Computed tomography pulmonary angiography is overused to diagnose pulmonary embolism in the emergency department of academic community hospital.

Background: Pulmonary embolism (PE) is a common disease in the USA responsible for up to 10% of hospital mortality. Modified wells score (MWS) and D-dimer assay are used to categorize patients into high or low probability of PE. Patient with high probability need Computed tomography pulmonary angiography (CTPA), while patients with low probability and low D-dimer can safely forgo the CTPA. Objectives: The aim of this study was to investigate the rate of inappropriate CTPA use in the emergency department of a community teaching hospital. Methods: A retrospective chart review of adult patients who underwent CTPA for suspected PE in the emergency department for 2015 was done. CTPA use was considered inappropriate if MWS was less than or equal to 4 and D-dimer was either not ordered or its value was less than 500 µg/L. Bivariate analysis with Fisher's exact tests and Student's t-tests as well as multivariate logistic regression analysis were done to examine relationship between study explanatory variables and study outcome. Results: 295 patients were included in the study. The mean age was 51.2(±14.5) years, 68.8% were females. The prevalence of PE was 5.4% and 41% of the CTPAs -were inappropriately ordered. Males were twice (OR 2.1; 95% CI 1.2, 3.6) as likely as females to have an inappropriately ordered CTPA after controlling for a high MWS, age, and tobacco history. Conclusion: CTPA is overused to diagnose PE in the emergency department. Quality improvement projects are needed to encourage physicians to adhere to the current guidelines.

Laparoscopic esophageal myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized controlled trials.

BACKGROUND: Achalasia is a primary esophageal motility disorder of unknown etiology associated with abnormalities in peristalsis and lower esophageal sphincter relaxation. The disease is incurable; however, definitive treatment procedures like pneumatic dilation (PD)/balloon dilation and laparoscopic esophageal myotomy (LEM) are performed to relieve dysphagia and related symptoms. Currently, there is paucity of data comparing the outcomes of these procedures. The aim of this meta-analysis is to compare the short- and long-term success rates of PD and LEM. METHODS: A thorough systematic search of PubMed, Scopus, clinicaltrials.gov, and Cochrane library was conducted for randomized controlled trials (RCTs) comparing the outcomes of PD versus LEM in the treatment of achalasia. The Mantel-Haenszel method and random effect model were used to analyze the data. RCTs with outcome data at 3-month, 1-year, and 5-year intervals were analyzed. RESULTS: A total of 437,378 and 254 patients at 3-month, 1-year, and 5-year intervals were analyzed for outcome data. At 3 months and 1 year, PD was not as effective as LEM (odds ratio [OR]: 0.50; confidence interval [CI] 0.31-0.82; P = 0.009 and OR: 0.47; CI 0.22-0.99; P = 0.21) but at 5 years, one procedure was non-inferior to the other (OR: 0.62; 0.33-1.19; P = 0.34). CONCLUSION: PD was as effective as LEM in relieving symptoms of achalasia in the long-term.

Drug-eluting stent placement versus coronary artery bypass surgery for unprotected left main coronary artery disease: A meta-analysis of randomized controlled trials.

BACKGROUND: Coronary artery bypass grafting (CABG) is the standard of care for treating left main coronary lesions. However, recently published randomized controlled trials (RCT) have shown conflicting results. We sought to compare clinical outcomes of percutaneous coronary intervention (PCI) with drug-eluting stent placement to CABG using a meta-analysis of randomized controlled trials. METHODS: A systemic search of Pubmed, Scopus, Cochrane library, and Clinicaltrials.gov was performed for randomized controlled trials comparing PCI with CABG in patients with left main stenosis. Data were analyzed using random effect models and Mantel-Haenszel methods. The primary outcome was major adverse cardiovascular and cerebral events (MACCE). The secondary outcomes were myocardial infarction, stroke, cardiac, and all-cause mortality. A subgroup analysis based on SYNTAX score was also performed. RESULTS: A total of 4595 patients (2297 in the PCI group and 2298 in the CABG group) from five RCTs were included in the analysis. There were significant differences in MACCE (odds ratio [OR] 1.36, confidence interval [CI] 95%, 1.18-1.58, p-value: < 0.0001) and repeat revascularization (OR 1.85, CI 95%, 1.53-2.23, p-value: < 0.00001) favoring CABG. There were no significant differences in the incidence of myocardial infarction, stroke, or cardiac and all-cause mortality. Based on SYNTAX score, CABG was superior in terms of MACCE only in the subgroup with SYNTAX score of 33 or more. CONCLUSIONS: CABG results in fewer MACCE and need for repeat revascularization than PCI in patients with unprotected left main disease.

Impact of cyclosporine A use in the prevention of reperfusion injury in acute myocardial infarction: A meta-analysis.

BACKGROUND: Reperfusion injury is an important limiting factor associated with revascularization in acute myocardial infarction (AMI). Various therapies have been tried in an attempt to prevent reperfusion injury, but the search has been elusive. The role of cyclosporine A (CsA) in the prevention of reperfusion injury in AMI is still not clear. The objective of this study was to find out whether CsA is beneficial in reducing reperfusion injury in acute ST elevation myocardial infarction. METHODS: We performed a systematic search of Pubmed, Scopus, clinicaltrial.gov, and Cochrane Database for randomized control trials (RCT) measuring the effect of CsA in AMI compared to a placebo. The Mantel-Haenszel method and random effect model were used to analyze the data. A total of 1,566 patients (776 in the CsA group and 790 in the placebo group), who participated in 5 RCTs were included in our meta-analysis. RESULTS: We did not find any significant differences between the CsA and placebo groups in terms of all-cause death (odds ratio [OR] 1.21, 95% confidence interval [CI] 0.78-1.87) and cardiovascular death (OR 1.05, 95% CI 0.66-2.49). Similarly, we did not find any significant differences in terms of cardiogenic shock, recurrent ischemia and myocardial infarction, heart failure and echocardiographic outcomes. CONCLUSIONS: Cyclosporine A is not helpful in preventing reperfusion injury in AMI.