Alpha-synuclein pathology in isolated rapid eye movement sleep behaviour disorder: a meta-analysis.

Accumulating evidence indicates that patients with isolated rapid eye movement sleep behaviour disorder (iRBD), a prodromal stage of synucleinopathies, show abnormal deposition of misfolded alpha-synuclein (a-Syn) in peripheral tissues. The clinical utility of testing for a-Syn in iRBD is unclear. This meta-analysis focused on the utility of testing for the abnormal a-Syn phosphorylated at Ser129 (p-syn) and a-Syn seeding activity (a-Syn seed amplification assays [aSyn-SAA]). Following an electronic database search, 15 studies were included that provided at a minimum data on test positivity in participants with iRBD. Test positivity from cerebrospinal fluid (CSF) was 80% (95% confidence interval [CI] 68-88%, I2 = 71%) and for skin was 74.8% (95% CI 53.2-88.5%, I2 = 64%) for aSyn-SAA and 78.5% (95% CI 70.4-84.9%, I2 = 14%) for p-syn. The phenoconversion rate ratio of biopsy-positive versus biopsy-negative iRBD was 1.28 (95% CI 0.68-2.41, I2 = 0%). Skin as a source had a specificity of 99% (95% CI 95-100%, I2 = 0%; p = 0.01 compared to CSF). As a test, p-syn, had a specificity of 100% (95% CI 93-100%, I2 = 0%; p < 0.001) compared to aSyn-SAA. The odds ratio of a-Syn test positivity in iRBD versus other RBDs was 112 (95% CI 20-629, I2 = 0%). These results demonstrate clinically significant test positivity in iRBD and favour skin over CSF as the source of a-Syn pathological analysis, and p-syn over aSyn-SAA as the testing method. Overall, these findings indicate that testing for a-Syn could help in differentiating iRBD from RBD secondary to other conditions.

Management of Acute Lymphoblastic Leukemia During Pregnancy: A Case Report and Review of the Literature.

Acute lymphoblastic leukemia (ALL) during pregnancy necessitates treatment with high-dose chemotherapy, which can threaten the lives of both the mother and fetus. The aim of the treatment not only focuses on selecting and administering optimal chemotherapy with appropriate doses to the mother but also reflects the crucial understanding of the fetal gestational age at the time of administration of chemotherapy to minimize fetal exposure. We describe the case of a 19-year-old patient diagnosed with ALL at 29 weeks gestation. She received treatment in the third trimester with the Berlin-Frankfurt-Munster (BFM) 2000 induction chemotherapy protocol consisting of a combination of daunorubicin, vincristine, pegaspargase, prednisolone, and intrathecal (IT) methotrexate and gave birth to a healthy baby girl via vaginal delivery four weeks after initiating the induction of chemotherapy.

SPECT Ventilation/Perfusion Imaging for Acute Pulmonary Embolism: Meta-analysis of Diagnostic Test Accuracy.

RATIONALE AND OBJECTIVES: This study aimed to evaluate the diagnostic accuracies of ventilation/perfusion-single photon emission computed tomography (V/Q-SPECT) imaging modalities for acute pulmonary embolism (PE). These included, in addition to V/Q-SPECT, V/Q-SPECT with low-dose computed tomography (CT; V/Q-SPECT-CT), Q-SPECT with low-dose CT (Q-SPECT-CT), and Q-SPECT. MATERIALS AND METHODS: PubMed, Embase, CINAHL, and Web of Science databases were searched, and studies included if they studied ≥10 adult participants with acute PE and reported data on the imaging tests' diagnostic performance. Data were meta-analyzed using bivariate random effects regression model. RESULTS: Data from participants totaling 4146 from 11 V/Q-SPECT studies, 785 from 7 V/Q-SPECT-CT studies, 1196 from 7 Q-SPECT-CT studies, and 728 from five Q-SPECT studies were separately meta-analyzed. The bivariate weighted mean sensitivity and specificity were 0.94 (95% confidence interval [CI]: 0.88-0.97) and 0.95 (95% CI: 0.87-0.98) for V/Q-SPECT, 0.95 (95% CI: 0.88-0.98) and 0.99 (95% CI: 0.92-1.00) for V/Q-SPECT-CT, 0.92 (95% CI: 0.79-0.97) and 0.92 (95% CI: 0.83-0.96) for Q-SPECT-CT, and 0.89 (95% CI: 0.76-0.95) and 0.86 (95% CI: 0.67-0.95) for Q-SPECT studies. The positive and negative likelihood ratios (+LRs and -LRs) were 17.4 (6.9-44.0) and 0.06 (0.03-0.13), 76.7 (11.8-498.0) and 0.06 (0.02-0.13), 11.0 (5.3-22.9) and 0.09 (0.04-0.23), and 6.4 (2.6-15.8) and 0.13 (0.07-0.27) for V/Q-SPECT, V/Q-SPECT-CT, Q-SPECT-CT, and Q-SPECTs, respectively. CONCLUSION: In the diagnosis of acute PE, this meta-analysis showed that V/Q-SPECT-CT had the highest specificity and +LR. Conversely, Q-SPECT showed the lowest specificity and an unfavorably high -LR.

Diagnoses and Outcomes of Patients with Suspicion of Acute Coronary Syndrome and Raised High Sensitive Troponin I: A Single Center Study from Pakistan.

Objectives Troponins are classically raised in acute coronary syndrome (ACS) although other cardiovascular and non-cardiovascular causes are recognized. We aimed to see the association of high sensitivity (Hs) Troponin I values exceeding the sex-specific 99th percentile upper reference limit (URL) with diagnoses, emergency department (ED) outcomes, 30-day outcomes of admitted patients and predictors of ACS in both genders. Materials and Methods A retrospective study of all patients presenting to the emergency department from January 2019 to April 2021 with suspicion of ACS and Hs-Troponin I values greater than the sex-specific 99th percentile URL. Statistical Analysis SPSS version 24 was used, Pearson's chi-square tests, Fisher's exact test, Kruskal-Wallis test, Mann-Whitney U test, and odds ratios, including the 95% confidence intervals, for each characteristic were used for analysis. A p -value of < 0.05 was considered significant. Results There were a total of 5,982 patients (3,031 males, 2,951 females), out of which 878 patients were admitted under the cardiology specialty. In patients who were admitted to the ward, mortality was higher in females (8.2%) with less than a 10-fold rise in Hs-Troponin I while similar in both genders (7.6%) in patients with Hs-troponin I greater than 10-fold of sex-specific 99th percentile URL. Raised low-density lipoprotein-cholesterol was a significant factor associated with 2.4 times higher odds of ACS. Conclusion Women with Hs-Troponin values up to 10 times the URL, i.e., 15.6-160 ng/L have higher mortality than their male counterparts. LDL-cholesterol is a significant risk factor for ACS which should be controlled for its prevention.

Constitutional Mismatch Repair Deficiency (CMMRD) Syndrome: A Case Report of a Patient With Multiple Metachronous Malignancies.

Defective repair of DNA when heterozygous leads to Lynch syndrome (LS) which is inherited in an autosomal dominant fashion. When homozygous, defective repair of DNA leads to constitutional mismatch repair deficiency syndrome (CMMRD), inherited in an autosomal recessive fashion with a predisposition to develop a pattern of childhood malignancies including hematological and solid cancers. We report such a case of a 21-year-old male who developed anaplastic astrocytoma, Burkitt lymphoma, osteochondroma, and colon cancer successively. Each cancer was treated successfully except for colon cancer which developed liver metastasis after the initial treatment with curative intent. However, the patient has been treated for liver metastasis with curative intent and is currently on follow-up. This case report highlights the importance of maintaining a low threshold for investigating CMMRD and other potential cancer predisposition syndromes when a patient presents with multiple cancers in the early years of their life.

Accuracy of residual respiratory event detection by CPAPs: a meta-analysis.

PURPOSE: Most continuous positive airway pressure (CPAP) machines have built-in manufacturer-specific proprietary algorithms for automatic respiratory event detection (AED) based on very specific respiratory events scoring criteria. With regards to the accuracy of these data from CPAP machines, evidence from the literature seems conflicting, which formed the basis for this meta-analysis. METHODS: A meta-analysis was performed on studies that reported Bland-Altman analysis data on agreement (mean bias and limits of agreement [LoA]) of CPAP-determined apnea-hypopnea index (AHI) at therapeutic pressures (AHIFLOW) with that determined from simultaneously conducted polysomnograms (AHIPSG). RESULTS: In six studies, ResMed CPAPs were used, and in another six studies, Respironics CPAPs were used, while only one study used Fisher & Paykel (F&P) CPAPs. The pooled mean AHI bias from ResMed CPAP studies was - 1.01 with pooled LoAs from - 3.55 to 1.54 (I2 = 17.5%), and from Respironics CPAP studies, pooled mean AHI bias was - 0.59 with pooled LoAs from - 3.22 to 2.05 (I2 = 0%). Pooled percentage errors (corresponding to LoAs) from four ResMed CPAP studies, four Respironics CPAP studies, and the F&P CPAP study were 73%, 59%, and 112%, respectively. A review of the literature for this meta-analysis also revealed lack of uniformity not only in the CPAP manufacturers' respiratory events scoring criteria but also in that used for PSGs across the studies analyzed. CONCLUSIONS: Even though the pooled results of mean AHI bias suggest good clinical agreement between AHIPSG and AHIFLOW, percentage errors calculated in this meta-analysis indicate the possibility of a significant degree of imprecision in the estimation of AHIFLOW by CPAP machines.

Comparative efficacy of mandibular advancement devices in obstructive sleep apnea: a network meta-analysis.

PURPOSE: To analyze relative efficacies of mandibular advancement devices (MAD) in sleep apnea treatment. METHODS: From eligible randomized controlled trials (RCT), MADs were classified based on their mechanistic designs. Data on apnea-hypopnea index (AHI), Epworth sleepiness scale (ESS), nadir oxygen saturation (minSaO2), and sleep efficiency (SE%) from RCTs were then analyzed in network meta-analyses, and relative ranking of different MADs was computed based on P scores (a method of ranking similar to SUCRA). Similar analyses were conducted based on the different brands of MADs. RESULTS: There were no statistically significant differences between MADs in any of the outcomes analyzed. However, the P-scores, based on the point estimates and standard errors of the network estimates, ranked some MADs higher than others in some of the outcomes. Of the different mechanistic designs, the highest P scores were achieved for attached midline traction (P score = 0.84) and unattached bilateral interlocking (P score = 0.78) devices for AHI reduction, attached bilateral traction (P score = 0.78) and unattached bilateral interlocking (P score = 0.76) for ESS, monobloc (P score = 0.91) and unattached bilateral interlocking (P score = 0.64) for minSaO2, and unattached bilateral interlocking (P score = 0.82) and attached bilateral traction (P score = 0.77) for SE%. Notable findings in the network meta-analyses based on MAD brands, of the limited number of studies that specified them were the effects of SomnoDent Flex™, TAP™, and IST® in their effects on AHI reduction, with P scores of 0.94, 0.83, and 0.82, respectively. Monobloc decreased supine-AHI the most (- 44.46 [- 62.55; - 26.36], P score = 0.99), and unattached bilateral interlocking had the greatest effect on REM-AHI (- 11.10 [- 17.10; - 5.10], P score = 0.87). CONCLUSIONS: Findings from this study show clinically (but not statistically) significant differences between MADs in terms of their relative efficacy when analyzed for different sleep apnea treatment outcomes and sleep apnea phenotypes.

Central sleep apnea treatment in patients with heart failure with reduced ejection fraction: a network meta-analysis.

PURPOSE: Adaptive servo-ventilation (ASV) is contraindicated for the treatment of central sleep apnea (CSA) in patients with heart failure with reduced ejection fraction (HFrEF), limiting treatment options. Though continuous positive airway pressure (CPAP), bi-level PAP with back-up rate (BPAP-BUR), and transvenous phrenic nerve stimulation (TPNS) are alternatives, not much is known about their comparative efficacies, which formed the basis of conducting this network meta-analysis. We sought to analyze their comparative effectiveness in reducing apnea hypopnea index (AHI). Additionally, we also studied their comparative effectiveness on subjective daytime sleepiness as assessed by Epworth sleepiness score (ESS). METHODS: Randomized controlled trials (RCTs) from PubMed were analyzed in a network meta-analysis and relative superiority was computed based on P-score ranking and Hasse diagrams. RESULTS: Network meta-analysis based on 8 RCTs showed that when compared to guideline-directed medical therapy (GDMT-used as a common comparator across trials), reduction in AHI by ASV (- 26.05 [- 38.80; - 13.31]), TPNS (- 24.90 [- 42.88; - 6.92]), BPAP-BUR (- 20.36 [- 36.47; - 4.25]), and CPAP (- 16.01 [- 25.42; - 6.60]) were statistically significant but not between the interventions. Based on 6 RCTs of all the interventions, only TPNS showed a statistically significant decrease in ESS (- 3.70 (- 5.58; - 1.82)) when compared to GDMT, while also showing significant differences when compared with ASV (- 3.20 (- 5.86; - 0.54)), BPAP-BUR (- 4.00 (- 7.33; - 0.68)), and CPAP (- 4.45 (- 7.75; - 1.14)). Ranking of treatments based on Hasse diagram, accounting for both AHI and ESS as outcomes for relative hierarchy showed relative superiority of both ASV and TPNS over BPAP-BUR and CPAP. CONCLUSIONS: Results indicated relative superiority of TPNS and ASV to BPAP-BUR and CPAP in their effects on AHI and ESS.

A meta-analysis of diagnostic test performance of peripheral arterial tonometry studies.

STUDY OBJECTIVES: The objective of this meta-analysis was to analyze agreement in apnea-hypopnea index (AHI) determination between peripheral arterial tonometry (PAT) and polysomnography (PSG) studies. METHODS: Mean AHI bias and standard deviation extracted from Bland-Altman plots reported in studies were pooled in a meta-analysis, which was then used to calculate percentage errors of limit agreement in AHI determination by PAT using PSG AHI as the reference. Individual participant data (where reported in studies) were used to compute Cohen's kappa to assess agreement between PSG and PAT on sleep apnea severity and for computing the sensitivity and specificity of PAT at different AHI thresholds using PSG AHI as the reference. RESULTS: From 17 studies and 1,318 participants (all underwent simultaneous PSG and use of the WatchPAT device), a pooled mean AHI bias of 0.30 (standard error [SE], 0.74) and a WatchPAT AHI percentage error of 230% was calculated. The meta-analysis of Cohen's kappa for agreement between PSG and WatchPAT studies for classifying patients with no sleep apnea, mild, moderate, or severe sleep apnea severity was 0.45 (SE, 0.06), 0.29 (SE, 0.05), 0.25 (SE, 0.07), and 0.64 (SE, 0.05), respectively. At AHI thresholds of 5, 15 and 30 events/h, WatchPAT studies showed pooled sensitivities and specificities of 94.11% and 43.47%, 92.21% and 72.39%, and 74.11% and 87.10%, respectively. Likelihood ratios were not significant at any AHI threshold. CONCLUSIONS: The results of this meta-analysis suggest clinically significant discordance between WatchPAT and PSG measurements of AHI, significant sleep apnea severity misclassification by PAT studies, and poor diagnostic test performance. CITATION: Iftikhar IH, Finch CE, Shah AS, Augunstein CA, Ioachimescu OC. A meta-analysis of diagnostic test performance of peripheral arterial tonometry studies. J Clin Sleep Med. 2022;18(4):1093-1102.

Love in the time of COVID-19: a scoping review on male sexual health.

The coronavirus disease 2019 (COVID-19) outbreak constitutes an unparalleled socioeconomic burden on the global scale. In critically ill COVID-19 patients, the disease manifests as a state of hyper inflammation causing the 'cytokine storm', which leads to various pulmonary, cardiovascular, and spurious manifestations. One such reported sequelae of COVID-19 is sexual dysfunction in males even after recovery from the disease. Various mechanisms have been proposed regarding the erectile dysfunction a patient suffers after COVID-19. Most important is the hypothesis of endothelial dysregulation, subclinical hypogonadism, psychosocial misery, and pulmonary impairment contributing to erectile dysfunction. Assessment of testicular function and hormonal axis is needed to assess the novel association of COVID-19 with sexual and reproductive health issues in males.

It's a Trap: A Case of Strangulated Coronary Guidewire and Longitudinal Stent Deformation in the Right Coronary Artery.

BACKGROUND Strangulation of the coronary guidewire is an infrequent complication of percutaneous coronary intervention (PCI), and it can lead to disastrous outcomes of stent thrombosis, vessel occlusion, and vessel damage. CASE REPORT Early-generation stents were made from stainless steel and had a bulky design as compared to cobalt-chromium or platinum chromium alloys, which have superior trackability at the cost of a thin core and low-strength struts, resulting in increased incidence of longitudinal stent deformation. We present a case of a 62-year-old active smoker with effort angina of Canadian Cardiovascular Society (CCS) class III. His coronary angiogram revealed a totally occluded right coronary artery (RCA). After placing 2 coronary guidewires (Run-through and Balanced middle-weight), Xience Xpedition (3.25×48 mm) and Promus Element (2.75×32 mm) were deployed through the whole length of the RCA. While placing the distal stent, the guidewire securing the posterior left ventricular (PLV) was trapped between 2 stents and all attempted maneuvers were unsuccessful in retrieving the wire. The stents sustained longitudinal deformation by the guide catheter, and subsequent arteriotomy for stent and wire retrieval and coronary artery bypass graft surgery were (CABG) performed. CONCLUSIONS Despite the remarkable safety profiles of the percutaneous equipment, complications still occur even with experienced operators. Calcified and tortuous vessels are primarily at risk for wire strangulation between stents or side-branches, and better deliverability of newer drug-eluting stents (DES) comes at the cost of reduced longitudinal strength.

A network meta-analysis of different positive airway pressure interventions in obesity hypoventilation syndrome.

Continuous positive airway pressure (CPAP) and different types of non-invasive ventilation (NIV) have been studied in obesity hypoventilation syndrome such as bi-level PAP with back-up rate (BPAP-BUR), BPAP without BUR, and the new hybrid devices that target a pre-set volume by adjustment of pressure support (VT-PS). Although several studies have compared one PAP intervention with the other, none has compared all four in a head-to-head design, which formed the basis of this network meta-analysis. PubMed and Web of Science were searched for potentially includable randomised active comparator trials. Changes in partial pressure of carbon dioxide (PaCO2 ) and Epworth Sleepiness Score (ESS) were the primary outcomes of interest. Network meta-analysis was done in R program using the 'frequentist' framework. A total of seven trials were included. Only VT-PS and BPAP-BUR showed statistically significant reductions in PaCO2 compared to control, with no significant inter-PAP differences except for the comparison between VT-PS and CPAP. Only VT-PS showed a statistically significant improvement in ESS as compared to control, with no other significant inter-PAP differences. P-score ranking (based on effect size and standard errors) and Hasse diagram ranked VT-PS and BPAP as superior to other PAPs for both primary outcomes. There were no significant differences between the different PAP interventions for hospital or emergency department admissions. The results of this network meta-analysis suggest superiority of VT-PS and BPAP over other PAP interventions at least for daytime hypercapnia and subjective daytime somnolence.

Myocardial blush grade: a determinant of left ventricular ejection fraction and adverse outcomes in STEMI.

BACKGROUND AND AIMS: Despite restoration of blood flow, subtle microvascular obstruction can occur. This obstruction can be graded using myocardial blush grade. We aimed to investigate the role of myocardial blush grade in ejection fraction and adverse outcomes, after percutaneous intervention. METHODS: A prospective, observational study was conducted at our institute with a calculated sample size. Variables such as age, gender, and ejection fraction were noted before the intervention. The patients were followed for 3 months to determine the outcomes. The data was analyzed using IBM SPSS software version 26.0. P-value of less than 0.05 was considered significant for the statistical tests. RESULTS: There were 74 male and 36 female participants in the study. The mean age was 52.20 ± 10.02 years. The most common adverse outcome was heart failure (18%). There was a significant Pearson's correlation between myocardial blush grade and improvement in ejection fraction (p < 0.05). Improvement in myocardial blush grade was significantly related to a decrease in adverse outcomes (p < 0.05). Regression analysis proved myocardial blush grade and diabetes status as independent predictors of percentage increase in ejection fraction (p < 0.05). CONCLUSION: High myocardial blush grade is one of the independent predictors of better outcomes in ST-elevation myocardial infarction.

Optical coherence tomography: assessment of coronary artery disease and guide to percutaneous coronary intervention.

BACKGROUND AND AIMS: Angiographic guidance for percutaneous coronary intervention (PCI) has significant limitations in interpretation. The superior spatial resolution of optical coherence tomography (OCT) can provide meaningful clinical benefits, although limited data is available on Asian populations. This study aimed to determine whether OCT can provide additional advantages and useful clinical information beyond that obtained by angiography alone in decision making for PCI. METHODS: This was an observational study based on a single tertiary cardiac center in Pakistan, which includes 67 patients who underwent coronary angiogram and stenting. Their pre and post stenting OCT findings were recorded. Any additional intervention was also recorded. The data were analysed using IBM SPSS software version 26.0. RESULTS: The mean age was 55.00 ± 9.00 years. Majority of the patients were males (65.7%). On angiography, there was an equal number of stable and ruptured plaques (38.8%). Post stenting results showed 29.9% under deployed stents and 34.3% were either undersized or mal-apposed. Out of 67 patients, 50 (74.6%) needed re-intervention after PCI. Among different procedures, post-dilatation was most common. CONCLUSION: The main OCT benefit is in borderline lesions on CA, in whom OCT identifies significant coronary stenosis and leads to PCI indication in patients. In the post-PCI context, OCT leads to an indication of PCI optimisation in half of the coronary lesions.

Bronchoscopic Lung Volume Reduction with Valves and Coils. A Network Meta-analysis.

Background: Coils and endobronchial valves are the most widely used bronchoscopic lung volume reduction devices in patients with advanced emphysema. However, the choice of each specific device depends on emphysema characteristics (homogeneous vs. heterogeneous) and presence of lobar collateral ventilation (CV). These devices have not been compared in a head-to-head study design.Objectives: To conduct a network comparative meta-analysis studying the effect of valves in patients with heterogeneous emphysema without CV, and to also study the effects of valves and coils in patients with mixed homogeneous and heterogeneous emphysema.Data Sources and Data Extraction: PubMed and Web of Science were searched for potentially includable randomized active comparator trials from inception to January 20, 2020, and data were extracted in the working sheets of Comprehensive Meta-analysis.Synthesis: Network meta-analysis was conducted in R program using package "netmeta."Results: In patients with heterogeneous emphysema without CV, both Spiration and Zephyr valves showed significant increases in forced expiratory volume in 1 second (FEV1) (0.11 L [95% confidence interval (CI), 0.05 to 0.16] and 0.14 L [0.08 to 0.19], respectively) and in reducing St. Georges Respiratory Questionnaire (SGRQ) scores (-9.32 [-14.18 to -4.45] and -8.14 [-11.94 to -4.35], respectively) as compared with control, with no significant interintervention differences. Only Zephyr valves showed significant improvement (52.3 m [95% CI, 26.53 to 77.93]) in six-minute walk distance (6MWD). Both were ranked as equally efficacious in these patients. In the mixed homogeneous and heterogeneous emphysema group of patients, both Zephyr valves and coils showed significant increases in FEV1 and 6MWD and reduction in SGRQ, as compared with control. Although there were no significant interintervention differences, the magnitude of improvement in these parameters was highest with Zephyr valves (e.g., 6MWD increased by 56.74 m [23.66 to 89.81] vs. 30.31 m [4.00 to 56.63]) in coils), ranking them first. In both populations, these interventions showed a statistically significant association with procedure-related pneumothorax but not with chronic obstructive pulmonary disease exacerbation.Conclusions: In patients with heterogeneous emphysema without CV, both Zephyr and Spiration valves were equally efficacious in FEV1 and SGRQ improvement. However, in the mixed patients with homogeneous and heterogeneous emphysema, Zephyr valves show relative superiority over coils especially with respect to improvement in 6MWD.

Effect of Anti-IL5, Anti-IL5R, Anti-IL13 Therapy on Asthma Exacerbations: A Network Meta-analysis.

BACKGROUND: Several new treatments for severe asthma have become available in the last decade; yet, little data exist to guide their use in specific patient populations. OBJECTIVE: A network meta-analysis was conducted comparing the efficacy of FDA-approved monoclonal antibody therapies in preventing exacerbations in patients with severe eosinophilic asthma. METHODS: PubMed and Ovid were searched from inception until July 2019 for randomized controlled trials that studied the efficacy of benralizumab, dupilumab, mepolizumab, and reslizumab, in preventing acute exacerbations of asthma. Studies were included if they reported data for patients with severe eosinophilic asthma (defined in this meta-analysis as absolute eosinophil count ≥ 250 cells/µL). Annualized rate ratios for asthma exacerbations (during treatment) were calculated and converted to log rate ratios. Direct and indirect treatment estimates (for inter-drug differences) were analyzed using frequentist network meta-analysis methodology in R and treatments were ranked based on P-scores. RESULTS: In total, nine studies were included in the final analysis. Network meta-analysis revealed that all drugs were superior to placebo in preventing rates of asthma exacerbation in the study population and no inter-drug differences existed. Dupilumab was found to have the greatest magnitudes of effect on decreasing log rate ratio of asthma exacerbation based on P-score (0.83). CONCLUSION: Benralizumab, dupilumab, mepolizumab, and reslizumab are all associated with decreased asthma exacerbations in patients with eosinophilic asthma, with no significant inter-drug differences.

A Single Coronary Artery with an Absent Right Coronary and a Superdominant Left Circumflex Giving off a Branch Supplying the Right Coronary Artery Territory.

An absent right coronary artery (RCA) with single left coronary artery (LCA) originating from left aortic sinus with a superdominant left circumflex (LCX) and giving off an RCA branch is one of the rarest coronary artery anomalies. It occurs with an incidence of less than 0.1%. Usually, patients are asymptomatic and abnormality is found incidentally on cardiac catheterisation or CT angiography. We present a case report of an unusual coronary anomaly in a patient who presented with anterior myocardial infarction. Patient was subjected to coronary angiography, which revealed absent RCA originating from distal LCX artery, supplying the base of heart and RCA territory. He underwent primary percutaneous intervention (PCI) with stenting to the left anterior descending (LAD) artery. This type of anomaly, in which single LCA from which dominant LCX continues as RCA, is important to diagnose and manage if diseased, as stenosis of the dominant LCX artery in such cases can jeopardise a large portion of myocardium, which can lead to increased morbidity and mortality, if left untreated.

Optical Coherence Tomography-guided Intervention in STEMI Patients with Normal Looking Coronaries.

Optical coherence tomography (OCT) is an increasingly available intracoronary imaging modality that provides highresolution imaging of coronary arteries and guides operators in percutaneous coronary intervention (PCI) by accurately defining luminal geometry and detailed plaque composition. The two cases under discussion in this report, presented with acute ST elevation myocardial infarction (STEMI) with angiography showing minor narrowing (<30%) with TIMI III flow in which OCT-guided approach was used regarding the management owing to its improved temporal and axial resolution, thus providing proper plaque assessment and subsequent proper management.