Comparison Between Currently Recommended Long-Term Medical Management of Coronary Artery Aneurysms After Kawasaki Disease and Actual Reported Management in the Last Two Decades.

In the 2017 American Heart Association (AHA) Kawasaki disease (KD) guidelines, risk levels (RLs) for long-term management are defined by both maximal and current coronary artery (CA) dimensions normalized as z-scores. We sought to determine the degree to which current recommended practice differs from past actual practice, highlighting areas for knowledge translation efforts. The International KD Registry (IKDR) included 1651 patients with CA aneurysms (z-score > 2.5) from 1999 to 2016. Patients were classified by AHA RL using maximum CA z-score (RL 3 = small, RL 4 = medium, RL 5 = large/giant) and subcategorized based on decreases over time. Medical management provided was compared to recommendations. Low-dose acetylsalicylic acid (ASA) use ranged from 86 (RL 3.1) to 95% (RL 5.1) for RLs where use was "indicated." Dual antiplatelet therapy (ASA + clopidogrel) use ranged from 16% for RL 5.2 to 9% for RL 5.4. Recommended anticoagulation (warfarin or low molecular weight heparin) use was 65% for RL 5.1, while 12% were on triple therapy (anticoagulation + dual antiplatelet). Optional statin use ranged from 2 to 8% depending on RL. Optional beta-blocker use was 2-25% for RL 5, and 0-5% for RLs 3 and 4 where it is not recommended. Generally, past practice was consistent with the latest AHA guidelines, taking into account the flexible wording of recommendations based on the limited evidence, as well as unmeasured patient-specific factors. In addition to strengthening the overall evidence base, knowledge translation efforts may be needed to address variation in thromboprophylaxis management.

Is phenol a safe local anaesthetic for grommet insertion?

Two studies were performed to determine whether topical phenol is a safe and well tolerated local anaesthetic for grommet insertion. Study 1 was a retrospective examination of audiological outcomes and complications. Data were obtained regarding 71 procedures in 57 patients. One late infection and nine early extrusions were noted. No statistically significant changes between pre- and post-operative bone conduction thresholds were found. Study 2 was a prospective analysis of patients' perceptions of the procedure. Data from 17 patient questionnaires were analysed as follows: pain rating--not painful, three patients; slightly painful, 14 patients. Overall experience rating--pleasant, four patients; slightly unpleasant, 10; unpleasant, three. All patients stated that they would undergo the procedure again. In conclusion, we found no evidence of phenol-induced hearing loss. The complication rate was within normal limits and patients were satisfied with the procedure. Grommet insertion using phenol as a local anaesthetic is safe and acceptable to patients.

Single sweep three-dimensional carotid ultrasound: reproducibility in plaque and artery volume measurements.

BACKGROUND: There is a need for non-invasive and accurate techniques for assessment of severity of atherosclerotic disease in the carotid arteries. Recently an automated single sweep three-dimensional ultrasound (3D US) technique became available. The aims of this study were to evaluate the feasibility and reproducibility of the automated single sweep method in a cohort of patients undergoing clinically indicated carotid ultrasound. METHODS: Consecutive patients with a history of stroke or transient ischemic attack (TIA) and having a plaque in the internal carotid artery (ICA) were recruited for this study. Imaging was performed using a Philips iU 22 ultrasound system equipped with the single sweep volumetric transducer vL 13-5. Analysis was performed offline with software provided by the manufacturer. Two independent observers performed all measurements. RESULTS: Of 137 arteries studied (from 79 patients), plaque and artery volumes could be measured in 106 (77%). Reproducibility of plaque volume measurements was assessed in 82 arteries. Bland-Altman analysis demonstrated good inter-observer reproducibility with limits of agreement -0.06 to +0.07 ml. The mean percentage difference between two observers was 5.6% ± 6.0%. Reproducibility of artery volume measurement was assessed in 31 cases. Bland-Altman analysis demonstrated limits of agreement from -0.15 to +0.15 ml. The mean percentage difference was 6.4 ± 5.9%. CONCLUSION: The new automated single sweep 3D ultrasound is feasible in the majority of patients. Good reproducibility in plaque and artery volume measurements makes this technique suitable for serial assessment of carotid plaques.