Resistance to Antiplatelet Therapy Is Associated With Symptoms of Cerebral Ischemia in Carotid Artery Disease.

BACKGROUND: Platelet inhibitory therapy is prescribed to prevent arterial thromboembolism in patients with atherosclerotic disease. Although taken by millions of people, around 30% are resistant to the treatment they are being prescribed. AIMS: To determine whether symptoms of cerebral ischemia, or pre-operative cerebral emboli, in patients admitted for a carotid endarterectomy were associated with resistance to aspirin or clopidogrel. METHODS: Venous blood from 133 patients immediately before carotid endarterectomy (CEA) was analyzed for resistance to aspirin and clopidogrel by multiplate impedance aggregometry. The number of emboli/hour entering the ipsilateral middle cerebral artery was counted by transcranial Doppler (TCD) on the day before surgery in 33 of these patients. RESULTS: Resistance was found in 21 (26.3%) of 100 patients taking aspirin and 14 (42%) of 33 taking clopidogrel. Mean (sd) residual platelet aggregation was significantly higher at 41.9(32) Au in patients who had suffered recent symptoms of cerebral ischemia compared with 30.8(16) Au in asymptomatic patients (p = 0.012). Residual platelet aggregation also correlated significantly with the number of emboli/hour counted by TCD in the ipsilateral middle cerebral artery (r = 0.45, p = 0.009). CONCLUSION: Antiplatelet resistance was associated with the frequency of cerebral emboli and recent symptoms of cerebral ischemia in patients with carotid disease. Definitive clinical studies are needed to explore whether testing for antiplatelet resistance should be undertaken routinely in patients starting platelet inhibitory therapy for cardiovascular disease.

Do emergency department physiotherapy practitioner's, emergency nurse practitioners and doctors investigate, treat and refer patients with closed musculoskeletal injuries differently?

INTRODUCTION: This paper aims to assess whether emergency department physiotherapy practitioner's (EDPPs), emergency nurse practitioner's (ENPs) and emergency department doctors investigate, treat and refer patients with closed musculoskeletal injuries differently. METHOD: The emergency department records of patients who fitted the departmental criteria for being treated by either ENPs, EDPPs or doctors were selected retrospectively during a 2 1/2 month period between 1 March and 15 May 2005. The investigation, management and referral or discharge of these patients were analysed. RESULTS: There was no significant difference between the proportion of patients sent for x ray and the type of clinician. (p = 0.17) There was also no significant difference between the proportions of x rays found to have fractures/dislocations with each type of clinician (p = 0.99). All fractures and dislocations were found to have been managed following the written departmental protocols. Consequently, further analysis was for soft tissue injuries only. For soft tissue injuries, senior house officers gave more patients analgesia/non-steroidal anti-inflammatory drugs compared with other clinicians (86%, p<0.001). ENPs gave more structural support (bandages, etc) compared with other clinicians (80%, p<0.001). Consultant's arranged the least formal follow-up although this was not significant (7.6%, p = 0.054) and middle grades offered the most follow-up (17%, p = 0.054) with this again not being significant. However, EDPPs referred significantly more patients for physiotherapy follow-up (9.2%, p = 0.031). CONCLUSION: ENPs, EDPPs and doctors of all grades investigated patients with fractures and dislocations similarly and managed them following the written departmental guidelines. However, there were statistically significant differences in the way patients with closed soft tissue injuries were treated and followed-up.