Abciximab and bleeding during coronary surgery: results from the EPILOG and EPISTENT trials. Improve Long-term Outcome with abciximab GP IIb/IIIa blockade. Evaluation of Platelet IIb/IIIa Inhibition in STENTing.

BACKGROUND: Abciximab during percutaneous coronary revascularization reduces ischemic complications, but concern exists regarding increased bleeding risk should emergency coronary surgical procedures be required. METHODS: Outcomes were assessed among 85 patients who required coronary artery bypass grafting operations after coronary intervention in two randomized placebo-controlled trials of abciximab. Comparisons were made between patients in the pooled placebo and abciximab groups. RESULTS: The incidence of coronary surgical procedures was 2.17% and 1.28% among patients randomized to placebo and abciximab, respectively (p = 0.021). Platelet transfusions were administered to 32% and 52% of patients in the placebo and abciximab groups, respectively (p = 0.059). Rates of major blood loss were 79% and 88% in the placebo and abciximab groups, respectively (p = 0.27); transfusions of packed red blood cells or whole blood were administered in 74% and 80% of patients, respectively (p = 0.53). Surgical reexploration for bleeding was required in 3% and 12% of patients, respectively. Death and myocardial infarction tended to occur less frequently among patients who had received abciximab. CONCLUSIONS: Urgent coronary artery bypass grafting operations can be performed without an incremental increase in major hemorrhagic risk among patients on abciximab therapy.

Coronary artery bypass graft in abciximab-treated patients.

In an assessment of available literature regarding appropriate treatment algorithms for patients who fail cardiac interventions and require coronary bypass grafting with abciximab "on board," few surgeons reported significant variation in bleeding or other issues. There are many problems with postmarketing data collection, and such data would lack rigor and randomization. Prospective collection of data would be extremely difficult. Few patients go to surgery nowadays, and it is generally believed that because of the wealth of data supporting glycoprotein (GP) IIb/IIIa inhibition associated with percutaneous intervention, it would be unethical to subject patients to a placebo control in the catheterization laboratory. For those reasons, we returned to the clinical trials database and did a retrospective analysis of EPILOG and EPISTENT, the two studies that most appropriately reflect state-of-the-art intervention and abciximab use. We omitted EPIC, the original registration trial of high-risk angioplasty patients, because this study no longer reflects current recommendations regarding heparinization, abciximab administration, or groin care.

Management of esophageal gunshot wounds.

The records of 20 patients with gunshot wounds of the esophagus seen from 1973 through 1985 were reviewed. Nine perforations were cervical, 10 were thoracic, and 1 was abdominal. Because physical findings and plain roentgenograms lack specificity, a high index of suspicion based on the path of the bullet tract is essential for early diagnosis. Esophageal injury should especially be suspected when the bullet wound is transcervical or transmediastinal. Perforation was diagnosed by esophagoscopy in 9 patients, esophagography in 4, and surgical exploration in 7. Mean time from admission to operation was 3.8 hours. Associated injuries occurred frequently. Eighteen patients were treated by primary closure and wide drainage, and 2 were managed by esophageal exclusion. There were 2 perioperative deaths, both in patients with associated aortic injuries, and 1 late death, for an overall mortality of 15%. There was one postoperative leak following a cervical repair. No leaks occurred in patients having a thoracic repair. The findings indicate that esophageal perforation must be sought by a variety of methods. With prompt diagnosis and early operation, primary repair can be safely accomplished. When sepsis from esophageal leak is avoided, mortality and major morbidity are related to associated injuries.

Improved graft patency associated with altered platelet function induced by marine fatty acids in dogs.

Female mongrel dogs fed a marine fish diet rich in long-chain polyenoic fatty acids had improved patency of small-diameter arterial prosthetic grafts as compared to controls. Also, in vivo platelet function as measured by bleeding times was significantly prolonged. Eicosapentaenoic acid, not found in the serum of control animals, was present in relatively high concentrations in both the serum and a platelet-rich fraction of the marine oil-fed group. Eicosapentaenoic acid, unlike arachidonic acid, does not induce platelet aggregation and this phenomonon may account for the altered platelet function demonstrated in our animals and hence the improved graft patency. These data lend further support to the role of platelets in determining the patency of vascular grafts.

The sore psoas: a difficult diagnosis in childhood.

Nontuberculous psoas abscess is an unusual disease of childhood. The symptoms closely mimic those of other disorders and delay of treatment is commonplace. Eight children (age range 1.5-12 yr) have been treated for psoas abscess. Each presented with a history of fever (38-40 degrees C) and pain. The pain was localized to the hip (3-right, 4-left) and aggravated by ambulation in 7 cases. In 6 children, there was associated lower abdominal tenderness and flexion of the involved hip at rest with resistance to extension. Only 1 child was correctly suspected of having a psoas abscess. Delay in appropriate therapy averaged 5 days (range 1-20 days). Five children underwent joint aspiration and an additional 3 underwent abdominal exploration prior to diagnosis. Surgical drainage was subsequently performed in each case. A retroperitoneal approach, either flank or inguinal, was employed. Staphylococcus aureus was isolated from all cultures. Primary psoas abscess is seldom included in the differential diagnosis of septic lower abdominal and/or lower extremity pain. It should, however, be considered, particularly in the child with classic findings of psoas irritation.