HTAHealth Technology Update

Supporting informed decisions . . . www.cadth.ca

Scanning the HorizonInforming Decision Makers About Emerging Medical Technologies

Issue 3 May 2006

A newsletter on new and emerging health care technologies in Canada

HearTwave®: a non-invasive testmay help predict which patientswith chronic heart disease mightbenefit from an implanted cardiacdefibrillator.

Medicinal leeches: an age-oldtreatment is being prescribed toremove pools of congested bloodafter tissue grafting and limb re-attachment surgery.

SuturTek 3600 Fascia ClosureDevice: a reusable device enclosinga disposable suture cartridge and

needle is designed to reduceneedlestick injuries in the operating room.

Balloon Sinuplasty™ System: anoutpatient sinusitis treatment usesa minimally invasive technique toopen blocked sinus passages with aflexible balloon-tipped wire.

Laser-induced interstitial ther-motherapy: a laser procedure isbeing used to destroy liver tumoursand improve survival in patientswho are ineligible for traditionalsurgery.

PET-MRI scanners: machines thatcombine the capability of positronemission tomography (PET) withmagnetic resonance imaging (MRI)are now under development.

New and emerging health technologyreports: a listing of recent publica-tions from CADTH and other healthtechnology assessment agencies.

In April 2006, the Canadian CoordinatingOffice for Health Technology Assessment(CCOHTA) was renamed the CanadianAgency for Drugs and Technologies inHealth (CADTH).

At the same time, all of our publicationsreceived a new “look,” including thisnewsletter. However, the goal of theHealth Technology Update remains thesame: to provide brief, informative arti-cles about new and emerging healthtechnologies.

This issue brings you information aboutdiagnostic, biologic, surgical, and radiology-based health technologies that have beennewly introduced or that are expected toemerge shortly in Canada. We hope thatyou will find the Health TechnologyUpdate informative and useful. Inukshuk at Clyde River, Nunavut.

Ph

oto

co

mp

osi

tio

n b

y P

au

l Tin

g a

nd

Ve

ra S

alt

zma

n.

In this Issue

Your feedback on the newsletter is alwayswelcome, as are suggestions for new

technologies to review in future issues. Pleasesend comments to: Catherine Allison, Editor.

E-mail: catherinea@cadth.ca

25

6

7

8

3

4

2 Issue 3 May 2006

HEALTH TECHNOLOGY UPDATE

application for the HeartTwave® II Systemwas submitted to Health Canada inMarch 2006.

Selecting Patients for ICDs

ICDs effectively prevent death from ven-tricular arrhythmias in patients withimpaired left ventricular ejection fraction.1

Using MTWA testing as a risk stratifica-tion tool could potentially identify whichheart patients are at a negligible risk ofsudden death and could therefore avoidcostly ICD therapy and its attendantrisks.2 Other than measuring left ventric-ular ejection fraction (commonly meas-ured by echocardiography), there are noalternative non-invasive tests.3

Evidence

A meta-analysis evaluating the predictivevalue of MTWA testing in 2,608 patientswith various types of heart disease foundthat 97.2% of those with a negativeMTWA test had no ventricular arrhyth-mias during an average follow-up of 21months. However, of the patients whohad a positive MTWA test, ventriculararrhythmias occurred in only 19.3%.4

A multicentre US study found thatamong patients with heart disease and a left ventricular ejection fraction of lessthan 40%, MTWA testing could identifypatients at high risk for sudden cardiacdeath, and patients at low risk who areunlikely to benefit from ICDs.1

The microvolt T-wave alternans (MTWA)test detects minute fluctuations in theportion of the electrocardiogram (ECG)known as the T-wave. This electrical insta-bility may precede ventricular tachyarrhyth-mia in patients with chronic heart disease.

How the Test Works

High-resolution electrodes are placed onthe patient’s chest before controlled exer-cise. Voltage changes are measured and theresults are interpreted by a cardiologist.

The HearTwave® II System (CambridgeHeart, Bedford, MA) is a commercialMTWA test that uses spectral analysis.Another MTWA system, the Marquette(GE Healthcare) uses an algorithm, butnot spectral analysis, to detect fluctua-tions in the T-wave.

Regulatory Status

The HearTwave® II System receivedapproval from the US Food and DrugAdministration (FDA) in April 2005 for useas an adjunct therapy to clinical historyand other diagnostic tests. A licensing

A test that measures tinychanges in the electrical activityof the heart may identify whichpatients with heart disease areat negligible risk of suddencardiac death due to ventriculararrhythmia and therefore maynot benefit from an implantablecardioverter defibrillator (ICD).The ICD is a device thatterminates arrhythmias with a high-energy shock.

References

1 Bloomfield DM, et al. J Am Coll Cardiol 2006;47(2):456-63.

2 Decision memo for Microvolt T-wave Alternans (CAG-00293N). In: Medicare coverage database.Washington: U.S. Dept. of Health and Human Services; 2006. Available:https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=165.

3 Microvolt T-wave alternans testing to risk stratify patients being considered for ICD therapy for primary prevention of sudden death. [TEC assessment vol 20, no 9]. Washington: Blue Cross Blue Shield Association; 2005. Available: http://www.bcbs.com/tec/Vol20/20_09.pdf.

4 Gehi AK, et al. J Am Coll Cardiol 2005;46(1):75-82.

Cost

The HearTwave II System costs US$29,900.Each set of single-use Micro-V Alternans™sensors costs approximately US$75.

US Policy Decisions

Blue Cross Blue Shield recently concludedthat there was insufficient evidence toreimburse for MTWA testing.3 However, inMarch 2006, the US Centers for Medicareand Medicaid Services decided to reim-burse for MTWA testing because of thehigher risk of sudden cardiac death due to ventricular arrhythmia and anincreased likelihood of potential harmscaused by ICD placement in the olderMedicare population.2

HearTwave® II Microvolt T-Wave

Alternans System.

Ph

oto

co

urt

esy

of

Ca

mb

rid

ge

He

art

.

Test to Predict Who May Benefit fromImplanted Defibrillators

Issue 3 May 2006 3

HEALTH TECHNOLOGY UPDATE

Leeches are being prescribed by Canadiansurgeons to remove pools of congestedblood after operations to re-attach sev-ered fingers, ears and other body parts.Pooled blood interferes with circulationand can cause tissue death.1

The Benefit of the Bite

A leech bite in the grafted or replantedarea removes about 5 mL of congestedblood. However, the major therapeuticbenefit is linked to natural anticoagulantsand vasodilators in the leech saliva thatcause the bite wound to ooze blood (upto 50 mL) for six or more hours followingdetachment.2

New leeches are applied several timesdaily for three to seven days until newblood vessels grow and restore regularblood flow in the affected tissue.1

Cost

Leeches cost US$9.45 each. Same-daydelivery can add significantly to the cost. Toronto-based Canada World Wide is the distributor for Leeches U.S.A. Ltd.(Westbury, NY), which imports theleeches from Ricarimpex SAS, in France.

Patient Population

The frequency of leech use followingreconstructive and plastic surgery inCanada is unknown. According to Rudy Rosenberg, co-owner of Leeches

U.S.A. Ltd., approximately 8,000 leecheswere shipped to Canadian hospitals in2005, a number that has been steadilyincreasing during the last 20 years.

Regulatory Status

The US Food and Drug Administrationapproved Hirudo medicinalis as a medicaldevice in June 2004.1 Medicinal leechesare regulated as biologic products byHealth Canada’s Biologics and GeneticTherapies Directorate.

Evidence

A meta-analysis of 36 reports of medici-nal leech use after tissue grafting in 108 patients showed that tissue thatwould have otherwise required debride-ment or amputation was successfully salvaged in 70% to 80% of cases.3

Patient Care Implications

Applying and monitoring leech therapyrequires significant nursing staff time to ensure that leeches do not feed onhealthy tissue or migrate during treatment.Bite wounds require close monitoringafter the leech detaches. Patient accept-ance of leech therapy depends largely onthorough pre-treatment counselling.

Treatment Risk

The risks associated with leech therapyinclude infection, excessive blood lossrequiring transfusion, migration ofleeches into body orifices and allergicreactions to leech saliva. Leeches have the potential to transmit blood-borneviruses such as hepatitis and HIV. Theyare intended for single use only and mustbe handled as biohazardous waste.2Prophylactic intravenous antibiotics arerecommended to protect patients againstleech bacteria.2

Hospital Policies

Hospital staff must be familiar with pro-cedures for the safe acquisition, storage,dispensing and disposal of these live par-asites. A standardized protocol will helpmeet the challenges of using this therapy.

References

1 Horowitz S. Altern Complement Ther2005;11(1):12-6.

2 Weinfeld AB, et al. Ann Plast Surg2000;45(2):207-12.

3 de Chalain TM. J Reconstr Microsurg1996;12(3):165-72.

The Hirudo medicinalis leech has 300 sharp teeth within the muscular head sucker.

Ph

oto

co

urt

esy

of

Ric

ari

mp

ex

.

Creepy Crawly Care: Medicinal Leeches inModern Medicine

An age-old treatment,medicinal leeches have madea comeback as emergencysalvage therapy when surgicaloptions fail to re-establish bloodflow after tissue grafting andlimb re-attachment surgery.

4 Issue 3 May 2006

HEALTH TECHNOLOGY UPDATE

Most needlestick injuries in the OR occurduring fascia closure.1 The fascia is thetough band of fibrous connective tissuebetween the skin and underlying musclesand organs that must be closed at theend of most major surgical procedures.

How it Works

The SuturTek 360° Fascia Closure Device is a reusable unit that encloses a pre-loaded, single-use suture cartridge andcurved fascia closure needle. When the

suturing is complete, the cartridge andneedle are disposed of in standard hospi-tal sharps containers.

Prevalence of NeedlestickInjuries

Needlestick injuries are a major occupa-tional health concern for hospital staff asthese “sharps” injuries can spread infec-tious diseases, particularly blood-borneviruses, such as hepatitis B, hepatitis Cand HIV.

The Canadian Institute for HealthInformation estimates that approxi-mately 180 Canadian health care workersexperience needlestick injuries each day,or about 66,000 per year.2 According tothe Canadian Needle Stick SurveillanceNetwork, five categories of devices areresponsible for 62% of sharps injuries. Ofthese, 12% are caused by suture needles.3

Regulatory Status

The SuturTek 3600 Fascia Closure Devicewas developed by SuturTek Inc. (NorthChelmsford, MA). SuturTek was commer-cially launched in the US at the end of

2005, following US Food and DrugAdministration (FDA) approval. TheSuturTek device is not yet licensed byHealth Canada.

Cost

According to the manufacturer, theSuturTek 3600 Fascia Closure Device isoften supplied at no charge to hospitalsthat purchase the disposable suture car-tridges. The cartridges cost approximatelyUS$300 per box of 12.

Evidence

Many sharps injury prevention programsrecommend the introduction of safetyengineered devices that are evaluated bythe health care workers who use them.4,5

SuturTek Inc. provided the FDA with simu-lated use testing data, demonstratingzero needlestick injuries with the device.Further clinical studies of the device areunderway, though published results arenot yet available.

Suturing Device to Reduce NeedlestickInjuries in the Operating Room

References

1 American College of Surgeons. Statement onblunt suture needles [ST-52]. Chicago: TheCollege; 2005 Nov. Available: http://www.facs.org/fellows_info/statements/st-52.html.

2 Moser MA. Safe Angle 2004;5-7. Available: http://www.hchsa.on.ca/misc_pdf/NeedStikArt.pdf.

3 Needlestick injuries [OSH answers]. Hamilton(ON): Canadian Centre for Occupational Healthand Safety; 2005. Available: http://www.ccohs.ca/oshanswers/diseases/needlestick_injuries.html.

4 Sharps safety. A practical guide for establishingand evaluating a sharps injury preventionprogram. Health Devices 2002;31(3):81-94.

5 Division of Healthcare Quality Promotion,Centers for Disease Control and Prevention.Workbook for designing, implementing andevaluating a sharps injury prevention program.Atlanta: The Division; 2004. Available:http://www.cdc.gov/sharpssafety/index.html.

The SuturTek 360° FasciaClosure Device™ is designedto reduce needlestick injuriesduring suturing procedures in the operating room (OR).The needle is contained withina cartridge, thus avoidingexposed “sharps” that mayinjure the surgeon, other OR staff, or the patient.

The SuturTek 360° Fascia Closure Device with disposable needle-protected suture cartridge.

Ph

oto

co

urt

esy

of

Su

turT

ek

Inc.

can be used on several sinuses in onepatient. Patients can return to normalactivities within a day.1

Limitations

People are not candidates for balloon sin-uplasty if they have extensive scarringfrom previous sinus surgery; cystic fibro-sis; nasal polyps; sinonasal tumours orobstruction; or ciliary dysfuntion.3

Regulatory Status

The Balloon Sinuplasty™ System, manu-factured by Acclarent Inc. (Menlo Park,CA), is not yet licensed for use in Canada.The US Food and Drug Administrationgranted approval in August 2005 for its

Issue 3 May 2006 5

HEALTH TECHNOLOGY UPDATE

How it Works

Performed through the nostrils, a flexibleballoon-tipped wire is threaded throughthe delicate twists and turns of the sinuspassages under fluoroscopic guidance. Anear, nose and throat (ENT) surgeon or rhi-nologist inflates the balloon slightly to gen-tly restructure and widen the sinus walls torestore normal drainage and function.

The procedure dilates the sinus passagesby 3 mm to 7 mm, depending on the sizeof the sinus balloon catheter used.1

The one-time outpatient procedure isdone under general anesthesia or con-scious sedation and takes 30 to 120 min-utes, depending on the number of sinuspassages to be treated. The same catheter

use in diagnostic and therapeutic proce-dures of the sinus cavities.

Evidence

In a small feasibility pilot study, no adverseevents occurred among 10 patients.3 Evidenceof long-term patency (openness) of the sinuspassages is lacking. A multicentre registry(CLEAR) is prospectively collecting data onsinus passageway patency,adverse event ratesand quality of life outcomes six months afterballoon sinuplasty surgery in 115 patients.4

Other Sinus Surgeries

Functional endoscopic sinus surgery(FESS) to remove bone and tissue is themost common surgery for patients withsinusitis who do not respond to medicaltreatment. Tissue trauma and bleedingwith balloon sinuplasty may be less thanwhat is encountered during FESS.1,3

Balloon sinuplasty may be combined with other sinus surgery techniques.

Cost

The disposable components of theBalloon Sinuplasty System cost approxi-mately US$1,200 per procedure. TheSystem includes the Relieva™ sinus bal-loon catheter, guide catheter, guidewire,lavage catheter, exchange catheter andthe sinus balloon inflation device.

New Sinusitis Treatment May Be a Breath of Fresh Air

A minimally invasive procedurefor opening blocked sinuspassages uses techniquessimilar to those used in balloonangioplasty to unblockcoronary arteries.

Ph

oto

co

urt

esy

of

Acc

lare

nt

Inc.

A flexible balloon catheter is inserted (Step 1), then inflated (Step 2), to widen the sinus passages.

References

1 Acclarent. Balloon Sinuplasty™ technology.Menlo Park (CA): Acclarent; 2005. Available:http://www.acclarent.com.

2 Rapoport J, et al. Chronic Dis Can 2004;25(1):13-21. Available:http://www.phac-aspc.gc.ca/publicat/cdic-mcc/25-1/c_e.html.

3 Brown CL, et al. Ann Otol Rhinol Laryngol2006;115(4):293-9.

4 Clinical evaluation to confirm safety andefficacy of sinuplasty in the paranasal sinuses(CLEAR). In: ClinicalTrials.Gov [database online].Bethesda (MD): National Institutes of Health;2005. NCT00231062. Available:http://clinicaltrials.gov/show/NCT00231062.

Prevalence and SymptomsSix to seven per cent of Canadiansreport symptoms of chronic sinusitis,2which include:• nasal congestion, obstruction

and postnasal drainage• facial pressure and pain• headache• fatigue• loss of smell and taste

Step 1 Step 2

6 Issue 3 May 2006

HEALTH TECHNOLOGY UPDATE

Evidence

In a 12-year prospective case series, 646patients with five or fewer liver metas-tases who underwent MR-guided LITTdemonstrated an average survival time of48 months from the first treatment.4 Thiscompares with an average survival timeof 25 to 35 months for patients whoundergo liver resection.5

Low rates of major complications follow-ing 2,132 MR-guided LITT procedures werereported in one study, including pleuraleffusion requiring thoracentesis (0.8%),liver abscess (0.7%), bile duct injury(0.2%), segmental infarction (0.1%) andhemorrhage requiring blood transfusion(0.05%). The death rate was 0.1%.2 Bycomparison, the mortality rate followingsurgical resection of liver tumours isapproximately 5.0%.3

MR-guided LITT has not been used in ran-domized studies. Dr. Martin Mack, a LITTresearcher (Institute of Diagnostics andInterventional Radiology, Frankfurt) saidthat efforts to conduct a randomizedstudy have been unsuccessful becausemost patients refused open surgery overthe less invasive MR-guided LITT.

Cost

According to the manufacturer, theMedilas Fibertom 5100 laser costs approx-imately US$65,000. Dr. Mack estimatesthat MR-guided LITT costs approximatelyC$7,000 per patient procedure dependingon the size of tumours. This cost includesall required materials and diagnostics.

provides the visualization necessary toprecisely position the laser probe in thetumour.

The Procedure

An interventional radiologist performsMR-guided LITT in an outpatient settingwhere patients receive local anesthesia.2The laser procedure takes approximately20 minutes.3 Larger or multiple tumourscan be treated simultaneously using mul-tiple laser applicators.

Patient Group

Unlike liver resection, MR-guided LITT is a suitable treatment for multiple livertumours, tumours in both lobes of theliver and tumour recurrence.3 However,the treatment is generally limited topatients with five or fewer tumours that each measure less than 5 cm.2-4

Regulatory Status

The Medilas Fibertom 5100 laser is notlicensed in Canada. It received US Foodand Drug Administration approval inFebruary 1997.

A New Treatment Option

The standard treatment for patients withmetastatic liver cancer is surgical resec-tion to remove part of the liver; however,70% to 90% of patients are ineligible forresection due to the number, size or posi-tion of the tumours.1 A new option forthese patients is to destroy the livertumour(s) using magnetic resonance-guided laser-induced interstitial ther-motherapy (MR-guided LITT).

The Technology

MR-guided LITT is performed with theMedilas™ Fibertom 5100 laser (Dornier,Germany) and a laser application kit(Somatex, Germany). The laser applicatoris compatible with MR imaging, which

Ph

oto

co

urt

esy

of

Dr.

M.M

ack

.

The laser is directly applied to the tumour through optical fibres.

Using Lasers to Destroy Liver TumoursLaser energy can destroy livertumours in patients who areineligible for surgery, resultingin survival outcomes similar to patients who undergotraditional surgery.

References

1 Gannon CJ, et al. Semin Radiat Oncol2005;15(4):265-72.

2 Vogl TJ, et al. Radiology 2002;225(2):367-77.

3 Vogl TJ, et al. Med Laser Appl 2005;20(2):115-8.

4 Mack MG, et al. Presentation at RSNA 2005;2005 Nov 27-Dec 2; Chicago.

5 Vogl TJ, et al. Radiology 2004;230(2):450-8.

Engineering Challenges andOpportunities

There are technical difficulties in engi-neering a hybrid that has PET and MRIscanners in a single unit.

A process known as image fusion hasbeen used for some time, where a com-posite picture is produced by overlayingimages obtained after patients are scanned

in separate PET and MRI machines. Thecomposite image is then used to helpguide diagnosis, treatment planning andfollow-up.

A hybrid PET–MRI scanner would reduceimaging time and potentially increasepatient throughput. A combined unitmight also avoid errors due to a partialmismatch of images caused by variationsin patient position in the separate scanners.

Clinical Applications of PET–MRIImage Fusion

PET–MRI fusion has been used for the initial evaluation of brain tumours, aswell as treatment planning and follow-upafter therapy.1 Diagnosis with PET–MRIfusion has been associated withincreased survival times for patients withrecurrent high grade gliomas treated byradiotherapy,2 and with more specificdiagnoses of brain tumours in children.3

PET–MRI fusion has been used to managethe treatment of patients with sometypes of brain tumours and those withintractable epilepsy, sometimes with theuse of additional images from CT or singlephoton emission computed tomography(SPECT). The combined images provideadditional information on the volume of

the brain to be treated, permitting morecomplete destruction of the target lesionand potentially reducing adverse eventsassociated with the treatment (surgery or radiotherapy).

The use of PET–MRI has improved thedetection of epileptogenic regions in children with a genetic disorder who arebeing evaluated for epilepsy surgery.4PET–MRI fusion has also been used with a frameless surgical guidance system topermit more precise excision of epilepto-genic tissue and minimize damage tonormal tissue.5

Cost

The cost of a PET–MRI machine is unknown,but it is likely to be higher than theUS$2.5 to US$3 million for a hybridPET–CT scanner.6 A cost-effectivenessevaluation of the technology would needto take into account the cost offsetsgained through faster imaging.

Future Directions

Comparative clinical benefits for existingPET-MRI or PET-CT approaches need to beestablished, as well as the caseload andcasemix required for effective utilizationof a hybrid PET-MRI scanner.

Issue 3 May 2006 7

HEALTH TECHNOLOGY UPDATE

PET-MRI Scanners: A Further Evolution inDiagnostic Imaging

Ph

oto

co

urt

esy

of

GE

He

alt

hca

re.

Black and white MRI images beside coloured MRI-PET fusion images.

References

1 Wong TZ, et al. Cancer J 2004;10(4):234-42.

2 Grosu AL, et al. Int J Radiat Oncol Biol Phys2005;63(2):511-9.

3 Borgwardt L, et al. J Clin Oncol 2005;23(13):3030-7.

4 Asano E, et al. Neurology 2000;54(10):1976-84.

5 Murphy M, et al. J Clin Neurosci 2001;8(6):534-8.

6 Hibbs CW, et al. Academy Journal 2004;1.Available:

http://www.aia.org/aah_a_jrnl_0401_ar&grand Ch=yes.ticle5

Scanners that combine thecapability of positron emissiontomography (PET) withmagnetic resonance imaging(MRI) are now being developed.PET evaluates metabolic aspectsof disease, while MRI provideshigh-resolution anatomicalinformation.The PET-MRIscanner is a further evolution ofan earlier hybrid, PET–CT, whichcombines PET with computedtomography (CT) imaging.

www.cadth.ca

HEALTH TECHNOLOGY UPDATE

Production Notes

Health Technology Update is published by:

Canadian Agency for Drugs and Technologies in Health (CADTH)600-865 Carling AveOttawa, ON Canada K1S 5S8

Tel.: (613) 226-2553Fax: (613) 226-5392Web site: www.cadth.ca

Editor/Writer: Catherine AllisonContributing Writers: Rhonda Boudreau,David Hailey, Leigh-Ann TopferInformation Specialists: Kaitryn Campbell,Shaila Mensinkai, Andra Morrison,Becky SkidmoreCopy Editor: Jane MosgroveLayout and design: Holly MichaelWeb Designers: Martha Hodgson-Oram, Paul Ting

This newsletter is available free of charge, in bothEnglish and French. Readers may subscribe toreceive e-mail notification of new issues usingthe subscription link on the CADTH web site orthe following URL:http://www.cadth.ca/index.php/en/subscribe

Reproduction of this document for non-commercial purposes is permitted provided appropriate credit is given to CADTH.

Health Technology Update is an informationsource for those involved in planning and provid-ing health care in Canada. The informationincluded in this newsletter is based on a limitedliterature review and should not be construed asa recommendation for or against the use of aparticular health technology. Readers are alsocautioned that a lack of good quality evidence tosupport effectiveness does not necessarily meana lack of effectiveness, particularly in the case ofnew and emerging technologies.

Production of this newsletter is made possible bya financial contribution from Health Canada’sHealth Care Strategies and Policy, federal, provin-cial and territorial partnership grant program.CADTH takes sole responsibility for the final formand content of this newsletter. The statements,conclusions and views expressed herein do notnecessarily represent the view of Health Canadaor any provincial or territorial government.

82006 Canadian Agency for Drugs andTechnologies in HealthISSN: 1715-5541 (print) • ISSN: 1715-555X (online)

Printed in Canada

New and Emerging HealthTechnology ReportsRecent Reports from CADTH and Other HTA Agencies

� BRCA1 and BRCA2 Predictive GeneticTesting for Breast and Ovarian Cancers:A Systematic Review of Clinical Evidence.

Available: http://www.cadth.ca/index.php/en/hta/reports-publications/publication/605

� Radiofrequency Ablation in theTreatment of Kidney CancerAvailable: http://www.cadth.ca/media/pdf/376_radiofreqency_cetap_e_2006feb2.pdf

� Intragastric Balloons: A TemporaryTreatment for Obesity

Available: http://www.cadth.ca/media/pdf/401_balloons_cetap_e.pdf

Ontario Medical Advisory Secretariat(MAS)

� Coil Embolization for IntracranialAneurysms: Update

Available: http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_coil_010106.pdf

� Air Cleaning Technologies

Available: http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_act_110105.pdf

UK National Institute for Health andClinical Excellence (NICE)

� Image-guided Vacuum-assisted ExcisionBiopsy of Benign Breast Lesions [Guidance]

Available: http://www.nice.org.uk/down-load.aspx?o=IPG156guidance

� Mosaicplasty for Knee Cartilage Defects[Guidance]

Available: http://www.nice.org.uk/download.aspx?o=IPG162guidance

These reports are available without costat the web sites shown below:

Agence d’évaluation des technologies et des modes d’intervention en santé(AÉTMIS)

� Contribution of BRCA1/2 MutationTesting to Risk Assessment forSusceptibility to Breast and Ovarian Cancer

Available: http://www.aetmis.gouv.qc.ca/site/download.php?2501702e99ce72da75947eee15042d5a

� The 13C-urea Breath Test for Detectionof Helicobacter Pylori: PotentialApplications in Québec

Available: http://www.aetmis.gouv.qc.ca/site/download.php?708aebb0649b329815b19b9f83bd31d5

� Telehealth: Clinical Guidelines andTechnological Standards for Telepsychiatry(English summary).

Available: http://www.aetmis.gouv.qc.ca/site/download.php?e084149977c6efcd98580a98e3a43a87

Alberta Heritage Foundation forMedical Research (AHFMR)

� Gastric Electrical Stimulation (Enterra™Therapy system) for the Treatment ofGastroparesis

Available: http://www.ahfmr.ab.ca/down-load.php/7473fe4af4860313deb92b2fd87d2e3d

Canadian Agency for Drugs andTechnologies in Health (CADTH)

� CYP450 Genotyping for DeterminingDrug Metabolizer Status

Available: http://www.cadth.ca/media/pdf/375_armplichip_cetap_e.pdf