Use of prasugrel in the setting of clopidogrel hypersensitivity: Case report and systematic review of the literature.

Allergic reactions to clopidogrel soon after coronary stent implantation pose an important and challenging clinical problem. We describe a 44-year-old man who developed a diffuse maculopapular rash four days after initiation of clopidogrel with drug-eluting coronary stent placement. An initial treat-through strategy was unsuccessful due to patient intolerance to corticosteroids. Because of persistent hypersensitivity, clopidogrel was substituted with prasugrel which was continued successfully for one year without reaction. A systematic review of the literature was performed which identified 10 prior case reports of patients with clopidogrel hypersensitivity who were subsequently treated with prasugrel. Patient characteristics and clinical outcomes of these patients plus the current case were reviewed. There were 9 men and 2 women with ages from 44 to 76 years. All patients had undergone coronary stent procedures. Prasugrel was successfully used without cross-reactivity in 9 of the 11 patients (82%). Cross-reactivity was reported in two patients who developed hypersensitivity reactions to prasugrel similar to those experienced on clopidogrel. In conclusion, prasugrel can be used successfully in most patients with a history of clopidogrel hypersensitivity. However, potential cross-reactivity between these two thienopyridines may occur in some patients.

Impact of an Educational Intervention on the Opioid Knowledge and Prescribing Behaviors of Resident Physicians.

OBJECTIVES: The opioid epidemic is a multifactorial issue, which includes pain mismanagement. Resident physician education is essential in addressing this issue. We aimed to analyze the effects of an educational intervention on the knowledge and potential prescribing habits of emergency medicine (EM), general surgery (GS), and internal medicine residents (IM). METHODS: Resident physicians were provided with educational materials and were given pre-tests and post-tests to complete. Descriptive statistics were used to analyze pre-test and post-test responses. Chi-squared analysis was used to identify changes between the pre-tests and post-tests. A p < 0.05 value was considered statistically significant.  Results: Following the educational intervention, we observed improvement in correct prescribing habits for acute migraine management among emergency medicine residents (from 14.8% to 38.5%). Among general surgery residents, there was a significant improvement in adherence to narcotic amounts determined by recent studies for sleeve gastrectomy (p= 0.01) and laparoscopic cholecystectomy (p= 0.002). Additionally, we observed a decrease in the number of residents who would use opioids as a first-line treatment for migraines, arthritic joint pain, and nephrolithiasis. DISCUSSION: Resident physicians have an essential role in combating the opioid epidemic. There was a significant improvement in various aspects of opioid-related pain management among emergency medicine, internal medicine, and general surgery residents following the educational interventions. We recommend that medical school and residency programs consider including opioid-related pain management in their curricula.

Percutaneous coronary intervention of totally occluded coronary venous bypass grafts: An exercise in futility?

BACKGROUND: Percutaneous coronary intervention (PCI) of diseased saphenous vein grafts (SVG) continues to pose a clinical challenge. Current PCI guidelines give a class III recommendation against performing PCI on chronically occluded SVG. However, contemporary outcomes after SVG intervention have incrementally improved with distal protection devices, intracoronary vasodilators, drug-eluting stents, and prolonged dual antiplatelet therapy. AIM: To reassess the procedural and long-term outcomes of PCI for totally occluded SVG with contemporary techniques. METHODS: This was a retrospective observational study conducted at a single university hospital. The study population consisted of 35 consecutive patients undergoing PCI of totally occluded SVG. Post-procedure dual antiplatelet therapy was continued for a minimum of one year and aspirin was continued indefinitely. Clinical outcomes were assessed at a mean follow-up of 1221 ± 1038 d. The primary outcome was freedom from a major adverse cardiac event (MACE) defined as the occurrence of any of the following: death, myocardial infarction, stroke, repeat bypass surgery, repeat PCI, or graft reocclusion. RESULTS: The study group included 29 men and 6 women with a mean age of 69 ± 12 years. Diabetes was present in 14 (40%) patients. All patients had Canadian Heart Classification class III or IV angina. Clinical presentation was an acute coronary syndrome in 34 (97%) patients. Mean SVG age was 12 ± 5 years. Estimated duration of occlusion was acute (< 24 h) in 34% of patients, subacute (> 24 h to 30 d) in 26%, and late (> 30 d) in 40%. PCI was initially successful in 29/35 SVG occlusions (83%). Total stent length was 52 ± 35 mm. Intraprocedural complications of distal embolization or no-reflow occurred in 6 (17%) patients. During longer term follow-up, MACE-free survival was only 30% at 3 years and 17% at 5 years. CONCLUSION: PCI of totally occluded SVG can be performed with a high procedural success rate. However, its clinical utility remains limited by poor follow-up outcomes.