Effectiveness of platelet inhibition on major adverse cardiac events in non-cardiac surgery after percutaneous coronary intervention: a prospective cohort study

BACKGROUND

Platelet inhibition is mandatory therapy after percutaneous coronary intervention (PCI). Withdrawal of oral antiplatelet agents has been linked to increased incidence of postoperative adverse cardiac events in post-PCI patients having non-cardiac surgery (NCS). There is limited knowledge of temporal changes in platelet inhibition in this high-risk surgical population. We therefore performed a multicentre prospective cohort study evaluating perioperative platelet function and its association with postoperative major adverse cardiac events (MACE).

METHODS

In 201 post-PCI patients having NCS, we assessed the association between platelet function and postoperative MACE. We performed perioperative platelet function testing using a platelet mapping assay (PMA). Troponin-I was measured every 8 h for 2 days, then daily until day 5. Myocardial infarction was assessed using the third universal definition. We used multivariable logistic regression to assess the association between platelet inhibition and MACE.

RESULTS

Major adverse cardiac events occurred in 40 patients within 30 days of surgery. Thirty-two of these events were non-ST-elevation myocardial infarction, four ST-elevation myocardial infarction, and four exacerbation of congestive heart failure. We were unable to show an association between platelet inhibition and MACE. The PMA showed declining levels of platelet inhibition the longer the antiplatelet therapy was withheld before surgery. Logistic regression did not show an association between preoperative platelet function or the type of stent and MACE. We found an increased cardiac risk of MACE after surgery within 6 weeks of PCI.

CONCLUSIONS

The incidence of MACE in patients undergoing NCS after previous PCI is high in spite of adequate perioperative antiplatelet therapy.

CLINICAL TRIAL REGISTRATION

NCT 01707459 (registered at http://www.clinicaltrials.gov).

Developmental aspects of the deviated nose -a verwoerd study-

In childhood functional, infectious, aesthetic and social problems can result from a deviated septum and nose, further research on the anatomic development, the mechanism of growth, and the process of wound healing is needed to develop surgical techniques that not only correct the present problem but also ensure the further normal growth of the septum and nose.

Moyamoya vasculopathy in a child after hemolytic uremic syndrome: a possible etiopathogenesis

Moyamoya disease is a cerebral vasculopathy of unknown etiology frequently seen in the Asian population. We report a case of moyamoya vasculopathy in an African-American child who had renal failure followed by cerebral ischemia. Our patient presented with hemolytic uremic syndrome (HUS) and renal failure, and later developed seizures. We believe that in this patient HUS led to the pathogenesis of moyamoya disease. We suggest that patients with HUS who develop any neurological symptoms should be investigated for moyamoya vasculopathy for early diagnosis and treatment.

Economic incentives for rain forest conservation across scales

Globally, tropical deforestation releases 20 to 30% of anthropogenic greenhouse gases. Conserving forests could reduce emissions, but the cost-effectiveness of this mechanism for mitigation depends on the associated opportunity costs. We estimated these costs from local, national, and global perspectives using a case study from Madagascar. Conservation generated significant benefits over logging and agriculture locally and globally. Nationally, however, financial benefits from industrial logging were larger than conservation benefits. Such differing economic signals across scales may exacerbate tropical deforestation. The Kyoto Protocol could potentially overcome this obstacle to conservation by creating markets for protection of tropical forests to mitigate climate change.

Urodynamic correlates of resolution of reflux in meningomyelocele patients

PURPOSE

Resolution of reflux in meningomyelocele patients is a reflection of improved bladder storage. We correlated resolution of reflux with changes observed in sequential urodynamic studies.

MATERIALS AND METHODS

The study included 27 children with meningomyelocele born between 1975 and 1985 who presented with or developed vesicoureteral reflux. Resolution of reflux was observed during the 10-year followup period as they were treated with a regimen of clean intermittent catheterization and pharmaco-therapy. Urodynamic studies were performed when vesicoureteral reflux was present and subsequent to its resolution. The urodynamic parameters compared in the 2 studies included bladder capacity, pressure specific bladder volume, bladder compliance and leak point pressure.

RESULTS

Significant increases in bladder capacity, pressure specific bladder volume and bladder compliance were noted. Leak point pressure appeared to be decreased subsequent to resolution of reflux.

CONCLUSIONS

Resolution of reflux in meningomyelocele patients correlates with changes in parameters of bladder storage observed on sequential urodynamic studies.

Autoregulation of cerebral blood flow: influence of local brain development and postnatal age

To investigate whether the efficiency of cerebral blood flow autoregulation depends on local brain maturity, we examined the effect of development on the local autoregulatory response. We measured local brain blood flow using laser-Doppler flowmetry and quantitative autoradiography during hemorrhagic hypotension and hypertension (intravenous norepinephrine) in newborn 1- to 2-day-old (P1), 7- to 8-day-old (P8), 16- to 18-day-old (P17), and adult rabbits. Autoregulation within the cortex was less efficient than within the medulla in young (P1 or P8) compared with older rabbits (P17 or adult). Blood pressure increased during development, and the autoregulatory range extended up to 10, 15, 35, and over 100 mmHg about the normal pressure in P1, P8, P17, and adult animals, respectively. Acute severe hypertension readily produced focal areas of hyperemia within the cortex, thalamus, hippocampus, and/or cerebellum in young (P1 and P8) but not P17 animals. Severe hypotension produced profound reductions in blood flow within the cortex and subcortical white matter but not within deep forebrain and brain stem structures. Thus the efficiency of the autoregulatory response in general improved with increasing age and maturity of the brain region indicating that immature brain is susceptible to both ischemia during hypotension and hyperemia during hypertension.