Repeat percutaneous coronary revascularization: Indications and outcomes in a “Real World” cohort

Objectives : To investigate rates of and reasons for second and subsequent stent procedures in an unselected, “real‐world” population. Background : Repeat stenting is the primary difference reported in clinical trials of alternative revascularization strategies. The incidence, indication, and outcome for repeat stenting in contemporary practice outside the more selective populations of trials and registries has not been described. Method : All patients undergoing a first percutaneous coronary intervention (PCI) procedure with stenting from January 2001 to August 2009 (10,509) from a large UK tertiary referral and district general hospital were identified. Mortality and the incidence, timing, and indication for repeat revascularization in this population were investigated from patient records. Results : Of 10,509 patients undergoing a first PCI and stent implant 23.5% underwent repeat angiography of which 11.2% required repeat PCI and 2% coronary artery bypass grafting (median follow‐up of 3.8 years). A total of 1.3% went on to a third PCI. The commonest indication for repeat stenting was disease progression remote from the original stent (46%) and planned staged PCI (23%); 21% had a stent‐related indication. Functional assessment before repeat stenting was used in one‐third of stable patients. Mortality was 2.5% per annum. Conclusions : In contemporary practice, patients undergoing a first stenting procedure have a low subsequent mortality, and the substantial majority (86.4%) requires no further revascularization over a median 3.8 year follow‐up. For those who do require repeat stenting, this is most commonly at a site remote from the first stent. © 2012 Wiley Periodicals, Inc.     

Safety of repetitive nerve stimulation in patients with cardiac implantable electronic devices

Introduction: Pacemakers and implantable cardioverter-defibrillators (ICDs) are vulnerable to inappropriate sensing of electromagnetic interference (EMI), such as from nerve conduction studies. We conducted a prospective study to assess the safety of repetitive nerve stimulation (RNS). Methods: Fourteen patients undergoing insertion of 10 ICDs and 4 pacemakers under general anesthesia received RNS of the median, axillary, and spinal accessory nerves at 2 HZ and 50 HZ . We recorded detection of EMI and whether or not this resulted in an arrhythmia diagnosis or change in pacing output. Results: EMI was visible in 2 ICDs, without spurious tachyarrhythmia detection. EMI was observed in 3 of the 4 pacemakers, which led to pacing inhibition and a pause in 2, both of which were programmed to a unipolar sensing configuration. Conclusions: RNS is safe in patients with ICDs. In pacemaker patients, RNS appears safe during bipolar sensing, but caution is recommended in pacemaker patients with unipolar sensing. Muscle Nerve 47: 840–844, 2013     

Access to Cytotoxic Medicines by Children With Cancer: A Focus on Low and Middle Income Countries

Background

The Essential Medicines Working Group of the International Society of Pediatric Oncology (SIOP) has proposed a list of antineoplastic drugs that should be available in low and middle income countries.

Procedure

Data were extracted on the listing of 18 essential and 8 ancillary antineoplastic medicines in the national essential medicines lists (NEMLs) or national reimbursable medicines lists (NRMLs) of 135 countries with gross national income (GNI) per capita of less than US $25,000. Correlations between numbers of medicines listed and GNI per capita, annual government health expenditure (AGHE) per capita, and the number of physicians per million people were examined.

Results

Listing of the 18 essential antineoplastic drugs ranged from 27% (thioguanine) to 95% (methotrexate). The median number of medicines listed was 7 (0–18) in low income countries (n = 26) and 14 in lower‐middle (n = 42), upper‐middle (n = 44), and high income countries (n = 20). For the ancillary eight medicines, the median was one (0–8) across the 135 countries. Correlations with GNI per capita (r = 0.17, P = 0.0266) and physician density (r = 0.25, P = 0.0017) were statistically significant; not so for AGHE per capita (r = 0.00, P = 0.5000).

Conclusions

There was large variability within income groups in numbers of antineoplastic agents identified as essential in NEMLs and NRMLs. While not a direct measure of availability, listing is an important step, guiding procurement for the public sector. These results focus attention on deficits in NEMLs and NMRLs as a step to improving access to effective antineoplastic medicines for cancers in children in low and middle income countries. Pediatr Blood Cancer © 2015 Wiley Periodicals, Inc.