Richard Pullicino

Functional outcomes and recanalization rates of stent retrievers in acute ischaemic stroke: A systematic review and meta-analysis

Background and purpose Intra-arterial therapy for acute ischaemic stroke has evolved rapidly in the last few years. Stent retrievers have now replaced ‘first-generation’ devices, which have been the principle devices tested in stroke trials. Our aims were to determine the rates of successful recanalization and functional independence in acute stroke patients treated with stent retrievers. We also sought to assess the safety outcomes of stent retrievers by assessing the rates of mortality and intra-cranial haemorrhage. Materials and methods We conducted a systematic review and meta-analysis of studies which utilized stent retrievers as sole treatment or as part of a multi-modal approach in acute ischaemic stroke. Results We identified 20 eligible studies: 17 on Solitaire (ev3/Covidien, Irvine, California, USA) (n = 762) and three on Trevo (Stryker, Kalamazoo, Michigan, USA) (n = 210). The mean age of participants was 66.8 (range 62.1–73.0) years and the M:F ratio was 1.1:1. The average stroke severity score (National Institutes of Health Stroke Scale (NIHSS)) at presentation was 17.2. The weighted mean symptom onset to arterial puncture and procedural duration were 265.4 minutes and 54.8 minutes, respectively. Successful recanalization was achieved in 84.5% of patients with a weighted mean of 2.0 stent retriever passes. Independent functional outcome was achieved in 51.2% and the mortality rate was 16.8%. Conclusion Stent retrievers have the potential to achieve a high rate of recanalization and functional independence whilst being relatively safe. They should be assessed in well-designed randomized controlled trials to determine their efficacy and assess whether they compare favourably with ‘standard treatment’ in stroke.

An efficacy and safety comparison between different stentriever designs in acute ischaemic stroke: a systematic review and meta-analysis.

AIM To assess the recanalisation rates and long-term functional outcomes of the Solitaire and Trevo devices; to compare these results to those from the Solitaire With the Intention For Thrombectomy (SWIFT) trial and TREVO 2 studies; and to assess for statistical differences in the outcomes between the two devices. MATERIALS AND METHODS A systematic review and meta-analysis of studies that utilised stentrievers in the treatment of acute ischaemic stroke was conducted. The results were compared to those of the SWIFT and TREVO 2 trials and outcome differences between Trevo (Stryker, Kalamazoo, Michigan, USA) and Solitaire (ev3/Covidien, Irvine, California, USA) were analysed statistically. RESULTS Solitaire had a lower mortality rate compared to Trevo (16.2% [95% confidence interval {CI}: 13.1%, 19.8%] versus 22.2% [95% CI: 10.8%, 40.2%]) and achieved a higher rate of functional independence (52.1% [95% CI: 46.3%, 57.8%] versus 47.6% [95% CI: 36.7%, 58.8%]). Statistical tests, however, failed to demonstrate significant differences in either functional outcomes or 3-month mortality rates. No significant differences were noted in weighted mean recanalisation rates between the Solitaire and Trevo groups. CONCLUSION Stentrievers achieve a high rate of recanalisation and functional independence in acute ischaemic stroke and have a relatively good safety profile. No significant differences in functional outcomes, mortality, and symptomatic intra-cranial haemorrhage could be demonstrated between two popular stentrievers designs, namely Trevo and Solitaire.

A local perspective to asthma management in the accident and emergency department in Malta

Aim: This study was performed to assess the management of adult patients presenting to the Mater Dei Hospital Accident and Emergency (A&E) department with acute asthma. Subjects and Methods: Asthmatic patients age 14 or older who presented to A&E department between January and October 2010 with asthma exacerbations were included. Data were collected from the clinical notes and analyzed. Results: A total of 244 patients (67.2% females) were included, 126 (51.6%) were admitted, 97 (39.8%) discharged and 21 (8.6%) discharged themselves against medical advice. There was a decline in the presentations between January and July, followed by an upward trend until October (P = 0.42). Pulse oximetry was performed in 207 patients (84.8%), arterial blood gases in 133 (54.5%), peak expiratory flow rate in 106 (43.4%) and chest radiography in 206 (84.4%) patients. The respiratory rate was documented in 151 (61.8%), heart rate in 204 (83.6%) and ability to complete sentences in 123 (50.4%) patients. One hundred and ninety six patients (80.3%) were given nebulized bronchodilators, 103 (42.2%) intravenous corticosteroids, 7 (2.87%) oral corticosteroids, 109 (44.7%) oxygen, 28 (11.5%) antibiotics and 9 (3.69%) magnesium. Systemic corticosteroids and antibiotics were more commonly prescribed to patients admitted (P < 0.001). Conclusion: Management of acute asthma in Malta requires optimization in order to compare with international guidelines.

Freedom of movement across the EU: legal and ethical issues for children with chronic disease

While freedom of movement has been one of the most highly respected human right across the EU, there are various aspects which come into play which still need to be resolved for this to be achieved in practice. One of these key issues is cross border health care. Indeed, there is an increasing awareness of standardisation of health service provision and cross border collaboration in the EU. However, certain groups particularly children may be at risk of suboptimal treatment as a result. We present the case of a child patient which highlights the complexity of this matter spanning family law, health law, social security law as well as ethical issues. EU legislation needs to ensure that children patients have access to high quality care across the EU borders.

Continuous positive airway pressure: Is it a route for infection in those with Obstructive Sleep Apnoea?

Introduction Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnoea (OSA), with limited data about the prevalence of respiratory infections and microbial colonization in these patients. Objectives The aim of this study was to determine if CPAP use is associated with respiratory infections and to identify the organisms that colonize or infect these patients. Method A retrospective, case-controlled study in patients diagnosed with OSA was carried out. 137 patients were recruited and interviewed using a questionnaire. A nasal swab was taken from each patient. Patients using CPAP machines had swabs taken from masks and humidifiers. Results 66 (48.2%) patients received CPAP treatment with 60.6% of them having a heated humidifier. 78.8% were male, with the majority using a full face mask (63.6%). No significant difference was seen in the prevalence of rhinosinusitis, lower respiratory tract infections and hospital admissions for pneumonia between CPAP and non-CPAP treated patients. The presence of a humidifier did not influence the prevalence of infections. Commensal flora was predominantly cultured from nasal swabs from both patient groups. Coagulase Negative Staphylococci and Diphtheroids were the main organisms cultured from masks and humidifiers respectively. Conclusions This study shows that the use of CPAP, choice of mask and humidifier have no significant impact on the prevalence of infections and micro-organisms isolated. This is very reassuring to the physician prescribing CPAP therapy and users.

A rare case of pulmonary alveolar microlithiasis

A 47-year-old asymptomatic man with no significant family history was referred to our faculty because of an abnormal chest X-ray (CXR). The CXR, similar to his CXR 10 years previously, showed bilaterally increased interstitial markings suggestive of pulmonary fibrosis. High-resolution CT (HRCT) showed multiple bilateral branching calcifications, mostly in the lung bases (figures 1 and 2), with ground-glass opacities in the lingula, and no enlarged mediastinal lymph nodes. Spirometry was normal (forced expiratory volume in 1 s 102%, forced vital capacity 118%), as were total lung capacity, 117%, and diffusion capacity of the lung …

Tullio phenomenon in superior semicircular canal dehiscence (SSCD)

A 68-year-old woman presented with worsening sound-induced vertigo (Tullio phenomenon) and left-sided hearing loss. Webers test lateralised to the affected ear and audiography confirmed mild conductive hearing loss. Neurological assessment was remarkable for torsional/vertical noise and vibration-induced nystagmus. The patient demonstrated low threshold cervical vestibular-evoked myogenic potential responses, and superior semicircular canal dehiscence was suspected. Otoscopy, tympanography and stapedial reflexes were normal bilaterally. High-resolution CT of …

The elephant man syndrome

We describe a case of Proteus syndrome in a 34-year-old man who started to notice growths over his left frontal and temporal regions about 15 years ago. An abdominal ultrasound confirmed splenomegaly which was palpable on clinical examination. A skull X-ray showed well-circumscribed lesions over the left frontal bone and at the mastoid processes with a hazy appearance of the matrix, a narrow zone of transition and no periosteal reaction. CT demonstrated …

Beware the person with the glass eye and the large liver

A 67-year-old woman presented to the emergency department reporting of epigastric fullness, fatigue and weight loss. Physical examination revealed three fingerbreadths of hepatomegaly. Blood tests were unremarkable, save for a moderately raised erythrocyte sedimentation rate. An urgent CT of her abdomen demonstrated two large liver lesions of low attenuation on the non-enhanced scan (figure 1A), showing heterogeneous enhancement in the arterial phase (figure 1B) with contrast washout after a 5 min delay (figure 1C), an appearance typical of hypervascular metastasis. Ultrasound-guided biopsy of one of these lesions was performed as a …

Lower back pain in a patient on long-term haemodialysis.

A 60-year-old woman with end-stage renal disease secondary to adult polycystic kidney disease, presented with a 6-month history of worsening sacral and rectal pain. She reported anorexia and significant weight loss. She was on haemodialysis for 5 years prior to receiving a renal transplant, which failed after 8 years. She was then recommenced haemodialysis for another 4 years to date. She underwent bilateral nephrectomy of her native kidneys prior to transplantation. Clinical examination showed cachexia, hepatomegaly and a right iliac fossa graft. Rectal examination was normal. Passive movements of both lower limbs were painful; however, there was no neurological deficit. Investigations showed a chronic normocytic …