High prevalence of previous antiplatelet drug use in patients with new or recurrent ischemic stroke: Buffalo metropolitan area and Erie County stroke study.

STUDY OBJECTIVE: To determine the proportion of patients in a large metropolitan population who developed ischemic stroke despite having received antiplatelet drug therapy, and their associated characteristics and in-hospital outcomes. DESIGN: Retrospective, cross-sectional study. SETTING: Eleven hospitals in western New York State. PATIENTS: One thousand five hundred eighty-two patients with new or recurrent ischemic stroke who were admitted to one of the 11 study hospitals between January 1 and December 31, 2000, and for whom data were available regarding previous drug therapy. MEASUREMENTS AND MAIN RESULTS: The proportion of patients taking antiplatelet drugs before the onset of stroke was determined. Demographic and clinical characteristics, stroke subtypes, in-hospital bleeding complications, mortality, and discharge drugs were compared between patients with and those without previous antiplatelet drug use. Previous use of antiplatelet drugs was observed in 642 (41%) of the 1582 patients admitted with ischemic stroke. The antiplatelet drugs were aspirin alone (494 patients), clopidogrel alone (70), aspirin and clopidogrel (36), aspirin in combination with other antiplatelet drugs (20), and others (22). Patients with previous use of antiplatelet drugs were older and more likely to have hypertension, diabetes mellitus, hyperlipidemia, and a history of cardiovascular disease. The proportion of patients with large-vessel disease was greater among patients with previous use of antiplatelet drugs. Patients with previous use of antiplatelet drugs were more likely to be discharged with aspirin, clopidogrel, and an aspirin-dipyridamole combination. CONCLUSION: The relatively high proportion of patients who developed ischemic stroke despite taking antiplatelet drugs observed in this regional hospital-based study mandates clinical trials specifically addressing therapeutic intervention for this group of patients.

Buffalo metropolitan area and Erie County stroke study: rationale, design, and methods.

OBJECTIVES: The primary objective of this study was to define the incidence, disability, and death associated with stroke in the Buffalo metropolitan area and Erie County. This area has the highest stroke rate in New York State and therefore represents an ideal site to develop a successful model for prevention and management of stroke. DESIGN: A cross-sectional design to study all new and recurrent strokes that occurred in the calendar year 2000 in the geographical location of Buffalo metropolitan area and Erie County. PATIENTS AND DATA COLLECTED: A retrospective review of an estimated 5,000 patients with new stroke will be performed at regional hospitals and the coroner's office to determine the stroke subtypes, cerebrovascular risk factors, diagnostic investigations, treatment provided, and outcome. The total population residing in Buffalo in the year 2000 is available through the recent census. The study will also evaluate the quality of care provided for stroke patients including effectiveness of primary and secondary stroke prevention measures within this geographical region. CONCLUSIONS: We believe that this information will assist in allocation of resources and implementation of steps to improve stroke prevention and treatment.

Are you ready to become a robo-surgeon?

Robotic and minimally invasive surgery represents the future of modern surgical care. However, its role during the training of surgical residents has yet to be investigated. A previous study conducted by our group surveyed program directors at accredited general surgery training programs in the United States to determine the prevalence and application of robotics in their residency programs. This current study is a follow-up survey sent to residents across the United States to see whether they were being adequately trained and exposed to robotic surgery during their training. A survey was sent to 1800 general surgery residents, and their responses were tabulated and analyzed. Twenty-three per cent of the 1800 residents responded to our survey. An overwhelming 57 per cent of the responders indicated a high interest in robotic surgery. However, 80 per cent of the responders indicated not having a robotic training program. Robotic surgery has led to many promising advancements within the surgical subspecialties. With this emerging technology comes the need for a greater emphasis on the training of surgeons in robotics during their residency.

REVIEW: Fast-Tracking Cardiac Surgery.

A "fast track" approach to cardiac surgery can be defined as a perioperative process involving rapid progress from preoperative preparation through surgery and discharge from the hospital. Although highly individualized among the various heart surgery centers, the fast-track process is a team activity. It requires a team of health care providers to interact with the patient at various phases, from admission to discharge. The necessary elements of the fast-track program are choice and the titration of short-acting anesthetic drugs, standardized surgical procedures, early extubation, rewarming and sustained postoperative normothermia, postoperative pain control, early ambulation, alimentation and discharge, and follow-up after discharge. We review the current approaches to some of these aspects of patient care.

Heparin dose, transfusion rates, and intraoperative graft patency in minimally invasive direct coronary artery bypass.

BACKGROUND: Many investigators have demonstrated the short-term and midterm efficacy of minimally invasive direct coronary artery bypass (MIDCAB). However, the influence of heparin dosing during MIDCAB on postoperative and immediate graft patency is less well defined. This report outlines our experience with MIDCAB employing a variety of heparinization protocols. METHODS: The traditional MIDCAB approach was used in 152 patients who underwent single-vessel off-pump coronary artery bypass. Before the left internal mammary artery was divided, a 150-U/kg bolus of heparin sodium was given to 76 patients (group 1), and 300 U/kg was given to another 76 patients (group 2). Additional heparin was given during the procedures to maintain an activated clotting times of greater than 300 seconds for group 1 and greater than 400 seconds for group 2. RESULTS: On average, patients in group 1 required more boluses of heparin during treatment than patients in group 2. A larger standard deviation from the mean was observed for the activated clotting time in group 1 at any time during treatment than for patients in group 2. The number of revised grafts was smaller in group 2 (1/76, 1.3%) than in group 1 (4/76, 5.2%). All of these revisions revealed thrombus at the site of anastomosis. In addition, noncoronary thrombotic complications were seen in 5 patients in group 1, and none were seen in group 2. CONCLUSION: Coronary artery surgery without cardiopulmonary bypass does not trigger the systemic inflammatory response, but surgical tissue trauma remains a constant. The preserved hemostasis theoretically may lead to a procoagulant state. This study demonstrates that insufficient anticoagulation therapy can lead to intracoronary thrombosis following MIDCAB as well as increased noncoronary thrombotic complications.

The telecommunication revolution in the medical field: present applications and future perspective.

In the present review, we analyze the achievements of telecommunication innovations in the medical field focusing on patient care and medical-education aspects. In this regard, the telecommunication revolution has offered medical professionals the possibility to transmit information of any sort zeroing transmission time latency and annihilating spatial distances. Although telemedicine is still in its infancy, multiple applications of this science have already been successfully tested. As an example, robotically mediated telesurgery has it made possible for surgeons to operate standing at a considerable distance from the operating table without even touching or directly seeing the surgical field. Moreover, medical education and medical consulting have acquired new and wider ranges of applicability thanks to the introduction of teleproctoring, telementoring, and teleconsulting. Finally, in the very near future, telepresence surgery will permit "virtual" operations on patients where surgeons can project their manual dexterity, psychomotor skills, and problem-solving ability to remote locations. In this context, telemedicine will support a more equal distribution of medical knowledge and promote excellence in patients' care even in the most disadvantaged environments.

Third generation thrombolytics for the treatment of ischemic stroke.

The field of intravenous and intra-arterial thrombolysis for the treatment of acute ischemic stroke is rapidly advancing. Limitations of existing thrombolytic agents have prompted the development of new thrombolytic agents over the last decade. These new agents are broadly classified as third generation thrombolytics. Two of the several third generation thrombolytic agents have been investigated for the treatment of acute ischemic stroke and include tenecteplase (Genentech Inc) and reteplase (Roche Holding AG). By virtue of structural modifications, third generation thrombolytics have longer half-lives and greater penetration into the thrombus matrix. Tenecteplase has been evaluated in experimental models of ischemic stroke. These experimental studies have observed faster and more complete recanalization of occluded arteries compared with second-generation thrombolytics. The first prospective human clinical trial evaluated the safety and efficacy of intra-arterial reteplase in 16 patients with ischemic stroke who were poor candidates for intravenous alteplase therapy. Near complete or complete recanalization was observed after treatment in 88% of the patients. The development and use of third generation thrombolytics is expected to increase the rate of recanalization and clinical recovery in patients with ischemic stroke. Clinical trials are required to determine the appropriate dose and patient selection for these emerging pharmacological agents.