ObjectivesTo study if four cycles of remote ischemic preconditioning (RIPC) could offer protection against contrast induced nephropathy (CIN) and post procedural renal dysfunction in high risk patients undergoing percutaneous coronary intervention (PCI).MethodsThis was a prospective single blind randomized sham controlled trial where patients undergoing coronary angioplasty with stage III chronic kidney disease were randomized into sham preconditioning and remote ischemic preconditioning. The primary outcome was the reduction in the incidence of CIN. The secondary outcomes were the maximum improvement in eGFR, maximum reduction in serum creatinine and composite of requirement of hemodialysis, death and rehospitalization for heart failure up to 6 weeks after PCI.ResultsEleven out of fifty patients in the study group developed CIN (22%) compared to eighteen out of the fifty control patients (36%) (p = 0.123). There was a statistically significant improvement in the post procedure creatinine values at 24 h (p = 0.013), 48 h (p = 0.015), 2 weeks (p = 0.003), 6 weeks (p = 0.003) and post procedure glomerular filtration rate (eGFR) values at 24 h (p = 0.026), 48 h (p = 0.044), 2 weeks (p = 0.015) and 6 weeks (p = 0.011) in study group compared to control group. The secondary outcome composite of requirement of hemodialysis, death and rehospitalization for heart failure was not statistically significant (p: 0.646).ConclusionRIPC does not result in significant reduction of CIN. However RIPC helps in the prevention of post procedural worsening in eGFR and serum creatinine even up to 6 weeks.

A 40-year-old man who was a smoker with no history of intravenous drug use presented to a tertiary hospital with a week-long high-grade fever, dry cough, and streaky hemoptysis. He had hypoxia at room air. Chest x-ray showed bilateral ground-glass opacities with relative sparing of apexes and left base (Figure 1).Sputum and blood cultures (including fungal) and HIV tests were negative. He had received intravenous piperacillin and tazobactam empirically for a week, with fair clinical improvement and resolution of radiological shadows. He was referred to our tertiary center for further management. Ocular fundi had multiple preretinal hemorrhages, a few with central clearing (Figure 2).Transthoracic echocardiogram revealed a bilobed, oscillating, 2ϫ1.5-cm right ventricular mass with peduncle arising from the anterior end of the moderator band ( Figure 3A and Movie I of the online Data Supplement).Transesophageal echocardiogram ( Figure 3B and Movie II) showed a 2-mm patent foramen ovule, and all valves were normal. The mass was visualized in a modified 4-chamber midesophageal view. Sixty-four-slice computed tomography pulmonary angiography showed no filling defects in the pulmonary artery. Cardiac magnetic resonance imaging (Figure 4 and Movie III) showed the contrast-nonenhancing mass and confirmed a structurally normal heart. His blood cultures were negative even after prolonged culture. He was started on empirical endocarditic therapy with vancomycin and gentamicin on suspicion of the mass being infective vegetation. Because the fever continued beyond a week of antibiotics, the decision to remove the mass was made.He underwent right atriotomy under cardiopulmonary bypass. The right ventricle and tricuspid valve were normal. A linear 2ϫ0.5-cm pale white growth and a smaller 0.5ϫ0.5-cm pale gray growth that were loosely attached to the moderator band were noted and removed. Right ventricular endothelium was normal throughout, and excision of the moderator band was not done.Histopathological examination showed fibrinous material with predominantly neutrophilic infiltrates ( Figure 5) and Gram-positive cocci (Figure 6). Culture of specimen yielded Staphylococcus aureus sensitive to methicillin and gentamicin. Hence, oxacillin and gentamicin were continued for another 2 weeks. The patient became afebrile, and C-reactive protein values were normalized. He was doing well at the 1-year follow-up visit.

Background: The study was designed to find out whether the addition of clopidogrel for patients with ST- elevation myocardial infarction [STEMI] who are receiving a standard fibrinolytic therapy, including aspirin, reduce the incidence of primary and secondary end points like recurrent ischemia, re-infarction, need for urgent Target Vessel Revascularisation [TVR], mortality & bleeding. Methods: The patients were randomly assigned to receive the study medication. The patients were divided into two groups. Those receiving fibrinolytic therapy & aspirin were included in Group A. Those receiving the study drug in addition to aspirin & fibrinolytic agent were included in Group B. The study drug was given daily upto 1 month. These patients were assessed during their hospital stay & followed up for a period of 30 days for end points like recurrent ischemia, re-infarction, need for urgent TVR, bleeding episodes & mortality. Results: There was reduction in primary endpoints in group B compared to group A of which only reduction of recurrent ischemia was statistically significant (26% vs 2%). The same pattern of benefit was seen with secondary end points with significant reduction in recurrent ischemia in group B (28% vs 2%). Safety end points showed some increased bleeding in group B patients which was statistically insignificant (4% vs 0). Conclusion: Addition of Clopidogrel to aspirin and fibrinolytic therapy in ST-elevation MI showed a significant reduction in recurrent ischemia during in hospital stay and during the first 30 days. The patients received clopidogrel had less mortality compared to aspirin group. There were only minor bleeding episodes reported with use of clopidogrel. [Int J Basic Clin Pharmacol 2013; 2(4.000): 480-484