Catheter-directed therapies for pulmonary embolism: considerations for patients with patent foramen ovale.

Pulmonary embolism can be fatal, especially in high-risk patients who have contraindications to systemic thrombolysis or surgical embolectomy. For this population, interventionalists can provide catheter-directed therapies, including catheter-directed thrombolysis and thrombectomy, using a wide array of devices. Endovascular treatment of pulmonary embolism shows great promise through fractionated thrombolytic drug delivery, fragmentation, and aspiration mechanisms with thrombectomy devices. Although successful outcomes have been reported after using these treatments, evidence is especially limited in patients with both a patent foramen ovale (PFO) and acute pulmonary embolism. In patients with PFO, it is important to consider whether catheter-directed therapy is appropriate or whether surgical embolectomy should instead be performed. An increased risk of paradoxical embolus in these patients supports the use of diagnostic echocardiography with possible surgical closure of PFO after one episode of pulmonary embolism. Percutaneous PFO closure, which can be performed at the time of catheter-based therapy, theoretically reduces risk of future paradoxical embolization, although more data are needed before making a recommendation for this specific group of patients.

Evaluation of Quantitative Measurement Techniques for Head Tremor With Thalamic Deep Brain Stimulation.

BACKGROUND: Ventralis intermedius thalamic deep brain stimulation (VIM DBS) has shown to be safe and effective for medically refractory essential tremor (ET). We evaluate the use of quantitative tremor measurement methods for head tremor in ET using a "smart" hat and a smartphone application. METHODS: We enrolled 13 ET patients who previously underwent VIM DBS. Head and arm tremor was measured ON and OFF stimulation using the clinical gold standard Fahn-Tolosa-Marin Tremor Rating Scale (TRS). Results were then compared to two quantitative measurement techniques: Lift Pulse (smartphone application) and modified Nizet (adapted laser point measurement from Nizet et al.). Spearman's rank correlation was used to compare tremor severity and improvement on stimulation using TRS and quantitative methods to measure tremor. RESULTS: Lift Pulse tremor severity measurement significantly correlated with TRS for head (ρ = 0.53, p < 0.01) and arm tremor (ρ = 0.49, p < 0.01). Modified Nizet tremor severity measurement significantly correlated with TRS for head (ρ = 0.83, p < 0.001) and arm tremor (ρ = 0.50, p < 0.01). Inter-method correlation for head tremor severity was significant (ρ = 0.45, p < 0.05). Lift Pulse tremor improvement measurement significantly correlated with TRS for arm tremor (ρ = 0.56, p < 0.05). Modified Nizet tremor improvement measurement significantly correlated with TRS for head tremor (ρ = 0.53, p < 0.01). DISCUSSION: Our results show that Lift Pulse and modified Nizet are both effective techniques to quantitatively measure head and arm tremor severity. We also show the utility of a "smart" hat to measure head tremor. Modified Nizet technique is more effective for measuring head tremor, while Lift Pulse is an effective measure of tremor severity, especially arm tremor improvement.

Effect of Eye Opening on Single-Unit Activity and Local Field Potentials in the Subthalamic Nucleus.

BACKGROUND: Subthalamic nucleus deep brain stimulation (STN DBS) is an established treatment in Parkinson's disease (PD). We investigate the effect of eye opening on neuronal activity and local field potentials (LFPs) in the STN. METHODS: We prospectively enrolled 25 PD patients undergoing STN DBS in our institution. During DBS, single-unit activity (SUA) and LFPs were measured when eyes were open and closed. As movement is known to result in changes in LFPs, we tested response to eye opening in the presence and absence of movement. RESULTS: Neither eye state nor arm movement has a significant influence on SUA recordings. There is a statistically significant interaction between eye state and arm movement (p < 0.05). In the presence of movement, STN SUA increase when eyes open (p < 0.05). When eyes are closed, STN SUA decrease with movement (p < 0.05). STN theta LFP oscillations decrease when eyes are open compared to closed, irrespective of movement status (p < 0.05). DISCUSSION: STN activity is influenced by eye state and arm movement. It is unclear whether this is attributed to a change in the STN's role in oculomotor control or from a change in attentional state. Understanding how physiologic normal activity alters neural activity is critical for the optimization of DBS therapy, particularly in closed-loop neuromodulation.

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.

Differences in perceptions and fast food eating behaviours between Indians living in high- and low-income neighbourhoods of Chandigarh, India.

BACKGROUND: Increased density of fast food restaurants is associated with increased prevalence of obesity in developed countries. However, less is known about this relationship in developing countries undergoing rapid urbanization and how differences in neighbourhood income affect the patronage of fast food outlets. The purpose of the study is to explore the differences in fast food preferences, perceptions, and patronage between Indians living in high- and low-income neighbourhoods. METHODS: This cross-sectional study recruited 204 men and women (35 to 65 years in age) from high- and low-income neighbourhoods who completed a questionnaire on fast food consumption. The questionnaire asked participants to define fast food and to provide reasons for and frequency of visits to fast food restaurants. The differences were analyzed using Chi square and t-tests for categorical and continuous variables, respectively. RESULTS: Participants from a high-income neighbourhood were more likely to perceive Western -style fast food as fast food, while people from the low-income neighbourhood were more likely to identify food sold by street vendors as fast food (p <0.001). Furthermore, compared to participants from the high-income neighbourhood, people from the low-income neighbourhood were more likely to report buying food from street vendors while less likely to dine out at both fast food and non-fast food restaurants (p<0.001). Although the high-income neighbourhood group was more likely to report enjoying eating at fast food restaurants than their low-income neighbourhood counterparts, there were no significant differences in the reasons for visiting fast food restaurants (convenience, price, social enjoyment, and quality of meals) between the two groups. Both groups preferred home cooked over restaurant meals, and they recognized that home cooked food was healthier. CONCLUSIONS: Overall, consumption of fast food was low. People from a high-income neighbourhood dined out more frequently and were more likely to perceive Western-style food as fast food compared to their counterparts from the low-income neighbourhood.

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.

Hypertension in people with type 2 diabetes: Update on pharmacologic management.

OBJECTIVE: To summarize the evidence for the need to improve pharmacologic management of hypertension in people with type 2 diabetes and to provide expert advice on how blood pressure (BP) treatment can be improved in primary care. SOURCES OF INFORMATION: Studies were obtained by performing a systematic review of the literature on hypertension and diabetes, from which management recommendations were developed, reviewed, and voted on by a group of experts selected by the Canadian Hypertension Education Program and the Canadian Diabetes Association; authors' expert opinions on optimal pharmacologic management were also considered during this process. MAIN MESSAGE: The pathogenesis of hypertension in patients with diabetes is complex, involving a range of biological and environmental factors and genetic predisposition; as a result, hypertension in people with diabetes incurs higher associated risks and adverse events. Mortality and morbidity are heightened in diabetes patients who do not achieve BP control (ie, a target value of less than 130/80 mm Hg). Large randomized controlled trials and meta-analyses of randomized controlled trials have shown that reducing BP pharmacologically is single-handedly the most effective way to reduce rates of death and disability in patients with diabetes, particularly associated cardiovascular risks. Often, combinations of 2 or more drugs (diuretics, angiotensin-converting enzyme inhibitors, ß-blockers, angiotensin receptor blockers, calcium channel blockers, spironolactone, etc) are required for pharmacotherapy to be effective, particularly for patients in whom BP is difficult to control. However, the health care costs associated with extensively lowering BP are substantially less than the costs associated with treating the complications that can be prevented by lowering BP. CONCLUSION: Detecting and managing hypertension in people with diabetes is one of the most effective measures to prevent adverse events, and pharmacotherapy is one of the most effective ways to maintain target BP levels in primary care.

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.

Mechanical thrombectomy for pulmonary embolism in patients with patent foramen Ovale.

BACKGROUND: The current level of evidence for mechanical thrombectomy (MT) of pulmonary embolism (PE) in patients with patent foramen ovale (PFO) is limited. RESULTS: This was a retrospective analysis of 9 patients with PFO and acute high-risk or intermediate-high-risk PE, 6 with intermediate-high risk and 3 with high-risk PE. All underwent MT using the Inari FlowTriever System from Dec 2018 to November 2019. Six of these patients had confirmed deep venous thrombosis. The technical and clinical success rate for MT in all patients was 100% and 77.8%, respectively. Right-heart strain improved in 6/8 patients on follow-up echocardiography. Mean main pulmonary artery (MPA) pressure significantly decreased after MT (p < 0.012). One patient presented with altered mental status (somnolence and disorientation) prior to coronary artery angiogram and thrombectomy, developed a middle cerebral artery embolic stroke 1 day after MT, and recovered with minor sequalae and later was discharged. There was no in-hospital mortality. CONCLUSIONS: MT using FlowTriever was feasible and safe, successfully improving MPA pressure in patients presenting with concurrent PFO and PE.

Visceral adipose tissue accumulation differs according to ethnic background: results of the Multicultural Community Health Assessment Trial (M-CHAT).

BACKGROUND: It was suggested that body fat distribution differs across ethnic groups, and this may be important when considering risk of disease. Previous studies have not adequately investigated differences in discrete regions of abdominal adiposity across ethnic groups. OBJECTIVE: We compared the relation between abdominal adipose tissue and total body fat between persons living in Canada of Aboriginal, Chinese, and South Asian origin with persons of European origin. DESIGN: Healthy Aboriginal, Chinese, European, and South Asian participants (n = 822) aged between 30 and 65 y were matched by sex, ethnicity, and body mass index (BMI; in kg/m(2)) range. Total abdominal adipose tissue (TAT), subcutaneous abdominal adipose tissue (SAT), visceral adipose tissue (VAT), total body fat mass, lifestyle, and demographics were assessed. Relations between BMI and total body fat, TAT, SAT, and VAT and between total body fat and TAT, SAT, and VAT were investigated. RESULTS: BMI significantly underestimated VAT in all non-European groups. Throughout a range of total body fat mass, VAT was not significantly different between the Aboriginals and the Europeans. With total body fat >9.1 kg, Chinese participants had increasingly greater amounts of VAT than did the Europeans (P for interaction = 0.008). South Asians had less VAT with total body fat >37.4 kg but more VAT below that amount than did Europeans (P for interaction < 0.001). CONCLUSION: Compared with Europeans, the Chinese and South Asian cohorts had a relatively greater amount of abdominal adipose tissue, and this difference was more pronounced with VAT. No significant differences were observed between the Aboriginals and the Europeans.

Impact of World Hypertension Day.

It is estimated that nearly one billion people are affected by hypertension worldwide, and this figure is predicted to increase to 1.5 billion by 2025. Nearly one-half of this population are unaware of their condition. Hypertension is the primary risk factor for heart disease and stroke. World Hypertension Day (WHD) has been an initiative of the World Hypertension League to raise hypertension awareness. In the past two years, many countries have taken an active part in promoting awareness through a number of initiatives in their respective countries. In Canada, WHD was a resounding success in 2005 and 2006, and major plans are underway for WHD 2007. The success of the Canadian WHD depends mainly on the partnership and shared values of all stakeholders, including professional societies, nongovernment organizations, government agencies and industry. Although it is too early to assess the impact of hypertension, it is evident that the countries involved are taking hypertension in the population seriously and are moving in the right direction. If the momentum continues, a drastic reduction in the prevalence of worldwide hypertension can be anticipated.

Practical advice for home blood pressure measurement.

Early diagnosis of hypertension is one benefit of home blood pressure monitoring. Home measurement may also be used for the detection of masked hypertension. Home blood pressure readings have a strong correlation with risk, and the method has many advantages over office measurement in the management of hypertension, especially in patients with chronic kidney disease or diabetes. The present article provides practical advice on incorporating home blood pressure monitoring into practice. Patient education and training are discussed, as are tips to aid in the selection of devices for blood pressure measurement at home.

Dietary sodium and cardiovascular outcomes: a rational approach.

Hypertension, the leading risk factor for mortality in the world, affects nearly one in four Canadians. There is substantive evidence that high dietary sodium contributes to hypertension. Animal studies consistently demonstrate increased blood pressure and cardiovascular morbidity and mortality with high dietary sodium intake. Evidence of the adverse health effects in humans associated with increased sodium intake is accumulating rapidly. Previously, limitations on sodium consumption were recommended only for those identifiable groups of people shown to be at higher risk. With the lifetime risk of developing hypertension being more than 90% in an average lifespan, the need for a population-based approach to reducing hypertension is clear. The present paper reviews the evidence of sodium and cardiovascular disease, resulting in the 2007 Canadian Hypertension Education Program recommendation of daily intake of less than 100 mmol of sodium in both normotensive and hypertensive adults.

The 2007 Canadian Hypertension Education Program recommendations for the management of hypertension: part 1- blood pressure measurement, diagnosis and assessment of risk.

OBJECTIVE: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension. OPTIONS AND OUTCOMES: The diagnosis of hypertension is dependent on the appropriate measurement of blood pressure, the timely assessment of serially elevated readings, the degree of blood pressure elevation, the method of measurement (office, ambulatory, home) and any associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk, and to determine the urgency, intensity and type of treatment required. EVIDENCE: MEDLINE searches were conducted from November 2005 to October 2006 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed, full-text articles only. RECOMMENDATIONS: Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages in 2007 include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of assessing the risk of cerebrovascular events as part of global risk assessment, the need for ongoing reassessment of patients with high normal blood pressure, and reviews of recent studies involving laboratory testing and home monitoring. VALIDATION: All recommendations were graded according to strength of the evidence and were voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here received at least 70% consensus. These guidelines will continue to be updated annually.