Primary stenting versus balloon angioplasty in occluded coronary arteries: the Total Occlusion Study of Canada (TOSCA).

BACKGROUND: Balloon angioplasty (PTCA) of occluded coronary arteries is limited by high rates of restenosis and reocclusion. Although stenting improves results in anatomically simple occlusions, its effect on patency and clinical outcome in a broadly selected population with occluded coronary arteries is unknown. METHODS AND RESULTS: Eighteen centers randomized 410 patients with nonacute native coronary occlusions to PTCA or primary stenting with the heparin-coated Palmaz-Schatz stent. The primary end point, failure of sustained patency, was determined at 6-month angiography. Repeat target-vessel revascularization, adverse cardiovascular events, and angiographic restenosis (>50% diameter stenosis) constituted secondary end points. Sixty percent of patients had occlusions of >6 weeks' duration, baseline flow was TIMI grade 0 in 64%, and median treated segment length was 30.5 mm. With 95.6% angiographic follow-up, primary stenting resulted in a 44% reduction in failed patency (10.9% versus 19.5%, P=0.024) and a 45% reduction in clinically driven target-vessel revascularization at 6 months (15.4% versus 8.4%, P=0.03). The incidence of adverse cardiovascular events was similar for both strategies (PTCA, 23.6%; stent, 23.3%; P=NS). Stenting resulted in a larger mean 6-month minimum lumen dimension (1.48 versus 1.23 mm, P<0.01) and a reduced binary restenosis rate (55% versus 70%, P<0.01). CONCLUSIONS: Primary stenting of broadly selected nonacute coronary occlusions is superior to PTCA alone, improving late patency and reducing restenosis and target-vessel revascularization.

Short-term changes in tonic accommodation.

Experiments were performed to determine the diurnal variation of, as well as the influence of total darkness on, tonic accommodation. In general, under both conditions trend analysis showed that variations in tonic accommodation over time were either nonsystematic in nature or could be best described by a simple linear function. Given the relatively small range of mean tonic accommodation values over time (0.5 to 1.1 D), the results demonstrate the robustness and stability of tonic accommodation under naturally occurring viewing conditions during the course of a day. In contrast, during the 2-hr period in total darkness, tonic accommodation exhibited a three-fold increase in mean range (0.6 to 2.5 D) as well as a significant increasing linear trend in some subjects, suggesting less stability of tonic accommodation in the absence of visual stimuli.

Locomotion of bluefish.

1. Pressure previously measured on the body surface of swimming bluefish were resolved into their backward vectorial components to allow calculation of profile drag. It was 0.18 kg at a speed of 1.8 m/sec. Tangential drag was calculated as if for a thin plate of an area equal to that of the fish. It was 0.08 kg at 1.8 m/sec. Net drag, 0.26 kg, was the sum of profile and tangential drag. 2. Thrust and drag also were calculated from the changes of acceleration measured during steady swimming, assuming that thrust took place only during the acceleration phase, whereas drag occurred during both acceleration and deceleration. This drag was 0.08 kg at a speed of 1.1 m/sec. It is compatible with the drag of 0.26 at 1.8 m/sec calculated from profile and tangential drag provided drag varies as the square of velocity. 3. The force required to produced maximal acceleration was measured during a scare. It was calculated to be 6.9 kg at a peak acceleration of 3 g. 4. The compression strength of th vertebrae was found to be approximately 20 kg per cm2, or roughly three times the force encountered during maximal acceleration. This safety factor of 3 would be reduced when the back was curved, or if opposing groups of muscles were under tension. 5. The finding that a bluefish can accelerate at 3 g and that the vertebral column is strongg enough to withstand this force indicates that the muscles and body structure of a bluefish would be able to withstand the force of gravity if the fish were otherwise equipped for terrestrial life. This fish may have evolved these strengths simultaneously with land animals. It is speculated that other fish may have evolved some degree of strength to overcome inertia and drag during aquatic locomotion, and this evolution may have been a prelude to terrestrial locomotion.

Peri-operative hypoxaemia in children undergoing application of a plaster jacket for scoliosis.

Twenty children (six female), median age 24 months (range 12-156) who presented for application of a plaster jacket for scoliosis were studied pre-operatively with pulse oximetry overnight and on the first postoperative night. Pre-operatively the median (range) arterial oxygen saturation was 97 (95-98)%, although eight children had short episodes of desaturation to < 90%. Postoperatively the median saturation was unchanged, and nine children had short episodes of desaturation. Neither the presence of episodes of desaturation pre-operatively, nor the median or lowest saturation recorded were predictors of postoperative median saturation or the presence of episodes of desaturation. Despite the presumed reduction in chest wall compliance, the application of a plaster jacket for scoliosis in these young children was not associated with a significant change in their oxygenation.

Hand injuries: incidence and epidemiology in an emergency service.

During a four-month period, 1,164 patients presented to the surgical section of our Emergency Services (ES) with chief complaints involving the hand. Patient records were analyzed for several variables including demographics, diagnosis and therapeutic procedures. Lacerations were the most frequent injury, 61.5% (n=716) with deep structure injuries present in 6.1% (n=44). Of deep structure injuries, 36.4% were tendon lacerations, 27.2% were nerve injuries, and 36.4% were compound fractures. "Bites" accounted for 5.2% (37) of all lacerations, eight of which were human bites. Fractures were the second most frequent injury, (11.4%) and involved 143 separate bones. Infections were present in 7%; over half were paronychias. There were 42 (3.6%) thermal injuries.

In vitro detection of heparin-induced humoral antiplatelet activity.

We investigated the etiology of thrombocytopenia, with or without platelet thrombi, occurring while patients are receiving parenteral heparin. We used two in vitro methods to detect possible humoral factors in the sera of patients who became thrombocytopenic while receiving heparin. In the presence of heparin, four of four such patients' serum caused platelet aggregation. Only serum from the patient most severely affected clinically caused release of platelet factor 3 (PF3). All control sera gave negative results by both methods. We propose that platelet aggregation studies may be a sensitive and reliable method of confirming that thrombocytopenia occurring during heparin therapy is due to a humoral factor requiring the presence of heparin.