Canadian Consensus Recommendations Research Articles

EP13.07-08 Canadian Consensus Recommendations: Use of Radiation Therapy among Patients with ES-SCLC receiving Immunotherapy

EP13.07-08 Canadian Consensus Recommendations: Use of Radiation Therapy among Patients with ES-SCLC receiving Immunotherapy

95 Use of Radiation Therapy Among Patients with Extensive-Stage Small-Cell Lung Cancer Receiving Immunotherapy: Canadian Consensus Recommendations

95 Use of Radiation Therapy Among Patients with Extensive-Stage Small-Cell Lung Cancer Receiving Immunotherapy: Canadian Consensus Recommendations

Use of radiation therapy among patients with Extensive-stage Small-cell lung cancer receiving Immunotherapy: Canadian consensus recommendations

ObjectivesThoracic radiation therapy (TRT) and prophylactic cranial irradiation (PCI) are commonly used in the management of extensive-stage small-cell lung cancer (ES-SCLC); however, Phase III trials of first-line immunotherapy often excluded these options. Guidance is needed regarding appropriate use of TRT, PCI, and magnetic resonance imaging (MRI) surveillance while new data are awaited. Materials and methodsIn two web-based meetings, a pan-Canadian expert working group of five radiation oncologists and four medical oncologists addressed eight clinical questions regarding use of radiation therapy (RT) and MRI surveillance among patients with ES-SCLC receiving immunotherapy. A targeted literature review was conducted using PubMed and conference proceedings to identify recent (January 2019–April 2022) publications in this setting. Fifteen recommendations were developed; online voting was conducted to gauge agreement with each recommendation. ResultsAfter considering recently available evidence across lung cancer populations and clinical experience, the experts recommended that all patients with a response to chemo-immunotherapy, good performance status (PS), and limited metastases be considered for consolidation TRT (e.g., 30 Gy in 10 fractions). When considered appropriate after multidisciplinary team discussion, TRT can be initiated during maintenance immunotherapy. All patients who respond to concurrent chemo-immunotherapy should undergo restaging with brain MRI to guide decision-making regarding PCI versus MRI surveillance alone. MRI surveillance should be conducted for two years after response to initial therapy. PCI (e.g., 25 Gy in 10 fractions or 20 Gy in 5 fractions) can be considered for patients without central nervous system involvement who have a response to chemo-immunotherapy and good PS. Concurrent treatment with PCI and immunotherapy or with TRT, PCI, and immunotherapy is appropriate after completion of initial therapy. All recommendations were agreed upon unanimously. ConclusionsThese consensus recommendations provide practical guidance regarding appropriate use of RT and immunotherapy in ES-SCLC while awaiting new clinical trial data.

Canadian consensus recommendations for a research agenda in pulmonary rehabilitation post-acute exacerbation of COPD: A meeting report

RATIONALE: A recent Cochrane review concluded that Pulmonary Rehabilitation (PR) post-acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is safe, reduces hospital admissions and improves quality of life and exercise capacity of patients post-AECOPD. Despite these benefits, recent reports have highlighted poor referral, uptake and completion rates of early post-AECOPD PR. These concerns provided the foundation for the “PR Post-AECOPD Meeting”, which was funded by the Canadian Institutes of Health Research and held in Montreal in November 2017. OBJECTIVES The objectives were to identify key research priorities in the complex area of care of delivering PR post-AECOPD. METHODS Meeting participants were asked to complete a pre-meeting survey in order to foster thinking prior to the beginning of the discussions. The first day of the meeting involved presentations from experts and a review of the pre-meeting survey results. Facilitated small group discussions occurred using the consensus building technique (Strengths, Weaknesses, Opportunities, and Threats [SWOT] method). The second day focused on large group discussions in order to identify the research themes. RESULTS The top three research themes identified were: 1) a phased approach to PR post-AECOPD, 2) patient-centered interventions and outcomes and 3) gaining a greater understanding of the emotional and psychological impacts of AECOPD. Other identified themes were: how to improve referral, uptake and access to PR post-AECOPD, how to reach under-served patient groups and cost-effectiveness of potential individualized interventions. CONCLUSIONS In this meeting, the stakeholders identified research priorities that should guide clinicians and researchers in their efforts to produce high-quality evidence.

Evolving role of MRI in optimizing the treatment of multiple sclerosis: Canadian Consensus recommendations.

BackgroundMagnetic resonance imaging (MRI) is increasingly important for the early detection of suboptimal responders to disease-modifying therapy for relapsing–remitting multiple sclerosis. Treatment response criteria are becoming more stringent with the use of composite measures, such as no evidence of disease activity (NEDA), which combines clinical and radiological measures, and NEDA-4, which includes the evaluation of brain atrophy.MethodsThe Canadian MRI Working Group of neurologists and radiologists convened to discuss the use of brain and spinal cord imaging in the assessment of relapsing–remitting multiple sclerosis patients during the treatment course.ResultsNine key recommendations were developed based on published sources and expert opinion. Recommendations addressed image acquisition, use of gadolinium, MRI requisitioning by clinicians, and reporting of lesions and brain atrophy by radiologists. Routine MRI follow-ups are recommended beginning at three to six months after treatment initiation, at six to 12 months after the reference scan, and annually thereafter. The interval between scans may be altered according to clinical circumstances.ConclusionsThe Canadian recommendations update the 2006 Consortium of MS Centers Consensus revised guidelines to assist physicians in their management of MS patients and to aid in treatment decision making.

Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 1: prophylaxis.

Patients with cancer are at increased risk of venous thromboembolism (vte). Anticoagulation therapy has been shown to prevent vte; however, unique clinical circumstances in patients with cancer can often complicate the decisions surrounding the administration of prophylactic anticoagulation. No national Canadian guidelines on the prevention of cancer-associated thrombosis have been published. We therefore aimed to develop a consensus-based, evidence-informed guideline on the topic. PubMed was searched for clinical trials and meta-analyses published between 2002 and 2013. Reference lists of key articles were hand-searched for additional publications. Content experts from across Canada were assembled to review the evidence and make recommendations. Low molecular weight heparin can be used prophylactically in cancer patients at high risk of developing vte. Direct oral anticoagulants are not recommended for vte prophylaxis at this time. Specific clinical scenarios, including renal insufficiency, thrombocytopenia, liver disease, and obesity can warrant modifications in the administration of prophylactic anticoagulant therapy. There is no evidence to support the monitoring of anti-factor Xa levels in clinically stable cancer patients receiving prophylactic anticoagulation; however, factor Xa levels could be checked at baseline and periodically in patients with renal insufficiency. The use of anticoagulation therapy to prolong survival in cancer patients without the presence of risk factors for vte is not recommended.

Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 2: treatment.

Patients with cancer are at increased risk of venous thromboembolism (vte). Anticoagulation therapy is used to treat vte; however, patients with cancer have unique clinical circumstances that can often make decisions surrounding the administration of therapeutic anticoagulation complicated. No national Canadian guidelines on the management of established cancer-associated thrombosis have been published. We therefore aimed to develop a consensus-based, evidence-informed guideline on the topic. PubMed was searched for clinical trials and meta-analyses published between 2002 and 2013. Reference lists of key articles were hand-searched for additional publications. Content experts from across Canada were assembled to review the evidence and make recommendations. Low molecular weight heparin is the treatment of choice for cancer patients with established vte. Direct oral anticoagulants are not recommended for the treatment of vte at this time. Specific clinical scenarios, including the presence of an indwelling venous catheter, renal insufficiency, and thrombocytopenia, warrant modifications in the therapeutic administration of anticoagulation therapy. Patients with recurrent vte should receive extended (>3 months) anticoagulant therapy. Incidental vte should generally be treated in the same manner as symptomatic vte. There is no evidence to support the monitoring of anti-factor Xa levels in clinically stable cancer patients receiving prophylactic anticoagulation; however, levels of anti-factor Xa could be checked at baseline and periodically thereafter in patients with renal insufficiency. Follow-up and education about the signs and symptoms of vte are important components of ongoing patient care.

Multidisciplinary Canadian consensus recommendations for the management and treatment of hepatocellular carcinoma

Globally, hepatocellular carcinoma (hcc) is the third most common cause of death from cancer, after lung and stomach cancer. The incidence of hcc in Canada is increasing and is expected to continue to increase over the next decade. Given the high mortality rate associated with hcc, steps are required to mitigate the impact of the disease. To address this challenging situation, a panel of 17 hcc experts, representing gastroenterologists, hepatologists, hepatobiliary surgeons, medical oncologists, pathologists, and radiologists from across Canada, convened to provide a framework that, using an evidence-based approach, will assist clinicians in optimizing the management and treatment of hcc. The recommendations, summarized here, were developed based on a rigorous methodology in a pre-specified process that was overseen by the steering committee. Specific topics were identified by the steering committee and delegated to a group of content experts within the expert panel, who then systematically reviewed the literature on that topic and drafted the related content and recommendations. The set of recommendations for each topic were reviewed and assigned a level of evidence and grade according to the levels of evidence set out by the Centre for Evidence-based Medicine, Oxford, United Kingdom. Agreement on the level of evidence for each recommendation was achieved by consensus. Consensus was defined as agreement by a two-thirds majority of the 17 members of the expert panel. Recommendations were subject to iterative review and modification by the expert panel until consensus could be achieved.

A Systematic Review and Canadian Consensus Recommendations on the Use of Biomarkers in the Treatment of Non-small Cell Lung Cancer

Greater understanding of molecular pathways important in cell growth and proliferation of thoracic malignancies, particularly non-small cell lung cancer (NSCLC), has resulted in intense clinical and translational research. There is now considerable interest in personalizing treatment based on an understanding of tumor histology and molecular abnormalities. However, there is a multiplicity of data, often with discordant results resulting in confusion and uncertainty among clinicians. We conducted a systematic review and a consensus meeting of Canadian lung cancer oncologists and pathologists to make recommendations on the use of biomarkers in NSCLC. PubMed covering 2005 to March 2010 was searched using MESH terms for NSCLC and randomized trials, plus text words for the biomarkers of interest. Conference proceedings from 2005 to 2009 ASCO, ESMO, IASLC, and USCAP were also searched. The articles were reviewed by pairs of oncologists and pathologists to determine eligibility for inclusion. Ten oncologists and pathologists reviewed and summarized the literature at a meeting attended by 37 individuals. Draft recommendations were formulated and agreed upon by consensus process. There is some evidence that histology is prognostic for survival. There is evidence from multiple randomized clinical trials to recommend the following: histologic subtype is predictive of treatment efficacy and for some agents toxicity. Immunohistochemistry testing should be performed on NSCLC specimens that cannot be classified accurately with conventional H&E staining. As EGFR mutations are predictive of benefit from tyrosine kinase inhibitors, diagnostic NSCLC samples should be routinely tested for EGFR-activating mutations. Clinical data on K-RAS mutations are inconsistent, therefore testing is not recommended. There is insufficient evidence to recommend other biomarker testing. No biomarkers to date reliably predict improved efficacy for anti-VEGF therapy. Routine assessment for EML4/ALK mutations is not recommended at present, although emerging data suggest that it may become valuable in the near future. Assessment of NSCLC biomarkers is becoming increasingly important. Therefore, adequate diagnostic material must be obtained for accurate histologic subtyping and relevant molecular biology assays.

Canadian Expert Group Consensus Recommendations: KRAS Testing in Colorectal Cancer

Monoclonal antibodies against the epidermal growth factor receptor (anti-egfr) when used in the treatment of metastatic colorectal cancer are associated with improved survival. Patients whose tumours harbor a KRAS mutation in codon 12 or 13 have been shown not to benefit from anti-egfr antibodies. The importance of KRAS mutation status in the management of patients with metastatic colorectal cancer has led to the elaboration of Canadian consensus recommendations on KRAS testing, with the aim of standardizing practice across Canada and reconciling testing access with the clinical demand for testing. The present guidelines were developed at a Canadian consensus meeting held in Montreal in April 2010. The best available evidence and expertise were used to develop recommendations for various aspects of KRAS testing, including indications and timing for testing, sample requirements, recommendations for reporting requirements, and acceptable turnaround times.

Clinical Management Recommendations for Surveillance and Risk-Reduction Strategies for Hereditary Breast and Ovarian Cancer Among Individuals Carrying a Deleterious BRCA1 or BRCA2 Mutation

BackgroundIn Canada, there are wide variations in services for patients at risk for hereditary breast and ovarian cancer (HBOC), and clinical interventions and recommendations differ between regions and/or provinces. National strategies for the clinical management of HBOC exist in the United Kingdom, France, and Australia, and clinical programs in Canada would benefit from similar national recommendations and a consistent approach to clinical management. The National Hereditary Cancer Task Force developed recommendations to address the clinical management of patients at high risk of HBOC and related cancers. These recommendations are based on current practice in high-risk cancer clinics that provide care for individuals with known BRCA1 or BRCA2 mutations. MethodsCanadian consensus recommendations were generated by the National Hereditary Cancer Task Force and compared mainly with two recently published guidance documents on the clinical management of women with increased risk of HBOC, one from the United Kingdom and the other from France. After review of these documents and the associated supporting scientific evidence, the Canadian consensus recommendations were modified and rated using predefined criteria. ConclusionsThese recommendations pertain to (1) surveillance options including breast self-examination, clinical breast examination, breast surveillance by imaging, ovarian cancer surveillance, and surveillance for men; (2) risk-reduction strategies including prophylactic mastectomy, prophylactic salpingo-oophorectomy, and pharmacoprevention; and (3) the use of exogenous hormones. Regular updates should occur as new evidence becomes available.

Do patients receive recommended treatment of osteoporosis following hip fracture in primary care?

BackgroundOsteoporosis results in fractures and treatment of osteoporosis has been shown to reduce risk of fracture particularly in those who have had a history of fracture.MethodsA prospective study was conducted using patients admitted to a hip fracture rehabilitation program at a large referral center to evaluate the use of treatments recommended for secondary prevention of osteoporotic fracture between September 1, 2001 and September 30, 2003. The frequency of medication use for the treatment of osteoporosis including estrogen replacement therapy, bisphosponates, calcitonin, calcium and vitamin D therapy was determined on admission, at 6 weeks post discharge and one year following discharge. All patients were discharged to the care of their family physician. All family physicians in the referral region received a copy of the Canadian Consensus recommendations for osteoporosis management 1–3 months prior to the study.ResultsDuring the study period, 174 patients were enrolled and 121 completed all assessments. Fifty-seven family physicians were identified as caring for 1 or more of the study patients. Only 7 patients had previous BMD, only 5 patients had previously been prescribed a bisphosponate and 14 patients were taking calcium and/or vitamin D. All patients were prescribed 2500 mg calcium, 400 IU vitamin D and 5 mg residronate daily during rehabilitation and at discharge.Following discharge, a significant improvement was seen in all clinical indices of functional mobility, including the functional independence measure (FIM), walking distance, fear of falling score (FFS), and the Berg balance score (BBS). At six weeks a significant (p < 0.01) decrease in calcium and vitamin D use was observed. All patients remained compliant with residronate therapy. At twelve months 71 patients remained on residronate (p < 0.01), 10 were now taking alternate bisphosphonate therapy and few were taking calcium and/or vitamin D (p < 0.001). FIM, FFS and Berg scores were significantly decreased from discharge (p < 0.001) while walking distance was unchanged.ConclusionFew patients admitted for hip fracture had previously taken recommended osteoporosis therapy including bisphosphonates. While compliance with Canadian Consensus recommendations was observed at six weeks, this was not the case at twelve months post hip fracture rehabilitation. Interventions to improve not only the detection and treatment of osteoporosis but also the ongoing treatment and management post-fracture need to be developed and implemented.

Canadian Consensus Recommendations for the Optimal Use of Enfuvirtide in HIV/AIDS Patients

An eight-member group consisting of Canadian infectious disease and immunology specialists and a family physician with significant experience in HIV management was convened to update existing recommendations, specifically intended for use by Canadian HIV-treating physicians, on the appropriate use of enfuvirtide in HIV/AIDS patients with resistance to other antiretroviral drugs. Evidence from the literature and expert opinions of the group members formed the basis of the guidelines. Comments on the draft guidelines were obtained from other physicians across Canada with HIV expertise. The final guidelines represent the group's consensus agreement. The recommendations were developed to guide physicians in optimal practices in patient selection for enfuvirtide treatment and subsequent patient management. The issues considered include positive predictors of response to enfuvirtide, stage of disease, optimization of the background regimen, early indicators of enfuvirtide response, and patient education and support.

Reflected High-intensity Motion Signals: Can This Ultrasound Phenomenon Be Used for Assessment of Left Ventricular Function?

In this pioneer study, we aimed to evaluate the diagnostic role of reflected high-intensity motion signals (RIMS) in the assessment of left ventricular (LV) systolic and diastolic function and to analyze the reproducibility of RIMS. RIMS are also known under the name of "spectral Doppler artifacts" and to date have been attributed only to the category of useless noises. The value of RIMS in the evaluation of LV function was analyzed in 173 subjects (57 healthy volunteers and 116 patients with chronic coronary and myocardial diseases and arterial hypertension). The level of intra- and inter-observer reproducibility of RIMS was assessed according to the Bland-Altman method in 29 subjects. To record RIMS by conventional pulsed wave Doppler, an apical 4-chamber view was used and the sample volume was placed 3 - 4 cm laterally to the left border of the mitral annulus in projection of the pulmonary tissue. Three components of RIMS are visualized with each cardiac cycle: one systolic (Sa) component and two diastolic (Ea and Aa) components. We have found that RIMS registration did not depend on the quality of LV visualization. In patients with adequate visualization of the cardiac structures and in "difficult" patients with poor LV visualization, RIMS recordings were visually equal. In our study, correlations between LV ejection fraction (EF) and Sa and Aa were found; the cutoff value of Sa < or = 13 cm/s and Aa < or = 15 cm/s separated patients with EF < or = 40 % from other subjects with a sensitivity of 88.2 % and 94.1 % and a specificity of 93.0 % (p <.0001) and 76.9 % (p <.0001), respectively. It was shown that RIMS correlate with the LV diastolic function. The Ea cutoff value of < or = 20 cm/s distinguished subjects with a normal diastolic function from patients with a sensitivity of 88.6 % and a specificity of 80.0 % (p <.0001); the cutoff values of Sa < or = 10 cm/s and Aa < 12 cm/s separated patients with a Grade 4 diastolic dysfunction (according to Canadian consensus recommendations) from other subjects with a sensitivity of 81.8 % and 90.9 %, and a specificity of 98.1 % (p <.0001) and 91.8 % (p <.0001), respectively. The combined evaluation of traditional transmitral E/A ratio and RIMS components allow differentiating of all standard stages of LV diastolic dysfunction in an easy and effective way. The level of intra- and inter-observer reproducibility of RIMS appeared to be acceptable. 1. Systolic and late diastolic components of RIMS correlate with LV global systolic function, and all components of RIMS correlate with LV global diastolic function; 2. The reproducibility of RIMS components is at an acceptable level; 3. Combined analysis of transmitral E/A ratio and RIMS components can become a promising approach for easy and effective separation of patients with different grades of diastolic dysfunction.

Diagnosis of Diastolic Dysfunction: Importance of Spectral Doppler Imaging

In Response: Dr. Poelaert’s comments are of great interest to us and we agree that Doppler pattern can be influenced by loading condition. This is particularly true for transmitral valve velocity pattern, but the pulmonary venous flow is also affected by other factors, including age, heart rate, cardiac output, left ventricular systolic function, and left atrial function (1). In our study, the diagnosis of diastolic dysfunction was based not only on the mitral valve inflow but also on the pulmonary vein velocity signal as suggested by the Canadian Consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography (2). The Doppler examination was performed, as we mentioned, “before pericardiotomy during a period of hemodynamic stability.” We routinely evaluate both pulmonary veins and have rarely encountered significant velocity differences before cardiac surgery Doppler signal from the right and left pulmonary veins are similar unless the Doppler signal intensity is attenuated because of improper positioning. The Doppler signal from the pulmonary vein can vary with mechanical ventilation, as we published before (1), but the systolic to diastolic ratio stayed the same. Klein et al. (3) observed discrepancies in velocities in up to 24% of patients with significant mitral regurgitation but in their series, the pulmonary flow was still abnormal in both veins. The use of a loading test (4) was not published when we collected the data and the use of tissue Doppler (5–8) was not a modality available on our transesophageal echocardiographic system at the time of the study. Furthermore, they are not yet part of the Canadian Consensus, which we used in the evaluation of diastolic dysfunction (2). We do agree however that they provide complementary and useful information on the appreciation of diastolic function. Our cardiologist, who was familiar with the use of tissue Doppler, did evaluate the mitral annular displacement in a semiqualitative fashion and could predict and confirm the type of diastolic abnormality based on visual inspection. This mode of evaluation, which is frequently discussed among “diastologists,” had not been formally validated at the time of the study, so we could not mention it in the methodology. André Denault, MD, FRCPC Francis Bernard, MD, FRCPC Pierre Couture, MD, FRCPC

Physician asthma management practices in Canada.

To establish national baseline information on asthma management practices of physicians, to compare the reported practices with the Canadian Consensus recommendations and to identify results potentially useful for interventions that improve physician asthma management practices. National, stratified cross-sectional survey. The 10 provinces and two territories of Canada, from 1996 to 1997. Questionnaires were sent to 4489 physicians stratified by province/territory and specialty group (family/general practice, respirology, internal medicine, pediatrics and allergy/immunology); 2605 responses were received. Methods for the diagnosis, treatment, education and follow-up of patients with asthma ('asthma management practices'). Significant variations existed among the five specialty groups in asthma management practices. A low use of objective measures of airflow limitation to assist with diagnosis was found among some respondents (mostly family physicians). Up to 40% of physicians regarded the daily fixed dosing (three or four times a day) of inhaled, short acting beta2-agonist as 'first-line therapy' for moderate to severe asthma. A minority of physicians reported using written action plans for patients or referring them to other health professionals for asthma education. Insufficient time during appointments and a perceived lack of appropriate educational materials were frequently cited as reasons for not providing asthma education. The perceived knowledge of the Canadian Consensus recommendations varied among physicians but was lowest among nonspecialists. The survey showed variations in certain aspects of the management of asthma by physicians. The findings will help to target specific areas for future physician education programs and other behavioural change strategies.

U.S.‐Canadian consensus recommendations on the immunophenotypic analysis of hematologic neoplasia by flow cytometry: Medical indications

CytometryVolume 30, Issue 5 p. 249-263 Special ReportFree Access U.S.-Canadian consensus recommendations on the immunophenotypic analysis of hematologic neoplasia by flow cytometry: Medical indications Bruce H. Davis, Corresponding Author Bruce H. Davis bdavis@beaumont.edu William Beaumont Hospital, Royal Oak, MichiganDept. of Clinical Pathology, Wm. Beaumont Hospital, 3601 W. Thirteen Mile Rd., Royal Oak, Michigan 48073-6769Search for more papers by this authorKathy Foucar, Kathy Foucar University of New Mexico, Albuquerque, New MexicoSearch for more papers by this authorWlodek Szczarkowski, Wlodek Szczarkowski Cytometry Associates, Brentwood, TennesseeSearch for more papers by this authorEdward Ball, Edward Ball University of Pittsburgh, Pittsburgh, PennsylvaniaSearch for more papers by this authorTom Witzig, Tom Witzig Mayo Clinic, Rochester, MinnesotaSearch for more papers by this authorKenneth A. Foon, Kenneth A. Foon Markey Cancer Center, Lexington, KentuckySearch for more papers by this authorDenise Wells, Denise Wells Hematologics, Seattle, WashingtonSearch for more papers by this authorPat Kotylo, Pat Kotylo Indiana University, Indianapolis, IndianaSearch for more papers by this authorRebecca Johnson, Rebecca Johnson Berkshire Medical Center, Pittsfield, MassachusettsSearch for more papers by this authorCurtis Hanson, Curtis Hanson Mayo Clinic, Rochester, MinnesotaSearch for more papers by this authorDavid Bessman, David Bessman University of Texas, Galveston, TexasSearch for more papers by this author Bruce H. Davis, Corresponding Author Bruce H. Davis bdavis@beaumont.edu William Beaumont Hospital, Royal Oak, MichiganDept. of Clinical Pathology, Wm. Beaumont Hospital, 3601 W. Thirteen Mile Rd., Royal Oak, Michigan 48073-6769Search for more papers by this authorKathy Foucar, Kathy Foucar University of New Mexico, Albuquerque, New MexicoSearch for more papers by this authorWlodek Szczarkowski, Wlodek Szczarkowski Cytometry Associates, Brentwood, TennesseeSearch for more papers by this authorEdward Ball, Edward Ball University of Pittsburgh, Pittsburgh, PennsylvaniaSearch for more papers by this authorTom Witzig, Tom Witzig Mayo Clinic, Rochester, MinnesotaSearch for more papers by this authorKenneth A. Foon, Kenneth A. Foon Markey Cancer Center, Lexington, KentuckySearch for more papers by this authorDenise Wells, Denise Wells Hematologics, Seattle, WashingtonSearch for more papers by this authorPat Kotylo, Pat Kotylo Indiana University, Indianapolis, IndianaSearch for more papers by this authorRebecca Johnson, Rebecca Johnson Berkshire Medical Center, Pittsfield, MassachusettsSearch for more papers by this authorCurtis Hanson, Curtis Hanson Mayo Clinic, Rochester, MinnesotaSearch for more papers by this authorDavid Bessman, David Bessman University of Texas, Galveston, TexasSearch for more papers by this author First published: 26 December 2002 https://doi.org/10.1002/(SICI)1097-0320(19971015)30:5<249::AID-CYTO6>3.0.CO;2-CCitations: 46AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume30, Issue515 October 1997Pages 249-263 RelatedInformation

U.S.‐Canadian consensus recommendations on the immunophenotypic analysis of hematologic neoplasia by flow cytometry: Data reporting

U.S.‐Canadian consensus recommendations on the immunophenotypic analysis of hematologic neoplasia by flow cytometry: Data reporting

Canadian consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography

Abnormalities of diastolic filling are increasingly recognized as a cause of symptoms and predictors of outcome in patients with most forms of heart disease. Noninvasive assessment of diastolic filling is possible in almost all patients, but accurate evaluation must relate echocardiographic Doppler measurements to the complex physiologic and hemodynamic factors responsible for normal and abnormal filling. This evaluation has been facilitated by recent correlation of Doppler measurement of mitral and pulmonary venous inflow with hemodynamic studies. These studies have confirmed that when a careful, integrated approach is taken, Doppler flow patterns can document a progressive pattern of abnormality in many conditions. Impaired left ventricular (LV) relaxation is seen early and is recognized by a decrease in early transmitral LV filling and an increased proportion of filling during atrial contraction. As abnormalities progress, increasing LV chamber stiffness and elevated left atrial pressure lead to a “pseudonormal” filling pattern that previously has caused considerable confusion. This can be unmasked by careful evaluation of pulmonary venous inflow and the use of the Valsalva maneuver. When marked diastolic abnormalities are present, LV filling has restrictive features characterized by rapid early filling, a very stiff left ventricle with high filling pressures, and a poor prognosis. Routine measurement of indexes of diastolic filling have been hampered by uncertainty as to what should be measured, what techniques should be used, definition of normal values, and a clear method of reporting findings. This report represents the efforts of a Canadian consensus group to define a national standard for the performance and reporting of echocardiographic Doppler studies of diastolic filling.