Non ST-elevation acute coronary syndrome.

INTRODUCTION: Non ST-elevation acute coronary syndrome (NSTE-ACS, here defined as unstable angina and non ST-elevation MI) is characterised by episodes of chest pain at rest or with minimal exertion, which increase in frequency or severity, often with dynamic ECG changes. Between 9% and 19% of people with NSTE-ACS die in the first 6 months after diagnosis, with about half of these deaths occurring within 4 weeks of diagnosis. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of: antiplatelet; antithrombin; anti-ischaemic; lipid-lowering; and invasive treatments? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 32 systematic reviews, RCTs, or observational studies that met our inclusion criteria. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: aspirin, beta-blockers, calcium channel blockers, clopidogrel, direct thrombin inhibitors, glycoprotein IIb/IIIa inhibitors (oral or intravenous), heparin (low molecular weight, unfractionated), fondaparinux, nitrates, routine early cardiac catheterisation and revascularisation, statins, and warfarin

Acute coronary syndrome (unstable angina and non-ST elevation MI)

Acute coronary syndrome (ACS, here defined as unstable angina and non-ST elevation MI) is characterised by episodes of chest pain at rest or with minimal exertion, which are increasing in frequency or severity often with dynamic ECG changes. Aspirin reduces the risk of death, MI, and stroke compared with placebo in people with ACS at doses up to 325 mg daily; higher doses of aspirin are no more effective, and increase the risk of complications.Adding clopidogrel to aspirin may reduce the combined outcome of mortality and MI, but may increase the risk of bleeding. Intravenous glycoprotein IIb/IIIa platelet receptor inhibitors reduce the combined end point of death and MI at 6 months in people with ACS, but increase the risk of bleeding. Unfractionated or low molecular weight heparin plus aspirin may reduce death or MI at 1 week, but longer-term benefits are unclear. Low molecular weight heparin may reduce MI compared with unfractionated heparin Direct thrombin inhibitors (hirudin and bivalirudin) may reduce death or MI compared with unfractionated heparin. Warfarin has not been shown to be beneficial and increases the risk of major bleeding

Bare metal stent thrombosis 13 years after implantation.

There has been a great deal of recent controversy regarding the risk of very late stent thrombosis with drug eluting stents, especially in the context of antiplatelet therapy cessation. We report a case of very late stent thrombosis of a bare metal stent initially implanted for treatment of a myocardial infarction. The patient presented thirteen years later with a recurrent myocardial infarction three days after discontinuing aspirin. Angiography demonstrated thrombotic occlusion and severe underlying restenosis of the stent. To our knowledge, this is the latest bare metal stent thrombosis described in the world medical literature

Comprehensive meta-analysis on drug-eluting stents versus bare-metal stents during extended follow-up.

BACKGROUND: Several observational reports have documented both increased and decreased cardiac mortality or Q-wave myocardial infarction with drug-eluting stents compared with bare-metal stents. METHODS: We sought to evaluate the safety and efficacy of drug-eluting stents compared with bare-metal stents early after intervention (\u3c1 \u3eyear) and late (\u3e1 year) among a broad population of patients, using a meta-analysis of randomized clinical trials. RESULTS: We identified 28 trials with a total of 10,727 patients and a mean follow-up of 29.6 months. For early outcomes (\u3c1 \u3eyear), all-cause mortality for drug-eluting stents versus bare-metal stents was 2.1% versus 2.4% (risk ratio [RR] 0.91, [95% confidence interval (CI), 0.70-1.18]; P=.47), non-Q-wave myocardial infarction was 3.3% versus 4.4% (RR 0.78 [95% CI, 0.61-1.00]; P=.055), target lesion revascularization was 5.8% versus 18.4% (RR 0.28 [95% CI, 0.21-0.38]; P1 year), all-cause mortality for drug-eluting stents versus bare-metal stents was 5.9% versus 5.7% (RR 1.03 [95% CI, 0.83-1.28]; P=.79), target lesion revascularization was 4.0% versus 3.3% (RR 1.22 [95% CI, 0.92-1.60]; P=.16), non-Q-wave myocardial infarction was 1.6% versus 1.2% (RR 1.36 [95% CI, 0.74-2.53]; P=.32) and stent thrombosis was 0.7% versus 0.1% (RR 4.57 [95% CI, 1.54-13.57]; P=.006). CONCLUSIONS: There was no excess mortality with drug-eluting stents. Within 1 year, drug-eluting stents appear to be safe and efficacious with possibly decreased non-Q-wave myocardial infarction compared with bare-metal stents. After 1 year, drug-eluting stents still have similar mortality, despite increased stent thrombosis. The reduction in target lesion revascularization with drug-eluting stents mainly happens within 1 year, but is sustained thereafter

Water Controversies Between Conflict and Cooperation: Agent-Based Models for Non-traditional Security in D. Secchi, M. Neumann (eds.), Agent-Based Simulation of Organizational Behavior

In the last decade, a lot of attention has been increasingly devoted to 6 ABMs (Agent-Based Models), facilitated also by the availability of computational 7 power and open-source platforms. ABMs are thus becoming especially popular in 8 social and political sciences for modelling complex situations with multiple actors 9 that can evolve in highly unpredictable scenarios, due to a series of endogenous and 10 exogenous variables often difficult to identify and even less to measure and predict. 11 Conflicts and wars often qualify as ones. The aim of the present paper is to apply 12 ABMs to analyse the complex issues arising from dam development on the Mekong 13 River and the endless controversies this development has provoked since the 1960s, 14 making it one of the most pressing non-traditional security issues in the region. It 15 will preliminary examine the challenges of implementing ABMs to complex real- 16 world situation like the ones into exam and which preliminary steps and theoretical 17 considerations are necessary before the formulation of a definitive model. Finally, 18 it will provide indications the state of the work in progress on the model created 19 for this case-study, a few preliminary conclusions about its effectiveness, and some 20 notes for future development