Telemonitoring and hemodynamic monitoring to reduce hospitalization rates in heart failure： a systematic review and meta-analysis of randomized controlled trials and real-world studies

Background Heart failure is a significant problem leading to repeated hospitalizations. Telemonitoring and hemodynamic monitoring have demonstrated success in reducing hospitalization rates, but not all studies reported significant effects. The aim of this systematic review and meta-analysis is to examine the effectiveness of telemonitoring and wireless hemodynamic monitoring devices in reducing hospitalizations in heart failure. Methods ＆ Results PubMed and Cochrane Library were searched up to 1st May 2017 for articles that investigated the effects of telemonitoring or hemodynamic monitoring on hospitalization rates in heart failure. In 31,501 patients （mean age： 68 ± 12 years; 61% male; follow-up 11 ± 8 months）, telemonitoring reduced hospitalization rates with a HR of 0.73 （95% CI： 0.65-0.83; P 〈 0.0001） with significant heterogeneity （I2 = 94%）. These effects were observed in the short-term （≤ 6 months： HR = 0.77, 95% CI： 0.65-0.89; P 〈 0.01） and long-term （≥ 12 months： HR = 0.73, 95% CI： 0.62-0.87; P 〈 0.0001）. In 4831 patients （mean age 66 ± 18 years; 66% male; follow-up 13 ± 4 months）, wireless hemodynamic monitoring also reduced hospitalization rates with a HR of 0.60 （95% CI： 0.53-0.69; P 〈 0.001） with significant heterogeneity （I2 = 64%）.This reduction was observed both in the short-term （HR = 0.55, 95% CI： 0.45-0.68; P 〈 0.001; I2 = 72%） and long-term （HR = 0.64, 95% CI： 0.57-0.72; P 〈 0.001; I2 = 55%）. Conclusions Telemonitoring and hemodynamic monitoring reduce hospitalization in both short- and long-term in heart failure patients

Diagnosis of interatrial block

In the 70＇s, we classified for the first time the blocks at the atrial level into interatrial blocks （IAB）, partial and advanced, and other types of atrial blocks including the concept of atrial aberrancy, and atrial dissociation.

Brugada phenocopy: A new electrocardiogram phenomenon

Brugada phenocopies(BrP) are clinical entities that are etiologically distinct from true congenital Brugada syndrome. BrP are characterized by type 1 or type 2 Brugada electrocardiogram(ECG) patterns in precordial leads V1-V3. However, BrP are elicited by various un-derlying clinical conditions such as myocardial ischemia, pulmonary embolism, electrolyte abnormalities, or poor ECG filters. Upon resolution of the inciting underlying pathological condition, the BrP ECG subsequently nor-malizes. To date, reports have documented BrP in the context of singular clinical events. More recently, recur-rent BrP has been demonstrated in the context of re-current hypokalemia. This demonstrates clinical repro-ducibility, thereby advancing the concept of this new ECG phenomenon. The key to further understanding the pathophysiological mechanisms behind BrP requires experimental model validation in which these phenom-ena are reproduced under strictly controlled environ-mental conditions. The development of these validation models will help us determine whether BrP are tran-sient alterations of sodium channels that are not repro-ducible with a sodium channel provocative test or al-ternatively, a malfunction of other ion channels. In this editorial, we discuss the conceptual emergence of BrP as a new ECG phenomenon, review the progress made to date and identify opportunities for further investiga-tion. In addition, we also encourage investigators that are currently reporting on these cases to use the term BrP in order to facilitate literature searches and to help establish this emerging concept.

Hypertrophic cardiomyopathy: Can the noninvasive diagnostic testing identify high risk patients?

Hypertrophic cardiomyopathy(HCM) is the most common cause of sudden cardiac death(SCD) in the young, particularly among athletes. Identifying high risk individuals is very important for SCD prevention. The purpose of this review is to stress that noninvasive diagnostic testing is important for risk assessment. Extreme left ventricular hypertrophy and documented ventricular tachycardia and fibrillation increase the risk of SCD. Fragmented QRS and T wave inversion in multiple leads are more common in high risk patients. Cardiac magnetic resonance imaging provides complete visualization of the left ventricular chamber, allowing precise localization of the distribution of hypertrophy and measurement of wall thickness and cardiac mass. Moreover, with late gadolinium enhancement, patchy myocardial fibrosis within the area of hypertrophy can be detected, which is also helpful in risk stratification. Genetic testing is encouraged in all cases, especially in those with a family history of HCM and SCD.

Introduction of new techniques and technologies in surgery: Where is transanal total mesorectal excision today?

The introduction of new surgical techniques and technologies has traditionally been unregulated.In many settings surgeons frequently adopt novel procedures without following a structured program of implementation or supervision.The appearance of innovative technology played a pivotal role in the advancement of new surgical techniques during the industrial revolution.Innovation has been an essential component of surgical development,which led to contemporary surgical techniques such as minimally invasive surgery.Different initiatives have been developed to guide the safe introduction of new surgical techniques and other procedures.Those include comprehensive concepts such as the Idea,Development,Exploration,Assessment,Long-term study framework,which could be particularly relevant when reflecting on the novel transanal total mesorectal excision(taTME),introduced a decade ago.This relatively novel and complex procedure promised to overcome some of the major limitations of traditional surgical approaches for rectal cancer.According to the Idea,Development,Exploration,Assessment,Long-term study framework,taTME is in the phase of exploration,where there is an existing and increasing number of reports being published as the experience grows.The current management of rectal cancer is in a state of radical evolution,with multiple options that were not previously available.Ta TME is only one technique amongst many which could be part of a rectal cancer surgeon’s armamentarium;however,it requires further rigorous study and evaluation.

Advanced interatrial block as a key marker for atrial fibrillation recurrence： Bayes＇ syndrome

It was not until 1979 that Bayes de Ltma described atrial conduction blocks and classified them as interatrial and intra- atrial.Interatrial blocks refer to conduction disorders lo- cated between the atria, while intraalxial blocks occur within the same atrium. This work motivated several authors, in- cluding Bayes himself, to further investigate atrial conduc- tion and interatrial block （IAB）.

Extremely low-volume, high-intensity interval training improves exercise capacity and increases mitochondrial protein content in human skeletal muscle

Purpose: The purpose of the present study was to evaluate whole-muscle content of several proteins involved in the regulation of skeletal muscle mitochondrial protein content and anaerobic capacity following 4 weeks of extremely low-volume high-intensity interval training (HIT). Methods: Young, healthy, recreationally active adult males (n = 8) trained 4 times a week for 4 weeks on a cycle ergometer. Each session involved 4 min of total exercise comprised of eight 20 s intervals at ~170% of peak aerobic power separated by 10 s rest. Muscle biopsies were taken prior to (pre) and ~72 hrs post-training (post). Par- ticipants completed an incremental peak oxygen up- take (VO2peak) test and a Wingate test pre-, mid-, and post-training. Results: VO2peak was elevated (p p < 0.05) and post-training (pre: 40.5 ± 3.8 ml·kg-1·min-1, mid: 43.4 ± 2.5 ml·kg-1·min-1, post-: 47.2 ± 2.9 ml·kg-1·min-1). Wingate mean power also increased with training (pre-: 701.0 ± 73.0 W, mid-: 745.5 ± 73.3 W, post-: 786.8 ± 80.0 W). While maximal citrate synthase activity was unchanged, protein expression of the mitochondrial protein cytochrome c oxidase (COX) subunit I (+27%;p p p = 0.08) increased. Increases (p α (+19%), and nuclear PGC-1α (+46%) were also observed after 4 weeks of HIT. No changes were observed in the whole-muscle contents of PDHe1a, PDK4, SIRT1, mTOR, S6K1, MCT1, or PFK protein. Conclusions: These results demonstrate that several mitochondrial protein (but not citrate synthase activity), PGC-1α protein content, and exercise capacity can be improved in only 4 min of total training time per day, 4 days per wk using HIT cycle training.

Self-reported cigarette smoking status imprecisely quantifies exposure in pregnancy

Objective: We sought to determine the validity of self-reported smoking activity versus two quantitative measurements of tobacco exposure in pregnancy. We hypothesized that pregnant women would under-report their daily smoking amounts, due to the negative social stigmas associated with such a behavior. Methods: Cigarette-smoking and non-smoking pregnant women were recruited as part of a larger research study. Pregnant women with a singleton baby (>24 weeks) were recruited at a clinical appointment or prior to an elective caesarian section. Self-reported smoking status, including time since last cigarette, was recorded. End-tidal breath carbon monoxide (ETCO) levels and urine cotinine levels were measured and compared. Results: Both normotensive non-smoking (NTN) (n = 44) and normotensive smoking (NTS) (n = 24) pregnant women were recruited. A strong correlation was found between ETCO levels and urine cotinine measurements (r = 0.6566, p 0.05). Conclusion: Self-reported smoking status accurately identifies women who smoke in pregnancy, but not their level of tobacco exposure. Urine cotinine or ETCO are much better quantitative measurements of nicotine and carbon monoxide, respectively, and should be measured for a more precise indicator of smoking activity. These devices will allow for better counseling and monitoring of women who are trying to quit smoking and/or who enter into smoking cessation programs.

Awareness and use of cardiovascular risk scores by family physicians in southeastern Ontario

Background: Our objective was to determine the assessment of cardiovascular risk by family physicians. Methods: A questionnaire was sent by mail or fax regarding both awareness and use of the various CV risk scores in southeastern Ontario. Results: Of 181 family physicians surveyed, 96% were aware of at least one CV risk score and 40% were aware of the JUPITER study. Despite this awareness, 72% simply counted risk factors to assess risk, rather than to calculate risk using established scoring methods. Only 23% used the JUPITER study criteria. This suggests an under-estimated of overall CV risk by family physician’s practicing in southeastern Ontario. Interpetation: Cardiovascular risk in primary care is being underestimated in southeastern Ontario. Additional knowledge translation strategies are required to enhance the family physician’s awareness and use of established risk scoring methods if we are to reduce the burden of CV disease.

ST-Segment Depression in Leads I and aVL: Artifactual or Pathophysiological Findings ?

The 12-lead electrocardiogram(ECG)is a routinely performed test but is susceptible to misinterpretation even by experienced physicians.We report a case of a 72-year-old lady with no prior cardiac history presented to our hospital with atypical chest pain.Her initial electrocardiogram shows an initial ST depression followed by positive defl ections leads I and aVL.Non-physiological ST segment and T-wave changes are also observed in the precordial leads V2 to V6.By contrast,these abnormalities are notably absent in lead II.A repeat of the ECG taken 30 minutes later reveals the resolution of most abnormalities seen in the initial ECG on a background of high-frequency noise in the limb leads.She was referred to the cardiology department for further management.An urgent echocardiogram revealed no regional wall motion abnormalities with preserved ejection fraction,and her coronary angiogram revealed no signifi cant coro-nary stenosis.This case illustrates the importance of understanding different factors that can cause ST segment abnor-malities,notably artifactual changes that can mimic ST segment myocardial infarction.

Increasing Pupil Size Is Associated with Increasing Cognitive Processing Demands: A Pilot Study Using a Mobile Eye-Tracking Device

Previous studies have shown that increases in pupil size are correlated with increasing cognitive processing demands. Our aim was to confirm whether these findings could be replicated with new portable and less obtrusive eye-tracking technology. We assessed the percentage change of pupillary diameter from baseline as eight subjects completed a series of randomly ordered arithmetic problems of varying difficulty. The mean peak pupil diameter expressed as a percentage change from baseline was significantly greater when answering difficult questions compared to easier questions. Moreover, the time to reach peak pupillary diameter occurred significantly faster when participants answered easier questions compared to more difficult questions. Finally, there was a significant difference when all groups were compared to control. This experiment confirms findings of previous studies that show that pupillary size is related to cognitive processing demands. It also demonstrates that mobile eye-trackers can be used to reliably gather this type of data. Furthermore, this experiment provides the basis for future studies using eye-tracking technology in new environments, for example in the study of expertise and performance in medical crisis situations.

Novel Automated Paced Fractionation Detection Algorithm for Ablating Ventricular Tachycardia

Catheter ablation therapy has become a key intervention in treatment of ventriculartachycardia (VT). However, current fractionation mapping methods used to isolate the ablation targets in VT patients are done manually, and are therefore time consuming. They also have limited success rates (50% recurrence rate within 2 years). We present a fully automated fractionation detection algorithm for patients with VT which expands on previously defined fractionation features and which substantially decreases associated study times. Paced electrogram signals were collected from six patients during electrophysiologic study according to a modified paced electrogram fractionation analysis protocol. Data were exported and analyzed offline using custom written software. Electrograms from right ventricular pacing catheter were used as reference. Surface electrograms, along with ventricular geometry and relative catheter locations, were used to identify physiological interference and physiologically irrelevant features. A total of 264 electrograms, collected from a roving catheter, were manually and automatically annotated for fractionation as defined by three features: conduction time (CT), electrogram duration (ED), and number of deflections (ND). Of these, 60 were selected manually to have no discernable features and were successfully discarded by our algorithm;yielding a specificity of 100%. Of the remaining 204, 16 were erroneously discarded by our algorithm;yielding a sensitivity of 92.16%. A comparison between annotations showed correlations of 0.98, 0.97, and 0.94 for AL, ED, and ND respectively.

Does Minimizing Ventricular Pacing Reduce the Incidence of Atrial Fibrillation ? A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background:Right ventricular pacing disrupts atrioventricular synchrony and increases the risk of atrial fi brillation(AF).However,whether algorithms for minimizing ventricular pacing reduce the incidence of AF remains controversial.Therefore,we conducted a systematic review and meta-analysis to compare the incidence of AF between minimizing ventricular pacing and conventional pacing protocols in patients with pacemakers implanted.Methods:The PubMed,Embase,and Cochrane Library databases were searched up to August 1,2017,for randomized controlled trials that reported the incidence of AF in patients with and without the use of algorithms for minimizing ventricular pacing.Results:Eleven studies comprising 5705 participants(61%males,mean age 71 years[standard deviation 11 years])were fi nally included in the analysis.The mean follow-up duration was 24 months.Use of algorithms for minimizing ventricular pacing signifi cantly reduced the incidence of AF,with an odds ratio of 0.74(95%confi dence interval 0.55–1.00;P<0.05).There was moderate heterogeneity among studies(I 2=63%).Conclusions:The incidence of AF was reduced by 26%with use of algorithms for minimizing ventricular pacing.The incorporation of such algorithms in routine clinical practice should in theory lead to a decrease in AF-related morbidity and mortality.

Meta-analysis of T-wave indices for risk stratification in myocardial infarction

Ventricular tachy-arrhythmias are the commonest cause of sudden cardiac death in patients with ischemie heart dis- ease. It is estimated that up to 20% patients with acute myocardial infarction suffer from these arrhythmias.There is a growing need for developing tools for risk as- sessment for sudden cardiac death （SCD） in this population.

早产儿高输血量和标准输血量的比较

We compared high volume (20 ml/kg) with standard volume (15 ml/kg) packed red blood cell (PRBC) transfusions in a randomized trial. Ten high volume babies received a mean of 2.8 transfusions, while 10 standard volume babies received a mean of 3.4 (p = 0.58). No adverse events were attributed to the use of the high volume transfusions. Conclusion: Higher transfusion volumes appear to be well tolerated. The data can be used in the planning of larger controlled trials in VLBW infants.