members were used to identify other studies. Identified articles were reviewed and appraised using prespecified levels of evidence by content and methodological experts. As per previous years, the authors only included studies that had been published in the peer-reviewed literature and did not include evidence from abstracts, conference presentations or unpublished personal communications. RECOMMENDATIONS: The present document contains recommendations for blood pressure measurement, diagnosis of hypertension, and assessment of cardiovascular risk for adults with high blood pressure. These include the accurate measurement of blood pressure, criteria for the diagnosis of hypertension and recommendations for follow-up, assessment of overall cardiovascular risk, routine and optional laboratory testing, assessment for renovascular and endocrine causes, home and ambulatory blood pressure monitoring, and the role of echocardiography for those with hypertension. Key features of the 2006 recommendations include continued emphasis on an expedited diagnosis of hypertension, an in-depth review of the role of global risk assessment in hypertension therapy, and the use of home/self blood pressure monitoring for patients with masked hypertension (subjects with hypertension who have a blood pressure that is normal in clinic but elevated on home/self measurement). VALIDATION: All recommendations were graded according to the strength of the evidence and were voted on by the 45 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported herein received at least 95% consensus. These guidelines will continue to be updated annually.

Study design of the Multicultural Community Health Assessment Trial (M-CHAT): a comparison of body fat distribution in four distinct populations.

OBJECTIVE: To outline the study design of the Multicultural Community Health Assessment Trial (M-CHAT). The purpose of the study is to compare the relationship between visceral adipose tissue (VAT) and total body fat in men and women of Aboriginal, Chinese, and South Asian origin with a similar group of men and women of European origin. DESIGN: A total of 200 apparently healthy men and women between the ages of 30 and 65 will be recruited from each of the local Aboriginal, Chinese, and South Asian and European communities. Within each sex/ethnic group, an equal representation of participants will have a body mass index between 18.5 to 24.9, 25 to 29.9 and >30. Each participant will undergo an assessment for VAT, total body fat, metabolic risk factors, physical activity, diet, quality of life, and sociodemographics. MAIN OUTCOME MEASURES: The primary outcome of this study is the relationship between VAT and total body fat in each of the Aboriginal, Chinese, and South Asian cohorts; this relationship will be compared to the European cohort after adjustment for age, sex, socioeconomic status, smoking status, physical activity, diet, and body mass index. CONCLUSIONS: This study will be the first to identify differences in body fat distribution in these populations. We anticipate that in populations of Aboriginal, Chinese, and South Asian origin, a greater proportion of total body fat will be deposited as VAT compared to those of European origin.