A Comparative Study of Bivalirudin Plus Clopidogrel versus Bivalirudin Plus Prasugrel in Primary Angioplasty Using Propensity Score Matching

Introduction and Objectives

In primary angioplasty, bivalirudin is superior to treatment with heparin plus glycoprotein inhibitors for reducing cardiovascular events, although bivalirudin increases the risk of stent thrombosis. Our hypothesis is that the use of prasugrel plus bivalirudin in primary angioplasty would reduce stent thrombosis and cardiovascular events.

Method

Consecutive patients with acute ST‐segment elevation myocardial infarction who were treated by primary angioplasty within 12 hours of the onset of symptoms received bivalirudin plus clopidogrel (Group A) or bivalirudin plus prasugrel (Group B). We compared the groups using propensity score matching. The combined end‐point was cardiac death, thrombosis, acute myocardial infarction, and cerebrovascular accident at 30 days.

Results

We assessed 168 patients. The approach was preferentially radial (95.7%). No differences in baseline characteristics were observed between Groups A (n = 70) and B (n = 70). The total mortality and rate of major bleeding complications at 30 days were 0% for both of the groups. The rate of acute and subacute thrombosis was 4.3% in Group A and 0% in Group B (P = 0.08). We observed an increased rate of events in Group A (5.7%) versus Group B (0%) (P = 0.042).

Conclusions

The administration of bivalirudin plus prasugrel in primary percutaneous coronary intervention reduces cardiovascular effects compared to bivalirudin plus clopidogrel without increasing major bleeding complications during the first 30 days following primary angioplasty performed with a preferentially radial approach. (J Interven Cardiol 2013;26:463‐469)

     

Successful therapy of transplant-associated veno-occlusive disease with a combination of tissue plasminogen activator and defibrotide

A 36-year-old man underwent matched unrelated donor bone marrow transplantation for chronic myeloid leukaemia. He developed severe hepatic veno-occlusive disease as an early post-transplant complication. Tissue plasminogen activator was initially felt to be contraindicated since the patient had concomitant pericarditis. Defibrotide was therefore commenced as treatment for veno-occlusive disease. The pericarditis improved but the veno-occlusive disease continued to worsen (peak bilirubin 353 μmol/I). Tissue plasminogen activator followed by a heparin infusion was therefore administered. However, he proceeded to develop haemorrhagic cardiac tamponade that required drainage. Thrombolysis was therefore discontinued and treatment with defibrotide resumed after an interval of 48 h. The veno-occlusive disease gradually resolved and defibrotide was discontinued once the bilirubin had plateaued. He was discharged home on day +52 post-transplant.     

Meralgia paresthetica is related to degenerative pubic symphysis

OBJECTIVE: To investigate the relationship between meralgia paresthetica, a mononeuropathy of the lateral femoral cutaneous nerve that often starts in middle age, and radiological degeneration of the pubic symphysis. METHODS: A case-control study of patients aged 40 years and older with meralgia paresthetica who underwent surgical release of the lateral femoral cutaneous nerve; cases were included only when a pelvic radiograph was available. The control group was from a population study including persons aged 55 years and older and was matched to cases (4 controls per case) for sex and age as far as possible. We checked patient records from general practice to ensure control subjects had no symptoms of meralgia paresthetica during the previous 10 years. Radiological degeneration of the pubic symphysis was defined as present when 2 of 3 independent observers noted degeneration on the radiograph. RESULTS: Mantel-Haenszel procedure (stratified for age group and radiological osteoarthritis of the hip) showed a positive relationship (p = 0.004, OR = 4.38) between radiological degenerative pubic symphysis and meralgia paresthetica. In a separate analysis limited to men we also found this positive relationship. CONCLUSION: This study confirmed a positive relationship between radiological degeneration of the pubic symphysis and meralgia paresthetica.     

Serum oligoclonal IgG is a common and persistent finding in multiple sclerosis, and has a systemic source

Synthesis of oligoclonal IgG within the central nervous system is a well established feature of multiple sclerosis. The occurrence of oligoclonal IgG in the serum of patients with multiple sclerosis has received little attention. We detected such a serum response in 20/45 consecutive patients (44%, 95% CI 30-59%) but in only 3/41 age- and sex- matched healthy controls (p < 0.01). We present qualitative and quantitative evidence that this oligoclonal IgG has a systemic origin. The plasma cell clones responsible for the serum response are often also represented in the intrathecal compartment. In a further study of the clinical significance of serum oligoclonal bands, in 80 patients, their presence was associated with elevated levels of intrathecal synthesis, increasing age, later disease onset and the presence of serum autoantibodies. These findings add to the evidence that there is a systemic immune disturbance in multiple sclerosis.      

Radiographic measurement of the distal tibiofibular syndesmosis has limited use

Radiographs of 20 plastinated human cadaveric lower legs were obtained in 12 positions of rotation to determine the optimal parameter for reliable assessment of syndesmotic and ankle integrity, and to assess the effect of positioning of the ankle on this parameter. Three observers measured eight parameters twice after four repetitions of ankle positioning. Intraclass correlation coefficients and reproducibility were assessed. Some tibiofibular overlap was present in all radiographs in any position of rotation. The medial clear space was smaller than or equal to the superior clear space in all radiographs. Intraclass correlation coefficients of the other parameters were too weak for reliable quantitative measurements, as was shown with a mixed model analysis of variance. This resulted from the inability to reproduce ankle positioning, even under optimal laboratory circumstances. This study shows that no optimal radiographic parameter exists to assess syndesmotic integrity. Tibiofibular overlap and medial and superior clear space are the most useful, because one-sided traumatic absence of tibiofibular overlap may be an indication of syndesmotic injury, and a medial clear space larger than a superior clear space is indicative of deltoid injury. Additional quantitative measurement of all syndesmotic parameters with repeated radiographs of the ankle cannot be done reliably and therefore are of little value.     

FREDDY激光器的碎石效率的体外分析

背景和目的　双频双脉冲Nd :Yag(FREDDY)激光 (德国W .O .M .公司生产 )是一个短脉冲 ,双频率 ( 5 3 2nm和 10 64nm)的固体激光器。该激光器功率小 ,成本低 ,目前已在腔内碎石术中得到应用。我们设计了一个试验 ,以测试在不同能量和不同频率下的碎石效率。材料和方法　 40个预先称过重量的硫酸钙石头被分成 4组 ,在 5Hz和 10Hz情况下 ,分别碎石 2min和 4min。一个水下的试验装置包括一个支架和一个容器 ,使得石英玻璃光纤可以直接抵住石头 ,发射激光。光纤被剥离成直径为 2 80 μm的裸露光纤 ,以保证最佳的能量传输。碎石完成后 ,所有的残余颗粒都落在容器内 ,晾干 48小时后 ,再重新称重 ,根据重量缺失的百分比来测试碎石效果。结果　 5Hz时 ,碎石 2min的重量缺失为 2 4%;碎石 4min的重量缺失为 5 4%。 10Hz时 ,碎石 2min的情况与 5Hz时碎石 4min的结果相似 ,重量缺失为 5 1%;碎石 4min的重量缺失为 64 %,原先估计这么高的能量设置 ,重量缺失应该更大些。在高能量发射时 ,可以观察到光纤有损耗 ,这可能是导致碎石效率下降的原因。结论　FREDDY激光器在 5Hz时碎石 4min ,和在 10Hz时碎石 2min的效率是同等的 ,提示传输到结石的能量与碎石效率的相关性很好。而 10Hz、4min组的碎石效率比预期的略有下降 ,