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Background: Guidelines recommend delaying coronary artery bypass grafting (CABG) for 5 days after discontinuing clopidogrel. However, platelet function may recover quicker in certain individuals. Hypothesis: We hypothesized that perioperative measurement of platelet function with a point-of-care P2Y 12 inhibitor assay could predict bleeding during CABG in patients exposed to clopidogrel. Methods: Verify Pre-Op TIMI 45 was a prospective pilot study of 39 patients on clopidogrel who subsequently underwent CABG. Preoperative on-treatment platelet reactivity was assessed with VerifyNow P2Y 12 Reaction Units (PRU), with higher PRU indicating more reactive platelets. Outcomes were stratified by PRU quartiles, as well as prespecified cutpoints for the lowest quartile (PRU 173), a cutpoint for major bleeding determined by the Youden index using receiver operator curve analysis (PRU 207), and clopidogrel resistance (PRU 230). Results: Patients in higher PRU quartiles experienced smaller decreases in hemoglobin and hematocrit (P < 0.05 for all comparisons), less major bleeding (P = 0.021), and less major or minor bleeding (P = 0.003). Patients above the PRU 207 and 230 cutpoints had less chest-tube output (P = 0.041 and P = 0.012, respectively), less major bleeding (P = 0.005 and P = 0.036, respectively), and less major or minor bleeding (P = 0.013 and P < 0.001, respectively). By receiver operator curve analysis, preoperative PRU ≤ 207 discriminated between patients with and without major bleeding during surgery (area under the curve: 0.76, 95% confidence interval: 0.59-0.94, P = 0.018). Conclusions: In this pilot study, we found that point-of-care platelet function assessment could predict bleeding in patients recently exposed to clopidogrel undergoing CABG.

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Today, knowledge has become a pivotal tool of implementing strategies and approaches to achieve desired results. During the recent past, researches on knowledge management have grown rapidly in the management literature and tourism is no exception in this context. Moreover, the recent developments in tourism and hospitality marketplace have recognised knowledge as a key competitive tool and a determinant for socio-economic growth at destinations. Thus, it is obvious that if a tourism destination/nation/organisation is to remain competitive in the volatile tourism business environment, the application of knowledge management approach has become fundamental to transform tourism knowledge into capabilities for the survival, sustain and growth of tourism sector. The aim of this chapter is to conceptualize the application of knowledge concept and suggest further research issues in this area to develop a knowledge networks. Overall this chapter demonstrates the considerable utility of managing knowledge for tourism in delivering destination competitiveness.