Systematic review and meta-analysis of high-pressure intermittent limb compression for the treatment of intermittent claudication.

BACKGROUND: High-pressure intermittent limb compression (HPILC) has been proposed as an alternative treatment of disabling intermittent claudication. The objective of this study was to conduct a systematic review and meta-analysis of randomized controlled trials evaluating the efficacy of HPILC in improving walking distance in patients with intermittent claudication. METHODS: A search through December 31, 2016, was performed to identify all randomized controlled trials evaluating the efficacy of HPILC for the management of intermittent claudication. Applicable studies were assessed for quality and pooled using Cochrane systematic review guidelines. The primary outcome measured was absolute claudication distance (ACD). A random-effects model was used for meta-analysis. RESULTS: Eight studies eligible for inclusion were identified. These studies had a combined total of 290 subjects, 172 of whom were randomized to HPILC. All studies identified an increase in walking distance for subjects receiving compression therapy. On meta-analysis, the mean difference of ACD from baseline to follow-up among subjects receiving compression compared with controls was 125 m (95% confidence interval, 58.38-191.63 m; P < .01). CONCLUSIONS: HPILC is associated with a significant increase in ACD compared with controls. Limb compression appears to be an effective, noninvasive treatment option for patients with intermittent claudication. However, there are few studies comparing limb compression with other commonly used therapies. Further studies are needed to better guide the use of HPILC in the treatment of claudication.

Optimal duration of dual antiplatelet therapy after drug eluting stent implantation: a network meta-analysis.

OBJECTIVE: There has been much debate regarding the optimal duration of dual antiplatelet therapy (DAPT) cover after drug eluting stent (DES) implantation. We aimed to assess the relative benefits of shorter and longer durations of DAPT coverage. METHODS: We performed a network meta-analysis (NMA) of all the randomized clinical trials (RCT) comparing different time durations of DAPT cover. RESULTS: We included 11 unique trials with a total of 33,458 patients; the longest duration of follow-up was 48 months and the shortest was 3 months. NMA results demonstrated that compared with 12 months, longer DAPT of 30 months reduced the hazard ratio (HR) of stent thrombosis (HR, 0.29; 95% CrI, 0.17-0.49). There was no difference in mortality between shorter and longer durations of DAPT except for 30 vs. 48 months (HR, 0.48; 95% CrI, 0.23-0.98). Compared with 12 months, longer DAPT of 30 months reduced the risk of myocardial infarction (HR, 0.47; 95% CrI, 0.37-0.61). Results also demonstrated that compared with 12 months, a shorter-term DAPT reduced the risk of major bleeding (6 months: HR, 0.53; 95% CrI, 0.29-0.98), whereas longer-term DAPT increased the risk of major bleeding (30 months: HR, 1.61; 95% CrI, 1.21-2.15). CONCLUSION: As expected, bleeding was less in the shorter duration regimens, whereas the ischemic outcomes were better in the longer duration ones.

Invasive Hemodynamics of Pericardial Disease.

Pericardial diseases can be classified broadly as 3 entities: acute pericarditis, cardiac tamponade, and constrictive pericarditis. These disorders can be diagnosed and managed with noninvasive studies following a comprehensive history and physical examination, without the need for cardiac catheterization in most patients. Despite the advances in noninvasive cardiac imaging, there are limitations to their diagnostic accuracy. The invasive hemodynamic study offers the advantage of simultaneous, direct pressure measurement across multiple chambers, with direct examination of blood flow. Herein, the authors review the techniques for obtaining and interpreting invasive hemodynamic data in patients with suspected pericardial disease.

A systematic review on the safety of second-generation transcatheter aortic valves.

AIMS: To review the outcomes of studies and the safety of newer transcatheter aortic valves (THV). METHODS AND RESULTS: All studies reporting on second-generation THV were identified and pooled using the systematic review guidelines. Twenty-four reports on 1,708 patients and eight THV were included in the analysis. The pooled 30-day event rate for mortality after transcatheter aortic valve implantation (TAVI) was 5.7% (95% CI: 4.0-7.8), myocardial infarction (MI) was 1.7% (95% CI: 1.1-2.6), stage 3 acute kidney injury (AKI) was 3.4% (95% CI: 2.0-5.6), life-threatening bleeding was 5.1% (95% CI: 3.3-7.8), major vascular complications was 4.9% (95% CI: 3.5-6.6%), major bleeding was 10.5% (95% CI: 5.1-20.4), major stroke was 2.4% (95% CI: 1.7-3.4), permanent pacemaker utilisation was 13.5% (95% CI: 10.8-16.9), and coronary obstruction was 1.2% (95% CI: 0.6%-2.4%). Moderate or severe aortic insufficiency (AI) after TAVI was 4.2% (95% CI: 2.0-8.5). The pooled 30-day mean gradient and effective orifice area (EOA) were 11.63 mmHg (95% CI: 10.19-13.07) and 1.60 cm2 (95% CI: 1.5-1.7), respectively. All estimates compare favourably to events reported for first-generation valves. CONCLUSIONS: Our findings suggest that the new THV have a low risk of TAVI-related short-term complications.

Management of drug eluting stent in-stent restenosis: A systematic review and meta-analysis.

BACKGROUND: The optimal management for coronary drug eluting stent in-stent restenosis (DES ISR) is unclear. We performed a meta-analysis of observational and randomized studies to compare the outcomes of management of DES ISR using DES, drug eluting balloon (DEB), or balloon angioplasty (BA). METHODS: Eligible studies (25 single arm and 13 comparative, including 4 randomized studies with a total of 7,474 patients with DES ISR) were identified using MEDLINE search and proceedings of international meetings. Outcomes studied include major adverse cardiac events (MACE), target lesion revascularization (TLR), target vessel revascularization (TVR), myocardial infarction (MI), stent thrombosis (ST), and mortality. Follow-up ranged from 0.5 to 3.5 years (mean 1.4 years). RESULTS: The rate of TLR was significantly lower in the DES (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.36-0.69) and DEB (OR 0.31, 95% CI 0.18-0.55) groups compared to BA. Similarly, TVR rate was significantly lower in the DES (OR 0.55, 95% CI 0.39-0.77) and DEB (OR 0.32, 95% CI 0.18-0.58) groups compared to BA. All other outcomes were similar between the DES/BA and DEB/BA comparisons. TLR was significantly lower in the DES group compared to BA for vessels < or > 2.75 mm. CONCLUSION: Treatment of coronary DES ISR with DES or DEB is associated with a reduction in the risk of TLR and TVR compared to BA alone. The relative risk reduction for TLR with DES is similar to DEB. DEBs have a potential role in the treatment of DES ISR by avoiding placement of another layer of stent. © 2015 Wiley Periodicals, Inc.

Comparative efficacy of different modalities for treatment of right heart thrombi in transit: a pooled analysis.

The objective was to compare the efficacy of treatment options for right heart thrombi (RHT) in transit. All published reports between 1992 and 2013 were identified and pooled. We analyzed 328 patients with RHT and pulmonary embolism (PE). The treatments administered were none in 11 patients (3.4%), anticoagulation (AC) with heparin in 70 patients (21.3%), thrombolytics in 122 patients (37.2%), catheter-related treatments in five patients (1.5%) and surgical embolectomy in 120 patients (36.6%). The overall short-term mortality for the entire cohort was 23.2%. The mortality rate associated with no therapy was highest at 90.9%. The mortality associated with AC alone was significantly higher than surgical embolectomy or thrombolysis (37.1% vs 18.3% vs 13.7%, respectively). In univariate analysis, any therapy was better than no therapy with a favorable odds of 16.92 (95% CI 2.05-139.87) for AC, 61.76 (95% CI 7.42-513.81) for thrombolysis and 44.54 (95% CI 5.42-366.32) for surgical embolectomy. In multivariate analysis with age and hemodynamic status entered as covariates, thrombolytic therapy was better than AC with favorable odds of 4.83 (95% CI 1.52-15.36). Similarly, there was a trend in favor of surgical embolectomy with an odds of 2.61 (95% CI 0.90-7.58). The estimated probability of survival in hemodynamically unstable patients with AC, surgical embolectomy and thrombolysis was 47.7%, 70.45% and 81.5%, respectively. There was no significantly increased risk of complications with thrombolytic therapy. In conclusion, left untreated, patients with RHT and PE have very high mortality. Aggressive management with thrombolysis or surgical thrombectomy may be more effective than AC alone in the management of these patients.

Clinical and economic studies of eptifibatide in coronary stenting.

Platelet adhesion and aggregation at the site of coronary stenting can have catastrophic clinical and economic consequences. Therefore, effective platelet inhibition is vital during and after percutaneous coronary intervention. Eptifibatide is an intravenous antiplatelet agent that blocks the final common pathway of platelet aggregation and thrombus formation by binding to glycoprotein IIb/IIIa receptors on the surface of platelets. In clinical studies, eptifibatide was associated with a significant reduction of mortality, myocardial infarction, or target vessel revascularization in patients with acute coronary syndrome undergoing percutaneous coronary intervention. However, recent trials conducted in the era of dual antiplatelet therapy and newer anticoagulants failed to demonstrate similar results. The previously seen favorable benefit of eptifibatide was mainly offset by the increased risk of bleeding. Current American College of Cardiology/American Heart Association guidelines recommend its use as an adjunct in high-risk patients who are undergoing percutaneous coronary intervention with traditional anticoagulants (heparin or enoxaparin), who are not otherwise at high risk of bleeding. In patients receiving bivalirudin (a newer safer anticoagulant), routine use of eptifibatide is discouraged except in select situations (eg, angiographic complications). Although older pharmacoeconomic studies favor eptifibatide, in the current era of P2Y12 inhibitors and newer safer anticoagulants, the increased costs associated with bleeding make the routine use of eptifibatide an economically nonviable option. The cost-effectiveness of eptifibatide with the use of strategies that decrease the bleeding risk (eg, transradial access) is unknown. This review provides an overview of key clinical and economic studies of eptifibatide well into the current era of potent antiplatelet agents, novel safer anticoagulants, and contemporary percutaneous coronary intervention.

MitraClip for severe symptomatic mitral regurgitation in patients at high surgical risk: a comprehensive systematic review.

BACKGROUND: The optimal treatment of patients with severe mitral regurgitation (MR) at high surgical risk (HSR) is unknown. Recently, the EVEREST II (Endovascular Valve Edge-to-Edge Repair) High Risk Study suggested MitraClip (MC) was a safe and effective treatment option. METHODS: We performed a search strategy for MC or mitral valve surgery (MVS) in patients at HSR for surgical mortality (logistic EuroSCORE >18 or STS score > 10) using Medline databases, proceedings of international meetings, and the STS database. We identified 21 studies utilizing MC (n = 3,198) and MVS (n = 3,265, >90% from the STS database) from 2003 to 2013. Information about patient characteristics, surgical risk, and 30-day and 1-year outcomes were extracted. RESULTS: Patients who underwent MC or MVS had a mean age of 74 ± 10 years with no differences in surgical risk, NYHA class, or MR grade (P = 0.46). Technical success was achieved in 96% of patients undergoing MC versus 98% in the MVS group (P = 0.45). Patients undergoing MC were treated with one or two MC in 90% (n = 2,878) with only a few requiring repeat MC (0.4%, n = 13) or mitral surgery (0.3%, n = 52) at 30 days. The pooled event rates for mortality was 3.2% (95% CI [2.5-4.2]), stroke was 1.1% (95% CI [0.7-0.2]) at 30 days. At 31 days to 1 year, the pooled event rate for mortality was 13.0% [95% CI (9-18.3)], stroke was 1.6% [95% CI (0.8-3.2)], and repeat MVS was 1.3% [95% CI (0.7-2.6)] with the majority of patients in the mild/moderate MR grade and NYHA class after MC. The 30-day event rates for mortality and stroke were 16.8% (95% CI [14-19]) and 4.5% (95% CI [3.9-5.3]) after MVS, respectively. CONCLUSION: Based on high risk MC studies and high risk MVS data predominantly from STS database, patients with severe MR who are at HSR can be effectively treated with MC or MVS. MC can be safely implanted in high risk patients with relatively low mortality and stroke risk.

Influence of transcatheter aortic valve replacement strategy and valve design on stroke after transcatheter aortic valve replacement: a meta-analysis and systematic review of literature.

OBJECTIVES: The study undertook a systematic review to establish and compare the risk of stroke between the 2 widely used approaches (transfemoral [TF] vs. transapical [TA]) and valve designs (CoreValve, Medtronic, Minneapolis, Minnesota vs. Edwards Valve, Edwards Lifesciences, Irvine, California) for transcatheter aortic valve replacement (TAVR). BACKGROUND: There has been a rapid adoption and expansion in the use of TAVR. The technique is however far from perfect and requires further refinement to alleviate safety concerns that include stroke. METHODS: All studies reporting on the risk of stroke after TAVR were identified using an electronic search and pooled using established meta-analytical guidelines. RESULTS: 25 multicenter registries and 33 single-center studies were included in the analysis. There was no difference in pooled 30-day stroke post-TAVR between the TF and TA approach in multicenter (2.8% [95% confidence interval (CI): 2.4 to 3.4] vs. 2.8% [95% CI: 2.0 to 3.9]) and single-center studies (3.8% [95% CI: 3.1 to 4.6] vs. 3.4% [95% CI: 2.5 to 4.5]). Similarly, there was no difference in pooled 30-day stroke post TAVR between the CoreValve and Edwards Valve in multicenter (2.4% [95% CI: 1.9 to 3.2] vs. 3.0% [95% CI: 2.4 to 3.7]) and single-center studies (3.8% [95% CI: 2.8 to 4.9] vs. 3.2% [95% CI: 2.4 to 4.3]). There was a decline in stroke risk with experience and technological advancement. There was no difference in the outcome of 30-day stroke between TAVR and surgical aortic valve replacement. CONCLUSIONS: Our findings suggest that the risk of 30-day stroke after TAVR is similar between the approaches and valve types. There has been a decline in stroke risk after TAVR with improvements in valve technology, patient selection, and operator experience.

Late stroke: comparison of percutaneous coronary intervention versus coronary artery bypass grafting in patients with multivessel disease and unprotected left main disease: a meta-analysis and review of literature.

BACKGROUND AND PURPOSE: Studies have suggested that the early excess risk of stroke in coronary artery bypass grafting (CABG) may be compensated for by a slow but progressive catch-up phenomenon in patients undergoing percutaneous coronary intervention (PCI). We therefore undertook this analysis to compare the temporal stroke risk between PCI and CABG in patients with unprotected left main stenosis and multivessel coronary artery disease. METHODS: Studies of PCI versus CABG for unprotected left main stenosis and multivessel disease published between January 1994 (stent era) and July 2013 were identified using an electronic search and reviewed using meta-analytic techniques. RESULTS: We selected 57 reports for the meta-analysis by applying the inclusion and exclusion criteria. The analysis was performed on 80,314 patient records. There was a significantly lower risk of cumulative stroke in patients undergoing PCI with stenting at 1 year (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.42-0.71), 2 years (OR, 0.78; 95% CI, 0.66-0.92), 3 years (OR, 0.79; 95% CI, 0.67-0.92), 4 years (OR, 0.74; 95% CI, 0.56-0.97), and 5 years (OR, 0.79; 95% CI, 0.69-0.91). There was no significant difference in the incidence of stroke because of the small sample size (OR, 0.71; 95% CI, 0.46-1.08) at >5 years between PCI and CABG. Similar results were observed on subgroup analysis (multi-vessel coronary artery disease, unprotected left main, diabetics, and randomized trials) and for stroke within 30 days. Late stroke (stroke>30 days) was similar between the 2 groups. CONCLUSIONS: There is a significantly lower risk of stroke within 30 days and cumulative stroke with PCI as compared with CABG up to year 5. There is no late catch up of stroke in the PCI arm. The risk of stroke should be weighed in deciding between revascularization strategies.

Left main coronary artery stenosis: a meta-analysis of drug-eluting stents versus coronary artery bypass grafting.

OBJECTIVES: The goal of this study was to provide a systematic review comparing the long-term outcomes of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary artery bypass graft surgery (CABG) for unprotected left main coronary artery (UPLM) stenosis. BACKGROUND: One-year outcomes from randomized controlled trials, observational studies, and pooled analyses have demonstrated the safety and efficacy of PCI of the UPLM when compared with CABG. However, there remain concerns over the sustainability of PCI with DES at longer follow-up. METHODS: Studies published between January 2000 and December 2012 of PCI versus CABG for UPLM stenosis were identified using an electronic search and reviewed using meta-analytical techniques. RESULTS: Twenty-four studies comprising 14,203 patients were included in the analysis. There was no significant difference for all-cause mortality between PCI or CABG at 1 year (odds ratio [OR]: 0.792, 95% confidence interval [CI]: 0.53 to 1.19), 2 years (OR: 0.920, 95% CI: 0.67 to 1.26), 3 years (OR: 0.94, 95% CI: 0.60 to 1.48), 4 years (OR: 0.84, 95% CI: 0.53 to 1.33), and 5 years (OR: 0.79, 95% CI: 0.57 to 1.08). The need for target vessel revascularization (TVR) was significantly higher in patients undergoing PCI at all time points. The occurrence of stroke, however, was significantly less frequent in patients treated with PCI. The occurrence of nonfatal myocardial infarction showed a statistically significant trend towards a lower incidence in CABG patients at 1 year (OR: 1.62, 95% CI: 1.05 to 2.50), 2 years (OR: 1.60, 95% CI: 1.09 to 2.35), and 3 years (OR: 2.06, 95% CI: 1.36 to 3.1). There was no significant difference in combined major adverse cardiovascular and cerebrovascular events between the 2 groups. CONCLUSIONS: Our findings suggest that PCI with DES is a safe and durable alternative to CABG for the revascularization of UPLM stenosis in select patients at long-term follow-up.

Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: meta-analysis and systematic review of literature.

OBJECTIVES: This study was designed to establish the incidence, impact, and predictors of post-transcatheter aortic valve replacement (TAVR) aortic regurgitation (AR). BACKGROUND: AR is an important limitation of TAVR with ill-defined predictors and unclear long-term impact on outcomes. METHODS: Studies published between 2002 and 2012 with regard to TAVR were identified using an electronic search and reviewed using the random-effects model of DerSimonian and Laird. From 3,871 initial citations, 45 studies reporting on 12,926 patients (CoreValve [Medtronic CV Luxembourg S.a.r.l., Tolochenaz, Switzerland] n = 5,261 and Edwards valve [Edwards Lifesciences, Santa Ana, California] n = 7,279) were included in the analysis of incidence and outcomes of post-TAVR AR. RESULTS: The pooled estimate for moderate or severe AR post-TAVR was 11.7% (95% confidence interval [CI]: 9.6 to 14.1). Moderate or severe AR was more common with use of the CoreValve (16.0% vs. 9.1%, p = 0.005). The presence of moderate or severe AR post-TAVR increased mortality at 30 days (odds ratio: 2.95; 95% CI: 1.73 to 5.02) and 1 year (hazard ratio: 2.27; 95% CI: -1.84 to 2.81). Mild AR was also associated with an increased hazard ratio for mortality, 1.829 (95% CI: 1.005 to 3.329) that was overturned by sensitivity analysis. Twenty-five studies reported on predictors of post-TAVR AR. Implantation depth, valve undersizing, and Agatston calcium score (r = 0.47, p = 0.001) were identified as important predictors. CONCLUSIONS: Moderate or severe aortic regurgitation is common after TAVR and an adverse prognostic indicator of short- and long-term survival. Incidence of moderate or severe AR is higher with use of the CoreValve. Mild AR may be associated with increased long-term mortality. Therefore, every effort should be made to minimize AR by a comprehensive pre-procedural planning and meticulous procedural execution.

True coronary bifurcation lesions: meta-analysis and review of literature.

AIM: Percutaneous intervention of true coronary bifurcation lesions is challenging. Based on the results of randomized trials and registry data, the approach of stenting of main vessel only with balloon dilatation of the side branch has become the default approach for false bifurcation lesions except when a complication occurs or in cases of suboptimal result. However, the optimal stenting strategy for true coronary bifurcation lesions - to stent or not to stent the side branch - is still a matter of debate. The purpose of this study was, therefore, to compare the clinical and angiographic outcomes of the double stent technique (stenting of the main branch and side branch) over the single stent technique (stenting of main vessel only with balloon dilatation of the side branch) for treatment of true coronary bifurcation lesions, with drug-eluting stents (DES). METHODS: Comparative studies published between January 2000 and February 2009 of the double stent technique vs. single stent technique with DES for true coronary bifurcations were identified using an electronic search and reviewed using a random effects model. The primary endpoints of our study were side-branch and main-branch restenoses, all-cause mortality, myocardial infarction (MI) and target lesion revascularization (TLR) at longest available follow-up. The secondary endpoints of our analysis were postprocedural minimal luminal diameter (MLD) of the side branch and main branch, follow-up MLD of side branch and main branch and stent thrombosis. Heterogeneity was assessed and sensitivity analysis was performed to test the robustness of the overall summary odds ratios (ORs). RESULTS: Five studies comprising 1145 patients (616 single stent and 529 double stent) were included in the analysis. Three studies were randomized comparisons between the two techniques for true coronary bifurcation lesions. Incomplete reporting of data in the primary studies was common. The lengths of clinical and angiographic follow-up ranged between 6 and 12 months and 6 and 7 months, respectively. Postprocedural MLD of the side branch was significantly smaller in the single stent group [standardized mean difference (SMD) -0.71, 95% CI -0.88 to -0.54, P < 0.000, I2 = 0%]. The odds of side-branch restenosis (OR 1.11, 95% CI 0.47-2.67, P = 0.81, I2 = 76%), main-branch restenois (OR 0.88, 95% CI 0.56-1.39, P = 0.58, I = 0%), all-cause mortality (OR 0.52, 95% CI 0.11-2.45, P = 0.41, I2 = 0%), MI (OR 0.92, 95% CI 0.34-2.54, P = 0.87, I = 49%) and TLR (OR 0.87, 95% CI 0.46-1.65, P = 0.68, I2 = 0%) were similar between the two groups. Postprocedural MLD of the main branch [standardized mean difference (SMD) -0.08, 95% CI -0.42 to -0.26, P < 0.65, I2 = 67%], follow-up MLD of side branch (SMD -0.19, 95% CI -0.40 to 0.01, P < 0.31, I2 = 15%) and main branch MLD (SMD 0.17, 95% CI -0.18 to 0.542, P < 0.35, I2 = 65%) were also similar between the two groups. CONCLUSION: In patients undergoing percutaneous coronary intervention (PCI) for true coronary bifurcations, there is no added advantage of stenting both branches as compared with a conventional one-stent strategy. The results, however, need to be interpreted considering the poor study methods and/or poor quality of reporting in publications. We propose to move forward and consider the conduct of more systematic, well-designed and scientific trials to investigate the treatment of true coronary bifurcation lesions.

Multi-detector computerized tomography angiography for evaluation of acute chest pain--a meta analysis and systematic review of literature.

BACKGROUND: Evaluation of pain localized to the chest in the emergency room is, challenging, time-consuming, costly, and often inconclusive. Available research, though limited, suggests a role for MDCTA in the evaluation of patients with acute chest pain of low to intermediate risk, for identifying and excluding ACSs during the initial emergency department evaluation. Accordingly, our aim was to conduct a meta-analysis to assess the diagnostic accuracy of MDCTA in this setting. METHODS: We included all studies that compared MDCTA with either coronary angiography or standard of care for early and accurate triage of patients presenting with acute chest pain. Published studies were identified by searches of the Pubmed, Ovid and Google scholar databases as well as hand searches of selected references. Data were extracted independently by two reviewers. Included studies were evaluated for heterogeneity. Meta-analysis was performed at patient level using a random-effects model. RESULTS: 16 studies totaling 1119 patients were included in the current meta-analysis: one randomized trial, one retrospective analysis and fourteen prospective cohort studies. Pooled DOR was 190.80 (95%CI, 102.94-353.65). The pooled sensitivity and specificity were 0.96 (95%CI, 0.93-0.98) and 0.92(95%CI, 0.89-0.94) respectively. The pooled NLR and PLR were 0.09 (95%CI, 0.06-0.14) and 10.12 (95%CI, 6.73-15.22). CONCLUSION: MDCTA has an excellent diagnostic accuracy in detection of significant coronary artery stenosis in patients with acute chest pain. This diagnostic accuracy of MDCTA has a potential for rapid triage of patients in the ED, with acute chest pain of low to intermediate risk of acute coronary syndrome, to rule out significant epicardial stenosis as the etiology of chest pain.

Corticosteroid therapy for primary treatment of Kawasaki disease - weight of evidence: a meta-analysis and systematic review of the literature.

OBJECTIVE: Corticosteroids are the treatment of choice in most forms of vasculitis. However, their role in the primary treatment of Kawasaki disease (KD) is controversial. Our aim was to conduct a meta-analysis to assess the clinical course and coronary artery outcome of adding corticosteroids to standard therapy [intravenous immunoglobulin (IVIG) + aspirin] in patients with acute KD. METHODS: We included randomised trials comparing the addition of corticosteroids to conventional primary therapy for Kawasaki disease. RESULTS: A total of four studies were identified, which included 447 patients. The meta-analysis revealed a significant reduction in re-treatments with IVIG in patients receiving corticosteroid plus standard therapy compared with standard therapy alone [odds ratio (OR) 0.48; 95% confidence interval (CI): 0.24- 0.95]. There was however no significant reduction in the incidence of coronary artery aneurysms among patients who received corticosteroid therapy plus standard therapy, compared with standard therapy alone for either up to a month (OR 0.74; 95% CI: 0.23-2.40) or over one month ([OR 0.74; 95% CI: 0.37-1.51). Similarly no significant differences between treatment groups were noted in incidence of adverse events (OR 0.81; 95% CI: 0.05-0.88). CONCLUSION: The inclusion of corticosteroids in regimens for the initial treatment of Kawasaki disease decreased rates of re-treatment with intravenous immunoglobulin. However the addition of corticosteroids to standard therapy did not decrease the incidence of coronary aneurysms or adverse events.

Touraine Solente Gole syndrome: the disease and associated tongue fissuring.

Touraine Solente Gole syndrome, a relatively rare inherited disorder is epitomized by finger clubbing, skeletal changes and pachyderma. We report a typical case of complete pachydermoperiostosis in addition to a thick fissured tongue, a yet unrecognized association and discuss the social cum clinical relevance of identifying this relatively uncommon disorder.