On-Treatment Platelet Reactivity in Peripheral and Coronary Arterial Blood in Patients Undergoing Primary PCI for ST-Segment Elevation Myocardial Infarction (STEMI)

BACKGROUND Dual antiplatelet therapy is recommended in patients undergoing primary percutaneous coronary intervention (p-PCI) for ST-segment elevation myocardial infarction (STEMI). In the past few decades, oral antiplatelet agents have proved to significantly reduce the incidence of ischemic events in patients with atherothrombotic diseases. Nevertheless, recurrent ischemic events often occur in patients undergoing stent implantation. High platelets reactivity has been associated with a higher risk for major cardiovascular events in patients with acute coronary syndromes (ACS). Several pre-analytical variables may influence platelet function analysis. The aim of our study was to assess the on-treatment platelet reactivity in peripheral and coronary blood, in a group of patients receiving dual antiplatelet therapy undergoing primary percutaneous coronary intervention (p-PCI) for STEMI. METHODS Eligible patients for the study were considered as consecutively admitted patients to the emergency department of University-Hospital of Padua with a diagnosis of ACS with ST-segment elevation scheduled for an urgent procedure of coronary angioplasty. One hundred nine patients who consecutively underwent p-PCI (males: 72%, females: 28%; mean age: 64±13 years) were enrolled. Before the coronary angioplasty intervention, the patients were treated with dual antiplatelet therapy (aspirin 250mg I.V in association with one another oral thienopyridines; Clopidogrel 300/600mg, Prasugrel 60 mg or Ticagrelor 180 mg) and with anticoagulant therapy (unfractionated heparin 70U/Kg I.V). During the coronary angioplasty intervention two different samples were obtained, one from peripheral artery and the other from coronary blood. The platelet aggregation was studied using the impedance aggregometry Multiplate®, according to manufacturer’s indications. For each patient the values of “Area Under the Curve” (AUC) in ADP-test and ASPI-test were considered, both in the peripheral and in coronary blood. “Low responders of antiplatelet therapy” were considered when an AUC value of ASPI-test or ADP-test greater than or equal to a pre-established cut-off. RESULTS The Multiplate® analysis of ADP-test revealed that mean values were slightly higher in peripheral blood compared to coronary blood (peripheral blood: 41±28 U; coronary blood: 39±28 U), However these values with no statistically significant difference (p=0.68). Likewise, for the ASPI-test; no statistically significant difference between the mean values in the peripheral blood compared to the coronary blood (peripheral blood: 23±4 U; coronary blood: 17±2 U; p=0.06). The percentage of low-responders to ADP-receptor inhibitors was significantly greater than the percentage of low-responders to acetylsalicylic acid at time of primary PCI both in the peripheral and in the coronary blood samples (peripheral ADP-test: 38%; peripheral ASPI-test: 14%; p0.05). Finally, a positive and statistically significant linear correlation was observed for both ASPI-test and ADP-test in peripheral and coronary blood (r2 0.23, p <0.001 and r2 0.12, p <0.001; respectively). That means; those who are resistant to acetylsalicylic acid tend to be resistant to ADP receptor inhibitors, and vice versa; those who are sensitive to acetylsalicylic acid therapy tend to be sensitive to ADP inhibitor therapy also. Our observed data did not show a correlation between platelet function and clinical outcome both for in-hospital and 1-year clinical outcomes. CONCLUSIONS In this study we observed that the overall platelet reactivity in coronary blood is lower than in peripheral blood, though not statistically significant. This more likely appears to be due to high antiplatelet drugs effect at plaque ulceration/thrombus site, where the hemostatic process is highly active at onset of STEMI. Larger studies are needed for better evaluation of these mechanisms in term of pharmacodynamic, pharmacokinetic and receptor kinetic properties of antiplatelet agents. The other interesting result emerging from data processing is the high incidence (about 30%) of low response to thienopyridine type antiplatelet drugs at the time of primary angioplasty. This result, moreover known for Clopidogrel in addition our results include patients treated with Prasugrel and Ticagrelor also. An explanation of this phenomenon which also involves potent recent drugs, requires careful analysis and further studies. The significant direct correlation between platelet reactivity in peripheral and in coronary blood is still a matter of debate. Larger studies are needed for in-depth assessment of any correlation between on–treatment platelet reactivity measured in coronary blood and clinical outcome

The Effectiveness of Using the Visual-Spatial Approach to Teach Physics on Developing Reflection Skills for Grade Ten Female Students, Al-Shamayatain District, Taiz Governorate

هدفت هذه الدراسة التعرف إلى فعالية استخدام المدخل البصري المكاني في تدريس الفيزياء في تنمية مهارات التفكير التأملي لدى طالبات الصف العاشر بمديرية (الشمايتين) بمحافظة تعز. ولتحقيق أهداف الدراسة قام الباحثان بإعداد دليل تدريس وحدة "القياسات الحرارية"، ووحدة "أثر الحرارة على الأجسام"، وفقًا للمدخل البصري المكاني، وتم بناء اختبار مهارات التفكير التأملي، وقد تكوّن بصورته النهائية من (24) فقرة من نوع (اختيار من متعدد)، بعد التأكد من صدقه وثباته، وطبق على عينة تكونت من (85) طالبة من طالبات مدرسة الخير – عزاعز – بطريقة قصدية، قُسمت إلى مجموعتين مجموعة تجريبية تكونت من (42) طالبة درسن الوحدتين بالمدخل البصري المكاني، ومجموعة ضابطة تكونت من (43) طالبة درسن نفس الوحدتين بالطريقة التقليدية المعتادة. وأظهرت النتائج وجود فروق دالة إحصائيًا عند مستوى دلالة (0.05=α) بين متوسطات درجات طالبات المجموعتين التجريبية والضابطة على اختبار مهارات التفكير التأملي في التطبيق البعدي، لصالح طالبات المجموعة التجريبية، وهو ما يعني تأثير تطبيق المدخل البصري المكاني على الطريقة العادية في تنمية مهارات التفكير التأملي لدى طالبات المجموعة التجريبية، كما كشفت النتائج عن وجود فروق دالة إحصائيًا بين متوسطات نتائج التطبيقين القبلي والبعدي على المجموعة التجريبية لصالح التطبيق البعدي. وفي ضوء النتائج قدم الباحثان عددًا من التوصيات والمقترحات، أهمها ضرورة استخدام المدخل البصري المكاني في تدريس الفيزياء بالمرحلة الثانوية، والعمل على تدريب مُعلمي الفيزياء على استخدام المدخل البصري المكاني في عملية التدريس. الكلمات المفتاحية: المدخل البصري المكاني، تدريس الفيزياء، مهارات التفكير التأملي.The aim of this study was to identify the effectiveness of using the Visual-Spatial Approach (VSA) to teach physics and its effect on reflection skills of Grade 10 female students, Al-Shamayatain District, Taiz Governorate. To achieve the aims of this study and according to the VSA, the researchers prepared a guide to teach two units from the book of Physics of Grade 10 which are “Thermometry” and “The Effect of Heat on Objects”. To examine the students’ reflection skills, the researchers prepared a test consisting of 24 multiple choice items; the test was checked for its validity and reliability. The test was administered to a purposive sample of 85 students at Al-Khair School, Aza’iz village. The students were divided into two groups: the experimental group which consisted of 42 students and the control group which consisted of 43 students. The participants of the experimental group were taught the two units using the VSA, whereas the participants of the control group were taught the same units using the traditional method. The results showed that there were significant statistical differences at the level (α = 0.05) between the average scores of the two groups, in favor of the experimental group. This indicated that the VSA approach has an effect on reflection skills compared to the traditional one. Furthermore, the results showed that there were significant statistical differences between the average results of pre and posttests, in favor of the post test administered to the experimental group. Based on these results, it is recommended that the Visual-Spatial Approach be used to teach physics for secondary school students. It is also advised that Physics’ teachers should be trained to use this approach in teaching. Keywords: Visual-spatial approach, Teaching of physics, Reflection skills

Localised Skin Hyperpigmentation as a Presenting Symptom of Vitamin B12 Deficiency Complicating Chronic Atrophic Gastritis

Vitamin B12 deficiency is common in developing countries and should be suspected in patients with unexplained anaemia or neurological symptoms. Dermatological manifestations associated with this deficiency include skin hyper- or hypopigmentation, angular stomatitis and hair changes. We report a case of a 28-year-old man who presented to the Sultan Qaboos University Hospital in Muscat, Oman, in November 2013 with localised hyperpigmentation of the palmar and dorsal aspects of both hands of two months’ duration. Other symptoms included numbness of the hands, anorexia, weight loss, dizziness, fatigability and a sore mouth and tongue. There was no evidence of hypocortisolaemia and a literature search revealed a possible B12 deficiency. The patient had low serum B12 levels and megaloblastic anaemia. An intrinsic factor antibody test was negative. A gastric biopsy revealed chronic gastritis. After B12 supplementation, the patient’s symptoms resolved. Family physicians should familiarise themselves with atypical presentations of B12 deficiency. Many symptoms of this deficiency are reversible if detected and treated early

The Role of Yemen's Awqaf in Solving the Problem of Low Income Housing: A Case Study of Sana'a Capital

يدرس هذا البحث دور أوقاف أمانة العاصمة صنعاء منذ منتصف سبعينات القرن الماضي وإسهاماته بحل مشكلة إسكان ذوي الدخل المحدود بالتعاون مع القطاعين العام والخاص، وإمكانيات الأوقاف في حل هذه المشكلة سواء&nbsp; بتوفير الأرض أو في رأس مال التنفيذ أو بالأثنين معا، ويتطرق إلى المشكلة التي أدت إلى تراجع الأوقاف من الاستمرار في تبنى هذا النوع من المشاريع واهمها عدم تحقيق العائد الاستثماري المرجو منها. ويهدف البحث إلى إبراز دور الوقف في الإسهام بحل مشكلة الإسكان في أمانة العاصمة على وجه الخصوص من خلال تسليط الضوء على مشاريع الوقف السكنية التي شيدت فيها خلال ثمانينيات القرن الماضي والأسباب التي أدت إلى تراجعه، وتأتي أهمية هذا البحث في أنه يسعى إلى توعية المجتمع بعضمه وأهمية الوقف الإسلامي ودورة في خدمة المجتمع وخصوصا في مجال الإسكان، وإمكانيه عودته مرة أخرى للمساهمة وبفاعلية لتحقيق الخدمات الاجتماعية المرجوة منه، مع تحقيق الجدوى الاقتصادية المؤملة ليتمكن من تحقيق التنمية المستدامة الشاملة والمتوازنة التي تحقق مصلحة الطرفين الوقف والمجتمع، وتضمنت منهجية الباحث اتباع أسلوب التحليل الوصفي للمشاريع المقامة وتقيمها للوصول من خلالها إلى النتائج المرجوة لتحقيق الأهداف الرئيسية للبحث، وخلص البحث إلى عدة توصيات تسهم في استعادة دور الوقف في خدمة المجتمع خصوصا في مجال توفير المسكن لذوي الدخل المحدود. الكلمات المفتاحية: الوقف، الأعيان (أرضي ومباني الوقف)، الحبس، الدخل المحدود، الإسكان.This research deals with the extent to which the Waqf has contributed since the mid-1970s to solving the problem of low income housing in cooperation with the public and private sectors, and discusses the multi-faceted aspects of the endowments of land, capital, or both. The factors that led to the decline of the investment sector in the Ministry of Awqaf to continue to adopt this type of projects and most importantly not to achieve the investment return desired. The research aims to highlight the role of the Waqf in contributing to solving the problem of housing in the Municipality of the capital in particular by highlighting the projects of the residential stay in which it was built and the reasons that led to its decline. The importance of the research is to highlight the role of the Waqf in contributing to solving societal problems. The Municipality of the capital, such as the problem of housing with low income, and the possibility of returning again to contribute effectively and achieve the desired objectives, while achieving economic feasibility so as to be able to achieve comprehensive and balanced sustainable development that achieve the interest of the parties endowment and society. The research focuses on the identification and adoption of modern scientific methods in the field of investment. The study concluded several recommendations that contribute to restoring the role of the Waqf in the service of society, especially in the provision of housing for people with low income. Keywords: Waqf, Aian (land, building), Prevention, Low income, Housing

TCT-338 Spontaneous coronary Artery dissection in sudden death victims and surviving patients: which are the differences?

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Late stent fracture - A potential role of left ventricular dilatation

none3nononeAl Mamary, Ahmed; Dariol, Gilberto; Napodano, MassimoAL MAMARY, AHMED HUSSIEN HUSSIEN; Dariol, Gilberto; Napodano, Massim

Neo-atherosclerosis in very late stent thrombosis of drug eluting stent

AbstractBackgroundRecent studies have described neo-atherosclerosis, developing inside the stent, as cause of very late stent thrombosis.Case reportA 59-year-old man, with family history of coronary artery disease, presented to our Department because of anterior ST-segment elevation myocardial infarction. Two years before he had underwent percutaneous coronary intervention with multiple drug-eluting stents (DES) implantation on proximal-mid left anterior descending artery (LAD), and mid-right coronary artery (RCA), respectively. The angiogram revealed stent thrombosis with total occlusion of proximal LAD. Multiple passages with manual thrombus-aspiration catheter were successfully performed with improvement in TIMI flow. Optical Coherence Tomography (OCT) imaging revealed fully expanded stents without areas of inappropriate apposition to vessel wall; and mild to moderate intimal hyperplasia throughout the stented segment, with full covered stent struts; areas of ulcerated and ruptured plaque within the proximal struts of stented segment was depicted with intraluminal protruding material. Thus, an additional bare metal stent (BMS) was deployed inside and overlapping the previous in order to seal this plaque. OCT post procedure revealed optimal stent expansion and apposition, without residual protruding material. At 9-month follow-up patient was alive and free from symptoms. Coronary angiogram revealed patency of implanted stents without significant restenosis.ConclusionsNeo-atherosclerosis with thrombosis on top of ruptured necrotic plaque core may play a role in the pathophysiology of very late stent thrombosis in both BMS and DES. Our report highlights the role OCT to assess the mechanism of VLST

A combination of drug-eluting stents and bioresorbable vascular scaffolds in the treatment of multivessel coronary artery disease

Optimal management of multivessel coronary artery disease can be complex. We report a 67-year-old male patient who was admitted to the Padua University Hospital, Padua, Italy, in 2014 with a non-ST-elevation myocardial infarction. Coronary angiography showed diffuse multiple sub-occlusive lesions of the proximal and distal left coronary vessels involving a long segment of the vessel. On intravascular ultrasonography (IVUS), the left main artery was moderately diseased with critically stenotic and calcified branch ostia. A successful percutaneous coronary intervention using the T-stenting and small protrusion technique with two drug-eluting stents (DES) was performed on the left main artery and its main branches. Two bioresorbable vascular scaffolds were also deployed in overlap at the mid to distal segments of the left anterior descending artery and overlapping a previous DES at the proximal segment. The full expansion and apposition of the struts and scaffolds to the vessel wall without residual stenosis was confirmed by IVUS