Ghassan Bachuwa

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

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.

Cryptococcal sternal osteomyelitis in a healthy woman: a review of Cryptococcus neoformans

Cryptococcus, an opportunistic yeast, known to afflict immune-compromised patients is often overlooked in immune-competent patients. This has led to increasing morbidity and mortality worldwide. We present a case of Cryptococcus causing sternal osteomyelitis in an immune-competent individual. Till date no case of Cryptococcus causing sternal osteomyelitis in an immune-competent patient has been reported in the English literature since 1946–2011. With the rising incidence of Cryptococcus infection it should be included among the list of infections causing osteomyelitis. Early detection and prompt treatment can decrease both morbidity and mortality.

Deep Vein Thrombosis Provoked by Inferior Vena Cava Agenesis

Inferior vena cava agenesis (IVCA) is a rare congenital anomaly that can be asymptomatic or present with vague, nonspecific symptoms, such as abdominal or lower back pain, or deep vein thrombosis (DVT). Here, we present a 55-year-old male who came with painless swelling and redness of his left lower limb. On examination, swelling and redness were noted extending from the left foot to the upper thigh; it was also warm compared to his right lower limb. Venous Doppler ultrasound was done which showed DVT extending up to the common femoral vein. Subsequently, computed-tomography (CT) of the chest and abdomen was done to exclude malignancy or venous flow obstruction; it revealed congenital absence (agenesis) of the infrarenal inferior vena cava (IVC).

Balloon enteroscopy versus spiral enteroscopy for small-bowel disorders: a systematic review and meta-analysis

BACKGROUND AND AIMSnTwo novel enteroscopic procedures, balloon enteroscopy and spiral enteroscopy, have revolutionized the diagnostic and therapeutic approach to small-bowel disorders. These disorders that historically required surgical interventions are now investigated and managed nonsurgically. Only a few weakly powered studies have compared the outcomes of spiral enteroscopy and balloon enteroscopy. We conducted a systematic review and meta-analysis to compare the efficacy and safety of these 2 procedures.nnnMETHODSnPubMed, Cochrane Library, Scopus, and clinicaltrials.gov databases were searched for all studies published up to January 12, 2017 comparing the efficacy and safety of balloon enteroscopy (single or double) and spiral enteroscopy. Primary outcomes of interest were diagnostic and therapeutic success rates. Other outcomes included procedure length, depth of maximal insertion (DMI), rate of complete enteroscopy, and adverse events. We calculated Odds ratios (ORs) for categorical variables and mean difference (MD) for continuous variables. The Mantel-Haenszel method was used to analyze the data. Fixed and random effect models were used forxa0<50% heterogeneity and >50% heterogeneity, respectively.nnnRESULTSnEight studies met the inclusion criteria for this meta-analysis. A total of 615 procedures were analyzed, which included 394 balloon enteroscopy and 221 spiral enteroscopy procedures. There were no significant differences in diagnostic and therapeutic success rates (OR, 1.27; 95% confidence interval [CI], .86-1.88; Pxa0= .22; and OR, 1.23; 95% CI, .82-1.84; Pxa0= .32, respectively) between the 2 procedures. Similarly, DMI was not significantly different between the 2 groups (MD, 26.29; 95% CI, 20.92-73.49; Pxa0= .28). However, the procedure time was significantly shorter for the spiral enteroscopy group compared with the balloon enteroscopy group (MD, 11.26; 95% CI, 2.72-19.79; Pxa0= .010). A subgroup analysis comparing double balloon enteroscopy with spiral enteroscopy yielded similar results.nnnCONCLUSIONSnBoth procedures achieved similar diagnostic and therapeutic outcomes and with similar depth of insertion. Spiral enteroscopy has the benefit of shorter procedural time.

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.

Carbon Dioxide versus Air Insufflation in Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Aims Endoscopic submucosal dissection (ESD) with air insufflation is commonly used for the staging and treatment of early gastric carcinoma. However, carbon dioxide (CO2) use has been shown to cause less post-procedural pain and fewer adverse events. The objective of this study was to compare the post-procedural pain and adverse events associated with CO2 and air insufflation in ESD. Methods A systematic search was conducted for randomized control trials (RCTs) comparing the two approaches in ESD. The Mantel-Haenszel method was used to analyze the data. The mean difference (MD) and odds ratio (OR) were used for continuous and categorical variables, respectively. Results Four RCTs with a total of 391 patients who underwent ESD were included in our meta-analysis. The difference in maximal post-procedural pain between the two groups was statistically significant (MD, -7.41; 95% confidence interval [CI], -13.6 – -1.21; p=0.020). However, no significant differences were found in the length of procedure, end-tidal CO2, rate of perforation, and postprocedural hemorrhage between the two groups. The incidence of overall adverse events was significantly lower in the CO2 group (OR, 0.51; CI, 0.32–0.84; p=0.007). Conclusions: CO2 insufflation in gastric ESD is associated with less post-operative pain and discomfort, and a lower risk of overall adverse events compared with air insufflation.

Surveying Resident and Faculty Physician Knowledge, Attitudes, and Experiences in Response to Public Lead Contamination.

Environmental health crises can appear anywhere and without warning. After research revealed a significant incidence of elevated pediatric blood lead levels following a water source change, Genesee County declared a public health emergency in Flint, Michigan. Hospital patients and family members began approaching Hurley Medical Centers physicians with questions regarding the health implications of the lead contamination. Many of the physicians voiced concerns about responding appropriately to patient needs and increasing demands for information. As a result, a Hurley research team decided to conduct an informal survey across training programs to determine the need for added education.Because of heightened patient anxiety, it was necessary for the timeline to progress quickly. In creating the survey, the teams objective was to assess resident and faculty physician knowledge, attitudes, and experiences concerning lead contamination. The results revealed a critical need for supplementary training. Therefore, Hurley embarked on an education campaign for its graduate medical education programs, benefiting physicians and patients alike.Patient and physician needs may change drastically following an environmental health emergency. It is the duty of medical centers to ensure their clinicians are well equipped to confront such threats. As prompt treatment is often a key to positive health outcomes, the authors stress the importance of acting quickly and suggest conducting informal surveys to identify gaps in physician knowledge. Likewise, the authors encourage medical educators nationwide to examine their environmental health curricula. It appears lead-contaminated water is not just a Flint problem but may have far-reaching implications for many cities.

Nitrofurantoin-induced interstitial pneumonitis: albeit rare, should not be missed.

Interstitial lung disease (ILD) is a rare adverse effect of nitrofurantoin and can range from benign infiltrates to a fatal condition. Nitrofurantoin acts via inhibiting the protein synthesis in bacteria by helping reactive intermediates and is known to produce primary lung parenchymal injury through an oxidant mechanism. Stopping the drug leads to complete recovery of symptoms. In this report, we present a case of nitrofurantoin-induced ILD with the recovery of symptoms and disease process after stopping the drug.

Resolution of neurological deficits secondary to spontaneous intracranial haemorrhage and posterior reversible encephalopathy syndrome (PRES) in a patient with hepatitis C-associated cryoglobulinaemia: a role for plasmapheresis.

Essential mixed cryoglobulinaemia or type II cryoglobulinaemia is an important extrahepatic manifestation of chronic hepatitis C. Cryoglobulinaemia results in the deposition of immune complexes in small or medium-sized blood vessels leading to palpable purpura, arthralgia, renal disease and peripheral neuropathy. Posterior reversible encephalopathy syndrome (PRES) is a distinct phenomenon characterised by vasogenic oedema in the posterior circulation of brain. Cryoglobulinaemic vasculitis leading to spontaneous intracranial haemorrhage and PRES syndrome is rarely reported in the medical literature. In this report, we present an unusual case of spontaneous intracranial haemorrhage and PRES secondary to hepatitis C-associated cryoglobulinaemia presenting as right dense hemiplegia. Prompt institution of plasmapheresis resulted in successful resolution of symptoms in our patient, followed by full neurological recovery. To the best of our knowledge, this case describes the first successful use of plasmapheresis in alleviating neurological complications resulting from cryoglobulinaemic vasculitis and PRES secondary to chronic hepatitis C.

Ticagrelor versus clopidogrel after fibrinolytic therapy in patients with ST-elevation myocardial infarction: a systematic review and meta-analysis of randomized clinical trials

Dual antiplatelet therapy with aspirin and clopidogrel are recommended as adjuncts to fibrinolytic-treated patients with ST-elevation myocardial infarction (STEMI). However, the role of switching to ticagrelor within 24xa0h of fibrinolytics compared with clopidogrel continuation in this setting is uncertain. Hence, we conducted a comprehensive search of electronic databases for all randomized clinical trials (RCTs) that evaluated the safety and efficacy of ticagrelor versus clopidogrel after fibrinolytic therapy in patients with STEMI. A random-effects model was used to calculate the risk ratios (RRs) and 95% confidence intervals (CIs). A total of 5 RCTs that evaluated the efficacy of ticagrelor post-fibrinolysis were identified. We included 3 RCTs with 3999 total patients for our meta-analysis. The results showed similar short-term clinical outcomes between ticagrelor and clopidogrel with regard to rates of Bleeding Academic Research Consortium (BARC) typeu2009≥u20092 bleeding (RR 0.94; 95% CI 0.56–1.60; Pu2009=u20090.83), major adverse cardiovascular events (RR 0.87; 95% CI 0.49–1.52; Pu2009=u20090.62), mortality (RR 0.92; 95% CI 0.53–1.59; Pu2009=u20090.77), myocardial infarction (RR 0.76; 95% CI 0.43–1.36; Pu2009=u20090.36), and stroke (RR 0.93; 95% CI 0.50–1.73; Pu2009=u20090.82). Our results demonstrate that in STEMI patients treated with fibrinolytic therapy, switching to ticagrelor was associated with similar bleeding and ischemic outcomes compared with clopidogrel continuation.