Pavlos Texakalidis

Emerging treatments for ulcerative colitis: a systematic review

Abstract Objectives: Various investigational medicinal products have been developed for ulcerative colitis (UC). Our aim was to systematically evaluate novel pharmacological therapeutic agents for the treatment of UC. Material and methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations were followed. A search of the medical literature was conducted in the MEDLINE database for original research papers published between 01 January 2010 and 31 October 2014. Results: Twenty one studies, including 11,524 adults were analyzed. Thirteen different novel therapeutic drug options were identified. Vedolizumab and golimumab were superior to placebo as induction and maintenance therapy. Tofacitinib showed dose related efficacy for induction therapy. Etrolizumab showed higher clinical remission rates compared to placebo. Phosphatidylcholine led to an improved clinical activity index. HMPL-004 may become a mesalamine alternative for mild to moderate UC. PF00547,659 was well tolerated. Statins were not beneficial for acute exacerbations of UC. Abatacept, rituximab and visilizumab did not lead to improved outcomes compared to placebo. Higher concentration of BMS 936557 was associated with improved efficacy compared to placebo. Basiliximab did not enhance corticosteroid efficacy. Conclusions: Patients with UC might achieve clinical response or remission by utilizing some of these agents with a favorable side effect profile. Further studies are needed to evaluate their short- and long-term efficacy and safety.

Pediatric Cardiac Trauma in the United States: A Systematic Review

Literature discussing cardiac injuries in children is limited. Systematic search of PubMed identified 21 studies enrolling 1,062 pediatric patients who experienced cardiac trauma in the United States during the period 1961 to 2012. The predominant type of injury was blunt cardiac contusion affecting 59.7% (n = 634/1,062) of the study population. Motor vehicle crashes (53.5%, n = 391/731) were the leading cause of blunt cardiac trauma, while gunshot wounds (50%, n = 150/300) accounted for most penetrating injuries. Overall mortality rate was 35.2% (n = 374/1,062).

Revascularization of radiation-induced carotid artery stenosis with carotid endarterectomy vs. carotid artery stenting: A systematic review and meta-analysis

OBJECTIVE The incidence of carotid artery stenosis after head and neck radiation is anticipated to rise due to the increasing survival of patients with head and neck malignancies. It remains unclear whether carotid artery stenting (CAS) or endarterectomy (CEA) is the best treatment strategy for radiation-induced carotid artery stenosis. MATERIALS & METHODS This study was performed according to the PRISMA and MOOSE guidelines. Eligible studies were identified through a comprehensive search of PubMed, Scopus and Cochrane Central until July 20, 2017. A meta-analysis of random effects model was conducted. The I-square statistic was used to assess for heterogeneity. RESULTS Five studies and 143 patients were included. Periprocedural stroke, myocardial infarction (MI) and death rates were similar between the two revascularization approaches. However, the risk for cranial nerve (CN) injury was higher in the CEA group (OR: 7.09; 95% CI: 1.17-42.88; I2 = 0%). CEA was associated with lower mortality rates after a mean follow-up of 50 months (OR: 0.29; 95% CI: 0.09-0.97; I2 = 0%). No difference was identified in long-term restenosis rates between CEA and CAS. CONCLUSIONS Patients with radiation-induced carotid artery stenosis can safely undergo both CAS and CEA with similar risks of periprocedural stroke, MI and death. However, patients treated with CEA have a higher risk for periprocedural CN injuries and a lower risk for long-term mortality.

Flow diversion with the pipeline embolization device for patients with intracranial aneurysms and antiplatelet therapy: A systematic literature review

Flow diversion with the Pipeline Embolization Device (PED) is reported as a safe and efficient treatment for patients with intracranial aneurysms; however, literature discussing the antiplatelet (APT) regimen used before and after the PED is limited. Our aim was to systematically review and summarize available data regarding the APT regimen and the platelet function test (PFT) that was used. We also sought to provide an overview of the aneurysm morphologies and adverse event rates associated with the PED use. This systematic review was conducted according to the PRISMA statement and eligible studies were identified through search of the PubMed and Cochrane databases. We reviewed 28 studies, involving 1556 patients that underwent aneurysm treatment with the PED. The preprocedural aspirin (ASA) 300- 325mg (2-14days) combined with clopidogrel 75mg (3 to >10days) were used as a treatment strategy in 61.7% of patients and ASA 81mg with clopidogrel 75mg for 5-10days for 27%. Patients who received low versus high dose pre-PED ASA, were at less risk for a hemorrhagic event (0.7% versus 3.3%, p=0.053); however no statistical significance was reached. There was also lack of relationship between patients that received low versus high preprocedural ASA in terms of thromboembolic events. Regarding postprocedural APT, ASA (>6months) and clopidogrel (3- 12 months) was the regimen of choice for 93% of patients. Most studies conducted at least one PFT, most common being the VerifyNow. The most frequently reported target P2Y12 Reaction unit (PRU) and Aspirin Reaction Unit (ARU) values were <230 and <550 respectively. There was no statistically demonstrable difference in regards to thrombotic events between centers that conducted at least one PFT and centers that did not test their patients with a PFT. The overall rates of symptomatic thrombotic episodes were 6.6% and hemorrhagic were 3%. The pre- and post-PED APT dose and duration varies across different institutions. More prospective studies are needed to compare the efficacy of different APT agents and reach conclusions regarding use of PFT and platelet reaction values in order to decrease hemorrhagic and thromboembolic complications associated with the PED.

Vessel Wall Imaging of Intracranial Aneurysms: Systematic Review and Meta-analysis

Vessel wall imaging (VWI) is emerging as a novel imaging tool for the management and risk stratification of patients with intracranial saccular aneurysms. Our objective was to compare the rates of wall enhancement in unstable (ruptured, growing, or symptomatic) and stable aneurysms and assess the ability of VWI with high-resolution magnetic resonance imaging to distinguish between these 2 entities. This study was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, and eligible studies were identified through a comprehensive literature review. A meta-analysis was conducted to examine the association between aneurysm wall enhancement and aneurysm instability with the use of a random effects model. The I2 statistic was used to assess for heterogeneity. Six studies comprising 505 saccular aneurysms were included. Aneurysms that showed vessel wall enhancement had statistically significant higher odds of being unstable (odds ratio [OR]: 20; 95% confidence interval [CI]: 6.4-62.1; I2: 63.1%). The sensitivity, specificity, positive predictive value, and negative predictive value of VWI in identifying unstable aneurysms were 95.0% (90.4-97.8), 62.7% (57.1-67.9), 55.8% (52.2-59.4), and 96.2% (92.8-98.0), respectively. There is a statistically significant association between vessel wall enhancement and aneurysm instability. Importantly, the lack of wall enhancement is a strong predictor of aneurysm stability. VWI could potentially provide new insights in the management of intracranial aneurysms.

Preventing pediatric cardiothoracic trauma: Role of policy and legislation

Data from the last 50 years suggest that pediatric patients typically suffer cardiothoracic injuries following blunt traumatic force (70%) in the setting of either motor vehicle crashes (53.5%) or vehicle-pedestrian accidents (18.2%). Penetrating trauma accounts for 30% of pediatric cardiothoracic injuries, half of which are gunshot wounds. Graduated driver licensing programs, gun-control legislation, off-road vehicle regulation, initiatives such as “Prevent the Bleed”, as well as professional society recommendations are key in preventing pediatric cardiothoracic injuries.

CAROTID ARTERY ENDARTERECTOMY VERSUS CAROTID ARTERY STENTING FOR RESTENOSIS AFTER CAROTID ARTERY ENDARTERECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Carotid artery restenosis may occur after ipsilateral carotid endarterectomy (CEA). It remains unclear whether carotid artery stenting (CAS) or a repeat CEA (redoCEA) is the best treatment strategy for carotid artery restenosis. This study was performed according to the PRISMA and MOOSE guidelines

A meta-analysis of randomized trials comparing bovine pericardium and other patch materials for carotid endarterectomy

Objective: Patch angioplasty during carotid endarterectomy is commonly used to treat symptomatic and asymptomatic carotid artery stenosis. The objective of the present study was to compare the different patch materials that are currently available (synthetic vs venous vs bovine pericardium) in terms of short‐ and long‐term outcomes. Methods: This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA) guidelines and eligible randomized control trials were identified through a comprehensive search of PubMed, Scopus, and Cochrane Central published until September 2017. A meta‐analysis was conducted with the use of a random effects model. The I2 statistic was used to assess for heterogeneity. The primary study end point was the incidence of long‐term restenosis. Secondary study end points were 30‐day stroke, transient ischemic attack (TIA), myocardial infarction, neck wound infection, local hematoma, carotid artery thrombosis, cranial nerve injury, long‐term stroke incidence, and death. Results: Eighteen studies and 3234 patients were included. The risk of 30‐day stroke (relative risk [RR], 1.00; 95% confidence interval [CI], 0.45‐2.19; I2 = 0%), TIA (RR, 1.14; 95% CI, 0.41‐3.19; I2 = 0%), myocardial infarction (odds ratio, 0.75; 95% CI, 0.14‐3.97; I2 = 0%), death (RR, 0.53; 95% CI, 0.21‐1.34; I2 = 0%), wound infection (RR, 1.84; 95% CI, 0.43‐7.81; I2 = 0%), carotid artery thrombosis (RR, 1.47; 95% CI, 0.44‐4.97; I2 = 0%), cranial nerve palsy (RR, 1.21; 95% CI, 0.53‐2.77; I2 = 0%), and long‐term stroke (RR, 2.33; 95% CI, 0.76‐7.10; I2 = 0%), death (RR, 1.09; 95% CI, 0.65‐1.83; I2 = 0%) and restenosis of greater than 50% (RR, 0.48; 95% CI, 0.19‐1.20; I2 = 0%) were similar between the synthetic vs venous patch groups. Also, no differences in terms of 30‐day stroke (RR, 0.31; 95% CI, 0.02‐5.16; I2 = 63.1%), TIA (RR, 0.49; 95% CI, 0.14‐1.76; I2 = 0%), death (RR, 0.74; 95% CI, 0.05‐10.51; I2 = 31.7%), carotid artery thrombosis (RR, 0.13; 95% CI, 0.02‐1.07; I2 = 0%), and long‐term restenosis of greater than 70% (RR, 0.15; 95% CI, 0.01‐2.29; I2 = 70.9%) were detected between the synthetic polytetrafluoroethylene and Dacron patch groups. The comparison between the bovine pericardium vs synthetic patch did not yield any statistically significant results in terms of 30‐day stroke (RR, 1.44; 95% CI, 0.19‐10.79; I2 = 12.7%), TIA (RR, 1.05; 95% CI, 0.11‐10.27; I2 = 0%), local neck hematoma (RR, 4.01; 95% CI, 0.46‐34.85; I2 = 0%), and death (RR, 4.01; 95% CI, 0.46‐34.85; I2 = 0%). Conclusions: Closure of the carotid arteriotomy with any of the studied patch materials seems to be similar in terms of short‐ and long‐term end points. However, additional randomized trials with adequate follow‐up periods are needed to compare bovine pericardium patches with other patch materials.

Effect of Open- vs Closed-Cell Stent Design on Periprocedural Outcomes and Restenosis After Carotid Artery Stenting: A Systematic Review and Comprehensive Meta-analysis

Purpose:To compare periprocedural complications and in-stent restenosis rates associated with open- vs closed-cell stent designs used in carotid artery stenting (CAS). Methods: A systematic search was conducted to identify all randomized and observational studies published in English up to October 31, 2017, that compared open- vs closed-cell stent designs in CAS. Identified studies were included if they reported the following outcomes: stroke, transient ischemic attack (TIA), myocardial infarction (MI), hemodynamic depression, new ischemic lesions detected on imaging, and death within 30 days, as well as the incidence of in-stent restenosis. A random-effects model meta-analysis was employed. Model results are reported as the odds ratio (OR) and 95% confidence interval (CI). The I2 statistic was used to assess heterogeneity. Results: Thirty-three studies (2 randomized trials) comprising 20, 291 patients (mean age 71.3±3.0 years; 74.6% men) were included. Patients in the open-cell stent group had a statistically significant lower risk of restenosis ⩾40% (OR 0.42, 95% CI 0.19 to 0.92; I2=0%) and ⩾70% (OR 0.23, 95% CI 0.10 to 0.52; I2=0%) at a mean follow-up of 24 months. No statistically significant differences were identified for periprocedural stroke, TIA, new ischemic lesions, MI, hemodynamic depression, or death within 30 days after CAS. Sensitivity analysis of the 2 randomized controlled trials only did not point to any significant differences either. Conclusion: Use of open-cell stent design in CAS is associated with a decreased risk for restenosis when compared to the closed-cell stent, without significant differences in periprocedural outcomes.

Proximal embolic protection versus distal filter protection versus combined protection in carotid artery stenting: A systematic review and meta-analysis

OBJECTIVE Proximal embolic protection devices (P-EPD) and distal filters (DF) are used to prevent distal cerebral embolizations during carotid artery stenting (CAS). We compared their comparative effectiveness in regards to prevention of intraprocedural and periprocedural adverse events, including ischemic lesions (ipsilateral and contralateral), stroke, transient ischemic attacks (TIA) and death. We also compared the combination of the two neuroprotection strategies vs. a single strategy in regards to ischemic lesions and stroke. MATERIALS & METHODS This study was performed according to the PRISMA and MOOSE guidelines and eligible studies were identified through search of PubMed, Scopus and Cochrane Central. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess for heterogeneity. RESULTS Twenty-nine studies involving 16,307 patients were included. There was a significant reduction in ischemic lesions with the use of P-EPD among observational studies (RR: 0.66 [0.45-0.97]). There were no statistically significant differences for the other outcomes between the two treatment groups. CONCLUSIONS There is a number of studies reporting outcomes on the comparison between P-EPD and DF for CAS. P-EDP can reduce distal embolization phenomena resulting into ischemic lesions when compared to DF based on the results from real-world studies. P-EPD was not superior however, in regards to periprocedural stroke, TIA and death. Further studies are anticipated to provide a clear answer to this debate.