St Martha's Regional Hospital

The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

INTRODUCTION: Cholinesterase inhibitors (ChEIs) and memantine are medications used to treat the symptoms of specific types of dementia. Their benefits and harms can change over time, particularly during long term use. Therefore, appropriate use of ChEIs and memantine involves both prescribing these medications to individuals who are likely to benefit, and deprescribing (withdrawing) them from individuals when the risks outweigh the benefits. We recently developed an evidence-based clinical practice guideline for deprescribing ChEIs and memantine, using robust international guideline development processes. MAIN RECOMMENDATIONS: Our recommendations aim to assist clinicians to: identify individuals who may be suitable for a trial of deprescribing ChEIs and memantine (such as those who do not have an appropriate indication, those who have never experienced a benefit, those who appear to be no longer benefitting, and those who have severe or end-stage dementia); and taper treatment and monitor individuals during the deprescribing process. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE: Deprescribing ChEIs and memantine through shared decision making with individuals and their caregivers by: ▶determining their treatment goals; ▶discussing benefits and harms of continuing and ceasing medication, from the start of therapy and throughout; and ▶engaging them in monitoring after discontinuation, while informing carers that the individual will continue to decline after discontinuation. This approach may reduce adverse drug reactions and medication burden, leading to improved quality of life in people with dementia.

In 6-month anti-dementia drug trials, a 4-point change in the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) is held to be clinically important. We examined how this change compared with measures of clinical meaningfulness. This is a secondary analysis of a 12 month open-label study of 100 patients (71 women) diagnosed with mild to moderate AD treated with 5–10 mg of donepezil daily. We studied the observed case, 6-month change from baseline on the ADAS-Cog, the Clinician's Interview Based Impression of Change-Plus Caregiver Input (CIBIC-Plus), patient-Goal Attainment Scaling (PGAS) and clinician-GAS (CGAS). At 6 months, donepezil-treated patients (n = 95) were more likely to show no change (+/- 3 points) on the ADAS-Cog (56%) than to improve (20%) or decline (24%) by 4-points. ADAS-Cog change scores were little correlated with other measures: from -0.09 for PGAS to 0.27 for the CIBIC-Plus. While patients who improved on the ADAS-Cog were less likely to decline on the clinical measures (26%), 43% of patients who declined on the ADAS-Cog improved on at least two of the clinical measures. The ADAS-Cog did not capture all clinically important effects. In general, ADAS-Cog improvement indicates clinical improvement, whereas many people with ADAS-Cog decline do not show clinical decline. The open-label design of this study does not allow us to know whether this is a treatment effect, which requires further investigation.

Goal Attainment Scaling (GAS), an individualized measurement approach, is particularly attractive for the evaluation and care planning of frail elders, who often experience multiple, complex problems. Some service providers find GAS too unwieldy for routine use. A modified version of GAS that uses a standardized menu of goals and attainment levels has been developed by the Geriatric Assessment and Rehabilitation Unit of a regional referral hospital in Nova Scotia, Canada. This article reviews the development, implementation, benefits, and challenges of the standardized menu, as well as the results of a retrospective descriptive study of its measurement properties. The standardized menu appears to be a feasible, valid, and responsive alternative to traditional GAS, while retaining much of its individualized nature.

BACKGROUND: A minimum 4-point change at 6 months on the Alzheimer's disease assessment scale-cognitive subscale (ADAS-cog) is deemed clinically important, but this cut-point has been little studied in relation to clinical meaningfulness. In an investigator-initiated, clinical trial of galantamine, we investigated the extent to which a 4-point change classifies goal attainment by individual patients. METHODS: Secondary analysis of the video imaging synthesis of treating Alzheimer's disease (VISTA) study: a 4-month, multi-centre, parallel-group, double-blind, placebo-controlled, trial of galantamine in 130 mild-moderate Alzheimer's disease patients (4-month open-label follow-up). ADAS-cog responses at 6 months were compared with outcomes on three clinical measures: clinician's interview based impression of change-plus caregiver input (CIBIC+), patient/carer-goal attainment scaling (PGAS) and clinician-GAS (CGAS). RESULTS: Thirty-seven of 99 patients improved by > or = 4 points on the ADAS-cog at 6 months, and 16/99 showed > or = 4-point worsening. ADAS-cog change scores correlated notionally to modestly with changes on the CGAS (r = -0.31), the PGAS (r = -0.29) and the CIBIC+ (r = 0.31). As a group, patients with ADAS-cog improvement were significantly more likely to improve on the clinical measures; those who worsened showed non-significant clinical decline. Individually, about half were misclassified in relation to each clinical measure; often when the ADAS-Cog detected 'no change', clinically meaningful effects could be detected. Even so, no ADAS-Cog cut-point optimally classified patients' clinical responses. CONCLUSION: A 4-point ADAS-cog change at 6 months is clinically meaningful for groups. Substantial individual misclassification between the ADAS-cog and clinical measures suggests no inherent meaning to a 4-point ADAS-cog change for a given patient.

PURPOSE: Home blood pressure (BP) monitoring is increasingly prevalent. The Canadian Hypertension Education Program (CHEP) developed a Family Practice BP tracking diary for home readings with an educational booklet. We evaluated the effectiveness of these tools compared with the standard approach of a hypertension information leaflet on BP-related knowledge, attitudes and behaviours of hypertensive family practice patients. METHOD: Single-blind randomized control trial on patients with raised BP. RESULTS: Three practices in Ontario, Quebec and Nova Scotia recruited a total of 109 eligible patients. The average age was 66.1 (SD 9.3) years and 58 (54.7%) were male. There was a statistically significant increase in the mean number of correct responses to 20 hypertension knowledge questions of 1.14 from 15.3 (SD 2.2) at baseline to 16.4 (SD 2.2) at 3 months in both groups (n=72, P<0.001). Patients frequently did not realize that usually more than one drug plus lifestyles changes were necessary to reduce BP to target or that it might take 6 weeks for some drugs to achieve their full effect. The BP tracking diary and the booklet had positive evaluation from the patients. CONCLUSIONS: Most patients have a good baseline of knowledge about hypertension but there are still important areas that need to be addressed. The booklet and tracker were well received by patients but the simple leaflet was as effective at improving knowledge.

BACKGROUND: Eustachian tube dysfunction (ETD) is a common medical issue, occurring in at least 1% of the adult population. Patients suffering from ET dysfunction typically present with complaints of hearing loss or sensation of pressure or plugged ear, which can lead to impaired quality of life. Over time ETD can result in conductive hearing loss or choleastatoma formation. Effective theraputic options for ET dysfunction are few. Eustachian tube balloon dilation is a novel surgical technique being used to treat ETD. The aim of our study is to objectively measure the success of Eustachian tube balloon dilation by comparing pre and post-operative middle ear pressures using tympanometric testing. METHODS: RA retrospective chart review was preformed on all patients who underwent balloon dilation of the Eustachian tube by authors NC or MB from 2010 to 2014. Pre and post-operative tympanograms were analyzed and categorized based on type (Type A, Type B, Type C). Success was defined by an improvement in tympanogram type: Type B or C to Type A, or Type B to type C. Pre and post-operative tympanograms were further analyzed using middle ear pressure values. Follow-up ranged from 3 to 15 months. RESULTS: Twenty-five ears (18 patients) were included in the study. Overall 36% of ears had improvement in tympanogram type, and 32% had normalization of tympanogram post-operatively. The Jerger tympanogram type improved significantly following the procedure (p = 0.04). Patients also had statistically significant improvement in measured middle ear pressure post-operatively (P = 0.003). CONCLUSION: The natural history of Eustachian tube dysfunction is poorly understood, and evidence for current treatments are limited. Eustachian tube balloon dilation is a safe procedure, and produces significant improvement in tympanogram values up to 15 months post-operatively. Further refinement of patient selection and standardization of technique is required to optimize the effect of this therapy. Longterm follow-up data will clarify the persistence of the effect.

Merkel cell carcinoma (MCC) is a rare, frequently lethal, primary neuroendocrine carcinoma of the skin. Histopathologically, it appears as a dermal nodule of small, undifferentiated malignant cells. Historically, MCC was considered to be an eccrine carcinoma. Recognition of its neuroendocrine features later led to the hypothesis that it arose from Merkel cells in the skin, although recent evidence revisits the question of an epithelial origin. We present a case of MCC arising on the temple of a 78-year-old male, in association with an actinic keratosis. Three years later, a local tumor recurrence showed a mixed malignancy comprising small cell neuroendocrine and large cell squamoid components. A further recurrence at the site two years later, after local radiotherapy, revealed a bizarre pleomorphic large cell morphology with retention of immunohistochemical features of a neuroendocrine carcinoma. Evolution to a bizarre pleomorphic large cell neoplasm has been recorded in malignant tumors treated by radiotherapy, but is unique for MCC. The association of this MCC with an actinic keratosis and the development of squamoid differentiation in a local recurrence support the link between MCC and epithelial neoplasia. In addition, its evolution to an atypical fibroxanthoma-like morphology is of interest, because some view atypical fibroxanthomas as bizarre variants of squamous cell carcinoma.

Incorporation of 1-hexanol close to the palisade layer of CTAT micelles favors transition of worm-like micelles to vesicular structures<italic>via</italic>formation of elongated worm-like micelles.

Lamellar, or layered, potassium niobium oxide perovskites are a class of underdeveloped semiconductors in organic photocatalysis that offer the inherent advantages of larger particle size and ease of recoverability as compared to traditional semiconductor materials.

BACKGROUND: the Pictorial Fit-Frail Scale (PFFS) was designed as a simple and practical approach to the identification of frailty. OBJECTIVES: To investigate the feasibility and reliability of this visual image-based tool, when used by patients, caregivers and healthcare professionals (HCPs) in clinical settings. DESIGN: observational study. SETTING: three outpatient geriatric healthcare settings. SUBJECTS: patients (n = 132), caregivers (n = 84), clinic nurses (n = 7) and physicians (n = 10). METHODS: the PFFS was administered to all patients. Where available, HCPs and caregivers completed the scale based on the patients' health. In the geriatric day hospital, the PFFS was completed on admission and administered again within 7-14 days. Time and level of assistance needed to complete the scale were recorded. Intraclass correlation coefficients (ICCs) and 95% confidence intervals (CIs) were used to assess test-retest and inter-rater reliability. RESULTS: mean time to complete the scale (minutes:seconds ± SD) was 4:30 ± 1:54 for patients, 3:13 ± 1:34 for caregivers, 1:28 ± 0:57 for nurses and 1:32 ± 1:40 for physicians. Most patients were able to complete the scale unassisted (64%). Mean patient PFFS score was 11.1 ± 5.3, mean caregiver score was 13.2 ± 6.3, mean nurse score was 10.7 ± 4.5 and mean physician score was 11.1 ± 5.6; caregiver scores were significantly higher than patient (P < 0.01), nurse (P < 0.001) and physician (P < 0.01) scores. Test-retest reliability was good for patients (ICC = 0.78, [95%CI = 0.67-0.86]) and nurses (ICC = 0.88 [0.80-0.93]). Inter-rater reliability between HCPs was also good (ICC = 0.75 [0.63-0.83]). CONCLUSION: the PFFS is a feasible and reliable tool for use with patients, caregivers and HCPs in clinical settings. Further research on the validity and responsiveness of the tool is necessary.

Novel gold nanoparticle@niobium oxide perovskite composites promote the photoreduction of <italic>para</italic>-substituted nitroarenes, where electron-withdrawing groups accelerate the photocatalytic reaction.

The tetanus, diphtheria, and acellular pertussis vaccine (Tdap) is recommended for all adults in both Canada and the United States. There are few data on the proportion of Canadian adults vaccinated with Tdap; however, anecdotal reports indicate that uptake is low. This study aimed to explore the knowledge, attitudes, beliefs, and behaviors of Canadian health care providers (HCPs) in an attempt to identify potential barriers and facilitators to Tdap uptake. HCPs were surveyed and a geographic and practice representative sample was obtained (N =1,167). In addition, 8 focus groups and 4 interviews were conducted nationwide. Results from the survey indicate that less than half (47.5%) of all respondents reported being immunized with Tdap themselves, while 58.5% routinely offer Tdap to their adult patients. Knowledge scores were relatively low (63.2% correct answers). The best predictor of following the adult Tdap immunization guidelines was awareness of and agreement with those recommendations. Respondents who were aware of the recommendations were more likely to think that Tdap is safe and effective, that their patients are at significant risk of getting pertussis, and to feel that they have sufficient information (p < 0.0001 for each statement). Focus group data supported the survey results and indicated that there are substantial gaps in knowledge of pertussis and Tdap among Canadian HCPs. Lack of public knowledge about adult immunization, lack of immunization registries, a costing differential between Td and Tdap, workload required to deliver the vaccine, and vaccine hesitancy were identified as barriers to compliance with the national recommendations for universal adult immunization, and suggestions were provided to better translate recommendations to front-line practitioners.

Along with the development of the Industrial Internet of Things, human activity recognition (HAR) has received widespread attention in many fields. Support Vector Machine (SVM), is widely used by researchers for human activity recognition. However, the inherent difference of signal properties from different sensors and various orientations is potentially lost when using the vector-based SVM for human activity recognition. What's more, the outlier sensitivity problem of the standard SVM reduces the accuracy of human activity recognition. To tackle this problem, we present a tensor-based feature representation model and a weighted support tensor machine (WSTM) for human activity recognition. Specifically, tensor-based representations are first used to model features from different sensors and various orientations to retain the latent relationship. In addition, the weighted support tensor machine is proposed to classify the human activities in tensor space while avoiding the outlier sensitivity problem. Experimental results demonstrate the proposed WSTM algorithm.

BACKGROUND: Iodine requirements are increased during pregnancy to maintain maternal and fetal euthyroidism. There have been recent improvements in iodized salt coverage in India, but whether iodized salt is sufficient to sustain iodine requirements during pregnancy remains uncertain. Our aims were to measure thyroid status in first trimester pregnant women in southern India and assess potential determinants of thyroid function, including iodine status, thyroid autoimmunity, dietary patterns, body weight, and anemia. METHODS: This was a cross-sectional study among 334 pregnant women of ≤ 14 weeks' gestation, in Bangalore, India. We measured anthropometrics, urinary iodine concentration (UIC), maternal thyroid volume (by ultrasound), and thyroid function. We applied a thyrotropin (TSH) upper limit of 2.5 mIU/L to classify thyroid insufficiency. Using a questionnaire, we obtained sociodemographic and dietary data, obstetric history, and use of iodized salt and iodine supplements. RESULTS: Among the women, the mean (standard deviation) gestational age was 10.3 (2.5) weeks, 67% were nulliparous, 21% were vegetarian, 19% were anemic, and 23% were overweight or obese. Iodized salt was used by 98% of women, and they were iodine sufficient: median UIC (range) was 184.2 μg/L (8.1-1152 μg/L) and all had a normal thyroid volume. However, 18% of the women had thyroid insufficiency: 3.7% had overt hypothyroidism (83% with positive TPO-Ab), 9.2% had subclinical hypothyroidism, and 5.2% had hypothyroxinemia. Women consuming vegetarian diets did not have significantly lower iodine intakes or higher risk of hypothyroidism than those consuming mixed diets, but overweight/obesity and anemia predicted thyroid insufficiency. CONCLUSION: In this urban population of southern India, pregnant women have adequate iodine status in the first trimester. Despite this, many have thyroid insufficiency, and the prevalence of overt hypothyroidism is more than fivefold higher than reported in other iodine sufficient populations of pregnant women.

Blending and interesterification of high oleic algal oil with medium chain triglycerides decreased viscosity and inhibited crystallization of triacylglycerol oils used as sustainable lubricant feedstocks.

Remimazolam is made by combining midazolam and remifentanil as an alternative to conventional sedatives. To evaluate the efficacy of remimazolam for sedation in patients undergoing colonoscopy, we conducted a systematic review and meta-analysis of the available randomized controlled trials (RCTs) comparing remimazolam and midazolam. A search was conducted using PubMed, Cochrane Library, and clinicaltrial.gov from inception till December 26, 2021, for RCTs that investigated the efficacy of remimazolam during the above-mentioned procedure. There was no restriction of language. A quality assessment was performed using the Cochrane Risk-of-Bias tool. The data were pooled, and a meta-analysis was completed. The systemic review was conducted in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) guideline statement. Three randomized controlled trials involving 539 patients were included in the meta-analysis. Compared with midazolam during colonoscopy, remimazolam results in reduced need for top-up doses (RR= 3.45, 95% CI=1.07 to 11.14; P=0.04, I2=84%). The need for rescue medication was reduced with remimazolam as compared to midazolam (RR=2.42, 95%CI=1.04 to 5.61; P=0.04, I2=96%). There was no significant difference observed between the two drugs on completion of colonoscopy and the overall procedural sedation, but the sensitivity analysis favored remimazolam over midazolam for procedural sedation (RR=4.08, 95%CI=2.35 to 7.09; P<0.00001, I2=39%). This analysis demonstrates the advantages of remimazolam over other agents and sets a platform for relevant future studies.

Idiopathic Pulmonary Arterial Hypertension (IPAH) is a deadly and disabling disease characterized by severe vascular remodeling of small pulmonary vessels by fibroblasts, myofibroblasts and vascular smooth muscle cell proliferation. Recent studies suggest that the Natriuretic Peptide Clearance Receptor (NPR-C) signaling pathways may play a crucial role in the development of IPAH. Reduced expression or function of NPR-C signaling in pulmonary artery smooth muscle cells may contribute to the pulmonary vascular remodeling, which is characteristic of this disease. The likely mechanisms may involve an impaired interaction between NPR-C, specific growth factors and other signal transduction pathways including but not limited to Gqα/mitogen-activated protein kinase (MAPK)/PI3K and AKT signaling. The resulting failure of growth suppression in pulmonary artery smooth muscle cells provides critical clues to the cellular pathobiology of IPAH. The reciprocal regulation of NPR-C signaling in models of tissue remodeling may thus provide new insights to our understanding of IPAH.

Underwater superoleophobic surfaces can be considered a particular type of lubricant-infused surface, that have anti-fouling properties by virtue of a trapped water layer that repels oils. However, as their function relies on a water layer being trapped in the surface roughness, it is crucial to understand the factors that determine the layer stability. In this work, the forces that are responsible for the stability of thin liquid films within structured surfaces were quantified, and the conclusions were tested against the performance of wrinkled surfaces as underwater superoleophobic coatings. Here, the system studied was a family of wrinkled surfaces made of hydrophilic poly(4-vinylpyridine) (P4VP), whereby the wrinkle width could be controllably tuned in the range 90 nm to 8000 nm. The van der Waals free energy was quantified and the capillary forces trapping water in the surface micro- and nano-wrinkle structure were estimated. P4VP surfaces with micro-scale wrinkles had underwater superoleophobic properties, and low adhesion to different oils with droplet roll-off angle below 6° ± 1°. Despite the van der Waals free energy of the system pointing to the dewetting of a water film under oil on top of a smooth P4VP film, the wrinkled structure is sufficient to induce a Cassie state with a trapped water layer. The micro-scale wrinkles (average width 4-12 μm) were found to be particularly effective in the trapping of the water in a Cassie non-adhesive state. The P4VP wrinkled surfaces are superamphiphobic, as when they were first infused with oil, and then exposed to a droplet of water under oil, they exhibited superhydrophobic behavior. The P4VP wrinkles have the additional useful feature of being transparent underwater, which makes them useful candidates for the protection of underwater cameras and sensors.

A 65-year-old male with known hypertension and hypercholesterolemia sought medical attention because of a 3-month history of skin swelling on his upper back. Histopathology and molecular techniques were employed and identified an organism in the Onchocerca genus. This represents a very uncommon example of cutaneous infection by a zoonotic Onchocerca species.