Systematic review and meta-analysis: incidence of variceal hemorrhage in patients with cirrhosis undergoing transesophageal echocardiography
Alimentary pharmacology & therapeutics. 2022
BACKGROUND The presence of esophageal varices is considered a relative contraindication to transesophageal echocardiography (TEE) by cardiology professional societies, so gastroenterologists are often consulted to perform upper endoscopy prior to TEE in patients with cirrhosis. AIM: To perform a systematic review to quantify the risk of bleeding complications in patients with cirrhosis following TEE. METHODS Two reviewers searched Ovid MEDLINE, MEDLINE In-Process and EMBASE databases from January 1992 to May 2021 for studies reporting bleeding complications from TEE in patients with cirrhosis. We calculated the pooled incidence rate of bleeding events using the metaprop command with a random effect model. RESULTS We identified 21 studies comprising 4050 unique patients with cirrhosis; 9 studies (n = 3015) assessed the risk of intraoperative TEE during liver transplant (LT) and 12 studies (n = 1035) assessed bleeding risk in patients undergoing TEE for other indications. The pooled incidence of bleeding post-TEE was 0.37% (95% CI 0.04-0.94%) across all studies. Bleeding complications were low among patients undergoing TEE during LT as well as those undergoing TEE for other diagnostic reasons (0.97% vs. 0.004%) and among studies with mean MELD >18 compared to those with mean MELD <18 (0.43% vs. 0.08%). Few studies had a comparator arm, and data on patient-level factors impacting bleeding complications (including degree of liver dysfunction and coagulopathy) were limited across studies. CONCLUSIONS The risk of bleeding complications following TEE is low in patients with cirrhosis, suggesting TEE is safe and risk stratification with upper endoscopy may not be necessary.
Biologic Treatment Outcomes in Mucous Membrane Pemphigoid: A Systematic Review
Journal of the American Academy of Dermatology. 2021
BACKGROUND Mucous membrane pemphigoid (MMP) is an autoimmune disease, which can lead to fibrosis of mucous membranes and functional impairment. Biologic agents should be explored as alternative treatment options to improve outcomes. OBJECTIVE To conduct a systematic review of biologic treatment outcomes in patients with MMP. METHODS MEDLINE and EMBASE search was conducted on July 23(rd), 2020 to include 63 studies using PRISMA guidelines. RESULTS Use of IVIG (n=154), rituximab (n=112), TNFα inhibitors (n=7), and combination treatments (n=58) were reported in 331 patients with MMP. IVIG led to complete resolution in 61.7% (n=95/154) of patients within 26.0 months, with a recurrence rate of 22.7% (n=35/154) and headache as the most common side effect (8.4%, n=13/154). Rituximab led to complete resolution in 70.5% (n=79/112) of patients within 8.7 months, with a recurrence rate of 35.7% (n=40/112). Most commonly reported side effects were urinary tract infections (4.5%, n=5/112), leukocytopenia (2.7%, n=3/112), death due to severe infections (1.8%, n=2/112). TNFα inhibitors led to complete resolution in 71.4% (n=5/7) of patients within 3.9 months of treatment, without reported adverse events. CONCLUSIONS Randomized clinical trials with long term follow up are required to conclude the promising safety and efficacy of biologic agents in MMP patients.