Clinical Manifestation and Prognosis of Early versus Late Stent Thrombosis of Drug-Eluting Stents

Background: Stent thrombosis (ST) is a serious complication of drug-eluting stents (DES), leading to catastrophic events. ST can occur early or late following the percutaneous coronary intervention (PCI) with different possible consequences.
Methods: The records of 91 consecutive patients who presented with a definite ST (as defined by the Academic Research Consortium) from 2003 to 2007 were reviewed. Clinical presentation and outcome were compared based on the time of the event. Fifty-one patients presented with an early ST versus 40 with a late ST. The primary end-point was a composite of death-recurrent myocardial infarction (MI)-recurrent ST at 1 year.
Results: Baseline characteristics were similar. Patients with early ST had more initial stent implantation for an acute MI indication and presented more with cardiogenic shock when compared to patients with late ST: 43.1% versus 17.5% (P = 0.007) and 39.2% versus 20% (P = 0.042), respectively. There was no difference in the ST treatment except for more intraaortic balloon pump (IABP) use in the early ST group (28% vs. 10%, P = 0.034). Angiographic success rates were similar. The incidence of the composite primary end-point was 52.9% in the early ST group versus 30% in the late ST group (P = 0.034).
Conclusion: Early definite ST is associated with more dramatic presentation and worse long-term prognosis when compared with definite late ST. This could be explained at least in part by the occurrence of two successive MIs within 30 days in almost 45% of the patients with early ST, leading to a higher rate of cardiogenic shock.     

Student status in nursing – a discussion on the status of the student and how it affects training

Though the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) refers to student status as an 'emotive term' (UKCC 1982), the author through this small-scale study looks at the advantages and disadvantages of its implementation. Alternative models of training and other implications are also considered, the findings indicating that implementation is important for the learners' ongoing education and professional development, but not without further investigation of some of the issues raised.     

Adjuvant Post-Operative Radiotherapy in Rectal Cancer: Results from the ANZ Bowel Cancer Trial (Protocol 8202)

In July 1982 the Gastrointestinal Section of The Clinical Oncological Society of Australia began a multicentre randomized trial to assess the value of post-operative pelvic radiotherapy in the local control of stage B and C carcinoma of the rectum. Patients who had undergone a potentially curative resection were randomized either to no further treatment (NO RT) or to pelvic radiotherapy (RT), 45 Gy in 25 fractions (plus a perineal boost of 5 Gy in 2 fractions after abdomino-perineal resection). The trial was prematurely terminated in December 1985 owing to slow accrual after 70 patients had been randomized: 36 patients to RT and 34 patients to NO RT. Two patients in each group were found to be ineligible after randomization and, for a variety of reasons, thirteen patients who were randomized to RT did not receive that treatment. The incidences of post-operative complications were comparable in both groups, indicating that radiotherapy produced no additional problems. Radiotherapy-related morbidity comprised mainly diarrhoea (grade 1 = 2/21; grade 2 = 5/21; grade 3 = 0/21; grade 4 = 1/21). There were no deaths due to radiotherapy and only one patient, with grade 4 diarrhoea, failed to complete the prescribed course of radiotherapy. After an average follow-up period of 52 months there were 15 local recurrences, 8 in the RT group and 7 in the NO RT group, giving an actuarial 2 year local recurrence rate of 16%. There was no difference in the time to local recurrence, either by randomization group (p=0.50) or by actual treatment received (p=0.91). Distant metastases occurred in 25 patients, 12 in the RT group and 13 in the NO RT group. Thirty one patients have died, 26 from cancer, 3 from intercurrent illness without evidence of cancer and two from surgical complications. There was no difference in survival time between the randomized groups: 16 deaths in the RT group and 15 deaths in the NO RT group (p=0.46). The only important factor predictive of local recurrence was age 65 years and over (p=0.002).     

Anxiety and Depression in Patients with Life-Threatening Ventricular Arrhythmias: Impact of the Implantable Cardioverter-Defibrillator

In order to assess the psychological responses to the automatic implantable cardioverter-defibrillator (AICD), 18 patients with a history of life-threatening ventricular arrhythmias were requested to complete the Spielberger State-Trait Anxiety Inventory and the Beck Depression Inventory. The patients were divided into three groups of six and matched for age, sex, underlying cardiac disease, ejection fraction, and NYHA Functional Classification. Group I had experienced conscious discharges from the AICD, group II had the AICD but without discharges, and group III without the AICD were treated with antiarrhythmic medications alone based on electrophysiological guided testing. Patients with the AICD were also requested to complete a questionnaire directed specifically at their experiences with the AICD. All of the 18 patients completed the study responses and results were analyzed by blinded review. There were no significant differences in anxiety and depression scores in the three groups studied, nor any significant differences in responses to the questionnaire in group I versus group II. One patient in group I reported experiencing adverse psychological responses to the AICD. Although there appears to be no significant differences in psychological responses as a result of the AICD implantation in patients with life-threatening ventricular arrhythmias, further study with larger patient groups is needed to identify and support patients who may develop adverse responses to the AICD.     

Increase of Initial Success and Safety of Single-Vessel Percutaneous Transluminal Coronary Angioplasty in 1371 Patients: A Seven-Year Experience

Three successive time periods were compared to study the impact of evolving techniques and new equipment on the immediate results of single-vessel percutaneous transluminal coronary angioplasty (PTCA), the initial success rate and major complication rate (death, myocardial infarction, and urgent surgery). The three periods were selected on the basis of a significant advance in either PTCA technique or equipment. In period I from 1980 to 1983 a nonsteerable catheter system was used. In period II from 1983 to 1986 a steer-able catheter was used. In period HI from 1986 to 1987 the long guidewire technique and/or monorail system was used. A total of 1,371 successive patients underwent single-vessel dilatation for stable angina (848 patients) or for unstable angina (523 patients). Initial success was defined as a reduction of the stenosis to less than 50% with no major complications (myocardial infarction or death, or the necessity of proceeding to coronary artery bypass surgery). The initial success rate increased from 68% (period I) to 88% (period II) and to 91% (period III) for all attempts. When attempts of dilatation of totally occluded vessels were excluded these figures were 71%, 91%, and 95%, respectively. The overall major complication rate decreased from 16% (period I) to 8% (period II) to 3.5% (period III). Thus, increase in investigator experience, technical improvements of balloon catheter systems, and introduction of new PTCA techniques have resulted in an increase in success and safety of PTCA procedures. (J Inter-ven Cardiol 1988:1:1)     

Factors Influencing Alcohol Consumption in a Workspace Setting

A survey was undertaken with staff from the head office of amajor multinational company, about their attitudes towards alcoholconsumption and their own level of use. After reporting someof the main findings, a model is presented for discussion whichpurports to explain how such behaviour may arise and be maintainedvia the interaction of a number of factors operating at differentlevels of their social and personal environment. Requests for reprints should be addressed to: Ron Roberts, Academic Department of Community Medicine, King's College School of Medicine and Dentistry, Bessemer Road, Camberwell, London SE5 9RS, UK     

Changing caries prevalence in primary and permanent teeth of children in a Jerusalem neighbourhood

The objective of the present study was to conduct cross-sectional surveys of caries prevalence in Jerusalem schoolchildren from one geographic region over time (9 years for 6-year-old first graders and 6 years for 9-year-old fourth graders), and to examine possible changes in caries levels. Dental caries was assessed among school children in one Jerusalem neighbourhood, employing the DMFS and dmfs indices, for permanent and primary teeth respectively. One epidemiologist in the team of examiners participated in all stages of the surveys and served as the calibrator. Data indicated a decline among 6-year-old children of mean DMFS scores from 1·64 in 1983, to 0·32 in 1992, and of mean dmfs values from 13·95 to 8·09. Among 9-year-old children, mean DMFS scores declined from 3·50 in 1986 to 2·50 in 1992. The water supply of Jerusalem was optimally fluoridated to 0·9 ppm in 1988, and this is suggested as a contributor to the decline in caries prevalence.