Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents.

BACKGROUND Dual antiplatelet therapy is recommended after coronary stenting to prevent thrombotic complications, yet the benefits and risks of treatment beyond 1 year are uncertain. METHODS Patients were enrolled after they had undergone a coronary stent procedure in which a drug-eluting stent was placed. After 12 months of treatment with a thienopyridine drug (clopidogrel or prasugrel) and aspirin, patients were randomly assigned to continue receiving thienopyridine treatment or to receive placebo for another 18 months; all patients continued receiving aspirin. The coprimary efficacy end points were stent thrombosis and major adverse cardiovascular and cerebrovascular events (a composite of death, myocardial infarction, or stroke) during the period from 12 to 30 months. The primary safety end point was moderate or severe bleeding. RESULTS A total of 9961 patients were randomly assigned to continue thienopyridine treatment or to receive placebo. Continued treatment with thienopyridine, as compared with placebo, reduced the rates of stent thrombosis (0.4% vs. 1.4%; hazard ratio, 0.29 [95% confidence interval {CI}, 0.17 to 0.48]; P<0.001) and major adverse cardiovascular and cerebrovascular events (4.3% vs. 5.9%; hazard ratio, 0.71 [95% CI, 0.59 to 0.85]; P<0.001). The rate of myocardial infarction was lower with thienopyridine treatment than with placebo (2.1% vs. 4.1%; hazard ratio, 0.47; P<0.001). The rate of death from any cause was 2.0% in the group that continued thienopyridine therapy and 1.5% in the placebo group (hazard ratio, 1.36 [95% CI, 1.00 to 1.85]; P=0.05). The rate of moderate or severe bleeding was increased with continued thienopyridine treatment (2.5% vs. 1.6%, P=0.001). An elevated risk of stent thrombosis and myocardial infarction was observed in both groups during the 3 months after discontinuation of thienopyridine treatment. CONCLUSIONS Dual antiplatelet therapy beyond 1 year after placement of a drug-eluting stent, as compared with aspirin therapy alone, significantly reduced the risks of stent thrombosis and major adverse cardiovascular and cerebrovascular events but was associated with an increased risk of bleeding. (Funded by a consortium of eight device and drug manufacturers and others; DAPT ClinicalTrials.gov number, NCT00977938.).

Signal Processing for the Measurement of the Deuterium/Hydrogen Ratio in the Local Interstellar Medium

We report on a comprehensive signal processing procedure for very low signal levels for the measurement of neutral deuterium in the local interstellar medium from a spacecraft in Earth orbit. The deuterium measurements were performed with the IBEX-Lo camera on NASA’s Interstellar Boundary Explorer (IBEX) satellite. Our analysis technique for these data consists of creating a mass relation in three-dimensional time of flight space to accurately determine the position of the predicted D events, to precisely model the tail of the H events in the region where the H tail events are near the expected D events, and then to separate the H tail from the observations to extract the very faint D signal. This interstellar D signal, which is expected to be a few counts per year, is extracted from a strong terrestrial background signal, consisting of sputter products from the sensor’s conversion surface. As reference we accurately measure the terrestrial D/H ratio in these sputtered products and then discriminate this terrestrial background source. During the three years of the mission time when the deuterium signal was visible to IBEX, the observation geometry and orbit allowed for a total observation time of 115.3 days. Because of the spinning of the spacecraft and the stepping through eight energy channels the actual observing time of the interstellar wind was only 1.44 days. With the optimised data analysis we found three counts that could be attributed to interstellar deuterium. These results update our earlier work.

Stent Thrombosis in Drug-Eluting or Bare-Metal Stents in Patients Receiving Dual Antiplatelet Therapy

OBJECTIVES This study sought to compare rates of stent thrombosis and major adverse cardiac and cerebrovascular events (MACCE) (composite of death, myocardial infarction, or stroke) after coronary stenting with drug-eluting stents (DES) versus bare-metal stents (BMS) in patients who participated in the DAPT (Dual Antiplatelet Therapy) study, an international multicenter randomized trial comparing 30 versus 12 months of dual antiplatelet therapy in subjects undergoing coronary stenting with either DES or BMS. BACKGROUND Despite antirestenotic efficacy of coronary DES compared with BMS, the relative risk of stent thrombosis and adverse cardiovascular events is unclear. Many clinicians perceive BMS to be associated with fewer adverse ischemic events and to require shorter-duration dual antiplatelet therapy than DES. METHODS Prospective propensity-matched analysis of subjects enrolled into a randomized trial of dual antiplatelet therapy duration was performed. DES- and BMS-treated subjects were propensity-score matched in a many-to-one fashion. The study design was observational for all subjects 0 to 12 months following stenting. A subset of eligible subjects without major ischemic or bleeding events were randomized at 12 months to continued thienopyridine versus placebo; all subjects were followed through 33 months. RESULTS Among 10,026 propensity-matched subjects, DES-treated subjects (n = 8,308) had a lower rate of stent thrombosis through 33 months compared with BMS-treated subjects (n = 1,718, 1.7% vs. 2.6%; weighted risk difference -1.1%, p = 0.01) and a noninferior rate of MACCE (11.4% vs. 13.2%, respectively, weighted risk difference -1.8%, p = 0.053, noninferiority p < 0.001). CONCLUSIONS DES-treated subjects have long-term rates of stent thrombosis that are lower than BMS-treated subjects. (The Dual Antiplatelet Therapy Study [DAPT study]; NCT00977938).

Antiplatelet therapy duration following bare metal or drug-eluting coronary stents: the dual antiplatelet therapy randomized clinical trial

IMPORTANCE Despite antirestenotic efficacy of coronary drug-eluting stents (DES) compared with bare metal stents (BMS), the relative risk of stent thrombosis and adverse cardiovascular events is unclear. Although dual antiplatelet therapy (DAPT) beyond 1 year provides ischemic event protection after DES, ischemic event risk is perceived to be less after BMS, and the appropriate duration of DAPT after BMS is unknown. OBJECTIVE To compare (1) rates of stent thrombosis and major adverse cardiac and cerebrovascular events (MACCE; composite of death, myocardial infarction, or stroke) after 30 vs 12 months of thienopyridine in patients treated with BMS taking aspirin and (2) treatment duration effect within the combined cohorts of randomized patients treated with DES or BMS as prespecified secondary analyses. DESIGN, SETTING, AND PARTICIPANTS International, multicenter, randomized, double-blinded, placebo-controlled trial comparing extended (30-months) thienopyridine vs placebo in patients taking aspirin who completed 12 months of DAPT without bleeding or ischemic events after receiving stents. The study was initiated in August 2009 with the last follow-up visit in May 2014. INTERVENTIONS Continued thienopyridine or placebo at months 12 through 30 after stent placement, in 11,648 randomized patients treated with aspirin, of whom 1687 received BMS and 9961 DES. MAIN OUTCOMES AND MEASURES Stent thrombosis, MACCE, and moderate or severe bleeding. RESULTS Among 1687 patients treated with BMS who were randomized to continued thienopyridine vs placebo, rates of stent thrombosis were 0.5% vs 1.11% (n = 4 vs 9; hazard ratio [HR], 0.49; 95% CI, 0.15-1.64; P = .24), rates of MACCE were 4.04% vs 4.69% (n = 33 vs 38; HR, 0.92; 95% CI, 0.57-1.47; P = .72), and rates of moderate/severe bleeding were 2.03% vs 0.90% (n = 16 vs 7; P = .07), respectively. Among all 11,648 randomized patients (both BMS and DES), stent thrombosis rates were 0.41% vs 1.32% (n = 23 vs 74; HR, 0.31; 95% CI, 0.19-0.50; P < .001), rates of MACCE were 4.29% vs 5.74% (n = 244 vs 323; HR, 0.73; 95% CI, 0.62-0.87; P < .001), and rates of moderate/severe bleeding were 2.45% vs 1.47% (n = 135 vs 80; P < .001). CONCLUSIONS AND RELEVANCE Among patients undergoing coronary stent placement with BMS and who tolerated 12 months of thienopyridine, continuing thienopyridine for an additional 18 months compared with placebo did not result in statistically significant differences in rates of stent thrombosis, MACCE, or moderate or severe bleeding. However, the BMS subset may have been underpowered to identify such differences, and further trials are suggested. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00977938.

Bacillus anthracis Diversity and Geographic Potential across Nigeria, Cameroon and Chad: Further Support of a Novel West African Lineage.

Zoonoses, diseases affecting both humans and animals, can exert tremendous pressures on human and veterinary health systems, particularly in resource limited countries. Anthrax is one such zoonosis of concern and is a disease requiring greater public health attention in Nigeria. Here we describe the genetic diversity of Bacillus anthracis in Nigeria and compare it to Chad, Cameroon and a broader global dataset based on the multiple locus variable number tandem repeat (MLVA-25) genetic typing system. Nigerian B. anthracis isolates had identical MLVA genotypes and could only be resolved by measuring highly mutable single nucleotide repeats (SNRs). The Nigerian MLVA genotype was identical or highly genetically similar to those in the neighboring countries, confirming the strains belong to this unique West African lineage. Interestingly, sequence data from a Nigerian isolate shares the anthrose deficient genotypes previously described for strains in this region, which may be associated with vaccine evasion. Strains in this study were isolated over six decades, indicating a high level of temporal strain stability regionally. Ecological niche models were used to predict the geographic distribution of the pathogen for all three countries. We describe a west-east habitat corridor through northern Nigeria extending into Chad and Cameroon. Ecological niche models and genetic results show B. anthracis to be ecologically established in Nigeria. These findings expand our understanding of the global B. anthracis population structure and can guide regional anthrax surveillance and control planning.

Zuni elders: Ethnography of American Indian aging

Problem/purpose. The specific aim of this focused ethnography was to provide insight into the experience of aging of the American Indian (AI) elder as demonstrated by one tribe, the Zuni of New Mexico. Discovering how Zuni elders construct the experience of aging and the associated behaviors allowed the researcher to deconstruct aging and then re-present it in a cogent description for this population. Such a description is lacking in the literature and will be useful in planning for culturally relevant eldercare services. ^ Methods. Ethnographic field techniques were used to sample from elders, pueblo members-at-large, activities, events and places. Over 1800 hrs were spent in the field spanning 14 months and five site visits, with the longest at almost 4 weeks. Developing codes for transcribed interviews, field notes, supplementary documents, photographs, videos, and artifacts was carried out during analysis. Categories and ultimately a cognitive map and model were developed which represented aging in Zuni Pueblo in 2000. ^ Findings. Zuni elders are aging in two worlds. Their primary world has been described as a sevenfold universe, a complicated structure with seven planes wherein the middle plane refers to themselves, a synthesis of all the other planes. The increasing influence of the white world has formed a ‘new middle’ out of which everyday aspects of aging are viewed. ^ Implications for nursing/gerontology. Nurses and others in gerontology must recognize that vast differences in worldviews are present between themselves and AI elders regarding health practices, spirituality, eating patterns, family roles, medicine, religion and countless other aspects of life. Their centuries old beliefs and practices drive these differences coupled with a collision with the white world. Making a paradigm shift using an appropriate lens with which to view these differences can only increase our understanding and efficacy in delivering culturally relevant care. ^

Abundance of Cnidaria and Ctenophora in the North Atlantic sampled during the G. O. Sars Cruise in May 2013

In recent years a global increase in jellyfish (i.e. Cnidarians and Ctenophores) abundance and a rise in the recurrence of jellyfish outbreak events have been largely debated, but a general consensus on this matter has not been achieved yet. Within this debate, it has been generally recognized that there is a lack of reliable data that could be analyzed and compared to clarify whether indeed jellyfish are increasing throughout the world ocean as a consequence of anthropogenic impact and hydroclimatic variability. During the G.O. Sars cruise jellyfish were collected at different depths in the 0-1000m layer using a standard 1 m**2 Multiple Opening/Closing Net and Environmental Sensing System (MOCNESS) (quantitative data), Harstad and macroplankton trawls (qualitative data). The comparison of records collected with different nets during the G.O. Sars transatlantic cruise shows that different sampling gears might provide very different information on jellyfish diversity. Indeed, the big trawls mostly collect relatively large scyphozoan and hydrozoan species such as Atolla, Pelagia, Praya, Vogtia, while small hydrozoans (e.g. Clytia, Gilia, Muggiaea) and early stages of ctenophora are only caught by the smaller nets.

Data collection of depth and time integrated Calanus finmarchicus abundances, averaged temperatures, and integrated Chlorophyll concentration in the North Atlantic Ocean

Here we present a new, pan-North-Atlantic compilation of data on key mesozooplankton species, including the most important copepod, Calanus finmarchicus. Distributional data of eight representative zooplankton taxa, from recent (2000-2009) Continuous Plankton Recorder data, are presented, along with basin-scale data of the phytoplankton colour index. Then we present a compilation of data on C. finmarchicus, including observations of abundance, demography, egg production and female size, with accompanying data on temperature and chlorophyll. . This is a contribution by Canadian, European and US scientists and their institutions.

MARECHIARA-mesozooplankton long-term time-series at the fixed coastal station in the Gulf of Naples: abundance and biomass, data for the years 1984-2006

The MARECHIARA-mesozooplankton dataset contains mesozooplankton data collected in the ongoing time-series at Sation MC (40°48.5' N, 14°15' E) in the Gulf of Naples. This dataset spans over the period 1984-2006 and contains data of mesozooplankton abundance and species composition as well as biomass (as dry weight). Mesozooplankton was regularly sampled in 1984-1990 and 1995-2006, only a few samples were collected in 1991-1992 and no samples in 1993-1994. During the first period of the series sampling frequency was fortnightly, and weekly since 1995.

Biogeography of jellyfish in the North Atlantic

In recent years a global increase in jellyfish (i.e. Cnidarians and Ctenophores) abundance and a rise in the recurrence of jellyfish outbreak events have been largely debated, but a general consensus on this matter has not been achieved yet. Within this debate, it has been generally recognised that there is a lack of reliable data that could be analysed and compared to clarify whether indeed jellyfish are increasing throughout the world ocean as a consequence of anthropogenic impact and hydroclimatic variability. Here we describe different jellyfish data sets produced within the EU program EUROBASIN, which have been assembled with the aim of presenting an up to date overview on the diversity and standing stocks of North Atlantic jellyfish. Abundance and species composition were determined in samples collected in the epipelagic layer (0- 200m), using a net well adapted to quantitatively catching gelatinous zooplankton. The samples were collected in spring-summer (April-August) 2010-2013, in inshore and offshore North Atlantic waters, between 59-68LatN and 62W-5ELong. Jellyfish were also identified and counted in samples opportunistically collected by other sampling gears in the same region and in two coastal stations in the Bay of Biscay and in the Gulf of Cadiz. Continuous Plankton Recorder (CPR) samples collected in 2009-2012 were re-analysed with the aim of identifying the time and location of jellyfish blooms across the North Atlantic basin.