PURPOSE: Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) has improved the ease with which practitioners can obtain mediastinum tissue samples. However, evidence-based studies are limited regarding best management of dual antiplatelet agents (DAPT) aspirin and clopidogrel, or clopidogrel alone in patients who undergo this procedure. One 2006 study recommended discontinuation of clopidogrel prior to transbronchial biopsy after documenting increased bleeding severity in patients taking clopidogrel. However, a recent retrospective review of 12 patients, suggested that EBUS-TBNA can be performed safely by experienced operators in patients taking clopidogrel. Our study further evaluates adverse bleeding events following EBUS-TBNA in patients exposed to DAPT, clopidogrel only, or aspirin (ASA) alone 5 days prior to the procedure versus patients unexposed to anti-platelet medications. METHODS: Retrospective chart review was conducted on patients aged 18 or older who underwent EBUS-TBNA between January 1, 2009 and December 31, 2014 at our institution. Patients were excluded from analysis if taking anti-platelet medications other than clopidogrel and/or aspirin, if using therapeutic anticoagulation, if had history of bleeding or clotting disorder, active disseminated intravascular coagulation, or platelet count <80,000. Adverse bleeding events were defined as any one of the following: immediate bleeding requiring procedural interruption and/or topical intervention, red blood cell transfusion requirement within 24 hours of procedure, hemoglobin drop $ 2 grams, or readmission within 48 hours of procedure for hemoptysis or anemia. Data included demographics, comorbidities, and pre/post procedure CBC. Data was analyzed via one-way ANOVA and chi-square tests. RESULTS: Of 476 patients, 67 were excluded. Of the remaining patients: DAPT n¼23; clopidogrel n¼13; ASA n¼103; unexposed n¼270. Overall bleeding events were low, occurring in 2.9% of all patients: DAPT n¼2 (8.7%); clopidogrel n¼1 (7.7%); ASA n¼1 (<1%); unexposed n¼8 (2.9%), p ¼ 0.164. No immediate bleeding events were recorded for patients taking DAPT or clopidogrel alone, but these patients were more likely to experience hemoglobin drop > 2g: DAPT n¼1 (4.3%); clopidogrel n¼1 (7.7%); ASA n¼0 (0.0%); unexposed n¼2 (0.7%), p ¼ 0.019. Patients taking DAPT were more likely to be readmitted in 48 hours: DAPT n¼1 (4.3%); clopidogrel n¼0 (0.0%); ASA n¼0 (0.0%); unexposed n¼1 (0.4%), p ¼ 0.053. CONCLUSIONS: Similar rates of bleeding suggest that discontinuation of DAPT or clopidogrel may not be necessary prior to EBUS-TBNA. However, the absolute number of bleeding complications was low in both exposed and unexposed patients and definitive recommendations require a larger patient population to achieve adequate statistical power. CLINICAL IMPLICATIONS: Clinicians should weigh individual risks and benefits when deciding to discontinue DPTA or clopidogrel before EBUS-TBNA.
Introduction. Ethanol is a commonly used fixative. Fixation of the inner layers of the tissue depends on the ability of the fixative to diffuse into the tissue. It is unknown whether the concentration of ethanol affects its penetration into tissues. This study aimed to compare the penetration rates of 50% and 100% ethanol into bovine heart and liver tissues. Materials and methods. The penetration distance and tissue shrinkage or expansion were measured by analysing the digital images of the heart and liver tissues before and after immersion in ethanol at 20°C for 2, 6, 24 or 30 hours. The penetration coefficients were calculated as the slope of the regression line using the linear regression function between the penetration distance and square root of fixation time. Differences in tissue shrinkage or expansion and penetration distance at various time points between the two concentrations of ethanol were analysed using a mixed design ANOVA followed by Bonferroni's post-hoc test. Results. The penetration distance of 100% ethanol was significantly greater in both heart and liver tissues compared with that of 50% ethanol (n = 4, p < 0.05 for both). 100% ethanol shrank immersed liver tissue significantly more than 50% ethanol (p = 0.002), but the shrinkage of the heart tissue caused by two concentrations of ethanol did not significantly differ (p = 0.054). The greater penetration distance of 100% over 50% ethanol remained unchanged after normalising the penetration distance to the individual tissue's shrinkage (n = 4, p < 0.001). The mean penetration coefficient of 100% ethanol was significantly greater than 50% ethanol in the heart tissue (0.906 vs. 0.442, p = 0.003) and in the liver tissue (0.988 vs. 0.622, p = 0.028). Conclusions. It was proven that in two types of tissue that substantially differ in histological structures, 100% ethanol penetrated tissue significantly faster than 50% ethanol.
SUMMARYThe clinical and pathological data from 46 patients who died during or shortly after coronary bypass surgery and one patient who died shortly after angiography were studied. Each patient was placed into one In this study, we examined the clinical and pathological features in 47 anginal patients who had been evaluated clinically. Forty-six of these were operated upon soon after examination and died either at the time of or shortly after coronary bypass surgery. With this patient selection, it was felt that any pathological changes occurring subsequent to operation could be identified. Pathological changes not so identified could thus be correlated with clinical studies, usually done within two weeks of operation. Specific pathological profiles corresponding with the various clinical types of angina were sought. Of interest, also, was the question of frequency of clinically unidentified acute myocardial infarction in patients with unstable angina pectoris. cmary heart disease Materials and Methods Forty-seven patients with various types of angina were studied. Forty-six died after a coronary bypass procedure and one other patient died shortly after coronary arteriography. From the clinical records, each patient was classified as to the type of angina according to the following definitions.Angina pectoris was subdivided into major types, stable and unstable. Stable angina was defined as anterior thoracic pain related to effort and relieved by rest. The duration varied from between three and ten minutes. The pattern of occurrence of stable angina does not change but may be of varied severity and may be subdivided into the moderate and severe types. Characteristic of stable angina was prompt relief of discomfort with rest or nitroglycerin.Unstable angina was characterized as angina of recent onset (less than three weeks prior to clinical evaluation) or as angina characterized by a recent change in pattern (i.e., stable angina which has recently worsened in terms of frequency, severity, intensity and ease of provocation). Nocturnal or angina at rest, as well as episodes of prolonged angina, were often characteristic in these patients. There was no electrocardiographic or enzymatic evidence of recent myocardial infarction.Most patients with unstable angina had been hospitalized for at least four days prior to operation, and clinical evaluation, including electrocardiographic and enzyme studies, had not shown evidence of acute myocardial infarction.The clinical records were abstracted for a history of previous myocardial infarction, valvular disease, diabetes and smoking habits, as well as levels of blood pressure, cholesterol and triglycerides. Also, the presence or absence of a family history of myocardial infarction was noted.At autopsy the hearts of each of the 47 cases were examined and the cardiac weight and thickness of the left ventricular wall were recorded. The coronary arteries were ex-
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