Urena M.,Quebec Heart and Lung Institute |
Rodes-Cabau J.,Quebec Heart and Lung Institute |
Freixa X.,Montreal Heart Institute |
Saw J.,Vancouver General Hospital |
And 8 more authors.
Journal of the American College of Cardiology | Year: 2013
Objectives The aim of this study was to evaluate the results associated with left atrial appendage closure (LAAC) with the AMPLATZER Cardiac Plug (ACP) (St. Jude Medical, Minneapolis, Minnesota) in patients with nonvalvular atrial fibrillation and absolute contraindications to anticoagulation therapy. Background Few data exist on the late outcomes after LAAC in patients with absolute contraindications to warfarin. Methods A total of 52 patients with nonvalvular atrial fibrillation underwent LAAC with the ACP device in 7 Canadian centers. Most patients received short-term (1 to 3 months) dual-antiplatelet therapy after the procedure and single-antiplatelet therapy thereafter. A transesophageal echocardiography was performed in 74% of patients at the 6-month follow-up. No patient was lost to follow-up (≥12 months in all patients). Results The mean age and median (interquartile range) CHADS2 score were 74 ± 8 years and 3 (2 to 4), respectively. The procedure was successful in 98.1% of the patients, and the main complications were device embolization (1.9%) and pericardial effusion (1.9%), with no cases of periprocedural stroke. At a mean follow-up of 20 ± 5 months, the rates of death, stroke, systemic embolism, pericardial effusion, and major bleeding were 5.8%, 1.9%, 0%, 1.9%, and 1.9%, respectively. The presence of mild peridevice leak was observed in 16.2% of patients at the 6-month follow-up as evaluated by transesophageal echocardiography. There were no cases of device thrombosis. Conclusions In patients with nonvalvular atrial fibrillation at high risk of cardioembolic events and absolute contraindications to anticoagulation, LAAC using the ACP device followed by dual-/single-antiplatelet therapy was associated with a low rate of embolic and bleeding events after a mean follow-up of 20 months. No cases of severe residual leak or device thrombosis were observed at the 6-month follow-up. © 2013 American College of Cardiology Foundation.
Saw J.,Vancouver General Hospital |
Aymong E.,St Pauls Hospital |
Sedlak T.,Vancouver General Hospital |
Buller C.E.,St Michaels Hospital |
And 7 more authors.
Circulation: Cardiovascular Interventions | Year: 2014
Background: Nonatherosclerotic spontaneous coronary artery dissection (NA-SCAD) is underdiagnosed and an important cause of myocardial infarction in young women. The frequency of predisposing and precipitating conditions and cardiovascular outcomes remains poorly described.Methods and Results: Patients with NA-SCAD prospectively evaluated (retrospectively or prospectively identified) at Vancouver General Hospital were included. Angiographic SCAD diagnosis was confirmed by 2 experienced interventional cardiologists and categorized as type 1 (multiple lumen), 2 (diffuse stenosis), or 3 (mimic atherosclerosis). Fibromuscular dysplasia screening of renal, iliac, and cerebrovascular arteries were performed with angiography or computed tomographic angiography/MR angiography. Baseline, predisposing and precipitating conditions, angiographic, revascularization, inhospital, and long-term events were recorded. We prospectively evaluated 168 patients with NA-SCAD. Average age was 52.1±9.2 years, 92.3% were women (62.3% postmenopausal). All presented with myocardial infarction. ECG showed ST-segment elevation in 26.1%, and 3.6% had ventricular tachycardia/ventricular fibrillation arrest. Fibromuscular dysplasia was diagnosed in 72.0%. Precipitating emotional or physical stress was reported in 56.5%. Majority had type 2 angiographic SCAD (67.0%), only 29.1% had type 1, and 3.9% had type 3. The majority (134/168) were initially treated conservatively. Overall, 6 of 168 patients had coronary artery bypass surgery and 33 of 168 had percutaneous coronary intervention in-hospital. Of those treated conservatively (n=134), 3 required revascularization for SCAD extension, and all 79 who had repeat angiogram ≥26 days later had spontaneous healing. Two-year major adverse cardiac events were 16.9% (retrospectively identified group) and 10.4% (prospectively identified group). Recurrent SCAD occurred in 13.1%.. Conclusions: Majority of patients with NA-SCAD had fibromuscular dysplasia and type 2 angiographic SCAD. Conservative therapy was associated with spontaneous healing. NA-SCAD survivors are at risk for recurrent cardiovascular events, including recurrent SCAD. © 2014 American Heart Association, Inc.
Burns K.E.A.,University of Toronto |
Burns K.E.A.,Li Ka Shing Knowledge Institute |
Meade M.O.,McMaster University |
Lessard M.R.,Laval University |
And 6 more authors.
American Journal of Respiratory and Critical Care Medicine | Year: 2013
Rationale: Automated weaning has not been compared with a paper-based weaning protocol in North America. Objectives: We conducted a pilot randomized trial comparing automated weaning with protocolized weaning in critically ill adults to evaluate clinician compliance and acceptance of the weaning and sedation protocols, recruitment, and impact on outcomes. Methods: From August 2007 to October 2009, we enrolled critically ill adults requiring more than 24 hours of mechanical ventilation and at least partial reversal of the condition precipitating respiratory failure at nine Canadian intensive care units. We randomized patients who tolerated at least 30 minutes of pressure support and either failed or were not yet ready to undergo a spontaneous breathing trial to automated or protocolized weaning. Both groups used pressure support, included spontaneous breathing trials, used a common positive end-expiratory pressure-FIO2 chart, sedation protocol, and criteria for extubation, reintubation, and noninvasive ventilation. Measurements and Main Results: We recruited 92 patients (49 automated, 43 protocolized) over 26 months. Adherence to assigned weaning protocols and extreme sedation scale scores fell within pre-specified thresholds. Combined physician-respiratory therapist and nurse acceptance scores of the study weaning and sedation protocols, respectively, were not significantly different. Automated weaning patients had significantly shorter median times to first successful spontaneous breathing trial (1.0 vs. 4.0 d; P < 0.0001), extubation (3.0 vs. 4.0 d; P = 0.02), and successful extubation (4.0 vs. 5.0 d; P = 0.01), and underwent fewer tracheostomies and episodes of protracted ventilation. Conclusions: Compared with a standardized protocol, automated weaning was associated with promising outcomes that warrant further investigation. Minor protocol modifications may increase compliance, facilitate recruitment, and enhance feasibility. Clinical trial registered with www.controlled-trials.com (ISRCTN43760151) Copyright © 2013 by the American Thoracic Society.
Heyland D.K.,Queen's University |
Heyland D.K.,Kingston General Hospital |
Johnson A.P.,Queen's University |
Reynolds S.C.,Royal Columbian Hospital |
And 3 more authors.
Critical Care Medicine | Year: 2011
Objective: Procalcitonin may be associated with reduced antibiotic usage compared to usual care. However, individual randomized controlled trials testing this hypothesis were too small to rule out harm, and the full cost-benefit of this strategy has not been evaluated. The purpose of this analysis was to evaluate the effect of a procalcitonin-guided antibiotic strategy on clinical and economic outcomes. Interventions: The use of procalcitonin-guided antibiotic therapy. Methods and Main Results: We searched computerized databases, reference lists of pertinent articles, and personal files. We included randomized controlled trials conducted in the intensive care unit that compared a procalcitonin-guided strategy to usual care and reported on antibiotic utilization and clinically important outcomes. Results were qualitatively and quantitatively summarized. On the basis of no effect in hospital mortality or hospital length of stay, a cost or cost-minimization analysis was conducted using the costs of procalcitonin testing and antibiotic acquisition and administration. Costs were determined from the literature and are reported in 2009 Canadian dollars. Five articles met the inclusion criteria. Procalcitonin-guided strategies were associated with a significant reduction in antibiotic use (weighted mean difference -2.14 days, 95% confidence interval -2.51 to -1.78, p < .00001). No effect was seen of a procalcitonin-guided strategy on hospital mortality (risk ratio 1.06, 95% confidence interval 0.86-1.30, p = .59; risk difference 0.01, 95% confidence interval -0.04 to +0.07, p = .61) and intensive care unit and hospital lengths of stay. The cost model revealed that, for the base case scenario (daily price of procalcitonin Can$49.42, 6 days of procalcitonin measurement, and 2-day difference in antibiotic treatment between procalcitonin-guided therapy and usual care), the point at which the cost of testing equals the cost of antibiotics saved is when daily antibiotics cost Can$148.26 (ranging between Can$59.30 and Can$296.52 on the basis of different assumptions in sensitivity analyses). Conclusions: Procalcitonin-guided antibiotic therapy is associated with a reduction in antibiotic usage that, under certain assumptions, may reduce overall costs of care. However, the overall estimate cannot rule out a 7% increase in hospital mortality. Copyright © 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.
Saczkowski R.,Royal Columbian Hospital |
Dacey C.,Tufts Medical Center |
Bernier P.-L.,McGill University
Interactive Cardiovascular and Thoracic Surgery | Year: 2010
A best evidence topic (BET) in cardiac surgery was written according to a structured protocol. The question addressed was whether ABO-incompatible (ABO-I) heart transplant recipients have a similar survival rate as an ABO-compatible (ABO-C) transplant in the pediatric population <1 year of age. Altogether more than 112 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. Generally, ABO-I transplantation has been associated with the neonatal population because of the relative immaturity of the immune system for the first year of life. In the BET the search-term 'pediatric' was used as a method to ensure retrieval all relevant papers. However, the vast majority of the patients reviewed were <1 year of age with specific techniques undertaken to modulate preoperative, intraoperative and postoperative isohemagglutinin titer levels with rejection monitoring. Therefore, the BET conclusions should not be applied to the pediatric group as a broad age classification. Two large series are of particular interest. Patel et al. reviewed all primary heart transplantation recipients <1 year of age in the United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) registry (ABO-I = 35 vs. ABO-C=556). There was no difference in 30-day mortality (ABO-l = 5.9% vs. ABO-C=8.8%; P=0.55); one-year mortality (ABO-l = 16.6% vs. AB0-C=14.7%; P=0.77); graft rejection (AB0-I = 1 vs. ABO-C=0); and graft failure (AB0-I = 24% vs. AB0-C=24%; P>0.99). Three-year Kaplan-Meier survival was 70% (P=0.85). Propensity score adjusted analysis did not implicate ABO-I as a predictor of mortality [hazard ratio (HR) = 3.6, confidence interval (CI): 0.2-49.0; P=0.33]. The ABO-I group demonstrated an increased need for pacemaker (AB0-I = 3.1% vs. ABO-C=0.4%; P=0.03) and higher stroke rate (ABO-1 = 12.9% vs. AB0-C=1.3%; P<0.0001). Dipchand et al. published the results of the Toronto cohort from 1992 to 2006 (AB0-I = 16 vs. ABO-C=38). The median age at transplantation (ABO-l = 88 days vs. ABO-C=84 days; P=0.82) and the number of neonatal transplant recipients (ABO-I = 17% vs. ABO-C=22%; P=0.59) was similar. The freedom from post-transplantation death or retransplantation was equivalent at one year (AB0-I = 77% vs. ABO-C=84%) and seven years (AB0-I = 74% vs. AB0-C=74%; P=0.87). No significant difference was observed for the five-year freedom from: rejection (ABO-I = 60% vs. ABO-C=45%; P=0.41); renal dysfunction (AB0-I = 67% vs. AB0-C=72%; P=0.70); allograft vasculopathy (ABO-I = 87% vs. ABO-C=78%; P=0.45); and post-transplantation lymphoproliferative disorder (PTLD) (ABO-I = 87% vs. ABO-C=86%; P=0.93). We conclude that ABO-I transplantation is comparable to ABO-C transplantation, with several retrospective papers concluding there is no difference in mortality, morbidity or graft failure in the pediatric population <1 year of age. © 2010 Published by European Association for Cardio-Thoracic Surgery.
Iverson G.L.,University of British Columbia |
Lange R.T.,University of British Columbia |
Brooks B.L.,University of Calgary |
Rennison V.L.A.,Royal Columbian Hospital
Clinical Neuropsychologist | Year: 2010
A small percentage of people with a mild traumatic brain injury (MTBI) report persistent symptoms and problems many months or even years following injury. Preliminary research suggests that people who sustain an injury often underestimate past problems (i.e., good old days bias), which can impact their perceived level of current problems and recovery. The purpose of this study was to examine the influence of the good old bays bias on symptom reporting following MTBI. The MTBI sample consisted of 90 referrals to a concussion clinic (mean time from injury to evaluation = 2.1 months, SD = 1.5, range = 0.8-8.1). All were considered temporarily fully disabled from an MTBI and they were receiving financial compensation through the Worker's Compensation system. Patients provided post-injury and pre-injury retrospective ratings on the 16-item British Columbia Post-concussion Symptom Inventory (BC-PSI). Ratings were compared to 177 healthy controls recruited from the community and a local university. Consistent with the good old bays bias, MTBI patients retrospectively endorsed the presence of fewer pre-injury symptoms compared to the control group. Individuals who failed effort testing tended to retrospectively report fewer symptoms pre-injury compared to those patients who passed effort testing. Many MTBI patients report their pre-injury functioning as better than the average person. This can negatively impact their perception of current problems, recovery from injury, and return to work. © 2009 Psychology Press.
Stabler S.N.,Royal Columbian Hospital
Cochrane database of systematic reviews (Online) | Year: 2012
Garlic is widely used by patients for its blood pressure lowering effects. A meta-analysis published in 2008 concluded that garlic consumption lowers blood pressure in hypertensive and normotensive patients. Therefore, it is important to review the currently available evidence to determine whether garlic may also have a beneficial role in the reduction of cardiovascular events and mortality rates in patients with hypertension. To determine whether the use of garlic as monotherapy, in hypertensive patients, lowers the risk of cardiovascular morbidity and mortality compared to placebo. A systematic search for trials was conducted in the Cochrane Hypertension Group Specialised Register, CENTRAL, MEDLINE, EMBASE, AGRICOLA, AMED, and CINAHL up to November 2011. A hand search of reference lists of identified reviews was conducted. Experts in the area were also contacted to identify trials not found in the electronic search. Clinicaltrials.gov was searched for ongoing trials. Randomized, placebo-controlled trials of any garlic preparation versus placebo for the treatment of hypertension were included. Two reviewers independently extracted data and assessed trial quality using the risk of bias tool. Data synthesis and analysis was performed using RevMan 5. The search identified two randomized controlled trials for inclusion. One trial included 47 hypertensive patients and showed that garlic significantly reduces mean supine systolic blood pressure by 12 mmHg (95% CI 0.56 to 23.44 mmHg, p=0.04) and mean supine diastolic blood pressure by 9 mmHg (95% CI 2.49 to 15.51 mmHg, p=0.007) versus placebo. The authors state that garlic was "free from side effects" and that no serious side effects were reported. There were 3 cases "where a slight smell of garlic was noted."The second trial could not be meta-analysed as they did not report the number of people randomized to each treatment group. They did report that 200 mg of garlic powder given three times daily, in addition to hydrochlorothiazide-triamterene baseline therapy, produced a mean reduction of systolic blood pressure by 10-11 mmHg and of diastolic blood pressure by 6-8 mmHg versus placebo.Neither trial reported clinical outcomes and insufficient data was provided on adverse events. There is insufficient evidence to determine if garlic provides a therapeutic advantage versus placebo in terms of reducing the risk of mortality and cardiovascular morbidity in patients diagnosed with hypertension. There is also insufficient evidence to determine the difference in withdrawals due to adverse events between patients treated with garlic or placebo.Based on 2 trials in 87 hypertensive patients, it appears that garlic reduces mean supine systolic and diastolic blood pressure by approximately 10-12 mmHg and 6-9 mmHg, respectively, over and above the effect of placebo but the confidence intervals for these effect estimates are not precise and this difference in blood pressure reduction falls within the known variability in blood pressure measurements. This makes it difficult to determine the true impact of garlic on lowering blood pressure.
Messenger S.,Royal Columbian Hospital
Journal of Renal Nutrition | Year: 2014
Objectives: To determine if there is an improvement in the number of peritoneal dialysis (PD) patients who meet target goals for serum phosphorus and parathyroid hormone (iPTH) after the implementation of a dietitian led mineral metabolism protocol. Design: Retrospective, comparative, analytic study. Setting: Fraser Health Authority PD units in Abbotsford and New Westminster, British Columbia. Subjects: One hundred fourty patients from 2009 and 139 patients from 2011 stable on PD for a minimum of 3months. Main Outcome Measure: Change in number of patients meeting target goals for serum phosphorus and iPTH after the implementation of a mineral metabolism protocol for 6months. Results: After 6months of the protocol being initiated, there was no significant difference in number of patients meeting serum phosphorus targets (82.0% vs. 74.5%, P=126); however, a significant increase in the number of patients who met target iPTH range (60.4% vs. 48.5%, P=048) was shown. Conclusions: Use of a mineral metabolism protocol by dietitians in PD units supports an improvement in iPTH targets. © 2014 National Kidney Foundation, Inc.
Khangura S.,Royal Columbian Hospital |
Gordon W.L.,Royal Columbian Hospital
Canadian Journal of Cardiology | Year: 2011
Clopidogrel has mostly replaced the use of ticlopidine due to its more favourable hematologic adverse event profile. Prasugrel is the newest thienopyridine approved for use in Canada. This case describes a patient who was diagnosed with an acute coronary syndrome and treated with bare metal stenting of his coronary artery. He was discharged home on clopidogrel therapy. Two weeks later he presented with severe neutropenia. Clopidogrel was discontinued and prasugrel was initiated. Neutrophil count gradually increased and returned to normal. In patients with neutropenia associated with clopidogrel therapy, prasugrel may be considered as an alternative. © 2011 Canadian Cardiovascular Society.
Burns A.M.N.,University of British Columbia |
Erickson D.H.,Royal Columbian Hospital |
Brenner C.A.,University of British Columbia
Psychiatric Services | Year: 2014
Objective: Support for cognitive-behavioral therapy (CBT) for psychosis has accumulated, with several reviews and meta-analyses indicating its effectiveness for various intended outcomes in a broad variety of clinical settings. Most of these studies, however, have evaluated CBT provided to the subset of people with schizophrenia who continue to experience positive symptoms despite adequate treatment with antipsychotics. Despite several reviews and meta-analyses, a specific estimate of the effects of CBT for patients with medication-resistant positive symptoms, for whom CBT is frequently used in outpatient clinical settings, is lacking. This meta-analysis examined CBT's effectiveness among outpatients with medication-resistant psychosis, both on completion of treatment and at follow-up. Methods: Systematic searches (until May 2012) of the Cochrane Collaborative Register of Trials, MEDLINE, PsycINFO, and PubMed were conducted. Sixteen published articles describing 12 randomized controlled trials were used as source data for the meta-analysis. Effect sizes were estimated using the standardized mean difference corrected for bias, Hedges' g, for positive and general symptoms. Results: The trials included a total of 639 individuals, 552 of whom completed the posttreatment assessment (dropout rate of 14%). Overall beneficial effects of CBT were found at posttreatment for positive symptoms (Hedges' g=.47) and for general symptoms (Hedges' g=.52). These effects were maintained at follow-up for both positive and general symptoms (Hedges' g=.41 and .40, respectively). Conclusions: For patients who continue to exhibit symptoms of psychosis despite adequate trials of medication, CBT for psychosis can confer beneficial effects above and beyond the effects of medication.