804-4 A Randomized, Double-blind Trial of Streptokinase Versus Placebo for the Management of Unstable Angina and Non-Q-wave Myocardial Infarction in Patients with Previous Coronary Artery Bypass Surgery

This trial investigated the potential usefulness of thrombolysis in patients with previous coronary artery bypass surgery admired for unstable angina and non-Q-wave myocardial infarction, the rationale being more frequent non-Q-wave infarction in these patients and a high-fibrin content of older grafts. A total of 125 consecutive patients with symptoms evolving for less than 24 hr were randomized to intravenous streptokinase 1.5 million Units in 45 min, or to placebo. All patients received concomitant intravenous heparin, oral aspirin and standard anti-ischemic therapy. Mean age (62±9 yrs). sex (78% male). time of previous surgery (8±0.5 yrs), presence of a previous myocardial infarction (63%). prior medication including aspirin in 66%, an abnormal ECG at admission (79%) and time to treatment after the last ischemic episode (10±9 hr) were similar in the 2 study groups.Fatal and non-fatal myocardial infarctions in hospital occurred in 7 streptokinase (11.1%) and 3 placebo (4.8%) patients (relative risk 2.3, 95% confidence limits 0.62–8.48, p=0.19) and at 1 month in an additional 2 patients in each group. Refractory angina in hospital was observed in 12 (19.1%) streptokinase patients and 13 (20.9%) placebo patients. A revascularization procedure because of recurrent symptoms was required at 1 month in respectively 22 (34.9%) and 16 (25.8%) patients.ConclusionThe early cardiac event rate in unstable angina associated with previous bypass surgery is high. The nonsignificant excess in the risk of myocardial infarction with streptokinase in this population most likely to benefit, is similar to the excess reported in other populations of patients with unstable angina and non-a-wave myocardial infarction and supports the lack of benefit of thrombolysis in unstable angina

Investigation of 3D glenohumeral displacements from 3D reconstruction using biplane X-ray images: Accuracy and reproducibility of the technique and preliminary analysis in rotator cuff tear patients

Rotator cuff (RC) tears may be associated with increased glenohumeral instability; however, this instability is difficult to quantify using currently available diagnostic tools. Recently, the three-dimensional (3D) reconstruction and registration method of the scapula and humeral head, based on sequences of low-dose biplane X-ray images, has been proposed for glenohumeral displacement assessment. This research aimed to evaluate the accuracy and reproducibility of this technique and to investigate its potential with a preliminary application comparing RC tear patients and asymptomatic volunteers. Accuracy was assessed using CT scan model registration on biplane X-ray images for five cadaveric shoulder specimens and showed differences ranging from 0.6 to 1.4 mm depending on the direction of interest. Intra- and interobserver reproducibility was assessed through two operators who repeated the reconstruction of five subjects three times, allowing defining 95% confidence interval ranging from ±1.8 to ±3.6 mm. Intraclass correlation coefficient varied between 0.84 and 0.98. Comparison between RC tear patients and asymptomatic volunteers showed differences of glenohumeral displacements, especially in the superoinferior direction when shoulder was abducted at 20 and 45 . This study thus assessed the accuracy of the low-dose 3D biplane X-ray reconstruction technique for glenohumeral displacement assessment and showed potential in biomechanical and clinical research.Fondation Paris-Tech Programme BIOMECAM Chaire ParisTech Institut de Recherche Robert-Sauvé en Santé et Sécurité du Travail du Québec Natural Science and Engineering Research Council of Canada Fonds de Recherche sur la Nature et les Technologies du Québec Fonds de Recherche en Santé du Québec, EOS Imaging, and French pôle de compétitivité MEDICEN (STEREOS + program)

The Benefits Conferred by Radial Access for Cardiac Catheterization Are Offset by a Paradoxical Increase in the Rate of Vascular Access Site Complications With Femoral Access The Campeau Radial Paradox

AbstractObjectivesThe purpose of this study was to assess whether the benefits conferred by radial access (RA) at an individual level are offset by a proportionally greater incidence of vascular access site complications (VASC) at a population level when femoral access (FA) is performed.BackgroundThe recent widespread adoption of RA for cardiac catheterization has been associated with increased rates of VASCs when FA is attempted.MethodsLogistic regression was used to calculate the adjusted VASC rate in a contemporary cohort of consecutive patients (2006 to 2008) where both RA and FA were used, and compared it with the adjusted VASC rate observed in a historical control cohort (1996 to 1998) where only FA was used. We calculated the adjusted attributable risk to estimate the proportion of VASC attributable to the introduction of RA in FA patients of the contemporary cohort.ResultsA total of 17,059 patients were included. At a population level, the VASC rate was higher in the overall contemporary cohort compared with the historical cohort (adjusted rates: 2.91% vs. 1.98%; odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.17 to 1.89; p = 0.001). In the contemporary cohort, RA patients experienced fewer VASC than FA patients (adjusted rates: 1.44% vs. 4.19%; OR: 0.33, 95% CI: 0.23 to 0.48; p < 0.001). We observed a higher VASC rate in FA patients in the contemporary cohort compared with the historical cohort (adjusted rates: 4.19% vs. 1.98%; OR: 2.16, 95% CI: 1.67 to 2.81; p < 0.001). This finding was consistent for both diagnostic and therapeutic catheterizations separately. The proportion of VASCs attributable to RA in the contemporary FA patients was estimated at 52.7%.ConclusionsIn a contemporary population where both RA and FA were used, the safety benefit associated with RA is offset by a paradoxical increase in VASCs among FA patients. The existence of this radial paradox should be taken into consideration, especially among trainees and default radial operators

Predicting global killer whale population collapse from PCB pollution

This research was supported by grants to J.-P.D. from the Canadian National Science and Engineering Research Council (NSERC) (PGSD3-443700-2013) and Aarhus University’s Graduate School and Science and Technology (GSST) and Department of Bioscience; and by funding from the Danish DANCEA program (MST-112-00171 and MST-112-00199); the Defra, Scottish and Welsh Governments (for CSIP/SMASS/CEFAS); and the Icelandic Research Fund (i. Rannsóknasjóður; grant no. 120248042). B.M. was supported by funding from NERC (grant no. SMRU 10001). This paper is a contribution from the BONUS BALTHEALTH project, which has received funding from BONUS (Art. 185), funded jointly by the EU, Innovation Fund Denmark, Forschungszentrum Jülich GmbH, German Federal Ministry of Education and Research (grant no. FKZ 03F0767A), Academy of Finland (decision no. 311966), and Swedish Foundation for Strategic Environmental Research.Killer whales (Orcinus orca) are among the most highly polychlorinated biphenyl (PCB)–contaminated mammals in the world, raising concern about the health consequences of current PCB exposures. Using an individual-based model framework and globally available data on PCB concentrations in killer whale tissues, we show that PCB-mediated effects on reproduction and immune function threaten the long-term viability of >50% of the world’s killer whale populations. PCB-mediated effects over the coming 100 years predicted that killer whale populations near industrialized regions, and those feeding at high trophic levels regardless of location, are at high risk of population collapse. Despite a near-global ban of PCBs more than 30 years ago, the world’s killer whales illustrate the troubling persistence of this chemical class.PostprintPeer reviewe

Intravenous diltiazem in acute myocardial infarction Diltiazem as adjunctive therapy to activase (DATA) trial

AbstractObjectives. This study was defined as a pilot investigation of the usefulness and safety of intravenous diltiazem as adjunctive therapy to tissue plasminogen activator in acute myocardial infarction, followed by oral therapy for 4 weeks.Background. Experimental studies have documented that calcium antagonists protect the myocardial cell against the damage caused by coronary artery occlusion and reperfusion, yet no benefits have been conclusively demonstrated in acute myocardial infarction (AMI) in humans.Methods. In this pilot study, 59 patients with an AMI treated with tissue-type plasminogen activator (t-PA) were randomized, double blinded, to intravenous diltiazem or placebo for 48 h, followed by oral therapy for 4 weeks. The primary objective was to detect an effect on indices of regional left ventricular function and perfusion. Patients were also closely monitored for clinical events, coronary artery patency and indices of infarct size and of left ventricular function.Results. Creatine kinase elevation, Q wave score, global and regional left ventricular function and coronary artery patency at 48 h were not significantly different between the diltiazem and placebo groups. A greater improvement observed in regional perfusion and function with diltiazem was likely explained by initial larger defects. Diltiazem, compared to placebo, reduced the rate of death, reinfarction or recurrent ischemia at 35 days from 41% to 13% (p = 0.027) and prevented the need for an urgent intervention. The rate of death or myocardial infarction was reduced by 65% (p = 0.15). These benefits could not be explained by differences in baseline characteristics such as age, site and extent of infarction, time of inclusion or concomitant therapy. Heart rate and blood pressure were reduced throughout the study with active diltiazem treatment. Side effects of diltiazem were bradycardia and hypotension that required transient or permanent discontinuation of the study drug in 27% of patients, vs. 17% of patients with placebo.Conclusions. A protective effect for clinical events related to early postinfarction ischemia and reinfarction was suggested in this study, with diltiazem administered intravenously with t-PA followed by oral therapy for 1 month, with no effect on coronary artery patency and left ventricular function and perfusion