Light Chain Myeloma Precipitating Cryoglobulinemic Vasculitis.

Multiple Myeloma (MM) is characterized by monoclonal immunoglobulin production leading to widespread skeletal destruction and renal dysfunction. Light chain multiple myeloma (LCMM) affects 15% of individuals with MM and has an overall poor prognosis. Cutaneous manifestations are uncommon and it is rarely complicated by Type I Cryoglobulinemia (CG). Here we present an atypical case of κ-predominant LCMM complicated by Type I CG in an 80-year-old man who presented with a progressive non-blanching necrotic rash and ulcers involving his face, distal extremities, and oropharynx of two months duration prior to his admission at our facility. On admission to our facility, workup showed an overabundance of κ-light chains, elevated free κ/λ ratio, cryoglobulins, and an acute kidney injury. Marrow biopsy demonstrated 60% plasma cells with κ-light chain predominance. Cutaneous manifestations such as acral cyanosis and distal gangrene in LCMM indicate late stages of the disease, and such findings should raise suspicion for additional comorbid pathologies, including cryoglobulinemia, which could help direct earlier initiation of treatment.

Quality of life after amputation in patients with advanced complex regional pain syndrome: a systematic review.

The majority of included studies (8 out of 11, n = 54) supported the concept of considering amputation for selected, unresponsive cases of complex regional pain syndrome (CRPS) as a justifiable alternative to an unsuccessful multimodality nonoperative option.Of patients who underwent amputation, 66% experienced improvement in quality of life (QOL) and 37% were able to use a prosthesis, 16% had an obvious decline in QOL and for 12% of patients, no clear details were given, although it was suggested by authors that these patients also encountered deterioration after amputation.Complications of phantom limb pain, recurrence of CRPS and stump pain were predominant risks and were noticed in 65%, 45% and 30% of cases after amputation, respectively and two-thirds of patients were satisfied.Amputation can be considered by clinicians and patients as an option to improve QOL and to relieve agonizing, excruciating pain of severe, resistant CRPS at a specialized centre after multidisclipinary involvement but it must be acknowledged that evidence is limited, and the there are risks of aggravating or recurrence of CRPS, phantom pain and unpredictable consequences of rehabilitation.Amputation, if considered for resistant CRPS, should be carried out at specialist centres and after MDT involvement before and after surgery. It should only be considered if requested by patients with poor quality of life who have failed to improve after multiple treatment modalities.Further high quality and comprehensive research is needed to understand the severe form of CRPS which behaves differently form less severe stages. Cite this article: EFORT Open Rev 2019;4:533-540. DOI: 10.1302/2058-5241.4.190008.

Is valve-sparing root replacement a safe option in acute type A aortic dissection? A systematic review and meta-analysis.

OBJECTIVES: There are conflicting views regarding the status of valve-sparing root replacement (VSRR) as a proper treatment for acute type A aortic dissection (AAAD). Our goal was to compare the early and late outcomes of VSRR versus those of the Bentall procedure in patients with AAAD. METHODS: We performed a systematic review and meta-analysis of 9 studies to compare the outcomes of VSRR with those of the Bentall procedure in patients with AAAD. We focused on the following issues: early and late mortality rates, re-exploration, thromboembolization/bleeding events, infective endocarditis and reintervention rates. RESULTS: A total of 706 patients with AAAD who underwent aortic root surgery were analysed; 254 patients were treated with VSRR and 452 with the Bentall procedure. VSRR was associated with a reduced risk of early death [odds ratio (OR) 0.34; 95% confidence interval (CI) 0.21-0.57] and late death (OR 0.34; 95% CI 0.21-0.57) compared with the Bentall procedure. No statistically significant difference was observed between the VSRR and Bentall groups with pooled ORs (OR 0.77; 95% CI 0.47-1.27, OR 0.61; 95% CI 0.32-1.18 and OR 0.71; 95% CI 0.23-2.15) for re-exploration, thromboembolization/bleeding and postoperative infective endocarditis, respectively. An increased risk of reintervention was observed for the VSRR compared to the Bentall group (OR 3.79; 95% CI 1.27-11.30). The pooled rate of reintervention incidence was 1.6% (95% CI 0.0-3.7%) and 0.4% (95% CI 0.0-1.3%) for the VSRR and the Bentall groups, respectively. CONCLUSIONS: VSRR in patients with AAAD can be performed in experienced centres with excellent short- and long-term outcomes compared to those with the Bentall procedure and thus should be recommended especially for active young patients.

Outcomes with first- versus second-generation drug-eluting stents in coronary chronic total occlusions (CTOs): a systematic review and meta-analysis.

OBJECTIVE: The objective of the present study was to perform a systematic review and meta-analysis of studies reporting outcomes after first- and second-generation drug-eluting stent (DES) implantation in chronic total occlusions (CTOs). BACKGROUND: The effect of second- vs first-generation DESs on the outcomes after CTO percutaneous coronary intervention (PCI) has received limited study. METHODS: As of May 2013, thirty-one published studies reported outcomes after DES implantation in CTOs: thirteen uncontrolled studies (3161 patients), three randomized (220 patients) and ten non-randomized (2150 patients) comparative studies with bare-metal stents (BMSs), and two non-randomized (685 patients) and three randomized (489 patients) comparative studies between first- and second-generation DESs. Data from the five studies comparing first with second-generation DESs were pooled using random-effects meta-analysis models. RESULTS: The median and mean duration of follow-up were 12 and 14.4 months, respectively. Compared to first-generation DESs, second-generation DESs were associated with lower incidence of death (odds ratio [OR], 0.37; 95% confidence intervals [CI], 0.15-0.91), target vessel revascularization (OR, 0.59; 95% CI, 0.40-0.87), binary angiographic restenosis (OR, 0.68; 95% CI, 0.46-1.01) and reocclusion (OR, 0.35; 95% CI, 0.17-0.71), but similar incidence of myocardial infarction (OR, 0.45; 95% CI, 0.10-1.95) and stent thrombosis (OR, 0.34; 95% CI, 0.07-1.59). CONCLUSIONS: Compared to first-generation DESs, second-generation DESs are associated with improved angiographic and clinical outcomes in CTO PCI and are the preferred stents for these challenging lesions.

Bacteriological patterns and antibiotic sensitivities in calculus cholecystitis.

BACKGROUND: Calculus cholecystitis with its complications dominates the diseases of the biliary tract. There is an inherent difficulty in identifying patients having infected gall bladders who may have the risk of wound infection or gram negative septicaemia after cholecystectomy. This study was conducted to ascertain the bacteriological patterns and antibiotic sensitivities of bile in calculus cholecystitis patients presenting at a tertiary care hospital and formulate guidelines for prophylactic antibiotic therapy. METHODS: This descriptive study was conducted in Combined Military Hospital, Rawalpindi from 20th Dec 2006 to 19th Sep 2008. A total number of 150 patients presenting at CMH Rawalpindi for elective cholecystectomy were included in the study. Prophylactic antibiotics were given after the induction of anaesthesia, 5 ml of bile was aspirated from their intact gall bladder was subjected to bacteriological examination at Armed Forces Institute of Pathology. A pro forma was designed to record all the information regarding isolated bacteria and their sensitivities to various antibiotics. Data was analyzed using SPSS-11. RESULTS: Growth of bacteria was seen in 57 (38%) cases and no growth was seen in 93 (62%). Most common organism cultured was: Pseudomonas aeruginosa followed by Escherichia coli (E. Coli) and Klebsiella pneumoniae. The most effective antibiotic was Imipenem followed by Piperacillin- Tazobactum combination and Amikacin. CONCLUSIONS: Imipenem, Piperacillin-Tazobactum combination and Amikacin should be used for prophylaxis in cases of cholelithiasis undergoing elective cholecystectomy.

Prevalence and outcomes of intermediate saphenous vein graft lesions: findings from the stenting of saphenous vein grafts randomized-controlled trial.

BACKGROUND: We sought to examine the prevalence and progression rate of intermediate saphenous vein graft (SVG) lesions in the Stenting Of Saphenous vein grafts (SOS) trial. METHODS: The baseline and follow-up angiograms of 80 patients participating in the SOS trial were analyzed to determine the prevalence of intermediate (30-60% angiographic diameter stenosis) SVG lesions and their progression rate. RESULTS: At least one intermediate SVG lesion was present in 31 of 143 (22%) SVGs in 27 of 80 (34%) patients. Most intermediate lesions were present in the SOS stented SVGs (20 grafts in 19 patients). During a median follow-up of 35 months, angiographic follow-up was available for 28 grafts in 25 patients. Progression (defined as percent diameter stenosis ≥ 70% but <100% at follow-up angiography) was seen in 11 of 28 SVGs (39%) in 11 of 25 patients (44%). Progression rate at 12, 24 and 36 months was 28% and 47% and 84%, respectively. Seven of 11 patients (64%) with intermediate SVG lesion progression presented with an acute coronary syndrome and 8 (73%) underwent PCI. Four of the 28 grafts with intermediate lesions at baseline were 100% occluded at follow-up; all of those SVGs had received a stent in another location in the SVG as part of the SOS trial. CONCLUSIONS: Intermediate SVG lesions are common in patients undergoing SVG stenting, have high rates of progression and frequently present with an acute coronary syndrome. Further study of pharmacologic and mechanical treatments to prevent progression of these lesions is needed.

Multidrug resistant pneumonia treated with aerosolized amikacin in a patient with acute renal insufficiency.

Multidrug resistant pneumonia is an entity, which is difficult to treat, and in a patient with acute renal insufficiency, it leaves a physician with a handful of antibiotics to be considered. Aerosolized administration of antibiotics is one option that can be contemplated for a patient with acute renal insufficiency to avoid the nephrotoxic effect of the antibiotics.

Use of octreotide in the treatment of refractory orthostatic intolerance.

There have been reports on the use of octreotide in patients with orthostatic hypotension, postural tachycardia syndrome, and orthostatic syncope. However, there are little if any data on the use of octreotide in patients who have failed multiple other medications. This study was a retrospective chart analysis and was approved by our Institutional Review Board. A total of 12 patients were identified for inclusion in this study. The diagnosis of orthostatic intolerance was based on patient history, physical examination, and response to Head Up Tilt Table testing. These patients had failed multiple medications and were ultimately treated with octreotide. In a retrospective chart review, we collected data, including demographic information, presenting symptoms, laboratory data, tilt-table response, standing heart rate, standing blood pressure before and after treatment (wherever available), and treatment outcomes. Twelve patients aged 33 ± 18 years, eight (66.7%) females, were found to have symptoms of refractory orthostatic intolerance and failed multiple regimens of medication and were ultimately treated with octreotide administration. Five patients (41.7%) had demonstrated a postural tachycardia syndrome pattern, five (41.7%) a neurocardiogenic, and two (16.6%) a dysautonomic response on a Head Up Tilt Table. Symptoms of syncope and orthostatic palpitations improved in six (50%) of the patients. Standing heart rate was significantly reduced after octreotide administration (80 ± 8 versus 108 ± 13; P < 0.05). The standing systolic blood pressure was increased after octreotide administration (107 ± 26 versus 116 ± 22). Three patients (25%) reported complete elimination of syncope, whereas another three had reduction in the frequency of their syncope. However, symptoms of fatigue improved only in two (29%) of the seven patients. Octreotide may improve symptoms in some patients with refractory orthostatic intolerance.

Erythropoietin in the treatment of postural orthostatic tachycardia syndrome.

Erythropoietin has been reported to improve symptoms of orthostatic intolerance in patients suffering from orthostatic hypotension. Previous reports on the use of erythropoietin in patients with postural orthostatic tachycardia (POTS) have included only a very small number of patients. In the current study, we report on the use of erythropoietin in patients with refractory POTS. The study was approved by the institutional review board. A retrospective nonrandomized analysis was performed on 39 patients evaluated at our autonomic center for POTS from 2003 to 2010. The diagnosis of POTS was based on patient history, physical examination, and response to head-up tilt-table testing. The mean follow-up period was 6 months. The patients were included in the current study if they had a diagnosis of POTS with severe symptoms of orthostatic intolerance and were refractory to the commonly used medications. All these patients were started on erythropoietin, and the response to therapy was considered successful if it provided symptomatic relief. We screened 200 patients with POTS and found 39 patients (age 33 ± 12, 37 females) to be eligible for inclusion in the current study. The response to the treatment was assessed subjectively in each patient and was obtained in a retrospective fashion from patient charts and physician communications. Eight (21%) patients demonstrated no improvement in symptoms after administration of erythropoietin. Three (8%) patients showed an improvement in symptoms of orthostatic intolerance of <3 months. Twenty-seven (71%) patients demonstrated sustained improvement in their symptoms of orthostatic intolerance at the mean follow-up of 6 months. Erythropoietin significantly improved sitting diastolic blood pressure but had no effect on other hemodynamic parameters. In a select group of POTS patients who are refractory to commonly used medications, erythropoietin may help improve symptoms of orthostatic intolerance.

A case report of complete remission of pulmonary metastases from epithelioid sarcoma to navelbine chemotherapy.

Management of soft tissue sarcomas can be very challenging because they have a high rate of metastasis, especially to the lungs, and respond very poorly to the currently available chemotherapeutic drugs. We present a case of epithelioid sarcoma in which complete remission of pulmonary metastases was observed after treatment with a single agent, navelbine, a vinca alkaloid, and a potential therapeutic agent. The patient has been persistently free of metastases for 4 years since treatment with navelbine. Further studies are warranted to establish the role of navelbine for the treatment of soft tissue sarcoma and their metastases.

Use of methylphenidate in the treatment of patients suffering from refractory postural tachycardia syndrome.

Methylphenidate has been shown to be an effective therapy in patients with refractory neurocardiogenic syncope. However, the role of methylphenidate in patients suffering from postural orthostatic tachycardia (POTS) has not been reported. The study was approved by the institutional review board. A retrospective nonrandomized analysis was preformed on 24 patients evaluated at our autonomic center for POTS from 2003 to 2010. The diagnosis of POTS was based on patient history, physical examination, and response to head up tilt table testing. The mean follow-up period was 9 ± 3 months. The patients were included in the current study if they had a diagnosis of POTS with severe symptoms of orthostatic intolerance and were refractory to the commonly used medications. All of these patients were started on methylphenidate and the response to therapy was considered successful if it provided symptomatic relief. Twenty-four patients (age 28 ± 12, 20 women) met inclusion criterion for this study. The response to treatment was assed subjectively in each patient and was collected in a retrospective fashion from patient charts and physician communications. Four patients reported side effects in the form of nausea and 2 ultimately had to discontinue the treatment. Another 4 patients had a follow-up of less than 6 months. Thus, only 18 patients who received methylphenidate completed the follow-up of 6 months. Out of these 18 patients, 14 (77%) patients reported marked improvement in their symptoms. Nine out of 12 patients who had recurrent episodes of syncope reported no syncope at 6 months of follow-up. Fourteen (77%) patients reported marked improvement in their symptoms of fatigue and presyncope. Four patients continue to have symptoms of orthostatic intolerance and 3 continued to have recurrent episodes of syncope. Methylphenidate may be beneficial in patients with otherwise refractory postural tachycardia syndrome.

Paclitaxel-eluting stents reduce neointimal hyperplasia compared to bare metal stents in saphenous vein grafts: intravascular ultrasonography analysis of the SOS (Stenting of Saphenous Vein Grafts) trial.

AIMS: To compare the intravascular ultrasonography (IVUS) findings between saphenous vein grafts (SVG) treated with paclitaxel-eluting stents (PES) vs. bare metal stents (BMS) in the Stenting Of Saphenous Vein Grafts (SOS) trial. METHODS AND RESULTS: Of the 80 SOS trial patients, 38 had both baseline and follow-up IVUS examination and were included in this substudy: 17 patients received 28 BMS in 26 lesions and 21 patients received 30 PES in 28 lesions. Quantitative IVUS analysis was performed to determine the volume of in-stent neointimal hyperplasia (NIH) - defined as the difference between stent volume and lumen volume in the stented segments. Baseline characteristics were similar between patients who did and did not undergo baseline and follow-up IVUS. Patients receiving BMS and PES had similar stent and lumen volumes immediately after stenting. At 12-month follow-up, compared to BMS, PES-treated lesions had significantly less NIH volume (3.4 vs. 21.9 mm³, p<0.001) and neointima hyperplasia progression (1.6 vs. 17.1 mm³, p<0.001). No significant differences were seen in the 5 mm segment proximal and distal to the stent. CONCLUSIONS: Compared to BMS, use of PES in SVG lesions is associated with significantly lower NIH formation, which may help explain the improved clinical outcomes with PES in these lesions.

Clinical presentation and management of patients with hyperadrenergic postural orthostatic tachycardia syndrome. A single center experience.

BACKGROUND: We present our single center experience of 27 patients of hyperadrenergic postural orthostatic tachycardia syndrome (POTS). METHODS: In a retrospective analysis, we reviewed the charts of 300 POTS patients being followed at our autonomic center from 2003 to 2010, and found 27 patients eligible for inclusion in this study. POTS was defined as symptoms of orthostatic intolerance (of greater than six months' duration) accompanied by a heart rate increase of at least 30 bpm (or a rate that exceeds 120 bpm) that occurs in the first 10 min of upright posture or head up tilt test (HUTT) occurring in the absence of other chronic debilitating disorders. Patients were diagnosed as having the hyperadrenergic form based on an increase in their systolic blood pressure of ≥ 10 mm Hg during the HUTT (2) with concomitant tachycardia or their serum catecholamine levels (serum norepinephnrine level ≥ 600 pg/mL) upon standing. RESULTS: Twenty seven patients, aged 39 ± 11 years, 24, (89%) of them female and 22 (82%) Caucasian were included in this study. Most of these patients were refractory to most of the first and second line treatments, and all were on multiple combinations of medications. CONCLUSIONS: Hyperadrenergic POTS should be identified and differentiated from neuropathic POTS. These patients are usually difficult to treat and there are no standardized treatment protocols known at this time for patients with hyperadrenergic POTS.

Recurrent cardiovascular events with paclitaxel-eluting versus bare-metal stents in saphenous vein graft lesions: insights from the SOS (Stenting of Saphenous Vein Grafts) trial.

UNLABELLED: The Stenting of Saphenous Vein Grafts (SOS) trial demonstrated a reduction in clinical and angiographic adverse events with paclitaxel-eluting stents (PES) compared to bare-metal stents (BMS) in saphenous vein graft (SVG) lesions, but the rate of recurrent adverse events has not been described. METHODS: We performed a post hoc, landmark analysis to evaluate the risk of event recurrence following a non-fatal initial event among the SOS trial patients (pts). RESULTS: During a median follow-up of 35 months, the 80 pts enrolled in SOS experienced a total of 78 major cardiovascular events (MACE): 51 in the BMS group and 27 in PES group. No MACE were found in 28 pts (35%) while 52 pts (65%) had at least one event. The initial event was death in 13 pts (16%). Among the 39 pts whose initial event was not fatal, 12 (31%) had one or more subsequent MACE (50% of which were definitely related to the study SVG). The mean and median number of MACE per patient was significantly higher in patients receiving BMS versus PES (1.3 ± 1.2 and 1 ± 1.26 versus 0.6 ± 0.7 and 1 ± 0.825, p = 0.005 and p = 0.008, respectively). The rate of a second MACE following an initial event was 17% in the PES group and 37% in the BMS group (p = 0.24). Ten of 12 pts with recurrent events had received a BMS (83%). CONCLUSION: Pts undergoing SVG stenting had a high rate of recurrent events after an initial non-fatal event. These events were often related to the target vessel and most occurred in pts who had received a BMS, further supporting the benefit of PES over BMS in SVG lesions.

Pyridostigmine in the treatment of postural orthostatic tachycardia: a single-center experience.

BACKGROUND: The long-term efficacy of pyridostigmine, a reversible acetyl cholinesterase inhibitor, in the treatment of postural orthostatic tachycardia syndrome (POTS) patients remains unclear. We report our retrospective, single-center, long-term experience regarding the efficacy and adverse effect profile of pyridostigmine in the treatment of POTS patients. METHODS: This retrospective study included an extensive review of electronic charts and data collection in regards to patient demographics, orthostatic parameters, side-effect profile, subjective response to therapy, as well as laboratory studies recorded at each follow-up visit to our institution's Syncope and Autonomic Disorders Center. The response to pyridostigmine therapy was considered successful if patient had both symptom relief in addition to an objective response in orthostatic hemodynamic parameters (heart rate [HR] and blood pressure). Three hundred patients with POTS were screened for evaluation in this study. Of these 300, 203 patients with POTS who received pyridostigmine therapy were reviewed. Of these 203 patients, 168 were able to tolerate the medication after careful dose titration. The mean follow-up duration in this group of patients was 12 ± 3 (9-15) months. Pyridostigmine improved symptoms of orthostatic intolerance in 88 of 203 (43%) of total patients or 88 of 172 (51%) who were able to tolerate the drug. The symptoms that improved the most included fatigue (55%), palpitations (60%), presyncope (60%), and syncope (48%). Symptom reduction correlated with a statistically significant improvement in upright HR and diastolic blood pressure after treatment with pyridostigmine as compared to their baseline hemodynamic parameters (standing HR 94 ± 19 vs 82 ± 16, P < 0.003, standing diastolic blood pressure 71 ± 11 vs 74 ± 12, P < 0.02). Gastrointestinal problems were the most common adverse effects (n = 39, 19%) reported. The overall efficacy of pyridostigmine in our study was seen in 42% of total patients or 52% of patients who could tolerate taking the drug. CONCLUSION: The subgroup of POTS patients who can tolerate oral pyridostigmine may demonstrate improvement in their standing HR, standing diastolic blood pressure, and clinical symptoms of orthostatic intolerance.

Continued benefit from paclitaxel-eluting compared with bare-metal stent implantation in saphenous vein graft lesions during long-term follow-up of the SOS (Stenting of Saphenous Vein Grafts) trial.

OBJECTIVES: This study sought to report the long-term outcomes after drug-eluting stent (DES) implantation in saphenous vein graft (SVG) lesions in the SOS (Stenting of Saphenous Vein Grafts) trial. BACKGROUND: The long-term outcomes after DES implantation in SVGs are poorly studied. Apart from the SOS trial, the only other randomized trial comparing DES with bare-metal stents (BMS) in SVGs reported higher mortality in the DES group at 32 months. METHODS: In the SOS trial, 80 patients with 112 lesions in 88 SVGs were randomized to a BMS or paclitaxel-eluting stent (PES) and demonstrated improved short-term angiographic and clinical outcomes with PES. Extended clinical follow-up was subsequently obtained. RESULTS: Mean age was 67 ± 9 years, and all patients were men. The indications for stenting included acute coronary syndrome in 60% and stable angina in 31% of patients. The mean SVG age was 12 ± 6 years. The baseline characteristics of the patients in the 2 study groups were similar. Procedural success was achieved in 77 patients (96%). During a median follow-up of 35 months, compared with patients randomized to BMS, those receiving PES had a lower incidence of myocardial infarction (hazard ratio [HR]: 0.32, p = 0.01), target lesion revascularization (HR: 0.20, p = 0.004), target vessel revascularization (HR: 0.41, p = 0.03), and target vessel failure (HR: 0.34, p = 0.001) as well as a trend toward less definite or probable stent thrombosis (HR: 0.15, p = 0.08). All-cause mortality (HR: 2.04, p = 0.19) and cardiac mortality (HR: 0.62, p = 0.51) did not differ between groups. CONCLUSIONS: During long-term follow-up, use of PES was associated with significantly better clinical outcomes than BMS in SVG lesions. (Stenting of Saphenous Vein Grafts Trial [SOS]; NCT00247208).

Ventricular fibrillation associated with occult eating disorder - a clinical puzzle.

Eating disorders are not infrequent in adolescents, and associated cardiac arrhythmias (CA) are well described in these patients. However, CA in adult eating disorders have been reported only rarely. We report a case of ventricular fibrillation in a patient presenting with fatigue and a recent history of vomiting.

Preliminary observations suggesting that treatment with modafinil improves fatigue in patients with orthostatic intolerance.

Many patients who suffer from orthostatic intolerance (OI) may also have severe fatigue and extreme exercise intolerance. In some of these patients, fatigue may be so severe that they are unable to maintain employment. In some, even the activities of the daily living may be compromised. We report on the use of modafinil in a subgroup of patients who failed therapy with commonly used medication for fatigue in patients with OI. The study was approved by the institutional review board. A retrospective nonrandomized analysis was preformed on 60 patients evaluated at our autonomic center for OI from 2003 to 2010. The diagnosis of OI was based on patient history, physical examination, and reponse to head up tilt table testing. All these patients had fatigue as their predominant symptom. Multiple trials of stimulants including methylphenidate, amphetamine, or dextroamphetamine failed to provide symptomatic relief of fatigue in these patients. Each patient received modafinil (100-200 mg daily). The mean follow-up period was 9 ± 3 months. A treatment was considered successful if it provided symptomatic relief from fatigue for the patient. Sixty patients, age 29 ± 15, 52 women were included in the analysis. Migraine (57%) and joint hypermobility syndrome (33%) were common comorbidities. Out of 60 patients, 40 patients reported initial improvement with initiation of modafinil therapy. Twenty patients reported no change in their symptoms of fatigue. Of the 40 patients who showed initial improvement in their symptoms 4 had eventual recurrence of fatigue after 3 months of modafinil therapy. Thirty-six patients continued to demonstrate symptom relief from fatigue for more than 6 months. In a selective group of patients of OI, modafinil may improve fatigue.

Use of drug-eluting stents for chronic total occlusions: a systematic review and meta-analysis.

AIM: To perform a systematic review and meta-analysis of studies reporting outcomes after drug-eluting stent (DES) implantation in chronic total occlusions (CTOs). METHODS: A review of publications and online databases in January 2010 retrieved 17 published studies that reported outcomes after DES implantation in CTOs: eight uncontrolled studies, seven nonrandomized comparative studies with bare-metal stents (BMS), one post-hoc analysis of a randomized trial, and one randomized trial. Data were pooled using random-effects meta-analysis models. RESULTS: All published studies evaluated sirolimus- or paclitaxel-eluting stents. All studies reporting comparative angiographic outcomes revealed less binary angiographic restenosis with DES implantation compared to BMS (odds ratio: 0.15, 95% CI: 0.08, 0.26). Over a mean follow-up period of 18.9±16.5 months, the cumulative incidence of death, myocardial infarction, or stent thrombosis was similar between DES and BMS in all studies. Target lesion revascularization (odds ratio: 0.13, 95% CI: 0.06, 0.26) and target vessel revascularization (odds ratio 0.18, 95% CI: 0.11, 0.31) at 6-12 months were consistently lower among DES-treated patients. Similar patterns of safety and efficacy event rates were also observed in studies reporting>12 month outcomes. CONCLUSIONS: Compared with BMS, treatment of chronic total coronary occlusions with DES is associated with significant reductions in angiographic and clinical restenosis with similar safety. The consistency and magnitude of treatment effect across both individual trials and the pooled analysis establish DES as the preferred therapy for percutaneous revascularization of CTOs.

"Cardiac otalgia": acute coronary syndrome masquerading as bilateral ear pain.

Patients presenting with acute coronary syndromes are classically described as having chest pressure with radiation to the left arm. However, pain can be referred to multiple sites including the face, the neck, the abdomen and the contra-lateral arm. We present a case of sudden bilateral ear pain as the sole presentation of acute coronary syndrome in an elderly man. The importance of recognizing these atypical presentations is vital, as outcomes may be worsened as appropriate therapy may be delayed or misdirected.