Impact of sex on outcomes of percutaneous coronary intervention for chronic total occlusion: A meta-analysis.

BACKGROUND: Women are underrepresented in chronic total occlusion (CTO) trials and little is known about sex differences in the outcomes of CTO percutaneous coronary intervention (PCI). This meta-analysis aims to compare the outcomes of CTO PCI in males and females. METHODS: A comprehensive search of PubMed, EMBASE, Cochrane, Web of Science, and Google Scholar was performed for studies comparing outcomes of CTO PCI in females versus males from inception to January 26, 2021. The current statistical analysis was performed using STATA version 15.1 software (Stata Corporation, TX); P < 0.05 indicated statistical significance. RESULTS: Fourteen observational studies were included in the analysis with 75% males and 25% females. The mean age was 64.47 ± 10.5 years and 68.98 ± 9.5 years for males and females, respectively. The median follow-up duration was 2.4 years. Males had a higher Japanese-CTO (J-CTO) score compared with females (MD = -0.17; 95% CI: -0.25 to -0.10). Females had statistically higher success rates of CTO PCI (RR = 1.03; 95% CI: 1.01 to1.05), required less contrast volume (MD = -18.64: 95% CI: -30.89 to -6.39) and fluoroscopy time (MD = -9.12; 95% CI: -16.90 to -1.34) compared with males. There was no statistical difference in in-hospital (RR = 1.50; 95% CI: 0.73 to 3.09) or longer term (≥6 months) all-cause mortality (RR = 1.10; 95% CI: 0.86 to 1.42) between the two groups. CONCLUSIONS: CTO PCI is feasible and safe in female patients with comparable outcomes in female versus male patients.

Doppler Echocardiographic Phenotypes in Suspected 'Severe' Aortic Stenosis: Matrix-Based Approach to Diagnosis and Management.

BACKGROUND: Among patients with suspected severe aortic stenosis (AS), Doppler echocardiographic (DE) data are often discordant, and further analysis is required for accurate diagnosis and optimal management. In this study, an automated matrix-based approach was applied to an echocardiographic database of patients with AS that identified 5 discrete echocardiographic data patterns, 1 concordant and 4 discordant, each reflecting a particular pathophysiology/measurement error that guides further workup and management. METHODS: A primary/discovery cohort of consecutive echocardiographic studies with at least 1 DE parameter of severe AS and analogous data from an independent secondary/validation cohort were retrospectively analyzed. Parameter thresholds for inclusion were aortic valve area (AVA) <1.0 cm2, transaortic mean gradient (MG) ≥ 40 mmHg, and/or transaortic peak velocity (PV) ≥ 4.0 m/sec. Doppler velocity index (DVI) was also determined. Logic provided by an in-line SQL query embedded within the database was used to assign each patient to 1 of 5 discrete matrix patterns, each reflecting 1 or more specific pathophysiologies. Feasibility of automated pattern-driven triage of discordant cases was also evaluated. RESULTS: In both cohorts, data from each patient fitted only 1 data pattern. Of the 4,643 primary cohort patients, 39% had concordant parameters for severe AS and DVI <0.30 (pattern 1); 35% had AVA < 1.0 cm2, MG < 40 mm Hg, PV < 4 m/sec, DVI < 0.30 (pattern 2); 9% had MG ≥ 40 mmHg and/or PV ≥ 4 m/sec, DVI > 0.30 (pattern 3); 10% had AVA < 1.0 cm2, MG < 40 mmHg, PV < 4 m/sec, DVI >0.30 (pattern 4); and 7% had MG > 40 mmHg and/or PV ≥ 4 m/sec, AVA > 1.0 cm2, DVI < 0.30 (pattern 5). Findings were validated among the 387 secondary cohort patients in whom pattern distribution was remarkably similar. CONCLUSIONS: Matrix-based pattern recognition permits automated in-line identification of specific pathophysiology and/or measurement error among patients with suspected severe AS and discordant DE data.

Outcomes of transcatheter aortic valve replacement in patients with mitral annular calcification and concomitant mitral valve dysfunction: A systematic review and meta-analysis.

BACKGROUND: Calcific aortic stenosis is the principal indication for transcatheter aortic valve replacement (TAVR). Comorbid mitral annular calcification (MAC) is often present in patients undergoing TAVR. Limited data exist on the impact of MAC on TAVR outcomes. We conducted a systematic review and meta-analysis to explore the effects of MAC and concomitant mitral valve dysfunction (MVD) on TAVR outcomes. METHODS: A comprehensive literature review was conducted using PubMed, Embase, Google Scholar, ClinicalTrials.gov, Scopus, and OVID for studies until March 20, 2023. Using the random-effects Mantel-Haenszel method, we calculated pooled risk ratios (RRs) and their corresponding 95 % confidence intervals (CIs) for all dichotomous variables. RESULTS: Six studies comprising 5822 patients (2541 with MAC [severe MAC (>4 mm thickness) 583; non-severe MAC 1958; 400 with MVD; and 1071 without MVD], 3281 without MAC) met inclusion criteria. At 30 days and 1 year, no significant differences were observed between the overall MAC and no MAC groups in terms of mortality, stroke, and permanent pacemaker implantation. However, MAC with MVD was associated with a higher risk of all-cause mortality compared to MAC without MVD at 30 days (RR = 3.43, 95 % CI 2.04-5.76, P < 0.00001) and at 1 year (RR = 2.44, 95 % CI 1.85-3.20, P < 0.00001). Moreover, the risk of cardiovascular mortality was higher in patients with MAC and MVD compared to those with MAC alone (RR = 2.77, 95 % CI 1.89-4.06, P < 0.00001). Additionally, patients with severe MAC had a higher risk of major bleeding at 30 days compared to the non-severe MAC group (RR = 1.33, 95 % CI 1.04-1.69, P = 0.02). CONCLUSION: TAVR appears to be safe in patients with non-severe MAC, but severe MAC is associated with a higher risk of major bleeding and concomitant MVD increases the mortality risk in patients undergoing TAVR.

Bivalvular infective endocarditis complicated by perivalvular abscess and aorto-right atrium fistula.

Infective endocarditis caused by Pseudomonas aeruginosa in patients without a history of intravenous drug abuse and endovascular procedures is rare. We present a middle-aged man with fever, chills, night sweats and dyspnoea for 2 weeks. Physical examination and blood cultures were drawn, and the patient was empirically started on antibiotics. Unfortunately, the patient experienced progressive clinical deterioration requiring endotracheal intubation and vasopressor support. Transthoracic echocardiogram followed by transesophageal echocardiogram was performed that showed bicuspid aortic valve, severe aortic regurgitation, membranous ventricular septal defect, vegetations on aortic and tricuspid valves, dilated aortic root, and a fistula between the aorta and right atrium. The patient underwent emergent aortic valve and aortic root replacement along with tricuspid commissuroplasty and ventricular septal defect (VSD) closure. Later, intraoperative tissue cultures grew P. aeruginosa, and antipseudomonal antibiotic coverage was added. This case highlights that P. aeruginosa endocarditis can occur without risk factors and can lead to fatal cardiovascular complications.

Relationship of health-related social needs and hospital readmissions in patients following a hospitalization for atrial fibrillation.

Atrial fibrillation (AF) has a high economic burden on the healthcare system with rehospitalizations as the most significant contributing factor necessitating an understanding of aspects related to hospitalizations to minimize economic costs and improve patient outcomes. Our study aims to assess whether all-cause 30-day hospital readmission following AF-specific hospitalization is associated with health-related social needs (HRSN) using the Nationwide Readmissions Database (NRD). All hospitalization data were abstracted from the 2015-2019 NRD, including hospitalizations for patients at least 18 years of age with a primary discharge diagnosis of AF. For each hospitalization, we identified secondary diagnoses for five HRSN domains including employment, family, housing, psychosocial, and socioeconomic status. Primary outcomes included all-cause 30-day readmission rates. Secondary outcomes included all-cause 90-day readmissions and diagnosis on readmissions. An estimated 1,807,460 index hospitalizations in the United States included a primary discharge diagnosis of AF. Of these, 97.3 % included a diagnosis in only one HRSN domain with the most frequently diagnosed HRSN domain being housing (54.5 %) followed by socioeconomic (29.4 %), family (10.0 %), employment (6.1 %), and psychosocial (2.8 %). Index hospitalizations that included any HRSN diagnosis had 2.2-times greater unadjusted odds of all-cause 30-day readmission (95 % CI: 2.1 to 2.3-times greater, p < .001). Index hospitalizations that included an HRSN diagnosis were associated with higher rates of 90-day readmission due to conduction disorder and COPD. In conclusion, there is a significant association between HRSN and hospital readmissions in patients with AF. Further research is required to explain the true nature of this relationship with a specific emphasis on housing insecurity.

Is Methamphetamine-Linked Cardiomyopathy an Emerging Epidemic for New Generation?

The use of methamphetamines is growing worldwide with cardiovascular disease as the leading cause of mortality and morbidity. Long-term use of methamphetamines is associated with malignant hypertension, myocardial ischemia, pulmonary hypertension, and methamphetamines-associated cardiomyopathy. These effects are noted to be dose-dependent and potentially reversible with discontinuation of methamphetamines in the early stages when there is limited or no myocardial fibrosis. This review aims to (1) summarize the available data from epidemiologic studies, (2) describe pathophysiological mechanisms and clinical presentation, (3) Management of methamphetamines induced cardiomyopathy and potential complications associated with it, and (4) Strategies to reduce methamphetamines abuse and related hospitalization.

Left bundle branch area pacing vs biventricular pacing for cardiac resynchronization: A systematic review and meta-analysis.

Background: Left bundle branch area pacing (LBBAP) may offer greater physiological benefits than traditional biventricular pacing (BiVP). However, there are limited data comparing the efficacy of LBBAP vs BiVP in patients with systolic heart failure (HF). Objective: The purpose of this meta-analysis was to compare the feasibility and electromechanical and clinical outcomes of both LBBAP and BiVP. Methods: We conducted a systematic review of studies retrieved from various databases including PubMed, Embase, Google Scholar, Scopus, and Cochrane Central Register of Control Trials (CENTRAL) published up to May 22, 2023. The risk ratio (RR) and standardized mean difference (SMD) with corresponding 95% confidence intervals (CIs) were calculated for dichotomous and continuous outcomes, respectively. Results: We included 12 studies with a total of 3004 patients (LBBAP = 1242, BiVP = 1762). Pooled results showed that LBBAP resulted in a significant increase in left ventricular ejection fraction (SMD 0.40, 95% CI 0.25, 0.54, P < .00001), echocardiographic response (RR 1.19, 95% CI 1.10 to 1.29, P < .0001), improvement in New York Heart Association functional class (SMD -0.44, 95% CI -0.65 to -0.23, P < .0001), QRS duration reduction (SMD -0.90, 95% CI -1.14 to -0.66, P < .00001), left ventricular end-diastolic diameter reduction (SMD -0.31, 95% CI -0.57 to -0.05, P = .02), fewer HF hospitalizations (RR 0.72, 95% CI 0.62, 0.85, P < .0001), and improved survival (RR 0.73, 95% CI 0.58, 0.92, P = .007). In addition, LBBAP was associated with shorter fluoroscopy time (SMD -0.94, 95% CI -1.42 to -0.47, P < .0001) and lower pacing threshold at implantation (SMD -1.03, 95% CI -1.32 to -0.74, P < .00001) and at 6 months (SMD -1.44, 95% CI -2.11 to -0.77, P < .0001) as compared with BiVP. Conclusion: Compared with BiVP, LBBAP was associated with better electromechanical and clinical outcomes, including left ventricular ejection fraction, QRS duration, echocardiographic response, New York Heart Association functional class, HF hospitalization, and all-cause mortality in patients with systolic HF.

Catheter ablation of atrial fibrillation in hypertrophic cardiomyopathy: A proportional meta-analysis and systematic review of single-arm studies.

Background: Atrial fibrillation (AF) is the most common arrhythmia in patients with hypertrophic cardiomyopathy (HCM). Limited data exists about the efficacy and clinical outcomes of AF ablation in HCM. Objective: The purpose of this meta-analysis was to evaluate the role of catheter-based ablation for treatment of AF in patients with HCM. Methods: PubMed, SCOPUS, Web of Science, Embase, Cochrane library, and ClinicalTrials.gov were searched for studies discussing outcomes of catheter-based ablation for AF in patients with HCM. Two reviewers independently screened studies and extracted relevant data. Incidence rate estimates from individual studies underwent logit transformation to calculate the weighted summary proportion under the random effect model. Results: A total of 19 reports met the inclusion criteria (1183 patients). The single ablation procedure was successful in 39% patients. Up to 34% patients underwent a repeat ablation. About 41% patients in normal sinus rhythm after successful AF ablation received postprocedure antiarrhythmic drug (AAD) therapy. Patients undergoing successful AF ablation experienced a significant improvement in the New York Heart Association functional class (standardized mean difference -1.03; 95% confidence interval -1.23 to -0.83; P < .00001). Conclusion: AF ablation appears to be safe and feasible in patients with HCM. Freedom from AF after undergoing successful ablation is associated with significant improvement in heart failure symptoms.

Impella Versus Extracorporeal Membranous Oxygenation (ECMO) for Cardiogenic Shock: A Systematic Review and Meta-analysis.

The use of mechanical circulatory support (MCS) in cardiogenic shock (CS) is increasing. We conducted a systematic review and meta-analysis to compare the outcomes of Impella use with extracorporeal membranous oxygenation (ECMO) support in patients with CS. We searched the Medline, EMBASE, Cochrane, and Clinicaltrials.gov databases for observational studies comparing Impella to ECMO in patients with CS. Risk ratios (RRs) for categorical variables and standardized mean differences (SMDs) for continuous variables were calculated with 95% confidence intervals (CIs) using a random-effects model. Twelve retrospective studies and one prospective study (Impella n=6652, ECMO n=1232) were identified. Impella use was associated with lower incidence of in-hospital mortality (RR 0.88 [95% CI 0.80-0.94], P=0.0004), stroke (RR 0.30 [0.21-0.42], P<0.00001), access-site bleeding (RR 0.50 [0.37-0.69], P<0.0001), major bleeding (RR 0.56 [0.39-0.80], P=0.002), and limb ischemia (RR 0.42 [0.27-0.65], P=0.0001). Baseline lactate levels were significantly lower in the Impella group (SMD -0.52 [-0.73- -0.31], P<0.00001). There was no significant difference in mortality at 6-12 months, MCS duration, need for MCS escalation, bridge-to-LVAD or heart transplant, and renal replacement therapy use between Impella and ECMO groups. In patients with CS, Impella device use was associated with lower in-hospital mortality, stroke, and device-related complications than ECMO. However, patients in the ECMO group had higher baseline lactate levels.

Outcomes of Prediabetes Compared with Normoglycaemia and Diabetes Mellitus in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis.

Background: Patients with prediabetes are at increased risk of coronary artery disease (CAD). However, the association between prediabetes and adverse clinical outcomes following percutaneous coronary intervention (PCI) is inconsistent, in contrast to outcomes in patients with diabetes mellitus (DM). Thus, this meta-analysis evaluated the impact of dysglycaemia on PCI outcomes. Methods: The PubMed, Embase, Cochrane, and ClinicalTrials.gov databases were systematically reviewed from inception of databases until June 2022. In 17 studies, outcomes of PCI in patients with prediabetes were compared with patients who were normoglycaemic, and patients with DM. The primary outcome was all-cause mortality at the longest follow-up. Results: Included were 12 prospective and five retrospective studies, with 11,868, 14,894 and 13,536 patients undergoing PCI in the prediabetes, normoglycaemic and DM groups, respectively. Normoglycaemic patients had a statistically lower risk of all-cause mortality, (risk ratio [RR] 0.66, 95% confidence interval [CI] 0.52-0.84), myocardial infarction (MI; RR 0.76, 95% CI 0.61-0.95) and cardiac mortality (RR 0.58, 95% CI 0.39-0.87) compared with prediabetic patients undergoing PCI at the longest follow-up. Patients with prediabetes had a lower risk of all-cause mortality (RR=0.72 [95% CI 0.53-0.97]) and cardiac mortality (RR =0.47 [95% CI 0.23-0.93]) compared with patients with DM who underwent PCI. Conclusion: Among patients who underwent PCI for CAD, the risk of all-cause and cardiac mortality, major adverse cardiovascular events and MI in prediabetic patients was higher compared with normoglycaemic patients but lower compared with patients with DM.

Selective serotonin reuptake inhibitors increase risk of upper gastrointestinal bleeding when used with NSAIDs: a systemic review and meta-analysis.

The use of selective serotonin reuptake inhibitors (SSRIs) can increase the risk of gastrointestinal (GI) bleeding. Similarly, it is well known that the use of NSAIDs predisposes patients to upper GI bleeding. The aim of this study was to explore if the addition of SSRIs in patients already taking NSAIDs significantly increases their risk for upper GI bleeding. An electronic literature search was conducted using the SCOPUS and MEDLINE databases from inception through September 2020. Cohort and case-control trials that reported patients with upper GI bleeding on NSAIDs with SSRIs, compared to controls on NSAIDs only were included. Newcastle-Ottawa checklist was used to ensure inclusion of high-quality studies. Data was extracted by the lead investigator and cross-checked by the second author. Dichotomous data was pooled to obtain an odds ratio (OR) of the risk of upper GI bleeding in patients on NSAIDs with concomitant SSRI use. The primary endpoint of the study was the risk of upper GI bleeding with SSRIs and NSAIDs compared to NSAIDs alone. A total of 366 citations were reviewed, and 21 were selected for full-text evaluation. 1 cohort and 9 case-control studies were eligible. There was an additional increased risk of upper GI bleeding in patients on NSAIDs with concomitant SSRI use (OR 1.75, 95% CI = 1.32-2.33). In patients already on NSAID therapy, the concomitant use of SSRIs can significantly increase the risk of upper of GI bleeding.

Implementation of Multiple Evidence-Based Heart Failure Therapies.

Despite the advancements in the management of heart failure, acute heart failure is one of the most common causes of mortality and morbidity. In light of the financial burden imposed by heart failure hospitalizations on the health care system, this area remains the focus of research, clinical advances, and policy changes aimed at improving the quality of care and outcomes. Despite practice guidelines, high-quality trial data, and consensus statements, barriers to therapy remain. The barriers related to physician, patient, economic, health care system, and logistical factors prevent widespread adoption of available therapeutics. In this review article, we outline guidelines directed therapies for heart failure, challenges associated with their implementation, and potential solutions to these challenges to help reduce mortality and improve clinical outcomes in this patient population.

Bilateral Primary Adrenal B-Cell Lymphoma Diagnosed by Workup for Primary Adrenal Deficiency.

Primary adrenal lymphoma (PAL) often occurs bilaterally and is a rare malignancy of old age. Workup for primary adrenal insufficiency often unmasks this underlying grave pathology. In this article, we present a case of a 73-yearold patient who presented with features of primary adrenal insufficiency and renal colic. Diagnostic abdominal imaging revealed bilateral suprarenal masses as the cause of adrenal gland destruction and the patient's symptoms. FDG PET-CT scan and histopathology confirmed the diagnosis of mature bilateral B-cell primary adrenal lymphomas. Though the patient showed an excellent initial response to the first four chemotherapy cycles, a relapse resulted in metastatic disease. This article highlights the PAL's disease course, imaging features, and management dilemma due to Chemotherapy's side effects and a higher recurrence rate. Keywords: Primary adrenal lymphoma, Primary adrenal insufficiency, R-CHOP, Role of imaging.

A new dawn in internal medicine education curriculum-a project by the residents, with the residents, for the residents.

The academic half-day (AHD) curriculum is an alternative to the noon conference (NC) approach. To date, there is little literature evaluating the transition from NC to AHD in internal medicine residency programs. We investigated the effectiveness of AHD by comparing in-training exam (ITE) and American Board of Internal Medicine (ABIM) certifying exam scores of residents before and after implementation of AHD. In 2019, we transitioned to the AHD curriculum. Averages of three consecutive years of NC (2016-2018) and AHD (2019-2021) were used for statistical testing to determine ITE and ABIM score changes. The class of 2018 experienced both approaches. Cohen's d effect sizes were calculated to assess the magnitude of change in ITE and ABIM scores between NC (2016-2018) and AHD (2019-2021) cohorts. Residents' performance significantly improved (P < 0.05) on ABIM scores (513.80 ± 48.34) on average from 2019 to 2021 compared to ABIM scores (452.42 ± 49.72) on average from 2016 to 2018 with a large effect size of 1.27. Similarly, a significant (P = 0.005) improvement in ITE scores was observed from 2019 to 2021 with implementation of AHD compared to preceding NC scores (2016-2018) with a moderate effect size of 0.52. Participating residents in AHD sessions had higher ITE and ABIM scores compared to those in hourly NC didactic sessions with significantly improved resident attendance and overall satisfaction.

Impact of Diabetes Mellitus on Outcomes of Percutaneous Coronary Intervention in Chronic Total Occlusions: A Systematic Review and Meta-Analysis.

BACKGROUND: Patients with diabetes mellitus (DM) have a high prevalence of coronary chronic total occlusions (CTOs). We conducted a systematic review and meta-analysis to characterize outcomes after CTO percutaneous coronary intervention (PCI) in patients without or with DM. METHODS: PubMed, EMBASE, Cochrane, and Google Scholar were queried for studies comparing non-DM vs. DM patients undergoing attempted CTO PCI. The primary outcome was all-cause mortality at longest follow-up (at least 6 months). Secondary outcomes were major adverse cardiovascular events (MACE) which is a composite endpoint including myocardial infarction, cardiac or all-cause mortality and any revascularization in patients after CTO PCI, target vessel revascularization (TVR), myocardial infarction (MI), Japanese chronic total occlusion (J-CTO) score and prevalence of multivessel (MV) CTO disease. We used a random effects model to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Sixteen studies, including 2 randomized control trials and 14 observational studies, met inclusion criteria. At longest follow-up, all-cause mortality (OR 0.54 [95% CI 0.37-0.80], p < 0.0001) and MACE (OR 0.82 [95% CI 0.72-0.93], p < 0.00001) were significantly lower in non-DM CTO patients. MV CTO disease was less prevalent in patients without DM (OR 0.80 [95% CI 0.69-0.93], p = 0.004). However, there were no differences in MI, TVR and J-CTO score. CONCLUSIONS: Non-diabetics undergoing CTO PCI have lower all-cause mortality and MACE than diabetics. Future research may determine if DM control improves diabetics' CTO PCI outcomes.

Prevalence of Post-Heart Transplant Malignancies: A Systematic Review and Meta-Analysis.

The prevalence of different cancers after heart transplant (HT) is unclear due to small and conflicting prior studies. Herein, we report a systematic review and meta-analysis to highlight the prevalence and pattern of malignancies post-HT. We conducted an extensive literature search on PubMed, Scopus, Cochrane databases for prospective or retrospective studies reporting malignancies after HT. The proportions from each study were subjected to random effects model that yielded the pooled estimate with 95% confidence intervals (CI). Fifty-five studies comprising 60,684 HT recipients reported 7759 total cancers during a mean follow-up of 9.8 ± 5.9 years, with an overall incidence of 15.3% (95% CI = 12.7%-18.1%). Mean time from HT to cancer diagnosis was 5.1 ± 4 years. The most frequent cancers were gastrointestinal (7.6%), skin (5.7%), and hematologic/blood (2.5%). Meta-regression showed no association between incidence of cancer and mean age at HT (coeff: -0.008; P = 0.25), percentage of male recipients (coeff: -0.001; P = 0.81), donor age (coeff: -0.011; P = 0.44), 5-year (coeff: 0.003; P = 0.12) and 10-year (coeff: 0.02; P = 0.68) post-transplant survival. There is a substantial risk of malignancies in HT recipients, most marked for gastrointestinal, skin, and hematologic. Despite their occurrence, survival is not significantly impacted.

Transradial versus transfemoral approach for percutaneous coronary intervention in patients with ST-elevation myocardial infarction complicated by cardiogenic shock: a systematic review and meta-analysis.

BACKGROUND: In ST-elevation myocardial infarction (STEMI), transradial access (TRA) for percutaneous coronary intervention (PCI) is associated with less bleeding and mortality than transfemoral access (TFA). However, patients in cardiogenic shock (CS) are more often treated via TFA. The aim of this meta-analysis is to compare the safety and efficacy of TRA vs. TFA in CS. METHODS: Systematic review was performed querying PubMed, Google Scholar, Cochrane, and clinicaltrials.gov for studies comparing TRA to TFA in PCI for CS. Outcomes included in-hospital, 30-day and ≥1-year mortality, major and access site bleeding, TIMI3 (thrombolytics in myocardial infarction) flow, procedural success, fluoroscopy time, and contrast volume. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using random effects models. RESULTS: Six prospective and eight retrospective studies (TRA, n = 8032; TFA, n = 23 031) were identified. TRA was associated with lower in-hospital (RR 0.59, 95% CI 0.52-0.66, P < 0.0001), 30-day and ≥1-year mortality, as well as less in-hospital major (RR 0.41, 0.31-0.56, P < 0.001) and access site bleeding (RR 0.42, 0.23-0.77, P = 0.005). There were no statistically significant differences in post-PCI coronary flow grade, procedural success, fluoroscopy time, and contrast volume between TRA vs. TFA. CONCLUSIONS: In PCI for STEMI with CS, TRA is associated with significantly lower mortality and bleeding complications than TFA while achieving similar TIMI3 flow and procedural success rates.

Lemierre's syndrome with muscle necrosis and chronic osteomyelitis.

Lemierre's syndrome is a rare disorder characterized by thrombophlebitis of the internal jugular vein and is caused by gram-negative anaerobes, primarily Fusobacterium necrophorum. We report a case of a 20-year-old man who developed chronic osteomyelitis of the femur and myonecrosis of thigh muscles secondary to this syndrome. The diagnosis was made based on clinical presentation and evidence of thrombosis in the internal jugular vein on ultrasound. The patient was initially treated with antibiotics, and anticoagulants were added later due to deep vein thrombosis in the lower limb.

Outcomes of surgical versus transcatheter aortic valve replacement in nonagenarians- a systematic review and meta-analysis.

Introduction: Since the approval of transcatheter aortic valve replacement (TAVR), nonagenarian group patients are being increasingly considered for TAVR. Therefore, we compared the clinical outcomes of surgical aortic valve replacement (SAVR) vs TAVR in nonagenarians with severe aortic stenosis. Methods: A literature search was performed using MEDLINE, Embase, Web of Science, Cochrane, and Clinicaltrials.gov for studies reporting the comparative outcomes of TAVR versus SAVR in nonagenarians. The primary endpoint was short-term mortality. Secondary endpoints were post-operative incidences of stroke or transient ischemic attack (TIA), vascular complications, acute kidney injury (AKI), transfusion requirement, and length of hospital stay. Results: Four retrospective studies qualified for inclusion with a total of 8,389 patients (TAVR = 3,112, SAVR = 5,277). Short-term mortality was similar between the two groups [RR = 0.91 (95% CI: 0.76-1.10), p = 0.318]. The average length of hospital stay was shorter by 3 days in the TAVR group (p = 0.037). TAVR was associated with a significantly lower risk of AKI [RR = 0.72 (95% CI: 0.62-0.83), p < 0.001] and a lower risk of transfusion [RR = 0.71 (95% CI: 0.62-0.81), p < 0.001]. There was no difference in risk of stroke/TIA[RR = 1.01 (95% CI: 0.70-1.45), p = 0.957]. The risk of vascular complications was significantly higher in the TAVR group [RR = 3.39 (95% CI: 2.65-4.333), p < 0.001]. Conclusion: In this high-risk population, TAVR compared to SAVR has similar short-term mortality benefit but has lower risks of perioperative complications and a higher number of patients being discharged to home.

Meta-Analysis of Transradial Versus Transfemoral Access for Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease.

Data comparing outcomes of transradial (TR) versus transfemoral (TF) access for percutaneous coronary intervention (PCI) in chronic kidney disease (CKD) including patients with eGFR< 30 ml/min/1.73m2 and patients with end-stage renal disease on dialysis (ESRD) are lacking. This meta-analysis compares the outcomes of TR versus TF approach for PCI in patients with CKD. PubMed, Embase, Cochrane, ClinicalTrials.gov, and Google Scholar were searched for studies including adults with CKD undergoing PCI via a TR versus TF approach from January 1, 2000, until January 15, 2021. The primary outcome was in-hospital all-cause mortality and secondary outcomes included major bleeding, stroke, myocardial infarction (MI), blood transfusion, contrast volume, and fluoroscopy time. The analysis was performed using a random-effects-model using the Mantel-Haenszel method. Five observational studies met inclusion criteria, including 1,156 and 6,156 patients in the TR and TF arms, respectively. The mean age of included patients was 70.5 years, 66% were male and 90% had ESRD. In patients with CKD, TR access for PCI was associated with lower all-cause mortality (RR = 0.48; 95% CI: 0.32 to 0.73), major bleeding (RR = 0.51; 95% CI: 0.36 to 0.73), blood transfusion (RR = 0.53, 95% CI: 0.42 to 0.68) and contrast volume (SMD -0.34 [-0.60 to -0.08]) with no difference in stroke, MI, or fluoroscopy time compared with TF access. In conclusion, in patients with CKD undergoing PCI, the TR approach was associated with a lower risk of in-hospital mortality, post-procedural bleeding, and blood transfusion compared with TF access.