WorldWideScience

Sample records for high maintenance-dose clopidogrel

  1. Influence of genetic polymorphisms on the effect of high- and standard-dose clopidogrel after percutaneous coronary intervention: the GIFT (Genotype Information and Functional Testing) study.

    Price, Matthew J; Murray, Sarah S; Angiolillo, Dominick J; Lillie, Elizabeth; Smith, Erin N; Tisch, Rebecca L; Schork, Nicholas J; Teirstein, Paul S; Topol, Eric J

    2012-05-29

    This study sought to evaluate the influence of single nucleotide polymorphisms (SNPs) on the pharmacodynamic effect of high- or standard-dose clopidogrel after percutaneous coronary intervention (PCI). There is a lack of prospective, multicenter data regarding the effect of different genetic variants on clopidogrel pharmacodynamics over time in patients undergoing PCI. The GRAVITAS (Gauging Responsiveness with A VerifyNow assay-Impact on Thrombosis And Safety) trial screened patients with platelet function testing after PCI and randomly assigned those with high on-treatment reactivity (OTR) to either high- or standard-dose clopidogrel; a cohort of patients without high OTR were also followed. DNA samples obtained from 1,028 patients were genotyped for 41 SNPs in 17 genes related to platelet reactivity. After adjusting for clinical characteristics, the associations between the SNPs and OTR using linear regression were evaluated. CYP2C19*2 was significantly associated with OTR at 12 to 24 h (R(2) = 0.07, p = 2.2 × 10(-15)), 30 days (R(2) = 0.10, p = 1.3 × 10(-7)), and 6 months after PCI (R(2) = 0.07, p = 1.9 × 10(-11)), whereas PON1, ABCB1 3435 C→T, and other candidate SNPs were not. Carriers of 1 and 2 reduced-function CYP2C19 alleles were significantly more likely to display persistently high OTR at 30 days and 6 months, irrespective of treatment assignment. The portion of the risk of persistently high OTR at 30 days attributable to reduced-function CYP2C19 allele carriage was 5.2% in the patients randomly assigned to high-dose clopidogrel. CYP2C19, but not PON1 or ABCB1, is a significant determinant of the pharmacodynamic effects of clopidogrel, both early and late after PCI. In patients with high OTR identified by platelet function testing, the CYP2C19 genotype provides limited incremental information regarding the risk of persistently high reactivity with clopidogrel 150-mg maintenance dosing. (Genotype Information and Functional Testing Study [GIFT]; NCT

  2. Prasugrel but not high dose clopidogrel overcomes the lansoprazole neutralizing effect of P2Y12 inhibition: Results of the randomized DOSAPI study.

    Collet, Jean-Philippe; Hulot, Jean-Sébastien; Abtan, Jérémie; Anzaha, Ghalia; Kerneis, Mathieu; Silvain, Johanne; Cayla, Guillaume; O'Connor, Stephen A; Barthélémy, Olivier; Beygui, Farzin; Galier, Sophie; Brugier, Delphine; Stanek, Eric J; Charland, Scott L; Gallois, Vanessa; Montalescot, Gilles

    2014-09-01

    The potential negative metabolic interaction between proton pump inhibitors and clopidogrel is an unsolved issue. We hypothesized that doubling the clopidogrel maintenance dose (150 mg) would be less effective than switching to prasugrel 10 mg maintenance dose (MD) to overcome this negative interaction. In a randomized study with a factorial design, 82 stable coronary artery disease patients treated with 75 mg clopidogrel MD and aspirin were assigned to receive in a double blind fashion lansoprazole (30 mg/day) or placebo and to receive in an open fashion 150 mg clopidogrel MD or 10 mg prasugrel MD. The primary endpoint was the relative change in residual platelet reactivity over the 14-day study period [(RPA14day-RPAbaseline)/RPAbaseline]. The effect of doubling the clopidogrel MD on relative change in RPA was neutralized by lansoprazole (-53.6±48.4% versus +0.8±53.7% without and with lansoprazole, respectively, p = 0.02) whereas 10 mg of prasugrel MD dramatically reduced RPA irrespective of lansoprazole co-administration (-81.8 %±24.8% vs. -72.9%±32.9% without and with lansoprazole, respectively, p = NS). Lansoprazole exposure was the only parameter with a significant interaction with RPA among subgroups. The higher platelet inhibitory effect obtained by doubling the clopidogrel MD was totally neutralized by the co-administration of lansoprazole. This drug interaction was not observed with prasugrel 10 mg.

  3. Tailored antiplatelet therapy can overcome clopidogrel and aspirin resistance - The BOchum CLopidogrel and Aspirin Plan (BOCLA-Plan to improve antiplatelet therapy

    Pepinghege Fenena

    2011-01-01

    Full Text Available Abstract Background Dual antiplatelet therapy using acetylsalicylic acid (ASA, aspirin and clopidogrel is of great importance following coronary stenting. However, the variable platelet inhibitory effectiveness compromises the antithrombotic advantages provided by dual antiplatelet therapy. The aim of this single-center prospective study was to reduce the low response incidence of dual antiplatelet therapy with ASA and clopidogrel according to a prespecified therapy algorithm. Methods Platelet function testing using whole blood aggregometry (Chronolog 590 was performed 48 hours following coronary stenting (for either acute coronary syndromes or stable coronary artery disease on 504 patients. The antiplatelet therapy included a loading dose of 600 mg clopidogrel and 500 mg ASA, followed by 75 mg clopidogrel and 100 mg ASA once daily. Clopidogrel low responders (CLR: >5 ohm; adenosine diphosphate (ADP 5 μM and/or ASA low responders (ALR: >0 ohm; arachidonic acid 10 μM were treated according to a structured therapy plan: in the case of CLR, the maintenance + dose was doubled (repeated loading dose followed by 150 mg daily, and when still ineffective ticlopidine or prasugrel, if available and not contraindicated, were used. ALR was treated by increasing the dose to 300 mg in a first step or to 500 mg ASA when the first modification did not take effect sufficiently. In addition, ADP receptor antagonist 2-methylthioadenosine 5'-monophosphate triethylammonium salt (MeSAMP testing and ASA incubation were performed to rule out either a platelet ADP-receptor defect or an ASA pharmacokinetic resistance. Results Of the total cohort of 504 patients, we detected 30.8% clopidogrel low-responders and 19.4% aspirin low-responders. For ALR, with a dose adjustment of 300 mg ASA daily, 94.6% of ALR were effectively treated and the residual 5.4% by administration of daily dosages of 500 mg ASA. This means that after modification of the ASA maintenance dose, all

  4. Genetics Home Reference: clopidogrel resistance

    ... Facebook Twitter Home Health Conditions Clopidogrel resistance Clopidogrel resistance Printable PDF Open All Close All Enable Javascript to view the expand/collapse boxes. Description Clopidogrel resistance is a condition in which the drug clopidogrel ...

  5. Effects of Ramadan fasting on platelet reactivity in diabetic patients treated with clopidogrel.

    Bouida, W; Baccouche, H; Sassi, M; Dridi, Z; Chakroun, T; Hellara, I; Boukef, R; Hassine, M; Added, F; Razgallah, R; Khochtali, I; Nouira, S

    2017-01-01

    The effects of Ramadan fasting (RF) on clopidogrel antiplatelet inhibition were not previously investigated. The present study evaluated the influence of RF on platelet reactivity in patients with high cardiovascular risk (CVR) in particular those with type 2 diabetes mellitus (DM). A total of 98 stable patients with ≥2 CVR factors were recruited. All patients observed RF and were taking clopidogrel at a maintenance dose of 75 mg. Clinical findings and serum lipids data were recorded before Ramadan (Pre-R), at the last week of Ramadan (R) and 4 weeks after the end of Ramadan (Post-R). During each patient visit, nutrients intakes were calculated and platelet reactivity assessment using Verify Now P2Y12 assay was performed. In DM patients, the absolute PRU changes from baseline were +27 ( p  = 0.01) and +16 ( p  = 0.02) respectively at R and Post-R. In addition, there was a significant increase of glycemia and triglycerides levels with a significant decrease of high-density lipoprotein. In non DM patients there was no significant change in absolute PRU values and metabolic parameters. Clopidogrel resistance rate using 2 cut-off PRU values (235 and 208) did not change significantly in DM and non DM patients. RF significantly decreased platelet sensitivity to clopidogrel in DM patients during and after Ramadan. This effect is possibly related to an increase of glycemia and serum lipids levels induced by fasting. Clinical Trials.gov NCT02720133. Registered 24 July 2014.Retrospectively registered.

  6. Study design and rationale of a comparison of prasugrel and clopidogrel in medically managed patients with unstable angina/non-ST-segment elevation myocardial infarction: the TaRgeted platelet Inhibition to cLarify the Optimal strateGy to medicallY manage Acute Coronary Syndromes (TRILOGY ACS

    Chin, Chee Tang; Roe, Matthew T; Fox, Keith A A

    2010-01-01

    Practice guidelines recommend dual antiplatelet therapy with aspirin and clopidogrel for patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) regardless of in-hospital management strategy. Prasugrel-a thienopyridine adenosine diphosphate receptor antagonist that provides...... higher and less variable levels of platelet inhibition than clopidogrel-has demonstrated benefit when used to treat ACS patients undergoing percutaneous coronary intervention. However, the optimal approach to antiplatelet therapy for high-risk, medically managed NSTE ACS patients remains uncertain...... revascularization procedures for their index event. Patients will be randomly allocated to prasugrel + aspirin versus clopidogrel + aspirin for a median duration of 18 months. A reduction in the maintenance dose of prasugrel for elderly patients (age >or=75 years) and those with body weight or=75 years). TRILOGY...

  7. Clopidogrel Resistance: Current Issues

    NS Neki

    2016-05-01

    Full Text Available Antiplatelet agents are mainly used in the prevention and management of atherothrombotic complications. Dual antiplatelet therapy, combining aspirin and clopidogrel, is the standard care for patients having acute coronary syndromes or undergoing percutaneous coronary intervention according to the current ACC/AHA and ESC guidelines. But in spite of administration of dual antiplatelet therapy, some patients develop recurrent cardiovascular ischemic events especially stent thrombosis which is a serious clinical problem. Antiplatelet response to clopidogrel varies widely among patients based on ex vivo platelet function measurements. Clopidogrel is an effective inhibitor of platelet activation and aggregation due to its selective and irreversible blockade of the P2Y12 receptor. Patients who display little attenuation of platelet reactivity with clopidogrel therapy are labeled as low or nonresponders or clopidogrel resistant. The mechanism of clopidogrel resistance remains incompletely defined but there are certain clinical, cellular and genetic factors including polymorphisms responsible for therapeutic failure. Currently there is no standardized or widely accepted definition of clopidogrel resistance. The future may soon be realised in the routine measurement of platelet activity in the same way that blood pressure, cholesterol and blood sugar are followed to help guide the therapy, thus improving the care for millions of people. This review focuses on the methods used to identify patients with clopidogrel resistance, the underlying mechanisms, metabolism, clinical significance and current therapeutic strategies to overcome clopidogrel resistance. J Enam Med Col 2016; 6(1: 38-46

  8. Clopidogrel paclitaxel drug-drug interaction

    Agergaard, K; Mau-Sørensen, M; Stage, T B

    2017-01-01

    register. Peripheral sensory neuropathy was retrospectively evaluated from medical charts and compared to that of 88 age and sex matched controls treated with paclitaxel and low dose aspirin. By a cumulative dose of 1500 mg paclitaxel, 35% of the patients had developed severe neuropathy. The overall hazard...... ratio between clopidogrel use and severe paclitaxel neuropathy was 1.7 (95% CI, 0.9-3.0). Among those receiving a high dose paclitaxel regimen, the hazard ratio was 2.3 (95% CI, 1.1-4.5). Our study indicates that clopidogrel is associated with a clinically relevant increased risk of neuropathy......Paclitaxel is mainly eliminated by CYP2C8 in the liver. CYP2C8 is strongly inhibited by the clopidogrel metabolite acyl-β-D-glucuronide. To determine if this interaction has clinical relevance, we identified 48 patients treated with clopidogrel and paclitaxel using databases and a prescription...

  9. Association of clopidogrel treatment with risk of mortality and cardiovascular events following myocardial infarction in patients with and without diabetes

    Andersson, Charlotte; Lyngbæk, Stig; Nguyen, Cu Dinh

    2012-01-01

    Pharmacodynamic studies have shown that persistently high platelet reactivity is common in patients with diabetes in spite of clopidogrel treatment. Clinical trials have not convincingly demonstrated that clopidogrel benefits patients with diabetes as much patients without diabetes....

  10. Effects of VKORC1 Genetic Polymorphisms on Warfarin Maintenance Dose Requirement in a Chinese Han Population

    Yan, Xiaojuan; Yang, Feng; Zhou, Hanyun; Zhang, Hongshen; Liu, Jianfei; Ma, Kezhong; Li, Yi; Zhu, Jun; Ding, Jianqiang

    2015-01-01

    Background VKORC1 is reported to be capable of treating several diseases with thrombotic risk, such as cardiac valve replacement. Some single-nucleotide polymorphisms (SNPs) in VKORC1 are documented to be associated with clinical differences in warfarin maintenance dose. This study explored the correlations of VKORC1–1639 G/A, 1173 C/T and 497 T/G genetic polymorphisms with warfarin maintenance dose requirement in patients undergoing cardiac valve replacement. Material/Methods A total of 298 patients undergoing cardiac valve replacement were recruited. During follow-up, clinical data were recorded. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method was applied to detect VKORC1–1639 G/A, 1173 C/T and 497 T/G polymorphisms, and genotypes were analyzed. Results Correlations between warfarin maintenance dose and baseline characteristics revealed statistical significances of age, gender and operation methods with warfarin maintenance dose (all PWarfarin maintenance dose in VKORC1–1639 G/A AG + GG carriers was obviously higher than in AA carriers (Pwarfarin maintenance dose was apparently higher in patients with CT genotype (Pwarfarin maintenance dose (all Pwarfarin maintenance dose in patients undergoing cardiac valve replacement; meanwhile, gender, operation method and method for heart valve replacement might also be correlate with warfarin maintenance dose. PMID:26583785

  11. Mechanisms of lower maintenance dose of tacrolimus in obese patients.

    Sawamoto, Kazuki; Huong, Tran T; Sugimoto, Natsumi; Mizutani, Yuka; Sai, Yoshimichi; Miyamoto, Ken-ichi

    2014-01-01

    A retrospective analysis suggested that blood tacrolimus concentrations were consistent among patients with a body mass index (BMI) that was lean (maintenance dose of tacrolimus in patients with BMI ≥ 25 was significantly lower compared with that in patients with a BMI of less than 25. Lean and obese Zucker rats fed a normal diet were given tacrolimus intravenously or orally. The blood concentrations of tacrolimus in obese rats were significantly higher than those in lean rats after administration via both routes. The moment analysis has suggested that CLtot and Vdss of tacrolimus were not significantly different between lean and obese rats. The bioavailability was higher in obese rats, compared with that in lean rats. The protein expression of Cyp3a2 in the liver was significantly decreased in obese rats, compared with lean rats, while P-gp in the small intestine was also significantly decreased in obese rats. These results suggested that the steady-state trough concentration of tacrolimus in obese patients was well maintained by a relatively low dose compared with that in normal and lean patients, presumably due to increased bioavailability.

  12. The impact of different doses of clopidogrel used after percutaneous coronary intervention on cardiovascular events: a Meta-analysis

    Li Diangeng; Chen Yao; Li Rongshan

    2011-01-01

    Objective: To make a comprehensive evaluation of the efficacy and safety of different doses of clopidogrel that was used after percutaneous coronary intervention (PCI) in preventing the cardiovascular events in order to provide scientific basis for physician in making therapeutic strategic decision. Methods: The authors searched the electronic databases (PubMed, Cochrane Central Register of Controlled Trials, CNKI and Wan Fan) and reference lists from original studies and reviewed the related articles.Statistical analysis was performed by using RevMan 4.2 software. Results: A total of 6 studies containing 1027 patients were included. The results of meta-analysis showed that significant differences in the rate of cardiovascular events [OR = 0.52, 95%CI (0.36, 0.77)] existed between higher clopidogrel maintenance dose and standard dose. No obvious difference was found in major or minor bleeding [OR=1.25, 95%CI(0.43, 3.63)] and [OR = 1.25, 95%CI (0.77, 2.02)]. Conclusion: A higher maintenance dose of clopidogrel employed in patients undergoing PCI can reduce the occurrence of cardiovascular events after PCI without increasing the bleeding risk. (J Intervent Radiol, 2011, 20 : 97-102) (authors)

  13. Clopidogrel and proton pump inhibitors--where do we stand in 2012?

    Drepper, Michael D

    2012-05-14

    Clopidogrel in association with aspirine is considered state of the art of medical treatment for acute coronary syndrome by reducing the risk of new ischemic events. Concomitant treatment with proton pump inhibitors in order to prevent gastrointestinal side effects is recommended by clinical guidelines. Clopidogrel needs metabolic activation predominantly by the hepatic cytochrome P450 isoenzyme Cytochrome 2C19 (CYP2C19) and proton pump inhibitors (PPIs) are extensively metabolized by the CYP2C19 isoenzyme as well. Several pharmacodynamic studies investigating a potential clopidogrel-PPI interaction found a significant decrease of the clopidogrel platelet antiaggregation effect for omeprazole, but not for pantoprazole. Initial clinical cohort studies in 2009 reported an increased risk for adverse cardiovascular events, when under clopidogrel and PPI treatment at the same time. These observations led the United States Food and Drug Administration and the European Medecines Agency to discourage the combination of clopidogrel and PPI (especially omeprazole) in the same year. In contrast, more recent retrospective cohort studies including propensity score matching and the only existing randomized trial have not shown any difference concerning adverse cardiovascular events when concomitantly on clopidogrel and PPI or only on clopidogrel. Three meta-analyses report an inverse correlation between clopidogrel-PPI interaction and study quality, with high and moderate quality studies not reporting any association, rising concern about unmeasured confounders biasing the low quality studies. Thus, no definite evidence exists for an effect on mortality. Because PPI induced risk reduction clearly overweighs the possible adverse cardiovascular risk in patients with high risk of gastrointestinal bleeding, combination of clopidogrel with the less CYP2C19 inhibiting pantoprazole should be recommended.

  14. Pharmacogenetic association study on clopidogrel response in Puerto Rican Hispanics with cardiovascular disease: a novel characterization of a Caribbean population

    Hernandez-Suarez DF

    2018-06-01

    Full Text Available Dagmar F Hernandez-Suarez,1 Mariana R Botton,2 Stuart A Scott,2 Matthew I Tomey,3 Mario J Garcia,4 Jose Wiley,4 Pedro A Villablanca,5 Kyle Melin,6 Angel Lopez-Candales,7 Jessicca Y Renta,8 Jorge Duconge9 1Cardiovascular Medicine Division, Department of Medicine, University of Puerto Rico School of Medicine, San Juan, PR, USA; 2Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 3Cardiovascular Medicine Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 4Division of Cardiovascular Diseases, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine New York, NY, USA; 5Division of Cardiology, Department of Medicine, New York University Langone Medical Center, New York, NY, USA; 6Department of Pharmacy Practice, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA; 7Cardiovascular Medicine Division, Department of Medicine, University of Puerto Rico School of Medicine, San Juan, PR, USA; 8Department of Biochemistry, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA; 9Pharmaceutical Sciences Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA Introduction: High on-treatment platelet reactivity (HTPR to clopidogrel imparts an increased risk for ischemic events in adults with coronary artery disease. Platelet reactivity varies with ethnicity and is influenced by both clinical and genetic variables; however, no clopidogrel pharmacogenetic studies with Puerto Rican patients have been reported. Therefore, we sought to identify clinical and genetic determinants of on-treatment platelet reactivity in a cohort of Puerto Rican patients with cardiovascular disease. Methods: We performed a retrospective study of 111 patients on 75 mg/day maintenance dose of clopidogrel. Patients were allocated into 2 groups: Group I, without HTPR; and Group II, with HTPR. Platelet function was

  15. Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular disease

    Squizzato, Alessandro; Keller, Tymen; Romualdi, Erica; Middeldorp, Saskia

    2011-01-01

    Aspirin is the prophylactic antiplatelet drug of choice for people with cardiovascular disease. Adding a second antiplatelet drug to aspirin may produce additional benefit for those at high risk and those with established cardiovascular disease. To quantify the benefit and harm of adding clopidogrel

  16. Prevalence and risk factors of clopidogrel non-response among Saudi patients undergoing coronary angiography

    Haitham I. Sakr

    2016-02-01

    Full Text Available Objectives: To estimate the prevalence of clopidogrel non-response and identify its risk factors among Saudi patients. Methods: This cross-sectional study was conducted at Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia between January and June 2013, to assess the degree of platelet inhibition using the VerifyNow assay (Accumetrics, San Diego, CA, USA after receiving clopidogrel standard loading dose. Clopidogrel resistance was defined as ≤15% platelet inhibition or greater than 213 P2Y12 reaction units (PRU. Results: Three hundred and four patients were included in the study. The mean age was 60.3 ± 11.4 years, and 73% were males. Clopidogrel doses were 300 mg (57%, 600 mg (27%, and 75 mg (16%. All patients used aspirin (81 mg in 94%. Approximately 66% (200/304 showed in vitro clopidogrel non-response, 54% had low platelet inhibitions, and 61% had high post-loading PRU. Using multivariate regression analysis that included all significant characteristics; only diabetes (odds ratio [OR]: 2.36, 95% confidence interval [CI]: 1.30-4.27, p=0.005 and higher preloading PRU (OR: 2.39, 95% CI: 1.40-4.11, p=0.002 remained significantly associated with higher clopidogrel non-response while myocardial infarction (OR: 0.34, 95% CI: 0.15-0.81, p=0.014 remained significantly associated with lower clopidogrel non-response. The associations of morbid obesity and diuretics use with higher clopidogrel non-response were slightly attenuated. Conclusion: Our findings indicate a high rate of clopidogrel in-vitro non-response among Saudi patients undergoing coronary angiography.

  17. A Novel Multiplex HRM Assay to Detect Clopidogrel Resistance.

    Zhang, Lichen; Ma, Xiaowei; You, Guoling; Zhang, Xiaoqing; Fu, Qihua

    2017-11-22

    Clopidogrel is an antiplatelet medicine used to prevent blood clots in patients who have had a heart attack, stroke, or other symptoms. Variability in the clinical response to clopidogrel treatment has been attributed to genetic factors. In particular, five SNPs of rs4244285, rs4986893, rs12248560, rs662 and rs1045642 have been associated with resistance to clopidogrel therapy in Chinese population. This work involves the development of a multiplex high-resolution melting (HRM) assay to genotype all five of these loci in 2 tubes. Amplicons corresponding to distinct SNPs in a common tube were designed with the aid of uMelt prediction software to have different melting temperatures Tm by addition of a GC-rich tail to the 5' end of the certain primers. Two kinds of commercial methods, Digital Fluorescence Molecular Hybridization (DFMH) and Sanger sequencing, were used as a control. Three hundred sixteen DFMH pretested samples from consecutive acute coronary syndrome patients were used for a blinded study of multiplex HRM. The sensitivity of HRM was 100% and the specificity was 99.93% reflecting detection of variants other than the known resistance SNPs. Multiplex HRM is an effective closed-tube, highly accurate, fast, and inexpensive method for genotyping the 5 clopidogrel resistance associated SNPs.

  18. LBA50 - Influence of concomitant clopidogrel consumption on development of paclitaxel-associated toxicity: A pharmacoepidemiological study

    K, Agergaard; Mau-Sørensen, M; Stage, Tore Bjerregaard

    clopidogrel to a metabolite, which is a strong inhibitor of CYP2C8. To determine if this interaction has clinical relevance, we investigated whether concomitant clopidogrel and paclitaxel was associated with severe paclitaxel toxicity, primarily peripheral sensory neuropathy. Methods Patients concomitantly...... from medical charts by reviewers partially blinded to clopidogrel exposure. The association of clopidogrel use and development of paclitaxel induced neuropathy was evaluated over accumulated paclitaxel dose with censoring after 1500 mg using Cox-regression analysis with adjustment for high intensity...... neuropathy or worse. Clopidogrel use was associated with increased risk of neuropathy with hazard ratios of 1.7 (95% CI 0.9-3.0), 2.0 (1.0-3.9) and 2.3 (1.1-4.5) in overall unadjusted, high intensity paclitaxel unadjusted and high intensity paclitaxel full adjusted analyses, respectively. Conclusions...

  19. Pharmacogenetic testing for clopidogrel using the rapid INFINITI analyzer: a dose-escalation study.

    Gladding, Patrick; White, Harvey; Voss, Jamie; Ormiston, John; Stewart, Jim; Ruygrok, Peter; Bvaldivia, Badi; Baak, Ruth; White, Catherine; Webster, Mark

    2009-11-01

    Our aim was to assess whether a higher clopidogrel maintenance dose has a greater antiplatelet effect in CYP2C19*2 allele carriers compared with noncarriers. Clopidogrel is a prodrug that is biotransformed by the cytochrome P450 enzymes CYP2C19, 2C9, and 3A4, 2B6, 1A2. The CYPC219*2 loss of function variant has been associated with a reduced antiplatelet response to clopidogrel and a 3-fold risk of stent thrombosis. Forty patients on standard maintenance dosage clopidogrel (75 mg), for 9.4 +/- 9.2 weeks, were enrolled into a dose escalation study. Platelet function was assessed at baseline and after 1 week of 150 mg once daily using the VerifyNow platelet function analyzer (Accumetrics Ltd., San Diego, California). Genomic DNA was hybridized to a BioFilmChip microarray on the INFINITI analyzer (AutoGenomics Inc., Carlsbad, California) and analyzed for the CYP19*2, *4, *17, and CYP2C9*2, *3 polymorphisms. Platelet inhibition increased over 1 week, mean +8.6 +/- 13.5% (p = 0.0003). Carriers of the CYP2C19*2 allele had significantly reduced platelet inhibition at baseline (median 18%, range 0% to 72%) compared with wildtype (wt) (median 59%, range 11% to 95%, p = 0.01) and at 1 week (p = 0.03). CYP2C19*2 allele carriers had an increase in platelet inhibition of (mean +9 +/- 11%, p = 0.03) and reduction in platelet reactivity (mean -26 +/- 38 platelet response unit, p = 0.04) with a higher dose. Together CYP2C19*2 and CYP2C9*3 loss of function carriers had a greater change in platelet inhibition with 150 mg daily than wt/wt (+10.9% vs. +0.7%, p = 0.04). Increasing the dose of clopidogrel in patients with nonresponder polymorphisms can increase antiplatelet response. Personalizing clopidogrel dosing using pharmacogenomics may be an effective method of optimizing treatment.

  20. P2Y12 Receptor Antagonist, Clopidogrel, Does Not Contribute to Risk of Osteoporotic Fractures in Stroke Patients

    Jørgensen, Niklas R; Schwarz, Peter; Iversen, Helle K

    2017-01-01

    Background: Stroke is a leading cause of mortality and morbidity. It is associated with excessive bone loss and risk of fracture in stroke patients is high. The P2Y12R antagonist and platelet inhibitor, clopidogrel, is widely used for secondary prevention after a stroke. However, recent studies...... have shown that clopidogrel has negative effects on bone and that long-term clopidogrel use is associated with increased fracture risk. The purpose of the current study was therefore to investigate the association of clopidogrel treatment with risk of fractures in stroke and TIA patients.......Methods:The study was a cohort study including all subjects who were prescribed clopidogrel between 1996 and 2008 in Denmark (n= 77,503). Age- and gender matched controls (n= 232,510) were randomly selected from the background population. The study end-points were occurrence of stroke or TIA and occurrence...

  1. The Clopidogrel-PPI Interaction

    Juel, Jacob; Pareek, Manan; Jensen, Svend Eggert

    2014-01-01

    the potential for PPIs, especially omeprazole, to decrease the efficacy of clopidogrel, and both the U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA) have issued warnings regarding the concomitant use of these medications. A review of the literature revealed that the pharmacodynamic...... studies support an interaction, whereas the clinical evidence, which is mainly based on nonrandomized, observational studies and secondary analyses of randomized trials, is conflicting. We conclude that PPIs should be prescribed together with DAPT for patients in whom they are recommended according...

  2. Association of platelet responsiveness with clopidogrel metabolism: role of compliance in the assessment of "resistance".

    Serebruany, Victor; Cherala, Ganesh; Williams, Craig; Surigin, Serge; Booze, Christopher; Kuliczkowski, Wiktor; Atar, Dan

    2009-12-01

    Noncompliance is probably the major cause of clopidogrel "resistance." However, noncompliance is difficult to prove without confirming that the drug has been administered. Therefore, detection of plasma clopidogrel and/or metabolite(s) as the reliable objective method to confirm compliance is important. We sought to correlate the inhibition of platelet aggregation (IPA) with plasma levels of unchanged clopidogrel (UC), active thiol metabolite (ATM), and inactive carboxyl metabolite (ICM) in a large cohort of patients with coronary artery disease and ischemic stroke treated with clopidogrel. We conducted secondary post-hoc analyses of IPA and plasma UC, ATM, and ICM in a dataset consisting of presumably compliant patients with coronary disease (n = 422) and post-stroke (n = 209). Overall noncompliance rate was 22% (n = 138), while such risks were significantly higher in stroke survivors (n = 79, or 38%) when compared to patients with coronary disease (14%; n = 59; P = .001). Only ICM (19,154 +/- 7,228 ng/ml) was suitable for detecting compliance, while UC (15.2 +/- 9.4 ng/ml), and ATM (8.1 +/- 3.7 ng/ml) in most cases are barely detectable, and diminish over time in the stored samples. The best correlation with IPA (r2 = 0.847) was observed for active metabolite, followed by unchanged clopidogrel (r2 = 0.602), and finally inactive metabolite (r2 = 0.529). The predictive value for noncompliance was also high for inactive metabolite (c-statistic = 0.911). Therapy with clopidogrel is associated with double-digit underestimated risks for noncompliance, especially in stroke survivors, supporting the hypothesis that lack of IPA, and clopidogrel "resistance" are attributed to hidden noncompliance. Plasma ICM, but not UC, or ATM is a useful marker to monitor compliance to clopidogrel in registries and clinical trials.

  3. Population pharmacokinetic analysis of clopidogrel in healthy Jordanian subjects with emphasis optimal sampling strategy.

    Yousef, A M; Melhem, M; Xue, B; Arafat, T; Reynolds, D K; Van Wart, S A

    2013-05-01

    Clopidogrel is metabolized primarily into an inactive carboxyl metabolite (clopidogrel-IM) or to a lesser extent an active thiol metabolite. A population pharmacokinetic (PK) model was developed using NONMEM(®) to describe the time course of clopidogrel-IM in plasma and to design a sparse-sampling strategy to predict clopidogrel-IM exposures for use in characterizing anti-platelet activity. Serial blood samples from 76 healthy Jordanian subjects administered a single 75 mg oral dose of clopidogrel were collected and assayed for clopidogrel-IM using reverse phase high performance liquid chromatography. A two-compartment (2-CMT) PK model with first-order absorption and elimination plus an absorption lag-time was evaluated, as well as a variation of this model designed to mimic enterohepatic recycling (EHC). Optimal PK sampling strategies (OSS) were determined using WinPOPT based upon collection of 3-12 post-dose samples. A two-compartment model with EHC provided the best fit and reduced bias in C(max) (median prediction error (PE%) of 9.58% versus 12.2%) relative to the basic two-compartment model, AUC(0-24) was similar for both models (median PE% = 1.39%). The OSS for fitting the two-compartment model with EHC required the collection of seven samples (0.25, 1, 2, 4, 5, 6 and 12 h). Reasonably unbiased and precise exposures were obtained when re-fitting this model to a reduced dataset considering only these sampling times. A two-compartment model considering EHC best characterized the time course of clopidogrel-IM in plasma. Use of the suggested OSS will allow for the collection of fewer PK samples when assessing clopidogrel-IM exposures. Copyright © 2013 John Wiley & Sons, Ltd.

  4. Influence of Genotype on Warfarin Maintenance Dose Predictions Produced Using a Bayesian Dose Individualization Tool.

    Saffian, Shamin M; Duffull, Stephen B; Roberts, Rebecca L; Tait, Robert C; Black, Leanne; Lund, Kirstin A; Thomson, Alison H; Wright, Daniel F B

    2016-12-01

    A previously established Bayesian dosing tool for warfarin was found to produce biased maintenance dose predictions. In this study, we aimed (1) to determine whether the biased warfarin dose predictions previously observed could be replicated in a new cohort of patients from 2 different clinical settings, (2) to explore the influence of CYP2C9 and VKORC1 genotype on predictive performance of the Bayesian dosing tool, and (3) to determine whether the previous population used to develop the kinetic-pharmacodynamic model underpinning the Bayesian dosing tool was sufficiently different from the test (posterior) population to account for the biased dose predictions. The warfarin maintenance doses for 140 patients were predicted using the dosing tool and compared with the observed maintenance dose. The impact of genotype was assessed by predicting maintenance doses with prior parameter values known to be altered by genetic variability (eg, EC50 for VKORC1 genotype). The prior population was evaluated by fitting the published kinetic-pharmacodynamic model, which underpins the Bayesian tool, to the observed data using NONMEM and comparing the model parameter estimates with published values. The Bayesian tool produced positively biased dose predictions in the new cohort of patients (mean prediction error [95% confidence interval]; 0.32 mg/d [0.14-0.5]). The bias was only observed in patients requiring ≥7 mg/d. The direction and magnitude of the observed bias was not influenced by genotype. The prior model provided a good fit to our data, which suggests that the bias was not caused by different prior and posterior populations. Maintenance doses for patients requiring ≥7 mg/d were overpredicted. The bias was not due to the influence of genotype nor was it related to differences between the prior and posterior populations. There is a need for a more mechanistic model that captures warfarin dose-response relationship at higher warfarin doses.

  5. Clopidogrel

    ... heart and blood vessels in people who have peripheral arterial disease (poor circulation in the blood vessels ... of reach of children. Store it at room temperature and away from excess heat and moisture (not ...

  6. Clinical determinants of clopidogrel responsiveness in a heterogeneous cohort of Puerto Rican Hispanics.

    Hernandez-Suarez, Dagmar F; Scott, Stuart A; Tomey, Matthew I; Melin, Kyle; Lopez-Candales, Angel; Buckley, Charlotte E; Duconge, Jorge

    2017-09-01

    Clopidogrel is by far the most prescribed platelet adenosine diphosphate (ADP) antagonist in Puerto Rico despite the advent of newer agents (prasugrel and ticagrelor). Given the paucity of data on clopidogrel responsiveness in Hispanics, we sought to determine the association between clinical characteristics and platelet reactivity in Puerto Rican patients on clopidogrel therapy. A total of 100 Puerto Rican patients on clopidogrel therapy were enrolled and allocated into two groups: Group I, without high on-treatment platelet reactivity (HTPR); and Group II, with HTPR. Platelet function was measured ex vivo using the VerifyNow® P2Y12 assay. The cohort was comprised of Hispanic patients with coronary artery disease (57%), peripheral artery disease (32%), carotid artery stenosis (7%), cerebral artery aneurysm (2%), and stroke (2%). Mean platelet reactivity was 200 ± 61 P2Y12 reaction units (PRUs) (range: 8-324), and 35% of patients had HTPR (PRUs ⩾ 230). Multivariable logistic regression analysis determined that diabetes mellitus (DM) [odds ratio (OR) = 3.27; 95% confidence interval (CI): 1.20-8.96], use of proton-pump inhibitors (PPIs) (OR = 3.60; 95% CI: 1.09-11.82), and calcium channel blockers (CCBs) (OR = 3.10; 95% CI: 1.09-8.83) were independent predictors of HTPR ( p Puerto Rican Hispanic patients on clopidogrel, 35% had HTPR. Furthermore, DM, PPIs and CCBs predicted HTPR. Clinical outcome data are needed to identify appropriate PRU thresholds for risk prediction in the Puerto Rican population.

  7. Effects of ticagrelor versus clopidogrel on platelet function in fibrinolytic-treated STEMI patients undergoing early PCI.

    Dehghani, Payam; Lavoie, Andrea; Lavi, Shahar; Crawford, Jennifer J; Harenberg, Sebastian; Zimmermann, Rodney H; Booker, Jeff; Kelly, Sheila; Cantor, Warren J; Mehta, Shamir R; Bagai, Akshay; Goodman, Shaun G; Cheema, Asim N

    2017-10-01

    Patients undergoing PCI early after fibrinolytic therapy are at high risk for both thrombotic and bleeding complications. We sought to assess the pharmacodynamic effects of ticagrelor versus clopidogrel in the fibrinolytic-treated STEMI patients undergoing early PCI. Patients undergoing PCI within 24 hours of tenecteplase (TNK), aspirin, and clopidogrel for STEMI were randomized to receive additional clopidogrel 300 mg followed by 75 mg daily or ticagrelor 180 mg followed by 90 mg twice daily. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline) at 4 and 24 hours post-PCI. The primary end point was PRU ≤208 at 4 hours. A total of 140 patients (74 in ticagrelor and 66 in clopidogrel group) were enrolled. The mean PRU values at baseline were similar for the 2 groups (257.8±52.9 vs 259.5±56.7, P=.85, respectively). Post-PCI, patients on ticagrelor, compared to those on clopidogrel, had significantly lower PRU at 4 hours (78.7±88 vs 193.6±86.5, respectively, PPCI frequently had PRU >208. In this high-risk population, ticagrelor provides more prompt and potent platelet inhibition compared with clopidogrel (Funded by Astra Zeneca; NCT01930591, https://clinicaltrials.gov/ct2/show/NCT01930591). Copyright © 2017 Elsevier Inc. All rights reserved.

  8. Clopidogrel reloading for patients with acute myocardial infarction already on clopidogrel therapy.

    Doll, Jacob A; Li, Shuang; Chiswell, Karen; Roe, Matthew T; Kosiborod, Mikhail; Scirica, Benjamin M; Wang, Tracy Y

    2018-01-14

    We sought to determine the association of clopidogrel reloading with in-hospital bleeding and mortality in contemporary practice. We examined clopidogrel reloading for ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients on pre-admission clopidogrel therapy in the ACTION Registry-GWTG from 2009 to 2014. We used inverse probability weighted propensity adjustment to compare in-hospital mortality and major bleeding risks between patients reloaded in the first 24 h with ≥300 mg of clopidogrel vs. those continued on a maintenance (therapy who were admitted with STEMI, 9369 (75.8%) received a loading dose. Of 39 158 patients with NSTEMI, 10 144 (25.9%) were reloaded. Reloaded patients were younger, had fewer comorbid conditions, and were more likely to be treated with primary PCI (STEMI) or an early invasive strategy (NSTEMI). Risks of major bleeding were not significantly different between patients with and without reloading, whether presenting with STEMI (OR 0.98, 95% CI 0.85-1.13) or NSTEMI (OR 1.00, 95% CI 0.90-1.11). Among STEMI patients, clopidogrel reloading was associated with lower risks of in-hospital mortality (OR 0.80, 95% CI 0.66-0.96), however no significant mortality difference was observed among NSTEMI patients (OR 1.13, 95% CI 0.93-1.37). Clopidogrel reloading occurs frequently among MI patients who are on pre-admission clopidogrel therapy, particularly among STEMI patients. We did not observe increased bleeding or mortality risk with clopidogrel reloading, and therefore reloading could be safe for most MI patients. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

  9. CYP2D6 Genetic Variation and Beta-Blocker Maintenance Dose in Patients with Heart Failure.

    Luzum, Jasmine A; Sweet, Kevin M; Binkley, Philip F; Schmidlen, Tara J; Jarvis, Joseph P; Christman, Michael F; Sadee, Wolfgang; Kitzmiller, Joseph P

    2017-08-01

    This study examined whether a CYP2D6 polymorphism (CYP2D6*4) was related to beta-blocker maintenance dose in patients with heart failure. Logistic regression modeling was utilized in a retrospective chart-review analysis of heart-failure patients (60% Male, 90% of European descent) to assess whether CYP2D6*4 (non-functional CYP2D6 allele present in 1 of 5 individuals of European descent) is associated with maintenance dose of carvedilol (n = 65) or metoprolol (n = 33). CYP2D6*4 was associated with lower maintenance dose of metoprolol (OR 0.13 [95% CI 0.02-0.75] p = 0.023), and a trend was observed between CYP2D6*4 and higher maintenance dose of carvedilol (OR 2.94 [95% CI 0.84-10.30] p = 0.093). None of the patients that carried CYP2D6*4 achieved the recommended target dose of metoprolol (200 mg/day). Consistent with the role of CYP2D6 in the metabolism of metoprolol, the tolerated maintenance dose of metoprolol was lower in CYP2D6*4 carriers compared to non-carriers. Consistent with the role of CYP2D6 in activation of carvedilol, tolerated maintenance dose of carvedilol was higher in CYP2D6*4 carriers compared to non-carriers. Further investigation is warranted to ascertain the potential of CYP2D6 as a potential predictive biomarker of beta-blocker maintenance dose in heart failure patients.

  10. [Clinical applications of dosing algorithm in the predication of warfarin maintenance dose].

    Huang, Sheng-wen; Xiang, Dao-kang; An, Bang-quan; Li, Gui-fang; Huang, Ling; Wu, Hai-li

    2011-12-27

    To evaluate the feasibility of clinical application for genetic based dosing algorithm in the predication of warfarin maintenance dose in Chinese population. The clinical data were collected and blood samples harvested from a total of 126 patients undergoing heart valve replacement. The genotypes of VKORC1 and CYP2C9 were determined by melting curve analysis after PCR. They were divided randomly into the study and control groups. In the study group, the first three doses of warfarin were prescribed according to the predicted warfarin maintenance dose while warfarin was initiated at 2.5 mg/d in the control group. The warfarin doses were adjusted according to the measured international normalized ratio (INR) values. And all subjects were followed for 50 days after an initiation of warfarin therapy. At the end of a 50-day follow-up period, the proportions of the patients on a stable dose were 82.4% (42/51) and 62.5% (30/48) for the study and control groups respectively. The mean durations of reaching a stable dose of warfarin were (27.5 ± 1.8) and (34.7 ± 1.8) days and the median durations were (24.0 ± 1.7) and (33.0 ± 4.5) days in the study and control groups respectively. Significant differences existed in the durations of reaching a stable dose between the two groups (P = 0.012). Compared with the control group, the hazard ratio (HR) for the duration of reaching a stable dose was 1.786 in the study group (95%CI 1.088 - 2.875, P = 0.026). The predicted dosing algorithm incorporating genetic and non-genetic factors may shorten the duration of achieving efficiently a stable dose of warfarin. And the present study validates the feasibility of its clinical application.

  11. The importance of bioequivalence study: focus on clopidogrel

    Arini Setiawati

    2011-05-01

    Full Text Available Bioequivalence (BE study is required to show whether a generic copy product can be interchangeable with the brand innovator product. The aim of this article is to provide the rationale for conducting BE studies, the main products requiring BE studies, the design and conduct of BE studies in general, with focus on clopidogrel. All of the clopidogrel generic products in Indonesia have been shown to be BE to the innovator product Plavix® and they contain API (active pharmaceutical ingredient clopidogrel form 1 that complies with USP 30, 1997 requirements: the R-enantiomer content is not more than 1%. A proof that bioequivalence (BE means therapeutic equivalence (TE is also provided for cardiovascular drugs. Clopidogrel has 2 polymorphic forms, form 1 and form 2, which have the same indications. At least one pivotal study of clopidogrel, CAPRIE, used clopidogrel form 1. An atherothrombotic event may be associated with clopidogrel resistance, which occur in about 4 to 30% of patients treated with conventional doses of clopidogrel. (Med J Indones 2011; 20:149-53Keywords: bioequivalent, clopidogrel

  12. Safety of carotid endarterectomy in patients concurrently on clopidogrel.

    Fleming, Mark D; Stone, William M; Scott, Paul; Chapital, Alyssa B; Fowl, Richard J; Money, Samuel R

    2009-01-01

    Clopidogrel (Plavix) usage is increasing, primarily for the management of patients with cerebrovascular symptoms and for those receiving drug-eluting coronary artery stents. A significant percentage of these patients will require carotid endarterectomy (CEA) while they are receiving clopidogrel. Recent data have demonstrated an increased incidence of coronary stent thrombosis when clopidogrel is discontinued. The objective of this study was to determine if CEA could be performed safely while patients are continued on clopidogrel therapy. A retrospective cohort design was employed to review consecutive patients who underwent CEA over a 24-month period ending March 2007. Patients were divided into two groups based on the perioperative use of clopidogrel. Preoperative demographics and postoperative results were compared between the two groups and statistically analyzed. Of the 100 patients who underwent CEA, 19 were taking clopidogrel within 5 days of surgery. This comprised the study group. The control group consisted of the 81 patients who did not receive clopidogrel. Heparin anticoagulation was routinely utilized prior to clamping in both groups. Demographics were similar between the groups. There were no statistical differences in morbidity or mortality between the control group and the clopidogrel group. Combined stroke/death rates were equivalent between the two groups (1.2% control vs. 0% clopidogrel). One hematoma developed in the control group, which did not require operative intervention. In this series, our results suggest that patients concurrently on clopidogrel can safely undergo CEA without increased risk of hematoma or neurological complications. In view of recent data demonstrating adverse outcomes in patients discontinuing clopidogrel, this study is useful in optimally managing this group of patients.

  13. A pharmacogenetics-based warfarin maintenance dosing algorithm from Northern Chinese patients.

    Jinxing Chen

    Full Text Available Inconsistent associations with warfarin dose were observed in genetic variants except VKORC1 haplotype and CYP2C9*3 in Chinese people, and few studies on warfarin dose algorithm was performed in a large Chinese Han population lived in Northern China. Of 787 consenting patients with heart-valve replacements who were receiving long-term warfarin maintenance therapy, 20 related Single nucleotide polymorphisms were genotyped. Only VKORC1 and CYP2C9 SNPs were observed to be significantly associated with warfarin dose. In the derivation cohort (n = 551, warfarin dose variability was influenced, in decreasing order, by VKORC1 rs7294 (27.3%, CYP2C9*3(7.0%, body surface area(4.2%, age(2.7%, target INR(1.4%, CYP4F2 rs2108622 (0.7%, amiodarone use(0.6%, diabetes mellitus(0.6%, and digoxin use(0.5%, which account for 45.1% of the warfarin dose variability. In the validation cohort (n = 236, the actual maintenance dose was significantly correlated with predicted dose (r = 0.609, P<0.001. Our algorithm could improve the personalized management of warfarin use in Northern Chinese patients.

  14. A Pharmacogenetics-Based Warfarin Maintenance Dosing Algorithm from Northern Chinese Patients

    Luo, Fang; Wang, Jin'e; Shi, Yi; Tan, Yu; Chen, Qianlong; Zhang, Yu; Hui, Rutai; Wang, Yibo

    2014-01-01

    Inconsistent associations with warfarin dose were observed in genetic variants except VKORC1 haplotype and CYP2C9*3 in Chinese people, and few studies on warfarin dose algorithm was performed in a large Chinese Han population lived in Northern China. Of 787 consenting patients with heart-valve replacements who were receiving long-term warfarin maintenance therapy, 20 related Single nucleotide polymorphisms were genotyped. Only VKORC1 and CYP2C9 SNPs were observed to be significantly associated with warfarin dose. In the derivation cohort (n = 551), warfarin dose variability was influenced, in decreasing order, by VKORC1 rs7294 (27.3%), CYP2C9*3(7.0%), body surface area(4.2%), age(2.7%), target INR(1.4%), CYP4F2 rs2108622 (0.7%), amiodarone use(0.6%), diabetes mellitus(0.6%), and digoxin use(0.5%), which account for 45.1% of the warfarin dose variability. In the validation cohort (n = 236), the actual maintenance dose was significantly correlated with predicted dose (r = 0.609, Pwarfarin use in Northern Chinese patients. PMID:25126975

  15. Effects of Clopidogrel Therapy on Oxidative Stress, Inflammation, Vascular Function and Progenitor Cells in Stable Coronary Artery Disease

    Ramadan, Ronnie; Dhawan, Saurabh S.; Syed, Hamid; Pohlel, F. Khan; Binongo, Jose Nilo G.; Ghazzal, Ziyad B.; Quyyumi, Arshed A.

    2014-01-01

    Background Traditional cardiovascular risk factors lead to endothelial injury and activation of leucocytes and platelets that initiate and propagate atherosclerosis. We proposed that clopidogrel therapy in patients with stable CAD imparts a pleiotropic effect that extends beyond anti-platelet aggregation to other athero-protective processes. Methods Forty-one subjects were randomized in a double-blind, placebo-controlled crossover study to either clopidogrel 75 mg daily or placebo for 6-weeks, and then transitioned immediately to the other treatment for an additional 6 weeks. We assessed 1) endothelial function as flow-mediated dilation of the brachial artery, 2) arterial stiffness and central augmentation index using applanation tonometry, 3) vascular function as fingertip reactive hyperemia index, 4) inflammation by measuring plasma CD40 ligand and serum high-sensitivity c-reactive protein levels, 5) oxidative stress by measuring plasma aminothiols, and 6) circulating progenitor cells, at baseline and at the end of each 6-week treatment period. Results Clopidogrel therapy resulted in a significant reduction in soluble CD40 ligand (p=0.03), a pro-thrombotic and pro-inflammatory molecule derived mainly from activated platelets. However, clopidogrel therapy had no effect on endothelial function, arterial stiffness, inflammatory and oxidative stress markers, or progenitor cells. Conclusions Our findings suggest a solitary anti-platelet effect of clopidogrel therapy in patients with stable CAD, with no effect on other sub-clinical markers of cardiovascular disease risk. PMID:24336012

  16. THERAPEUTIC EQUIVALENCE OF ORIGINAL CLOPIDOGREL (PLAVIX AND ITS GENERIC (EGITROMB. RESULTS OF COMPARATIVE RANDOMIZED CROSS-OVER BLIND STUDY

    V. V. Yakusevich

    2011-01-01

    Full Text Available Aim. To study therapeutic equivalence (efficacy, safety and tolerability of original clopidogrel (Plavix and its generic (Egitromb in patients of high cardiovascular risk. Material and methods. Thirty one patients with coronary heart disease and indications for clopidogrel therapy were involved into the randomized cross-over blind study. Half of the patients received original clopidogrel (75 mg daily during the first 2 weeks and then they received generic clopidogrel in the same dose during next 2 weeks. Another half of the patients received the drugs in reverse order. Antiplatelet activity of Plavix and Egitromb was estimated by effects on ADP-induced platelet aggregation initially and after 2 weeks of treatment with each drug. Study blinding was provided by the following approach: doctors of cardiology clinic performed clinical monitoring and drug distribution; coded blood samples for platelet aggregation assessment were studied in independent laboratory of thrombosis; statistical data analysis was performed by biostatistics expert in other research center. Results. 2-week therapy with each drug led to a significant decrease of ADP-induced platelet aggregation which remained low after switching from original drug to generic and vice versa. Aggregation dynamics did not depend on the first administered drug. There were no significant differences between aggregation changes as a result of treatment with original or generic drug. No one adverse event was observed in association with both drugs therapy. Conclusion. Generic drug Egitromb (Egis, Hungary and original clopidogrel Plavix (Sanofi-Aventis, France have equivalent antiplatelet effect.

  17. Clopidogrel discontinuation and platelet reactivity following coronary stenting

    2011-01-01

    Summary. Aims: Antiplatelet therapy with aspirin and clopidogrel is recommended for 1 year after drug-eluting stent (DES) implantation or myocardial infarction. However, the discontinuation of antiplatelet therapy has become an important issue as recent studies have suggested a clustering of ischemic events within 90 days of clopidogrel withdrawal. The objective of this investigation was to explore the hypothesis that there is a transient ‘rebound’ increase in platelet reactivity within 3 months of clopidogrel discontinuation. Methods and Results: In this prospective study, platelet function was assessed in patients taking aspirin and clopidogrel for at least 1 year following DES implantation. Platelet aggregation was measured using a modification of light transmission aggregometry in response to multiple concentrations of adenosine diphosphate (ADP), epinephrine, arachidonic acid, thrombin receptor activating peptide and collagen. Clopidogrel was stopped and platelet function was reassessed 1 week, 1 month and 3 months later. Thirty-two patients on dual antiplatelet therapy were recruited. Discontinuation of clopidogrel increased platelet aggregation to all agonists, except arachidonic acid. Platelet aggregation in response to ADP (2.5, 5, 10, and 20 μm) and epinephrine (5 and 20 μm) was significantly increased at 1 month compared with 3 months following clopidogrel withdrawal. Thus, a transient period of increased platelet reactivity to both ADP and epinephrine was observed 1 month after clopidogrel discontinuation. Conclusions: This study demonstrates a transient increase in platelet reactivity 1 month after clopidogrel withdrawal. This phenomenon may, in part, explain the known clustering of thrombotic events observed after clopidogrel discontinuation. This observation requires confirmation in larger populations.

  18. A review of a priori regression models for warfarin maintenance dose prediction.

    Ben Francis

    Full Text Available A number of a priori warfarin dosing algorithms, derived using linear regression methods, have been proposed. Although these dosing algorithms may have been validated using patients derived from the same centre, rarely have they been validated using a patient cohort recruited from another centre. In order to undertake external validation, two cohorts were utilised. One cohort formed by patients from a prospective trial and the second formed by patients in the control arm of the EU-PACT trial. Of these, 641 patients were identified as having attained stable dosing and formed the dataset used for validation. Predicted maintenance doses from six criterion fulfilling regression models were then compared to individual patient stable warfarin dose. Predictive ability was assessed with reference to several statistics including the R-square and mean absolute error. The six regression models explained different amounts of variability in the stable maintenance warfarin dose requirements of the patients in the two validation cohorts; adjusted R-squared values ranged from 24.2% to 68.6%. An overview of the summary statistics demonstrated that no one dosing algorithm could be considered optimal. The larger validation cohort from the prospective trial produced more consistent statistics across the six dosing algorithms. The study found that all the regression models performed worse in the validation cohort when compared to the derivation cohort. Further, there was little difference between regression models that contained pharmacogenetic coefficients and algorithms containing just non-pharmacogenetic coefficients. The inconsistency of results between the validation cohorts suggests that unaccounted population specific factors cause variability in dosing algorithm performance. Better methods for dosing that take into account inter- and intra-individual variability, at the initiation and maintenance phases of warfarin treatment, are needed.

  19. A review of a priori regression models for warfarin maintenance dose prediction.

    Francis, Ben; Lane, Steven; Pirmohamed, Munir; Jorgensen, Andrea

    2014-01-01

    A number of a priori warfarin dosing algorithms, derived using linear regression methods, have been proposed. Although these dosing algorithms may have been validated using patients derived from the same centre, rarely have they been validated using a patient cohort recruited from another centre. In order to undertake external validation, two cohorts were utilised. One cohort formed by patients from a prospective trial and the second formed by patients in the control arm of the EU-PACT trial. Of these, 641 patients were identified as having attained stable dosing and formed the dataset used for validation. Predicted maintenance doses from six criterion fulfilling regression models were then compared to individual patient stable warfarin dose. Predictive ability was assessed with reference to several statistics including the R-square and mean absolute error. The six regression models explained different amounts of variability in the stable maintenance warfarin dose requirements of the patients in the two validation cohorts; adjusted R-squared values ranged from 24.2% to 68.6%. An overview of the summary statistics demonstrated that no one dosing algorithm could be considered optimal. The larger validation cohort from the prospective trial produced more consistent statistics across the six dosing algorithms. The study found that all the regression models performed worse in the validation cohort when compared to the derivation cohort. Further, there was little difference between regression models that contained pharmacogenetic coefficients and algorithms containing just non-pharmacogenetic coefficients. The inconsistency of results between the validation cohorts suggests that unaccounted population specific factors cause variability in dosing algorithm performance. Better methods for dosing that take into account inter- and intra-individual variability, at the initiation and maintenance phases of warfarin treatment, are needed.

  20. Post Hoc Analyses of Randomized Clinical Trial for the Effect of Clopidogrel Added to Aspirin on Kidney Function.

    Ikeme, Jesse C; Pergola, Pablo E; Scherzer, Rebecca; Shlipak, Michael G; Benavente, Oscar R; Peralta, Carmen A

    2017-07-07

    Despite the high burden of CKD, few specific therapies are available that can halt disease progression. In animal models, clopidogrel has emerged as a potential therapy to preserve kidney function. The effect of clopidogrel on kidney function in humans has not been established. The Secondary Prevention of Small Subcortical Strokes Study randomized participants with prior lacunar stroke to treatment with aspirin or aspirin plus clopidogrel. We compared annual eGFR decline and incidence of rapid eGFR decline (≥30% from baseline) using generalized estimating equations and interval-censored proportional hazards regression, respectively. We also stratified our analyses by baseline eGFR, systolic BP target, and time after randomization. At randomization, median age was 62 (interquartile range, 55-71) years old; 36% had a history of diabetes, 90% had hypertension, and the median eGFR was 81 (interquartile range, 65-94) ml/min per 1 m 2 . Persons receiving aspirin plus clopidogrel had an average annual change in kidney function of -1.39 (95% confidence interval, -1.15 to -1.62) ml/min per 1.73 m 2 per year compared with -1.52 (95% confidence interval, -1.30 to -1.74) ml/min per 1.73 m 2 per year among persons receiving aspirin only ( P =0.42). Rapid kidney function decline occurred in 21% of participants receiving clopidogrel plus aspirin compared with 22% of participants receiving aspirin plus placebo (hazard ratio, 0.94; 95% confidence interval, 0.79 to 1.10; P =0.42). Findings did not vary by baseline eGFR, time after randomization, or systolic BP target (all P values for interaction were >0.3). We found no effect of clopidogrel added to aspirin compared with aspirin alone on kidney function decline among persons with prior lacunar stroke. Copyright © 2017 by the American Society of Nephrology.

  1. Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular events.

    Squizzato, Alessandro; Bellesini, Marta; Takeda, Andrea; Middeldorp, Saskia; Donadini, Marco Paolo

    2017-12-14

    Aspirin is the prophylactic antiplatelet drug of choice for people with cardiovascular disease. Adding a second antiplatelet drug to aspirin may produce additional benefit for people at high risk and people with established cardiovascular disease. This is an update to a previously published review from 2011. To review the benefit and harm of adding clopidogrel to aspirin therapy for preventing cardiovascular events in people who have coronary disease, ischaemic cerebrovascular disease, peripheral arterial disease, or were at high risk of atherothrombotic disease, but did not have a coronary stent. We updated the searches of CENTRAL (2017, Issue 6), MEDLINE (Ovid, 1946 to 4 July 2017) and Embase (Ovid, 1947 to 3 July 2017) on 4 July 2017. We also searched ClinicalTrials.gov and the WHO ICTRP portal, and handsearched reference lists. We applied no language restrictions. We included all randomised controlled trials comparing over 30 days use of aspirin plus clopidogrel with aspirin plus placebo or aspirin alone in people with coronary disease, ischaemic cerebrovascular disease, peripheral arterial disease, or at high risk of atherothrombotic disease. We excluded studies including only people with coronary drug-eluting stent (DES) or non-DES, or both. We collected data on mortality from cardiovascular causes, all-cause mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal ischaemic stroke, major and minor bleeding. The overall treatment effect was estimated by the pooled risk ratio (RR) with 95% confidence interval (CI), using a fixed-effect model (Mantel-Haenszel); we used a random-effects model in cases of moderate or severe heterogeneity (I 2 ≥ 30%). We assessed the quality of the evidence using the GRADE approach. We used GRADE profiler (GRADE Pro) to import data from Review Manager to create a 'Summary of findings' table. The search identified 13 studies in addition to the two studies in the previous version of our systematic review. Overall

  2. Influence of paraoxonase-1 Q192R and cytochrome P450 2C19 polymorphisms on clopidogrel response

    Li L

    2012-02-01

    Full Text Available Rolf P Kreutz1,2, Perry Nystrom2, Yvonne Kreutz2, Jia Miao2, Zeruesenay Desta2, Jeffrey A Breall1, Lang Li2, ChienWei Chiang2, Richard Kovacs1, David A Flockhart2, Yan Jin21Krannert Institute of Cardiology, 2Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN, USABackground: The metabolic activation of clopidogrel is a two-step process. It has been suggested that paraoxonase-1 (PON1 is a rate-limiting enzyme in the conversion of 2-oxo-clopidogrel to an active thiol metabolite. Conflicting results have been reported in regard to (1 the association of a common polymorphism of PON1 (Q192R with reduced rates of coronary stent thrombosis in patients taking clopidogrel and (2 its effects on platelet inhibition in patient populations of European descent. Methods: Blood samples from 151 subjects of mixed racial background with established coronary artery disease and who received clopidogrel were analyzed. Platelet aggregation was determined with light transmittance aggregometry and VerifyNow® P2Y12 assay. Genotyping for cytochrome P450 2C19 (CYP2C19*2 and *3 and PON1 (Q192R polymorphisms was performed.Results: Carriers of CYP2C19*2 alleles exhibited lower levels of platelet inhibition and higher on-treatment platelet aggregation than noncarriers. There was no significant difference in platelet aggregation among PON1 Q192R genotypes. Homozygous carriers of the wild-type variant of PON1 (QQ192 had similar on-treatment platelet reactivity to carriers of increased-function variant alleles during maintenance clopidogrel dosing, as well as after administration of a clopidogrel 600 mg loading dose.Conclusion: CYP2C19*2 allele is associated with impaired platelet inhibition by clopidogrel and high on-treatment platelet aggregation. PON1 (Q192R polymorphism does not appear to be a significant determinant of clopidogrel response.Keywords: PON1, platelet, aggregation, cytochrome P450 enzymes

  3. Effect of cytochrome P450 2C19 polymorphism on adverse cardiovascular events after drug-eluting stent implantation in a large Hakka population with acute coronary syndrome receiving clopidogrel in southern China.

    Zhong, Zhixiong; Hou, Jingyuan; Zhang, Qifeng; Li, Bin; Li, Cunren; Liu, Zhidong; Yang, Min; Zhong, Wei; He, Xuebo; Wu, Hesen; Zhong, Miaocai; Zhao, Pingsen

    2018-04-01

    The objective of this study is to evaluate the effects of cytochrome P450 2C19 (CYP2C19) polymorphism on adverse cardiovascular events (MACE) in Hakka patients with acute coronary syndrome (ACS) receiving clopidogrel who had undergone coronary drug-eluting stent placement after percutaneous coronary intervention (PCI) in southern China. Genotyping of CYP2C19 and MACE of 934 ACS patients with PCI on clopidogrel maintenance therapy were analyzed. Patients who carried loss-of-function CYP2C19 were treated with a 150-mg maintenance dose of clopidogrel or 90 mg of ticagrelor antiplatelet therapy, and patients who were non-carriers received clopidogrel therapy daily at a maintenance dose of 75 mg and the patients were followed-up for at least 12 months. The primary efficacy endpoint was a composite of cardiovascular death, myocardial infarction, and target vessel revascularization and stroke. The allelic frequency of CYP2C19*2 and CYP2C19*3 of Hakka patients in the current study was 31.64 and 5.19%, respectively. The CYP2C19 wild-type homozygotes (*1/*1) were the most predominant among the patients (40.36%), followed by the CYP2C19*2 heterozygotes (*1/*2) (40.26%). The distribution of CYP2C19 phenotypes was divided into extensive metabolizers (EM; 40.36%), intermediate metabolizers (IM; 45.61%), and poor metabolizers (PM; 14.03%). Based on the genotype-guided antiplatelet therapy, there was no significant association between the carrier status and the clinical outcome at 1, 6, and 12 months. In addition, no significant difference in the rates of bleeding was found among the three groups. After logistic regression analysis, hypertension was the only independent predictor of cardiovascular events (relative risk, 1.501; 95% CI, 1.011 to 2.229; P = 0.044). Our results shed new light on the important benefit of testing CYP2C19 polymorphisms before prescribing clopidogrel in patients treated with drug-eluting stent implantation after PCI. The testing may help to

  4. Effect of Smoking on Pharmacokinetics of Clopidogrel, an ...

    ... in patients undergoing PCI. Keywords: Antiplatelet, Clopidogrel, Pharmacokinetics, Smoking, Cigarette ..... regimen of choice to prevent thrombotic complications. [2,16]. ... either the parent drug [19] or the carboxylic acid metabolite as an ...

  5. Aspirin and clopidogrel resistance: methodological challenges and opportunities

    Armen Yuri Gasparyan

    2010-03-01

    Full Text Available Armen Yuri GasparyanClinical Research Unit, Russell’s Hall Hospital, Dudley Group of Hospitals NHS Foundation Trust, West Midlands, UKAbstract: Antiplatelet drug resistance is one of the urgent issues in current cardiovascular medicine. Many platelet function tests have been used to define responsiveness of patients with cardiovascular disease to aspirin and clopidogrel. In most studies, cut-off values of platelet function tests for defining responsiveness to antiplatelets were chosen arbitrarily. Different tests provided wide-ranging figures of the prevalence of aspirin and clopidogrel resistance, suggesting poor correlation between currently available platelet function tests. Measurement of platelet size seems to be a promising approach for monitoring antiplatelet drug therapy. This commentary highlights some limitations of studies on aspirin and clopidogrel resistance in patients undergoing coronary interventions.Keywords: aspirin, clopidogrel, resistance, cardiovascular disease, platelet function tests

  6. Pharmacogenetics of clopidogrel: comparison between a standard and a rapid genetic testing.

    Saracini, Claudia; Vestrini, Anna; Galora, Silvia; Armillis, Alessandra; Abbate, Rosanna; Giusti, Betti

    2012-06-01

    CYP2C19 variant alleles are independent predictors of clopidogrel response variability and occurrence of major adverse cardiovascular events in high-risk vascular patients on clopidogrel therapy. Increasing evidence suggests a combination of platelet function testing with CYP2C19 genetic testing may be more effective in identifying high-risk individuals for alternative antiplatelet therapeutic strategies. A crucial point in evaluating the use of these polymorphisms in clinical practice, besides test accuracy, is the cost of the genetic test and rapid availability of the results. One hundred acute coronary syndrome patients were genotyped for CYP2C19*2,*3,*4,*5, and *17 polymorphisms with two platforms: Verigene(®) and the TaqMan(®) system. Genotyping results obtained by the classical TaqMan approach and the rapid Verigene approach showed a 100% concordance for all the five polymorphisms investigated. The Verigene system had shorter turnaround time with respect to TaqMan. The cost of reagents for TaqMan genotyping was lower than that for the Verigene system, but the effective manual staff involvement and the relative cost resulted in higher cost for TaqMan than for Verigene. The Verigene system demonstrated good performance in terms of turnaround time and cost for the evaluation of the clopidogrel poor metabolizer status, giving genetic information in suitable time (206 min) for a therapeutic strategy decision.

  7. Adjustable Maintenance Dosing with Budesonide/Formoterol Reduces Asthma Exacerbations Compared with Traditional Fixed Dosing: A Five-Month Multicentre Canadian Study

    J Mark FitzGerlad

    2003-01-01

    Full Text Available BACKGROUND: Adjustable maintenance dosing with budesonide/formoterol in a single inhaler (Symbicort, AstraZeneca, Lund, Sweden may provide a convenient means of maintaining asthma control with the minimum effective medication level.

  8. Aspirin, but not clopidogrel, reduces collateral conductance in a rabbit model of femoral artery occlusion

    Hoefer, Imo E.; Grundmann, Sebastian; Schirmer, Stephan; van Royen, Niels; Meder, Benjamin; Bode, Christoph; Piek, Jan J.; Buschmann, Ivo R.

    2005-01-01

    OBJECTIVES The objective of this study was to test the potential of aspirin and clopidogrel to influence collateral artery growth (arteriogenesis). BACKGROUND Aspirin and clopidogrel are antiplatelet agents commonly used in the treatment of ischemic cardiovascular disease. Both inhibit platelet

  9. The impact of a 600-mg loading dose of clopidogrel in diabetic and non-diabetic patients undergoing elective PCI.

    Mohareb, Mina W; Abd Elghany, Mohamed; Sabry, Nirmeen A; Farid, Samar F

    2016-08-01

    High platelet reactivity (HPR) and suboptimal response to dual antiplatelet therapy (DAPT) may explain high recurrent rates of ischemic events in type 1 and 2 diabetes mellitus (DM) patients undergoing percutaneous coronary intervention (PCI). The aim of this study was to determine the effect of diabetes mellitus on clopidogrel activity in cardiac patients undergoing PCI. This is an observational study. Patients were categorized according to DM status into diabetic group (N.=30) and non-diabetic group (N.=33). All patients received clopidogrel in a loading dose of 600 mg before PCI. Platelet function was assessed using light transmittance aggregometry (LTA) technique at baseline (before clopidogrel administration), 24 hour after clopidogrel loading dose administration and 7-10 days after PCI. All patients were followed up for at least one year after PCI for recurrence of acute cardiac events. There was no statistically significant difference between the two groups with respect to 10 µm adenosine diphosphate (ADP)-induced platelet aggregation measured at baseline (P=0.64), 24 hours after PCI (P=0.874), and 7-10 days after PCI (0.643). Diabetics were not significantly different from non-diabetics in terms of post-PCI acute stent thrombosis (P=0.945), sub-acute stent thrombosis (P=0.945), unstable angina (P=0.29) and cardiac death (P=0.64). There was a statistically significant difference between patients with and without post-PCI acute events regarding ADP aggregation measured 24 hours and 7-10 days after PCI. The use of a high loading dose of clopidogrel (600 mg) in patients undergoing elective PCI can overcome the significant increase in post-PCI platelet aggregation and rate of acute cardiac events induced by diabetes mellitus as co-morbidity in those patients.

  10. Correlation between Colon Transit Time Test Value and Initial Maintenance Dose of Laxative in Children with Chronic Functional Constipation

    Kim, Mock Ryeon; Park, Hye Won; Son, Jae Sung; Lee, Ran

    2016-01-01

    Purpose To evaluate the correlation between colon transit time (CTT) test value and initial maintenance dose of polyethylene glycol (PEG) 4000 or lactulose. Methods Of 415 children with chronic functional constipation, 190 were enrolled based on exclusion criteria using the CTT test, defecation diary, and clinical chart. The CTT test was performed with prior disimpaction. The laxative dose for maintenance was determined on the basis of the defecation diary and clinical chart. The Shapiro-Wilk test and Pearson's and Spearman's correlations were used for statistical analysis. Results The overall group median value and interquartile range of the CTT test was 43.8 (31.8) hours. The average PEG 4000 dose for maintenance in the overall group was 0.68±0.18 g/kg/d; according to age, the dose was 0.73±0.16 g/kg/d (encopresis, abnormal CTT test subtype) for either laxative. Even in the largest group (overall, n=109, younger than 8 years and on PEG 4000), the correlation was weak (Pearson's correlation coefficient [R]=0.268, p=0.005). Within the abnormal transit group, subgroup (n=73, younger than 8 years and on PEG 4000) correlation was weak (R=0.267, p=0.022). Conclusion CTT test value cannot predict the initial maintenance dose of PEG 4000 or lactulose with linear correlation. PMID:27738600

  11. Platelet function testing to predict hyporesponsiveness to clopidogrel in patients with chest pain seen in the emergency department

    Sharma RK

    2013-05-01

    Full Text Available Rakesh K Sharma,1 Stephen W Erickson,1 Rohit Sharma,2 Donald J Voelker,1 Hanumanth K Reddy,1 Harvinder Dod,2 James D Marsh1 1Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, 2Medical Center of South Arkansas, El Dorado, AR, USA Background: A dual antiplatelet regimen has been shown to reduce the risk of major adverse cardiovascular events after percutaneous coronary intervention. However, there is little information available on inhibition of platelet aggregation in patients with a prior coronary stent presenting with chest pain. This study evaluated the prevalence of hyporesponsiveness to clopidogrel and factors associated with this in patients presenting to our emergency department with chest pain who had previously undergone coronary stent placement and were prescribed dual antiplatelet therapy. Methods: Responsiveness to clopidogrel was evaluated in a cohort of 533 consecutive stented patients presenting to the emergency department with chest pain. P2Y12 reaction units (PRU and percent P2Y12 inhibition with clopidogrel were measured in all patients. Of 533 patients, 221 (41.6% had PRU ≥ 230. A multivariate logistic regression model was used to determine the relationship between hyporesponsiveness to clopidogrel (defined as PRU ≥ 230 and several potential risk factors, ie, gender, age, race, type 1 or type 2 diabetes, hypertension, smoking, chronic renal failure, and obesity. Results: There was a greater risk of hyporesponsiveness in African Americans than in non-African American patients (adjusted odds ratio [OR] = 2.165, in patients with type 2 diabetes than in those without (adjusted OR = 2.109, and in women than in men (adjusted OR = 1.813, as well as a greater risk of hyporesponsiveness with increasing age (adjusted OR = 1.167 per decade. Conclusion: There was a high prevalence of hyporesponsiveness to clopidogrel in patients presenting with chest pain and a prior coronary stent. Non

  12. Desensitization to clopidogrel: a tailor-made protocol.

    Barreira, P; Cadinha, S; Malheiro, D; Moreira da Silva, J P

    2014-01-01

    Clopidogrel is an antiplatelet drug widely used for treatment and prevention of a variety of cardiovascular diseases. We report a successful desensitization to clopidogrel in a 70-year-old Caucasian man with delayed hypersensitivity (HS) reaction. He developed lip, hand and foot swelling, erythematous papular non-pruritic lesions and arthralgias 2 weeks after starting treatment with clopidogrel 75 mg/d. A 3-hour desensitization protocol was started, achieving a cumulative dose of 154 mg without any reaction, and a daily dose of 75 mg was recommended. On the 4th day, the patient developed skin lesions similar to the previously described. He was treated with topical steroids and oral antihistamines, and the daily dose of clopidogrel was reduced to 20 mg. A new desensitization protocol was established, with a slow dose increment, according to the patient's response. It was only possible to achieve the dose of 75 mg/d after 2 months. Although well tolerated by most patients, HS reactions with clopidogrel may occur and desensitization is rising as a safe alternative in those patients. In delayed reactions with cutaneous lesions, a slower desensitization protocol may be necessary, as in this case.

  13. Efficacy of Clopidogrel and Clinical Outcome When Clopidogrel Is Coadministered With Atorvastatin and Lansoprazole

    Zhang, Jian-rong; Wang, Di-qing; Du, Jun; Qu, Guang-su; Du, Jian-lin; Deng, Song-bai; Liu, Ya-jie; Cai, Jin-xi; She, Qiang

    2015-01-01

    Abstract This prospective, randomized, nonblind, controlled trial evaluated the effects of clopidogrel on platelet function upon coadministration with atorvastatin and lansoprazole. One hundred four adult patients with non-ST-segment elevated acute coronary syndrome (NSTE-ACS) who underwent percutaneous coronary intervention (PCI) with drug-eluting stent implantation were included. All patients were treated with standard dual antiplatelet therapy (DAPT) plus rosuvastatin 10 mg daily after the operation. On the sixth day after PCI, patients were randomly divided into 4 groups, Group A: DAPT + atorvastatin 20 mg daily (a change from rosuvastatin to atorvastatin) + lansoprazole 30 mg daily, Group B: DAPT + atorvastatin 20 mg daily (a change from rosuvastatin to atorvastatin), Group C: DAPT + lansoprazole 30 mg daily (continuing to take rosuvastatin), Group D is the control group. Additional drugs were used according to the situation of patients. Platelet function and concentrations of platelet activation markers (granular membrane protein 140 (P-selectin), thromboxane B2 (TXB2), and human soluble cluster of differentiation 40 ligand (sCD40L)) were assessed before randomization and at 15- and 30-day follow-up visits. All patients were maintained on treatment for 6 months and observed for bleeding and ischemic events. A total of 104 patients were enrolled, 27 patients in group A, 26 patients in Group B/C, 25 patients in Group D separately, and all the patients were analyzed. There were no differences in platelet function and the levels of platelet activation markers (P-selectin, TXB2, and sCD40L) among or within the 4 groups at the 3 time points of interest (P > 0.05). In the subsequent 6 months, no significant bleeding events occurred, and 12 patients experienced ischemic events, these results were also not significantly different among the groups (P > 0.05). In patients diagnosed with NSTE-ACS who have had drug-eluting stent

  14. ANTI-INFLAMMATORY EFFECT OF CLOPIDOGREL IN ATHEROSCLEROSIS

    L. I. Buriachkovskaia

    2011-01-01

    Full Text Available Aim. To analyze the literary and own data about clopidogrel influence on platelets during inflammation and to reveal particularities of its usage in ischemic heart disease (IHD patients with active inflammation. Material and methods. The platelet morphology and a number of leukocyte-platelet aggregates (LTA were investigated with scanning electron microscopy in 110 patients with stable angina pectoris of I-III functional class and 18 healthy volunteers. Spontaneous and ADP-induced platelet aggregation were assessed with laser aggregatometre manufactured by LLC “BIOLA”. Mean platelet volume (MPV was estimated with the hematological analyzer . All investigations were performed in IHD patients before and after 2 months of clopidogrel treatment 75 mg a day. Results. IHD patients demonstrated appearance of LTA and big reticular platelets in the blood, increase in MPV and spontaneous aggregation. ADP-induced platelet aggregation was rarely increased probably due to acetylsalicylic acid therapy in all IHD patients. These platelet activity changes are connected with increased risk of thrombotic events and correlated with inflammation markers levels. After 2 months of clopidogrel treatment LTA number reduced in 4 times and big reticular platelets number decreased in 2.5 times as well as MPV and spontaneous aggregation achieved the normal ranges. Conclusion. Clopidogrel has not only antithrombotic effect but also can diminish platelets morphological and functional changes connected with inflammation.

  15. Clopidogrel in infants with systemic-to-pulmonary-artery shunts

    Wessel, David L; Berger, Felix; Li, Jennifer S

    2013-01-01

    BACKGROUND: Infants with cyanotic congenital heart disease palliated with placement of a systemic-to-pulmonary-artery shunt are at risk for shunt thrombosis and death. We investigated whether the addition of clopidogrel to conventional therapy reduces mortality from any cause and morbidity relate......-related morbidity. (Funded by Sanofi-Aventis and Bristol-Myers Squibb; ClinicalTrials.gov number, NCT00396877.)....

  16. The paradox of clopidogrel use in patients with acute coronary syndromes and diabetes: insight from the Diabetes and Acute Coronary Syndrome Registry.

    Ferlini, Marco; Musumeci, Giuseppe; Grieco, Niccolò; Rossini, Roberta; De Servi, Stefano; Mafrici, Antonio; Sponzilli, Carlo; Demarchi, Andrea; Assanelli, Emilio M; Camisasca, Paola; Chizzola, Giuliano; Corrada, Elena; Farina, Andrea; Pedrinazzi, Claudio; Lettieri, Corrado; Oltrona Visconti, Luigi

    2018-06-01

    Patients with diabetes mellitus (DM) and acute coronary syndromes have a greater level of platelet aggregation and a poor response to oral antiplatelet drugs. Clopidogrel is still widely used in clinical practice, despite the current evidence favoring ticagrelor and prasugrel. The aim of this study was to investigate the determinants of clopidogrel use in the population of the multicenter prospective 'Acute Coronary Syndrome and Diabetes Registry' carried out during a 9-week period between March and May 2015 at 29 Hospitals. A total of 559 consecutive acute coronary syndrome patients [mean age: 68.7±11.3 years, 50% ST-elevation myocardial infarction (STEMI)], with 'known DM' (56%) or 'hyperglycemia' at admission, were included in the registry; 460 (85%) patients received a myocardial revascularization. At hospital discharge, dual antiplatelet therapy was prescribed to 88% of the patients (clopidogrel ticagrelor and prasugrel to 39, 38, and 23%, respectively). Differences in P2Y12 inhibitor administration were recorded on the basis of history of diabetes, age, and clinical presentation (unstable angina/non-STEMI vs. non-STEMI). On univariate analysis, age older than 75 years or more, known DM, peripheral artery disease, previous myocardial infarction, previous revascularization, complete revascularization, previous cerebrovascular event, creatinine clearance, unstable angina/non-STEMI at presentation, Global Registry of Acute Coronary Events Score, EuroSCORE, CRUSADE Bleeding Score, and oral anticoagulant therapy were significantly associated with clopidogrel choice at discharge. On multivariate analysis, only oral anticoagulant therapy and the CRUSADE Bleeding Score remained independent predictors of clopidogrel prescription. In the present registry of a high-risk population, clopidogrel was the most used P2Y12 inhibitor at hospital discharge, confirming the 'paradox' to treat sicker patients with the less effective drug. Diabetic status, a marker of higher

  17. Does "smoker's paradox" exist in clopidogrel-treated Turkish patients with acute coronary syndrome.

    Edem, Efe; Kirdök, Ali Hikmet; Kınay, Ahmet Ozan; Tekin, Ümit İlker; Taş, Sedat; Alpaslan, Erkan; Pabuccu, Mustafa Türker; Akdeniz, Bahri

    2016-01-01

    Previously conducted studies revealed that smoking enhanced the efficacy of clopidogrel by increasing formation of the active metabolite (AM) from the prodrug through induction of the cytochrome CYP1A2. The expression of cytochrome enzymes depends on genotype and no data exists in literature conducted in Turkish patients comparing the clopidogrel responsiveness between active smokers and non-active smokers treated with clopidogrel. In this study, our aim was to investigate the clopidogrel responsiveness in clopidogrel-treated Turkish acute coronary syndrome (ACS) patients according to their smoking status. We retrospectively enrolled 258 patients who were hospitalized due to ACS. Clinical variables of the patients, especially smoking status were recorded. Clopidogrel resistance was evaluated by using adenosine diphosphate (ADP) induced platelet aggregometry. Clopidogrel resistance was detected as a change in maximal aggregation ≤20% from baseline. A total of 139 patients were active smokers while 12 were former smokers. 107 patients did not have a history of smoking. Ten of the smokers were hyporesponsive to clopidogrel, whereas 36 of non-smokers were hyporesponsive to clopidogrel (p value >612.5 predicted the clopidogrel resistance with a sensitivity of 60% (OR: 100.65, %95 CI = 19.996-506.615 p paradox" probably exists in Turkish ACS patients.

  18. CYP2C19*17 increases clopidogrel-mediated platelet inhibition but does not alter the pharmacokinetics of the active metabolite of clopidogrel

    Pedersen, Rasmus Steen; Nielsen, Flemming; Stage, Tore Bjerregaard

    2014-01-01

    *1/*1, 11 CYP2C19*1/*17 and nine CYP2C19*17/*17). In Phase A, the pharmacokinetics of the derivatized active metabolite of clopidogrel (CAMD) and platelet function were determined after administration of a single oral dose of 600 mg clopidogrel (Plavix; Sanofi-Avensis, Horsholm, Denmark). In Phase B...

  19. Influence of CYP3A5 genetic variation on everolimus maintenance dosing after cardiac transplantation.

    Lesche, Dorothea; Sigurdardottir, Vilborg; Setoud, Raschid; Englberger, Lars; Fiedler, Georg M; Largiadèr, Carlo R; Mohacsi, Paul; Sistonen, Johanna

    2015-12-01

    Everolimus (ERL) has become an alternative to calcineurin inhibitors (CNIs) due to its renal-sparing properties, especially in heart transplant (HTx) recipients with kidney dysfunction. However, ERL dosing is challenging due to its narrow therapeutic window combined with high interindividual pharmacokinetic variability. Our aim was to evaluate the effect of clinical and genetic factors on ERL dosing in a pilot cohort of 37 HTx recipients. Variants in CYP3A5, CYP3A4, CYP2C8, POR, NR1I2, and ABCB1 were genotyped, and clinical data were retrieved from patient charts. While ERL trough concentration (C0 ) was within the targeted range for most patients, over 30-fold variability in the dose-adjusted ERL C0 was observed. Regression analysis revealed a significant effect of the non-functional CYP3A5*3 variant on the dose-adjusted ERL C0 (p = 0.031). ERL dose requirement was 0.02 mg/kg/d higher in patients with CYP3A5*1/*3 genotype compared to patients with CYP3A5*3/*3 to reach the targeted C0 (p = 0.041). ERL therapy substantially improved estimated glomerular filtration rate (28.6 ± 6.6 mL/min/1.73 m(2)) in patients with baseline kidney dysfunction. Everolimus pharmacokinetics in HTx recipients is highly variable. Our preliminary data on patients on a CNI-free therapy regimen suggest that CYP3A5 genetic variation may contribute to this variability. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

  20. Haplotype of platelet receptor P2RY12 gene is associated with residual clopidogrel on-treatment platelet reactivity.

    Nie, Xiao-Yan; Li, Jun-Lei; Zhang, Yong; Xu, Yang; Yang, Xue-Li; Fu, Yu; Liang, Guang-Kai; Lu, Yun; Liu, Jian; Shi, Lu-Wen

    To investigate a possible association between common variations of the P2RY12 and the residual clopidogrel on-treatment platelet reactivity after adjusting for the influence of CYP2C19 tested by thromboelastography (TEG). One hundred and eighty patients with acute coronary syndrome (ACS) treated with clopidogrel and aspirin were included and platelet function was assessed by TEG. Five selected P2RY12 single nucleotide polymorphisms (SNPs; rs6798347, rs6787801, rs6801273, rs6785930, and rs2046934), which cover the common variations in the P2RY12 gene and its regulatory regions, and three CYP2C19 SNPs ( * 2, * 3, * 17) were genotyped and possible haplotypes were analyzed. The high on-treatment platelet reactivity (HTPR) prevalence defined by a platelet inhibition rate <30% by TEG in adenosine diphosphate (ADP)-channel was 69 (38.33%). Six common haplotypes were inferred from four of the selected P2RY12 SNPs (denoted H 0 to H 5 ) according to the linkage disequilibrium R square (except for rs2046934). Haplotype H 1 showed a significantly lower incidence of HTPR than the reference haplotype (H 0 ) in the total study population while haplotypes H 1 and H 2 showed significantly lower incidences of HTPR than H 0 in the nonsmoker subgroup after adjusting for CYP2C19 effects and demographic characteristics. rs2046934 (T744C) did not show any significant association with HTPR. The combination of common P2RY12 variations including regulatory regions rather than rs2046934 (T744C) that related to pharmacodynamics of clopidogrel in patients with ACS was independently associated with residual on-clopidogrel platelet reactivity. This is apart from the established association of the CYP2C19. This association seemed more important in the subgroup defined by smoking.

  1. Clopidogrel plus long-term aspirin after femoro-popliteal stenting. The CLAFS project: 1- and 2-year results

    Strecker, Ernst-Peter K.; Boos, Irene B.L.; Goettmann, Dieter; Vetter, Sylvia [Department of Imaging, Interventional Radiology, and Nuclear Medicine, Diakonissen Hospital, Diakonissenstrasse 28, 76199, Karlsruhe (Germany)

    2004-02-01

    The aim of this study was to determine the patency rate after femoro-popliteal stenting followed by oral clopidogrel plus long-term aspirin. In a prospective trial, 31 patients with a total of 33 femoro-popliteal artery lesions (21 stenoses, 12 occlusions; 24 femoral, 9 popliteal) were treated with flexible tantalum stents after unsuccessful percutaneous transluminal angioplasty (PTA) preceded by local fibrinolysis in 5 of 12 patients with total occlusion. Post-interventionally, oral aspirin 100 mg was started simultaneously for the long term and was combined with an oral loading dose of 300 mg clopidogrel, followed by 75 mg clopidogrel daily for 28 days. Patients were followed for at least 12 months (maximum 34 months) by clinical examination, Doppler pressure measurement, color and duplex sonography, and angiography in case of suspicion of restenosis. In a retrospective analysis, the results were compared with those of historical groups of patients having received aspirin only (41 patients) or a long-term high-dose low molecular weight heparin (LMWH)+aspirin treatment (42 patients). Three small puncture aneurysms were treated successfully by conservative means and were categorized as minor bleeding complication. Cumulative primary patency rate (PPR) was 76{+-}7.5% (1 year), and 70{+-}9.6% (2 years) in the clopidogrel+aspirin group, thus being tendentiously better than in the aspirin-only group showing 75{+-}4.6% (1 year), and 50{+-}8.1% (2 years). Long-term high-dose LMWH+aspirin treatment showed 87{+-}5.8% (1 year), and 72{+-}9.1% (2 years), thus being superior to the other treatment regimes, with a statistically significant difference (p<0.05) between the LMWH+aspirin and the aspirin group. Clopidogrel plus aspirin is a safe medication regimen and may be effective in the prevention of early stent thrombosis. Mid- and long-term patency rate seems to be intermediate as compared with other therapeutic regimens. The LMWH+aspirin seems to be superior compared with

  2. Clopidogrel plus long-term aspirin after femoro-popliteal stenting. The CLAFS project: 1- and 2-year results

    Strecker, Ernst-Peter K.; Boos, Irene B.L.; Goettmann, Dieter; Vetter, Sylvia

    2004-01-01

    The aim of this study was to determine the patency rate after femoro-popliteal stenting followed by oral clopidogrel plus long-term aspirin. In a prospective trial, 31 patients with a total of 33 femoro-popliteal artery lesions (21 stenoses, 12 occlusions; 24 femoral, 9 popliteal) were treated with flexible tantalum stents after unsuccessful percutaneous transluminal angioplasty (PTA) preceded by local fibrinolysis in 5 of 12 patients with total occlusion. Post-interventionally, oral aspirin 100 mg was started simultaneously for the long term and was combined with an oral loading dose of 300 mg clopidogrel, followed by 75 mg clopidogrel daily for 28 days. Patients were followed for at least 12 months (maximum 34 months) by clinical examination, Doppler pressure measurement, color and duplex sonography, and angiography in case of suspicion of restenosis. In a retrospective analysis, the results were compared with those of historical groups of patients having received aspirin only (41 patients) or a long-term high-dose low molecular weight heparin (LMWH)+aspirin treatment (42 patients). Three small puncture aneurysms were treated successfully by conservative means and were categorized as minor bleeding complication. Cumulative primary patency rate (PPR) was 76±7.5% (1 year), and 70±9.6% (2 years) in the clopidogrel+aspirin group, thus being tendentiously better than in the aspirin-only group showing 75±4.6% (1 year), and 50±8.1% (2 years). Long-term high-dose LMWH+aspirin treatment showed 87±5.8% (1 year), and 72±9.1% (2 years), thus being superior to the other treatment regimes, with a statistically significant difference (p<0.05) between the LMWH+aspirin and the aspirin group. Clopidogrel plus aspirin is a safe medication regimen and may be effective in the prevention of early stent thrombosis. Mid- and long-term patency rate seems to be intermediate as compared with other therapeutic regimens. The LMWH+aspirin seems to be superior compared with CLAFS

  3. Prediction of warfarin maintenance dose in Han Chinese patients using a mechanistic model based on genetic and non-genetic factors.

    Lu, Yuan; Yang, Jinbo; Zhang, Haiyan; Yang, Jin

    2013-07-01

    Many attempts have been made to predict the warfarin maintenance dose in patients beginning warfarin therapy using a descriptive model based on multiple linear regression. Here we report the first attempt to develop a comprehensive mechanistic model integrating in vitro-in vivo extrapolation (IVIVE) with a pharmacokinetic-pharmacodynamic model to predict the warfarin maintenance dose in Han Chinese patients. The model incorporates demographic factors [sex, age, body weight (BW)] and the genetic polymorphisms of cytochrome P450 (CYP) 2C9 (CYP2C9) and vitamin K epoxide reductase complex subunit 1 (VKORC1). Information on the various factors, mean warfarin daily dose and International Normalized Ratio (INR) was available for a cohort of 197 Han Chinese patients. Based on in vitro enzyme kinetic parameters for S-warfarin metabolism, demographic data for Han Chinese and some scaling factors, the S-warfarin clearance (CL) was predicted for patients in the cohort with different CYP2C9 genotypes using IVIVE. The plasma concentration of S-warfarin after a single oral dose was simulated using a one-compartment pharmacokinetic model with first-order absorption and a lag time and was combined with a mechanistic coagulation model to simulate the INR response. The warfarin maintenance dose was then predicted based on the demographic data and genotypes of CYP2C9 and VKORC1 for each patient and using the observed steady-state INR (INRss) as a target value. Finally, sensitivity analysis was carried out to determine which factor(s) affect the warfarin maintenance dose most strongly. The predictive performance of this mechanistic model is not inferior to that of our previous descriptive model. There were significant differences in the mean warfarin daily dose in patients with different CYP2C9 and VKORC1 genotypes. Using IVIVE, the predicted mean CL of S-warfarin for patients with CYP2C9*1/*3 (0.092 l/h, n = 11) was 57 % less than for those with wild-type *1/*1 (0.215 l/h, n

  4. Influence of titration schedule and maintenance dose on the tolerability of adjunctive eslicarbazepine acetate: An integrated analysis of three randomized placebo-controlled trials.

    Krauss, Gregory; Biton, Victor; Harvey, Jay H; Elger, Christian; Trinka, Eugen; Soares da Silva, Patrício; Gama, Helena; Cheng, Hailong; Grinnell, Todd; Blum, David

    2018-01-01

    To examine the influence of titration schedule and maintenance dose on the incidence and type of treatment-emergent adverse events (TEAEs) associated with adjunctive eslicarbazepine acetate (ESL). Data from three randomized, double-blind, placebo-controlled trials were analyzed. Patients with refractory partial-onset seizures were randomized to maintenance doses of ESL 400, 800, or 1200mg QD (dosing was initiated at 400 or 800mg QD) or placebo. The incidence of TEAEs was analyzed during the double-blind period (2-week titration phase; 12-week maintenance phase), according to the randomized maintenance dose and the titration schedule. 1447 patients were included in the analysis. During the first week of treatment, 62% of patients taking ESL 800mg QD had ≥1 TEAE, vs 35% of those taking 400mg QD and 32% of the placebo group; dizziness, somnolence, nausea, and headache were numerically more frequent in patients taking ESL 800mg than those taking ESL 400mg QD. During the double-blind period, the incidences of common TEAEs were lower in patients who initiated ESL at 400mg vs 800mg QD. For the 800 and 1200mg QD maintenance doses, rates of TEAEs leading to discontinuation were lower in patients who began treatment with 400mg than in those who began taking ESL 800mg QD. Initiation of ESL at 800mg QD is feasible. However, initiating treatment with ESL 400mg QD for 1 or 2 weeks is recommended, being associated with a lower incidence of TEAEs, and related discontinuations. For some patients, treatment may be initiated at 800mg QD, if the need for more immediate seizure reduction outweighs concerns about increased risk of adverse reactions during initiation. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

  5. Is clopidogrel superior to aspirin in secondary prevention of vascular disease?

    Algra Ale

    2000-11-01

    Full Text Available Abstract The cornerstone in clinical evidence of the relative efficacy of thienopyridines (clopidogrel, ticlopidine versus aspirin in the secondary prevention of vascular disease is the Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events trial. This trial showed a modest benefit in the reduction of vascular events by clopidogrel. The results differed according to qualifying disorder: myocardial infarction, -3.7%; ischaemic stroke, +7.3%; and peripheral arterial disease, +23.8% (P = 0.042. Similar results were found for ticlopidine after brain ischaemia. The safety of clopidogrel appears to be similar to that of aspirin and better than that of ticlopidine. However, the recent report of thrombotic thrombocytopenic purpura in association with clopidogrel causes concern.

  6. Clopidogrel-Induced Insulin Autoimmune Syndrome: A Newly Recognized Cause of Hypoglycemia in a Patient Without Diabetes.

    Rajpal, Aman; Kassem, Laure Sayyed; Moscoso-Cordero, Maria; Arafah, Baha M

    2017-09-01

    Insulin autoimmune syndrome (IAS), defined as hyperinsulinemic hypoglycemia with high titers of anti-insulin antibodies, is frequently reported in Japanese patients but rarely observed in whites. We report in this study on a 79-year-old white male without diabetes who developed IAS following exposure to clopidogrel, a drug not previously known to cause hypoglycemia. The patient presented with recurrent symptomatic hypoglycemia. During one episode, serum glucose was 45 mg/dL, whereas insulin and C-peptide levels were 40,000 mIU/mL and 40 ng/mL, respectively. Additional studies revealed no intake of insulin or its secretagogues, whereas anti-insulin antibody titer was high (59.3 nmol/L). Although total insulin levels were consistently high, free insulin concentrations (polyethylene glycol precipitation) were appropriate for ambient glycemia. The patient was found to have HLA-DRB1*0404, a feature often reported in Japanese patients with IAS. Three weeks prior to symptom onset, he was started on clopidogrel, a drug that does not have a sulfhydryl group, but its active metabolite does. Clopidogrel was switched to a nonsulfhydryl antiplatelet agent, and glucocorticoid therapy was initiated. Shortly thereafter, the frequency of hypoglycemic episodes decreased, and glucocorticoids were tapered over the ensuing 3 months. No hypoglycemic episodes were noted during 6 months of observation after discontinuing glucocorticoids, whereas the total insulin and anti-insulin antibody levels normalized. The data indicate that IAS should be considered in the differential diagnosis of hyperinsulinemic hypoglycemia in seemingly well individuals, even when no drugs known to cause IAS were used. Clinical suspicion of IAS can avoid expensive imaging and unnecessary surgery in affected patients.

  7. New in vitro effects of clopidogrel on platelets in hyperlipidemic and healthy subjects

    Derya Özsavcı

    2010-06-01

    Full Text Available Objective: We aimed to detect novel in vitro effects of clopidogrel on platelets by assessment of the following parameters: malondialdehyde, glutathione, nitrite, aggregation response, and expressions of P-selectin, fibrinogen, apolipoprotein A1, apolipoprotein B, and phosphatidylserine.Materials and Methods: Platelets were obtained from healthy (n: 9 and hyperlipidemic (n: 9 volunteers. Expressions of P-selectin, fibrinogen, apolipoproteins A1/B and phosphatidylserine with and without clopidogrel were assayed by flow cytometry. Malondialdehyde, glutathione, aggregation and nitrite levels were also assayed. Results: Without clopidogrel, the baseline values of platelet aggregation, malondialdehyde, and expressions of P-selectin, fibrinogen and phosphatidylserine were significantly higher, whereas nitrite and expression of apolipoproteins A1/B were significantly lower in hyperlipidemics than in the healthy group. In both groups, clopidogrel significantly reduced aggregation and expression of fibrinogen, but it elevated nitrite levels. Clopidogrel significantly decreased P-selectin and phosphatidylserine expression and malondialdehyde but increased expressions of apolipoproteins A1/B only in hyperlipidemics. Conclusion: It seems that clopidogrel has some new in vitro antiplatelet effects. The present study is a basic in vitro study to suggest new insights into the effects of clopidogrel on platelet functions.

  8. Predictors of premature clopidogrel discontinuation within 30 days of successful coronary artery stenting

    Çayan Cakir

    2018-01-01

    Full Text Available Objective: We aimed to determine the prevalence, predictors, and mortality rate of premature clopidogrel discontinuation within 30 days of successful coronary stenting. Methods: All consecutive patients who underwent successful coronary stent implantation at our hospital between December 2006 and December 2007 were prospectively included in this study. Patients were interviewed by telephone 30 days after stent implantation. Premature clopidogrel discontinuation was defined as follows: patients who did not continue clopidogrel after discharge were defined as “never used” and patients who received clopidogrel for <20 days or interrupted therapy for at least 5 successive days within the first 30 days were defined as “partially used.” Results: Follow-up data were available for 381 patients and 58 (15.2% patients reported premature clopidogrel discontinuation. No mortality and only 1 (0.3% stent thrombosis occurred in adherent patients, whereas there were 2 (3.4% mortalities and 6 (10.3% stent thrombosis in the patients who prematurely discontinued clopidogrel. Those who discontinued clopidogrel therapy were older (P = 0.02, more likely to be female (P = 0.02, single (P = 0.03, of lower economic (P < 0.05 and educational status (P < 0.01, more likely to have chronic disease (P = 0.04, less likely to have undergone previous stenting (P = 0.01, and were more likely to be receiving a larger number of drugs (P < 0.05. In multivariate analysis, low- or intermediate-economic status, no history of previous stent implantation, and total number of prescribed drugs using were factors independently associated with premature clopidogrel discontinuation. Conclusion: This study demonstrates several predictors of premature clopidogrel discontinuation. This data may help clinicians pay particular attention to these patients in an attempt to improve the outcomes of coronary stenting.

  9. Formulation and evaluation of orally disintegrating clopidogrel tablets

    Gamal Mohamed Mahrous

    Full Text Available ABSTRACT Recent advances in drug delivery systems have aimed to achieve better patient compliance. One of these advances is the formulation of orally disintegrating tablets (ODTs that dissolve instantaneously, releasing drugs within a few seconds without the need of water. The main objective of this paper was to prepare and develop ODTs of clopidogrel. The ODTs were prepared by direct compression. The effect of three superdisintegrants, namely crospovidone, croscarmellose sodium, and sodium starch glycolate, using three different disintegration times on the dissolution rate was investigated. The prepared tablets were evaluated for hardness, friability, disintegration time and in vitro drug release. Furthermore, the interaction of clopidogrel with the formulation excipients was studied using differential scanning calorimetry (DSC. DSC studies revealed that there were no interactions between the drug and the excipients used. All tablets had hardness values in the range 4.0-5.2 kp and friability lower than 1%. The weight and drug content uniformity of all formulations was within official limits according to BP. In vitro drug release studies of the ODTs showed that more than 90% of the drug was released within ten minutes. A palatability test in human volunteers showed acceptable taste and mouth feel. Thus, the obtained results conclusively demonstrated successful rapid disintegration of the formulated tablets and acceptable palatability.

  10. Comparative bioavailability of two oral formulations of clopidogrel: Determination of clopidogrel and its carboxylic acid metabolite (SR26334 under fasting and fed conditions in healthy subjects

    Brvar Nina

    2014-03-01

    Full Text Available Two randomized, single dose, 2-period, 2-sequence crossover studies were conducted to evaluate the comparative bioavailability of two clopidogrel formulations under fasting and fed conditions. Assessment of bioequivalence was based upon measurement of plasma concentrations of the parent drug, clopidogrel, and its major (inactive metabolite, clopidogrel carboxylic acid, using improved methanol-free extraction. Bioequivalence of Krka’s formulation to the innovator’s formulation was demonstrated under both fasting and fed conditions on 205 volunteers. Confidence intervals for AUC0-t, AUC0-inf and Cmax of clopidogrel and its main metabolite were well within the acceptance range of 80.00 to 125.00 %. Food substantially increased the bioavailability of clopidogrel from both formulations, while no effect of food on the extent and rate of exposure to the metabolite was observed. The effect of food was comparable between the two formulations, as indicated by the same direction and rank of food impact on the bioavailability of both formulations.

  11. Dual antiplatelet therapy with prasugrel or ticagrelor versus clopidogrel in interventional cardiology

    Clemmensen, Peter; Dridi, Nadia Paarup; Holmvang, Lene

    2013-01-01

    For several years, clopidogrel plus aspirin has been the dual antiplatelet therapy (DAPT) of choice for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) with stent implantation. More recently, prasugrel and ticagrelor have demonstrated greater effica...

  12. Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery.

    Stone, David H; Goodney, Philip P; Schanzer, Andres; Nolan, Brian W; Adams, Julie E; Powell, Richard J; Walsh, Daniel B; Cronenwett, Jack L

    2011-09-01

    Persistent variation in practice surrounds preoperative clopidogrel management at the time of vascular surgery. While some surgeons preferentially discontinue clopidogrel citing a perceived risk of perioperative bleeding, others will proceed with surgery in patients taking clopidogrel for an appropriate indication. The purpose of this study was to determine whether preoperative clopidogrel use was associated with significant bleeding complications during peripheral arterial surgery. We reviewed a prospective regional vascular surgery registry recorded by 66 surgeons from 15 centers in New England from 2003 to 2009. Preoperative clopidogrel use within 48 hours of surgery was analyzed among patients undergoing carotid endarterectomy (CEA), lower extremity bypass (LEB), endovascular abdominal aortic aneurysm repair (EVAR), and open abdominal aortic aneurysm repair (oAAA). Ruptured AAAs were excluded. Endpoints included postoperative bleeding requiring reoperation, as well as the incidence and volume of blood transfusion. Statistical analysis was performed using analysis of variance, Fisher exact, χ(2), and Wilcoxon rank-sum tests. Over the study interval, a total of 10,406 patients underwent surgery, including 5264 CEA, 2883 LEB, 1125 EVAR, and 1134 oAAA repair. Antiplatelet use among all patients varied, with 19% (n = 2010) taking no antiplatelet agents, 69% (n = 7132) taking aspirin (ASA) alone, 2.2% (n = 229) taking clopidogrel alone, and 9.7% (n = 1017) taking both ASA and clopidogrel. Clopidogrel alone or as dual antiplatelet therapy was most frequently used prior to CEA and least frequently prior to oAAA group (CEA 16.1%, LEB 9.0%, EVAR 6.5%, oAAA 5%). Reoperation for bleeding was not significantly different among patients based on antiplatelet regimen (none 1.5%, ASA 1.3%, clopidogrel 0.9%, ASA/clopidogrel 1.5%, P = .74). When analyzed by operation type, no difference in reoperation for bleeding was seen across antiplatelet regimens. There was also no

  13. Pharmacokinetic drug interactions with clopidogrel: updated review and risk management in combination therapy

    Wang ZY

    2015-03-01

    Full Text Available Zhi-Yu Wang,1 Meng Chen,1 Ling-Ling Zhu,2 Lu-Shan Yu,3 Su Zeng,3 Mei-Xiang Xiang,4 Quan Zhou1 1Department of Pharmacy, 2VIP Care Ward, Division of Nursing, the Second Affiliated Hospital, School of Medicine, 3Department of Pharmaceutical Analysis and Drug Metabolism, College of Pharmaceutical Sciences, 4Department of Cardiology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People’s Republic of China Background: Coprescribing of clopidogrel and other drugs is common. Available reviews have addressed the drug–drug interactions (DDIs when clopidogrel is as an object drug, or focused on combination use of clopidogrel and a special class of drugs. Clinicians may still be ignorant of those DDIs when clopidogrel is a precipitant drug, the factors determining the degree of DDIs, and corresponding risk management.Methods: A literature search was performed using PubMed, MEDLINE, Web of Science, and the Cochrane Library to analyze the pharmacokinetic DDIs of clopidogrel and new P2Y12 receptor inhibitors.Results: Clopidogrel affects the pharmacokinetics of cerivastatin, repaglinide, ferulic acid, sibutramine, efavirenz, and omeprazole. Low efficacy of clopidogrel is anticipated in the presence of omeprazole, esomeprazole, morphine, grapefruit juice, scutellarin, fluoxetine, azole antifungals, calcium channel blockers, sulfonylureas, and ritonavir. Augmented antiplatelet effects are anticipated when clopidogrel is coprescribed with aspirin, curcumin, cyclosporin, St John’s wort, rifampicin, and angiotensin-converting enzyme inhibitors. The factors determining the degree of DDIs with clopidogrel include genetic status (eg, cytochrome P540 [CYP]2B6*6, CYP2C19 polymorphism, CYP3A5*3, CYP3A4*1G, and CYP1A2-163C>A, species differences, and dose strength. The DDI risk does not exhibit a class effect, eg, the effects of clopidogrel on cerivastatin versus other statins, the effects of proton pump

  14. Tailored antiplatelet therapy to improve prognosis in patients exhibiting clopidogrel low-response prior to percutaneous coronary intervention for stable angina or non-ST elevation acute coronary syndrome

    Paarup Dridi, Nadia; Johansson, Pär I; Lønborg, Jacob T

    2015-01-01

    Abstract Aim: To investigate whether an intensified antiplatelet regimen could improve prognosis in stable or non-ST elevation in acute coronary syndrome (ACS) patients exhibiting high on-treatment platelet reactivity (HTPR) on clopidogrel and treated with percutaneous coronary intervention (PCI...

  15. Effect of scutellarin on the metabolism and pharmacokinetics of clopidogrel in rats.

    Chen, Xinmeng; Jin, Jing; Chen, Yaobin; Peng, Lingling; Zhong, Guoping; Li, Jiali; Bi, Huichang; Cai, Yefeng; Huang, Min

    2015-01-01

    Erigeron breviscapus (Vant.) Hand-Mazz, a traditional Chinese medicine, is often co-prescribed with clopidogrel for the treatment of ischemic vascular diseases. Scutellarin is the representative bioactive flavonoid isolated from this herb. The aim of this study was to explore the effect of scutellarin on the metabolism and pharmacokinetics of clopidogrel. The in vitro studies using rat liver microsomes showed that scutellarin significantly inhibited the metabolism of clopidogrel. The IC50 value was 2.1 µM. Ten male rats were employed to investigate the effect of scutellarin on the pharmacokinetics of clopidogrel in vivo. After pretreatment with scutellarin, there were significant increases in the AUC0-∞ (from 0.9 ± 0.4 to 1.7 ± 0.6 ng/ml h; p <0.05) and Cmax (from 0.4 ± 0.1 to 0.9 ± 0.1 ng/ml; p <0.05) of clopidogrel. The pharmacokinetic data for clopidogrel active metabolite showed significant decreases in AUC0-∞ (18.2 ± 5.6 to 11.4 ± 3.7 ng/ml h; p <0.05) and Cmax (from 8.2 ± 1.2 to 4.3 ± 0.3 ng/ml; p <0.05) after pretreatment with scutellarin. Collectively, the metabolism and pharmacokinetics of clopidogrel were significantly affected by scutellarin. This study indicated that potential herb-drug interaction between scutellarin and clopidogrel should be taken into consideration in clinical use. Copyright © 2014 John Wiley & Sons, Ltd.

  16. Effects of clopidogrel on the pharmacokinetics of sibutramine and its active metabolites.

    Bae, Jung-Woo; Jang, Choon-Gon; Lee, Seok-Young

    2011-12-01

    Sibutramine is metabolized by the enzymes CYP2B6 and CYP2C19 into 2 active metabolites, M1 (mono-desmethyl sibutramine) and M2 (di-desmethyl sibutramine). Clopidogrel is a mechanism-based inhibitor of CYP2B6 and CYP2C19. In this study, 13 extensive metabolizers of CYP2B6 and CYP2C19 were evaluated to clarify whether clopidogrel inhibits the formation of the active metabolites of sibutramine. In the control phase, each subject received a 15-mg oral dose of sibutramine. After a washout period of 2 weeks, in the clopidogrel phase, the subjects received 300 mg of clopidogrel on the first day and then 75-mg once daily for 6 days. One hour after the last dosing of clopidogrel, all subjects received 15-mg of sibutramine. Compared with the control phase, the mean sibutramine and M1 plasma concentrations were higher after clopidogrel treatment. Clopidogrel significantly increased the half-life (242% of control phase) and area under the plasma concentration-time curve from 0 to infinity (AUC(inf)) (227% of control phase) of sibutramine and decreased the apparent oral clearance (31% of control phase) of sibutramine. Pharmacokinetic analysis showed significant increases in the AUC(inf) (162% of control phase) of M1. The CYP2B6 and CYP2C19 inhibitor clopidogrel significantly inhibited the formations of M1 from sibutramine and M2 from sibutramine by 37% and 64%, respectively. Therefore, CYP2B6 and CYP2C19 are in vivo catalysts for the formation of the 2 active metabolites of sibutramine.

  17. Efficacy of Clopidogrel and Clinical Outcome When Clopidogrel Is Coadministered With Atorvastatin and Lansoprazole: A Prospective, Randomized, Controlled Trial.

    Zhang, Jian-rong; Wang, Di-qing; Du, Jun; Qu, Guang-su; Du, Jian-lin; Deng, Song-bai; Liu, Ya-jie; Cai, Jin-xi; She, Qiang

    2015-12-01

    This prospective, randomized, nonblind, controlled trial evaluated the effects of clopidogrel on platelet function upon coadministration with atorvastatin and lansoprazole. One hundred four adult patients with non-ST-segment elevated acute coronary syndrome (NSTE-ACS) who underwent percutaneous coronary intervention (PCI) with drug-eluting stent implantation were included. All patients were treated with standard dual antiplatelet therapy (DAPT) plus rosuvastatin 10  mg daily after the operation. On the sixth day after PCI, patients were randomly divided into 4 groups, Group A: DAPT + atorvastatin 20  mg daily (a change from rosuvastatin to atorvastatin) + lansoprazole 30  mg daily, Group B: DAPT + atorvastatin 20  mg daily (a change from rosuvastatin to atorvastatin), Group C: DAPT + lansoprazole 30  mg daily (continuing to take rosuvastatin), Group D is the control group. Additional drugs were used according to the situation of patients. Platelet function and concentrations of platelet activation markers (granular membrane protein 140 (P-selectin), thromboxane B2 (TXB2), and human soluble cluster of differentiation 40 ligand (sCD40L)) were assessed before randomization and at 15- and 30-day follow-up visits. All patients were maintained on treatment for 6 months and observed for bleeding and ischemic events. A total of 104 patients were enrolled, 27 patients in group A, 26 patients in Group B/C, 25 patients in Group D separately, and all the patients were analyzed. There were no differences in platelet function and the levels of platelet activation markers (P-selectin, TXB2, and sCD40L) among or within the 4 groups at the 3 time points of interest (P > 0.05). In the subsequent 6 months, no significant bleeding events occurred, and 12 patients experienced ischemic events, these results were also not significantly different among the groups (P > 0.05). In patients diagnosed with NSTE-ACS who have had drug-eluting stent implantation

  18. The Effect of Combined Aspirin and Clopidogrel Treatment on Cancer Incidence.

    Leader, Avi; Zelikson-Saporta, Ravit; Pereg, David; Spectre, Galia; Rozovski, Uri; Raanani, Pia; Hermoni, Doron; Lishner, Michael

    2017-07-01

    Multiple studies have shown an association between aspirin treatment and a reduction in newly diagnosed cancer. Conversely, there are conflicting clinical and laboratory data on the effect of combined clopidogrel and aspirin therapy on cancer incidence, including analyses suggesting an increased cancer risk. No large-scale cohort study has been performed to address this issue in a heterogeneous real-world scenario. We investigated the effect of clopidogrel and aspirin on cancer incidence compared with aspirin alone and no antiplatelet therapy. A population-based historical cohort study of subjects aged ≥50 years covered by Clalit Health Services, an Israeli health maintenance organization, was performed. Patients treated with the newer antiplatelet drugs, prasugrel or ticagrelor, which, like clopidogrel, inhibit adenosine diphosphate receptors, and those with prior cancer were excluded. Prescription records of antiplatelet medication were retrieved. The cohort included 183,912 subjects diagnosed with 21,974 cancer cases based upon the International Classification of Diseases, Ninth Revision. Dual aspirin and clopidogrel was prescribed in 9.6%, while 49% received aspirin alone and 41% used neither. Compared with nonusers, there was a lower risk of cancer in subjects exposed to aspirin with (hazard ratio [HR] 0.46; 95% confidence interval [CI], 0.44-0.49) or without clopidogrel (HR 0.54; 95% CI, 0.52-0.56), on long-term follow-up. Combined treatment was associated with a lower cancer risk than the aspirin-only group (HR 0.92; 95% CI, 0.86-0.97). Dual clopidogrel and aspirin treatment is safe regarding the cancer risk. This study generates the hypothesis that clopidogrel may reduce cancer incidence. Copyright © 2017 Elsevier Inc. All rights reserved.

  19. Inhibition of platelet aggregation by AZD6140, a reversible oral P2Y12 receptor antagonist, compared with clopidogrel in patients with acute coronary syndromes

    Storey, Robert F; Husted, Steen; Harrington, Robert A

    2007-01-01

    OBJECTIVES: In a substudy of DISPERSE (Dose confIrmation Study assessing anti-Platelet Effects of AZD6140 vs. clopidogRel in non-ST-segment Elevation myocardial infarction)-2, we compared the antiplatelet effects of AZD6140 and clopidogrel and assessed the effects of AZD6140 in clopidogrel...

  20. Use of clopidogrel in the reduction of myocardial damage during percutaneous coronary intervention

    Arijit Dasgupta

    2009-03-01

    Full Text Available Arijit Dasgupta, Debabrata MukherjeeGill Heart Institute, University of Kentucky, Lexington, KY, USAAbstract: It is estimated that approximately a quarter of patients undergoing coronary intervention may have significant post-procedural creatinine (CK/creatinine kinase myocardial band (CK-MB elevations and approximately half may have post-procedural troponin elevations. Current data suggest that periprocedural infarction is associated with short-, intermediate-, and long-term adverse outcomes, most notably mortality. This review examines the role of clopidogrel in decreasing periprocedural myonecrosis following percutaneous coronary intervention (PCI. Clopidogrel is an important pharmacologic agent used to reduce myocardial infarction post-coronary intervention as assessed directly by the evaluation of cardiac biomarkers and indirectly by the evaluation of short-term ischemic events. The optimal dose of clopidogrel is considered to be at least 300 mg given 6 to 15 hours prior to PCI but there is considerable evidence to suggest that a loading dose of 600 mg given 2 to 6 hours prior to PCI may be more efficacious in limiting post-coronary intervention events. The benefit obtained from clopidogrel appears independent of and incremental to that of other antiplatelet and antithrombotic agents used during and after coronary intervention.Keywords: percutaneous coronary intervention, myonecrosis, clopidogrel, antiplatelet agents, myocardial infarction 

  1. Optimizing clopidogrel dose response: a new clinical algorithm comprising CYP2C19 pharmacogenetics and drug interactions

    Saab YB

    2015-09-01

    Full Text Available Yolande B Saab,1 Rony Zeenny,2 Wijdan H Ramadan2 1School of Pharmacy, Pharmaceutical Sciences Department, 2School of Pharmacy, Pharmacy Practice Department, Lebanese American University, Byblos, Lebanon Purpose: Response to clopidogrel varies widely with nonresponse rates ranging from 4% to 30%. A reduced function of the gene variant of the CYP2C19 has been associated with lower drug metabolite levels, and hence diminished platelet inhibition. Drugs that alter CYP2C19 activity may also mimic genetic variants. The aim of the study is to investigate the cumulative effect of CYP2C19 gene polymorphisms and drug interactions that affects clopidogrel dosing, and apply it into a new clinical-pharmacogenetic algorithm that can be used by clinicians in optimizing clopidogrel-based treatment. Method: Clopidogrel dose optimization was analyzed based on two main parameters that affect clopidogrel metabolite area under the curve: different CYP2C19 genotypes and concomitant drug intake. Clopidogrel adjusted dose was computed based on area under the curve ratios for different CYP2C19 genotypes when a drug interacting with CYP2C19 is added to clopidogrel treatment. A clinical-pharmacogenetic algorithm was developed based on whether clopidogrel shows 1 expected effect as per indication, 2 little or no effect, or 3 clinical features that patients experience and fit with clopidogrel adverse drug reactions. Results: The study results show that all patients under clopidogrel treatment, whose genotypes are different from *1*1, and concomitantly taking other drugs metabolized by CYP2C19 require clopidogrel dose adjustment. To get a therapeutic effect and avoid adverse drug reactions, therapeutic dose of 75 mg clopidogrel, for example, should be lowered to 6 mg or increased to 215 mg in patients with different genotypes. Conclusion: The implementation of clopidogrel new algorithm has the potential to maximize the benefit of clopidogrel pharmacological therapy

  2. Assessment of analytical techniques for characterization of crystalline clopidogrel forms in patent applications

    Luiz Marcelo Lira

    2014-04-01

    Full Text Available The aim of this study was to evaluate two important aspects of patent applications of crystalline forms of drugs: (i the physicochemical characterization of the crystalline forms; and (ii the procedure for preparing crystals of the blockbuster drug clopidogrel. To this end, searches were conducted using online patent databases. The results showed that: (i the majority of patent applications for clopidogrel crystalline forms failed to comply with proposed Brazilian Patent Office guidelines. This was primarily due to insufficient number of analytical techniques evaluating the crystalline phase. In addition, some patent applications lacked assessment of chemical/crystallography purity; (ii use of more than two analytical techniques is important; and (iii the crystallization procedure for clopidogrel bisulfate form II were irreproducible based on the procedure given in the patent application.

  3. Perioperative clopidogrel is associated with increased bleeding and blood transfusion at the time of lower extremity bypass.

    Jones, Douglas W; Schermerhorn, Marc L; Brooke, Benjamin S; Conrad, Mark F; Goodney, Philip P; Wyers, Mark C; Stone, David H

    2017-06-01

    Controversy persists surrounding the perceived bleeding risk associated with perioperative clopidogrel use in patients undergoing lower extremity bypass (LEB). The purpose of this study was to examine the LEB bleeding risk and clinical sequelae associated with clopidogrel. All LEBs in the Vascular Quality Initiative (VQI) from 2008 to 2014 were studied. The exposure was perioperative clopidogrel. Primary outcomes were blood transfusion, estimated blood loss ≥500 mL, and reoperation for bleeding. Secondary outcomes included mean operative time, major cardiac events, respiratory complications, infectious complications, and in-hospital mortality. Univariate and multivariable analyses were used to analyze patients on the basis of clopidogrel use and its association with outcomes. Nonparametric test for trend and Mantel-Haenszel methods were used to analyze association of clopidogrel use with blood transfusion and secondary outcomes. Among the LEB cohort (N = 9179), 28% (n = 2544) were taking clopidogrel and 72% (n = 6635) were not. Patients taking clopidogrel were more likely to have coronary disease, prior coronary intervention, abnormal findings on stress test, and aspirin use (P blood transfusion (38% vs 24%; P blood loss ≥500 mL (21% vs 12%; P blood transfusion (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.1; P 2-unit blood transfusion (OR, 2.0; 95% CI, 1.7-2.5; P blood transfusion amount revealed no remaining effect of clopidogrel on major cardiac events (OR, 1.1; P = .4) or respiratory complications (OR, 1.0; P = .8). Perioperative clopidogrel use in LEB surgery is associated with increased blood loss and blood transfusion. Associated clinical sequelae include increased cardiac and pulmonary complications. Accordingly, surgeons should consider discontinuation of perioperative clopidogrel when it is clinically appropriate unless it is strongly indicated at the time of LEB. Copyright © 2017 Society for Vascular Surgery. Published by

  4. Safety and Efficacy of Acute Clopidogrel Load in Patients with Moderate and Severe Ischemic Strokes

    Amir Shaban

    2016-01-01

    Full Text Available Objective. To study the safety and efficacy of a clopidogrel loading dose in patients with moderate and severe acute ischemic strokes. Background. The safety of clopidogrel loading has been extensively investigated in patients with minor strokes and transient ischemic attacks. Methods. Acute ischemic stroke patients presenting consecutively to our center from 07/01/08 to 07/31/13 were screened. Clopidogrel loading was defined as at least 300 mg dose (with or without aspirin given within 6 hours of admission. We compared outcomes in patients with baseline NIHSS > 3 with and without clopidogrel loading. Results. Inclusion criteria were met for 1011 patients (43.6% females, 69.1% black, median age 63. Patients with clopidogrel loading had lower baseline NIHSS than patients who were not loaded (8 versus 9, p=0.005. The two groups had similar risk for hemorrhagic transformation (p=0.918 and symptomatic hemorrhage (p=0.599. Patients who were loaded had a lower rate of neurological worsening (38.9% versus 48.3%, p=0.031 and less in-hospital mortality (4.3% versus 13.4%, p=0.001 compared to those who were not loaded. The likelihood of having a poor functional outcome did not differ between the two groups after adjusting for NIHSS on admission (OR = 0.71, 95% CI 0.4633–1.0906, p=0.118. Conclusion. Clopidogrel loading dose was not associated with increased risk for hemorrhagic transformation or symptomatic intracranial hemorrhage in our retrospective study and was associated with reduced rates of neuroworsening following moderate and severe stroke.

  5. Effect of CYP2C9, VKORC1, CYP4F2 and GGCX genetic variants on warfarin maintenance dose and explicating a new pharmacogenetic algorithm in South Indian population.

    Krishna Kumar, Dhakchinamoorthi; Shewade, Deepak Gopal; Loriot, Marie-Anne; Beaune, Philippe; Balachander, Jayaraman; Sai Chandran, B V; Adithan, Chandrasekaran

    2014-01-01

    To determine the influence of genetic polymorphisms on warfarin maintenance dose and to explicate an algorithm using the pharmacogenetic and clinical factors to determine the maintenance and/or starting dose of warfarin in South Indian patients receiving warfarin therapy. Patients receiving stabilized warfarin therapy (n=257) were included in the study. Single nucleotide polymorphisms (SNPs) of CYP2C9 (rs1799853 and rs1057910), VKORC1 (rs9923231, rs7196161, rs2884737, rs9934438, rs8050894, rs2359612 and rs7294), CYP4F2 (rs2108622) and GGCX (rs11676382) were genotyped by the quantitative real time-PCR method. The mean daily maintenance dose of warfarin was found to be 4.7 ± 2.1 mg/day. Patients with the CYP2C9*1/*2, *1/*3 and *2/*3 variant genotypes required a 51.0 (2.8 mg), 60.9 (2.3 mg) and 62.2 % (2.2 mg) lower daily maintenance dose of warfarin, respectively, than those patients with the CYP2C9*1/*1 wild-type genotype (5.2 mg) (pmaintenance dose. Genetic polymorphisms of CYP2C9, VKORC1, CYP4F2 and GGCX are important predictive factors of warfarin maintenance dose, and the developed algorithm will be useful to predict the required maintenance and/or starting warfarin dose in South Indian populations.

  6. Comparative effect of clopidogrel plus aspirin and aspirin monotherapy on hematological parameters using propensity score matching

    Hayasaka M

    2013-02-01

    Full Text Available Masatoshi Hayasaka,1 Yasuo Takahashi,2 Yayoi Nishida,2 Yoshikazu Yoshida,1 Shinji Hidaka,3 Satoshi Asai41Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, 2Division of Genomic Epidemiology and Clinical Trials, Clinical Trials Research Center, Nihon University School of Medicine, Tokyo, 3Laboratory of Pharmaceutical Regulatory Science, Department of Pharmacy, School of Pharmacy, Nihon University, Chiba, 4Division of Pharmacology, Department of Biomedical Sciences, Nihon University School of Medicine, Tokyo, JapanBackground: Clopidogrel and aspirin are antiplatelet agents that are recommended to reduce the risk of recurrent stroke and other cardiovascular events. Dual antiplatelet therapy with clopidogrel and aspirin has been shown to increase the risk of hemorrhage, but the effects of the drugs on laboratory parameters have not been well studied in real-world clinical settings. Therefore, we evaluated and compared the effects of combination therapy with clopidogrel plus aspirin and aspirin monotherapy on laboratory parameters.Methods: We used data from the Nihon University School of Medicine Clinical Data Warehouse obtained between November 2004 and May 2011 to identify cohorts of new users (n = 130 of clopidogrel (75 mg/day plus aspirin (100 mg/day and a propensity score matched sample of new users (n = 130 of aspirin alone (100 mg/day. We used a multivariate regression model to compare serum levels of creatinine, aspartate aminotransferase, and alanine aminotransferase, as well as hematological parameters including hemoglobin level, hematocrit, and white blood cell, red blood cell, and platelet counts up to 2 months after the start of administration of the study drugs.Results: There were no significant differences for any characteristics and baseline laboratory parameters between users of clopidogrel plus aspirin and users of aspirin alone. Reductions in white blood cell and red blood cell counts, hemoglobin levels, and

  7. Blødningskomplikationer ved behandling med clopidogrel og acetylsalicylsyre efter akut koronart syndrom

    Kjær, Janus; Larsen, Christian Hastrup; Poulsen, Tina Svenstrup

    2006-01-01

    INTRODUCTION: The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) study showed that patients with unstable angina pectoris (UAP) and non-ST-elevation myocardial infarction (NSTEMI) benefit from combined therapy with acetylsalicylic acid (ASA) and clopidogrel. However, only...... patients entering clinical randomized trials were studied. We sought to assess whether the risk of bleeding increased after the introduction of the CURE criteria in an unselected population of Danish patients with NSTEMI or UAP. MATERIALS AND METHODS: The CURE criteria were implemented in the Department...

  8. Analysis of the Interaction between Clopidogrel, Aspirin, and Proton Pump Inhibitors Using the FDA Adverse Event Reporting System Database.

    Suzuki, Yukiya; Suzuki, Honami; Umetsu, Ryogo; Uranishi, Hiroaki; Abe, Junko; Nishibata, Yuri; Sekiya, Yasuaki; Miyamura, Nobuteru; Hara, Hideaki; Tsuchiya, Teruo; Kinosada, Yasutomi; Nakamura, Mitsuhiro

    2015-01-01

    Clopidogrel is an antiplatelet agent widely used in combination with aspirin to limit the occurrence of cardiovascular (embolic/thrombotic) events. Consensus guidelines recommend proton pump inhibitors (PPIs) as a gastrointestinal (GI) prophylactic measure for all patients receiving dual antiplatelet therapy with clopidogrel and aspirin. The objective of this study was to analyze the effect of the simultaneous use of clopidogrel, aspirin, and PPIs on hemorrhagic and embolic/thrombotic events using the U.S. Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database. Reports of hemorrhagic and embolic/thrombotic events between 2004 and 2013 were analyzed with a reporting odds ratio (ROR) algorithm and logistic regression methods. The Medical Dictionary for Regulatory Activities Preferred Terms was used to identify such events. Regarding hemorrhagic events, the adjusted RORs of the concomitant use of aspirin and clopidogrel and those of PPIs prescribed with aspirin and clopidogrel were 4.40 (95% confidence interval [CI], 4.02-4.81) and 3.40 (95% CI, 2.84-4.06), respectively. For embolic/thrombotic events, the adjusted RORs of the concomitant use of aspirin and clopidogrel and those of PPIs prescribed with aspirin and clopidogrel were 2.37 (95% CI, 2.16-2.59) and 2.38 (95% CI, 2.00-2.84), respectively. Among patients included in the FAERS database, the concurrent use of aspirin and clopidogrel with PPIs reduced the adjusted ROR of GI hemorrhagic events. PPIs had little influence on the adjusted ROR of embolic/thrombotic events. These results support the use of PPIs as a preventive measure against GI hemorrhagic events for patients receiving clopidogrel and aspirin.

  9. Cardiovascular events in acute coronary syndrome patients with peripheral arterial disease treated with ticagrelor compared to clopidogrel: Data from the PLATO trials

    Patel, Manesh R.; Becker, Richard C.; Wojdyla, Daniel M.

    Abstract 14299: Cardiovascular Events in Acute Coronary Syndrome Patients With Peripheral Arterial Disease Treated With Ticagrelor Compared to Clopidogrel: Data From the PLATO Trial Manesh R Patel1; Richard C Becker1; Daniel M Wojdyla2; Håkan Emanuelsson3; William Hiatt4; Jay Horrow5; Steen Husted6...... Uppsala, Sweden 10 Cardiology, Uppsala Clinical Rsch center, 75185 Uppsala, Sweden Background: Patients with peripheral artery disease (PAD) and acute coronary syndrome (ACS) are at high risk for clinical events and are often difficult to manage. We evaluated cardiovascular outcomes of ACS patients...

  10. Policy objective of generic medicines from the investment perspective: The case of clopidogrel.

    Elek, Péter; Harsányi, András; Zelei, Tamás; Csetneki, Kata; Kaló, Zoltán

    2017-05-01

    The objective of generic drug policies in most countries is defined from a disinvestment perspective: reduction in expenditures without compromising health outcomes. However, in countries with restricted access of patients to original patented drugs, the objective of generic drug policies can also be defined from an investment perspective: health gain by improved patient access without need for additional health budget. This study examines the investment aspect of generic medicines by analyzing clopidogrel utilization in European countries between 2004 and 2014 using multilevel panel data models. We find that clopidogrel consumption was strongly affected by affordability constraints before the generic entry around 2009, but this effect decayed by 2014. After controlling for other variables, utilization had a substantially larger trend increase in lower-income European countries than in the higher-income ones. Generic entry increased clopidogrel consumption only in lower- and average-income countries but not in the highest-income ones. An earlier generic entry was associated with a larger effect. The case of clopidogrel indicates that the entrance of generics may increase patient access to effective medicines, most notably in lower-income countries, thereby reducing inequalities between European patients. Policymakers should also consider this investment aspect of generic medicines when designing pharmaceutical policies. Copyright © 2017 Elsevier B.V. All rights reserved.

  11. Effect of exercise on platelet activation during aspirin or clopidogrel intake in healthy men

    Hjorth Madsen, Esben; Christiansen, Morten Krogh; Schmidt, Erik Berg

    2009-01-01

    aggregometry. A significant increase in plasma von Willebrand Factor was also found in response to exercise. In conclusion, platelet activation occurs during exercise in healthy individuals. This activation is not prevented by use of aspirin or clopidogrel, and may partly be explained by an increase in plasma...

  12. Role of newly formed platelets in thrombus formation in rat after clopidogrel treatment

    Kuijpers, Marijke J E; Megens, Remco T A; Nikookhesal, Elham

    2011-01-01

    Platelet P2Y₁₂ receptors play an important role in arterial thrombosis by stimulating thrombus growth. Both irreversibly (clopidogrel) and reversibly binding (ticagrelor, AZD6140) P2Y₁₂ antagonists are clinically used for restricted periods, but possible differences in platelet function recovery ...

  13. Costs and consequences of direct-to-consumer advertising for clopidogrel in Medicaid.

    Law, Michael R; Soumerai, Stephen B; Adams, Alyce S; Majumdar, Sumit R

    2009-11-23

    Direct-to-consumer advertising (DTCA) is assumed to be a major driver of rising pharmaceutical costs. Yet, research on how it affects costs is limited. Therefore, we studied clopidogrel, a commonly used and heavily marketed antiplatelet agent, which was first sold in 1998 and first direct-to-consumer advertised in 2001. We examined pharmacy data from 27 Medicaid programs from 1999 through 2005. We used interrupted time series analysis to analyze changes in the number of units dispensed, cost per unit dispensed, and total pharmacy expenditures after DTCA initiation. In 1999 and 2000, there was no DTCA for clopidogrel; from 2001 through 2005, DTCA spending exceeded $350 million. Direct-to-consumer advertising did not change the preexisting trend in the number of clopidogrel units dispensed per 1000 enrollees (P = .10). However, there was a sudden and sustained increase in cost per unit of $0.40 after DTCA initiation (95% confidence interval, $0.31-$0.49; P consumer advertising was not associated with an increase in clopidogrel use over and above preexisting trends. However, Medicaid pharmacy expenditures increased substantially after the initiation of DTCA because of a concomitant increase in the cost per unit. If drug price increases after DTCA initiation are common, there are important implications for payers and for policy makers in the United States and elsewhere.

  14. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke

    Sacco, Ralph L; Diener, Hans-Christoph; Yusuf, Salim

    2008-01-01

    BACKGROUND: Recurrent stroke is a frequent, disabling event after ischemic stroke. This study compared the efficacy and safety of two antiplatelet regimens--aspirin plus extended-release dipyridamole (ASA-ERDP) versus clopidogrel. METHODS: In this double-blind, 2-by-2 factorial trial, we randomly...

  15. Effect of Co-Administration of Rivaroxaban and Clopidogrel on Bleeding Time, Pharmacodynamics and Pharmacokinetics: A Phase I Study

    Michael Becka

    2012-02-01

    Full Text Available Dual antiplatelet therapy with acetylsalicylic acid and a thienopyridine, such as clopidogrel, is effective for the secondary prevention of cardiovascular events in patients with acute coronary syndrome, but there is still a substantial residual risk of recurrence. Although anticoagulant therapy with a vitamin K antagonist (e.g. warfarin in conjunction with antiplatelet therapy has been shown to reduce the risk of cardiovascular events, the rates of bleeding were increased with these combination therapies; hence, triple therapy with warfarin is currently only recommended in patients at low risk of bleeding. In addition, there are other limitations associated with vitamin K antagonist therapy, including the need for routine coagulation monitoring and dose adjustment to maintain the treatment within the therapeutic range. Rivaroxaban is an oral, direct Factor Xa inhibitor; in clinical practice, it is likely that rivaroxaban will be given to patients who also receive antiplatelet therapy, such as clopidogrel. This randomized, non-blinded, three-way crossover study investigated the effect of rivaroxaban on bleeding time when co­administered with clopidogrel. In addition, the influence of clopidogrel on the safety, tolerability, pharmacodynamics and pharmacokinetics of rivaroxaban was investigated. Of 27 healthy male subjects who received a single 300 mg dose of clopidogrel, 14 were identified as clopidogrel responders and were then randomized to the following three treatments: (A two doses of clopidogrel on two consecutive days (300 mg on day 1; 75 mg on day 2; (B one dose of rivaroxaban (15 mg; or (C a combination of treatments A and B (rivaroxaban given on day 2. All treatments were well tolerated. Bleeding time with co­administration of rivaroxaban and clopidogrel was significantly prolonged in four subjects, compared with either drug alone: combination treatment increased the overall least squares-means to 3.77 times baseline (90% confidence

  16. Serious clopidogrel associated renal hematoma in a type 2 diabetic patient with primary hyperparathyroidism after extracorporeal shock wave lithotripsy

    Bahceci, Mithat; Tuzcu, Alpaslan; Agil, Cuneyt; Akay, Ferruh; Akay, Hatice

    2005-01-01

    Renal hematoma after extracorporeal shock wave lithotripsy SWL is a rare complication. We report a case of a large renal hematoma following SWL that resulted in nephrectomy in a type 2 diabetic patient with primary hyperparathyroidism using clopidogrel due to coronary heart disease CHD. Although it was claimed that preoperative use of clopidogrel was not associated with increased bleeding, all patients who are scheduled for SWL should be interrogated in terms of using of platelet aggregation inhibitors such as clopidogrel, and these drugs should be interrupted appropriately before undergoing SWL. (author)

  17. Warfarin maintenance dose in older patients: higher average dose and wider dose frequency distribution in patients of African ancestry than those of European ancestry.

    Garwood, Candice L; Clemente, Jennifer L; Ibe, George N; Kandula, Vijay A; Curtis, Kristy D; Whittaker, Peter

    2010-06-15

    Studies report that warfarin doses required to maintain therapeutic anticoagulation decrease with age; however, these studies almost exclusively enrolled patients of European ancestry. Consequently, universal application of dosing paradigms based on such evidence may be confounded because ethnicity also influences dose. Therefore, we determined if warfarin dose decreased with age in Americans of African ancestry, if older African and European ancestry patients required different doses, and if their daily dose frequency distributions differed. Our chart review examined 170 patients of African ancestry and 49 patients of European ancestry cared for in our anticoagulation clinic. We calculated the average weekly dose required for each stable, anticoagulated patient to maintain an international normalized ratio of 2.0 to 3.0, determined dose averages for groups 80 years of age and plotted dose as a function of age. The maintenance dose in patients of African ancestry decreased with age (PAfrican ancestry required higher average weekly doses than patients of European ancestry: 33% higher in the 70- to 79-year-old group (38.2+/-1.9 vs. 28.8+/-1.7 mg; P=0.006) and 52% in the >80-year-old group (33.2+/-1.7 vs. 21.8+/-3.8 mg; P=0.011). Therefore, 43% of older patients of African ancestry required daily doses >5mg and hence would have been under-dosed using current starting-dose guidelines. The dose frequency distribution was wider for older patients of African ancestry compared to those of European ancestry (PAfrican ancestry indicate that strategies for initiating warfarin therapy based on studies of patients of European ancestry could result in insufficient anticoagulation and thereby potentially increase their thromboembolism risk. Copyright 2010 Elsevier Inc. All rights reserved.

  18. Neurotoxicity and low paclitaxel clearance associated with concomitant clopidogrel therapy in a 60 year old Caucasian woman with ovarian carcinoma

    Bergmann, Troels K; Filppula, Anne M; Launiainen, Terhi

    2015-01-01

    % of the cohort geometric mean (385 L/h; range 176-726). She was hospitalised thrice, developed severe neuropathy and paclitaxel treatment was subsequently discontinued. In vitro, 30 min preincubation with 100 μM clopidogrel acyl-β-D-glucuronide inhibited the depletion rate of 0.5 μM paclitaxel by 51......AIM: The aim of this case report is to describe a novel pharmacokinetic drug-drug interaction between the antiplatelet agent clopidogrel and the antineoplastic agent paclitaxel. METHODS: The patient was identified in a previously described cohort of 93 patients with ovarian carcinoma treated...... with paclitaxel. The effect of clopidogrel acyl-β-D-glucuronide on the metabolism of paclitaxel was assessed in human liver microsomes. The analysis of clopidogrel in plasma and the quantification of paclitaxel and 6α-hydroxypaclitaxel in in vitro samples were performed by liquid chromatography tandem mass...

  19. The effectiveness, side effects and acceptability of locally available brand of Clopidogrel (Osvix as antiplatelet tablet in CABG patients

    Behzad Imani

    2014-07-01

    Conclusion: This study showed the Iranian brand of Clopidogrel (Osvix is significantly different from the original brand (Plavix in terms of performance factors in preventing platelet aggregation in patients undergoing coronary artery bypass grafting.

  20. Calcium-channel blockers do not alter the clinical efficacy of clopidogrel after myocardial infarction: a nationwide cohort study

    Olesen, Jonas B; Gislason, Gunnar H; Charlot, Mette G

    2011-01-01

    Objectives The purpose of this study was to determine the risk of adverse cardiovascular events associated with concomitant use of clopidogrel and calcium-channel blockers (CCBs) in patients with myocardial infarction (MI). Background CCBs inhibit a variety of cytochrome P-450 enzymes, some...... patients treated and not treated with clopidogrel, with a hazard ratio of 1.15 (95% confidence interval [CI]: 1.07 to 1.24) and 1.05 (95% CI: 1.01 to 1.11), respectively. The increased risk was independent of clopidogrel use; the hazard rate ratio was 1.08 (95% CI: 0.99 to 1.18). Analyses of all additional...... adverse end points and propensity score–matched models provided similar results. Conclusions The clinical efficacy of clopidogrel in patients with a recent MI is not modified by concomitant CCB treatment. This potential drug interaction is unlikely to have clinical significance....

  1. Effect of addition of clopidogrel to aspirin on subdural hematoma: meta-analysis of randomized clinical trials.

    Bakheet, Majid F; Pearce, Lesly A; Hart, Robert G

    2015-06-01

    Clopidogrel combined with aspirin is routinely prescribed after coronary artery stenting, in patients with acute coronary syndromes, and recently to prevent stroke in patients with acute minor ischemic stroke and TIA. Subdural hematomas are an important complication of antithrombotic treatment, but the risk associated with clopidogrel plus aspirin has not been previously defined. To quantify the risk of subdural hematoma associated with dual antiplatelet therapy with clopidogrel plus aspirin. Randomized clinical trials comparing clopidogrel plus aspirin with aspirin alone were identified by searching the Cochrane Central Register of Controlled Trials from 1990 to 2014, and restricted to those with more than 7 days of treatment. Two reviewers independently extracted data about subdural hematomas. Of 24 randomized trials testing clopidogrel added to aspirin, results for subdural hematoma were available for 11 trials, of which eight did not identify any subdural hematomas. The three trials reporting subdural hematomas were double-blind and included patients with recent lacunar stroke, acute coronary syndromes or atrial fibrillation with a total of 23,136 patients (mean age 66 years) and reported 39 subdural hematomas during a mean follow-up 2.1 years per patient. Clopidogrel plus aspirin was associated with a significantly increased risk of subdural hematoma compared with aspirin alone (risk ratio 2.0, 95% CI 1.0, 3.8; P = 0.04; fixed effects model; I2 for heterogeneity of 0%, P = 0.51). The average absolute incidence of subdural hematoma averaged 1.1 (95% CI 0.7,1.6) per 1000 patient - years among those assigned clopidogrel plus aspirin in 11 randomized trials. The absolute rate of subdural hematoma during dual antiplatelet therapy is low, averaging 1.1 per 1000 patient-years. Chronic treatment with clopidogrel plus aspirin significantly increases the risk of subdural hematoma compared with aspirin alone. © 2014 World Stroke Organization.

  2. Ticagrelor versus clopidogrel in real-world patients with ST elevation myocardial infarction: 1-year results by propensity score analysis

    Vercellino, Matteo; S?nchez, Federico Ariel; Boasi, Valentina; Perri, Dino; Tacchi, Chiara; Secco, Gioel Gabrio; Cattunar, Stefano; Pistis, Gianfranco; Mascelli, Giovanni

    2017-01-01

    Background European guidelines recommend the use of ticagrelor versus clopidogrel in patients with ST elevation myocardial infarction (STEMI). This recommendation is based on inconclusive results and subanalyses from clinical trials. Few data are available on the effects of ticagrelor in a real-world population. Methods To compare the effects of ticagrelor and clopidogrel in a real-world STEMI population, we conducted a pre-post case-control study examining all patients with STEMI included in...

  3. Effect of Clopidogrel on Platelet CD Markers in Normal Individuals and in Patients with Untreated Type 2 Diabetes Mellitus

    Saboor, M.; Moinuddin, M.; Ilyas, S.

    2015-01-01

    The objective of this study was to evaluate the effect of clopidogrel response in patients with untreated type 2 diabetes mellitus as compared with normal individuals. One hundred and seven subjects i.e. 32 normal and 75 patients with untreated type 2 diabetes mellitus were enrolled in this study. In the first step, normal subjects as well as diabetic patients were selected and tested for various laboratory parameters and platelets flow cytometry. In the second step, an antiplatelet drug (clopidogrel) was administered for 10 days to each individual enrolled in the study. After 10 days blood samples were collected for platelets flow cytometry. CD41 and CD61 did not show any change after the administration of clopidogrel in resting and activated platelets. CD63 and CD62p positivity was increased in normal and in diabetic patients' platelets after activation with ADP before clopidogrel. It was decreased in normal resting and ADP stimulated platelets after clopidogrel treatment. CD63 and CD62p positivity in resting and ADP stimulated patients platelets was also decreased after clopidogrel treatment. The change was, however, not as marked as in normal subjects. (author)

  4. Clopidogrel, a P2Y12 receptor antagonist, potentiates the inflammatory response in a rat model of peptidoglycan polysaccharide-induced arthritis.

    Garcia, Analia E; Mada, Sripal R; Rico, Mario C; Dela Cadena, Raul A; Kunapuli, Satya P

    2011-01-01

    The P2Y12 receptor plays a crucial role in the regulation of platelet activation by several agonists, which is irreversibly antagonized by the active metabolite of clopidogrel, a widely used anti-thrombotic drug. In this study, we investigated whether reduction of platelet reactivity leads to reduced inflammatory responses using a rat model of erosive arthritis. We evaluated the effect of clopidogrel on inflammation in Lewis rats in a peptidoglycan polysaccharide (PG-PS)-induced arthritis model with four groups of rats: 1) untreated, 2) clopidogrel-treated, 3) PG-PS-induced, and 4) PG-PS-induced and clopidogrel-treated. There were significant differences between the PG-PS+clopidogrel group when compared to the PG-PS group including: increased joint diameter and clinical manifestations of inflammation, elevated plasma levels of pro-inflammatory cytokines (IL-1 beta, interferon (IFN) gamma, and IL-6), an elevated neutrophil blood count and an increased circulating platelet count. Plasma levels of IL-10 were significantly lower in the PG-PS+clopidogrel group compared to the PG-PS group. Plasma levels of platelet factor 4 (PF4) were elevated in both the PG-PS and the PG-PS+clopidogrel groups, however PF4 levels showed no difference upon clopidogrel treatment, suggesting that the pro- inflammatory effect of clopidogrel may be due to its action on cells other than platelets. Histology indicated an increase in leukocyte infiltration at the inflammatory area of the joint, increased pannus formation, blood vessel proliferation, subsynovial fibrosis and cartilage erosion upon treatment with clopidogrel in PG-PS-induced arthritis animals. In summary, animals treated with clopidogrel showed a pro-inflammatory effect in the PG-PS-induced arthritis animal model, which might not be mediated by platelets. Elucidation of the mechanism of clopidogrel-induced cell responses is important to understand the role of the P2Y12 receptor in inflammation.

  5. Clopidogrel, a P2Y12 receptor antagonist, potentiates the inflammatory response in a rat model of peptidoglycan polysaccharide-induced arthritis.

    Analia E Garcia

    Full Text Available The P2Y12 receptor plays a crucial role in the regulation of platelet activation by several agonists, which is irreversibly antagonized by the active metabolite of clopidogrel, a widely used anti-thrombotic drug. In this study, we investigated whether reduction of platelet reactivity leads to reduced inflammatory responses using a rat model of erosive arthritis. We evaluated the effect of clopidogrel on inflammation in Lewis rats in a peptidoglycan polysaccharide (PG-PS-induced arthritis model with four groups of rats: 1 untreated, 2 clopidogrel-treated, 3 PG-PS-induced, and 4 PG-PS-induced and clopidogrel-treated. There were significant differences between the PG-PS+clopidogrel group when compared to the PG-PS group including: increased joint diameter and clinical manifestations of inflammation, elevated plasma levels of pro-inflammatory cytokines (IL-1 beta, interferon (IFN gamma, and IL-6, an elevated neutrophil blood count and an increased circulating platelet count. Plasma levels of IL-10 were significantly lower in the PG-PS+clopidogrel group compared to the PG-PS group. Plasma levels of platelet factor 4 (PF4 were elevated in both the PG-PS and the PG-PS+clopidogrel groups, however PF4 levels showed no difference upon clopidogrel treatment, suggesting that the pro- inflammatory effect of clopidogrel may be due to its action on cells other than platelets. Histology indicated an increase in leukocyte infiltration at the inflammatory area of the joint, increased pannus formation, blood vessel proliferation, subsynovial fibrosis and cartilage erosion upon treatment with clopidogrel in PG-PS-induced arthritis animals. In summary, animals treated with clopidogrel showed a pro-inflammatory effect in the PG-PS-induced arthritis animal model, which might not be mediated by platelets. Elucidation of the mechanism of clopidogrel-induced cell responses is important to understand the role of the P2Y12 receptor in inflammation.

  6. Salmeterol/fluticasone stable-dose treatment compared with formoterol/budesonide adjustable maintenance dosing: impact on health-related quality of life

    Williams Angela E

    2007-07-01

    Full Text Available Abstract Background Improving patients' health-related quality of life (HRQoL is recognized as a fundamental part of asthma management. The aims of this study were to evaluate the long-term efficacy (including symptom-free days and exacerbations and impact on HRQoL of a stable-dose regimen of salmeterol/fluticasone propionate (SAL/FP and an adjustable maintenance dosing (AMD regimen of formoterol/budesonide (FOR/BUD where treatment is adjusted based on symptoms [SAM40056]. Methods A total of 688 outpatients with asthma receiving regular low-dose inhaled corticosteroids (ICS plus a long-acting β2-agonist, or medium dose ICS alone participated in this randomized, double-blind, double-dummy, parallel-group, 1-year trial, which was conducted in 91 centers in 15 countries. Patients were randomized to receive 1 inhalation of SAL/FP 50/250 μg BID or 2 inhalations of FOR/BUD 6/200 μg BID during Weeks 1–4. For Weeks 5–52, patients meeting strict continuation criteria for stable asthma at Week 4 received AMD with FOR/BUD or stable-dose SAL/FP. Results The percentage of symptom-free days was significantly greater (58.8% vs 52.1%; p = 0.034 and the annual exacerbation rate was significantly lower (47%; p = 0.008 with stable-dose SAL/FP compared with FOR/BUD AMD. A total of 568 patients completed the Asthma Quality of Life Questionnaire (AQLQ at least once during the study. The mean change from baseline in AQLQ overall score was numerically greater with SAL/FP than FOR/BUD at week 28 and week 52, but did not reach statistical significance (p = 0.121 at Week 52. However, in a post hoc logistic regression analyses for any AQLQ improvement, significant benefits with SAL/FP were seen at both time points (p = 0.038 and p = 0.009, respectively. The minimally important difference of ≥ 0.5-point improvement in AQLQ overall score was achieved by a significantly greater number of patients receiving SAL/FP at Week 28 (68% vs 60%; p = 0.049; a trend for this

  7. Attenuated expression of the tight junction proteins is involved in clopidogrel-induced gastric injury through p38 MAPK activation

    Wu, Hai-Lu; Gao, Xin; Jiang, Zong-Dan; Duan, Zhao-Tao; Wang, Shu-Kui; He, Bang-Shun; Zhang, Zhen-Yu; Xie, Hong-Guang

    2013-01-01

    Highlights: ► Clopidogrel suppressed GES-1 cell viability in a concentration- and time-dependent manner. ► Clopidogrel significantly increased dextran permeability, reduced occludin and ZO-1 expression, and induced cell apoptosis. ► Clopidogrel activated p38 MAPK signaling pathway. ► Activation of p38 activity was involved in clopidogrel-induced increase in gastric epithelial cells permeability and disruption of TJ. -- Abstract: Bleeding complications and delayed healing of gastric ulcer associated with use of clopidogrel is a common clinical concern; however, the underlying mechanisms remain to be determined. This study aimed to clarify whether clopidogrel could cause the damage of the human gastric epithelial cells and to further elucidate the mechanisms involved. After human gastric epithelial cell line GES-1 had been treated with clopidogrel (0.5–2.5 mM), the cell proliferation was examined by MTT assay, apoptosis was measured with DAPI staining and flow cytometry analysis, and the barrier function of the tight junctions (TJ) was evaluated by permeability measurement and transmission electron microscopy. Moreover, expression of the TJ proteins occludin and ZO-1 and the phosphorylation of the mitogen-activated protein kinases (MAPK) p38, ERK, and JNK were examined by western blot. In addition, three MAPK inhibitors specific to p38, ERK and JNK were used, respectively, to verify the signaling pathways responsible for regulating the expression of the TJ proteins being tested. Results showed that clopidogrel significantly increased dextran permeability, induced apoptosis, suppressed GES-1 cell viability, and reduced the expression of the TJ proteins (occludin and ZO-1), acting through p38 MAPK phosphorylation. Furthermore, these observed effects were partially abolished by SB-203580 (a p38 MAPK inhibitor), rather than by either U-0126 (an ERK inhibitor) or SP-600125 (a JNK inhibitor), suggesting that clopidogrel-induced disruption in the gastric

  8. Mortality in primary angioplasty patients starting antiplatelet therapy with prehospital prasugrel or clopidogrel

    Goldstein, Patrick; Grieco, Niccolò; Ince, Hüseyin

    2016-01-01

    hospitalization, we report here the 1-year follow-up data, including cardiovascular (CV) mortality. METHODS AND RESULTS: MULTIPRAC is a multinational, prospective registry of patients with ST-elevation myocardial infarction (STEMI) from 25 hospitals in nine countries, all of which had an established practice...... of prehospital start of dual antiplatelet therapy in place. The key outcome was CV death at 1 year. Among 2,036 patients followed-up through 1 year, 49 died (2.4%), 10 during the initial hospitalization and 39 within 1 year after hospital discharge. The primary analysis was based on the P2Y12-inhibitor, used...... from prehospital loading dose through hospital discharge. Prasugrel (n=824) was more commonly used than clopidogrel (n=425). The observed 1-year rates for CV death were 0.5% with prasugrel and 2.6% with clopidogrel. After adjustment for differences in baseline characteristics, treatment with prasugrel...

  9. Concomitant nitrates enhance clopidogrel response during dual anti-platelet therapy.

    Lee, Dong Hyun; Kim, Moo Hyun; Guo, Long Zhe; De Jin, Cai; Cho, Young Rak; Park, Kyungil; Park, Jong Sung; Park, Tae-Ho; Serebruany, Victor

    2016-01-15

    Despite advances in modern anti-platelet strategies, clopidogrel still remains the cornerstone of dual anti-platelet therapy (DAPT) in patients undergoing percutaneous coronary interventions (PCI). There is some inconclusive evidence that response after clopidogrel may be impacted by concomitant medications, potentially affecting clinical outcomes. Sustained released nitrates (SRN) are commonly used together with clopidogrel in post-PCI setting for mild vasodilatation and nitric oxide-induced platelet inhibition. We prospectively enrolled 458 patients (64.5 ± 9.6 years old, and 73.4% males) following PCI undergoing DAPT with clopidogrel and aspirin. Platelet reactivity was assessed by the VerifyNow™ P2Y12 assay at the maintenance outpatient setting. Concomitant SRN (n=266) significantly (p=0.008) enhanced platelet inhibition after DAPT (251.6 ± 80.9PRU) when compared (232.1 ± 73.5PRU) to the SRN-free (n=192) patients. Multivariate logistic regression analysis with the cut-off value of 253 PRU for defining heightened platelet reactivity confirmed independent correlation of more potent platelet inhibition during DAPT and use of SRN (Relative risk=1.675; Odds ratio [1.059-2.648]; p=0.027). In contrast, statins, calcium-channel blockers, beta blockers, angiotensin receptor blockers, ACE-inhibitors, diuretics, and anti-diabetic agents did not significantly impact platelet inhibition following DAPT. The synergic ability of SRN to enhance response during DAPT may have important clinical implications with regard to better cardiovascular protection, but extra bleeding risks, requiring further confirmation in a large randomized study. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  10. Valsartan combined with clopidogrel and/or leflunomide for the treatment of progressive immunoglobulin A nephropathy.

    Cheng, Genyang; Liu, Dongwei; Margetts, Peter; Liu, Limin; Zhao, Zhanzheng; Liu, Zhangsuo; Tang, Lin; Fang, Yudong; Li, Haijian; Guo, Yuanyuan; Chen, Fengmei; Liu, Fengxun

    2015-02-01

    The current standard treatment for IgA nephropathy relies on steroid and/or immunosuppressive therapy and angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blocker (ARB). This study examines the benefits and safety of combining valsartan with clopidogrel and leflunomide as a treatment for progressive IgA nephropathy. Patients with primary IgA nephropathy, confirmed by renal biopsy, were recruited for this study. Patients were separated into four groups (n = 42 each) after 2 months of run-in period of valsartan treatment. All patients were treated with valsartan alone (Group 1) or valsartan and either clopidogrel (Group 2) or leflunomide (Group 3) or both clopidogrel and leflunomide (Group 4). Each group was followed up for their next 24 months for 24 h urinary protein excretion, serum creatinine and estimated glomerular filtration rate (eGFR) to assess the effect of the treatment. Adverse effects were recorded concurrently to evaluate the safety of the treatment. Of all 168 patients, 107 were males and 61 were females, with an average age of 33.8 ± 8.79 years. Baseline characteristics were comparable among the four groups (P > 0.05) prior to the experimental treatment. There was a significant (P Valsartan combined with Clopidogrel and Leflunomide can reduce the urinary proteins loss and renal function deterioration for IgA nephropathy patients and cause minimal adverse reactions. Our study suggests a new clinical treatment option for IgA nephropathy. © 2014 Asian Pacific Society of Nephrology.

  11. Platelet aggregation according to body mass index in patients undergoing coronary stenting: should clopidogrel loading-dose be weight adjusted?

    Angiolillo, Dominick J; Fernández-Ortiz, Antonio; Bernardo, Esther; Barrera Ramírez, Carlos; Sabaté, Manel; Fernandez, Cristina; Hernández-Antolín, Rosana; Escaned, Javier; Alfonso, Fernando; Macaya, Carlos

    2004-04-01

    A 300 mg clopidogrel loading-dose (LD) is widely used as an adjunct antithrombotic treatment to reduce the risk of thrombotic events early after coronary stenting (CS). Antithrombotic drugs commonly used during percutaneous coronary interventions, such as heparin and platelet glycoprotein IIb/IIIa inhibitors, but not clopidogrel LD, are weight-adjusted, and few data are available on which is the most effective clopidogrel LD regimen. The aim of this study was to assess whether body mass index (BMI) influenced platelet response to clopidogrel LD in patients undergoing CS. Adenosine diphosphate (ADP)-induced platelet aggregation (PA) was assessed by light transmittance aggregometry in 48 patients on aspirin treatment undergoing CS receiving a 300 mg clopidogrel LD at intervention time. PA was assessed at baseline and up to 24 hours after intervention. Patients were divided into 2 groups according to BMI: overweight (BMI greater than or equal to 25 kg/m2; 29 patients) and normal weight (BMI<25 kg/m2; 19 patients). PA was significantly higher in overweight than in normal weight patients at baseline (60.1+/-18.6%; versus 47.6+/-13.5%; p=0.01), at 24 hours (42.3+/-18.4% versus 38.5+/-18.3%; p=0.02) and during the overall study time (p=0.025). Percentage of inhibition of PA 24 hours following clopidogrel LD was suboptimal (<40%) in 59% and 26% of overweight and normal weight patients, respectively (p=0.04). An elevated BMI was the only independent predictor of suboptimal platelet response. These data suggest that overweight patients may need a higher loading-dose of clopidogrel and/or an adjunct antithrombotic treatment to adequately inhibit platelet aggregation early after CS.

  12. Clopidogrel administration prior to coronary artery bypass grafting surgery: the cardiologist's panacea or the surgeon's headache?

    Kapetanakis, Emmanouil I; Medlam, Diego A; Boyce, Steven W; Haile, Elizabeth; Hill, Peter C; Dullum, Mercedes K C; Bafi, Ammar S; Petro, Kathleen R; Corso, Paul J

    2005-03-01

    Thrombotic complications after percutaneous coronary intervention procedures have decreased in past years mainly due to the use of clopidogrel antiplatelet therapy. However, the risk of bleeding due to enhanced and irreversible platelet inhibition in patients who will require surgical coronary revascularization instead has not been adequately addressed in the literature. The purpose of this study was to evaluate the effect of pre-operative clopidrogel exposure in haemorrhage-related re-exploration rates, peri-operative transfusion requirements, morbidity, and mortality in patients undergoing coronary artery bypass grafting (CABG) surgery. A study population of 2359 patients undergoing isolated CABG between January 2000 and June 2002 was reviewed. Of these, 415 (17.6%) received clopidogrel prior to CABG surgery, and 1944 (82.4%) did not. A risk-adjusted logistic regression analysis was used to assess the association between clopidogrel pre-medication (vs. no) and haemostatic re-operation, intraoperative and post-operative blood transfusion rates, and multiple transfusions received. Haemorrhage-related pre-operative risk factors identified from the literature and those found significant in a univariate model were used. Furthermore, a sub-cohort, matched-pair by propensity scores analysis, was also conducted. The clopidogrel group had a higher likelihood of haemostatic re-operation [OR = 4.9, (95% CI, 2.63-8.97), P < 0.01], an increase in total packed red blood cell transfusions [OR = 2.2, (95% CI, 1.70-2.84), P < 0.01], multiple unit blood transfusions [OR = 1.9, (95% CI, 1.33-2.75), P < 0.01] and platelet transfusions [OR = 2.6, (95% CI, 1.95-3.56), P < 0.01]. Surgical outcomes and operative mortality [OR = 1.5, (95% CI, 0.36-6.51), P = 0.56] were not significantly different. Pre-operative clopidogrel exposure increases the risk of haemostatic re-operation and the requirements for blood and blood product transfusion during, and after, CABG surgery.

  13. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial

    Dewilde, Willem J. M.; Oirbans, Tom; Verheugt, Freek W. A.; Kelder, Johannes C.; de Smet, Bart J. G. L.; Herrman, Jean-Paul; Adriaenssens, Tom; Vrolix, Mathias; Heestermans, Antonius A. C. M.; Vis, Marije M.; Tijsen, Jan G. P.; van 't Hof, Arnoud W.; ten Berg, Jurriën M.; Schölzel, B. E.; van den Branden, B. J.; Plokker, H. W. M.; Bosschaert, M. A.; Slagboom, T.; Vos, J.; Brueren, B. R. G.; Breet, N. J.; Sheikjoesoef, K.; Aarnoudse, W.; Rasoul, S.; van Mieghem, C.; Vandendriessche, T.; Cornelis, K.

    2013-01-01

    If percutaneous coronary intervention (PCI) is required in patients taking oral anticoagulants, antiplatelet therapy with aspirin and clopidogrel is indicated, but such triple therapy increases the risk of serious bleeding. We investigated the safety and efficacy of clopidogrel alone compared with

  14. Increased mortality associated with low use of clopidogrel in patients with heart failure and acute myocardial infarction not undergoing percutaneous coronary intervention: a nationwide study

    Bonde, Lisbeth; Sorensen, Rikke; Fosbøl, Emil Loldrup

    2010-01-01

    We studied the association of clopidogrel with mortality in acute myocardial infarction (AMI) patients with heart failure (HF) not receiving percutaneous coronary intervention (PCI).......We studied the association of clopidogrel with mortality in acute myocardial infarction (AMI) patients with heart failure (HF) not receiving percutaneous coronary intervention (PCI)....

  15. Increased mortality associated with low use of clopidogrel in patients with heart failure and acute myocardial infarction not undergoing percutaneous coronary intervention

    Bonde, Lisbeth; Sorensen, Rikke; Fosbøl, Emil Loldrup

    2010-01-01

    with patients not treated with clopidogrel. Similarly, 2 groups without HF were identified. Risks of all-cause death were obtained by the Kaplan-Meier method and Cox regression analyses. RESULTS: We identified 56,944 patients with first-time AMI. In the matched cohort with HF (n = 5,050) and a mean follow......OBJECTIVES: We studied the association of clopidogrel with mortality in acute myocardial infarction (AMI) patients with heart failure (HF) not receiving percutaneous coronary intervention (PCI). BACKGROUND: Use of clopidogrel after AMI is low in patients with HF, despite the fact that clopidogrel...... is associated with absolute mortality reduction in AMI patients. METHODS: All patients hospitalized with first-time AMI (2000 through 2005) and not undergoing PCI within 30 days from discharge were identified in national registers. Patients with HF treated with clopidogrel were matched by propensity score...

  16. Impact of CYP2C19 Metabolizer Status on Patients With ACS Treated With Prasugrel Versus Clopidogrel.

    Doll, Jacob A; Neely, Megan L; Roe, Matthew T; Armstrong, Paul W; White, Harvey D; Prabhakaran, Dorairaj; Winters, Kenneth J; Duvvuru, Suman; Sundseth, Scott S; Jakubowski, Joseph A; Gurbel, Paul A; Bhatt, Deepak L; Ohman, E Magnus; Fox, Keith A A

    2016-03-01

    Certain alleles of the CYP2C19 gene are associated with higher platelet reactivity and increased ischemic events among patients treated with clopidogrel. However, the relationship of CYP2C19 genotype and outcomes in medically managed patients with acute coronary syndromes (ACS) is not known. This study sought to assess the effect of CYP2C19 genotype on ischemic outcomes in patients with ACS initially managed medically without revascularization who were randomized to either clopidogrel or prasugrel. We classified patients as extensive metabolizers (EM) or reduced metabolizers (RM) based on CYP2C19 genotype and evaluated ischemic outcomes and platelet reactivity. Among 9,326 patients enrolled from 2008 to 2011, 5,736 participated in the genetics cohort; of these, 2,236 had platelet function testing data. There was no association between CYP2C19 metabolizer status (EM vs. RM) and the primary composite endpoint of cardiovascular death, myocardial infarction (MI), or stroke (hazard ratio [HR]: 0.86). EM and RM patients had similar rates of the primary endpoint whether treated with prasugrel (HR: 0.82) or clopidogrel (HR: 0.91; p for interaction = 0.495). After adjusting for clinical and treatment variables, EM patients had a lower risk of MI versus RM patients (HR: 0.80), but risks of other outcomes were similar. RM patients had significantly higher mean P2Y12 reaction units versus EM patients when treated with clopidogrel (39.93), but not with prasugrel (3.87). CYP2C19 metabolizer status is not associated with the composite outcome of cardiovascular death, MI, or stroke in medically managed ACS patients treated with clopidogrel or prasugrel. Our findings do not support routine CYP2C19 genetic testing in this population. (A Comparison of Prasugrel and Clopidogrel in Acute Coronary Syndrome Subjects [TRILOGY ACS]; NCT00699998). Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

  17. Clopidogrel bioactivation and risk of bleeding in patients cotreated with angiotensin-converting enzyme inhibitors after myocardial infarction

    Kristensen, K E; Zhu, H-J; Wang, X

    2014-01-01

    in vitro and linked the results with a pharmacoepidemiological study. In vitro, ACEIs inhibited CES1-mediated hydrolysis of a model substrate, and trandolapril and enalapril increased formation of clopidogrel active metabolite. In 70,934 patients with myocardial infarction, hazard ratios for clinically...... significant bleeding in ACEI-treated patients cotreated with or without clopidogrel were 1.10 (95% confidence interval (CI): 0.97-1.25, P = 0.124) and 0.90 (95% CI: 0.81-0.99, P = 0.025), respectively, as compared with patients who did not receive ACEIs. This difference was statistically significant (P = 0...

  18. Comparison of effect of locally available brands of clopidogrel on platelet aggregation in patients with coronary disease

    Khan, S.B.; Hameedullah; Noor, L.; Awan, Z.A.; Din, S.U.; Muhammad Hafeezullah, M.

    2010-01-01

    Background: Anticoagulant effect of clopidogrel is of utmost importance in coronary artery disease, especially in prevention of coronary stent thrombosis. Recently, many new local brands of clopidogrel have been launched, with unknown efficacy. This study was conducted with the aim to compare two locally prepared clopidogrel brands, in terms of the effect of a loading dose of 600 mg on inhibition of platelet aggregation in patients with coronary artery disease. Methods: This was a double blind randomised study. Sample population consisting of 35 patients, were admitted at Lady Reading Hospital, Peshawar, for the management of coronary artery disease. Baseline platelet aggregation of all these patients was measured. These patients were divided in two groups randomly. Group-A consisting of 18 patients was given brand 'A' clopidogrel 600 mg, while Group-B consisting of 17 patients was give brand 'B' of clopidogrel 600 mg. The platelet aggregation of both groups was then measured at baseline, and at 2, 4, and 6 hours after taking the loading dose of 600 mg. Results: Platelet aggregation time at baseline in Group-A was 2.61+- 2.28 sec. and in Group-B it was 2.24 +- 1.52 sec. (p=0.57). After 2 hours of clopidogrel administration in Group-A the platelet aggregation time was 1.44 +- 1.58 sec. and in Group-B it was 1.53 +- 1.107 sec. (p=0.85). Platelet aggregation time after 4 hours in Group-A was 0.28 +- 0.57 sec. and in Group-B 1.06 +- 1.03 sec. (p=0.009), and after 6 hours it was 0.00 +- 0.00 sec. in Group-A and in Group-B it was 0.59 +- 0.71 sec. (p=0.001). Conclusion: The two brands of clopidogrel had a significant difference in their effect on inhibition of platelet aggregation. Different brands of clopidogrel may not be equally effective. (author)

  19. Eight-year follow-up of the Clopidogrel After Surgery for Coronary Artery Disease (CASCADE) trial.

    Hage, Ali; Voisine, Pierre; Erthal, Fernanda; Larose, Éric; Glineur, David; Chow, Benjamin; Tremblay, Hugo; Fortier, Jacqueline; Ko, Gifferd; Une, Dai; Farkouh, Michael; Mesana, Thierry G; LeMay, Michel; Kulik, Alexander; Ruel, Marc

    2018-01-01

    In this 8 years' follow-up study, we evaluated the long-term outcomes of the addition of clopidogrel to aspirin during the first year after coronary artery bypass grafting, versus aspirin plus placebo, with respect to survival, major adverse cardiac, or major cerebrovascular events, including revascularization, functional status, graft patency, and native coronary artery disease progression. In the initial Clopidogrel After Surgery for Coronary Artery Disease trial, 113 patients were randomized to receive either daily clopidogrel (n = 56) or placebo (n = 57), in addition to aspirin, in a double-blind fashion for 1 year after coronary artery bypass grafting. All patients were re-evaluated to collect long-term clinical data. Surviving patients with a glomerular filtration rate > 30 mL/min were asked to undergo a coronary computed tomography angiogram to evaluate the late saphenous vein graft patency and native coronary artery disease progression. At a median follow-up of 7.6 years, survival rate was 85.5% ± 3.8% (P = .23 between the 2 groups). A trend toward enhanced freedom from all-cause death or major adverse cardiac or cerebrovascular events, including revascularization, was observed in the aspirin-clopidogrel group (P = .11). No difference in functional status or freedom from angina was observed between the 2 groups (P > .57). The long-term patency of saphenous vein graft was 89.11% in the aspirin-clopidogrel group versus 91.23% in the aspirin-placebo group (P = .79). A lower incidence of moderate to severe native disease progression was observed in the aspirin-clopidogrel group versus the aspirin-placebo group (7 out of 122 vs 13 out of 78 coronary segments that showed progression, respectively [odds ratio, 0.3 ± 0.2; 95% confidence interval, 0.1-0.8; P = .02]). At 8 years' follow-up, the addition of clopidogrel to aspirin during the first year after coronary artery bypass grafting exhibited a lower incidence of moderate to severe

  20. Safety of Prasugrel Loading Doses in Patients Pre-Loaded With Clopidogrel in the Setting of Primary Percutaneous Coronary Intervention

    Räber, Lorenz; Klingenberg, Roland; Heg, Dik

    2015-01-01

    OBJECTIVES: The aim of this study was to assess the safety of the concurrent administration of a clopidogrel and prasugrel loading dose in patients undergoing primary percutaneous coronary intervention. BACKGROUND: Prasugrel is one of the preferred P2Y12 platelet receptor antagonists for ST-segment.......62, p = 0.36). CONCLUSIONS: This observational, nonrandomized study of ST-segment elevation myocardial infarction patients suggests that the administration of a loading dose of prasugrel in patients pre-treated with a loading dose of clopidogrel is not associated with an excess of major bleeding events...

  1. Long-term cost-effectiveness of ticagrelor versus clopidogrel in acute coronary syndrome in Spain

    E. Molina-Cuadrado

    2014-07-01

    Full Text Available Objective: To assess the cost-effectiveness relationship of Ticagrelor versus Clopidogrel for the management of acute coronary syndrome in Spain. Methods: The data from the PLATO study were used for the calculation of the events rate and health-related quality of life for Ticagrelor and Clopidogrel for the first 12 months, whereas the costs were obtained from Spanish sources. Quality of lifeadjusted survival and costs were estimated according to the fact that the patients did not suffer any thrombotic event (myocardial infarction or ictus or this one was not fatal. The lifetime cots, life years gained, and the quality of life-adjusted survival were estimated for both treatment arms. Incremental costeffectiveness ratios were assessed through the perspective of the Spanish healthcare system for 2013, by using a macro-costs strategy based on published literature and the survival tables for the Spanish population. Results: Treatment with Ticagrelor was associated to an incremental cost of 1,228 per year, an increase in 0.1652 life years gained, and 0.1365 years adjusted by quality of life, as compared to Clopidogrel. The cost for one quality of life-adjusted life year was 8,997 and the cost per one gained life year of 7,435 . The sensitivity analysis showed consistent results. Conclusions: Treatment of acute coronary syndrome for 12 months with Ticagrelor was associated with a cost per 1 life year of quality of life-adjusted cost below the cost-effectiveness limits generally accepted in Spain.

  2. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data

    Sørensen, Rikke; Hansen, Morten L; Abildstrøm, Steen

    2009-01-01

    BACKGROUND: Combinations of aspirin, clopidogrel, and vitamin K antagonists are widely used in patients after myocardial infarction. However, data for the safety of combinations are sparse. We examined the risk of hospital admission for bleeding associated with different antithrombotic regimens...... according to the following groups: monotherapy with aspirin, clopidogrel, or vitamin K antagonist; dual therapy with aspirin plus clopidogrel, aspirin plus vitamin K antagonist, or clopidogrel plus vitamin K antagonist; or triple therapy including all three drugs. Risk of hospital admission for bleeding...... was 2.6% for the aspirin group, 4.6% for clopidogrel, 4.3% for vitamin K antagonist, 3.7% for aspirin plus clopidogrel, 5.1% for aspirin plus vitamin K antagonist, 12.3% for clopidogrel plus vitamin K antagonist, and 12.0% for triple therapy. With aspirin as reference, adjusted hazard ratios...

  3. Vascular risk levels affect the predictive value of platelet reactivity for the occurrence of MACE in patients on clopidogrel. Systematic review and meta-analysis of individual patient data.

    Reny, Jean-Luc; Fontana, Pierre; Hochholzer, Willibald; Neumann, Franz Josef; Ten Berg, Jurriën; Janssen, Paul W; Geisler, Tobias; Gawaz, Meinrad; Marcucci, Rossella; Gori, Anna-Maria; Cuisset, Thomas; Alessi, Marie-Christine; Berdagué, Philippe; Gurbel, Paul A; Yong, Gerald; Angiolillo, Dominick J; Aradi, Dániel; Beigel, Roy; Campo, Gianluca; Combescure, Christophe

    2016-04-01

    Prior studies have shown an association between high on-clopidogrel platelet reactivity (PR) and the risk of major adverse cardiovascular events (MACE). However, large intervention trials on PR-tailored treatments have been neutral. The role and usefulness of PR with regard to levels of cardiovascular risk are unclear. We undertook a systematic review and meta-analysis of individual patient data on MACE outcomes (acute coronary syndromes (ACS), ischaemic strokes, and vascular deaths) in relation to PR and its interaction with cardiovascular risk levels. PR was determined using ADP-induced light transmission aggregometry with a primary concentration of 20 µM ADP. Thirteen prospective studies totaled 6,478 clopidogrel-treated patients who experienced 421 MACE (6.5 %) during a median follow-up of 12 months. The strength of the association between the risk of MACE and PR increased significantly (p=0.04) with the number of risk factors present (age> 75 years, ACS at inclusion, diabetes, and hypertension). No association was detected in patients with no risk factor (p=0.48). In patients presenting one risk factor, only high-PR was associated with an increased risk of MACE (HR 3.2, p=0.001). In patients presenting ≥ 2 risk factors, the increase of risk started from medium-PR (medium-PR: HR=2.9, p=0.0004; high-PR: HR=3.7, p=0.0003). PR allowed the reclassification of 44 % of the total population to a different risk level for the outcome of MACE, mostly in intermediate or high risk patients. In conclusion, the magnitude of the association between PR and MACE risk is strongly dependent on the level of cardiovascular risk faced by patients on clopidogrel.

  4. Clopidogrel discontinuation within the first year after coronary drug-eluting stent implantation

    Thim, Troels; Johansen, Martin Berg; Chisholm, Gro Egholm

    2014-01-01

    BACKGROUND: The impact of adherence to the recommended duration of dual antiplatelet therapy after first generation drug-eluting stent implantation is difficult to assess in real-world settings and limited data are available. METHODS: We followed 4,154 patients treated with coronary drug-eluting ......BACKGROUND: The impact of adherence to the recommended duration of dual antiplatelet therapy after first generation drug-eluting stent implantation is difficult to assess in real-world settings and limited data are available. METHODS: We followed 4,154 patients treated with coronary drug......-eluting stents in Western Denmark for 1 year and obtained data on redeemed clopidogrel prescriptions and major adverse cardiovascular events (MACE, i.e., cardiac death, myocardial infarction, or stent thrombosis) from medical databases. RESULTS: Discontinuation of clopidogrel within the first 3 months after...... stent implantation was associated with a significantly increased rate of MACE at 1-year follow-up (hazard ratio (HR) 2.06; 95% confidence interval (CI): 1.08-3.93). Discontinuation 3-6 months (HR 1.29; 95% CI: 0.70-2.41) and 6-12 months (HR 1.29; 95% CI: 0.54-3.07) after stent implantation were...

  5. Initiation and persistence with clopidogrel treatment after acute myocardial infarction: a nationwide study

    Sørensen, Rikke; Gislason, G H; Fosbøl, E L

    2008-01-01

    AIMS: To identify possible underuse by analysing initiation and persistence with clopidogrel treatment in an unselected population of patients admitted with myocardial infarction (MI) with or without subsequent percutaneous coronary intervention (PCI). METHODS: Patients admitted with first-time MI...... proportional hazard models. RESULTS: A total of 46,190 MI patients were included in the study, of whom 14,939 were treated with PCI. From 2000 to 2005 initiation of clopidogrel increased from 80.4 to 93.7% among MI patients with PCI and from 2.8 to 39.3% among MI patients without PCI. MI patients...... with concomitant heart failure received less treatment [odds ratio (OR) 0.49, confidence interval (CI) 0.43, 0.56 among patients with PCI and OR 0.90, CI 0.81, 0.99 among patients without PCI in 2002-2003, and OR 0.89, CI 0.80, 1.00 in 2004-2005, respectively]. Of MI patients with PCI, 77.5% completed 9 months...

  6. PlA polymorphism and platelet reactivity following clopidogrel loading dose in patients undergoing coronary stent implantation.

    Angiolillo, Dominick J; Fernandez-Ortiz, Antonio; Bernardo, Esther; Alfonso, Fernando; Sabaté, Manel; Fernández, Cristina; Stranieri, Chiara; Trabetti, Elisabetta; Pignatti, Pier Franco; Macaya, Carlos

    2004-01-01

    The PlA polymorphism (Leu33Pro) of the platelet glycoprotein (GP) IIIa gene has been suggested to play an important role in coronary thrombosis. In vitro studies have shown differences for this polymorphism in platelet sensitivity towards antiplatelet drugs (aspirin and abciximab), suggesting a pharmacogenetic modulation. The aim of the study was to assess the modulatory effect of the PlA polymorphism on clopidogrel-induced antiplatelet effects in 38 patients undergoing coronary stent implantation receiving a 300 mg clopidogrel loading-dose. Platelet reactivity was assessed as GPIIb/IIIa activation and P-selectin expression in platelets stimulated with 2 micromol/l adenosine diphosphate using whole blood flow cytometry. The distribution of the homozygous PlA1/A1 and heterozygous PlA1/A2 genotypes were 74 and 26%, respectively. PlA2 carriers had a higher degree of GPIIb/IIIa activation (P = 0.05) and P-selectin expression (P = 0.02) during the overall study time course and a lower antiplatelet effect to a 300 mg clopidogrel loading-dose up to 24 h following intervention (P < 0.05). In conclusion, the Pl polymorphism of the GPIIIa gene modulates platelet reactivity towards clopidogrel front loading in patients undergoing coronary stenting. This suggests the need for individualized antithrombotic regimens to optimally inhibit platelet reactivity. Copyright 2004 Lippincott Williams and Wilkins

  7. Prasugrel versus clopidogrel for patients with unstable angina or non-ST-segment elevation myocardial infarction with or without angiography

    Wiviott, Stephen D; White, Harvey D; Ohman, E Magnus

    2013-01-01

    Treatment with prasugrel and aspirin improves outcomes compared with clopidogrel and aspirin for patients with acute coronary syndrome who have had angiography and percutaneous coronary intervention; however, no clear benefit has been shown for patients managed first with drugs only. We assessed ...

  8. Characterization of degradation products of amorphous and polymorphic forms of clopidogrel bisulphate under solid state stress conditions

    Raijada, Dhara K; Prasad, Bhagwat; Paudel, Amrit

    2010-01-01

    The present study deals with the stress degradation studies on amorphous and polymorphic forms of clopidogrel bisulphate. The objective was to characterize the degradation products and postulate mechanism of decomposition of the drug under solid state stress conditions. For that, amorphous form, ...

  9. Relation between the Change in Mean Platelet Volume and Clopidogrel Resistance in Patients Undergoing Percutaneous Coronary Intervention.

    Koh, Young-Youp; Kim, Hyung Ho; Choi, Dong-Hyun; Lee, Young-Min; Ki, Young-Jae; Kang, Seong-Ho; Park, Geon; Chung, Joong-Wha; Chang, Kyong-Sig; Hong, Soon-Pyo

    2015-01-01

    We aimed to determine the association between the change in mean platelet volume (MPV) over time and aspirin/ clopidogrel resistance in patients undergoing percutaneous coronary intervention (PCI). The MPV and platelet function were analysed in 302 patients who underwent PCI. MPV changes were associated with increased aspirin reaction units (ARU, r = 0.114; P = 0.047), increased P2Y12 reaction units (PRU, r = 0.193; P = 0.001), and decreased P2Y12% inhibition (PI%, r = - 0.273; P resistant group (≥235 PRU or ≤15% of PI%) showed a significantly higher positive change in MPV (ΔMPV) values than the clopidogrel responder group (0.53 ± 0.78 vs. 0.13 ± 0.69 fL, P resistant and responder groups were 72.6% and 59.3%, respectively. After adjusting for traditional risk factors, the odds ratio in the clopidogrel resistant group with ΔMPV ≥0.2 fL was 4.10 (95% confidence interval; 1.84-9.17). In conclusion, ΔMPV was associated with PRU and PI%; a positive ΔMPV was an independent predictive marker for clopidogrel resistance after PCI.

  10. Effect of clopidogrel premedication in off-pump cardiac surgery: are we forfeiting the benefits of reduced hemorrhagic sequelae?

    Kapetanakis, Emmanouil I; Medlam, Diego A; Petro, Kathleen R; Haile, Elizabeth; Hill, Peter C; Dullum, Mercedes K C; Bafi, Ammar S; Boyce, Steven W; Corso, Paul J

    2006-04-04

    Premedication with clopidogrel has reduced thrombotic complications after percutaneous coronary revascularization procedures. However, because of the enhanced and irreversible platelet inhibition by clopidogrel, patients requiring surgical revascularization have a higher risk of bleeding complications and transfusion requirements. A principal benefit of surgical coronary revascularization without cardiopulmonary bypass is its lower hemorrhagic sequelae. The purpose of this study was to evaluate the effect of preoperative clopidogrel administration in the incidence of hemostatic reexploration, blood product transfusion rates, morbidity, and mortality in patients undergoing off-pump coronary artery bypass graft surgery using a large patient sample and a risk-adjusted approach. Two hundred eighty-one patients (17.9%) did and 1291 (82.1%) did not receive clopidogrel before their surgery, for a total of 1572 patients undergoing isolated off-pump coronary artery bypass graft surgery between January 2000 and June 2002. Risk-adjusted logistic regression analyses and a matched pair analyses by propensity scores were used to assess the association between clopidogrel administration and reoperation as a result of bleeding, intraoperative and postoperative blood transfusions received, and the need for multiple transfusions. Hemorrhage-related preoperative risk factors identified in the literature and those found significant in a univariate model were used. The clopidogrel group had a higher likelihood of hemostatic reoperations (odds ratio [OR], 5.1; 95% confidence interval [CI], 2.47 to 10.47; P<0.01) and an increased need in overall packed red blood cell (OR, 2.6; 95% CI, 1.94 to 3.60; P<0.01), multiple unit (OR, 1.6; 95% CI, 1.07 to 2.48; P=0.02), and platelet (OR, 2.5; 95% CI, 1.77 to 3.66; P<0.01) transfusions. Surgical outcomes and operative mortality (1.4% versus 1.4%; P=1.00) were not statistically different. Clopidogrel administration in the cardiology suite increases

  11. Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular events

    Squizzato, Alessandro; Bellesini, Marta; Takeda, Andrea; Middeldorp, Saskia; Donadini, Marco Paolo

    2017-01-01

    Aspirin is the prophylactic antiplatelet drug of choice for people with cardiovascular disease. Adding a second antiplatelet drug to aspirin may produce additional benefit for people at high risk and people with established cardiovascular disease. This is an update to a previously published review

  12. Use of and inhospital outcomes after early clopidogrel therapy in patients not undergoing an early invasive strategy for treatment of non-ST-segment elevation myocardial infarction: results from Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines (CRUSADE).

    Alexander, Deepu; Ou, Fang-Shu; Roe, Matthew T; Pollack, Charles V; Ohman, E Magnus; Cannon, Christopher P; Gibler, W Brian; Fintel, Dan J; Peterson, Eric D; Brown, David L

    2008-09-01

    Although current guidelines recommend early initiation of clopidogrel in patients with non-ST-segment elevation myocardial infarction (NSTEMI), the degree to which it has been adopted in clinical practice remains unclear. We sought to determine patterns of early (vs 9.5%, P = .90). Until recently, up to 50% of NSTEMI patients in contemporary practice in the United States not undergoing PCI within 24 hours of arrival in the United States are not treated according to guideline recommendations. Among a high-risk NSTEMI population not undergoing PCI within 24 hours of arrival, the nonrandomized short-term use of clopidogrel is associated with a lower risk of inhospital mortality without an increased risk of major bleeding.

  13. The role of clopidogrel in early and sustained arterial patency after fibrinolysis for ST-segment elevation myocardial infarction: the ECG CLARITY-TIMI 28 Study.

    Scirica, Benjamin M; Sabatine, Marc S; Morrow, David A; Gibson, C Michael; Murphy, Sabina A; Wiviott, Stephen D; Giugliano, Robert P; McCabe, Carolyn H; Cannon, Christopher P; Braunwald, Eugene

    2006-07-04

    This study was designed to determine the relationship between clopidogrel and early ST-segment resolution (STRes) and the interaction of the two with clinical outcomes after fibrinolysis. ST-segment resolution is an early noninvasive marker of coronary reperfusion. The CLARITY-TIMI 28 (Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction 28) trial randomized 3,491 patients with ST-segment elevation myocardial infarction (STEMI) undergoing fibrinolysis to clopidogrel versus placebo. ST-segment resolution was defined as complete (>70%), partial (30% to 70%), or none (STRes between the clopidogrel and placebo groups at 90 min (38.4% vs. 36.6% at 90 min). When patients were stratified by STRes category, treatment with clopidogrel resulted in greater benefit among those with evidence of early STRes, with greater odds of an open artery at late angiography in patients with partial (odds ratio [OR] 1.4, p = 0.04) or complete (OR 2.0, p STRes, but no improvement in those with no STRes at 90 min (OR 0.89, p = 0.48) (p for interaction = 0.003). Clopidogrel was also associated with a significant reduction in the odds of an in-hospital death or myocardial infarction in patients who achieved partial (OR 0.30, p = 0.003) or complete STRes at 90 min (OR 0.49, p = 0.056), whereas clinical benefit was not apparent in patients who had no STRes (OR 0.98, p = 0.95) (p for interaction = 0.027). By 30 days, the clinical benefit of clopidogrel was predominately seen in patients with complete STRes. Clopidogrel appears to improve late coronary patency and clinical outcomes by preventing reocclusion of open arteries rather than by facilitating early reperfusion.

  14. Benefit of Clopidogrel Therapy in Patients With Myocardial Infarction and Chronic Kidney Disease

    Blicher, Thalia Marie; Hommel, Kristine; Kristensen, Søren Lund

    2014-01-01

    to percutaneous coronary intervention (PCI) treatment.A total of 69 082 incident MI patients in the period 2002-2011 were included. Clopidogrel treatment was associated with hazard ratios (HRs) for the combined endpoint of all-cause mortality and recurrent MI in PCI-treated patients of 0.90 (95% confidence...... interval [CI], 0.47 to 1.72) in renal replacement therapy (RRT) patients, 0.59 (95% CI: 0.40 to 0.88) in non-end-stage CKD patients and 0.69 (95% CI, 0.61 to 0.77) in patients without kidney disease (P for interaction=0.60). In patients not treated with PCI, HRs were 0.90 (95% CI, 0.68 to 1.21) in RRT...

  15. Chromatographic determination of clopidogrel bisulfate; detection and quantification of counterfeit Plavix® tablets

    Mona E. ElTantawy

    2014-06-01

    Full Text Available Counterfeiting of pharmaceutical products is a global problem. Upon using quality-ensuring methods of international pharmacopoeias, additional impurities and the low content of the active pharmaceutical ingredients were detected. In this paper, two chromatographic HPLC and TLC-densitometric methods were proposed as fast and reliable methods for detection and quantitation of counterfeit Plavix® tablets. These tablets were chemically counterfeited by aspirin, its degradate salicylic acid and metronidazole which were separated, besides the active ingredient clopidogrel bisulfate, by the proposed methods. Also, counterfeit was in packaging, strips and tablets’ color and these could be seen by visual inspection compared to original drug. The proposed methods can easily differentiate genuine from counterfeited tablets without need of prior separation. The proposed methods were validated according to ICH guidelines and applied to eleven batches, also were compared statistically with the reported one.

  16. Effects of preoperative aspirin and clopidogrel therapy on perioperative blood loss and blood transfusion requirements in patients undergoing off-pump coronary artery bypass graft surgery.

    Shim, Jae Kwang; Choi, Yong Seon; Oh, Young Jun; Bang, Sou Ouk; Yoo, Kyung Jong; Kwak, Young Lan

    2007-07-01

    Preoperative exposure to clopidogrel and aspirin significantly increases postoperative bleeding in patients undergoing on-pump coronary artery bypass graft surgery. Off-pump coronary bypass grafting has been proposed as an alternative technique to attenuate postoperative bleeding associated with clopidogrel. This study aimed to determine the effects of aspirin and clopidogrel therapy on perioperative blood loss and blood transfusion requirements in off-pump coronary artery bypass grafting. One hundred six patients scheduled for off-pump coronary artery bypass grafting were divided into three groups: aspirin and clopidogrel discontinued more than 6 days before surgery (group 1, n = 35), aspirin and clopidogrel continued until 3 to 5 days before surgery (group 2, n = 51), and both medications continued within 2 days of surgery (group 3, n = 20). Thromboelastographic tracings were analyzed before induction of anesthesia. Routine coagulation profiles were measured before and after surgery. A cell salvage device was used during surgery and salvaged blood was reinfused. Chest tube drainage and blood transfusion requirement were recorded postoperatively. Patient characteristics, operative data, and thromboelastographic tracings were similar among the groups. There were significant decreases in hematocrit level and platelet count and prolongation in prothrombin time postoperatively in all groups without any intergroup differences. The amounts of perioperative blood loss and blood transfusion required were all similar among the groups. Preoperative clopidogrel and aspirin exposure even within 2 days of surgery does not increase perioperative blood loss and blood transfusion requirements in patients undergoing elective off-pump coronary artery bypass grafting.

  17. Duration of clopidogrel treatment and risk of mortality and recurrent myocardial infarction among 11 680 patients with myocardial infarction treated with percutaneous coronary intervention: a cohort study

    Køber Lars

    2010-01-01

    Full Text Available Abstract Background The optimal duration of clopidogrel treatment after percutaneous coronary intervention (PCI is unclear. We studied the risk of death or recurrent myocardial infarction (MI in relation to 6- and 12-months clopidogrel treatment among MI patients treated with PCI. Methods Using nationwide registers of hospitalizations and drug dispensing from pharmacies we identified 11 680 patients admitted with MI, treated with PCI and clopidogrel. Clopidogrel treatment was categorized in a 6-months and a 12-months regimen. Rates of death, recurrent MI or a combination of both were analyzed by the Kaplan Meier method and Cox proportional hazards models. Bleedings were compared between treatment regimens. Results The Kaplan Meier analysis indicated no benefit of the 12-months regimen compared with the 6-months in all endpoints. The Cox proportional hazards analysis confirmed these findings with hazard ratios for the 12-months regimen (the 6-months regimen used as reference for the composite endpoint of 1.01 (confidence intervals 0.81-1.26 and 1.24 (confidence intervals 0.95-1.62 for Day 0-179 and Day 180-540 after discharge. Bleedings occurred in 3.5% and 4.1% of the patients in the 6-months and 12-months regimen (p = 0.06. Conclusions We found comparable rates of death and recurrent MI in patients treated with 6- and 12-months' clopidogrel. The potential benefit of prolonged clopidogrel treatment in a real-life setting remains uncertain.

  18. A Cost-Effectiveness Analysis of Clopidogrel for Patients with Non-ST-Segment Elevation Acute Coronary Syndrome in China.

    Cui, Ming; Tu, Chen Chen; Chen, Er Zhen; Wang, Xiao Li; Tan, Seng Chuen; Chen, Can

    2016-09-01

    There are a number of economic evaluation studies of clopidogrel for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) published from the perspective of multiple countries in recent years. However, relevant research is quite limited in China. We aimed to estimate the long-term cost effectiveness for up to 1-year treatment with clopidogrel plus acetylsalicylic acid (ASA) versus ASA alone for NSTEACS from the public payer perspective in China. This analysis used a Markov model to simulate a cohort of patients for quality-adjusted life years (QALYs) gained and incremental cost for lifetime horizon. Based on the primary event rates, adherence rate, and mortality derived from the CURE trial, hazard functions obtained from published literature were used to extrapolate the overall survival to lifetime horizon. Resource utilization, hospitalization, medication costs, and utility values were estimated from official reports, published literature, and analysis of the patient-level insurance data in China. To assess the impact of parameters' uncertainty on cost-effectiveness results, one-way sensitivity analyses were undertaken for key parameters, and probabilistic sensitivity analysis (PSA) was conducted using the Monte Carlo simulation. The therapy of clopidogrel plus ASA is a cost-effective option in comparison with ASA alone for the treatment of NSTEACS in China, leading to 0.0548 life years (LYs) and 0.0518 QALYs gained per patient. From the public payer perspective in China, clopidogrel plus ASA is associated with an incremental cost of 43,340 China Yuan (CNY) per QALY gained and 41,030 CNY per LY gained (discounting at 3.5% per year). PSA results demonstrated that 88% of simulations were lower than the cost-effectiveness threshold of 150,721 CYN per QALY gained. Based on the one-way sensitivity analysis, results are most sensitive to price of clopidogrel, but remain well below this threshold. This analysis suggests that treatment with

  19. Systemic low-dose aspirin and clopidogrel independently attenuate reflex cutaneous vasodilation in middle-aged humans.

    Holowatz, Lacy A; Jennings, John D; Lang, James A; Kenney, W Larry

    2010-06-01

    Chronic systemic platelet cyclooxygenase (COX) inhibition with low-dose aspirin [acetylsalicylic acid (ASA)] significantly attenuates reflex cutaneous vasodilation in middle-aged humans, whereas acute, localized, nonisoform-specific inhibition of vascular COX with intradermal administration of ketorolac does not alter skin blood flow during hyperthermia. Taken together, these data suggest that platelets may be involved in reflex cutaneous vasodilation, and this response is inhibited with systemic pharmacological platelet inhibition. We hypothesized that, similar to ASA, specific platelet ADP receptor inhibition with clopidogrel would attenuate reflex vasodilation in middle-aged skin. In a double-blind crossover design, 10 subjects (53+/-2 yr) were instrumented with four microdialysis fibers for localized drug administration and heated to increase body core temperature [oral temperature (Tor)] 1 degrees C during no systemic drug (ND), and after 7 days of systemic ASA (81 mg) and clopidogrel (75 mg) treatment. Skin blood flow (SkBF) was measured using laser-Doppler flowmetry over each site assigned as 1) control, 2) nitric oxide synthase inhibited (NOS-I; 10 mM NG-nitro-L-arginine methyl ester), 3) COX inhibited (COX-I; 10 mM ketorolac), and 4) NOS-I+COX-I. Data were normalized and presented as a percentage of maximal cutaneous vascular conductance (%CVCmax; 28 mM sodium nitroprusside+local heating to 43 degrees C). During ND conditions, SkBF with change (Delta) in Tor=1.0 degrees C was 56+/-3% CVCmax. Systemic low-dose ASA and clopidogrel both attenuated reflex vasodilation (ASA: 43+/-3; clopidogrel: 32+/-3% CVCmax; both P0.05). NOS-I attenuated vasodilation in ND and ASA (ND: 28+/-6; ASA: 25+/-4% CVCmax; both P0.05). NOS-I+COX-I was not different compared with NOS-I alone in either systemic treatment condition. Both systemic ASA and clopidogrel reduced the time required to increase Tor 1 degrees C (ND: 58+/-3 vs. ASA: 45+/-2; clopidogrel: 39+/-2 min; both Preflex

  20. Cost-effectiveness of clopidogrel in myocardial infarction with ST-segment elevation: a European model based on the CLARITY and COMMIT trials.

    Berg, Jenny; Lindgren, Peter; Spiesser, Julie; Parry, David; Jönsson, Bengt

    2007-06-01

    Several health economic studies have shown that the use of clopidogrel is cost-effective to prevent ischemic events in non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina. This study was designed to assess the cost-effectiveness of clopidogrel in short- and long-term treatment of ST-segment elevation myocardial infarction (STEMI) with the use of data from 2 trials in Sweden, Germany, and France: CLARITY (Clopidogrel as Adjunctive Reperfusion Therapy) and COMMIT (Clopidogrel and Metoprolol in Myocardial Infarction Trial). A combined decision tree and Markov model was constructed. Because existing evidence indicates similar long-term outcomes after STEMI and NSTEMI, data from the long-term NSTEMI CURE trial (Clopidogrel in Unstable Angina to Prevent Recurrent Events) were combined with 1-month data from CLARITY and COMMIT to model the effect of treatment up to 1 year. The risks of death, myocardial infarction, and stroke in an untreated population and long-term survival after all events were derived from the Swedish Hospital Discharge and Cause of Death register. The model was run separately for the 2 STEMI trials. A payer perspective was chosen for the comparative analysis, focusing on direct medical costs. Costs were derived from published sources and were converted to 2005 euros. Effectiveness was measured as the number of life-years gained (LYG) from clopidogrel treatment. In a patient cohort with the same characteristics and event rates as in the CLARITY population, treatment with clopidogrel for up to 1 year resulted in 0.144 LYG. In Sweden and France, this strategy was dominant with estimated cost savings of euro 111 and euro 367, respectively. In Germany, clopidogrel treatment had an incremental cost-effectiveness ratio (ICER) of euro 92/LYG. Data from the COMMIT study showed that clopidogrel treatment resulted in 0.194 LYG at an incremental cost of euro 538 in Sweden, euro 798 in Germany, and euro 545 in France. The corresponding

  1. Cardiovascular outcomes associated with concomitant use of clopidogrel and proton pump inhibitors in patients with acute coronary syndrome in Taiwan

    Lin, Chen-Fang; Shen, Li-Jiuan; Wu, Fe-Lin Lin; Bai, Chyi-Huey; Gau, Churn-Shiouh

    2012-01-01

    AIMS Our study aimed to examine the impact of concomitant use of proton pump inhibitors (PPIs) with clopidogrel on the cardiovascular outcomes of patients with acute coronary syndrome (ACS). Furthermore, we sought to quantify the effects of five individual PPIs when used concomitantly with clopidogrel. METHODS We conducted a retrospective cohort study of patients who were newly hospitalized for ACS between 1 January 2006 and 31 December 2007 retrieved from the Taiwan National Health Insurance Research Database (NHIRD) and who were prescribed clopidogrel (n= 37 099) during the follow-up period. A propensity score technique was used to establish a matched cohort in 1:1 ratio (n= 5173 for each group). The primary clinical outcome was rehospitalization for ACS, while secondary outcomes were rehospitalization for percutaneous transluminal coronary angioplasty (PTCA) with stent, PTCA without stent and revascularization (PTCA or coronary artery bypass graft surgery) after the discharge date for the index ACS event. RESULTS The adjusted hazard ratio of rehospitalization for ACS was 1.052 (95% confidence interval, 0.971–1.139; P= 0.214) in the propensity score matched cohort. Among all PPIs, only omeprazole was found to be statistically significantly associated with an increased risk of rehospitalization for ACS (adjusted hazard ratio, 1.226; 95% confidence interval, 1.066–1.410; P= 0.004). Concomitant use of esomeprazole, pantoprazole, rabeprazole and lansoprazole did not increase the risk. CONCLUSIONS Our study indicated no statistically significant increase in the risk of rehospitalization for ACS due to concurrent use of clopidogrel and PPIs overall. Among individual PPIs, only omeprazole was found to be statistically significantly associated with increased risk of rehospitalization for ACS. PMID:22364155

  2. Prasugrel vs. clopidogrel in contemporary Western European patients with acute coronary syndromes receiving drug-eluting stents

    Wein, Bastian; Coslovsky, Michael; Jabbari, Reza

    2017-01-01

    BACKGROUND: Clinical and cost-effectiveness of prasugrel vs. clopidogrel in acute coronary syndrome (ACS) was only evaluated using TRITON-TIMI 38 event rates. A comparative analysis of both drugs in contemporary European ACS patients is lacking. METHODS: To address this issue, cardiac and bleedin......=0.255), but more major bleedings (4.0% vs. 1.7%, pexpenditures per patient: 1116.3 (DNK), 1063.5 (GER) and 880.8 (SUI) EURO, respectively. Accordingly, incremental cost...

  3. Ticagrelor versus clopidogrel in real-world patients with ST elevation myocardial infarction: 1-year results by propensity score analysis.

    Vercellino, Matteo; Sànchez, Federico Ariel; Boasi, Valentina; Perri, Dino; Tacchi, Chiara; Secco, Gioel Gabrio; Cattunar, Stefano; Pistis, Gianfranco; Mascelli, Giovanni

    2017-04-05

    European guidelines recommend the use of ticagrelor versus clopidogrel in patients with ST elevation myocardial infarction (STEMI). This recommendation is based on inconclusive results and subanalyses from clinical trials. Few data are available on the effects of ticagrelor in a real-world population. To compare the effects of ticagrelor and clopidogrel in a real-world STEMI population, we conducted a pre-post case-control study examining all patients with STEMI included in the Cardio-STEMI Sanremo registry between February 2011 and June 2013. Cases and controls were defined according to P2Y 12 inhibitors, correcting the bias due to lack of randomization by propensity score analysis. Ticagrelor was introduced in 2012 in both in-hospital and pre-hospital settings independently of this study. Of the 416 patients enrolled in the Cardio-STEMI registry, 401 with a definite diagnosis of STEMI were included in this study. One hundred forty-two patients received ticagrelor and 259 received clopidogrel. Regarding clinical presentation and procedural data, those in the ticagrelor group had lower CRUSADE scores (23 [14-36] vs 27 [18-38]; p = 0.015] but a higher proportion of radial access (33% vs 14%; p word propensity score analysis, ticagrelor did not affect the risk of MACE during the hospital phase, or the incidence of hospital bleeding in patients with STEMI. However, in this mono-centric experience, ticagrelor resulted in improved 1-year survival, even after correction by propensity score.

  4. Different effects of clopidogrel and clarithromycin on the enantioselective pharmacokinetics of sibutramine and its active metabolites in healthy subjects.

    Shinde, Dhananjay D; Kim, Ho-Sook; Choi, Jae-Seok; Pan, Wei; Bae, Soo Kyung; Yeo, Chang-Woo; Shon, Ji-Hong; Kim, Dong-Hyun; Shin, Jae Gook

    2013-05-01

    In this study, we assessed the effects of clopidogrel and clarithromycin, known CYP2B6 and CYP3A inhibitors, respectively, on the enantioselective disposition of racemic sibutramine in conjunction with CYP2B6 polymorphisms in humans. Sibutramine showed enantioselective plasma profiles with consistently higher concentrations of R-enantiomers. Clopidogrel and clarithromycin significantly increased the sibutramine plasma concentration, but their effects differed between enantiomers; a 2.2-fold versus 4.1-fold increase in the AUC in S-enantiomer and 1.8-fold versus 2.0-fold for the R-enantiomer, respectively. The AUCs of S- and R-desmethyl metabolites changed significantly during the clopidogrel phase (P sibutramine was higher in subjects with the CYP2B6*6/*6 genotype, but no statistical difference was observed among the CYP2B6 genotypes. These results suggest that the enantioselective disposition of sibutramine and its active metabolites are influenced by the altered genetic and environmental factors of CYP2B6 and CYP3A activity in vivo. © The Author(s) 2013.

  5. Effects of continuous administration of clopidogrel before off-pump coronary artery bypass grafting in patients with acute coronary syndrome. A propensity score analysis

    Song, Suk-Won; Youn, Young-Nam; Yi, Gijong; Lee, Sak; Yoo, Kyung-Jong

    2008-01-01

    Clopidogrel has become standard treatment after urgent percutaneous coronary revascularization. Due to its enhanced and irreversible platelet inhibition, patients undergoing urgent surgical revascularization have a higher risk of bleeding complications and transfusions. Therefore, the effect of preoperative continuous administration of clopidogrel on the incidence of hemorrhagic complications in patients undergoing off-pump coronary artery bypass surgery with acute coronary syndrome was evaluated. From March 2004 to September 2006, 172 patients with acute coronary syndrome underwent isolated off-pump coronary artery bypass surgery; 70 (40.7%) and 102 (59.3%) of these patients did or did not take clopidogrel before surgery respectively. Seventy patients in each group were matched using propensity scores and associations between preoperative continuous administration of clopidogrel and postoperative bleeding, hemostatic reoperation, blood products received, the need for multiple transfusions and early graft patency by coronary computed tomography were assessed. Univariate analysis showed the continuous clopidogrel group had similar levels of postoperative bleeding for 24 h (601.4±312.6 ml vs 637.2±452.4 ml, p=0.616) and rates of reexploration (1.4% vs 1.4%), perioperative blood transfusion (33.3% vs 34.3%, p>0.05) and platelet transfusion (2.9% vs 7.1%, p=0.44) compared with the non-continuous group. Preoperative continuous administration of clopidogrel did not increase the risk of hemorrhagic complications in patients with acute coronary syndrome undergoing isolated off-pump coronary artery bypass surgery. These findings indicate that surgery after clopidogrel treatment in patients with acute coronary syndrome should not be delayed until platelet function returns to normal because they may have a higher risk of recurrent myocardial ischemic events. (author)

  6. Clopidogrel in a combined therapy with anticancer drugs-effect on tumor growth, metastasis, and treatment toxicity: Studies in animal models.

    Agnieszka Denslow

    Full Text Available Clopidogrel, a thienopyridine derivative with antiplatelet activity, is widely prescribed for patients with cardiovascular diseases. In addition to antiplatelet activity, antiplatelet agents possess anticancer and antimetastatic properties. Contrary to this, results of some studies have suggested that the use of clopidogrel and other thienopyridines accelerates the progression of breast, colorectal, and prostate cancer. Therefore, in this study, we aimed to evaluate the efficacy of clopidogrel and various anticancer agents as a combined treatment using mouse models of breast, colorectal, and prostate cancer. Metastatic dissemination, selected parameters of platelet morphology and biochemistry, as well as angiogenesis were assessed. In addition, body weight, blood morphology, and biochemistry were evaluated to test toxicity of the studied compounds. According to the results, clopidogrel increased antitumor and/or antimetastatic activity of chemotherapeutics such as 5-fluorouracil, cyclophosphamide, and mitoxantrone, whereas it decreased the anticancer activity of doxorubicin, cisplatin, and tamoxifen. The mechanisms of such divergent activities may be based on the modulation of tumor vasculature via factors, such as transforming growth factor β1 released from platelets. Moreover, clopidogrel increased the toxicity of docetaxel and protected against mitoxantrone-induced toxicity, which may be due to the modulation of hepatic enzymes and protection of the vasculature, respectively. These results demonstrate that antiplatelet agents can be useful but also dangerous in anticancer treatment and therefore use of thienopyridines in patients undergoing chemotherapy should be carefully evaluated.

  7. VKORC1-1639G>A, CYP2C9, EPHX1691A>G genotype, body weight, and age are important predictors for warfarin maintenance doses in patients with mechanical heart valve prostheses in southwest China.

    Gu, Qiang; Kong, Yan; Schneede, Jörn; Xiao, Ying-Bin; Chen, Lin; Zhong, Qian-Jin; Wang, Xue-Feng; Hao, Jia; Chen, Bai-Cheng; Chen, Jing-Jin

    2010-12-01

    To investigate the contribution of genetic polymorphisms of vitamin K epoxide reductase complex subunit 1 gene VKORC1-1639G>A, cytochrome P450 2C9 gene (CYP2C9), EPHXI, and clinical factors to warfarin sensitivity in southwest Chinese Han patients with mechanical heart valve prostheses. A total of 127 patients with mechanical heart valve prostheses who have been followed up at our department during the past 23 years were enrolled in this study and compared to a control group that consisted of 133 randomly selected healthy blood donors. These Chinese patients met stable warfarin dosage requirements and had reached the target international normalized ratio (INR) of 1.5-2.0. PCR and direct sequencing were carried out to identify the polymorphisms of VKORC1-1639G>A (rs9923231), CYP2C9*3 (rs1057910), CYP2C9 IVS3-65G>C (rs9332127), and EPHX1691A>G (rs4653436). In addition, total and free (non-protein-bound) warfarin concentrations were analyzed. There were great interindividual differences in warfarin maintenance dosage (ranging from 0.6 to 8.4 mg/day) among the 127 patients with mechanical heart valve prostheses. VKORC1-1639G>A, CYP2C9, EPHX1691A>G polymorphism, body weight, and age were found to affect the dose demands. Multiple linear regression models incorporating genetic polymorphisms of VKORC1, CYP2C9, EPHX1691A>G, and the nongenetic factors of age and body weight were developed, and explained up to 76.8% of the total variation (adjusted R (2) of 0.743) in warfarin maintenance doses in southwest Chinese patients with mechanical heart valve prostheses.

  8. THE ROLE OF CLOPIDOGREL IN PATIENTS WITH ACUTE CORONARY SYNDROME AFTER THE EMERGENCE OF MORE POWERFUL INHIBITORS OF P2Y12 RECEPTOR

    S. R. Gilyarevsky

    2014-07-01

    Full Text Available The role of P2Y12 receptor blocker clopidogrel after the introduction into clinical practice of new, more powerful and stable operating drugs belonging to this class of antiplatelet agents is discussed. The advantages and disadvantages of each of the currently used antiplatelet drugs that block the receptor P2Y12 are reviewed. On the basis of the analysis concludes that, despite the emergence of new antiplatelet agents clopidogrel, appears to be widely used for a long time in the treatment of patients with acute coronary syndrome and / or after coronary stenting. This is primarily due to the presence of large evidence base, and confirmation of safety of long-term therapy clopidogrel.

  9. A randomized, 2-period, crossover design study to assess the effects of dexlansoprazole, lansoprazole, esomeprazole, and omeprazole on the steady-state pharmacokinetics and pharmacodynamics of clopidogrel in healthy volunteers.

    Frelinger, Andrew L; Lee, Ronald D; Mulford, Darcy J; Wu, Jingtao; Nudurupati, Sai; Nigam, Anu; Brooks, Julie K; Bhatt, Deepak L; Michelson, Alan D

    2012-04-03

    The aim of this study was to assess the effects of different proton pump inhibitors (PPIs) on the steady-state pharmacokinetics and pharmacodynamics of clopidogrel. Metabolism of clopidogrel requires cytochrome P450s (CYPs), including CYP2C19. However, PPIs may inhibit CYP2C19, potentially reducing the effectiveness of clopidogrel. A randomized, open-label, 2-period, crossover study of healthy subjects (n = 160, age 18 to 55 years, homozygous for CYP2C19 extensive metabolizer genotype, confined, standardized diet) was conducted. Clopidogrel 75 mg with or without a PPI (dexlansoprazole 60 mg, lansoprazole 30 mg, esomeprazole 40 mg, or, as a positive control to maximize potential interaction and demonstrate assay sensitivity, omeprazole 80 mg) was given daily for 9 days. Pharmacokinetics and pharmacodynamics were assessed on days 9 and 10. Pharmacodynamic end-points were vasodilator-stimulated phosphoprotein P2Y(12) platelet reactivity index, maximal platelet aggregation to 5 and 20 μmol/l adenosine diphosphate, and VerifyNow P2Y12 platelet response units. Pharmacokinetic and pharmacodynamic responses with omeprazole demonstrated assay sensitivity. The area under the curve for clopidogrel active metabolite decreased significantly with esomeprazole but not with dexlansoprazole or lansoprazole. Similarly, esomeprazole but not dexlansoprazole or lansoprazole significantly reduced the effect of clopidogrel on vasodilator-stimulated phosphoprotein platelet reactivity index. All PPIs decreased the peak plasma concentration of clopidogrel active metabolite (omeprazole > esomeprazole > lansoprazole > dexlansoprazole) and showed a corresponding order of potency for effects on maximal platelet aggregation and platelet response units. Generation of clopidogrel active metabolite and inhibition of platelet function were reduced less by the coadministration of dexlansoprazole or lansoprazole with clopidogrel than by the coadministration of esomeprazole or omeprazole. These

  10. Aspirin Versus Aspirin Plus Clopidogrel as Antithrombotic Treatment Following Transcatheter Aortic Valve Replacement With a Balloon-Expandable Valve: The ARTE (Aspirin Versus Aspirin + Clopidogrel Following Transcatheter Aortic Valve Implantation) Randomized Clinical Trial.

    Rodés-Cabau, Josep; Masson, Jean-Bernard; Welsh, Robert C; Garcia Del Blanco, Bruno; Pelletier, Marc; Webb, John G; Al-Qoofi, Faisal; Généreux, Philippe; Maluenda, Gabriel; Thoenes, Martin; Paradis, Jean-Michel; Chamandi, Chekrallah; Serra, Vicenç; Dumont, Eric; Côté, Mélanie

    2017-07-10

    The aim of this study was to compare aspirin plus clopidogrel with aspirin alone as antithrombotic treatment following transcatheter aortic valve replacement (TAVR) for the prevention of ischemic events, bleeding events, and death. Few data exist on the optimal antithrombotic therapy following TAVR. This was a randomized controlled trial comparing aspirin (80 to 100 mg/day) plus clopidogrel (75 mg/day) (dual antiplatelet therapy [DAPT]) versus aspirin alone (single-antiplatelet therapy [SAPT]) in patients undergoing TAVR with a balloon-expandable valve. The primary endpoint was the occurrence of death, myocardial infarction (MI), stroke or transient ischemic attack, or major or life-threatening bleeding (according to Valve Academic Research Consortium 2 definitions) within the 3 months following the procedure. The trial was prematurely stopped after the inclusion of 74% of the planned study population. A total of 222 patients were included, 111 allocated to DAPT and 111 to SAPT. The composite of death, MI, stroke or transient ischemic attack, or major or life-threatening bleeding tended to occur more frequently in the DAPT group (15.3% vs. 7.2%, p = 0.065). There were no differences between groups in the occurrence of death (DAPT, 6.3%; SAPT, 3.6%; p = 0.37), MI (DAPT, 3.6%; SAT, 0.9%; p = 0.18), or stroke or transient ischemic attack (DAPT, 2.7%; SAPT, 0.9%; p = 0.31) at 3 months. DAPT was associated with a higher rate of major or life-threatening bleeding events (10.8% vs. 3.6% in the SAPT group, p = 0.038). There were no differences between groups in valve hemodynamic status post-TAVR. This small trial showed that SAPT (vs. DAPT) tended to reduce the occurrence of major adverse events following TAVR. SAPT reduced the risk for major or life-threatening events while not increasing the risk for MI or stroke. Larger studies are needed to confirm these results. (Aspirin Versus Aspirin + Clopidogrel Following Transcatheter Aortic Valve Implantation: The ARTE

  11. Implementation of Cell Samples as Controls in National Proficiency Testing for Clopidogrel Therapy-Related CYP2C19 Genotyping in China: A Novel Approach.

    Guigao Lin

    Full Text Available Laboratories are increasingly requested to perform CYP2C19 genetic testing when managing clopidogrel therapy, especially in patients with acute coronary syndrome undergoing percutaneous coronary intervention. To ensure high quality molecular testing and ascertain that the referring clinician has the correct information for CYP2C19 genotype-directed antiplatelet therapy, a proficiency testing scheme was set up to evaluate the laboratory performance for the entire testing process. Proficiency panels of 10 cell samples encompassing the common CYP2C19 genetic polymorphisms were distributed to 62 participating laboratories for routine molecular testing and the responses were analyzed for accuracy of genotyping and the reporting of results. Data including the number of samples tested, the accreditation/certification status, and test methodology of each individual laboratory were also reviewed. Fifty-seven of the 62 participants correctly identified the CYP2C19 variants in all samples. There were six genotyping errors, with a corresponding analytical sensitivity of 98.5% (333/338 challenges; 95% confidence interval: 96.5-99.5% and an analytic specificity of 99.6% (281/282; 95% confidence interval: 98.0-99.9%. Reports of the CYP2C19 genotyping results often lacked essential information. In conclusion, clinical laboratories demonstrated good analytical sensitivity and specificity; however, the pharmacogenetic testing community requires additional education regarding the correct reporting of CYP2C19 genetic test results.

  12. Early clinical outcomes as a function of use of newer oral P2Y inhibitors versus clopidogrel in the EUROMAX trial

    Huber, Kurt; Ducrocq, Gregory; Hamm, Christian W

    2017-01-01

    prehospital bivalirudin with heparin with optional glycoprotein IIb/IIIa inhibitor treatment in patients with ST-segment elevation myocardial infarction triaged to pPCI. Choice of P2Y12 inhibitor was at the investigator's discretion. In a prespecified analysis, we compared event rates with clopidogrel....... Logistic regression was used to adjust for differences in baseline characteristics. Results: Prasugrel or ticagrelor was given as the loading P2Y12 inhibitor in 49% of 2198 patients and as a maintenance therapy in 59%. No differences were observed in rates of acute stent thrombosis for clopidogrel versus...

  13. Clopidogrel (Plavix®), a P2Y(12) receptor antagonist, inhibits bone cell function in vitro and decreases trabecular bone in vivo

    Syberg, Susanne; Brandao-Burch, Andrea; Patel, Jessal J

    2012-01-01

    Clopidogrel (Plavix®), a selective P2Y(12) receptor antagonist, is widely prescribed to reduce the risk of heart attack and stroke and acts via the inhibition of platelet aggregation. Accumulating evidence now suggests that extracellular nucleotides, signalling through P2 receptors, play...... a significant role in bone, modulating both osteoblast and osteoclast function. In this study, we investigated the effects of clopidogrel treatment on (1) bone cell formation, differentiation and activity in vitro; and, (2) trabecular and cortical bone parameters in vivo. P2Y(12) receptor expression...

  14. Traditional clinical risk factors predict clopidogrel hypo-responsiveness in unselected patients undergoing non-emergent percutaneous coronary intervention

    Ratcovich, Hanna; Holmvang, Lene; Johansson, Pär Inge

    2016-01-01

    patients with HPR and LPR. Nine hundred and twenty-three consecutive patients undergoing non-emergent PCI were enrolled. Platelet reactivity (PR) was determined using Multiplate assays. Patients were grouped into quintiles based on their PR values. Upper and lower quintiles defined HPR and LPR......, respectively, whereas quintiles 2-4 defined normal responders. All patients were assigned PREDICT score points in clinical categories (age > 65, reduced left ventricular function, reduced kidney function, acute coronary syndrome (ACS) and diabetes). We found an association between the cumulative number...... of PREDICT score variables and the incidence of HPR for clopidogrel (HPR (ADP)) (p 

  15. Influence of microenvironment pH, humidity, and temperature on the stability of polymorphic and amorphous forms of clopidogrel bisulfate

    Raijada, Dhara K; Singh, Saranjit; Bansal, Arvind K

    2010-01-01

    The effect of microenvironment pH, humidity, and temperature was evaluated on the stability of polymorphic and amorphous forms of clopidogrel bisulfate, when present alone or in combinations. Oxalic acid and sodium carbonate were used as solid stressors to create acidic and alkaline p...... more degradation than the individual forms above critical relative humidity (85% RH). Similar higher degradation was observed between 75% RH and 85% RH in case of acid-stressed samples. In alkaline microenvironment, all the samples showed identical decomposition attributed to conversion of bisulfate...

  16. Ticagrelor, but not clopidogrel active metabolite, displays antithrombotic properties in the left atrial endocardium.

    Reiner, Martin F; Breitenstein, Alexander; Holy, Erik W; Glanzmann, Martina; Amstalden, Heidi; Stämpfli, Simon F; Bonetti, Nicole R; Falk, Volkmar; Keller, Stephan; Savarese, Gianluigi; Benussi, Stefano; Maisano, Francesco; Lüscher, Thomas F; Beer, Jürg H; Steffel, Jan; Camici, Giovanni G

    2017-03-21

    Oral anticoagulation is considered standard therapy for stroke prevention in atrial fibrillation (AF). Endocardial activation triggers expression of pro-thrombotic mediators including tissue factor (TF) and plasminogen activator inhibitor-1 (PAI-1), and contributes to thrombus formation in the left atrial appendage (LAA) of AF patients. Recently, pleiotropic effects of specific P2Y12 receptor antagonists were demonstrated; however, whether these drugs possess antithrombotic effects on LAA endocardial cells currently remains unknown. LAA were obtained from 14 patients with known AF undergoing elective cardiac surgery including LAA removal at the University Hospital Zurich. LAA endocardial cells were isolated and pre-incubated with ticagrelor (10-7, 10-6, 10-5M) or clopidogrel active metabolite (CAM) (1.5 × 10-8, 1.5 × 10-7, 1.5 × 10-6 M) before stimulation with tumour necrosis factor-alpha (TNF-α) (10 ng/mL). Finally, TF and PAI-1 expression and activity were analysed. Ticagrelor, unlike CAM, concentration dependently decreased TNF-α-induced TF expression and TF activity in LAA endocardial cells. Further, ticagrelor, but not CAM reduced PAI-1 expression and enzyme activity in TNF-α-stimulated LAA endocardial cells. In contrast, TF pathway inhibitor (TFPI) remained unaffected by both dugs. Ticagrelor, but not CAM, reduces expression and activity of TF and PAI-1 in LAA endocardial cells isolated from patients with AF, indicating possible local antithrombotic effects. Such pleiotropic properties of ticagrelor may contribute to a reduction in thromboembolic complications in patients with AF. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

  17. CYP2C19 and PON1 polymorphisms regulating clopidogrel bioactivation in Chinese, Malay and Indian subjects.

    Chan, Mark Y; Tan, Karen; Tan, Huay-Cheem; Huan, Pei-Tee; Li, Bei; Phua, Qian-Hui; Lee, Hong-Kai; Lee, Chi-Hang; Low, Adrian; Becker, Richard C; Ong, Wen-Chong; Richards, Mark A; Salim, Agus; Tai, E-Shyong; Koay, Evelyn

    2012-04-01

    AIM, MATERIALS & METHODS: We investigated the functional significance of CYP2C19*2, *3, *17 and PON1 Q192R SNPs in 89 consecutive Asian patients on clopidogrel treatment and the prevalence of functionally significant polymorphisms among 300 Chinese, Malays and Asian Indians. Both CYP2C19 loss-of-function alleles (*2 or *3) were associated with higher platelet reactivity while the CYP2C19 gain-of-function allele (*17) had lower platelet reactivity. For PON1, the median PRI was not significantly different between the QQ, QR and RR groups. The allele frequencies of CYP2C19*2, CYP2C19*3 and CYP2C19*17 were 0.280, 0.065 and 0.010 (rare) for Chinese, 0.310, 0.050 and 0.025 for Malays, and 0.375, 0.010 (rare) and 0.165 for Indians, respectively. Our data suggest that genotyping studies to investigate clopidogrel response should include CYP2C19*2 and *3 but not *17 polymorphisms in Chinese, and CYP2C19*2 and *17 polymorphisms but not *3 in Indians. All three polymorphisms should preferably be genotyped in Malays.

  18. Identificación de dos formas polimórficas cristalinas de clopidogrel bisulfato en materia prima farmacéutica

    German Leonardo Madrigal Redondo

    Full Text Available Introducción: el clopidogrel bisulfato existe en numerosas formas cristalinas, que varían en su estabilidad fisicoquímica, por lo que algunas de estas formas, patentadas o no, son útiles en la fabricación de medicamentos. Objetivo: identificar las formas cristalinas existentes en dos muestras de clopidogrel bisulfato materia prima comercializadas para la fabricación de medicamentos y el estado de pureza de ambas muestras. Métodos: las muestras de materia prima se obtuvieron de una industria nacional. Se examinaron mediante técnicas analíticas avanzadas como difracción de rayos X, calorimetría diferencial de barrido, termogravimetría y espectroscopia infrarroja. Se compararon los valores encontrados con los del estado del arte reconocidos en la literatura revisada para el clopidogrel bisulfato materias primas y tomados como referencia. Resultados: se obtuvieron los difractogramas, termogramas y espectros de absorción correspondientes a las muestras analizadas. Se utilizó el software TA Universal Analysis para obtener el porcentaje de descomposición, punto de fusión y picos identificadores en las muestras. Conclusiones: la muestra 1 contiene la forma cristalina I del bisulfato de clopidogrel, que no es pura ya que existe una banda característica de la presencia de contaminación con la forma cristalina II. La muestra 2 corresponde a la forma cristalina II del producto en forma pura.

  19. Polymorphisms of MDR1, CYP2C19 and P2Y12 genes in Indian population: Effects on clopidogrel response

    Kavita K. Shalia

    2013-03-01

    Conclusion: The present study did show a trend toward impaired response of clopidogrel to inhibit platelet aggregation with variant genotypes of CYP2C19*2 and iT744C of P2Y12 compared to respective wild type genotype at 24 h.

  20. Ticlopidine-, clopidogrel-, and prasugrel-associated thrombotic thrombocytopenic purpura: a 20-year review from the Southern Network on Adverse Reactions (SONAR).

    Jacob, Sony; Dunn, Brianne L; Qureshi, Zaina P; Bandarenko, Nicholas; Kwaan, Hau C; Pandey, Dilip K; McKoy, June M; Barnato, Sara E; Winters, Jeffrey L; Cursio, John F; Weiss, Ivy; Raife, Thomas J; Carey, Patricia M; Sarode, Ravindra; Kiss, Joseph E; Danielson, Constance; Ortel, Thomas L; Clark, William F; Rock, Gail; Matsumoto, Masanori; Fujimura, Yoshihiro; Zheng, X Long; Chen, Hao; Chen, Fei; Armstrong, John M; Raisch, Dennis W; Bennett, Charles L

    2012-11-01

    Thienopyridine-derivatives (ticlopidine, clopidogrel, and prasugrel) are the primary antiplatelet agents. Thrombotic thrombocytopenic purpura (TTP) is a rare drug-associated syndrome, with the thienopyridines being the most common drugs implicated in this syndrome. We reviewed 20 years of information on clinical, epidemiologic, and laboratory findings for thienopyridine-associated TTP. Four, 11, and 11 cases of thienopyridine-associated TTP were reported in the first year of marketing of ticlopidine (1989), clopidogrel (1998), and prasugrel (2010), respectively. As of 2011, the FDA received reports of 97 ticlopidine-, 197 clopidogrel-, and 14 prasugrel-associated TTP cases. Severe deficiency of ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) was present in 80% and antibodies to 100% of these TTP patients on ticlopidine, 0% of the patients with clopidogrel-associated TTP (p < 0.05), and an unknown percentage of patients with prasugrel-associated TTP. TTP is associated with use of each of the three thienopyridines, although the mechanistic pathways may differ. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

  1. Latin American Clinical Epidemiology Network Series - Paper 8: Ticagrelor was cost-effective vs. clopidogrel in acute coronary syndrome in Chile.

    De la Puente, Catherine; Vallejos, Carlos; Bustos, Luis; Zaror, Carlos; Velasquez, Monica; Lanas, Fernando

    2017-06-01

    To evaluate the incremental cost-effectiveness ratio (ICER) of the use of ticagrelor as a substitute for clopidogrel for secondary prevention of acute coronary syndrome in Chile. Cost-effectiveness analysis based on a Markov model: Safety and effectiveness data of ticagrelor were obtained from a systematic review of the literature. Costs are expressed in Chilean pesos (CLP) as of 2013. The evaluation was conducted from the payer standpoint. A probabilistic sensitivity analysis comprising discount rates and national cost variability was done. A budget impact analysis estimated for 2015 was conducted to calculate the total cost for both treatments. The ICER with a discount rate of 6% for ticagrelor vs. clopidogrel was CLP 4,893,126 per quality-adjusted life-year (QALY) gained (=9,689 US$). In the budget impact analysis for the baseline scenario, considering 100% of treatment, coverage, and adherence, ticagrelor represented an additional cost of CLP 5,233,854,272, for 979 QALYs gained compared with clopidogrel. Ticagrelor is cost-effective in comparison with clopidogrel for the secondary prevention of acute coronary syndrome. These findings are similar to those reported in other international cost-effectiveness studies. Copyright © 2016 Elsevier Inc. All rights reserved.

  2. Concomitant use of proton pump inhibitors and clopidogrel in patients with coronary, cerebrovascular, or peripheral artery disease in the factores de Riesgo y ENfermedad Arterial (FRENA) registry.

    Muñoz-Torrero, Juan Francisco Sánchez; Escudero, Domingo; Suárez, Carmen; Sanclemente, Carmen; Pascual, Ma Teresa; Zamorano, José; Trujillo-Santos, Javier; Monreal, Manuel

    2011-01-01

    Among patients receiving clopidogrel for coronary artery disease, concomitant therapy with proton pump inhibitors (PPIs) has been associated with an increased risk for recurrent coronary events. Factores de Riesgo y ENfermedad Arterial (FRENA) is an ongoing, multicenter, observational registry of consecutive outpatients with coronary artery disease, cerebrovascular disease, or peripheral artery disease. We retrospectively examined the influence of concomitant use of PPIs on outcome in patients receiving clopidogrel. As of March 2009, 1222 patients were using clopidogrel: 595 had coronary artery disease, 329 cerebrovascular disease, and 298 had peripheral artery disease. Of these, 519 (42%) were concomitantly using PPIs. Over a mean follow-up of 15 months, 131 patients (11%) had 139 subsequent ischemic events: myocardial infarction 44, ischemic stroke 40, and critical limb ischemia 55. Seventeen of them (13%) died within 15 days of the subsequent event. PPI users had a higher incidence of myocardial infarction (rate ratio, 2.5; 95% confidence interval [CI], 1.3-4.8), ischemic stroke (rate ratio, 1.9; 95% CI, 1.03-3.7), and a nonsignificantly higher rate of critical limb ischemia (rate ratio, 1.6; 95% CI, 0.95-2.8) than nonusers. On multivariate analysis, concomitant use of clopidogrel and PPIs was independently associated with an increased risk for subsequent ischemic events both in the whole series of patients (hazard ratio, 1.8; 95% CI, 1.1-2.7) and in those with cerebrovascular disease or peripheral artery disease (hazard ratio, 1.5; 95% CI, 1.01-2.4). In patients with established arterial disease, concomitant use of PPIs and clopidogrel was associated with a nearly doubling of the incidence of subsequent myocardial infarction or ischemic stroke. This higher incidence persisted after multivariate adjustment.

  3. A validated HPLC-MS/MS assay for quantifying unstable pharmacologically active metabolites of clopidogrel in human plasma: application to a clinical pharmacokinetic study.

    Furlong, Michael T; Savant, Ishani; Yuan, Moucun; Scott, Laura; Mylott, William; Mariannino, Thomas; Kadiyala, Pathanjali; Roongta, Vikram; Arnold, Mark E

    2013-05-01

    Clopidogrel is prescribed for the treatment of Acute Coronary Syndrome and recent myocardial infarction, recent stroke, or established peripheral arterial disease. A sensitive and reliable high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) assay was developed and validated to enable reliable quantification of four diastereomeric and chemically reactive thiol metabolites, two of which are pharmacologically active, in human plasma. The metabolites were stabilized by alkylation of their reactive thiol moieties with 2-bromo-3'-methoxyacetophenone (MPB). Following organic solvent mediated-protein precipitation in a 96-well plate format, chromatographic separation was achieved by gradient elution on an Ascentis Express RP-amide column. Chromatographic conditions were optimized to ensure separation of the four derivatized active metabolites. Derivatized metabolites and stable isotope-labeled internal standards were detected by positive ion electrospray tandem mass spectrometry. The HPLC-MS/MS assay was validated over concentration ranges of 0.125-125 ng/mL for metabolites H1-H3 and 0.101-101 ng/mL for H4. Intra- and inter-assay precision values for replicate quality control samples were within 14.3% for all analytes during the assay validation. Mean quality control accuracy values were within ±6.3% of nominal values for all analytes. Assay recoveries were high (>79%). The four derivatized analytes were stable in human blood for at least 2 h at room temperature and on ice. The analytes were also stable in human plasma for at least 25 h at room temperature, 372 days at -20 °C and -70 °C, and following at least five freeze-thaw cycles. The validated assay was successfully applied to the quantification of all four thiol metabolites in human plasma in support of a human pharmacokinetic study. Copyright © 2013 Elsevier B.V. All rights reserved.

  4. Evaluación económica del tratamiento con ácido acetilsalicílico más esomeprazol comparado con clopidogrel en la prevención de la hemorragia gastrointestinal Economic evaluation of the treatment of aspirin plus esomeprazole compared to clopidogrel in gastrointestinal bleeding prevention

    Carme Piñol

    2006-02-01

    Full Text Available Objetivo: Evaluar la eficiencia del ácido acetilsalicílico (AAS más esomeprazol frente a clopidogrel en la prevención de la hemorragia gastrointestinal. Métodos: Análisis coste-efectividad (árbol de decisión de 2 ramas: AAS más esomeprazol y clopidogrel respecto a la evitación de casos de hemorragia gastrointestinal en 2 años, y análisis de sensibilidad. Resultados: El coste total del tratamiento con AAS más esomeprazol (2.865 S por paciente libre de hemorragia fue inferior al clopidogrel (2.965 S. El tratamiento con AAS resultó dominante. En todos los análisis de sensibilidad la combinación siguió siendo dominante. Al sustituir esomeprazol 40 mg por omeprazol 40 mg, el coste del tratamiento combinado descendió hasta 1.934S/por episodio evitado. Conclusiones: La asociación de esomeprazol y AAS es más coste-efectiva que clopidogrel en la prevención de la hemorragia gastrointestinal. La combinación con omeprazol resulta aún más coste-efectiva.Objective: To evaluate the use of aspirin plus esomeprazole vs. clopidogrel in the prevention of gastrointestinal bleeding. Methods: We performed a cost-effectiveness analysis (two-branch decision tree: aspirin plus esomeprazole or clopidogrel of prevention of gastrointestinal bleeding over a 2-year period, as well as sensitivity analyses. Results: The total cost of aspirin plus esomeprazole treatment (2,865S/patient free of hemorrhage was lower than that of clopidogrel (2,965S. Aspirin treatment was dominant. The combination continued to be dominant in all sensitivity analyses. When esomeprazole 40 mg was substituted by omeprazole 40 mg, the cost of combination therapy decreased to 1,934 S/prevented hemorrhage. Conclusions: The association of esomeprazole and aspirin is more cost-effective than clopidogrel in preventing gastrointestinal bleeding. Aspirin plus omeprazole was even more cost-effective.

  5. Safety, tolerability, and initial efficacy of AZD6140, the first reversible oral adenosine diphosphate receptor antagonist, compared with clopidogrel, in patients with non-ST-segment elevation acute coronary syndrome: primary results of the DISPERSE-2 trial

    Cannon, Christopher P; Husted, Steen; Harrington, Robert A

    2007-01-01

    , or clopidogrel 300-mg loading dose plus 75 mg once daily for up to 12 weeks. RESULTS: The primary end point, the Kaplan-Meier rate of major or minor bleeding through 4 weeks, was 8.1% in the clopidogrel group, 9.8% in the AZD6140 90-mg group, and 8.0% in the AZD6140 180-mg group (p = 0.43 and p = 0.......96, respectively, vs. clopidogrel); the major bleeding rates were 6.9%, 7.1%, and 5.1%, respectively (p = 0.91 and p = 0.35, respectively, vs. clopidogrel). Although not statistically significant, favorable trends were seen in the Kaplan-Meier rates of myocardial infarction (MI) over the entire study period (MI: 5...

  6. Prasugrel compared to clopidogrel in patients with acute coronary syndrome undergoing percutenaous coronary intervention: a Spanish model-based cost effectiveness analysis.

    Davies, A; Sculpher, M; Barrett, A; Huete, T; Sacristán, J A; Dilla, T

    2013-01-01

    To assess the long-term cost-effectiveness of 12 months treatment of prasugrel compared to clopidogrel in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) in the Spanish health care system. A Markov state transition model was developed to estimate health outcomes, quality adjusted life years (QALYs), life years (LY), and costs over patients' lifetimes. Clinical inputs were based on an analysis of the TRITON-TIMI 38 clinical trial. Hospital readmissions captured during the trial in a sub-study of patients from eight countries (and subsequent re-hospitalisations modelled to accrue beyond the time horizon of the trial), were assigned to Spanish diagnosis-related group payment schedules to estimate hospitalisation costs. Mean total treatment costs were ?11,427 and ?10,910 for prasugrel and clopidogrel respectively. The mean cost of the study drug was ?538 higher for prasugrel vs. clopidogrel, but rehospitalisation costs at 12 months were ?79 lower for prasugrel due to reduced rates of revascularisation. Hospitalisation costs beyond 12 months were higher with prasugrel by ?55, due to longer life expectancy (+0.071 LY and +0.054 QALYs) associated with the decreased nonfatal myocardial infarction rate in the prasugrel group. The incremental cost per life year and QALY gained with prasugrel was ?7,198, and ?9,489, respectively. Considering a willingness-to-pay threshold of ?30,000/QALY gained in the Spanish setting, prasugrel represents a cost-effective option in comparison with clopidogrel among patients with ACS undergoing PCI. Copyright © 2013 SEFH. Published by AULA MEDICA. All rights reserved.

  7. Bleeding tendency in dual antiplatelet therapy with aspirin/clopidogrel: rescue of the template bleeding time in a single-center prospective study

    Altman Raul

    2012-01-01

    Full Text Available Abstract Background Patients with heightened platelet reactivity in response to antiplatelet agents are at an increased risk of recurrent ischemic events. However, there is a lack of diagnostic criteria for increased response to combined aspirin/clopidogrel therapy. The challenge is to identify patients at risk of bleeding. This study sought to characterize bleeding tendency in patients treated with aspirin and clopidogrel. Patients/methods In a single-center prospective study, 100 patients under long-term aspirin/clopidogrel treatment, the effect of therapy was assayed by template bleeding time (BT and the inhibition of platelet aggregation (IPA by light transmission aggregometry (LTA. Arachidonic acid (0.625 mmol/L and adenosine diphosphate (ADP; 2, 4, and 8 μmol/L were used as platelet agonists. Results Bleeding episodes (28 nuisance, 2 hematuria [1 severe], 1 severe proctorrhagia, 1 severe epistaxis were significantly more frequent in patients with longer BT. Template BT ≥ 24 min was associated with bleeding episodes (28 of 32. Risk of bleeding increased 17.4% for each 1 min increase in BT. Correlation was found between BT and IPAmax in response to ADP 2 μmol/L but not to ADP 4 or 8 μmol/L. Conclusion In patients treated with dual aspirin/clopidogrel therapy, nuisance and internal bleeding were significantly associated with template BT and with IPAmax in response to ADP 2 μmol/L but not in response to ADP 4 μmol/L or 8 μmol/L.

  8. Development and Validation of an HPLC Method for Simultaneous Quantification of Clopidogrel Bisulfate, Its Carboxylic Acid Metabolite, and Atorvastatin in Human Plasma: Application to a Pharmacokinetic Study

    Octavian Croitoru

    2015-01-01

    Full Text Available A simple, sensitive, and specific reversed phase liquid chromatographic method was developed and validated for simultaneous quantification of clopidogrel, its carboxylic acid metabolite, and atorvastatin in human serum. Plasma samples were deproteinized with acetonitrile and ibuprofen was chosen as internal standard. Chromatographic separation was performed on an BDS Hypersil C18 column (250 × 4.6 mm; 5 μm via gradient elution with mobile phase consisting of 10 mM phosphoric acid (sodium buffer solution (pH = 2.6 adjusted with 85% orthophosphoric acid : acetonitrile : methanol with flow rate of 1 mL·min−1. Detection was achieved with PDA detector at 220 nm. The method was validated in terms of linearity, sensitivity, precision, accuracy, limit of quantification, and stability tests. Calibration curves of the analytes were found to be linear in the range of 0.008–2 μg·mL−1 for clopidogrel, 0.01–4 μg·mL−1 for its carboxylic acid metabolite, and 0.005–2.5 μg·mL−1 for atorvastatin. The results of accuracy (as recovery with ibuprofen as internal standard were in the range of 96–98% for clopidogrel, 94–98% for its carboxylic acid metabolite, and 90–99% for atorvastatin, respectively.

  9. Static platelet adhesion, flow cytometry and serum TXB2 levels for monitoring platelet inhibiting treatment with ASA and clopidogrel in coronary artery disease: a randomised cross-over study

    Hedbäck Bo

    2009-06-01

    Full Text Available Abstract Background Despite the use of anti-platelet agents such as acetylsalicylic acid (ASA and clopidogrel in coronary heart disease, some patients continue to suffer from atherothrombosis. This has stimulated development of platelet function assays to monitor treatment effects. However, it is still not recommended to change treatment based on results from platelet function assays. This study aimed to evaluate the capacity of a static platelet adhesion assay to detect platelet inhibiting effects of ASA and clopidogrel. The adhesion assay measures several aspects of platelet adhesion simultaneously, which increases the probability of finding conditions sensitive for anti-platelet treatment. Methods With a randomised cross-over design we evaluated the anti-platelet effects of ASA combined with clopidogrel as well as monotherapy with either drug alone in 29 patients with a recent acute coronary syndrome. Also, 29 matched healthy controls were included to evaluate intra-individual variability over time. Platelet function was measured by flow cytometry, serum thromboxane B2 (TXB2-levels and by static platelet adhesion to different protein surfaces. The results were subjected to Principal Component Analysis followed by ANOVA, t-tests and linear regression analysis. Results The majority of platelet adhesion measures were reproducible in controls over time denoting that the assay can monitor platelet activity. Adenosine 5'-diphosphate (ADP-induced platelet adhesion decreased significantly upon treatment with clopidogrel compared to ASA. Flow cytometric measurements showed the same pattern (r2 = 0.49. In opposite, TXB2-levels decreased with ASA compared to clopidogrel. Serum TXB2 and ADP-induced platelet activation could both be regarded as direct measures of the pharmacodynamic effects of ASA and clopidogrel respectively. Indirect pharmacodynamic measures such as adhesion to albumin induced by various soluble activators as well as SFLLRN

  10. Static platelet adhesion, flow cytometry and serum TXB2 levels for monitoring platelet inhibiting treatment with ASA and clopidogrel in coronary artery disease: a randomised cross-over study

    Eriksson, Andreas C; Jonasson, Lena; Lindahl, Tomas L; Hedbäck, Bo; Whiss, Per A

    2009-01-01

    Background Despite the use of anti-platelet agents such as acetylsalicylic acid (ASA) and clopidogrel in coronary heart disease, some patients continue to suffer from atherothrombosis. This has stimulated development of platelet function assays to monitor treatment effects. However, it is still not recommended to change treatment based on results from platelet function assays. This study aimed to evaluate the capacity of a static platelet adhesion assay to detect platelet inhibiting effects of ASA and clopidogrel. The adhesion assay measures several aspects of platelet adhesion simultaneously, which increases the probability of finding conditions sensitive for anti-platelet treatment. Methods With a randomised cross-over design we evaluated the anti-platelet effects of ASA combined with clopidogrel as well as monotherapy with either drug alone in 29 patients with a recent acute coronary syndrome. Also, 29 matched healthy controls were included to evaluate intra-individual variability over time. Platelet function was measured by flow cytometry, serum thromboxane B2 (TXB2)-levels and by static platelet adhesion to different protein surfaces. The results were subjected to Principal Component Analysis followed by ANOVA, t-tests and linear regression analysis. Results The majority of platelet adhesion measures were reproducible in controls over time denoting that the assay can monitor platelet activity. Adenosine 5'-diphosphate (ADP)-induced platelet adhesion decreased significantly upon treatment with clopidogrel compared to ASA. Flow cytometric measurements showed the same pattern (r2 = 0.49). In opposite, TXB2-levels decreased with ASA compared to clopidogrel. Serum TXB2 and ADP-induced platelet activation could both be regarded as direct measures of the pharmacodynamic effects of ASA and clopidogrel respectively. Indirect pharmacodynamic measures such as adhesion to albumin induced by various soluble activators as well as SFLLRN-induced activation measured by flow

  11. Effects of clopidogrel and clarithromycin on the disposition of sibutramine and its active metabolites M1 and M2 in relation to CYP2B6*6 polymorphism.

    Pan, Wei; Bae, Soo-Kyung; Shim, Eon-Jeong; Park, Sung-Eun; Lee, Sang-Seop; Park, Soo-Jin; Yeo, Chang-Woo; Zhou, Hong-Hao; Shon, Ji-Hong; Shin, Jae-Gook

    2013-02-01

    Plasma concentrations of sibutramine and its two active metabolites after single oral dose of sibutramine were determined in Korean healthy male subjects with different CYP2B6 genotypes (CYP2B6*1/*1, *1/*6 and *6/*6), either alone or after four-day pretreatment with clopidogrel or clarithromycin. The pretreatment with clopidogrel and clarithromycin raised the mean area under the concentration-time curve (AUC) of sibutramine by 163% and 255%, respectively. Co-administration of clarithromycin, combined with CYP2B6*6/*6 genotype, led to highest concentration of sibutramine. The molar sum AUC (M1 + M2) was raised by 35% in the clopidogrel phase but not significantly affected by clarithromycin or CYP2B6 genotype. The CYP2B6*6/*6 subjects in the clopidogrel phase showed the highest molar AUC (M1 + M2) among three genotype groups throughout the three phases. The exposure of sibutramine and its metabolites seemed to be associated with the CYP2B6 genotype. The treatment of clopidogrel significantly altered the disposition of active metabolites as well as sibutramine, but clarithromycin only affects the disposition of sibutramine. These results suggest that the perturbation of CYP2B6 activity may contribute to the inter-individual variation of sibutramine drug responses although the clinical relevance is remained to be established.

  12. Interaction study of aspirin or clopidogrel on pharmacokinetics of donepezil hydrochloride in rats by HPLC-fluorescence detection.

    Wada, Mitsuhiro; Nishiwaki, Junichiro; Yamane, Tomoko; Ohwaki, Yuichi; Aboul-Enein, Hassan Y; Nakashima, Kenichiro

    2007-06-01

    The present study aims to investigate the possibility of interaction of aspirin (Asp) or clopidogrel (CG) on donepezil (DP) hydrochloride in rats by HPLC-fluorescence detection. The separation of DP was achieved in ca. 13 min without interference of Asp and CG on the chromatogram. DP levels in rat plasma with a single administration of DP (5 mg/kg, i.p., group I) and those with a co-administration of Asp (200 mg/kg, p.o., group II or 200 mg/kg, i.p., group III) or CG (5 mg/kg, p.o., group IV) were monitored. The DP concentrations determined in rat plasma ranged from 25.0 to 336.1 ng/mL. Pharmacokinetic parameters for these groups were calculated and compared with one another. No significant difference was observed on the comparison of group I with other groups except for the mean resident time of group IV (p = 0.012). These basic findings may help clinical inference when DP is co-administered with Asp and CG to human. Copyright 2007 John Wiley & Sons, Ltd.

  13. Comparison of VerifyNow-P2Y12 test and Flow Cytometry for monitoring individual platelet response to clopidogrel. What is the cut-off value for identifying patients who are low responders to clopidogrel therapy?

    Castelli Alfredo

    2009-05-01

    Full Text Available Abstract Background Dual anti-platelet therapy with aspirin and a thienopyridine (DAT is used to prevent stent thrombosis after percutaneous coronary intervention (PCI. Low response to clopidogrel therapy (LR occurs, but laboratory tests have a controversial role in the identification of this condition. Methods We studied LR in patients with stable angina undergoing elective PCI, all on DAT for at least 7 days, by comparing: 1 Flow cytometry (FC to measure platelet membrane expression of P-selectin (CD62P and PAC-1 binding following double stimulation with ADP and collagen type I either in the presence of prostaglandin (PG E1; 2 VerifyNow-P2Y12 test, in which results are reported as absolute P2Y12-Reaction-Units (PRU or % of inhibition (% inhibition. Results Thirty controls and 52 patients were analyzed. The median percentage of platelets exhibiting CD62P expression and PAC-1 binding by FC evaluation after stimulation in the presence of PG E1 was 25.4% (IQR: 21.4–33.1% and 3.5% (1.7–9.4%, respectively. Only 6 patients receiving DAT (11.5% had both values above the 1st quartile of controls, and were defined as LR. Evaluation of the same patients with the VerifyNow-P2Y12 test revealed that the area under the receiver-operating-characteristic (ROC curve was 0.94 (95% CI: 0.84–0.98, p 213 PRU gave the maximum accuracy for the detection of patients defined as having LR by FC. Conclusion In conclusion our findings show that a cut-off value of ≤ 15% inhibition or > 213 PRU in the VerifyNow-P2Y12 test may provide the best accuracy for the identification of patients with LR.

  14. A prospective randomized trial of aspirin-clopidogrel combination therapy and dose-adjusted warfarin on indices of thrombogenesis and platelet activation in atrial fibrillation.

    Kamath, Sridhar; Blann, Andrew D; Chin, Bernard S P; Lip, Gregory Y H

    2002-08-07

    This study was designed to investigate whether or not combination aspirin-clopidogrel therapy would reduce markers of thrombogenesis and platelet activation in atrial fibrillation (AF), in a manner similar to warfarin. Dose-adjusted warfarin is beneficial as thromboprophylaxis in AF, but potentially serious side effects and regular monitoring leave room for alternative therapies. METHODS; We randomized 70 patients with nonvalvular AF who were not on any antithrombotic therapy to either dose-adjusted warfarin (international normalized ratio 2 to 3) (Group I) or combination therapy with aspirin 75 mg and clopidogrel 75 mg (Group II). Plasma indices of thrombogenesis (fibrin D-dimer, prothrombin fragment 1+2) and platelet activation (beta-thromboglobulin [TG] and soluble P-selectin) were quantified, along with platelet aggregation responses to standard agonists, at baseline (pretreatment) and at six weeks posttreatment. RESULTS; Pretreatment levels of fibrin D-dimer (p = 0.001), beta-TG (p = 0.01) and soluble P-selectin (p = 0.03) were raised in patients with AF, whereas plasma prothrombin fragment 1+2 levels and platelet aggregation were not significantly different compared with controls. Dose-adjusted warfarin reduced plasma levels of fibrin D-dimer, prothrombin fragment 1+2 and beta-thromboglobulin levels at six weeks (all p failed to reduce plasma indices of thrombogenesis and platelet activation in AF, although some aspects of ex vivo platelet aggregation were altered. Anticoagulation with warfarin may be superior to combination aspirin-clopidogrel therapy as thromboprophylaxis in AF.

  15. Associations Between Complex PCI and Prasugrel or Clopidogrel Use in Patients With Acute Coronary Syndrome Who Undergo PCI: From the PROMETHEUS Study.

    Chandrasekhar, Jaya; Baber, Usman; Sartori, Samantha; Aquino, Melissa; Kini, Annapoorna S; Rao, Sunil; Weintraub, William; Henry, Timothy D; Farhan, Serdar; Vogel, Birgit; Sorrentino, Sabato; Ge, Zhen; Kapadia, Samir; Muhlestein, Joseph B; Weiss, Sandra; Strauss, Craig; Toma, Catalin; DeFranco, Anthony; Effron, Mark B; Keller, Stuart; Baker, Brian A; Pocock, Stuart; Dangas, George; Mehran, Roxana

    2018-03-01

    Potent P2Y 12 inhibitors might offer enhanced benefit against thrombotic events in complex percutaneous coronary intervention (PCI). We examined prasugrel use and outcomes according to PCI complexity, as well as analyzing treatment effects according to thienopyridine type. PROMETHEUS was a multicentre observational study that compared clopidogrel vs prasugrel in acute coronary syndrome patients who underwent PCI (n = 19,914). Complex PCI was defined as PCI of the left main, bifurcation lesion, moderate-severely calcified lesion, or total stent length ≥ 30 mm. Major adverse cardiac events (MACE) were a composite of death, myocardial infarction, stroke, or unplanned revascularization. Outcomes were adjusted using multivariable Cox regression for effect of PCI complexity and propensity-stratified analysis for effect of thienopyridine type. The study cohort included 48.9% (n = 9735) complex and 51.1% (n = 10,179) noncomplex patients. Second generation drug-eluting stents were used in 70.1% complex and 66.2% noncomplex PCI patients (P PCI was associated with greater adjusted risk of 1-year MACE (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.20-1.39; P PCI patients (P = 0.30). Compared with clopidogrel, prasugrel significantly decreased adjusted risk for 1-year MACE in complex PCI (HR, 0.79; 95% CI, 0.68-0.92) but not noncomplex PCI (HR, 0.91; 95% CI, 0.77-1.08), albeit there was no evidence of interaction (P interaction = 0.281). Despite the use of contemporary techniques, acute coronary syndrome patients who undergo complex PCI had significantly higher rates of 1-year MACE. Adjusted magnitude of treatment effects with prasugrel vs clopidogrel were consistent in complex and noncomplex PCI without evidence of interaction. Copyright © 2018. Published by Elsevier Inc.

  16. Impact of smoking status on platelet function and clinical outcomes with prasugrel vs. clopidogrel in patients with acute coronary syndromes managed without revascularization

    Cornel, Jan H; Ohman, E Magnus; Neely, Benjamin

    2014-01-01

    managed medically without revascularization. METHODS AND RESULTS: A total of 7062 patients aged ..., or stroke in current smokers was significantly lower with prasugrel (11.7%) vs. clopidogrel (18.6%), but there was no difference in non-smokers (13.8% vs. 13.7%), with significant interaction between treatment and baseline smoking status (P = .0002). Bleeding events occurred more frequently in prasugrel......-treated patients with no significant interaction between treatment and baseline smoking status. CONCLUSIONS: Among medically managed ACS patients

  17. Safety and efficacy of the Perclose suture-mediated closure device following carotid artery stenting under clopidogrel platelet blockade

    Zorger, Niels; Finkenzeller, Thomas; Lenhart, Markus; Hamer, Okka; Paetzel, Christian; Borisch, Inghita; Toepel, Ingolf; Feuerbach, Stefan; Link, Johann [University of Regensburg Klinikum, Franz-Josef-Strauss-Allee 11, 93042, Regensburg (Germany)

    2004-04-01

    The aim of this study was evaluation of a closure device (Perclose, Menlo Park, Calif.) for closure of the femoral artery access site in patients undergoing aggressive anticoagulation and platelet blockade after carotid stenting. Fifty-five patients who received clopidogrel in addition to aspirin and heparin as medication for carotid stenting were included for suture of the femoral access site after using 7- or 8-F guide catheters. The technical success, the time for suture, the clotting parameters, and complications were examined. Follow-up investigations, including ultrasound and clinical examinations, were performed. The groin was checked for possible hematoma, pseudoaneurysm, arteriovenous fistula, and local infection. Technical success was obtained in 51 of 54 patients (94%) after a mean procedure time of 6 min (range 5-10 min). The suture device was not used in one patient (2%) for anatomical reasons and failed to obtain hemostasis in 3 of 54 (6%) patients. In 4 of 54 patients (7%) bleeding was observed at the punctured site 4-6 h after intervention which was treated by a compression bandage. The mean dedicated activated clotting time was 137 s (range 29-287 s) before intervention and 349 s (150-958 s) just before deploying the Perclose device. During follow-up after 2 days (range 2-6 days) and 6 months no further complications of the puncture site were observed except for two large groin hematomas. No major complications occurred. Closure of the femoral access site after carotid stenting using a Perclose closure device is safe and effective even in patients receiving an aggressive anticoagulation and antiplatelet therapy. (orig.)

  18. Direct healthcare costs and cost-effectiveness of acute coronary syndrome secondary prevention with ticagrelor compared to clopidogrel: economic evaluation from the public payer's perspective in Poland based on the PLATO trial results.

    Pawęska, Justyna; Macioch, Tomasz; Perkowski, Piotr; Budaj, Andrzej; Niewada, Maciej

    2014-01-01

    Ticagrelor is the first reversibly binding oral P2Y12 receptor antagonist designed to reduce clinical thrombotic events in patients with acute coronary syndrome (ACS). Compared to clopidogrel, ticagrelor has been proven to significantly reduce the rate of death from vascular causes, myocardial infarction (MI), or stroke without an increase in the rate of overall major bleeding in patients who have an ACS with or without ST-segment elevation (STEMI and NSTEMI) or unstable angina (UA). To evaluate the cost-effectiveness and healthcare costs associated with secondary prevention of ACS using ticagrelor or clopidogrel in patients after STEMI, NSTEMI and UA. An economic model based on results from the PLATO trial was used to evaluate the cost-effectiveness of one-year therapy with ticagrelor or clopidogrel. The structure of the model consisted of two parts, i.e. the decision tree with one-year PLATO results and the Markov model with lifelong estimations, which exceeded PLATO follow-up data. The model was adjusted to Polish settings with country-specific data on death rates in the general population and direct medical costs calculated from the public payer's perspective. Costs were derived from the National Health Fund (NHF) and the Ministry of Health and presented in PLN 2013 values. Annual mean costs of second and subsequent years after stroke or MI were obtained from the literature. Uncertainty of assumed parameters was tested in scenarios and probabilistic sensitivity analyses. The adopted model allowed the estimation of an incremental cost-effectiveness ratio for life years gained (LYG) and an incremental cost-utility ratio for quality adjusted life years (QALY). Total direct medical costs to the public payer at a one year horizon were 2,905 PLN higher with ticagrelor than with clopidogrel. However, mean healthcare costs at a one year horizon (excluding drug costs and concomitant drugs) were 690 PLN higher for patients treated with clopidogrel. In a lifetime horizon

  19. Anti-inflammatory and anti-thrombotic intervention strategies using atorvastatin, clopidogrel and knock-down of CD40L do not modify radiation-induced atherosclerosis in ApoE null mice

    Hoving, Saske [Division of Experimental Therapy, Netherlands Cancer Institute, Amsterdam (Netherlands); Heeneman, Sylvia [Department of Pathology, Cardiovascular Research Institute Maastricht (Netherlands); Gijbels, Marion J.J. [Department of Pathology, Cardiovascular Research Institute Maastricht (Netherlands); Department of Molecular Genetics, Cardiovascular Research Institute Maastricht (Netherlands); Poele, Johannes A.M. te [Division of Experimental Therapy, Netherlands Cancer Institute, Amsterdam (Netherlands); Pol, Jeffrey F.C.; Gabriels, Karen [Department of Pathology, Cardiovascular Research Institute Maastricht (Netherlands); Russell, Nicola S [Division of Radiotherapy, Netherlands Cancer Institute, Amsterdam (Netherlands); Daemen, Mat J.A.P. [Department of Pathology, Cardiovascular Research Institute Maastricht (Netherlands); Department of Pathology, AMC, Amsterdam (Netherlands); Stewart, Fiona A., E-mail: f.stewart@nki.nl [Division of Experimental Therapy, Netherlands Cancer Institute, Amsterdam (Netherlands)

    2011-10-15

    Background and purpose: We previously showed that irradiating the carotid arteries of ApoE{sup -/-} mice accelerated the development of macrophage-rich, inflammatory and thrombotic atherosclerotic lesions. In this study we investigated the potential of anti-inflammatory (atorvastatin, CD40L knockout) and anti-thrombotic (clopidogrel) intervention strategies to inhibit radiation-induced atherosclerosis. Material and methods: ApoE{sup -/-} mice were given 0 or 14 Gy to the neck and the carotid arteries were harvested at 4 or 28 weeks after irradiation. Atorvastatin (15 mg/kg/day) or clopidogrel (20 mg/kg/day) was given in the chow; control groups received regular chow. Clopidogrel inhibited platelet aggregation by 50%. CD40L{sup -/-}/ApoE{sup -/-} and ApoE{sup -/-} littermates were also given 0 or 14 Gy to the neck and the carotid arteries were harvested after 30 weeks. Results: Clopidogrel decreased MCP-1 expression in the carotid artery at 4 weeks after irradiation. Expression of VCAM-1, ICAM-1, thrombomodulin, tissue factor and eNOS was unchanged in atorvastatin and clopidogrel-treated mice. Neither drug inhibited either age-related or radiation-induced atherosclerosis. Furthermore, loss of the inflammatory mediator CD40L did not influence the development of age-related and radiation-induced atherosclerosis. Conclusions: The effects of radiation-induced atherosclerosis could not be circumvented by these specific anti-inflammatory and anti-coagulant therapies. This suggests that more effective drug combinations may be required to overcome the radiation stimulus, or that other underlying mechanistic pathways are involved compared to age-related atherosclerosis.

  20. Anti-inflammatory and anti-thrombotic intervention strategies using atorvastatin, clopidogrel and knock-down of CD40L do not modify radiation-induced atherosclerosis in ApoE null mice

    Hoving, Saske; Heeneman, Sylvia; Gijbels, Marion J.J.; Poele, Johannes A.M. te; Pol, Jeffrey F.C.; Gabriels, Karen; Russell, Nicola S.; Daemen, Mat J.A.P.; Stewart, Fiona A.

    2011-01-01

    Background and purpose: We previously showed that irradiating the carotid arteries of ApoE −/− mice accelerated the development of macrophage-rich, inflammatory and thrombotic atherosclerotic lesions. In this study we investigated the potential of anti-inflammatory (atorvastatin, CD40L knockout) and anti-thrombotic (clopidogrel) intervention strategies to inhibit radiation-induced atherosclerosis. Material and methods: ApoE −/− mice were given 0 or 14 Gy to the neck and the carotid arteries were harvested at 4 or 28 weeks after irradiation. Atorvastatin (15 mg/kg/day) or clopidogrel (20 mg/kg/day) was given in the chow; control groups received regular chow. Clopidogrel inhibited platelet aggregation by 50%. CD40L −/− /ApoE −/− and ApoE −/− littermates were also given 0 or 14 Gy to the neck and the carotid arteries were harvested after 30 weeks. Results: Clopidogrel decreased MCP-1 expression in the carotid artery at 4 weeks after irradiation. Expression of VCAM-1, ICAM-1, thrombomodulin, tissue factor and eNOS was unchanged in atorvastatin and clopidogrel-treated mice. Neither drug inhibited either age-related or radiation-induced atherosclerosis. Furthermore, loss of the inflammatory mediator CD40L did not influence the development of age-related and radiation-induced atherosclerosis. Conclusions: The effects of radiation-induced atherosclerosis could not be circumvented by these specific anti-inflammatory and anti-coagulant therapies. This suggests that more effective drug combinations may be required to overcome the radiation stimulus, or that other underlying mechanistic pathways are involved compared to age-related atherosclerosis.

  1. Clopidogrel-Proton Pump Inhibitor Drug-Drug Interaction and Risk of Adverse Clinical Outcomes Among PCI-Treated ACS Patients: A Meta-analysis.

    Serbin, Michael A; Guzauskas, Gregory F; Veenstra, David L

    2016-08-01

    Uncertainty regarding clopidogrel effectiveness attenuation because of a drug-drug interaction with proton pump inhibitors (PPI) has led to conflicting guidelines on concomitant therapy. In particular, the effect of this interaction in patients who undergo a percutaneous coronary intervention (PCI), a population known to have increased risk of adverse cardiovascular events, has not been systematically evaluated. To synthesize the evidence of the effect of clopidogrel-PPI drug interaction on adverse cardiovascular outcomes in a PCI patient population. We conducted a systematic literature review for studies reporting clinical outcomes in patients who underwent a PCI and were initiated on clopidogrel with or without a PPI. Studies were included in the analysis if they reported at least 1 of the clinical outcomes of interest (major adverse cardiovascular event [MACE], cardiovascular death, all-cause death, myocardial infarction, stroke, stent thrombosis, and bleed events). We excluded studies that were not exclusive to PCI patients or had no PCI subgroup analysis and/or did not report at least a 6-month follow-up. Statistical and clinical heterogeneity were evaluated and HRs and 95% CIs for adverse clinical events were pooled using the DerSimonian and Laird random-effects meta-analysis method. We identified 12 studies comprising 50,277 PCI patients that met our inclusion and exclusion criteria. Our analysis included retrospective analyses of randomized controlled trials (2), health registries (3), claims databases (2), and institutional records (5); no prospective studies of PCI patients were identified. On average, patients were in their mid-60s, male, and had an array of comorbidities, including hyperlipidemia, diabetes, hypertension, and smoking history. Concomitant therapy following PCI resulted in statistically significant increases in composite MACE (HR = 1.28; 95% CI = 1.24-1.32), myocardial infarction (HR = 1.51; 95% CI = 1.40-1.62), and stroke (HR = 1.46; 95

  2. Platelet reactivity in the early and late phases of acute coronary syndromes according to cytochrome P450 2C19 phenotypes.

    Nagashima, Zenko; Tsukahara, Kengo; Morita, Satoshi; Endo, Tsutomu; Sugano, Teruyasu; Hibi, Kiyoshi; Himeno, Hideo; Fukui, Kazuki; Umemura, Satoshi; Kimura, Kazuo

    2013-09-01

    It remains unknown whether the time course of the antiplatelet effects of clopidogrel differs according to cytochrome P450 (CYP) 2C19 phenotype in Japanese patients with acute coronary syndromes (ACS). Platelet reactivity was serially assessed by VerifyNow-P2Y12 assay (Accumetrics, San Diego, CA, USA). Results were expressed as P2Y12-reaction-units (PRU) in 177 patients with ACS who underwent stent implantation and received aspirin plus a 300-mg loading dose of clopidogrel followed by 75 mg/day. High on-clopidogrel treatment platelet reactivity (HTPR) was defined as PRU>235. On the basis of the CYP2C19*2 and *3 alleles, 46 patients (26.0%) were classified as extensive metabolizers (EM), 103 (58.2%) as intermediate metabolizers (IM), and 28 (15.8%) as poor metabolizers (PM). At fashion (168±99 vs. 213±77 vs. 278±69, pJapanese patients with ACS carried CYP2C19 variant alleles. The majority of IM and PM had increased platelet reactivity during the early phase of ACS. Although HTPR was frequently observed even 14-28 days after standard maintenance doses of clopidogrel in PM, the incidence of adverse outcomes did not differ, irrespective of CYP2C19 genotype. Copyright © 2013 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

  3. The proton pump inhibitor, omeprazole, but not lansoprazole or pantoprazole, is a metabolism-dependent inhibitor of CYP2C19: implications for coadministration with clopidogrel.

    Ogilvie, Brian W; Yerino, Phyllis; Kazmi, Faraz; Buckley, David B; Rostami-Hodjegan, Amin; Paris, Brandy L; Toren, Paul; Parkinson, Andrew

    2011-11-01

    As a direct-acting inhibitor of CYP2C19 in vitro, lansoprazole is more potent than omeprazole and other proton pump inhibitors (PPIs), but lansoprazole does not cause clinically significant inhibition of CYP2C19 whereas omeprazole does. To investigate this apparent paradox, we evaluated omeprazole, esomeprazole, R-omeprazole, lansoprazole, and pantoprazole for their ability to function as direct-acting and metabolism-dependent inhibitors (MDIs) of CYP2C19 in pooled human liver microsomes (HLM) as well as in cryopreserved hepatocytes and recombinant CYP2C19. In HLM, all PPIs were found to be direct-acting inhibitors of CYP2C19 with IC(50) values varying from 1.2 μM [lansoprazole; maximum plasma concentration (C(max)) = 2.2 μM] to 93 μM (pantoprazole; C(max) = 6.5 μM). In addition, we identified omeprazole, esomeprazole, R-omeprazole, and omeprazole sulfone as MDIs of CYP2C19 (they caused IC(50) shifts after a 30-min preincubation with NADPH-fortified HLM of 4.2-, 10-, 2.5-, and 3.2-fold, respectively), whereas lansoprazole and pantoprazole were not MDIs (IC(50) shifts lansoprazole, or pantoprazole, as irreversible (or quasi-irreversible) MDIs of CYP2C19. These results have important implications for the mechanism of the clinical interaction reported between omeprazole and clopidogrel, as well as other CYP2C19 substrates.

  4. Acinetobacter Prosthetic Joint Infection Treated with Debridement and High-Dose Tigecycline.

    Vila, Andrea; Pagella, Hugo; Amadio, Claudio; Leiva, Alejandro

    2016-12-01

    Prosthesis retention is not recommended for multidrug-resistant Acinetobacter prosthetic joint infection due to its high failure rate. Nevertheless, replacing the prosthesis implies high morbidity and prolonged hospitalization. Although tigecycline is not approved for the treatment of prosthetic joint infection due to multidrug resistant Acinetobacter baumannii, its appropriate use may preclude prosthesis exchange. Since the area under the curve divided by the minimum inhibitory concentration is the best pharmacodynamic predictor of its efficacy, we used tigecycline at high dose, in order to optimize its efficacy and achieve implant retention in 3 patients who refused prosthesis exchange. All patients with prosthetic joint infections treated at our Institution are prospectively registered in a database. Three patients with early prosthetic joint infection of total hip arthroplasty due to multidrug resistant A. baumannii were treated with debridement, antibiotics and implant retention, using a high maintenance dose of tigecycline (100 mg every 12 hours). The cases were retrospectively reviewed. All patients signed informed consent for receiving off-label use of tigecycline. Tigecycline was well tolerated, allowing its administration at high maintenance dose for a median of 40 days (range 30-60). Two patients were then switched to minocycline at standard doses for a median of 3.3 months in order to complete treatment. Currently, none of the patients showed relapse. Increasing the dose of tigecycline could be considered as a means to better attain pharmacodynamic targets in patients with severe or difficult-to-treat infections. Tigecycline at high maintenance dose might be useful when retention of the implant is attempted for treatment for prosthetic joint infections due to multidrug resistant Acinetobacter. Although this approach might be promising, off-label use of tigecycline should be interpreted cautiously until prospective data are available. Tigecycline is

  5. A review of antithrombotic therapy and the rationale and design of the randomized edoxaban in patients with peripheral artery disease (ePAD) trial adding edoxaban or clopidogrel to aspirin after femoropopliteal endovascular intervention.

    Tangelder, Marco J D; Nwachuku, Chuke E; Jaff, Michael; Baumgartner, Iris; Duggal, Anil; Adams, George; Ansel, Gary; Grosso, Michael; Mercuri, Michele; Shi, Minggao; Minar, Erich; Moll, Frans L

    2015-04-01

    Compared with the coronary setting, knowledge about antithrombotic therapies after endovascular treatment (EVT) is inadequate in patients with peripheral artery disease (PAD). Based on a review of trials and guidelines, which is summarized in this article, there is scant evidence that antithrombotic drugs improve outcome after peripheral EVT. To address this knowledge gap, the randomized, open-label, multinational edoxaban in patients with Peripheral Artery Disease (ePAD) study (ClinicalTrials.gov identifier NCT01802775) was designed to explore the safety and efficacy of a combined regimen of antiplatelet therapy with clopidogrel and anticoagulation with edoxaban, a selective and direct factor Xa inhibitor, both combined with aspirin. As of July 2014, 203 patients (144 men; mean age 67 years) from 7 countries have been enrolled. These patients have been allocated to once-daily edoxaban [60 mg for 3 months (or 30 mg in the presence of factors associated with increased exposure)] or clopidogrel (75 mg/d for 3 months). All patients received aspirin (100 mg/d) for the 6-month duration of the study. The primary safety endpoint is major or clinically relevant nonmajor bleeding; the primary efficacy endpoint is restenosis or reocclusion at the treated segment(s) measured at 1, 3, and 6 months using duplex ultrasound scanning. All outcomes will be assessed and adjudicated centrally in a masked fashion. The ePAD study is the first of its kind to investigate a combined regimen of antiplatelet therapy and anticoagulation through factor Xa inhibition with edoxaban. © The Author(s) 2015.

  6. Prevalence of Ex Vivo High On-treatment Platelet Reactivity on Antiplatelet Therapy after Transient Ischemic Attack or Ischemic Stroke on the PFA-100(®) and VerifyNow(®).

    Kinsella, Justin A

    2012-09-12

    BACKGROUND: The prevalence of ex vivo high on-treatment platelet reactivity (HTPR) to commonly prescribed antiplatelet regimens after transient ischemic attack (TIA) or ischemic stroke is uncertain. METHODS: Platelet function inhibition was simultaneously assessed with modified light transmission aggregometry (VerifyNow; Accumetrics Inc, San Diego, CA) and with a moderately high shear stress platelet function analyzer (PFA-100; Siemens Medical Solutions USA, Inc, Malvern, PA) in a pilot, cross-sectional study of TIA or ischemic stroke patients. Patients were assessed on aspirin-dipyridamole combination therapy (n = 51) or clopidogrel monotherapy (n = 25). RESULTS: On the VerifyNow, HTPR on aspirin was identified in 4 of 51 patients (8%) on aspirin-dipyridamole combination therapy (≥550 aspirin reaction units on the aspirin cartridge). Eleven of 25 (44%) patients had HTPR on clopidogrel (≥194 P2Y12 reaction units on the P2Y12 cartridge). On the PFA-100, 21 of 51 patients (41%) on aspirin-dipyridamole combination therapy had HTPR on the collagen-epinephrine (C-EPI) cartridge. Twenty-three of 25 patients (92%) on clopidogrel had HTPR on the collagen-adenosine diphosphate (C-ADP) cartridge. The proportion of patients with antiplatelet HTPR was lower on the VerifyNow than PFA-100 in patients on both regimens (P < .001). CONCLUSIONS: The prevalence of ex vivo antiplatelet HTPR after TIA or ischemic stroke is markedly influenced by the method used to assess platelet reactivity. The PFA-100 C-ADP cartridge is not sensitive at detecting the antiplatelet effects of clopidogrel ex vivo. Larger prospective studies with the VerifyNow and with the PFA-100 C-EPI and recently released Innovance PFA P2Y cartridges (Siemens Medical Solutions USA, Inc) in addition to newer tests of platelet function are warranted to assess whether platelet function monitoring predicts clinical outcome in ischemic cerebrovascular disease.

  7. VKORC1 polymorphisms and warfarin maintenance dose in population of Sakha (Yakuts).

    Chertovskikh, Y V; Malova, E U; Maksimova, N R; Popova, N V; Sychev, D A

    2015-01-01

    Vitamin K antagonists are effective in the prevention and treatment of thromboembolic disorders. Warfarin is one of the most widely prescribed vitamin K antagonists in the world [1, 2]. It has a narrow therapeutic range and a given dose may result in a large inter-individual variation of response. Insufficient dose may fail to prevent thromboembolism, while an overdose increases the risk of bleeding. Patient-specific factors (e.g., age, body size, race, concurrent diseases, and medications) explain some of the variability in warfarin dosage, but genetic factors influencing warfarin response explain a significantly higher proportion of this variability [3]. Molecular analysis of the gene that encodes the target enzyme vitamin K epoxide reductase complex 1 (VKORC1) strongly suggests that its genetic variations greatly affect the individual response to oral anticoagulants [4-7]. To evaluate effects of VKORC1 polymorphisms on warfarin dose excess anticoagulation (INR >4.0) in the population of Sakha (S) patients. 53 patients (29-women, 24-men) with atrial fibrillation (68%), congestive heart failure (60%), hypertension (49%) and cardiac valve replacement (26%) were recruited. The age range was 26-80 years, with a mean age of 62.87 ± 12.57 years.International normalized ratio and plasma warfarin concentrations were determined. Genotyping was carried out by RT-PCR (real-time PCR). The three genetic polymorphisms of the gene VKORC1 G3673A (rs9923231) were studied: normal (GG), heterozygous (GA) and homozygous (AA). Fisher exact probability test and chi-square test (with Yates correction) were applied to compare data among the AA and GG + GA groups; also Mann-Whitney test was used. The median maintenance daily dose of warfarin among AA carriers was 3.0 mg/day [1.25-7.5 mg], while in GG and GA patients it was 3.13 mg/day [1.88-7.92 mg]. The mean daily warfarin dosage was higher in GG and GA genotype carriers 4.05 mg/day (SD ± 1.7) than in patients with AA genotype 3.13 (SD ± 1.5). Differences are of borderline significance (p = 0.054). Of the 41 patients who required warfarin doses of less than 5 mg, 28 (63%) were found to be AA carriers and 14 (37%) were GG, GA carriers. Differences were not quite significant (p = 0.072). Among 31 homozygous polymorphism carriers 2 (4%) patients developed overanticoagulation (INR >4.0), while among 22 normal and heterozygous polymorphisms carriers only 3 (6%) patients developed overanticoagulation (INR >4.0). Differences were not statistically significant (p = 0.36). No significant association between VKORC1 polymorphisms and the frequency of excess anticoagulation (INR >4.0) was found. This may be explained by the number of cases included. AA polymorphisms compared to other polymorphisms shows borderline difference in the warfarin dose. The results can be used for the development of a pharmacogenetic-guided warfarin dosing algorithm.

  8. Development of predictive models for estimating warfarin maintenance dose based on genetic and clinical factors.

    Yang, Lu; Linder, Mark W

    2013-01-01

    In this chapter, we use calculation of estimated warfarin maintenance dosage as an example to illustrate how to develop a multiple linear regression model to quantify the relationship between several independent variables (e.g., patients' genotype information) and a dependent variable (e.g., measureable clinical outcome).

  9. A study on the impact of CYP2C19 genotype and platelet reactivity assay on patients undergoing PCI

    P.C. Rath

    2015-03-01

    Conclusion: Clopidogrel resistance was observed to be 16.5% in our study population. PRA was useful in monitoring the efficacy of thienopyridines. By having this test, one can be safely maintained on clopidogrel in non-carriers, or with increased dose of clopidogrel in intermediate metabolizers or with newer drugs such as ticagrelor or prasugrel in poor metabolizers. Patients on ticagrelor and prasugrel identified as non-carriers of gene mutations for clopidogrel metabolism could be offered clopidogrel resulting in economic benefits to the patients. Patients at high risk of bleeding were also identified by the PRA.

  10. Safety and efficacy of intensive vs. guideline antiplatelet therapy in high-risk patients with recent ischemic stroke or transient ischemic attack

    Christensen, Hanne Krarup

    2015-01-01

    RATIONALE: The risk of recurrence following a stroke or transient ischemic attack is high, especially immediately after the event. HYPOTHESIS: Because two antiplatelet agents are superior to one in patients with non-cardioembolic events, more intensive treatment might be even more effective. SAMPLE...... SIZE ESTIMATES: The sample size of 4100 patients will allow a shift to less recurrence, and less severe recurrence, to be detected (odds ratio 0·68) with 90% power at 5% significance. METHODS AND DESIGN: Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (ISRCTN47823388) is comparing...... the safety and efficacy of intensive (combined aspirin, clopidogrel, and dipyridamole) vs. guideline antiplatelet therapy, both given for one-month. This international collaborative parallel-group prospective randomized open-label blinded-end-point phase III trial plans to recruit 4100 patients with acute...

  11. Pharmacodynamic Comparison of Prasugrel Versus Ticagrelor in Patients With Type 2 Diabetes Mellitus and Coronary Artery Disease: The OPTIMUS (Optimizing Antiplatelet Therapy in Diabetes Mellitus)-4 Study.

    Franchi, Francesco; Rollini, Fabiana; Aggarwal, Niti; Hu, Jenny; Kureti, Megha; Durairaj, Ashwin; Duarte, Valeria E; Cho, Jung Rae; Been, Latonya; Zenni, Martin M; Bass, Theodore A; Angiolillo, Dominick J

    2016-09-13

    Patients with diabetes mellitus (DM) are at increased risk of atherothrombotic events, underscoring the importance of effective platelet inhibiting therapies. Prasugrel and ticagrelor reduce thrombotic complications to a greater extent than clopidogrel. Subgroup analyses of pivotal clinical trials testing prasugrel and ticagrelor versus clopidogrel showed DM patients to have benefits that were consistent with the overall trial populations, although the magnitude of the ischemic risk reduction appeared to be enhanced with prasugrel. Whether these findings may be attributed to differences in the pharmacodynamic profiles of these drugs in DM patients remains poorly explored and represented the aim of this study. In this prospective, randomized, double-blind, double-dummy, crossover pharmacodynamic study, aspirin-treated DM patients (n=50) with coronary artery disease were randomly assigned to receive prasugrel (60 mg loading dose [LD]/10 mg maintenance dose once daily) or ticagrelor (180 mg LD/90 mg maintenance dose twice daily) for 1 week. Pharmacodynamic assessments were conducted using 4 different assays, including VerifyNow P2Y12, vasodilator-stimulated phosphoprotein, light transmittance aggregometry, and Multiplate, which allowed us to explore ADP- and non-ADP-induced (arachidonic acid-, collagen-, thrombin receptor-activating, peptide-induced) platelet signaling pathways. The acute (baseline, 30 minutes, and 2 hours post-LD) and maintenance (1 week) effects of therapy were assessed. The primary end point of the study was the comparison of P2Y12 reaction units determined by VerifyNow P2Y12 at 1 week between prasugrel and ticagrelor. ADP- and non-ADP-induced measures of platelet reactivity reduced significantly with both prasugrel and ticagrelor LD and maintenance dose. P2Y12 reaction units defined by VerifyNow were similar between prasugrel and ticagrelor at 30 minutes and 2 hours post-LD. At 1 week, P2Y12 reaction units were significantly lower with ticagrelor

  12. Secundaire preventie met clopidogrel na TIA of herseninfarct

    Zuurbier, S. M. Yvonne; Vermeer, Sarah E.; Hilkens, Pieter H. E.; Algra, Ale; Roos, Yvo B. W. E. M.

    2013-01-01

    In patients with TIA or stroke of arterial origin various antiplatelet agents, or combinations of these, have been found to be effective to reduce the risk of new vascular complications. International guidelines currently recommend three treatment strategies with antiplatelet agents after TIA or

  13. Prasugrel versus clopidogrel for acute coronary syndromes without revascularization

    Roe, M.T.; Armstrong, P.W.; Fox, K.A.; White, H.D.; Prabhakaran, D.; Goodman, S.G.; Cornel, J.H.; Bhatt, D.L.; Clemmensen, P.; Martinez, F.; Ardissino, D.; Nicolau, J.C.; Boden, W.E.; Gurbel, P.A.; Ruzyllo, W.; Dalby, A.J.; McGuire, D.K.; Leiva-Pons, J.L.; Parkhomenko, A.; Gottlieb, S.; Topacio, G.O.; Hamm, C.; Pavlides, G.; Goudev, A.R.; Oto, A.; Tseng, C.D.; Merkely, B.; Gasparovic, V.; Corbalan, R.; Cinteza, M.; McLendon, R.C.; Winters, K.J.; Brown, E.B.; Lokhnygina, Y.; Aylward, P.E.; Huber, K.; Hochman, J.S.; Ohman, E.M.; Verheugt, F.W.A.; et al.,

    2012-01-01

    BACKGROUND: The effect of intensified platelet inhibition for patients with unstable angina or myocardial infarction without ST-segment elevation who do not undergo revascularization has not been delineated. METHODS: In this double-blind, randomized trial, in a primary analysis involving 7243

  14. Unmasking of Partial Diabetes Insipidus during Stress but Not Maintenance Dosing of Glucocorticoids in an Infant with Septo-Optic Dysplasia

    Loechner KarenJ

    2011-03-01

    Full Text Available Background. It is well acknowledged that glucocorticoid (GC replacement can unmask diabetes insipidus (DI in subjects with hypopituitarism. Objective. To increase the awareness and monitoring for transient and symptomatic DI in children with partial hypopituitarism during periods in which increased GC needs are required. Methods/Case. A 2-month-old female infant with septo-optic dysplasia (SOD; on thyroid and maintenance GC replacement therapy at 8 mg/m2/day developed transient DI during 2 separate episodes of stress (one hypothermia, one febrile when stress dosing of GC (25 mg/m2/day was instituted. Conclusion. Children not diagnosed with DI during initial evaluation for hypopituitarism may benefit from rescreening of serum sodium levels during acute periods of stress that demand "stress" GC dosing. This will permit treatment and/or increased vigilance for ensuing permanent DI.

  15. Venom Immunotherapy in High-Risk Patients: The Advantage of the Rush Build-Up Protocol.

    Rosman, Yossi; Confino-Cohen, Ronit; Goldberg, Arnon

    2017-01-01

    Venom immunotherapy (VIT) is considered to be the gold standard treatment for patients with hymenoptera venom allergy. This treatment induces systemic reactions (SR) in a significant number of patients. To evaluate the outcome of VIT in patients with known risk factors for VIT-induced SR and to compare rush VIT (RVIT) and conventional VIT (CVIT). All of the patients who received VIT and had at least one of the following risk factors were included: current cardiovascular disease, uncontrolled asthma, high basal serum tryptase, current treatment with β-blockers or angiotensin-converting enzyme inhibitors, and age >70 or bee venom. Thirty-five (54.7%) patients underwent RVIT and 29 CVIT. The incidence of patients who developed SR during the build-up phase was similar for RVIT and CVIT (25.7 and 27.5%, respectively; p = 1). However, the incidence of SR per injection was significantly higher in CVIT than in RVIT (5.6 and 2.75%, respectively; p = 0.01). Most reactions (79.1%) were mild, limited to the skin. Most of the patients (92.1%) reached the full maintenance dose of 100 μg. This dose was reached by a significantly larger number of patients receiving RVIT compared to CVIT (100 and 82.7%, respectively; p = 0.01). None of the patients experienced exacerbation of their concurrent chronic disease during VIT. VIT can be performed safely and efficiently in patients with risk factors for immunotherapy. In these patients RVIT appears to be safer and more efficient than CVIT. © 2017 S. Karger AG, Basel.

  16. Prevalence and impact of high platelet reactivity in chronic kidney disease: results from the Assessment of Dual Antiplatelet Therapy with Drug-Eluting Stents registry.

    Baber, Usman; Mehran, Roxana; Kirtane, Ajay J; Gurbel, Paul A; Christodoulidis, Georgios; Maehara, Akiko; Witzenbichler, Bernhard; Weisz, Giora; Rinaldi, Michael J; Metzger, D Christopher; Henry, Timothy D; Cox, David A; Duffy, Peter L; Mazzaferri, Ernest L; Xu, Ke; Parise, Helen; Brodie, Bruce R; Stuckey, Thomas D; Stone, Gregg W

    2015-06-01

    Chronic kidney disease (CKD) is associated with increased rates of adverse events after percutaneous coronary intervention. We sought to determine the impact of CKD on platelet reactivity in clopidogrel-treated patients and whether high platelet reactivity (HPR) confers a similar or differential risk for adverse events among patients with CKD and non-CKD. We performed a post hoc analysis of the Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents (ADAPT-DES) registry, which included 8582 patients undergoing percutaneous coronary intervention with drug-eluting stents and platelet function testing using the VerifyNow assay. We compared HPR and its impact on ischemic and bleeding events >2 years among patients with CKD and non-CKD. Patients with CKD (n=1367) were older, more often female, diabetic, and had lower ejection fraction compared with their non-CKD counterparts (n=7043). Although HPR prevalence increased with worsening renal function in unadjusted analyses, these associations were no longer present after adjustment. Major adverse cardiac event rates at 2 years among those without CKD or HPR, HPR alone, CKD alone, and both CKD and HPR were 9.0%, 11.2%, 13.3%, and 17.5%, respectively (Pimpact of HPR on ischemic and bleeding events is similar irrespective of CKD status. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00638794. © 2015 American Heart Association, Inc.

  17. A pilot study of omalizumab to facilitate rapid oral desensitization in high-risk peanut allergic patients

    Schneider, Lynda C.; Rachid, Rima; LeBovidge, Jennifer; Blood, Emily; Mittal, Mudita; Umetsu, Dale T.

    2015-01-01

    Background Peanut allergy is a major public health problem that affects 1% of the population and has no effective therapy. Objective To examine the safety and efficacy of oraldesensitization in peanut allergic children in combination with a brief course of anti-IgE monoclonal antibody (omalizumab, Xolair). Methods We performed oral peanut desensitization in peanut allergic children at high risk for developing significant peanut-induced allergic reactions. Omalizumab was administered prior to and during oral peanut desensitization. Results We enrolled 13 children (median age, 10 years), with a median peanut-specific IgE of 229 kUA/L and a median total serum IgE of 621 kU/L, who failed an initial double-blind placebo controlled food challenge at doses 100 mg peanut flour. After pre-treatment with omalizumab, all subjects tolerated the initial 11 desensitization doses given on the first day, including the maximum dose of 500 mg peanut flour (cumulative dose, 992 mg, equivalent to >2 peanuts), requiring minimal or no rescue therapy. 12 subjects then reached the maximum maintenance dose of 4,000 mg peanut flour/day in a median time of 8 weeks, at which point omalizumab was discontinued. All 12 subjects continued on 4,000 mg peanut flour/day and subsequently tolerated a challenge with 8,000 mg peanut flour (equivalent to about 20 peanuts), or 160 to 400 times the dose tolerated before desensitization. During the study, 6 of the 13 subjects experienced mild or no allergic reactions; 6 subjects had Grade 2, and 2 subjects Grade 3 reactions, all of which responded rapidly to treatment. Conclusions Among children with high-risk peanut allergy, treatment with omalizumab may facilitate rapid oral desensitization, and qualitativelyimprove the desensitization process. PMID:24176117

  18. A pilot study of omalizumab to facilitate rapid oral desensitization in high-risk peanut-allergic patients.

    Schneider, Lynda C; Rachid, Rima; LeBovidge, Jennifer; Blood, Emily; Mittal, Mudita; Umetsu, Dale T

    2013-12-01

    Peanut allergy is a major public health problem that affects 1% of the population and has no effective therapy. To examine the safety and efficacy of oral desensitization in peanut-allergic children in combination with a brief course of anti-IgE mAb (omalizumab [Xolair]). We performed oral peanut desensitization in peanut-allergic children at high risk for developing significant peanut-induced allergic reactions. Omalizumab was administered before and during oral peanut desensitization. We enrolled 13 children (median age, 10 years), with a median peanut-specific IgE level of 229 kU(A)/L and a median total serum IgE level of 621 kU/L, who failed an initial double-blind placebo-controlled food challenge at peanut flour doses of 100 mg or less. After pretreatment with omalizumab, all 13 subjects tolerated the initial 11 desensitization doses given on the first day, including the maximum dose of 500 mg peanut flour (cumulative dose, 992 mg, equivalent to >2 peanuts), requiring minimal or no rescue therapy. Twelve subjects then reached the maximum maintenance dose of 4000 mg peanut flour per day in a median time of 8 weeks, at which point omalizumab was discontinued. All 12 subjects continued on 4000 mg peanut flour per day and subsequently tolerated a challenge with 8000 mg peanut flour (equivalent to about 20 peanuts), or 160 to 400 times the dose tolerated before desensitization. During the study, 6 of the 13 subjects experienced mild or no allergic reactions, 5 subjects had grade 2 reactions, and 2 subjects had grade 3 reactions, all of which responded rapidly to treatment. Among children with high-risk peanut allergy, treatment with omalizumab may facilitate rapid oral desensitization and qualitatively improve the desensitization process. Copyright © 2013 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved.

  19. The association between high on-treatment platelet reactivity and early recurrence of ischemic events after minor stroke or TIA.

    Rao, Zilong; Zheng, Huaguang; Wang, Fei; Wang, Anxin; Liu, Liping; Dong, Kehui; Zhao, Xingquan; Wang, Yilong; Cao, Yibin

    2017-08-01

    To evaluate the role of HTPR in predicting early recurrence of ischemic events in patients with minor ischemic stroke or high-risk TIA. From January 2014 to September 2014, a single center continuously enrolled patients with minor ischemic stroke or high-risk TIA and gave them antiplatelet therapy consisting of aspirin with clopidogrel. HTPR was assessed by TEG after 7 days of antiplatelet therapy and detected CYP2C19 genotype. The incidence of recurrent ischemic events was assessed 3 months after onset. The incidence of recurrent ischemic events was compared between the HTPR and NTPR groups with the Kaplan-Meier method, and multivariate Cox proportional hazards models were used to determine the risk factors associated with recurrent ischemic events. We enrolled 278 eligible patients with minor ischemic stroke or high-risk TIA. Through TEG testing, patients with HTPR were 22.7%, and carriers were not associated with HTPR to ADP by TEG-ADP(%) (p = 0.193). A total of 265 patients completed 3 months of follow-up, and Kaplan-Meier analysis showed that patients with HTPR had a higher percentage of recurrent ischemic events compared with patients with NTPR (p = 0.002). In multivariate Cox proportional hazards models, history of ischemic stroke or TIA (HR 4.45, 95% CI 1.77-11.16, p = 0.001) and HTPR (HR 3.34, 95% CI 1.41-7.91, p = 0.006) was independently associated with recurrent ischemic events. In patients with minor stroke or TIA, the prevalence of HTPR was 22.7%, and HTPR was independently associated with recurrent ischemic events.

  20. Assessment of platelet function in healthy cats in response to commonly prescribed antiplatelet drugs using three point-of-care platelet function tests.

    Ho, Kimberly K; Abrams-Ogg, Anthony Cg; Wood, R Darren; O'Sullivan, M Lynne; Kirby, Gordon M; Blois, Shauna L

    2017-06-01

    Objectives The objective was to determine if decreased platelet function could be detected after treatment with aspirin and/or clopidogrel in healthy cats using three point-of-care platelet function tests that evaluate platelet function by different methods: Multiplate (by impedance), Platelet Function Analyzer 100 (by mechanical aperture closure) and Plateletworks (by platelet counting). Methods Thirty-six healthy cats were randomly assigned to receive one of three oral treatments over an 8 day period: (1) aspirin 5 mg q72h; (2) aspirin 20.25 mg q72h; or (3) clopidogrel 18.75 mg q24h. Cats treated with 5 and 20.25 mg aspirin also received clopidogrel on days 4-8. Platelet aggregation in response to adenosine diphosphate and collagen ± arachidonic acid was assessed on days 1 (baseline), 4 and 8. Aspirin and clopidogrel metabolites were measured by high-performance liquid chromatography. Platelet function in response to treatment was analyzed by ANCOVA, linear regression and Spearman correlation. Results The only solitary aspirin effect was detected using Plateletworks with collagen in cats treated with 20.25 mg. The only effect detected by Multiplate was using arachidonic acid in cats treated with both aspirin 20.25 mg and clopidogrel. All clopidogrel treatment effects were detected by Platelet Function Analyzer 100, Plateletworks (adenosine diphosphate) and Plateletworks (collagen). Drug metabolites were present in all cats, but concentrations were minimally correlated to platelet function test results. Conclusions and relevance Platelet Function Analyzer 100 and Plateletworks using adenosine diphosphate ± collagen agonists may be used to detect decreased platelet function in response to clopidogrel treatment. Either aspirin is not as effective an antiplatelet drug as clopidogrel, or the tests used were not optimal to measure aspirin effect. Cats with heart disease are commonly prescribed antiplatelet drugs to decrease the risk of aortic thromboembolism

  1. Bronchoscopic intratumoral injection of tranexamic acid to prevent excessive bleeding during multiple forceps biopsies of lesions with a high risk of bleeding: a prospective case series

    Zamani, Adil

    2014-01-01

    Significant bleeding may occur following endobronchial forceps biopsy or brushing of necrotic or hypervascular tumors in the airways. In some cases, methods such as endobronchial instillation of iced saline lavage and epinephrine may fail to control bleeding. The present study evaluated the efficacy and safety of a new bronchoscopic technique using intratumoral injection of tranexamic acid (IIT) for control of bleeding during forceps biopsy in patients with endobronchial tumors with a high risk of bleeding. The study was a prospective case series carried out in a single center. Bronchoscopic IIT was performed in those patients who had endoscopically visible tumoral lesions with persistent active bleeding following the first attempt at bronchoscopic sampling. Tranexamic acid (TEA) was injected through a 22-gauge Wang cytology needle into the lesion in nominal doses of 250–500 mg. After 2–3 minutes, multiple forceps biopsy specimens were obtained from the lesion. Of the 57 consecutive patients included in the study, 20 patients (35.1%) underwent bronchoscopic IIT. The first attempt in 18 patients was endobronchial forceps biopsy (EBB), and because of a high risk of bleeding, the first attempt for the remaining two patients, who were on continuous dual antiplatelet therapy (aspirin and clopidogrel), employed endobronchial needle aspiration (EBNA) as a precautionary measure. Following IIT, subsequent specimens were obtained using EBB in all patients. Multiple forceps biopsy specimens (3–10) were obtained from the lesions (8 necrotic and 12 hypervascular) without incurring active bleeding. The following histopathologic diagnoses were made: squamous cell carcinoma (n = 14), adenocarcinoma (n = 2), small-cell lung cancer (n = 3), and malignant mesenchymal tumor (n = 1). No side effects of TEA were observed. Bronchoscopic IIT is a useful and safe technique for controlling significant bleeding from a forceps biopsy procedure and can be considered as a pre

  2. Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS)

    Bath, Philip M; Woodhouse, Lisa J; Appleton, Jason P

    2018-01-01

    , and dipyridamole) with that of guideline-based antiplatelet therapy. METHODS: We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using...... was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using...... therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did...

  3. Bioavailability of House Dust Mite Allergens in Sublingual Allergy Tablets Is Highly Dependent on the Formulation.

    Ohashi-Doi, Katsuyo; Kito, Hirokazu; Du, Weibin; Nakazawa, Hiroshi; Ipsen, Henrik; Gudmann, Pernille; Lund, Kaare

    2017-01-01

    In sublingual immunotherapy (SLIT), the immune system is addressed by solubilized allergen that interacts with immunocompetent cells of the oral mucosa, the efficiency of which is governed by 2 main factors of SLIT allergen bioavailability: the allergen concentration and the mucosal contact time. Recently, 3 house dust mite (HDM) SLIT tablets were developed that differ with regard to allergen content, nominal strength (maintenance doses: 6 SQ-HDM/10,000 Japanese Allergen Units [JAU], 12 SQ-HDM/ 20,000 JAU, and 300 IR/57,000 JAU), and formulation (freeze-dried/compressed). Here, the importance of the SLIT tablet formulation for HDM major allergen bioavailability is examined. The HDM major allergen content, tablet disintegration times, and allergen release kinetics were determined. Dissolution kinetics (allergen concentration vs. time) of Der f 1, Der p 1, and Der 2 were measured. Area under the curve (AUC) was used as a surrogate parameter for allergen bioavailability. The release of HDM major allergens from the freeze-dried tablets was complete after 30 s, while only partial release was achieved with the compressed tablets, even after prolonged dissolution. At 1 min, i.e., the recommended sublingual holding time for the freeze-dried tablets, the allergen bioavailability (AUC) of the compressed 300 IR/57,000 JAU tablet was 4.7-fold (Der f 1), 10.8-fold (Der p 1), and 23.6-fold (Der 2) lower than that of the freeze-dried 12 SQ-HDM/20,000 JAU tablet and similar to (Der f 1) and 5.3-fold (Der p 1) and 12.5-fold (Der 2) lower than that of the freeze-dried 6 SQ-HDM/10,000 JAU tablet. SLIT tablet allergen bioavailability depends highly on the tablet formulation. Only the fast-dissolving freeze-dried tablets provide maximal delivery of soluble allergens and achieve allergen concentrations that reflect the nominal tablet strengths within the recommended sublingual holding time. © 2017 S. Karger AG, Basel.

  4. High PRF high current switch

    Moran, Stuart L.; Hutcherson, R. Kenneth

    1990-03-27

    A triggerable, high voltage, high current, spark gap switch for use in pu power systems. The device comprises a pair of electrodes in a high pressure hydrogen environment that is triggered by introducing an arc between one electrode and a trigger pin. Unusually high repetition rates may be obtained by undervolting the switch, i.e., operating the trigger at voltages much below the self-breakdown voltage of the device.

  5. High-Value Care in the Evaluation of Stroke.

    Urja, Prakrity; Nippoldt, Eric H; Barak, Virginia; Valenta, Carrie

    2017-08-01

    Value-based care emphasizes achieving the greatest overall health benefit for every dollar spent. We present an interesting case of stroke, which made us consider how frequently health care providers are utilizing value-based care. A 73-year-old Caucasian, who was initially admitted for a hypertensive emergency, was transferred to our facility for worsening slurring of speech and left-sided weakness. The patient had an extensive chronic cerebrovascular disease, including multiple embolic type strokes, mainly in the distribution of the right temporal-occipital cerebral artery and transient ischemic attacks (TIAs). The patient had a known history of patent foramen ovale (PFO) and occlusion of the right internal carotid artery. He was complicated by intracranial hemorrhage while on anticoagulation for pulmonary embolism. He was chronically on dual antiplatelet therapy (aspirin and clopidogrel) and statin.  Following the transfer, stroke protocol, including the activation of the stroke team, a computed tomography (CT) imaging study, and the rapid stabilization of the patient was initiated. His vitals were stable, and the physical examination was significant for the drooping of the left angle of the mouth, a nonreactive right pupil consistent with the previous stroke, a decreased strength in the left upper and lower extremities, and a faint systolic murmur. His previous stroke was shown to be embolic, involving both the right temporal and occipital regions, which was re-demonstrated in a CT scan. A magnetic resonance imaging (MRI) scan of the brain showed a new, restricted diffusion in the right pons that was compatible with an acute stroke as well as diffusely atherosclerotic vessels with a focal stenosis of the branch vessels. A transthoracic echocardiogram demonstrated no new thrombus in the heart. A transesophageal echocardiogram (TEE) showed known PFO, and repeat hypercoagulation evaluation was negative, as it was in his previous cerebrovascular accident (CVA

  6. Safety of low-dose aspirin in endovascular treatment for intracranial atherosclerotic stenosis.

    Ning Ma

    Full Text Available OBJECTIVES: To evaluate the safety of low-dose aspirin plus clopidogrel versus high-dose aspirin plus clopidogrel in prevention of vascular risk within 90 days of duration of dual antiplatelet therapy in patients treated with intracranial endovascular treatment. METHODS: From January 2012 to December 2013, this prospective and observational study enrolled 370 patients with symptomatic intracranial atherosclerotic stenosis of ≥70% with poor collateral undergoing intracranial endovascular treatment. Antiplatelet therapy consists of aspirin, at a low-dose of 100 mg or high-dose of 300 mg daily; clopidogrel, at a dose of 75 mg daily for 5 days before endovascular treatment. The dual antiplatelet therapy continued for 90 days after intervention. The study endpoints include acute thrombosis, subacute thrombosis, stroke or death within 90 days after intervention. RESULTS: Two hundred and seventy three patients received low-dose aspirin plus clopidogrel and 97 patients received high-dose aspirin plus clopidogrel before intracranial endovascular treatment. Within 90 days after intervention, there were 4 patients (1.5% with acute thrombosis, 5 patients (1.8% with subacute thrombosis, 17 patients (6.2% with stroke, and 2 death (0.7% in low-dose aspirin group, compared with no patient (0% with acute thrombosis, 2 patient (2.1% with subacute thrombosis, 6 patients (6.2% with stroke, and 2 death (2.1% in high-dose aspirin group, and there were no significant difference in all study endpoints between two groups. CONCLUSION: Low-dose aspirin plus clopidogrel is comparative in safety with high-dose aspirin plus clopidogrel within 90 days of duration of dual antiplatelet therapy in patients treated with intracranial endovascular treatment.

  7. The Vitamin D for Enhancing the Immune System in Cystic Fibrosis (DISC trial: Rationale and design of a multi-center, double-blind, placebo-controlled trial of high dose bolus administration of vitamin D3 during acute pulmonary exacerbation of cystic fibrosis

    Vin Tangpricha

    2017-06-01

    Full Text Available Vitamin D deficiency is highly prevalent in children and adults with cystic fibrosis (CF. Recent studies have found an association between vitamin D status and risk of pulmonary exacerbations in children and adults with CF. The ongoing Vitamin D for enhancing the Immune System in Cystic fibrosis (DISC study, a multi-center, double-blind, randomized, placebo-controlled trial, will test the hypothesis of whether high dose vitamin D given as a single oral bolus of 250,000 IU to adults with CF during a pulmonary exacerbation followed by a maintenance dose of vitamin D will improve time to next pulmonary exacerbation and re-hospitalization, improve survival and lung function compared to placebo and reduce the rates of pulmonary exacerbation. Subjects will be randomized 1:1 at each clinical site to vitamin D or placebo within 72 h of hospital admission for pulmonary exacerbation. Clinical follow-up visits will occur at 1, 2, 3, and 7 days, and 1, 3, 6 and 12 months after randomization. Blood and sputum will be collected and determination of clinical outcomes will be assessed at each visit. The primary endpoint will be the time to next pulmonary exacerbation requiring antibiotics, re-hospitalization or death. The secondary endpoints will include lung function assessed by forced expiratory volume in 1 s (FEV1, blood markers of inflammatory cytokines, anti-microbial peptide expression by peripheral blood mononuclear cells and circulating concentrations in blood. Other exploratory endpoints will examine the phenotype of neutrophils and monocyte/macrophages in sputum. Nutritional status will be assessed by 3 day food records and food frequency questionnaire.

  8. Gastrointestinal Events with Clopidogrel: A Nationwide Population-Based Cohort Study

    Grove, Erik; Würtz, Morten; Schwarz, Peter

    2012-01-01

    the background population (n = 232,510). ANALYSES: Follow-up began on January 1, 1996, and was censored on December 31, 2007, or if patients emigrated or died. The study endpoint was the occurrence of any gastritis, GI ulcer or bleeding. Analyses were adjusted for comorbidity and medication. RESULTS: Regardless...

  9. Highly efficient high temperature electrolysis

    Hauch, Anne; Ebbesen, Sune; Jensen, Søren Højgaard

    2008-01-01

    High temperature electrolysis of water and steam may provide an efficient, cost effective and environmentally friendly production of H-2 Using electricity produced from sustainable, non-fossil energy sources. To achieve cost competitive electrolysis cells that are both high performing i.e. minimum...... internal resistance of the cell, and long-term stable, it is critical to develop electrode materials that are optimal for steam electrolysis. In this article electrolysis cells for electrolysis of water or steam at temperatures above 200 degrees C for production of H-2 are reviewed. High temperature...... electrolysis is favourable from a thermodynamic point of view, because a part of the required energy can be supplied as thermal heat, and the activation barrier is lowered increasing the H-2 production rate. Only two types of cells operating at high temperature (above 200 degrees C) have been described...

  10. High Line

    Kiib, Hans

    2015-01-01

    At just over 10 meters above street level, the High Line extends three kilometers through three districts of Southwestern Manhattan in New York. It consists of simple steel construction, and previously served as an elevated rail line connection between Penn Station on 34th Street and the many....... The High Line project has been carried out as part of an open conversion strategy. The result is a remarkable urban architectural project, which works as a catalyst for the urban development of Western Manhattan. The greater project includes the restoration and reuse of many old industrial buildings...

  11. High Class

    Waldecker, Mark

    2005-01-01

    Education administrators make buying decisions for furniture based on many factors. Cost, durability, functionality, safety and aesthetics represent just a few. Those issues always will be important, but gaining greater recognition in recent years has been the role furniture plays in creating positive, high-performance learning environments. The…

  12. High Turbulence

    EuHIT, Collaboration

    2015-01-01

    As a member of the EuHIT (European High-Performance Infrastructures in Turbulence - see here) consortium, CERN is participating in fundamental research on turbulence phenomena. To this end, the Laboratory provides European researchers with a cryogenic research infrastructure (see here), where the first tests have just been performed.

  13. Highly dominating, highly authoritarian personalities.

    Altemeyer, Bob

    2004-08-01

    The author considered the small part of the population whose members score highly on both the Social Dominance Orientation scale and the Right-Wing Authoritarianism scale. Studies of these High SDO-High RWAs, culled from samples of nearly 4000 Canadian university students and over 2600 of their parents and reported in the present article, reveal that these dominating authoritarians are among the most prejudiced persons in society. Furthermore, they seem to combine the worst elements of each kind of personality, being power-hungry, unsupportive of equality, manipulative, and amoral, as social dominators are in general, while also being religiously ethnocentric and dogmatic, as right-wing authoritarians tend to be. The author suggested that, although they are small in number, such persons can have considerable impact on society because they are well-positioned to become the leaders of prejudiced right-wing political movements.

  14. High Energy $\

    2002-01-01

    This experiment is a high statistics exposure of BEBC filled with hydrogen to both @n and &bar.@n beams. The principal physics aims are : \\item a) The study of the production of charmed mesons and baryons using fully constrained events. \\end{enumerate} b) The study of neutral current interactions on the free proton. \\item c) Measurement of the cross-sections for production of exclusive final state N* and @D resonances. \\item d) Studies of hadronic final states in charged and neutral current reactions. \\item e) Measurement of inclusive charged current cross-sections and structure functions. \\end{enumerate}\\\\ \\\\ The neutrino flux is determined by monitoring the flux of muons in the neutrino shield. The Internal Picket Fence and External Muon Identifier of BEBC are essential parts of the experiment. High resolution cameras are used to search for visible decays of short-lived particles.

  15. SCN1A, ABCC2 and UGT2B7 gene polymorphisms in association with individualized oxcarbazepine therapy.

    Ma, Chun-Lai; Wu, Xun-Yi; Jiao, Zheng; Hong, Zhen; Wu, Zhi-Yuan; Zhong, Ming-Kang

    2015-01-01

    Associations between the effects of SCN1A, SCN2A, ABCC2 and UGT2B7 genetic polymorphisms and oxcarbazepine (OXC) maintenance doses in Han Chinese epileptic patients were investigated. Genetic polymorphisms were detected in 184 epileptic patients receiving OXC monotherapy by high-resolution melting curve and TaqMan method. Carriers of the SCN1A IVS5-91G>A, UGT2B7 c.802T>C and ABCC2 c.1249G>A variant alleles required significantly higher OXC maintenance doses than noncarriers (p GA > AA. SCN1A, UGT2B7 and ABCC2 genetic polymorphisms are associated with OXC maintenance doses and may be useful for the personalization of OXC therapy in epileptic patients. Further studies are needed. Original submitted 6 June 2014; Revision submitted 5 September 2014.

  16. High energy

    Bonner, B.E.; Roberts, J.B. Jr.

    1993-01-01

    We report here on progress made for the period from December 1, 1992 (the date of submission of our latest progress report) to November 30, 1993 for DOE Grant No. DE-FG05-92ER40717. The new results from the SMC experiment have generated a buzz of theoretical activity. Our involvement with the D0 experiment and the upgrade has increased substantially during the past two years so that we now have six people heavily committed and making what can only be described as a large and disproportionate impact on D0 physics output. Some of the new developments made here at Rice in Neural Network and Probability Density Estimation techniques for data analysis promise to have applications both in D0 and beyond. We report a load of new results from our high-p t jet photoproduction experiment. In addition we have been working on KTeV, albeit without having adequate funding for this work. Progress on the theoretical front has been nothing short of amazing, as is reported herein. In a grand lecture tour during this sabbatical year, Paul Stevenson has already reported his breakthroughs at ten institutions, including CERN, Oxford, Cambridge, Rutherford Lab, Imperial College, and Durham University. The group at Rice University has had an exceptionally productive year and we are justifiably proud of the progress which is reported here

  17. Non-steroidal anti-inflammatory high digestive bleeding hospital income / Ingresos hospitalarios por hemorragia digestiva alta por antiinflamatorios no esteroidicos

    Valls MD

    2004-12-01

    Full Text Available From year 1997 the Requena Hospital Pharmacy Service maintain a program of detection and prevention of drugs-related problems hospital income (DRPI. The program is coordinated with the Primary Care Pharmacy Service for the establishment of the preventive measures. The DRPI program establishes feedback, collective and/or individualized, on the agents of health of the Health Area and on the population in general, according to the cases, as it bases for the prevention of DRPIs. Methods: The detection of IDRP is made by means of revision of the diagnoses gathered in the admission book of the Emergency Department and the HIGIA database. Clinical records of the patients are retrospectively analyzed. Medical criteria, specifically gathered in clinical history, are accepted for the imputability establishment. Results: In period 1997-2003, 195 drug-related high digestive hemorrhage hospital income (HDH have been detected: 188 by non-steroidal anti-inflammatory drugs (NSAID, in two cases the NSAID could not settle down cause, 3 by ticlopidine, 3 by metamizole and 1 by clopidogrel. In 45 cases (23% the involved medicine was over the counter (OTC, 58 cases were related to low doses aspirin (AAS, 15 cases related to the association of NSAIDs or NSAIDs with low doses AAS and 70 cases were produced by non-aspirin-NSAIDs or non-OTC-AAS to doses of 500mg. 80% of the cases of HDH by AAS to low doses took place in patients of 69 years old or older. In 85% of the cases of HDH by non-aspirin- NSAID or non-OTC-AAS of 500mg with gastro-protection criteria this had not been used. In the three cases of HDH by metamizole patients were older than 80 years and with HDH antecedents. Conclusions: The low use of gastroprotection between the affected population of HDH by NSAIDs in spite of the existence of clear factors of risk concludes. Gastroprotection in patients dealt with low doses AAS and equal or greater age about 69 years although the age were the only factor of risk

  18. Update: Acute coronary syndromes (V). Personalized antiplatelet therapy.

    Gurbel, Paul A; Rafeedheen, Rahil; Tantry, Udaya S

    2014-06-01

    It is well established that high on-treatment platelet reactivity to adenosine diphosphate during clopidogrel therapy is an independent risk factor for ischemic event occurrences in a postpercutaneous coronary intervention patients. However, the precise role of platelet function testing remains debated. Platelet function testing to ensure optimal platelet inhibition has been recommended by some authorities to improve outcomes in patients treated with clopidogrel. Recent prospective, randomized trials of personalized antiplatelet therapy have failed to demonstrate a benefit of platelet function testing in improving outcomes. In this review article, we discuss the mechanisms responsible for clopidogrel nonreponsiveness, recent trials of platelet function testing, and other new developments in the field of personalized antiplatelet therapy. Copyright © 2014 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.

  19. High Combustion Research Facility

    Federal Laboratory Consortium — At NETL's High-Pressure Combustion Research Facility in Morgantown, WV, researchers can investigate new high-pressure, high-temperature hydrogen turbine combustion...

  20. Major bleeding in acute coronary syndromes: Incidence, predictors and prognostic value

    Walid Ammar

    2014-03-01

    Conclusions: Major bleeding is a powerful independent predictor of in-hospital and 30 day mortality in patients with ACS. Advanced age, renal insufficiency, high clopidogrel loading and invasive coronary procedures are independent risk factors for major bleeding in ACS patients.

  1. RESIDUAL PLATELET REACTIVITY DURING THERAPY WITH INHIBITORS OF CYCLOOXIGENASE OR ADENOSINE DIPHOSPHATE RECEPTORS

    A. A. Lomonosova

    2012-01-01

    Full Text Available Aim. To compare effects of acetylsalicylic acid (ASA and two clopidogrel drugs on residual platelet aggregative reactivity (RPAR. Material and methods. Patients (n=40 with ischemic heart disease aged under 70 years were involved into the crossover study. Clinical examination included questionnaire survey , blood pressure (BP measurement, ECG registration, 24-hour ECG and BP monitoring, determination of blood levels of total cholesterol, high density lipoproteins, triglycerides, transaminases, and creatinine, complete blood cell count, including platelets number and hemoglobin level. Besides evaluation of the platelet aggregation by optical aggregometry was performed initially , after one week ASA treatment and after every next 3 week clopidogrel treatment period.  Results. RPAR during ASA monotherapy was 56.4±0.3%. There were no significant differences in effects of original and generic clopidogrel on RPAR. Сlopidogrel therapy reduced RPAR more significantly (42.2±0.2% than ASA monotherapy did (p=0.0003. Authors proposed definition for high level of RPAR during therapy - it is platelet aggregation more than 46%. Data analysis taking into account this criterion showed that a number of patients with high RPAR was 70 and 30% among patients treated with enterosoluble ASA and clopidogrel, respectively. Conclusion. Study results show that a significant number of patients receiving antiplatelet monotherapy does not achieve the target level of RPAR(<46%. These results may be a rationale for combined therapy in patients of this type.

  2. Three days rush venom immunotherapy in bee allergy: safe, inexpensive and instantaneously effective.

    Goldberg, Arnon; Yogev, Ayala; Confino-Cohen, Ronit

    2011-01-01

    Rush venom immunotherapy (VIT) is highly effective in vespid venom allergy, but comparable data regarding bee venom (BV) allergy are sparse. We evaluated its safety, efficacy and cost in BV-allergic patients. Conventional or rush VIT were offered to all patients with systemic reaction to insect sting. Rush VIT was also given to hyperreactive patients who failed to reach the maintenance dose with conventional VIT due to multiple systemic reactions. In BV-allergic patients, honeybee sting challenge was performed within 1 week after reaching the maintenance dose. 179 patients, some of them allergic to more than one venom, received 246 rush VIT courses. Bee VIT was administered to 132 patients (73.7%); 173 patients (96.6%) reached the maintenance dose. The incidence of systemic reactions was 29.6%. They were more common in VIT with BV than with vespid venoms (31.1 and 16.3%, respectively, p = 0.01). After excluding the hyperreactive subgroup (n = 20), this difference was not significant (23.7 and 16%, respectively, p = 0.19). Despite the high incidence of systemic reactions (15 of 20, 75%) among hyperreactive patients, 17 patients (85%) achieved the maintenance dose. Sting challenges resulted in systemic reaction in 4 of 8 (50%) hyperreactive patients and in 2 of 47 (4.3%) ordinary patients. The cost of rush VIT was 41% of that of conventional VIT. Rush VIT with BV is safe, instantaneously effective, less expensive and enables most patients with previous failures of conventional VIT to reach the maintenance dose. Copyright © 2011 S. Karger AG, Basel.

  3. Early clinical outcomes as a function of use of newer oral P2Yinhibitors versus clopidogrel in the EUROMAX trial

    Huber, Kurt; Ducrocq, Gregory; Hamm, Christian W

    2017-01-01

    Objective: To ascertain whether different oral P2Y12inhibitors might affect rates of acute stent thrombosis and 30-day outcomes after primary percutaneous coronary intervention (pPCI). Methods: The European Ambulance Acute Coronary Syndrome Angiography (EUROMAX) randomised trial compared prehospi...

  4. [Comparison of efficacy and safety of treatment with drugs of clopidogrel in patients after coronary artery stenting].

    Avdeeva, L V; Shtegman, O A; Mosina, V A

    2011-01-01

    Proof of clinical equivalence of generic and original dugs - the way to lessen cost of therapy of patients while providing comparable clinical effects. We present in this paper results of 1 year follow-up of 115 patients receiving Egithromb or Plavics after coronary artery stenting. Comparable clinical efficacy and safety of Egithromb and Plavics has been established.

  5. A Comparative Study of Molecular Structure, pKa, Lipophilicity, Solubility, Absorption and Polar Surface Area of Some Antiplatelet Drugs

    Milan Remko

    2016-03-01

    Full Text Available Theoretical chemistry methods have been used to study the molecular properties of antiplatelet agents (ticlopidine, clopidogrel, prasugrel, elinogrel, ticagrelor and cangrelor and several thiol-containing active metabolites. The geometries and energies of most stable conformers of these drugs have been computed at the Becke3LYP/6-311++G(d,p level of density functional theory. Computed dissociation constants show that the active metabolites of prodrugs (ticlopidine, clopidogrel and prasugrel and drugs elinogrel and cangrelor are completely ionized at pH 7.4. Both ticagrelor and its active metabolite are present at pH = 7.4 in neutral undissociated form. The thienopyridine prodrugs ticlopidine, clopidogrel and prasugrel are lipophilic and insoluble in water. Their lipophilicity is very high (about 2.5–3.5 logP values. The polar surface area, with regard to the structurally-heterogeneous character of these antiplatelet drugs, is from very large interval of values of 3–255 Å2. Thienopyridine prodrugs, like ticlopidine, clopidogrel and prasugrel, with the lowest polar surface area (PSA values, exhibit the largest absorption. A high value of polar surface area (PSA of cangrelor (255 Å2 results in substantial worsening of the absorption in comparison with thienopyridine drugs.

  6. High Performance Networks for High Impact Science

    Scott, Mary A.; Bair, Raymond A.

    2003-02-13

    This workshop was the first major activity in developing a strategic plan for high-performance networking in the Office of Science. Held August 13 through 15, 2002, it brought together a selection of end users, especially representing the emerging, high-visibility initiatives, and network visionaries to identify opportunities and begin defining the path forward.

  7. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Español Hyperglycemia (High Blood Glucose) Hyperglycemia is the technical term for high blood glucose (blood sugar). High ... We Are Research Leaders We Support Your Doctor Student Resources Patient Access to Research Research Resources Practice ...

  8. High Blood Pressure

    ... normal blood pressure 140/90 or higher is high blood pressure Between 120 and 139 for the top number, ... prehypertension. Prehypertension means you may end up with high blood pressure, unless you take steps to prevent it. High ...

  9. High Blood Pressure Facts

    ... Stroke Heart Disease Cholesterol Salt Million Hearts® WISEWOMAN High Blood Pressure Facts Recommend on Facebook Tweet Share Compartir On ... Top of Page CDC Fact Sheets Related to High Blood Pressure High Blood Pressure Pulmonary Hypertension Heart Disease Signs ...

  10. High Blood Pressure (Hypertension)

    ... Print Page Text Size: A A A Listen High Blood Pressure (Hypertension) Nearly 1 in 3 American adults has ... weight. How Will I Know if I Have High Blood Pressure? High blood pressure is a silent problem — you ...

  11. High Throughput Facility

    Federal Laboratory Consortium — Argonne?s high throughput facility provides highly automated and parallel approaches to material and materials chemistry development. The facility allows scientists...

  12. High pressure, high current, low inductance, high reliability sealed terminals

    Hsu, John S [Oak Ridge, TN; McKeever, John W [Oak Ridge, TN

    2010-03-23

    The invention is a terminal assembly having a casing with at least one delivery tapered-cone conductor and at least one return tapered-cone conductor routed there-through. The delivery and return tapered-cone conductors are electrically isolated from each other and positioned in the annuluses of ordered concentric cones at an off-normal angle. The tapered cone conductor service can be AC phase conductors and DC link conductors. The center core has at least one service conduit of gate signal leads, diagnostic signal wires, and refrigerant tubing routed there-through. A seal material is in direct contact with the casing inner surface, the tapered-cone conductors, and the service conduits thereby hermetically filling the interstitial space in the casing interior core and center core. The assembly provides simultaneous high-current, high-pressure, low-inductance, and high-reliability service.

  13. Space Based Infrared System High (SBIRS High)

    2015-12-01

    elements (five SMGTs) for the S2E2 Mobile Ground System. ​ SBIRS Block Buy (GEO 5-6) The GEO 5-6 Tech Refresh (TR) Engineering Change Proposal was...Selected Acquisition Report (SAR) RCS: DD-A&T(Q&A)823-210 Space Based Infrared System High ( SBIRS High) As of FY 2017 President’s Budget Defense...Acquisition Management Information Retrieval (DAMIR) March 23, 2016 11:24:26 UNCLASSIFIED SBIRS High December 2015 SAR March 23, 2016 11:24:26

  14. Bumball: Highly Engaging, Highly Inclusive, and Highly Entertaining

    Hall, Amber; Barney, David; Wilkinson, Carol

    2014-01-01

    Physical educators are always looking for new and exciting games and activities in which students can participate. This article describes Bumball, a high-intensity game that provides the opportunity for students to use many common game skills, such as hand-eye coordination, passing to a target, running, playing defense, and getting to an open…

  15. High temperature high vacuum creep testing facilities

    Matta, M.K.

    1985-01-01

    Creep is the term used to describe time-dependent plastic flow of metals under conditions of constant load or stress at constant high temperature. Creep has an important considerations for materials operating under stresses at high temperatures for long time such as cladding materials, pressure vessels, steam turbines, boilers,...etc. These two creep machines measures the creep of materials and alloys at high temperature under high vacuum at constant stress. By the two chart recorders attached to the system one could register time and temperature versus strain during the test . This report consists of three chapters, chapter I is the introduction, chapter II is the technical description of the creep machines while chapter III discuss some experimental data on the creep behaviour. Of helium implanted stainless steel. 13 fig., 3 tab

  16. Why high energy physics

    Diddens, A.N.; Van de Walle, R.T.

    1981-01-01

    An argument is presented for high energy physics from the point of view of the practitioners. Three different angles are presented: The cultural consequence and scientific significance of practising high energy physics, the potential application of the results and the discovery of high energy physics, and the technical spin-offs from the techniques and methods used in high energy physics. (C.F.)

  17. Hypertension (High Blood Pressure)

    ... Safe Videos for Educators Search English Español Hypertension (High Blood Pressure) KidsHealth / For Teens / Hypertension (High Blood Pressure) What's ... rest temperature diet emotions posture medicines Why Is High Blood Pressure Bad? High blood pressure means a person's heart ...

  18. High-power, high-efficiency FELs

    Sessler, A.M.

    1989-04-01

    High power, high efficiency FELs require tapering, as the particles loose energy, so as to maintain resonance between the electromagnetic wave and the particles. They also require focusing of the particles (usually done with curved pole faces) and focusing of the electromagnetic wave (i.e. optical guiding). In addition, one must avoid transverse beam instabilities (primarily resistive wall) and longitudinal instabilities (i.e sidebands). 18 refs., 7 figs., 3 tabs

  19. High Temperature, High Power Piezoelectric Composite Transducers

    Lee, Hyeong Jae; Zhang, Shujun; Bar-Cohen, Yoseph; Sherrit, StewarT.

    2014-01-01

    Piezoelectric composites are a class of functional materials consisting of piezoelectric active materials and non-piezoelectric passive polymers, mechanically attached together to form different connectivities. These composites have several advantages compared to conventional piezoelectric ceramics and polymers, including improved electromechanical properties, mechanical flexibility and the ability to tailor properties by using several different connectivity patterns. These advantages have led to the improvement of overall transducer performance, such as transducer sensitivity and bandwidth, resulting in rapid implementation of piezoelectric composites in medical imaging ultrasounds and other acoustic transducers. Recently, new piezoelectric composite transducers have been developed with optimized composite components that have improved thermal stability and mechanical quality factors, making them promising candidates for high temperature, high power transducer applications, such as therapeutic ultrasound, high power ultrasonic wirebonding, high temperature non-destructive testing, and downhole energy harvesting. This paper will present recent developments of piezoelectric composite technology for high temperature and high power applications. The concerns and limitations of using piezoelectric composites will also be discussed, and the expected future research directions will be outlined. PMID:25111242

  20. Highly Accreting Quasars at High Redshift

    Mary L. Martínez-Aldama

    2018-01-01

    Full Text Available We present preliminary results of a spectroscopic analysis for a sample of type 1 highly accreting quasars (L/LEdd ~ 1.0 at high redshift, z ~2–3. The quasars were observed with the OSIRIS spectrograph on the GTC 10.4 m telescope located at the Observatorio del Roque de los Muchachos in La Palma. The highly accreting quasars were identified using the 4D Eigenvector 1 formalism, which is able to organize type 1 quasars over a broad range of redshift and luminosity. The kinematic and physical properties of the broad line region have been derived by fitting the profiles of strong UV emission lines such as Aliiiλ1860, Siiii]λ1892 and Ciii]λ1909. The majority of our sources show strong blueshifts in the high-ionization lines and high Eddington ratios which are related with the productions of outflows. The importance of highly accreting quasars goes beyond a detailed understanding of their physics: their extreme Eddington ratio makes them candidates standard candles for cosmological studies.

  1. Highly Accreting Quasars at High Redshift

    Martínez-Aldama, Mary L.; Del Olmo, Ascensión; Marziani, Paola; Sulentic, Jack W.; Negrete, C. Alenka; Dultzin, Deborah; Perea, Jaime; D'Onofrio, Mauro

    2017-12-01

    We present preliminary results of a spectroscopic analysis for a sample of type 1 highly accreting quasars (LLedd>0.2) at high redshift, z 2-3. The quasars were observed with the OSIRIS spectrograph on the GTC 10.4 m telescope located at the Observatorio del Roque de los Muchachos in La Palma. The highly accreting quasars were identified using the 4D Eigenvector 1 formalism, which is able to organize type 1 quasars over a broad range of redshift and luminosity. The kinematic and physical properties of the broad line region have been derived by fitting the profiles of strong UV emission lines such as AlIII, SiIII and CIII. The majority of our sources show strong blueshifts in the high-ionization lines and high Eddington ratios which are related with the productions of outflows. The importance of highly accreting quasars goes beyond a detailed understanding of their physics: their extreme Eddington ratio makes them candidates standard candles for cosmological studies.

  2. High assurance SPIRAL

    Franchetti, Franz; Sandryhaila, Aliaksei; Johnson, Jeremy R.

    2014-06-01

    In this paper we introduce High Assurance SPIRAL to solve the last mile problem for the synthesis of high assurance implementations of controllers for vehicular systems that are executed in today's and future embedded and high performance embedded system processors. High Assurance SPIRAL is a scalable methodology to translate a high level specification of a high assurance controller into a highly resource-efficient, platform-adapted, verified control software implementation for a given platform in a language like C or C++. High Assurance SPIRAL proves that the implementation is equivalent to the specification written in the control engineer's domain language. Our approach scales to problems involving floating-point calculations and provides highly optimized synthesized code. It is possible to estimate the available headroom to enable assurance/performance trade-offs under real-time constraints, and enables the synthesis of multiple implementation variants to make attacks harder. At the core of High Assurance SPIRAL is the Hybrid Control Operator Language (HCOL) that leverages advanced mathematical constructs expressing the controller specification to provide high quality translation capabilities. Combined with a verified/certified compiler, High Assurance SPIRAL provides a comprehensive complete solution to the efficient synthesis of verifiable high assurance controllers. We demonstrate High Assurance SPIRALs capability by co-synthesizing proofs and implementations for attack detection and sensor spoofing algorithms and deploy the code as ROS nodes on the Landshark unmanned ground vehicle and on a Synthetic Car in a real-time simulator.

  3. High concentration agglomerate dynamics at high temperatures.

    Heine, M C; Pratsinis, S E

    2006-11-21

    The dynamics of agglomerate aerosols are investigated at high solids concentrations that are typical in industrial scale manufacture of fine particles (precursor mole fraction larger than 10 mol %). In particular, formation and growth of fumed silica at such concentrations by chemical reaction, coagulation, and sintering is simulated at nonisothermal conditions and compared to limited experimental data and commercial product specifications. Using recent chemical kinetics for silica formation by SiCl4 hydrolysis and neglecting aerosol polydispersity, the evolution of the diameter of primary particles (specific surface area, SSA), hard- and soft-agglomerates, along with agglomerate effective volume fraction (volume occupied by agglomerate) is investigated. Classic Smoluchowski theory is fundamentally limited for description of soft-agglomerate Brownian coagulation at high solids concentrations. In fact, these high concentrations affect little the primary particle diameter (or SSA) but dominate the soft-agglomerate diameter, structure, and volume fraction, leading to gelation consistent with experimental data. This indicates that restructuring and fragmentation should affect product particle characteristics during high-temperature synthesis of nanostructured particles at high concentrations in aerosol flow reactors.

  4. High-frequency, high-intensity photoionization

    Reiss, H. R.

    1996-02-01

    Two analytical methods for computing ionization by high-frequency fields are compared. Predicted ionization rates compare well, but energy predictions for the onset of ionization differ radically. The difference is shown to arise from the use of a transformation in one of the methods that alters the zero from which energy is measured. This alteration leads to an apparent energy threshold for ionization that can, especially in the stabilization regime, differ strongly from the laboratory measurement. It is concluded that channel closings in intense-field ionization can occur at high as well as low frequencies. It is also found that the stabilization phenomenon at high frequencies, very prominent for hydrogen, is absent in a short-range potential.

  5. Western Canada: high prices, high activity

    Savidant, S

    2000-01-01

    The forces responsible for the high drilling and exploration activity in Western Canada (recent high prices, excess pipeline capacity, and the promise of as yet undiscovered natural gas resources) are discussed. Supply and demand signposts, among them weather impacts, political response by governments, the high demand for rigs and services, the intense competition for land, the scarcity of qualified human resources, are reviewed/. The geological potential of Western Canada, the implications of falling average pool sizes, the industry's ability to catch up to increasing declines, are explored. The disappearance of easy large discoveries, rising development costs involved in smaller, more complex hence more expensive pools are assessed and the Canadian equity and capital markets are reviewed. The predicted likely outcome of all the above factors is fewer players, increasing expectation of higher returns, and more discipline among the remaining players

  6. Hyperglycemia (High Blood Glucose)

    Full Text Available ... symptoms include the following: High blood glucose High levels of sugar in the urine Frequent urination Increased ... you should check and what your blood glucose levels should be. Checking your blood and then treating ...

  7. Hyperglycemia (High Blood Glucose)

    Full Text Available ... and Learning About Prediabetes Type 2 Diabetes Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose My Health Advisor Tools ...

  8. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose My Health Advisor Tools To Know Your Risk Alert Day Diabetes Basics Home Symptoms Diagnosis America's Diabetes Challenge Type 1 Type 2 Facts About Type 2 Enroll ...

  9. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose ... Clinical Practice Guidelines Patient Education Materials Scientific Sessions Journals for Professionals Professional Books Patient Access to Research ...

  10. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose ... Diabetes Meal Plans Create Your Plate Gluten Free Diets Meal Planning for Vegetarian Diets Cook with Heart- ...

  11. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose ... Index Low-Calorie Sweeteners Sugar and Desserts Fitness Exercise & Type 1 Diabetes Get Started Safely Get And ...

  12. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Diabetes Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood ... For Parents & Kids Safe at School Everyday Life Children and Type 2 Diabetes Know Your Rights Employment ...

  13. Hyperglycemia (High Blood Glucose)

    Full Text Available ... 2 Diabetes Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High ... What Can I Drink? Fruit Dairy Food Tips Eating Out Quick Meal Ideas Snacks Nutrient Content Claims ...

  14. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose My Health Advisor Tools To Know Your Risk Alert Day Diabetes Basics Home Symptoms Diagnosis America's Diabetes Challenge Type ...

  15. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Know Your Rights Employment Discrimination Health Care Professionals Law Enforcement Driver's License For Lawyers Food & Fitness Home ... symptoms include the following: High blood glucose High levels of sugar in the urine Frequent urination Increased ...

  16. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose ... Day in the Life of Diabetes Famous People Working to Stop Diabetes Common Terms Diabetes Statistics Infographics ...

  17. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Your Carbs Count Glycemic Index Low-Calorie Sweeteners Sugar and Desserts Fitness Exercise & Type 1 Diabetes Get ... the technical term for high blood glucose (blood sugar). High blood glucose happens when the body has ...

  18. Hyperglycemia (High Blood Glucose)

    Full Text Available ... and Learning About Prediabetes Type 2 Diabetes Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose My Health ...

  19. Supersymmetry at high temperatures

    Das, A.; Kaku, M.

    1978-01-01

    We investigate the properties of Green's functions in a spontaneously broken supersymmetric model at high temperatures. We show that, even at high temperatures, we do not get restoration of supersymmetry, at least in the one-loop approximation

  20. High speed data acquisition

    Cooper, P.S.

    1997-07-01

    A general introduction to high speed data acquisition system techniques in modern particle physics experiments is given. Examples are drawn from the SELEX(E78 1) high statistics charmed baryon production and decay experiment now taking data at Fermilab

  1. High blood sugar

    ... Alternative Names Hyperglycemia - self care; High blood glucose - self care; Diabetes - high blood sugar References American Diabetes Association. Standards of medical care in diabetes - 2017: 4. Lifestyle management and 6. Glycemic targets. Diabetes Care . 2017;40( ...

  2. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Diagnosing Diabetes and Learning About Prediabetes Type 2 Diabetes Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose My Health Advisor ...

  3. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose My Health Advisor Tools To ... Email: Sign Up Thank you for signing up ' + ' '); $('.survey-form').show(); }, success: function (data) { $('#survey-errors').remove(); $('. ...

  4. High blood pressure - children

    ... this page: //medlineplus.gov/ency/article/007696.htm High blood pressure - children To use the sharing features on this page, please enable JavaScript. High blood pressure (hypertension) is an increase in the force of ...

  5. Preventing High Blood Pressure

    ... Heart Disease Cholesterol Salt Million Hearts® WISEWOMAN Preventing High Blood Pressure: Healthy Living Habits Recommend on Facebook Tweet Share ... meal and snack options can help you avoid high blood pressure and its complications. Be sure to eat plenty ...

  6. High blood pressure - infants

    ... this page: //medlineplus.gov/ency/article/007329.htm High blood pressure - infants To use the sharing features on this page, please enable JavaScript. High blood pressure (hypertension) is an increase in the force of ...

  7. High blood pressure medications

    ... this page: //medlineplus.gov/ency/article/007484.htm High blood pressure medicines To use the sharing features on this page, please enable JavaScript. Treating high blood pressure will help prevent problems such as heart disease, ...

  8. High speed, High resolution terahertz spectrometers

    Kim, Youngchan; Yee, Dae Su; Yi, Miwoo; Ahn, Jaewook

    2008-01-01

    A variety of sources and methods have been developed for terahertz spectroscopy during almost two decades. Terahertz time domain spectroscopy (THz TDS)has attracted particular attention as a basic measurement method in the fields of THz science and technology. Recently, asynchronous optical sampling (AOS)THz TDS has been demonstrated, featuring rapid data acquisition and a high spectral resolution. Also, terahertz frequency comb spectroscopy (TFCS)possesses attractive features for high precision terahertz spectroscopy. In this presentation, we report on these two types of terahertz spectrometer. Our high speed, high resolution terahertz spectrometer is demonstrated using two mode locked femtosecond lasers with slightly different repetition frequencies without a mechanical delay stage. The repetition frequencies of the two femtosecond lasers are stabilized by use of two phase locked loops sharing the same reference oscillator. The time resolution of our terahertz spectrometer is measured using the cross correlation method to be 270 fs. AOS THz TDS is presented in Fig. 1, which shows a time domain waveform rapidly acquired on a 10ns time window. The inset shows a zoom into the signal with 100ps time window. The spectrum obtained by the fast Fourier Transformation (FFT)of the time domain waveform has a frequency resolution of 100MHz. The dependence of the signal to noise ratio (SNR)on the measurement time is also investigated

  9. High current and high power superconducting rectifiers

    Kate, H.H.J. ten; Bunk, P.B.; Klundert, L.J.M. van de; Britton, R.B.

    1981-01-01

    Results on three experimental superconducting rectifiers are reported. Two of them are 1 kA low frequency flux pumps, one thermally and magnetically switched. The third is a low-current high-frequency magnetically switched rectifier which can use the mains directly. (author)

  10. High energy neutron radiography

    Gavron, A.; Morley, K.; Morris, C.; Seestrom, S.; Ullmann, J.; Yates, G.; Zumbro, J.

    1996-01-01

    High-energy spallation neutron sources are now being considered in the US and elsewhere as a replacement for neutron beams produced by reactors. High-energy and high intensity neutron beams, produced by unmoderated spallation sources, open potential new vistas of neutron radiography. The authors discuss the basic advantages and disadvantages of high-energy neutron radiography, and consider some experimental results obtained at the Weapons Neutron Research (WNR) facility at Los Alamos

  11. High-pressure microbiology

    Michiels, Chris; Bartlett, Douglas Hoyt; Aertsen, Abram

    2008-01-01

    ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. High Hydrostatic Pressure Effects in the Biosphere: from Molecules to Microbiology * Filip Meersman and Karel Heremans . . . . . . . . . . . . 2. Effects...

  12. EVALUATION OF COST-EFFECTIVENESS OF PLATELET REACTIVITY ANALYSIS USING THE VERIFYNOW P2Y12 ASSAY IN PATIENTS AFTER ACUTE CORONARY SYNDROME

    A. V. Rudakova

    2015-09-01

    Full Text Available Dual antiplatelet therapy, including clopidogrel and aspirin, in a significant share of patients after acute coronary syndrome (ACS is characterized by high level of platelet reactivity, which is associated with an increased incidence of cardiovascular events. Perhaps it will make reasonable the prescription of new antiplatelet drugs, particularly the combination of ticagrelor with aspirin.Aim. To assess the cost-effectiveness of VerifyNow P2Y12 platelet reactivity testing in patients after ACS.Material and methods. The analysis was performed for patients aged 55 years after ACS by modeling based on the results of the PLATO trial considering Russian epidemiological data. The time horizon of simulation was 5 years. It was assumed that the patients were receiving either generic clopidogrel or ticagrelor for 1 year, or before maintenance treatment VerifyNow P2Y12 assay had been performed, and the patients with platelet reactivity index >230 24-48 hours after ACS were receiving ticagrelor and the remaining patients - generic clopidogrel. It was expected that after 1 year the patients would discontinue treatment with clopidogrel or ticagrelor, and hereafter additional therapeutic effect of their use would be absent. The costs of antiplatelet agents in the reference case corresponded to the weighted average price of public procurement in 2013 in Russia. The costs of treatment of complications corresponded to the compulsory health insurance rates for St. Petersburg in 2014. The cost and life expectancy were discounted at 3.5% per year.Results. The platelet reactivity test and the prescription by its results of the combination of clopidogrel plus aspirin or ticagrelor plus aspirin can prevent 5 myocardial infarction and 6 deaths per 1000 patients additionally as compared with the prescription of clopidogrel plus aspirin combination to all patients. The costs for one additional year of life as compared with the combination of clopidogrel plus aspirin

  13. High resolution, high speed ultrahigh vacuum microscopy

    Poppa, Helmut

    2004-01-01

    The history and future of transmission electron microscopy (TEM) is discussed as it refers to the eventual development of instruments and techniques applicable to the real time in situ investigation of surface processes with high resolution. To reach this objective, it was necessary to transform conventional high resolution instruments so that an ultrahigh vacuum (UHV) environment at the sample site was created, that access to the sample by various in situ sample modification procedures was provided, and that in situ sample exchanges with other integrated surface analytical systems became possible. Furthermore, high resolution image acquisition systems had to be developed to take advantage of the high speed imaging capabilities of projection imaging microscopes. These changes to conventional electron microscopy and its uses were slowly realized in a few international laboratories over a period of almost 40 years by a relatively small number of researchers crucially interested in advancing the state of the art of electron microscopy and its applications to diverse areas of interest; often concentrating on the nucleation, growth, and properties of thin films on well defined material surfaces. A part of this review is dedicated to the recognition of the major contributions to surface and thin film science by these pioneers. Finally, some of the important current developments in aberration corrected electron optics and eventual adaptations to in situ UHV microscopy are discussed. As a result of all the path breaking developments that have led to today's highly sophisticated UHV-TEM systems, integrated fundamental studies are now possible that combine many traditional surface science approaches. Combined investigations to date have involved in situ and ex situ surface microscopies such as scanning tunneling microscopy/atomic force microscopy, scanning Auger microscopy, and photoemission electron microscopy, and area-integrating techniques such as x-ray photoelectron

  14. Journalism Beyond High School.

    Turner, Sally

    2001-01-01

    Discusses the shift from high school journalism to college journalism for students. Describes the role of the high school journalism advisor in that process. Offers checklists for getting to know a college publication. Outlines ways high school journalism teachers can take advantage of journalism resources available at local colleges and…

  15. Evaluating High School IT

    Thompson, Brett A.

    2004-01-01

    Since its inception in 1997, Cisco's curriculum has entered thousands of high schools across the U.S. and around the world for two reasons: (1) Cisco has a large portion of the computer networking market, and thus has the resources for and interest in developing high school academies; and (2) high school curriculum development teams recognize the…

  16. Early College High Schools

    Dessoff, Alan

    2011-01-01

    For at-risk students who stand little chance of going to college, or even finishing high school, a growing number of districts have found a solution: Give them an early start in college while they still are in high school. The early college high school (ECHS) movement that began with funding from the Bill and Melinda Gates Foundation 10 years ago…

  17. High performance systems

    Vigil, M.B. [comp.

    1995-03-01

    This document provides a written compilation of the presentations and viewgraphs from the 1994 Conference on High Speed Computing given at the High Speed Computing Conference, {open_quotes}High Performance Systems,{close_quotes} held at Gleneden Beach, Oregon, on April 18 through 21, 1994.

  18. Photoproduction at high energy and high intensity

    2002-01-01

    The photon beam used for this programme is tagged and provides a large flux up to very high energies (150-200 GeV). It is also hadron-free, since it is obtained by a two-step conversion method. A spectrometer is designed to exploit this beam and to perform a programme of photoproduction with a high level of sensitivity (5-50 events/picobarn).\\\\ \\\\ Priority will be given to the study of processes exhibiting the point-like behaviour of the photon, especially deep inelastic Compton scattering. The spectrometer has two magnets. Charged tracks are measured by MWPC's located only in field-free regions. Three calorimeters provide a large coverage for identifying and measuring electrons and photons. An iron filter downstream identifies muons. Most of the equipment is existing and recuperated from previous experiments.

  19. The effect anticoagulation status on geriatric fall trauma patients.

    Coleman, Julia; Baldawi, Mustafa; Heidt, David

    2016-12-01

    This research study aims to identify the effect of anticoagulation status on hospital course, complications, and outcomes among geriatric fall trauma patients. The study design is a retrospective cohort study, looking at fall trauma among patients aged 60 to 80 years from 2009 to 2013 at a university hospital in the United States. The statistical analysis, conducted with SPSS software with a threshold for statistical significance of P patients included in this study was 1,121. Compared with patients not on anticoagulation, there was a higher LOS among patients on anticoagulation (6.3 ± 6.2 vs 4.9 ± 5.2, P = .001). A higher LOS (7.2 ± 6.8 vs 5.0 ± 5.3, P = .001) and days in the ICU (2.1 ± 5.4 vs 1.1 ± 3.8, P = .010) was observed in patients on warfarin. A higher mortality (7.1% vs 2.8%, P = .013), LOS (6.3 ± 6.2 vs 5.1 ± 5.396, P = .036), and complication rate (49.1 vs 36.7, P = .010) was observed among patients on clopidogrel. In this study, a higher mortality and complication rate were seen among clopidogrel, and a greater LOS and number of days in the ICU were seen in patients on warfarin. These differences are important, as they can serve as a screening tool for triaging the severity of a geriatric trauma patient's condition and complication risk. For patients on clopidogrel, it is essential that these patients are recognized early as high-risk patients who will need to be monitored more closely. For patients on clopidogrel or warfarin, bridging a patient's anticoagulation should be initiated as soon as possible to prevent unnecessary increased LOS. At last, these data also provide support against prescribing patients clopidogrel when other anticoagulation options are available. Published by Elsevier Inc.

  20. UP TO DATE ANTIPLATELET THERAPY IN PATIENTS WITH HIGH RISK OF THROMBOTIC EVENTS AND REAL CLINICAL PRACTICE

    S. Yu. Martsevich

    2012-01-01

    Full Text Available Aim. To assess the real rate of dual antiplatelet therapy (DAT, acetylsalicylic acid + clopidogrel use in patients having appropriate indications according to current clinical guidelines and to study the possibility of prescription rate improvement by education activity directed to doctors. Material and methods. The study consisted of 3 parts. Parts I and II present the results of two questionnaire surveys of patients with acute myocardial infarction, or stenting, who needed in DAT according to current clinical guidelines. The real use of the DAT was assessed in part III on the basis of the multicenter study conducted in different regions of Russia (ROMB study in a large sample of patients having DAT indications. Results. Part I - PROGNOZ-IBS study. According to the questionnaire survey only 112 out of 239 patients (47% having an absolute indications, received DOT. Part II - phone survey of patients with acute myocardial infarction in two towns of Lyubertsy and Podolsk. 28 of 71 patients (39% took the DAT (from some days to 6 months and 35 patients (49% — did not take it. Part III - ROMB study. 519 patients did not take DAT, at that 259 (50% in hospital and 260 (50% - in out-patient clinic. 521 patients took DAT according to indications, at that 238 (46% in hospital and 283 (54% - in out-patient clinic. Conclusion. Less than 50% of patients, having direct indications, received DAT in the real clinical practice. The prescription rate can be improved due to education activity directed to doctors and increase in clopidogrel drugs affordability.

  1. Technological Aspects: High Voltage

    Faircloth, D C

    2013-01-01

    This paper covers the theory and technological aspects of high-voltage design for ion sources. Electric field strengths are critical to understanding high-voltage breakdown. The equations governing electric fields and the techniques to solve them are discussed. The fundamental physics of high-voltage breakdown and electrical discharges are outlined. Different types of electrical discharges are catalogued and their behaviour in environments ranging from air to vacuum are detailed. The importance of surfaces is discussed. The principles of designing electrodes and insulators are introduced. The use of high-voltage platforms and their relation to system design are discussed. The use of commercially available high-voltage technology such as connectors, feedthroughs and cables are considered. Different power supply technologies and their procurement are briefly outlined. High-voltage safety, electric shocks and system design rules are covered. (author)

  2. Technological Aspects: High Voltage

    Faircloth, D.C.

    2013-12-16

    This paper covers the theory and technological aspects of high-voltage design for ion sources. Electric field strengths are critical to understanding high-voltage breakdown. The equations governing electric fields and the techniques to solve them are discussed. The fundamental physics of high-voltage breakdown and electrical discharges are outlined. Different types of electrical discharges are catalogued and their behaviour in environments ranging from air to vacuum are detailed. The importance of surfaces is discussed. The principles of designing electrodes and insulators are introduced. The use of high-voltage platforms and their relation to system design are discussed. The use of commercially available high-voltage technology such as connectors, feedthroughs and cables are considered. Different power supply technologies and their procurement are briefly outlined. High-voltage safety, electric shocks and system design rules are covered.

  3. High performance homes

    Beim, Anne; Vibæk, Kasper Sánchez

    2014-01-01

    Can prefabrication contribute to the development of high performance homes? To answer this question, this chapter defines high performance in more broadly inclusive terms, acknowledging the technical, architectural, social and economic conditions under which energy consumption and production occur....... Consideration of all these factors is a precondition for a truly integrated practice and as this chapter demonstrates, innovative project delivery methods founded on the manufacturing of prefabricated buildings contribute to the production of high performance homes that are cost effective to construct, energy...

  4. High temperature refrigerator

    Steyert, W.A. Jr.

    1978-01-01

    A high temperature magnetic refrigerator is described which uses a Stirling-like cycle in which rotating magnetic working material is heated in zero field and adiabatically magnetized, cooled in high field, then adiabatically demagnetized. During this cycle the working material is in heat exchange with a pumped fluid which absorbs heat from a low temperature heat source and deposits heat in a high temperature reservoir. The magnetic refrigeration cycle operates at an efficiency 70% of Carnot

  5. High-Risk List

    2017-01-01

    economy. The World Bank has said that “corruption creates an unfavorable business environment by undermining the operation efficiency of firms and... Bank Began as ‘Ponzi Scheme,’” 11/27/2012. 64 Independent Joint Anti-Corruption Monitoring and Evaluation Committee, Unfinished Business : The Follow...HIGH RISK AREA 7: Oversight 51 HIGH-RISK AREA 8: Strategy and Planning 55 CONCLUSION HIGH RISK LIST I JANUARY 11, 2017 2 EXECUTIVE SUMMARY

  6. Athletes at High Altitude.

    Khodaee, Morteza; Grothe, Heather L; Seyfert, Jonathan H; VanBaak, Karin

    2016-01-01

    Athletes at different skill levels perform strenuous physical activity at high altitude for a variety of reasons. Multiple team and endurance events are held at high altitude and may place athletes at increased risk for developing acute high altitude illness (AHAI). Training at high altitude has been a routine part of preparation for some of the high level athletes for a long time. There is a general belief that altitude training improves athletic performance for competitive and recreational athletes. A review of relevant publications between 1980 and 2015 was completed using PubMed and Google Scholar. Clinical review. Level 3. AHAI is a relatively uncommon and potentially serious condition among travelers to altitudes above 2500 m. The broad term AHAI includes several syndromes such as acute mountain sickness (AMS), high altitude pulmonary edema (HAPE), and high altitude cerebral edema (HACE). Athletes may be at higher risk for developing AHAI due to faster ascent and more vigorous exertion compared with nonathletes. Evidence regarding the effects of altitude training on athletic performance is weak. The natural live high, train low altitude training strategy may provide the best protocol for enhancing endurance performance in elite and subelite athletes. High altitude sports are generally safe for recreational athletes, but they should be aware of their individual risks. Individualized and appropriate acclimatization is an essential component of injury and illness prevention.

  7. High voltage engineering

    Rizk, Farouk AM

    2014-01-01

    Inspired by a new revival of worldwide interest in extra-high-voltage (EHV) and ultra-high-voltage (UHV) transmission, High Voltage Engineering merges the latest research with the extensive experience of the best in the field to deliver a comprehensive treatment of electrical insulation systems for the next generation of utility engineers and electric power professionals. The book offers extensive coverage of the physical basis of high-voltage engineering, from insulation stress and strength to lightning attachment and protection and beyond. Presenting information critical to the design, selec

  8. High enthalpy gas dynamics

    Rathakrishnan, Ethirajan

    2014-01-01

    This is an introductory level textbook which explains the elements of high temperature and high-speed gas dynamics. written in a clear and easy to follow style, the author covers all the latest developments in the field including basic thermodynamic principles, compressible flow regimes and waves propagation in one volume covers theoretical modeling of High Enthalpy Flows, with particular focus on problems in internal and external gas-dynamic flows, of interest in the fields of rockets propulsion and hypersonic aerodynamics High enthalpy gas dynamics is a compulsory course for aerospace engine

  9. High blood cholesterol levels

    Cholesterol - high; Lipid disorders; Hyperlipoproteinemia; Hyperlipidemia; Dyslipidemia; Hypercholesterolemia ... There are many types of cholesterol. The ones talked about most are: ... lipoprotein (HDL) cholesterol -- often called "good" cholesterol ...

  10. High voltage systems

    Martin, M.

    1991-01-01

    Industrial processes usually require electrical power. This power is used to drive motors, to heat materials, or in electrochemical processes. Often the power requirements of a plant require the electric power to be delivered at high voltage. In this paper high voltage is considered any voltage over 600 V. This voltage could be as high as 138,000 V for some very large facilities. The characteristics of this voltage and the enormous amounts of power being transmitted necessitate special safety considerations. Safety must be considered during the four activities associated with a high voltage electrical system. These activities are: Design; Installation; Operation; and Maintenance

  11. Hyperglycemia (High Blood Glucose)

    Full Text Available ... around 4:00 a.m. to 5:00 a.m.). What are the Symptoms of Hyperglycemia? The signs and symptoms include the following: High blood glucose High levels of sugar in the urine Frequent urination Increased ...

  12. High energy hadron scattering

    Johnson, R.C.

    1980-01-01

    High energy and small momentum transfer 2 'yields' 2 hadronic scattering processes are described in the physical framework of particle exchange. Particle production in high energy collisions is considered with emphasis on the features of inclusive reactions though with some remarks on exclusive processes. (U.K.)

  13. Hyperglycemia (High Blood Glucose)

    Full Text Available ... A A A Listen En Español Hyperglycemia (High Blood Glucose) Hyperglycemia is the technical term for high ... function (data) { $('#survey-errors').remove(); $('.survey-form .form-group .survey-alert-wrap').remove(); if (data.submitSurveyResponse.success == ' ...

  14. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose My Health Advisor ... Chat Closed engagement en -- Have Type 2 Diabetes? - 2017-03-lwt2d-en.html Have Type 2 Diabetes? ...

  15. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Research & Practice Ways to Give Close Are You at Risk? Home Prevention Diagnosing Diabetes and Learning About Prediabetes Type 2 Diabetes Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose ...

  16. High-Conflict Divorce.

    Johnston, Janet R.

    1994-01-01

    Reviews available research studies of high-conflict divorce and its effects on children. Factors believed to contribute to high-conflict divorce are explored, and a model of their interrelationships is proposed. Dispute resolution, intervention, and prevention programs are discussed, and implications for social policy are outlined. (SLD)

  17. Hyperglycemia (High Blood Glucose)

    Full Text Available ... You at Risk? Home Prevention Diagnosing Diabetes and Learning About Prediabetes Type 2 Diabetes Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose My Health Advisor Tools To Know Your Risk Alert Day Diabetes Basics ...

  18. High Blood Pressure (Hypertension)

    ... other risk factors, like diabetes, you may need treatment. How does high blood pressure affect pregnant women? A few women will get ... HIV, Birth Control Heart Health for Women Pregnancy Menopause More Women's Health ... High Blood Pressure--Medicines to Help You Women and Diabetes Heart ...

  19. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Type 2 Diabetes Risk Test Lower Your Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High ... Holiday Meal Planning What Can I Eat? Making Healthy Food Choices Diabetes ... Tips Eating Out Quick Meal Ideas Snacks Nutrient Content Claims ...

  20. The high energy galaxy

    Cesarsky, C.J.

    1986-08-01

    The galaxy is host to a wide variety of high energy events. I review here recent results on large scale galactic phenomena: cosmic-ray origin and confinement, the connexion to ultra high energy gamma-ray emission from X-ray binaries, gamma ray and synchrotron emission in interstellar space, galactic soft and hard X-ray emission

  1. Highly Skilled Migrants

    Hvidt, Martin

    2016-01-01

    . It is pointed out that while the system facilitated speedy entry to the job market, the lack of inclusion in the Gulf economies of the migrants, the lack of long-term prospects of residing in the countries and the highly asymmetric power balance between sponsor and migrant, provides few incentives...... for the highly skilled migrants to fully contribute to the Gulf economies....

  2. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Risk Healthy Eating Overweight Smoking High Blood Pressure Physical Activity High Blood Glucose My Health Advisor Tools ... Complications DKA (Ketoacidosis) & Ketones Kidney Disease ... than planned or exercised less than planned. You have stress from an illness, such as a cold or flu. You have ...

  3. Fixing High Schools

    Perkins-Gough, Deborah

    2005-01-01

    Reports from national education organizations in the US indicate the sorry state of high schools in the country that are accused of failing to adequately prepare their graduates for college or for the workforce, highlighting what is a serious problem in light of the troubled state of the US economy. The need to improve high schools is urgent and…

  4. High coking value pitch

    Miller, Douglas J.; Chang, Ching-Feng; Lewis, Irwin C.; Lewis, Richard T.

    2014-06-10

    A high coking value pitch prepared from coal tar distillate and has a low softening point and a high carbon value while containing substantially no quinoline insolubles is disclosed. The pitch can be used as an impregnant or binder for producing carbon and graphite articles.

  5. High Gravity (g) Combustion

    Zelina, Joseph

    2006-01-01

    .... The Ultra-Compact Combustor (UCC), a novel design based on trapped-vortex combustor (TVC) work that uses high swirl in a circumferential cavity to enhance reaction rates via high cavity g-loading on the order of 3000 g's...

  6. Very high energy colliders

    Richter, B.

    1986-03-01

    The luminosity and energy requirements are considered for both proton colliders and electron-positron colliders. Some of the basic design equations for high energy linear electron colliders are summarized, as well as design constraints. A few examples are given of parameters for very high energy machines. 4 refs., 6 figs

  7. High-pressure apparatus

    Schepdael, van L.J.M.; Bartels, P.V.; Berg, van den R.W.

    1999-01-01

    The invention relates to a high-pressure device (1) having a cylindrical high-pressure vessel (3) and prestressing means in order to exert an axial pressure on the vessel. The vessel (3) can have been formed from a number of layers of composite material, such as glass, carbon or aramide fibers which

  8. High-pressure crystallography

    Katrusiak, A.

    2008-01-01

    The history and development of high-pressure crystallography are briefly described and examples of structural transformations in compressed compounds are given. The review is focused on the diamond-anvil cell, celebrating its 50th anniversary this year, the principles of its operation and the impact it has had on high-pressure X-ray diffraction.

  9. Proxmox high availability

    Cheng, Simon MC

    2014-01-01

    If you want to know the secrets of virtualization and how to implement high availability on your services, this is the book for you. For those of you who are already using Proxmox, this book offers you the chance to build a high availability cluster with a distributed filesystem to further protect your system from failure.

  10. High Performance Marine Vessels

    Yun, Liang

    2012-01-01

    High Performance Marine Vessels (HPMVs) range from the Fast Ferries to the latest high speed Navy Craft, including competition power boats and hydroplanes, hydrofoils, hovercraft, catamarans and other multi-hull craft. High Performance Marine Vessels covers the main concepts of HPMVs and discusses historical background, design features, services that have been successful and not so successful, and some sample data of the range of HPMVs to date. Included is a comparison of all HPMVs craft and the differences between them and descriptions of performance (hydrodynamics and aerodynamics). Readers will find a comprehensive overview of the design, development and building of HPMVs. In summary, this book: Focuses on technology at the aero-marine interface Covers the full range of high performance marine vessel concepts Explains the historical development of various HPMVs Discusses ferries, racing and pleasure craft, as well as utility and military missions High Performance Marine Vessels is an ideal book for student...

  11. High altitude illness

    Hartman-Ksycińska, Anna; Kluz-Zawadzka, Jolanta; Lewandowski, Bogumił

    High-altitude illness is a result of prolonged high-altitude exposure of unacclimatized individuals. The illness is seen in the form of acute mountain sickness (AMS) which if not treated leads to potentially life-threatening high altitude pulmonary oedema and high-altitude cerebral oedema. Medical problems are caused by hypobaric hypoxia stimulating hypoxia-inducible factor (HIF) release. As a result, the central nervous system, circulation and respiratory system function impairment occurs. The most important factor in AMS treatment is acclimatization, withdrawing further ascent and rest or beginning to descent; oxygen supplementation, and pharmacological intervention, and, if available, a portable hyperbaric chamber. Because of the popularity of high-mountain sports and tourism better education of the population at risk is essential.

  12. Multidimensional high harmonic spectroscopy

    Bruner, Barry D; Soifer, Hadas; Shafir, Dror; Dudovich, Nirit; Serbinenko, Valeria; Smirnova, Olga

    2015-01-01

    High harmonic generation (HHG) has opened up a new frontier in ultrafast science where attosecond time resolution and Angstrom spatial resolution are accessible in a single measurement. However, reconstructing the dynamics under study is limited by the multiple degrees of freedom involved in strong field interactions. In this paper we describe a new class of measurement schemes for resolving attosecond dynamics, integrating perturbative nonlinear optics with strong-field physics. These approaches serve as a basis for multidimensional high harmonic spectroscopy. Specifically, we show that multidimensional high harmonic spectroscopy can measure tunnel ionization dynamics with high precision, and resolves the interference between multiple ionization channels. In addition, we show how multidimensional HHG can function as a type of lock-in amplifier measurement. Similar to multi-dimensional approaches in nonlinear optical spectroscopy that have resolved correlated femtosecond dynamics, multi-dimensional high harmonic spectroscopy reveals the underlying complex dynamics behind attosecond scale phenomena. (paper)

  13. High current high accuracy IGBT pulse generator

    Nesterov, V.V.; Donaldson, A.R.

    1995-05-01

    A solid state pulse generator capable of delivering high current triangular or trapezoidal pulses into an inductive load has been developed at SLAC. Energy stored in a capacitor bank of the pulse generator is switched to the load through a pair of insulated gate bipolar transistors (IGBT). The circuit can then recover the remaining energy and transfer it back to the capacitor bank without reversing the capacitor voltage. A third IGBT device is employed to control the initial charge to the capacitor bank, a command charging technique, and to compensate for pulse to pulse power losses. The rack mounted pulse generator contains a 525 μF capacitor bank. It can deliver 500 A at 900V into inductive loads up to 3 mH. The current amplitude and discharge time are controlled to 0.02% accuracy by a precision controller through the SLAC central computer system. This pulse generator drives a series pair of extraction dipoles

  14. High redshift quasars and high metallicities

    Ferland, Gary J.

    1997-01-01

    A large-scale code called Cloudy was designed to simulate non-equilibrium plasmas and predict their spectra. The goal was to apply it to studies of galactic and extragalactic emission line objects in order to reliably deduce abundances and luminosities. Quasars are of particular interest because they are the most luminous objects in the universe and the highest redshift objects that can be observed spectroscopically, and their emission lines can reveal the composition of the interstellar medium (ISM) of the universe when it was well under a billion years old. The lines are produced by warm (approximately 10(sup 4)K) gas with moderate to low density (n less than or equal to 10(sup 12) cm(sup -3)). Cloudy has been extended to include approximately 10(sup 4) resonance lines from the 495 possible stages of ionization of the lightest 30 elements, an extension that required several steps. The charge transfer database was expanded to complete the needed reactions between hydrogen and the first four ions and fit all reactions with a common approximation. Radiative recombination rate coefficients were derived for recombination from all closed shells, where this process should dominate. Analytical fits to Opacity Project (OP) and other recent photoionization cross sections were produced. Finally, rescaled OP oscillator strengths were used to compile a complete set of data for 5971 resonance lines. The major discovery has been that high redshift quasars have very high metallicities and there is strong evidence that the quasar phenomenon is associated with the birth of massive elliptical galaxies.

  15. High speed atom source

    Hoshino, Hitoshi.

    1990-01-01

    In a high speed atom source, since the speed is not identical between ions and electrons, no sufficient neutralizing effect for ionic rays due to the mixing of the ionic rays and the electron rays can be obtained failing to obtain high speed atomic rays at high density. In view of the above, a speed control means is disposed for equalizing the speed of ions forming ionic rays and the speed of electrons forming electron rays. Further, incident angle of the electron rays and/or ionic rays to a magnet or an electrode is made variable. As a result, the relative speed between the ions and the electrons to the processing direction is reduced to zero, in which the probability of association between the ions and the electrons due to the coulomb force is increased to improve the neutralizing efficiency to easily obtain fine and high density high speed electron rays. Further, by varying the incident angle, a track capable of obtaining an ideal mixing depending on the energy of the neutralized ionic rays is formed. Since the high speed electron rays has such high density, they can be irradiated easily to the minute region of the specimen. (N.H.)

  16. High performance germanium MOSFETs

    Saraswat, Krishna [Department of Electrical Engineering, Stanford University, Stanford, CA 94305 (United States)]. E-mail: saraswat@stanford.edu; Chui, Chi On [Department of Electrical Engineering, Stanford University, Stanford, CA 94305 (United States); Krishnamohan, Tejas [Department of Electrical Engineering, Stanford University, Stanford, CA 94305 (United States); Kim, Donghyun [Department of Electrical Engineering, Stanford University, Stanford, CA 94305 (United States); Nayfeh, Ammar [Department of Electrical Engineering, Stanford University, Stanford, CA 94305 (United States); Pethe, Abhijit [Department of Electrical Engineering, Stanford University, Stanford, CA 94305 (United States)

    2006-12-15

    Ge is a very promising material as future channel materials for nanoscale MOSFETs due to its high mobility and thus a higher source injection velocity, which translates into higher drive current and smaller gate delay. However, for Ge to become main-stream, surface passivation and heterogeneous integration of crystalline Ge layers on Si must be achieved. We have demonstrated growth of fully relaxed smooth single crystal Ge layers on Si using a novel multi-step growth and hydrogen anneal process without any graded buffer SiGe layer. Surface passivation of Ge has been achieved with its native oxynitride (GeO {sub x}N {sub y} ) and high-permittivity (high-k) metal oxides of Al, Zr and Hf. High mobility MOSFETs have been demonstrated in bulk Ge with high-k gate dielectrics and metal gates. However, due to their smaller bandgap and higher dielectric constant, most high mobility materials suffer from large band-to-band tunneling (BTBT) leakage currents and worse short channel effects. We present novel, Si and Ge based heterostructure MOSFETs, which can significantly reduce the BTBT leakage currents while retaining high channel mobility, making them suitable for scaling into the sub-15 nm regime. Through full band Monte-Carlo, Poisson-Schrodinger and detailed BTBT simulations we show a dramatic reduction in BTBT and excellent electrostatic control of the channel, while maintaining very high drive currents in these highly scaled heterostructure DGFETs. Heterostructure MOSFETs with varying strained-Ge or SiGe thickness, Si cap thickness and Ge percentage were fabricated on bulk Si and SOI substrates. The ultra-thin ({approx}2 nm) strained-Ge channel heterostructure MOSFETs exhibited >4x mobility enhancements over bulk Si devices and >10x BTBT reduction over surface channel strained SiGe devices.

  17. High performance germanium MOSFETs

    Saraswat, Krishna; Chui, Chi On; Krishnamohan, Tejas; Kim, Donghyun; Nayfeh, Ammar; Pethe, Abhijit

    2006-01-01

    Ge is a very promising material as future channel materials for nanoscale MOSFETs due to its high mobility and thus a higher source injection velocity, which translates into higher drive current and smaller gate delay. However, for Ge to become main-stream, surface passivation and heterogeneous integration of crystalline Ge layers on Si must be achieved. We have demonstrated growth of fully relaxed smooth single crystal Ge layers on Si using a novel multi-step growth and hydrogen anneal process without any graded buffer SiGe layer. Surface passivation of Ge has been achieved with its native oxynitride (GeO x N y ) and high-permittivity (high-k) metal oxides of Al, Zr and Hf. High mobility MOSFETs have been demonstrated in bulk Ge with high-k gate dielectrics and metal gates. However, due to their smaller bandgap and higher dielectric constant, most high mobility materials suffer from large band-to-band tunneling (BTBT) leakage currents and worse short channel effects. We present novel, Si and Ge based heterostructure MOSFETs, which can significantly reduce the BTBT leakage currents while retaining high channel mobility, making them suitable for scaling into the sub-15 nm regime. Through full band Monte-Carlo, Poisson-Schrodinger and detailed BTBT simulations we show a dramatic reduction in BTBT and excellent electrostatic control of the channel, while maintaining very high drive currents in these highly scaled heterostructure DGFETs. Heterostructure MOSFETs with varying strained-Ge or SiGe thickness, Si cap thickness and Ge percentage were fabricated on bulk Si and SOI substrates. The ultra-thin (∼2 nm) strained-Ge channel heterostructure MOSFETs exhibited >4x mobility enhancements over bulk Si devices and >10x BTBT reduction over surface channel strained SiGe devices

  18. High current ion sources

    Brown, I.G.

    1989-06-01

    The concept of high current ion source is both relative and evolutionary. Within the domain of one particular kind of ion source technology a current of microamperers might be 'high', while in another area a current of 10 Amperes could 'low'. Even within the domain of a single ion source type, what is considered high current performance today is routinely eclipsed by better performance and higher current output within a short period of time. Within their fields of application, there is a large number of kinds of ion sources that can justifiably be called high current. Thus, as a very limited example only, PIGs, Freemen sources, ECR sources, duoplasmatrons, field emission sources, and a great many more all have their high current variants. High current ion beams of gaseous and metallic species can be generated in a number of different ways. Ion sources of the kind developed at various laboratories around the world for the production of intense neutral beams for controlled fusion experiments are used to form large area proton deuteron beams of may tens of Amperes, and this technology can be used for other applications also. There has been significant progress in recent years in the use of microwave ion sources for high current ion beam generation, and this method is likely to find wide application in various different field application. Finally, high current beams of metal ions can be produced using metal vapor vacuum arc ion source technology. After a brief consideration of high current ion source design concepts, these three particular methods are reviewed in this paper

  19. High flying physics

    Anon.

    1981-01-01

    Cosmic ray physicists have always had to aim high. In the constant search for interactions produced as close as possible to the immensely high primary particles entering the earth's atmosphere from outer space, they have installed experiments on high mountain peaks and flown detectors aloft in balloons. In these studies, there have been periodic sightings of remarkable configurations of secondary particles. These events, many of which bear exotic names like Centauro, Andromeda, Texas Lone Star, etc., frequently defy explanation in terms of conventional physics ideas and give a glimpse of what may lie beyond the behaviour seen so far under laboratory conditions

  20. High Field Workshop

    Anon.

    1984-12-15

    A Workshop was held in Frascati at the end of September under the title 'Generation of High Fields for Particle Acceleration to Very High Energies'. It was organized by the CERN Accelerator School, the European Committee for Future Accelerators (ECFA) and the Italian INFN and was a further stage in the exploratory moves towards new techniques of acceleration. Such techniques might become necessary to respond to the needs of high energy physics some decades from now when the application of conventional techniques will probably have reached their limits.

  1. High voltage test techniques

    Kind, Dieter

    2001-01-01

    The second edition of High Voltage Test Techniques has been completely revised. The present revision takes into account the latest international developments in High Voltage and Measurement technology, making it an essential reference for engineers in the testing field.High Voltage Technology belongs to the traditional area of Electrical Engineering. However, this is not to say that the area has stood still. New insulating materials, computing methods and voltage levels repeatedly pose new problems or open up methods of solution; electromagnetic compatibility (EMC) or components and systems al

  2. High-density lipoprotein cholesterol: How High

    G Rajagopal

    2012-01-01

    Full Text Available The high-density lipoprotein cholesterol (HDL-C is considered anti-atherogenic good cholesterol. It is involved in reverse transport of lipids. Epidemiological studies have found inverse relationship of HDL-C and coronary heart disease (CHD risk. When grouped according to HDL-C, subjects having HDL-C more than 60 mg/dL had lesser risk of CHD than those having HDL-C of 40-60 mg/dL, who in turn had lesser risk than those who had HDL-C less than 40 mg/dL. No upper limit for beneficial effect of HDL-C on CHD risk has been identified. The goals of treating patients with low HDL-C have not been firmly established. Though many drugs are known to improve HDL-C concentration, statins are proven to improve CHD risk and mortality. Cholesteryl ester transfer protein (CETP is involved in metabolism of HDL-C and its inhibitors are actively being screened for clinical utility. However, final answer is still awaited on CETP-inhibitors.

  3. Hyperglycemia (High Blood Glucose)

    Full Text Available ... blood glucose High levels of sugar in the urine Frequent urination Increased thirst Part of managing your ... glucose is above 240 mg/dl, check your urine for ketones. If you have ketones, do not ...

  4. High-Speed Photography

    Paisley, D.L.; Schelev, M.Y.

    1998-01-01

    The applications of high-speed photography to a diverse set of subjects including inertial confinement fusion, laser surgical procedures, communications, automotive airbags, lightning etc. are briefly discussed. (AIP) copyright 1998 Society of Photo-Optical Instrumentation Engineers

  5. High-tech entrepreneurship

    Bernasconi, Michel; Harris, Simon; Mønsted, Mette

    High-tech businesses form a crucial part of entrepreneurial activity - in some ways representing very typical examples of entrepreneurship, yet in some ways representing quite different challenges. The uncertainty in innovation and advanced technology makes it difficult to use conventional economic...... focuses on the blend of theory and practice needed to inform advanced entrepreneurship students of the specifics of high-tech start-ups. Key topics covered include: uncertainty and innovation; entrepreneurial finance; marketing technological innovations; and high-tech incubation management.......Edited by a multi-national team, it draws together leading writers and researchers from across Europe, and is therefore a must-read for all those involved in advanced entrepreneurship with specific interests in high-tech start-ups....

  6. High Blood Pressure

    ... kidney disease, diabetes, or metabolic syndrome Read less Unhealthy lifestyle habits Unhealthy lifestyle habits can increase the risk of high blood pressure. These habits include: Unhealthy eating patterns, such as eating too much sodium ...

  7. High-power klystrons

    Siambis, John G.; True, Richard B.; Symons, R. S.

    1994-05-01

    Novel emerging applications in advanced linear collider accelerators, ionospheric and atmospheric sensing and modification and a wide spectrum of industrial processing applications, have resulted in microwave tube requirements that call for further development of high power klystrons in the range from S-band to X-band. In the present paper we review recent progress in high power klystron development and discuss some of the issues and scaling laws for successful design. We also discuss recent progress in electron guns with potential grading electrodes for high voltage with short and long pulse operation via computer simulations obtained from the code DEMEOS, as well as preliminary experimental results. We present designs for high power beam collectors.

  8. Hyperglycemia (High Blood Glucose)

    Full Text Available ... breast cancer and AIDS combined. Your gift today will help us get closer to curing diabetes and ... blood and then treating high blood glucose early will help you avoid problems associated with hyperglycemia. How ...

  9. Hyperglycemia (High Blood Glucose)

    Full Text Available ... and Learning About Prediabetes Type 2 Diabetes Risk Test Lower Your Risk Healthy Eating Overweight Smoking High ... excused. 86 million Americans have prediabetes. Take the test. Know where you stand. sticky en -- Chef Ronaldo's ...

  10. High blood pressure - adults

    ... pressure is found. This is called essential hypertension. High blood pressure that is caused by another medical condition or medicine you are taking is called secondary hypertension. Secondary hypertension may be due to: Chronic ...

  11. High potassium level

    ... level is very high, or if you have danger signs, such as changes in an ECG . Emergency ... Seifter JL. Potassium disorders. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine . 25th ed. Philadelphia, PA: ...

  12. Responsive design high performance

    Els, Dewald

    2015-01-01

    This book is ideal for developers who have experience in developing websites or possess minor knowledge of how responsive websites work. No experience of high-level website development or performance tweaking is required.

  13. High Blood Pressure

    ... factors Diabetes High blood pressure Family history Obesity Race/ethnicity Full list of causes and risk factors ... give Give monthly Memorials and tributes Donate a car Donate gently used items Stock donation Workplace giving ...

  14. High energy astrophysics

    Engel, A.R.

    1979-01-01

    High energy astrophysical research carried out at the Blackett Laboratory, Imperial College, London is reviewed. Work considered includes cosmic ray particle detection, x-ray astronomy, gamma-ray astronomy, gamma and x-ray bursts. (U.K.)

  15. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Blood Pressure Physical Activity High Blood Glucose My Health Advisor Tools To Know Your Risk Alert Day ... DKA (Ketoacidosis) & Ketones Kidney Disease (Nephropathy) Gastroparesis Mental Health Step On Up Treatment & Care Blood Glucose Testing ...

  16. High-Definition Medicine.

    Torkamani, Ali; Andersen, Kristian G; Steinhubl, Steven R; Topol, Eric J

    2017-08-24

    The foundation for a new era of data-driven medicine has been set by recent technological advances that enable the assessment and management of human health at an unprecedented level of resolution-what we refer to as high-definition medicine. Our ability to assess human health in high definition is enabled, in part, by advances in DNA sequencing, physiological and environmental monitoring, advanced imaging, and behavioral tracking. Our ability to understand and act upon these observations at equally high precision is driven by advances in genome editing, cellular reprogramming, tissue engineering, and information technologies, especially artificial intelligence. In this review, we will examine the core disciplines that enable high-definition medicine and project how these technologies will alter the future of medicine. Copyright © 2017 Elsevier Inc. All rights reserved.

  17. Hyperglycemia (High Blood Glucose)

    Full Text Available ... for Association Events Messaging Tools Recruiting Advocates Local Market Planning Training Webinars News & Events Advocacy News Call ... Care > Blood Glucose Testing Share: Print Page Text Size: A A A Listen En Español Hyperglycemia (High ...

  18. High Velocity Gas Gun

    1988-01-01

    A video tape related to orbital debris research is presented. The video tape covers the process of loading a High Velocity Gas Gun and firing it into a mounted metal plate. The process is then repeated in slow motion.

  19. High resolution solar observations

    Title, A.

    1985-01-01

    Currently there is a world-wide effort to develop optical technology required for large diffraction limited telescopes that must operate with high optical fluxes. These developments can be used to significantly improve high resolution solar telescopes both on the ground and in space. When looking at the problem of high resolution observations it is essential to keep in mind that a diffraction limited telescope is an interferometer. Even a 30 cm aperture telescope, which is small for high resolution observations, is a big interferometer. Meter class and above diffraction limited telescopes can be expected to be very unforgiving of inattention to details. Unfortunately, even when an earth based telescope has perfect optics there are still problems with the quality of its optical path. The optical path includes not only the interior of the telescope, but also the immediate interface between the telescope and the atmosphere, and finally the atmosphere itself

  20. Landforms of High Mountains

    Derek A. McDougall

    2016-05-01

    Full Text Available Reviewed: Landforms of High Mountains. By Alexander Stahr and Ewald Langenscheidt. Heidelberg, Germany: Springer, 2015. viii + 158 pp. US$ 129.99. Also available as an e-book. ISBN 978-3-642-53714-1.

  1. Hyperglycemia (High Blood Glucose)

    Full Text Available ... and Learning About Prediabetes Type 2 Diabetes Risk Test Lower Your Risk Healthy Eating Overweight Smoking High ... You at Risk? Diagnosis Lower Your Risk Risk Test Alert Day Prediabetes My Health Advisor Tools to ...

  2. Highly stretchable carbon aerogels.

    Guo, Fan; Jiang, Yanqiu; Xu, Zhen; Xiao, Youhua; Fang, Bo; Liu, Yingjun; Gao, Weiwei; Zhao, Pei; Wang, Hongtao; Gao, Chao

    2018-02-28

    Carbon aerogels demonstrate wide applications for their ultralow density, rich porosity, and multifunctionalities. Their compressive elasticity has been achieved by different carbons. However, reversibly high stretchability of neat carbon aerogels is still a great challenge owing to their extremely dilute brittle interconnections and poorly ductile cells. Here we report highly stretchable neat carbon aerogels with a retractable 200% elongation through hierarchical synergistic assembly. The hierarchical buckled structures and synergistic reinforcement between graphene and carbon nanotubes enable a temperature-invariable, recoverable stretching elasticity with small energy dissipation (~0.1, 100% strain) and high fatigue resistance more than 10 6 cycles. The ultralight carbon aerogels with both stretchability and compressibility were designed as strain sensors for logic identification of sophisticated shape conversions. Our methodology paves the way to highly stretchable carbon and neat inorganic materials with extensive applications in aerospace, smart robots, and wearable devices.

  3. High Performance Macromolecular Material

    Forest, M

    2002-01-01

    .... In essence, most commercial high-performance polymers are processed through fiber spinning, following Nature and spider silk, which is still pound-for-pound the toughest liquid crystalline polymer...

  4. Physics and high technology

    Shao Liqin; Ma Junru.

    1992-01-01

    At present, the development of high technology has opened a new chapter in world's history of science and technology. This review describes the great impact of physics on high technology in six different fields (energy technology, new materials, information technology, biotechnology, space technology, and Ocean technology). It is shown that the new concepts and new methods created in physics and the special conditions and measurements established for physics researches not only deepen human's knowledge about nature but also point out new directions for engineering and technology. The achievements in physics have been more and more applied to high technology, while the development of high technology has explored some new research areas and raised many novel, important projects for physics. Therefore, it is important for us to strengthen the research on these major problems in physics

  5. High temperature battery. Hochtemperaturbatterie

    Bulling, M.

    1992-06-04

    To prevent heat losses of a high temperature battery, it is proposed to make the incoming current leads in the area of their penetration through the double-walled insulating housing as thermal throttle, particularly spiral ones.

  6. High Energy Materials

    IAS Admin

    Propellants used in rockets, pyrotechnics used in festivities, explosives used for .... In World War II, Wernher von Braun designed the. V-2 rockets which were ... A. Solid Propellants. A solid propellant is made from low or diluted high explosives.

  7. Hyperglycemia (High Blood Glucose)

    Full Text Available ... your blood and then treating high blood glucose early will help you avoid problems associated with hyperglycemia. ... to detect hyperglycemia so you can treat it early — before it gets worse. If you're new ...

  8. High Plains Aquifer

    Kansas Data Access and Support Center — These digital maps contain information on the altitude of the base, the extent, and the 1991 potentiometric surface (i.e. altitude of the water table) of the High...

  9. High Resolution Elevation Contours

    Minnesota Department of Natural Resources — This dataset contains contours generated from high resolution data sources such as LiDAR. Generally speaking this data is 2 foot or less contour interval.

  10. HIGH-ALTITUDE ILLNESS

    Dwitya Elvira

    2015-05-01

    Full Text Available AbstrakHigh-altitude illness (HAI merupakan sekumpulan gejala paru dan otak yang terjadi pada orang yang baru pertama kali mendaki ke ketinggian. HAI terdiri dari acute mountain sickness (AMS, high-altitude cerebral edema (HACE dan high-altitude pulmonary edema (HAPE. Tujuan tinjauan pustaka ini adalah agar dokter dan wisatawan memahami risiko, tanda, gejala, dan pengobatan high-altitude illness. Perhatian banyak diberikan terhadap penyakit ini seiring dengan meningkatnya popularitas olahraga ekstrim (mendaki gunung tinggi, ski dan snowboarding dan adanya kemudahan serta ketersediaan perjalanan sehingga jutaan orang dapat terpapar bahaya HAI. Di Pherice, Nepal (ketinggian 4343 m, 43% pendaki mengalami gejala AMS. Pada studi yang dilakukan pada tempat wisata di resort ski Colorado, Honigman menggambarkan kejadian AMS 22% pada ketinggian 1850 m sampai 2750 m, sementara Dean menunjukkan 42% memiliki gejala pada ketinggian 3000 m. Aklimatisasi merupakan salah satu tindakan pencegahan yang dapat dilakukan sebelum pendakian, selain beberapa pengobatan seperti asetazolamid, dexamethasone, phosopodiestrase inhibitor, dan ginko biloba.Kata kunci: high-altitude illness, acute mountain sickness, edema cerebral, pulmonary edema AbstractHigh-altitude illness (HAI is symptoms of lung and brain that occurs in people who first climb to altitude. HAI includes acute mountain sickness (AMS, high-altitude cerebral edema (HACE and high altitude pulmonary edema (HAPE. The objective of this review was to understand the risks, signs, symptoms, and treatment of high-altitude illness. The attention was given to this disease due to the rising popularity of extreme sports (high mountain climbing, skiing and snowboarding and the ease and availability of the current travelling, almost each year, millions of people could be exposed to the danger of HAI. In Pherice, Nepal (altitude 4343 m, 43% of climbers have symptoms of AMS. Furthermore, in a study conducted at sites in

  11. High Performance Concrete

    Traian Oneţ

    2009-01-01

    Full Text Available The paper presents the last studies and researches accomplished in Cluj-Napoca related to high performance concrete, high strength concrete and self compacting concrete. The purpose of this paper is to raid upon the advantages and inconveniences when a particular concrete type is used. Two concrete recipes are presented, namely for the concrete used in rigid pavement for roads and another one for self-compacting concrete.

  12. Clustering at high redshifts

    Shaver, P.A.

    1986-01-01

    Evidence for clustering of and with high-redshift QSOs is discussed. QSOs of different redshifts show no clustering, but QSOs of similar redshifts appear to be clustered on a scale comparable to that of galaxies at the present epoch. In addition, spectroscopic studies of close pairs of QSOs indicate that QSOs are surrounded by a relatively high density of absorbing matter, possibly clusters of galaxies

  13. ANL high resolution injector

    Minehara, E.; Kutschera, W.; Hartog, P.D.; Billquist, P.

    1985-01-01

    The ANL (Argonne National Laboratory) high-resolution injector has been installed to obtain higher mass resolution and higher preacceleration, and to utilize effectively the full mass range of ATLAS (Argonne Tandem Linac Accelerator System). Preliminary results of the first beam test are reported briefly. The design and performance, in particular a high-mass-resolution magnet with aberration compensation, are discussed. 7 refs., 5 figs., 2 tabs

  14. High voltage engineering fundamentals

    Kuffel, E; Hammond, P

    1984-01-01

    Provides a comprehensive treatment of high voltage engineering fundamentals at the introductory and intermediate levels. It covers: techniques used for generation and measurement of high direct, alternating and surge voltages for general application in industrial testing and selected special examples found in basic research; analytical and numerical calculation of electrostatic fields in simple practical insulation system; basic ionisation and decay processes in gases and breakdown mechanisms of gaseous, liquid and solid dielectrics; partial discharges and modern discharge detectors; and over

  15. High performance polymeric foams

    Gargiulo, M.; Sorrentino, L.; Iannace, S.

    2008-01-01

    The aim of this work was to investigate the foamability of high-performance polymers (polyethersulfone, polyphenylsulfone, polyetherimide and polyethylenenaphtalate). Two different methods have been used to prepare the foam samples: high temperature expansion and two-stage batch process. The effects of processing parameters (saturation time and pressure, foaming temperature) on the densities and microcellular structures of these foams were analyzed by using scanning electron microscopy

  16. Converting high boiling hydrocarbons

    Terrisse, H; DuFour, L

    1929-02-12

    A process is given for converting high boiling hydrocarbons into low boiling hydrocarbons, characterized in that the high boiling hydrocarbons are heated to 200 to 500/sup 0/C in the presence of ferrous chloride and of such gases as hydrogen, water gas, and the like gases under a pressure of from 5 to 40 kilograms per square centimeter. The desulfurization of the hydrocarbons occurs simultaneously.

  17. High-pressure tritium

    Coffin, D.O.

    1976-01-01

    Some solutions to problems of compressing and containing tritium gas to 200 MPa at 700 0 K are discussed. The principal emphasis is on commercial compressors and high-pressure equipment that can be easily modified by the researcher for safe use with tritium. Experience with metal bellows and diaphragm compressors has been favorable. Selection of materials, fittings, and gauges for high-pressure tritium work is also reviewed briefly

  18. High energy positron imaging

    Chen Shengzu

    2003-01-01

    The technique of High Energy Positron Imaging (HEPI) is the new development and extension of Positron Emission Tomography (PET). It consists of High Energy Collimation Imaging (HECI), Dual Head Coincidence Detection Imaging (DHCDI) and Positron Emission Tomography (PET). We describe the history of the development and the basic principle of the imaging methods of HEPI in details in this paper. Finally, the new technique of the imaging fusion, which combined the anatomical image and the functional image together are also introduced briefly

  19. High speed heterostructure devices

    Beer, Albert C; Willardson, R K; Kiehl, Richard A; Sollner, T C L Gerhard

    1994-01-01

    Volume 41 includes an in-depth review of the most important, high-speed switches made with heterojunction technology. This volume is aimed at the graduate student or working researcher who needs a broad overview andan introduction to current literature. Key Features * The first complete review of InP-based HFETs and complementary HFETs, which promise very low power and high speed * Offers a complete, three-chapter review of resonant tunneling * Provides an emphasis on circuits as well as devices.

  20. High Burnup Effects Program

    Barner, J.O.; Cunningham, M.E.; Freshley, M.D.; Lanning, D.D.

    1990-04-01

    This is the final report of the High Burnup Effects Program (HBEP). It has been prepared to present a summary, with conclusions, of the HBEP. The HBEP was an international, group-sponsored research program managed by Battelle, Pacific Northwest Laboratories (BNW). The principal objective of the HBEP was to obtain well-characterized data related to fission gas release (FGR) for light water reactor (LWR) fuel irradiated to high burnup levels. The HBEP was organized into three tasks as follows: Task 1 -- high burnup effects evaluations; Task 2 -- fission gas sampling; and Task 3 -- parameter effects study. During the course of the HBEP, a program that extended over 10 years, 82 fuel rods from a variety of sources were characterized, irradiated, and then examined in detail after irradiation. The study of fission gas release at high burnup levels was the principal objective of the program and it may be concluded that no significant enhancement of fission gas release at high burnup levels was observed for the examined rods. The rim effect, an as yet unquantified contributor to athermal fission gas release, was concluded to be the one truly high-burnup effect. Though burnup enhancement of fission gas release was observed to be low, a full understanding of the rim region and rim effect has not yet emerged and this may be a potential area of further research. 25 refs., 23 figs., 4 tabs

  1. Kilburn High Road Revisited

    Cristina Capineri

    2016-07-01

    Full Text Available Drawing on John Agnew’s (1987 theoretical framework for the analysis of place (location, locale and sense of place and on Doreen Massey’s (1991 interpretation of Kilburn High Road (London, the contribution develops an analysis of the notion of place in the case study of Kilburn High Road by comparing the semantics emerging from Doreen Massey’s interpretation of Kilburn High Road in the late Nineties with those from a selection of noisy and unstructured volunteered geographic information collected from Flickr photos and Tweets harvested in 2014–2015. The comparison shows how sense of place is dynamic and changing over time and explores Kilburn High Road through the categories of location, locale and sense of place derived from the qualitative analysis of VGI content and annotations. The contribution shows how VGI can contribute to discovering the unique relationship between people and place which takes the form given by Doreen Massey to Kilburn High Road and then moves on to the many forms given by people experiencing Kilburn High Road through a photo, a Tweet or a simple narrative. Finally, the paper suggests that the analysis of VGI content can contribute to detect the relevant features of street life, from infrastructure to citizens’ perceptions, which should be taken into account for a more human-centered approach in planning or service management.

  2. High Gradient Accelerator Research

    Temkin, Richard

    2016-01-01

    The goal of the MIT program of research on high gradient acceleration is the development of advanced acceleration concepts that lead to a practical and affordable next generation linear collider at the TeV energy level. Other applications, which are more near-term, include accelerators for materials processing; medicine; defense; mining; security; and inspection. The specific goals of the MIT program are: • Pioneering theoretical research on advanced structures for high gradient acceleration, including photonic structures and metamaterial structures; evaluation of the wakefields in these advanced structures • Experimental research to demonstrate the properties of advanced structures both in low-power microwave cold test and high-power, high-gradient test at megawatt power levels • Experimental research on microwave breakdown at high gradient including studies of breakdown phenomena induced by RF electric fields and RF magnetic fields; development of new diagnostics of the breakdown process • Theoretical research on the physics and engineering features of RF vacuum breakdown • Maintaining and improving the Haimson / MIT 17 GHz accelerator, the highest frequency operational accelerator in the world, a unique facility for accelerator research • Providing the Haimson / MIT 17 GHz accelerator facility as a facility for outside users • Active participation in the US DOE program of High Gradient Collaboration, including joint work with SLAC and with Los Alamos National Laboratory; participation of MIT students in research at the national laboratories • Training the next generation of Ph. D. students in the field of accelerator physics.

  3. High Caloric Diet for ALS Patients: High Fat, High Carbohydrate or High Protein

    Sarvin Sanaie

    2015-01-01

    Full Text Available ALS is a fatal motor neurodegenerative disease characterized by muscle atrophy and weakness, dysarthria, and dysphagia. The mean survival of ALS patients is three to five years, with 50% of those diagnosed dying within three years of onset (1. A multidisciplinary approach is crucial to set an appropriate plan for metabolic and nutritional support in ALS. Nutritional management incorporates a continuous assessment and implementation of dietary modifications throughout the duration of the disease. The nutritional and metabolic approaches to ALS should start when the diagnosis of ALS is made and should become an integral part of the continuous care to the patient, including nutritional surveillance, dietary counseling, management of dysphagia, and enteral nutrition when needed. Malnutrition and lean body mass loss are frequent findings in ALS patients necessitating comprehensive energy requirement assessment for these patients. Malnutrition is an independent prognostic factor for survival in ALS with a 7.7 fold increase in risk of death. Malnutrition is estimated to develop in one quarter to half of people with ALS (2. Adequate calorie and protein provision would diminish muscle loss in this vulnerable group of patients. Although appropriate amount of energy to be administered is yet to be established, high calorie diet is expected to be effective for potential improvement of survival; ALS patients do not normally receive adequate  intake of energy. A growing number of clinicians suspect that a high calorie diet implemented early in their disease may help people with ALS meet their increased energy needs and extend their survival. Certain high calorie supplements appear to be safe and well tolerated by people with ALS according to studies led by Universitäts klinikum Ulm's and, appear to stabilize body weight within 3 months. In a recent study by Wills et al., intake of high-carbohydrate low-fat supplements has been recommended in ALS patients (3

  4. High availability using virtualization

    Calzolari, Federico; Arezzini, Silvia; Ciampa, Alberto; Mazzoni, Enrico; Domenici, Andrea; Vaglini, Gigliola

    2010-01-01

    High availability has always been one of the main problems for a data center. Till now high availability was achieved by host per host redundancy, a highly expensive method in terms of hardware and human costs. A new approach to the problem can be offered by virtualization. Using virtualization, it is possible to achieve a redundancy system for all the services running on a data center. This new approach to high availability allows the running virtual machines to be distributed over a small number of servers, by exploiting the features of the virtualization layer: start, stop and move virtual machines between physical hosts. The 3RC system is based on a finite state machine, providing the possibility to restart each virtual machine over any physical host, or reinstall it from scratch. A complete infrastructure has been developed to install operating system and middleware in a few minutes. To virtualize the main servers of a data center, a new procedure has been developed to migrate physical to virtual hosts. The whole Grid data center SNS-PISA is running at the moment in virtual environment under the high availability system.

  5. High temperature storage loop :

    Gill, David Dennis; Kolb, William J.

    2013-07-01

    A three year plan for thermal energy storage (TES) research was created at Sandia National Laboratories in the spring of 2012. This plan included a strategic goal of providing test capability for Sandia and for the nation in which to evaluate high temperature storage (>650ÀC) technology. The plan was to scope, design, and build a flow loop that would be compatible with a multitude of high temperature heat transfer/storage fluids. The High Temperature Storage Loop (HTSL) would be reconfigurable so that it was useful for not only storage testing, but also for high temperature receiver testing and high efficiency power cycle testing as well. In that way, HTSL was part of a much larger strategy for Sandia to provide a research and testing platform that would be integral for the evaluation of individual technologies funded under the SunShot program. DOEs SunShot program seeks to reduce the price of solar technologies to 6/kWhr to be cost competitive with carbon-based fuels. The HTSL project sought to provide evaluation capability for these SunShot supported technologies. This report includes the scoping, design, and budgetary costing aspects of this effort

  6. Cryogenic high current discharges

    Meierovich, B.E.

    1994-01-01

    Z-pinches formed from frozen deuterium fibers by a rapidly rising current have enhanced stability and high neutron yield. The efforts to understand the enhanced stability and neutron yield on the basis of classical picture of Bennett equilibrium of the current channel has not given satisfactory results. The traditional approach does not take into account the essential difference between the frozen deuterium fiber Z-pinches and the usual Z-pinches such as exploding wires or classical gas-puffed Z-pinches. The very low temperature of the fiber atoms (10 K), together with the rapidly rising current, result in the coexistence of a high current channel with unionized fiber atoms for a substantial period of time. This phenomena lasts during the risetime. This approach takes into account the difference of the breakdown in a dielectric deuterium fiber and the breakdown in a metallic wire. This difference is essential to the understanding of specific features of cryogenic high current discharges. Z-pinches in frozen deuterium fibers should be considered as a qualitatively new phenomenon on the boundary of cryogenic and high current physics. It is a start of a new branch in plasma physics: the physics of cryogenic high current discharges

  7. High Altitude and Heart

    Murat Yalcin

    2011-04-01

    Full Text Available Nowadays, situations associated with high altitude such as mountaineering, aviation increasingly draw the attention of people. Gas pressure decreases and hypoxia is encountered when climbing higher. Physiological and pathological responses of human body to different heights are different. Therefore, physiological and pathological changes that may occur together with height and to know the clinical outcomes of these are important . Acute mountain sickness caused by high altitude and high altitude cerebral edema are preventable diseases with appropriate precautions. Atmospheric oxygen decreasing with height, initiates many adaptive mechanisms. These adaptation mechanisms and acclimatization vary widely among individuals because of reasons such as environmental factors, exercise and cold. High altitude causes different changes in the cardiovascular system with various mechanisms. Although normal individuals easily adapt to these changes, this situation can lead to undesirable results in people with heart disease. For this reason, it should be known the effective evaluation of the people with known heart disease before traveling to high altitude and the complications due to the changes with height and the recommendations can be made to these patients. [TAF Prev Med Bull 2011; 10(2.000: 211-222

  8. High resolution data acquisition

    Thornton, Glenn W.; Fuller, Kenneth R.

    1993-01-01

    A high resolution event interval timing system measures short time intervals such as occur in high energy physics or laser ranging. Timing is provided from a clock (38) pulse train (37) and analog circuitry (44) for generating a triangular wave (46) synchronously with the pulse train (37). The triangular wave (46) has an amplitude and slope functionally related to the time elapsed during each clock pulse in the train. A converter (18, 32) forms a first digital value of the amplitude and slope of the triangle wave at the start of the event interval and a second digital value of the amplitude and slope of the triangle wave at the end of the event interval. A counter (26) counts the clock pulse train (37) during the interval to form a gross event interval time. A computer (52) then combines the gross event interval time and the first and second digital values to output a high resolution value for the event interval.

  9. High energy radiation detector

    Vosburgh, K.G.

    1975-01-01

    The high energy radiation detector described comprises a set of closely spaced wedge reflectors. Each wedge reflector is composed of three sides forming identical isoceles triangles with a common apex and an open base forming an equilateral triangle. The length of one side of the base is less than the thickness of the coat of material sensitive to high energy radiation. The wedge reflectors reflect the light photons spreading to the rear of the coat in such a way that each reflected track is parallel to the incident track of the light photon spreading rearwards. The angle of the three isosceles triangles with a common apex is between 85 and 95 deg. The first main surface of the coat of high energy radiation sensitive material is in contact with the projecting edges of the surface of the wedge reflectors of the reflecting element [fr

  10. Theoretical high energy physics

    Lee, T.D.

    1993-01-01

    Brief reports are given on the work of several professors. The following areas are included: quantum chromodynamics calculations using numerical lattice gauge theory and a high-speed parallel computer; the ''spin wave'' description of bosonic particles moving on a lattice with same-site exclusion; a high-temperature expansion to 13th order for the O(4)-symmetric φ 4 model on a four-dimensional F 4 lattice; spin waves and lattice bosons; superconductivity of C 60 ; meson-meson interferometry in heavy-ion collisions; baryon number violation in the Standard Model in high-energy collisions; hard thermal loops in QCD; electromagnetic interactions of anyons; the relation between Bose-Einstein and BCS condensations; Euclidean wormholes with topology S 1 x S 2 x R; vacuum decay and symmetry breaking by radiative corrections; inflationary solutions to the cosmological horizon and flatness problems; and magnetically charged black holes

  11. High-tech entrepreneurship

    Bernasconi, Michel; Harris, Simon; Mønsted, Mette

    ; entrepreneurial finance; marketing technological innovations; and high-tech incubation management. Including case studies to give practical insights into genuine business examples, this comprehensive book has a distinctly 'real-world' focus throughout.Edited by a multi-national team, this comprehensive book......High-tech businesses form a crucial part of entrepreneurial activity - in some ways representing very typical examples of entrepreneurship, yet in some ways representing quite different challenges. The uncertainty in innovation and advanced technology makes it difficult to use conventional economic...... planning models, and also means that the management skills used in this area must be more responsive to issues of risk, uncertainty and evaluation than in conventional business opportunities. Whilst entrepreneurial courses do reflect the importance of high-tech businesses, they often lack the resources...

  12. High brightness electron accelerator

    Sheffield, R.L.; Carlsten, B.E.; Young, L.M.

    1994-01-01

    A compact high brightness linear accelerator is provided for use, e.g., in a free electron laser. The accelerator has a first plurality of accelerating cavities having end walls with four coupling slots for accelerating electrons to high velocities in the absence of quadrupole fields. A second plurality of cavities receives the high velocity electrons for further acceleration, where each of the second cavities has end walls with two coupling slots for acceleration in the absence of dipole fields. The accelerator also includes a first cavity with an extended length to provide for phase matching the electron beam along the accelerating cavities. A solenoid is provided about the photocathode that emits the electrons, where the solenoid is configured to provide a substantially uniform magnetic field over the photocathode surface to minimize emittance of the electrons as the electrons enter the first cavity. 5 figs

  13. High-energy detector

    Bolotnikov, Aleksey E [South Setauket, NY; Camarda, Giuseppe [Farmingville, NY; Cui, Yonggang [Upton, NY; James, Ralph B [Ridge, NY

    2011-11-22

    The preferred embodiments are directed to a high-energy detector that is electrically shielded using an anode, a cathode, and a conducting shield to substantially reduce or eliminate electrically unshielded area. The anode and the cathode are disposed at opposite ends of the detector and the conducting shield substantially surrounds at least a portion of the longitudinal surface of the detector. The conducting shield extends longitudinally to the anode end of the detector and substantially surrounds at least a portion of the detector. Signals read from one or more of the anode, cathode, and conducting shield can be used to determine the number of electrons that are liberated as a result of high-energy particles impinge on the detector. A correction technique can be implemented to correct for liberated electron that become trapped to improve the energy resolution of the high-energy detectors disclosed herein.

  14. Timetabling at High Schools

    Sørensen, Matias

    on the publicly available XHSTT format for modeling instances and solutions of the HSTP) and the Danish High School Timetabling Problem (DHSTP). For both problems a complex Mixed-Integer Programming (MIP) model is developed, and in both cases are empirical tests performed on a large number of real-life datasets......High school institutions face a number of important planning problems during each schoolyear. This Ph.D. thesis considers two of these planning problems: The High School Timetabling Problem (HSTP) and the Consultation Timetabling Problem (CTP). Furthermore a framework for handling various planning....... The second part contains the main scienti_c papers composed during the Ph.D. study. The third part of the thesis also contains scienti_c papers, but these are included as an appendix. In the HSTP, the goal is to obtain a timetable for the forthcoming school-year. A timetable consists of lectures scheduled...

  15. High power microwaves

    Benford, James; Schamiloglu, Edl

    2016-01-01

    Following in the footsteps of its popular predecessors, High Power Microwaves, Third Edition continues to provide a wide-angle, integrated view of the field of high power microwaves (HPMs). This third edition includes significant updates in every chapter as well as a new chapter on beamless systems that covers nonlinear transmission lines. Written by an experimentalist, a theorist, and an applied theorist, respectively, the book offers complementary perspectives on different source types. The authors address: * How HPM relates historically and technically to the conventional microwave field * The possible applications for HPM and the key criteria that HPM devices have to meet in order to be applied * How high power sources work, including their performance capabilities and limitations * The broad fundamental issues to be addressed in the future for a wide variety of source types The book is accessible to several audiences. Researchers currently in the field can widen their understanding of HPM. Present or pot...

  16. High frequency energy measurements

    Stotlar, S.C.

    1981-01-01

    High-frequency (> 100 MHz) energy measurements present special problems to the experimenter. Environment or available electronics often limit the applicability of a given detector type. The physical properties of many detectors are frequency dependent and in some cases, the physical effect employed can be frequency dependent. State-of-the-art measurements generally involve a detection scheme in association with high-speed electronics and a method of data recording. Events can be single or repetitive shot requiring real time, sampling, or digitizing data recording. Potential modification of the pulse by the detector and the associated electronics should not be overlooked. This presentation will review typical applications, methods of choosing a detector, and high-speed detectors. Special considerations and limitations of some applications and devices will be described

  17. Clustering high dimensional data

    Assent, Ira

    2012-01-01

    High-dimensional data, i.e., data described by a large number of attributes, pose specific challenges to clustering. The so-called ‘curse of dimensionality’, coined originally to describe the general increase in complexity of various computational problems as dimensionality increases, is known...... to render traditional clustering algorithms ineffective. The curse of dimensionality, among other effects, means that with increasing number of dimensions, a loss of meaningful differentiation between similar and dissimilar objects is observed. As high-dimensional objects appear almost alike, new approaches...... for clustering are required. Consequently, recent research has focused on developing techniques and clustering algorithms specifically for high-dimensional data. Still, open research issues remain. Clustering is a data mining task devoted to the automatic grouping of data based on mutual similarity. Each cluster...

  18. High strength alloys

    Maziasz, Phillip James [Oak Ridge, TN; Shingledecker, John Paul [Knoxville, TN; Santella, Michael Leonard [Knoxville, TN; Schneibel, Joachim Hugo [Knoxville, TN; Sikka, Vinod Kumar [Oak Ridge, TN; Vinegar, Harold J [Bellaire, TX; John, Randy Carl [Houston, TX; Kim, Dong Sub [Sugar Land, TX

    2010-08-31

    High strength metal alloys are described herein. At least one composition of a metal alloy includes chromium, nickel, copper, manganese, silicon, niobium, tungsten and iron. System, methods, and heaters that include the high strength metal alloys are described herein. At least one heater system may include a canister at least partially made from material containing at least one of the metal alloys. At least one system for heating a subterranean formation may include a tubular that is at least partially made from a material containing at least one of the metal alloys.

  19. High loading uranium plate

    Wiencek, T.C.; Domagala, R.F.; Thresh, H.R.

    1990-01-01

    Two embodiments of a high uranium fuel plate are disclosed which contain a meat comprising structured uranium compound confined between a pari of diffusion bonded ductile metal cladding plates uniformly covering the meat, the meat hiving a uniform high fuel loading comprising a content of uranium compound greater than about 45 Vol. % at a porosity not greater than about 10 Vol. %. In a first embodiment, the meat is a plurality of parallel wires of uranium compound. In a second embodiment, the meat is a dispersion compact containing uranium compound. The fuel plates are fabricated by a hot isostatic pressing process

  20. JUNOS High Availability

    Sonderegger, James; Milne, Kieran; Palislamovic, Senad

    2009-01-01

    Whether your network is a complex carrier or just a few machines supporting a small enterprise, JUNOS High Availability will help you build reliable and resilient networks that include Juniper Networks devices. With this book's valuable advice on software upgrades, scalability, remote network monitoring and management, high-availability protocols such as VRRP, and more, you'll have your network uptime at the five, six, or even seven nines -- or 99.99999% of the time. Rather than focus on "greenfield" designs, the authors explain how to intelligently modify multi-vendor networks. You'll learn

  1. High availability IT services

    Critchley, Terry

    2014-01-01

    This book starts with the basic premise that a service is comprised of the 3Ps-products, processes, and people. Moreover, these entities and their sub-entities interlink to support the services that end users require to run and support a business. This widens the scope of any availability design far beyond hardware and software. It also increases the potential for service failure for reasons beyond just hardware and software; the concept of logical outages. High Availability IT Services details the considerations for designing and running highly available ""services"" and not just the systems

  2. High intensity hadron accelerators

    Teng, L.C.

    1989-05-01

    This rapporteur report consists mainly of two parts. Part I is an abridged review of the status of all High Intensity Hadron Accelerator projects in the world in semi-tabulated form for quick reference and comparison. Part II is a brief discussion of the salient features of the different technologies involved. The discussion is based mainly on my personal experiences and opinions, tempered, I hope, by the discussions I participated in in the various parallel sessions of the workshop. In addition, appended at the end is my evaluation and expression of the merits of high intensity hadron accelerators as research facilities for nuclear and particle physics

  3. Unexpected high plasma cobalamin

    Arendt, Johan F B; Nexo, Ebba

    2013-01-01

    It is well-established that more than 8% of patients examined for vitamin B12 deficiency unexpectedly have increased plasma levels of the vitamin, but so far there are no guidelines for the clinical interpretation of such findings. In this review, we summarise known associations between high plasma...... cobalamin binding proteins, transcobalamin and haptocorrin. Based on current knowledge, we suggest a strategy for the clinical interpretation of unexpected high plasma cobalamin. Since a number of the associated diseases are critical and life-threatening, the strategy promotes the concept of 'think...

  4. High speed rotary drum

    Sagara, H

    1970-03-25

    A high speed rotary drum is disclosed in which the rotor vessel is a double-wall structure comprising an inner wave-shaped pipe inserted coaxially within an outer straight pipe, the object being to provide a strengthened composite light-weight structure. Since force induced axial deformation of the straight pipe and radial deformation of the corrugated pipe are small, the composite effectively resists external forces and, if the waves of the inner pipe are given a sufficient amplitude, the thickness of both pipes may be reduced to lower the overall weight. Thus high angular velocities can be obtained to separate U/sup 235/ from gaseous UF/sub 6/.

  5. Theoretical high energy physics

    Lee, T.D.

    1991-01-01

    This report discusses theoretical research in high energy physics at Columbia University. Some of the research topics discussed are: quantum chromodynamics with dynamical fermions; lattice gauge theory; scattering of neutrinos by photons; atomic physics constraints on the properties of ultralight-ultraweak gauge bosons; black holes; Chern- Simons physics; S-channel theory of superconductivity; charged boson system; gluon-gluon interactions; high energy scattering in the presence of instantons; anyon physics; causality constraints on primordial magnetic manopoles; charged black holes with scalar hair; properties of Chern-Aimona-Higgs solitons; and extended inflationary universe

  6. High Pressure Biomass Gasification

    Agrawal, Pradeep K [Georgia Tech Research Corporation, Atlanta, GA (United States)

    2016-07-29

    According to the Billion Ton Report, the U.S. has a large supply of biomass available that can supplement fossil fuels for producing chemicals and transportation fuels. Agricultural waste, forest residue, and energy crops offer potential benefits: renewable feedstock, zero to low CO2 emissions depending on the specific source, and domestic supply availability. Biomass can be converted into chemicals and fuels using one of several approaches: (i) biological platform converts corn into ethanol by using depolymerization of cellulose to form sugars followed by fermentation, (ii) low-temperature pyrolysis to obtain bio-oils which must be treated to reduce oxygen content via HDO hydrodeoxygenation), and (iii) high temperature pyrolysis to produce syngas (CO + H2). This last approach consists of producing syngas using the thermal platform which can be used to produce a variety of chemicals and fuels. The goal of this project was to develop an improved understanding of the gasification of biomass at high pressure conditions and how various gasification parameters might affect the gasification behavior. Since most downstream applications of synags conversion (e.g., alcohol synthesis, Fischer-Tropsch synthesis etc) involve utilizing high pressure catalytic processes, there is an interest in carrying out the biomass gasification at high pressure which can potentially reduce the gasifier size and subsequent downstream cleaning processes. It is traditionally accepted that high pressure should increase the gasification rates (kinetic effect). There is also precedence from coal gasification literature from the 1970s that high pressure gasification would be a beneficial route to consider. Traditional approach of using thermogravimetric analyzer (TGA) or high-pressure themogravimetric analyzer (PTGA) worked well in understanding the gasification kinetics of coal gasification which was useful in designing high pressure coal gasification processes. However

  7. High temperature radioisotope capsule

    Bradshaw, G.B.

    1976-01-01

    A high temperature radioisotope capsule made up of three concentric cylinders, with the isotope fuel located within the innermost cylinder is described. The innermost cylinder has hemispherical ends and is constructed of a tantalum alloy. The intermediate cylinder is made of a molybdenum alloy and is capable of withstanding the pressure generated by the alpha particle decay of the fuel. The outer cylinder is made of a platinum alloy of high resistance to corrosion. A gas separates the innermost cylinder from the intermediate cylinder and the intermediate cylinder from the outer cylinder

  8. High alumina refractories

    Simao, L.C.; Lopes, A.B.; Galvao Filho, N.B.; Souza, R.B. de

    1989-01-01

    High alumina refractories with 92 to 96.5% Al 2 O 3 were produced using brown and white fused as aggregate. Those refractories present only alumina-α and mullite as crystalline mineralogical phase. Other physical and chemical characteristics are similar to the ones found in refractories produced in Brazil, Japan and U.S.A. The most important physical and chemical tests used for the characterization of the raw materials and refractories, complemented by those realized at high temperatures, plus X-ray Difractometry and optical microscopy are presented, besides the refractory formulation and main parameters of production [pt

  9. High-level verification

    Lerner, Sorin; Kundu, Sudipta

    2011-01-01

    Given the growing size and heterogeneity of Systems on Chip (SOC), the design process from initial specification to chip fabrication has become increasingly complex. This growing complexity provides incentive for designers to use high-level languages such as C, SystemC, and SystemVerilog for system-level design. While a major goal of these high-level languages is to enable verification at a higher level of abstraction, allowing early exploration of system-level designs, the focus so far for validation purposes has been on traditional testing techniques such as random testing and scenario-based

  10. High School Principals and the High School Journalism Program.

    Peterson, Jane W.

    A study asked selected high school principals to respond to statements about the value of high school journalism to the high school student and about the rights and responsibilities of the high school journalist. These responses were then checked against such information as whether or not the high school principal had worked on a high school…

  11. High performance conductometry

    Saha, B.

    2000-01-01

    Inexpensive but high performance systems have emerged progressively for basic and applied measurements in physical and analytical chemistry on one hand, and for on-line monitoring and leak detection in plants and facilities on the other. Salient features of the developments will be presented with specific examples

  12. High beta tokamaks

    Dory, R.A.; Berger, D.P.; Charlton, L.A.; Hogan, J.T.; Munro, J.K.; Nelson, D.B.; Peng, Y.K.M.; Sigmar, D.J.; Strickler, D.J.

    1978-01-01

    MHD equilibrium, stability, and transport calculations are made to study the accessibility and behavior of ''high beta'' tokamak plasmas in the range β approximately 5 to 15 percent. For next generation devices, beta values of at least 8 percent appear to be accessible and stable if there is a conducting surface nearby

  13. High temperature niobium alloys

    Wojcik, C.C.

    1991-01-01

    Niobium alloys are currently being used in various high temperature applications such as rocket propulsion, turbine engines and lighting systems. This paper presents an overview of the various commercial niobium alloys, including basic manufacturing processes, properties and applications. Current activities for new applications include powder metallurgy, coating development and fabrication of advanced porous structures for lithium cooled heat pipes

  14. High School Book Fairs

    Fitzgerald, Marianne

    2006-01-01

    Many secondary students have given up the joy of reading. When asked why they don't read for pleasure, students came up with many different reasons, the first being lack of time. High school students are busy with after school jobs, sports, homework, etc. With the growing number of students enrolled in AP classes, not only is there not much time…

  15. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Carbohydrate Counting Make Your Carbs Count Glycemic Index Low-Calorie Sweeteners Sugar and Desserts Fitness Exercise & Type ... Checking Your Blood Glucose A1C and eAG Hypoglycemia (Low blood glucose) Hyperglycemia (High blood glucose) Dawn Phenomenon ...

  16. Highly oxidized superconductors

    Morris, Donald E.

    1994-01-01

    Novel superconducting materials in the form of compounds, structures or phases are formed by performing otherwise known syntheses in a highly oxidizing atmosphere rather than that created by molecular oxygen at atmospheric pressure or below. This leads to the successful synthesis of novel superconducting compounds which are thermodynamically stable at the conditions under which they are formed.

  17. High strength ferritic alloy

    1977-01-01

    A high strength ferritic steel is specified in which the major alloying elements are chromium and molybdenum, with smaller quantities of niobium, vanadium, silicon, manganese and carbon. The maximum swelling is specified for various irradiation conditions. Rupture strength is also specified. (U.K.)

  18. High temperature interface superconductivity

    Gozar, A.; Bozovic, I.

    2016-01-01

    Highlight: • This review article covers the topic of high temperature interface superconductivity. • New materials and techniques used for achieving interface superconductivity are discussed. • We emphasize the role played by the differences in structure and electronic properties at the interface with respect to the bulk of the constituents. - Abstract: High-T_c superconductivity at interfaces has a history of more than a couple of decades. In this review we focus our attention on copper-oxide based heterostructures and multi-layers. We first discuss the technique, atomic layer-by-layer molecular beam epitaxy (ALL-MBE) engineering, that enabled High-T_c Interface Superconductivity (HT-IS), and the challenges associated with the realization of high quality interfaces. Then we turn our attention to the experiments which shed light on the structure and properties of interfacial layers, allowing comparison to those of single-phase films and bulk crystals. Both ‘passive’ hetero-structures as well as surface-induced effects by external gating are discussed. We conclude by comparing HT-IS in cuprates and in other classes of materials, especially Fe-based superconductors, and by examining the grand challenges currently laying ahead for the field.

  19. High altitude organic gold

    Pouliot, Mariève; Pyakurel, Dipesh; Smith-Hall, Carsten

    2018-01-01

    Ethnopharmacological relevance Ophiocordyceps sinensis (Berk.) G.H.Sung, J.M.Sung, Hywel-Jones & Spatafora, a high altitude Himalayan fungus-caterpillar product found in alpine meadows in China, Bhutan, Nepal, and India, has been used in the Traditional Chinese Medicine system for over 2000 years...

  20. High Brightness OLED Lighting

    Spindler, Jeffrey [OLEDWorks LLC; Kondakova, Marina [OLEDWorks LLC; Boroson, Michael [OLEDWorks LLC; Hamer, John [OLEDWorks LLC

    2016-05-25

    In this work we describe the technology developments behind our current and future generations of high brightness OLED lighting panels. We have developed white and amber OLEDs with excellent performance based on the stacking approach. Current products achieve 40-60 lm/W, while future developments focus on achieving 80 lm/W or higher.

  1. Knees Lifted High

    The Eagle Books are a series of four books that are brought to life by wise animal characters - Mr. Eagle, Miss Rabbit, and Coyote - who engage Rain That Dances and his young friends in the joy of physical activity, eating healthy foods, and learning from their elders about health and diabetes prevention. Knees Lifted High gives children fun ideas for active outdoor play.

  2. Hyperglycemia (High Blood Glucose)

    Full Text Available ... In Memory In Honor Become a Member En Español Type 1 Type 2 About Us Online Community ... Page Text Size: A A A Listen En Español Hyperglycemia (High Blood Glucose) Hyperglycemia is the technical ...

  3. Theoretical high energy physics

    Lee, T.D.

    1992-01-01

    This progress report discusses research by Columbia University staff in high energy physics. Some of the topics discussed are as follows: lattice gauge theory; quantum chromodynamics; parity doublets; solitons; baryon number violation; black holes; magnetic monopoles; gluon plasma; Chern-Simons theory; and the inflationary universe

  4. High-Sensitivity Spectrophotometry.

    Harris, T. D.

    1982-01-01

    Selected high-sensitivity spectrophotometric methods are examined, and comparisons are made of their relative strengths and weaknesses and the circumstances for which each can best be applied. Methods include long path cells, noise reduction, laser intracavity absorption, thermocouple calorimetry, photoacoustic methods, and thermo-optical methods.…

  5. Investing in High School

    Green, Daniel G.

    2012-01-01

    Strapped for cash, a Massachusetts high school creates its own venture capital fund to incentivize teachers to create programs that improve student learning. The result has been higher test scores and higher job satisfaction. One important program is credited with helping close the achievement gap at the school, while others have helped ambitious…

  6. High-fiber foods

    ... page: //medlineplus.gov/ency/patientinstructions/000193.htm High-fiber foods To use the sharing features on this page, ... Read food labels carefully to see how much fiber they have. Choose foods that have higher amounts of fiber, such as ...

  7. High resolution drift chambers

    Va'vra, J.

    1985-07-01

    High precision drift chambers capable of achieving less than or equal to 50 μm resolutions are discussed. In particular, we compare so called cool and hot gases, various charge collection geometries, several timing techniques and we also discuss some systematic problems. We also present what we would consider an ''ultimate'' design of the vertex chamber. 50 refs., 36 figs., 6 tabs

  8. Hyperglycemia (High Blood Glucose)

    Full Text Available ... Text Size: A A A Listen En Español Hyperglycemia (High Blood Glucose) Hyperglycemia is the technical term ... body can't use insulin properly. What Causes Hyperglycemia? A number of things can cause hyperglycemia: If ...

  9. High luminosity particle colliders

    Palmer, R.B.; Gallardo, J.C.

    1997-03-01

    The authors consider the high energy physics advantages, disadvantages and luminosity requirements of hadron (pp, p anti p), lepton (e + e - , μ + μ - ) and photon-photon colliders. Technical problems in obtaining increased energy in each type of machine are presented. The machines relative size are also discussed

  10. Fascination at high pressures

    Chidambaram, R.

    1992-01-01

    Research at high pressures has developed into an interdisciplinary area which has important implications for and applications in the areas of physics, chemistry, materials sciences, planetary sciences, biology, engineering sciences and technology. The state of-the-art in this field is reviewed and future directions are indicated. (M.G.B.)

  11. CSTI High Capacity Power

    Winter, J.M.

    1989-01-01

    The SP-100 program was established in 1983 by DOD, DOE, and NASA as a joint program to develop the technology necessary for space nuclear power systems for military and civil application. During FY-86 and 87, the NASA SP-100 Advanced Technology Program was devised to maintain the momentum of promising technology advancement efforts started during Phase 1 of SP-100 and to strengthen, in key areas, the chances for successful development and growth capability of space nuclear reactor power systems for future space applications. In FY-88, the Advanced Technology Program was incorporated into NASA's new Civil Space Technology Initiative (CSTI). The CSTI Program was established to provide the foundation for technology development in automation and robotics, information, propulsion, and power. The CSTI High Capacity Power Program builds on the technology efforts of the SP-100 program, incorporates the previous NASA SP-100 Advanced Technology project, and provides a bridge to NASA Project Pathfinder. The elements of CSTI High Capacity Power development include Conversion Systems, Thermal Management, Power Management, System Diagnostics, and Environmental Interactions. Technology advancement in all areas, including materials, is required to assure the high reliability and 7 to 10 year lifetime demanded for future space nuclear power systems. The overall program will develop and demonstrate the technology base required to provide a wide range of modular power systems as well as allowing mission independence from solar and orbital attitude requirements. Several recent advancements in CSTI High Capacity power development will be discussed

  12. High Collection Nonimaging Optics

    Winston, Roland

    1989-07-01

    Nonimaging optics departs from the methods of traditional optical design to develop instead techniques for maximizing the collecting power of concentrating elements and systems. Designs which exceed the concentration attainable with focusing techniques by factors of four or more and approach the theoretical limit are possible (ideal concentrators). The methodology for designing high collection nonirnaging systems is described.

  13. High energy astrophysics

    Shklorsky, I.S.

    1979-01-01

    A selected list of articles of accessible recent review articles and conference reports, wherein up-to-date summaries of various topics in the field of high energy astrophysics can be found, is presented. A special report outlines work done in the Soviet Union in this area. (Auth.)

  14. High frequency electromagnetic dosimetry

    Sánchez-Hernández, David A

    2009-01-01

    Along with the growth of RF and microwave technology applications, there is a mounting concern about the possible adverse effects over human health from electromagnetic radiation. Addressing this issue and putting it into perspective, this groundbreaking resource provides critical details on the latest advances in high frequency electromagnetic dosimetry.

  15. Reshaping High School English.

    Pirie, Bruce

    This book takes up the question of what shape high school English studies should take in the coming years. It describes an English program that blends philosophical depth with classroom practicality. Drawing examples from commonly taught texts such as "Macbeth,""To Kill a Mockingbird," and "Lord of the Flies," the…

  16. Nuclei in high forms

    Szymanski, Z.; Berger, J.F.; Heenen, P.H.; Heyde, K.; Haas, B.; Janssens, R.; Paya, D.; Gogny, D.; Huber, G.; Bjoernholm, S.; Brack, M.

    1991-01-01

    The purpose of 1991 Joliot-Curie Summer School is to review the most advances in the understanding of the nuclei physics after the considerable progress in gamma spectroscopy. It covers the following topics: Highly and super-deformed nuclei, nuclear structures, mean-field approach and beyond, fission isomers, nuclear excitations with long lifetime and metal clusters

  17. General Algorithm (High level)

    First page Back Continue Last page Overview Graphics. General Algorithm (High level). Iteratively. Use Tightness Property to remove points of P1,..,Pi. Use random sampling to get a Random Sample (of enough points) from the next largest cluster, Pi+1. Use the Random Sampling Procedure to approximate ci+1 using the ...

  18. High Temperature Electrolysis

    Elder, Rachael; Cumming, Denis; Mogensen, Mogens Bjerg

    2015-01-01

    High temperature electrolysis of carbon dioxide, or co-electrolysis of carbon dioxide and steam, has a great potential for carbon dioxide utilisation. A solid oxide electrolysis cell (SOEC), operating between 500 and 900. °C, is used to reduce carbon dioxide to carbon monoxide. If steam is also i...

  19. High on walking

    Woythal, Bente Martinsen; Haahr, Anita; Dreyer, Pia

    2018-01-01

    a leg, and people who live with Parkinson’s disease. The analysis of the data is inspired by Paul Ricoeur’s philosophy of interpretation. Four themes were identified: (a) I feel high in two ways; (b) Walking has to be automatic; (c) Every Monday, I walk with the girls in the park; and (d) I dream...

  20. High-temperature superconductivity

    Lynn, J.W.

    1990-01-01

    This book discusses development in oxide materials with high superconducting transition temperature. Systems with Tc well above liquid nitrogen temperature are already a reality and higher Tc's are anticipated. The author discusses how the idea of a room-temperature superconductor appears to be a distinctly possible outcome of materials research

  1. Hyperglycemia (High Blood Glucose)

    Full Text Available ... You At Risk? Diabetes Basics Living with Diabetes Food & Fitness In My Community Advocacy Research & Practice Ways to Give Close Are You at Risk? Home Prevention Diagnosing Diabetes and Learning About Prediabetes Type 2 Diabetes Risk Test Lower Your Risk Healthy Eating Overweight Smoking High ...

  2. High brightness ion source

    Dreyfus, R.W.; Hodgson, R.T.

    1975-01-01

    A high brightness ion beam is obtainable by using lasers to excite atoms or molecules from the ground state to an ionized state in increments, rather than in one step. The spectroscopic resonances of the atom or molecule are used so that relatively long wavelength, low power lasers can be used to obtain such ion beam

  3. High energy battery. Hochenergiebatterie

    Boehm, H.; Beyermann, G.; Bulling, M.

    1992-03-26

    In a high energy battery with a large number of individual cells in a housing with a cooling medium flowing through it, it is proposed that the cooling medium should be guided so that it only affects one or both sides of the cells thermally.

  4. Ghana's high forests

    Oduro, K.A.

    2016-01-01

    Deforestation and forest degradation in the tropics have been receiving both scientific and political attention in recent decades due to its impacts on the environment and on human livelihoods. In Ghana, the continuous decline of forest resources and the high demand for timber have raised

  5. High energy beam cooling

    Berger, H.; Herr, H.; Linnecar, T.; Millich, A.; Milss, F.; Rubbia, C.; Taylor, C.S.; Meer, S. van der; Zotter, B.

    1980-01-01

    The group concerned itself with the analysis of cooling systems whose purpose is to maintain the quality of the high energy beams in the SPS in spite of gas scattering, RF noise, magnet ripple and beam-beam interactions. Three types of systems were discussed. The status of these activities is discussed below. (orig.)

  6. Danish High Performance Concretes

    Nielsen, M. P.; Christoffersen, J.; Frederiksen, J.

    1994-01-01

    In this paper the main results obtained in the research program High Performance Concretes in the 90's are presented. This program was financed by the Danish government and was carried out in cooperation between The Technical University of Denmark, several private companies, and Aalborg University...... concretes, workability, ductility, and confinement problems....

  7. High energy colliders

    Palmer, R.B.; Gallardo, J.C.

    1997-02-01

    The authors consider the high energy physics advantages, disadvantages and luminosity requirements of hadron (pp, p anti p), lepton (e + e - , μ + μ - ) and photon-photon colliders. Technical problems in obtaining increased energy in each type of machine are presented. The machines relative size are also discussed

  8. Rocky Mountain High.

    Hill, David

    2001-01-01

    Describes Colorado's Eagle Rock School, which offers troubled teens a fresh start by transporting them to a tuition- free campus high in the mountains. The program encourages spiritual development as well as academic growth. The atmosphere is warm, loving, structured, and nonthreatening. The article profiles several students' experiences at the…

  9. High performance homes

    Beim, Anne; Vibæk, Kasper Sánchez

    2014-01-01

    . Consideration of all these factors is a precondition for a truly integrated practice and as this chapter demonstrates, innovative project delivery methods founded on the manufacturing of prefabricated buildings contribute to the production of high performance homes that are cost effective to construct, energy...

  10. High Energy Physics

    Untitled Document [Argonne Logo] [DOE Logo] High Energy Physics Home Division ES&H Personnel Collider Physics Cosmic Frontier Cosmic Frontier Theory & Computing Detector R&D Electronic Design Mechanical Design Neutrino Physics Theoretical Physics Seminars HEP Division Seminar HEP Lunch Seminar HEP

  11. High Selectivity Oxygen Delignification

    Arthur J. Ragauskas

    2005-09-30

    The overall objective of this program was to develop improved extended oxygen delignification (EOD) technologies for current U.S. pulp mill operations. This was accomplished by: (1) Identifying pulping conditions that optimize O and OO performance; (2) Identifying structural features of lignin that enhance reactivity towards EOD of high kappa pulps; (3) Identifying factors minimizing carbohydrate degradation and improve pulp strength of EOD high kappa pulps; (4) Developing a simple, reproducible method of quantifying yield gains from EOD; and (5) Developing process conditions that significantly reduce the capital requirements of EOD while optimizing the yield benefits. Key research outcomes included, demonstrating the use of a mini-O sequence such as (E+O)Dkf:0.05(E+O) or Dkf:0.05(E+O)(E+O) without interstage washing could capture approximately 60% of the delignification efficiency of a conventional O-stage without the major capital requirements associated with an O-stage for conventional SW kraft pulps. The rate of formation and loss of fiber charge during an O-stage stage can be employed to maximize net fiber charge. Optimal fiber charge development and delignification are two independent parameters and do not parallel each other. It is possible to utilize an O-stage to enhance overall cellulosic fiber charge of low and high kappa SW kraft pulps which is beneficial for physical strength properties. The application of NIR and multi-variant analysis was developed into a rapid and simple method of determining the yield of pulp from an oxygen delignification stage that has real-world mill applications. A focus point of this program was the demonstration that Kraft pulping conditions and oxygen delignification of high and low-kappa SW and HW pulps are intimately related. Improved physical pulp properties and yield can be delivered by controlling the H-factor and active alkali charge. Low AA softwood kraft pulp with a kappa number 30 has an average improvement of 2% in

  12. High Voltage Seismic Generator

    Bogacz, Adrian; Pala, Damian; Knafel, Marcin

    2015-04-01

    This contribution describes the preliminary result of annual cooperation of three student research groups from AGH UST in Krakow, Poland. The aim of this cooperation was to develop and construct a high voltage seismic wave generator. Constructed device uses a high-energy electrical discharge to generate seismic wave in ground. This type of device can be applied in several different methods of seismic measurement, but because of its limited power it is mainly dedicated for engineering geophysics. The source operates on a basic physical principles. The energy is stored in capacitor bank, which is charged by two stage low to high voltage converter. Stored energy is then released in very short time through high voltage thyristor in spark gap. The whole appliance is powered from li-ion battery and controlled by ATmega microcontroller. It is possible to construct larger and more powerful device. In this contribution the structure of device with technical specifications is resented. As a part of the investigation the prototype was built and series of experiments conducted. System parameter was measured, on this basis specification of elements for the final device were chosen. First stage of the project was successful. It was possible to efficiently generate seismic waves with constructed device. Then the field test was conducted. Spark gap wasplaced in shallowborehole(0.5 m) filled with salt water. Geophones were placed on the ground in straight line. The comparison of signal registered with hammer source and sparker source was made. The results of the test measurements are presented and discussed. Analysis of the collected data shows that characteristic of generated seismic signal is very promising, thus confirms possibility of practical application of the new high voltage generator. The biggest advantage of presented device after signal characteristics is its size which is 0.5 x 0.25 x 0.2 m and weight approximately 7 kg. This features with small li-ion battery makes

  13. Highly pathogenic avian influenza.

    Swayne, D E; Suarez, D L

    2000-08-01

    Highly pathogenic (HP) avian influenza (AI) (HPAI) is an extremely contagious, multi-organ systemic disease of poultry leading to high mortality, and caused by some H5 and H7 subtypes of type A influenza virus, family Orthomyxoviridae. However, most AI virus strains are mildly pathogenic (MP) and produce either subclinical infections or respiratory and/or reproductive diseases in a variety of domestic and wild bird species. Highly pathogenic avian influenza is a List A disease of the Office International des Epizooties, while MPAI is neither a List A nor List B disease. Eighteen outbreaks of HPAI have been documented since the identification of AI virus as the cause of fowl plague in 1955. Mildly pathogenic avian influenza viruses are maintained in wild aquatic bird reservoirs, occasionally crossing over to domestic poultry and causing outbreaks of mild disease. Highly pathogenic avian influenza viruses do not have a recognised wild bird reservoir, but can occasionally be isolated from wild birds during outbreaks in domestic poultry. Highly pathogenic avian influenza viruses have been documented to arise from MPAI viruses through mutations in the haemagglutinin surface protein. Prevention of exposure to the virus and eradication are the accepted methods for dealing with HPAI. Control programmes, which imply allowing a low incidence of infection, are not an acceptable method for managing HPAI, but have been used during some outbreaks of MPAI. The components of a strategy to deal with MPAI or HPAI include surveillance and diagnosis, biosecurity, education, quarantine and depopulation. Vaccination has been used in some control and eradication programmes for AI.

  14. High population increase rates.

    1991-09-01

    In addition to its economic and ethnic difficulties, the USSR faces several pressing demographic problems, including high population increase rates in several of its constituent republics. It has now become clear that although the country's rigid centralized planning succeeded in covering the basic needs of people, it did not lead to welfare growth. Since the 1970s, the Soviet economy has remained sluggish, which as led to increase in the death and birth rates. Furthermore, the ideology that held that demography could be entirely controlled by the country's political and economic system is contradicted by current Soviet reality, which shows that religion and ethnicity also play a significant role in demographic dynamics. Currently, Soviet republics fall under 2 categories--areas with high or low natural population increase rates. Republics with low rates consist of Christian populations (Armenia, Moldavia, Georgia, Byelorussia, Russia, Lithuania, Estonia, Latvia, Ukraine), while republics with high rates are Muslim (Tadzhikistan, Uzbekistan, Turkmenistan, Kirgizia, Azerbaijan Kazakhstan). The later group has natural increase rates as high as 3.3%. Although the USSR as a whole is not considered a developing country, the later group of republics fit the description of the UNFPA's priority list. Another serious demographic issue facing the USSR is its extremely high rate of abortion. This is especially true in the republics of low birth rates, where up to 60% of all pregnancies are terminated by induced abortions. Up to 1/5 of the USSR's annual health care budget is spent on clinical abortions -- money which could be better spent on the production of contraceptives. Along with the recent political and economic changes, the USSR is now eager to deal with its demographic problems.

  15. Intravascular ultrasound and angiographic demonstration of left main stem thrombus-high-risk presentation in a young adult with anabolic steroid abuse.

    Garg, Pankaj; Davis, Gershan; Wilson, John Ian; Sivananthan, Mohan

    2010-01-01

    We present a case of acute myocardial infarction in a young adult with a history of anabolic steroid abuse. On diagnostic coronary angiography and intravascular ultrasound, he was found to have a distal left main stem thrombus extending into the proximal left anterior descending artery and a large intermediate vessel. As he was hemodynamically stable and pain-free, he was managed conservatively with triple antiplatelet therapy (aspirin, clopidogrel, and abciximab). This was also to avoid the risk of 'wiring the vessel,' especially if there was underlying dissection. Repeat angiography a few weeks later showed complete thrombus resolution. This is the first reported case of extensive left main stem thrombus in a young patient with anabolic steroid abuse. Management of such cases is not straightforward and our case highlights one approach to both diagnosis and treatment.

  16. High energy nuclear physics

    Meyer, J.

    1988-01-01

    The 1988 progress report of the High Energy Nuclear Physics laboratory (Polytechnic School, France), is presented. The Laboratory research program is focused on the fundamental physics of interactions, on the new techniques for the acceleration of charged particles and on the nuclei double beta decay. The experiments are performed on the following topics: the measurement of the π 0 inclusive production and the photons production in very high energy nuclei-nuclei interactions and the nucleon stability. Concerning the experiments under construction, a new detector for LEP, the study and simulation of the hadronic showers in a calorimeter and the H1 experiment (HERA), are described. The future research programs and the published papers are listed [fr

  17. Dual Campus High School

    Carmen P. Mombourquette

    2013-04-01

    Full Text Available September 2010 witnessed the opening of the first complete dual campus high school in Alberta. Catholic Central High School, which had been in existence since 1967 in one building, now offered courses to students on two campuses. The “dual campus” philosophy was adopted so as to ensure maximum program flexibility for students. The philosophy, however, was destined to affect student engagement and staff efficacy as the change in organizational structure, campus locations, and course availability was dramatic. Changing school organizational structure also had the potential of affecting student achievement. A mixed-methods study utilizing engagement surveys, efficacy scales, and interviews with students and teachers was used to ascertain the degree of impact. The results of the study showed that minimal impact occurred to levels of student engagement, minor negative impact to staff efficacy, and a slight increase to student achievement results.

  18. High resolution photoelectron spectroscopy

    Arko, A.J.

    1988-01-01

    Photoelectron Spectroscopy (PES) covers a very broad range of measurements, disciplines, and interests. As the next generation light source, the FEL will result in improvements over the undulator that are larger than the undulater improvements over bending magnets. The combination of high flux and high inherent resolution will result in several orders of magnitude gain in signal to noise over measurements using synchrotron-based undulators. The latter still require monochromators. Their resolution is invariably strongly energy-dependent so that in the regions of interest for many experiments (h upsilon > 100 eV) they will not have a resolving power much over 1000. In order to study some of the interesting phenomena in actinides (heavy fermions e.g.) one would need resolving powers of 10 4 to 10 5 . These values are only reachable with the FEL

  19. High-Performance Networking

    CERN. Geneva

    2003-01-01

    The series will start with an historical introduction about what people saw as high performance message communication in their time and how that developed to the now to day known "standard computer network communication". It will be followed by a far more technical part that uses the High Performance Computer Network standards of the 90's, with 1 Gbit/sec systems as introduction for an in depth explanation of the three new 10 Gbit/s network and interconnect technology standards that exist already or emerge. If necessary for a good understanding some sidesteps will be included to explain important protocols as well as some necessary details of concerned Wide Area Network (WAN) standards details including some basics of wavelength multiplexing (DWDM). Some remarks will be made concerning the rapid expanding applications of networked storage.

  20. High temperature structural silicides

    Petrovic, J.J.

    1997-01-01

    Structural silicides have important high temperature applications in oxidizing and aggressive environments. Most prominent are MoSi 2 -based materials, which are borderline ceramic-intermetallic compounds. MoSi 2 single crystals exhibit macroscopic compressive ductility at temperatures below room temperature in some orientations. Polycrystalline MoSi 2 possesses elevated temperature creep behavior which is highly sensitive to grain size. MoSi 2 -Si 3 N 4 composites show an important combination of oxidation resistance, creep resistance, and low temperature fracture toughness. Current potential applications of MoSi 2 -based materials include furnace heating elements, molten metal lances, industrial gas burners, aerospace turbine engine components, diesel engine glow plugs, and materials for glass processing

  1. High temperature materials characterization

    Workman, Gary L.

    1990-01-01

    A lab facility for measuring elastic moduli up to 1700 C was constructed and delivered. It was shown that the ultrasonic method can be used to determine elastic constants of materials from room temperature to their melting points. The ease in coupling high frequency acoustic energy is still a difficult task. Even now, new coupling materials and higher power ultrasonic pulsers are being suggested. The surface was only scratched in terms of showing the full capabilities of either technique used, especially since there is such a large learning curve in developing proper methodologies to take measurements into the high temperature region. The laser acoustic system does not seem to have sufficient precision at this time to replace the normal buffer rod methodology.

  2. High field electron linacs

    Le Duff, J.

    1985-12-01

    High field electron linacs are considered as potential candidates to provide very high energies beyond LEP. Since almost twenty years not much improvement has been made on linac technologies as they have been mostly kept at low and medium energies to be used as injectors for storage rings. Today, both their efficiency and their performances are being reconsidered, and for instance the pulse compression sheme developed at SLAC and introduced to upgrade the energy of that linac is a first step towards a new generation of linear accelerators. However this is not enough in terms of power consumption and more development is needed to improve both the efficiency of accelerating structures and the performances of RF power sources

  3. High latitude ionospheric structure

    1984-06-01

    The Earth's ionosphere is an important element in solar-terrestrial energy transfer processes. As a major terrestrial sink for many solar and magnetospheric events, the ionosphere has characteristic features that are traced to such seemingly remote phenomena as solar flares, radiation belt wave-particle interactions and magnetospheric substorms. In considering the multiple of solar-terrestrial plasma interactions, it is important to recognize that the high-latitude ionosphere is not altogether a simple receptor of various energy deposition processes. The high-altitude ionosphere plays an active feedback role by controlling the conductivity at the base of far-reaching magnetic field lines and by providing a plasma source for the magnetosphere. Indeed, the role of the ionosphere during magnetospheric substorms is emerging as a topic for meaningful study in the overall picture of magnetospheric-ionospheric coupling

  4. High voltage isolation transformer

    Clatterbuck, C. H.; Ruitberg, A. P. (Inventor)

    1985-01-01

    A high voltage isolation transformer is provided with primary and secondary coils separated by discrete electrostatic shields from the surfaces of insulating spools on which the coils are wound. The electrostatic shields are formed by coatings of a compound with a low electrical conductivity which completely encase the coils and adhere to the surfaces of the insulating spools adjacent to the coils. Coatings of the compound also line axial bores of the spools, thereby forming electrostatic shields separating the spools from legs of a ferromagnetic core extending through the bores. The transformer is able to isolate a high constant potential applied to one of its coils, without the occurrence of sparking or corona, by coupling the coatings, lining the axial bores to the ferromagnetic core and by coupling one terminal of each coil to the respective coating encasing the coil.

  5. High thermal load component

    Fuse, Toshiaki; Tachikawa, Nobuo.

    1996-01-01

    A cooling tube made of a pure copper is connected to the inner portion of an armour (heat resistant member) made of an anisotropic carbon/carbon composite (CFC) material. The CFC material has a high heat conductivity in longitudinal direction of fibers and has low conductivity in perpendicular thereto. Fibers extending in the armour from a heat receiving surface just above the cooling tube are directly connected to the cooling tube. A portion of the fibers extending from a heat receiving surface other than portions not just above the cooling tube is directly bonded to the cooling tube. Remaining fibers are disposed so as to surround the cooling tube. The armour and the cooling tube are soldered using an active metal flux. With such procedures, high thermal load components for use in a thermonuclear reactor are formed, which are excellent in a heat removing characteristic and hardly causes defects such as crackings and peeling. (I.N.)

  6. High Latitude Polygons

    2005-01-01

    26 September 2005 This Mars Global Surveyor (MGS) Mars Orbiter Camera (MOC) image shows polygonal patterned ground on a south high-latitude plain. The outlines of the polygons, like the craters and hills in this region, are somewhat enhanced by the presence of bright frost left over from the previous winter. On Earth, polygons at high latitudes would usually be attributed to the seasonal freezing and thawing cycles of ground ice. The origin of similar polygons on Mars is less certain, but might also be an indicator of ground ice. Location near: 75.3oS, 113.2oW Image width: width: 3 km (1.9 mi) Illumination from: upper left Season: Southern Spring

  7. Prospects at high energies

    Quigg, C.

    1988-11-01

    I discuss some possibilities for neutrino experiments in the fixed-target environment of the SPS, Tevatron, and UNK, with their primary proton beams of 0.4, 0.9, and 3.0 TeV. The emphasis is on unfinished business: issues that have been recognized for some time, but not yet resolved. Then I turn to prospects for proton-proton colliders to explore the 1-TeV scale. I review the motivation for new physics in the neighborhood of 1 TeV and mention some discovery possibilities for high-energy, high-luminosity hadron colliders and the implications they would have for neutrino physics. I raise the possibility of the direct study of neutrino interactions in hadron colliders. I close with a report on the status of the SSC project. 38 refs., 17 figs

  8. High Contrast CRT.

    1980-02-01

    barium dioxide contains about 0.02% iron. For economical reasons, glass manufacturer’s probably use materials of lesser purity than reagent grade...otherwise the same procedure is followed. 2.4 Nonreflecting (NR) Film The NR film is a light abosrbing inhomogeneous film utilized to achieve a high...hour. No surface distortion of the disc occurred, thus ruling out any reaction between the carbon support plate and the glass disc that might have

  9. High-temperature superconductivity

    Ginzburg, V.L.

    1987-07-01

    After a short account of the history of experimental studies on superconductivity, the microscopic theory of superconductivity, the calculation of the control temperature and its possible maximum value are presented. An explanation of the mechanism of superconductivity in recently discovered superconducting metal oxide ceramics and the perspectives for the realization of new high-temperature superconducting materials are discussed. 56 refs, 2 figs, 3 tabs

  10. High energy medical accelerators

    Mandrillon, P.

    1990-01-01

    The treatment of tumours with charged particles, ranging from protons to 'light ions' (carbon, oxygen, neon), has many advantages, but up to now has been little used because of the absence of facilities. After the successful pioneering work carried out with accelerators built for physics research, machines dedicated to this new radiotherapy are planned or already in construction. These high energy medical accelerators are presented in this paper. (author) 15 refs.; 14 figs.; 8 tabs

  11. HIGH EFFICIENCY TURBINE

    VARMA, VIJAYA KRUSHNA

    2012-01-01

    Varma designed ultra modern and high efficiency turbines which can use gas, steam or fuels as feed to produce electricity or mechanical work for wide range of usages and applications in industries or at work sites. Varma turbine engines can be used in all types of vehicles. These turbines can also be used in aircraft, ships, battle tanks, dredgers, mining equipment, earth moving machines etc, Salient features of Varma Turbines. 1. Varma turbines are simple in design, easy to manufac...

  12. Highly Concurrent Scalar Processing.

    1986-01-01

    rearrangement arise from data dependencies between instructions, hence it is critical that artificial - dependencies are eliminated whenever possible...An important class of artificial depen- *. dencies arise due to register reuse. In the following example, no parallelism can be • . exploited in the...specific procedure call site. The use of inteligent procedure expansion techniques is expected to be crucial to the achievement of high performance

  13. Ultra high resolution tomography

    Haddad, W.S.

    1994-11-15

    Recent work and results on ultra high resolution three dimensional imaging with soft x-rays will be presented. This work is aimed at determining microscopic three dimensional structure of biological and material specimens. Three dimensional reconstructed images of a microscopic test object will be presented; the reconstruction has a resolution on the order of 1000 A in all three dimensions. Preliminary work with biological samples will also be shown, and the experimental and numerical methods used will be discussed.

  14. High boiling point hydrocarbons

    Pier, M

    1929-04-29

    A process is given for the production of hydrocarbons of high boiling point, such as lubricating oils, from bituminous substances, such as varieties of coal, shale, or other solid distillable carbonaceous materials. The process consists of treating the initial materials with organic solvents and then subjecting the products extracted from the initial materials, preferably directly, to a reducing treatment in respect to temperature, pressure, and time. The reduction treatment is performed by means of hydrogen under pressure.

  15. High temperature materials

    2003-01-01

    The aim of this workshop is to share the needs of high temperature and nuclear fuel materials for future nuclear systems, to take stock of the status of researches in this domain and to propose some cooperation works between the different research organisations. The future nuclear systems are the very high temperature (850 to 1200 deg. C) gas cooled reactors (GCR) and the molten salt reactors (MSR). These systems include not only the reactor but also the fabrication and reprocessing of the spent fuel. This document brings together the transparencies of 13 communications among the 25 given at the workshop: 1) characteristics and needs of future systems: specifications, materials and fuel needs for fast spectrum GCR and very high temperature GCR; 2) high temperature materials out of neutron flux: thermal barriers: materials, resistance, lifetimes; nickel-base metal alloys: status of knowledge, mechanical behaviour, possible applications; corrosion linked with the gas coolant: knowledge and problems to be solved; super-alloys for turbines: alloys for blades and discs; corrosion linked with MSR: knowledge and problems to be solved; 3) materials for reactor core structure: nuclear graphite and carbon; fuel assembly structure materials of the GCR with fast neutron spectrum: status of knowledge and ceramics and cermets needs; silicon carbide as fuel confinement material, study of irradiation induced defects; migration of fission products, I and Cs in SiC; 4) materials for hydrogen production: status of the knowledge and needs for the thermochemical cycle; 5) technologies: GCR components and the associated material needs: compact exchangers, pumps, turbines; MSR components: valves, exchangers, pumps. (J.S.)

  16. High-Assurance Spiral

    2017-11-01

    HIGH-ASSURANCE SPIRAL CARNEGIE MELLON UNIVERSITY NOVEMBER 2017 FINAL TECHNICAL REPORT APPROVED FOR PUBLIC RELEASE; DISTRIBUTION UNLIMITED STINFO...MU 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) Carnegie Mellon University 5000 Forbes Ave Pittsburgh, PA 15217 8. PERFORMING ORGANIZATION...Approved for Public Release; Distribution Unlimited. Carnegie Mellon Carnegie Mellon HA SPIRAL Code Synthesis KeYmaera X Hybrid Theorem Prover

  17. High resolution (transformers.

    Garcia-Souto, Jose A; Lamela-Rivera, Horacio

    2006-10-16

    A novel fiber-optic interferometric sensor is presented for vibrations measurements and analysis. In this approach, it is shown applied to the vibrations of electrical structures within power transformers. A main feature of the sensor is that an unambiguous optical phase measurement is performed using the direct detection of the interferometer output, without external modulation, for a more compact and stable implementation. High resolution of the interferometric measurement is obtained with this technique (transformers are also highlighted.

  18. Theoretical high energy physics

    Lee, T.D.

    1990-05-01

    This report discusses progress on theoretical high energy physics at Columbia University in New York City. Some of the topics covered are: Chern-Simons gauge field theories; dynamical fermion QCD calculations; lattice gauge theory; the standard model of weak and electromagnetic interactions; Boson-fermion model of cuprate superconductors; S-channel theory of superconductivity and axial anomaly and its relation to spin in the parton model

  19. High speed network sampling

    Rindalsholt, Ole Arild

    2005-01-01

    Master i nettverks- og systemadministrasjon Classical Sampling methods play an important role in the current practice of Internet measurement. With today’s high speed networks, routers cannot manage to generate complete Netflow data for every packet. They have to perform restricted sampling. This thesis summarizes some of the most important sampling schemes and their applications before diving into an analysis on the effect of sampling Netflow records.

  20. Deuterium high pressure target

    Perevozchikov, V.V.; Yukhimchuk, A.A.; Vinogradov, Yu.I.

    2001-01-01

    The design of the deuterium high-pressure target is presented. The target having volume of 76 cm 3 serves to provide the experimental research of muon catalyzed fusion reactions in ultra-pure deuterium in the temperature range 80-800 K under pressures of up to 150 MPa. The operation of the main systems of the target is described: generation and purification of deuterium gas, refrigeration, heating, evacuation, automated control system and data collection system

  1. Ghana's high forests

    Oduro, K.A.

    2016-01-01

    Deforestation and forest degradation in the tropics have been receiving both scientific and political attention in recent decades due to its impacts on the environment and on human livelihoods. In Ghana, the continuous decline of forest resources and the high demand for timber have raised stakeholders concerns about the future timber production prospects in the country. The principal drivers of deforestation and forest degradation in Ghana are agricultural expansion (50%), wood harvesting (35...

  2. High energy nuclear excitations

    Gogny, D.; Decharge, J.

    1983-09-01

    The main purpose of this talk is to see whether a simple description of the nuclear excitations permits one to characterize some of the high energy structures recently observed. The discussion is based on the linear response to different external fields calculated using the Random Phase Approximation. For those structure in heavy ion collisions at excitation energies above 50 MeV which cannot be explained with such a simple approach, we discuss a possible mechanism for this heavy ion scattering

  3. High energy dosimetry

    Ruhm, W.

    2010-01-01

    Full text: Currently, quantification of doses from high-energy radiation fields is a topical issue. This is so because high-energy neutrons play an important role for radiation exposure of air crew members and personnel outside the shielding of ion therapy facilities. In an effort to study air crew exposure from cosmic radiation in detail, two Bonner Sphere Spectrometers (BSSs) have recently been installed to measure secondary neutrons from cosmic radiation, one at the environmental research station 'Schneefernerhaus' at an altitude of 2650 m on the Zugspitze mountain, Germany, the other at the Koldewey station close to the North Pole on Spitsbergen. Based on the measured neutron fluence distributions and on fluence-to-dose conversion coefficients, mean ambient dose equivalent rate values of 75.0 ± 2.9 nSv/h and 8.7 ± 0.6 nSv/h were obtained for October 2008, respectively. Neutrons with energies above about 20 MeV contribute about 50% to dose, at 2650 m. Ambient dose equivalent rates measured by means of a standard rem counter and an extended rem counter at the Schneefernerhaus confirm this result. In order to study the response of state-of-the-art radiation instrumentation in such a high-energy radiation field, a benchmark exercise that included both measurements in and simulation of the stray neutron radiation field at the high-energy particle accelerator at GSI, Germany, were performed. This CONRAD (COordinated Network for RAdiation Dosimetry) project was funded by the European Commission, and the organizational framework was provided by the European Radiation Dosimetry Group, EURADOS. The Monte Carlo simulations of the radiation field and the experimental determination of the neutron spectra with various Bonner Sphere Spectrometers suggest the neutron fluence distributions to be very similar to those of secondary neutrons from cosmic radiation. The results of this intercomparison exercise in terms of ambient dose equivalent are also discussed

  4. High energy physics

    Kernan, A.; Shen, B.C.; Ma, E.

    1997-01-01

    This proposal is for the continuation of the High Energy Physics program at the University of California at Riverside. In hadron collider physics the authors will complete their transition from experiment UA1 at CERN to the DZERO experiment at Fermilab. On experiment UA1 their effort will concentrate on data analysis at Riverside. At Fermilab they will coordinate the high voltage system for all detector elements. They will also carry out hardware/software development for the D0 muon detector. The TPC/Two-Gamma experiment has completed its present phase of data-taking after accumulating 160 pb - 1 of luminosity. The UC Riverside group will continue data and physics analysis and make minor hardware improvement for the high luminosity run. The UC Riverside group is participating in design and implementation of the data acquisition system for the OPAL experiment at LEP. Mechanical and electronics construction of the OPAL hadron calorimeter strip readout system is proceeding on schedule. Data analysis and Monte Carlo detector simulation efforts are proceeding in preparation for the first physics run when IEP operation comenses in fall 1989

  5. High performance sapphire windows

    Bates, Stephen C.; Liou, Larry

    1993-02-01

    High-quality, wide-aperture optical access is usually required for the advanced laser diagnostics that can now make a wide variety of non-intrusive measurements of combustion processes. Specially processed and mounted sapphire windows are proposed to provide this optical access to extreme environment. Through surface treatments and proper thermal stress design, single crystal sapphire can be a mechanically equivalent replacement for high strength steel. A prototype sapphire window and mounting system have been developed in a successful NASA SBIR Phase 1 project. A large and reliable increase in sapphire design strength (as much as 10x) has been achieved, and the initial specifications necessary for these gains have been defined. Failure testing of small windows has conclusively demonstrated the increased sapphire strength, indicating that a nearly flawless surface polish is the primary cause of strengthening, while an unusual mounting arrangement also significantly contributes to a larger effective strength. Phase 2 work will complete specification and demonstration of these windows, and will fabricate a set for use at NASA. The enhanced capabilities of these high performance sapphire windows will lead to many diagnostic capabilities not previously possible, as well as new applications for sapphire.

  6. High Thermal Conductivity Materials

    Shinde, Subhash L

    2006-01-01

    Thermal management has become a ‘hot’ field in recent years due to a need to obtain high performance levels in many devices used in such diverse areas as space science, mainframe and desktop computers, optoelectronics and even Formula One racing cars! Thermal solutions require not just taking care of very high thermal flux, but also ‘hot spots’, where the flux densities can exceed 200 W/cm2. High thermal conductivity materials play an important role in addressing thermal management issues. This volume provides readers a basic understanding of the thermal conduction mechanisms in these materials and discusses how the thermal conductivity may be related to their crystal structures as well as microstructures developed as a result of their processing history. The techniques for accurate measurement of these properties on large as well as small scales have been reviewed. Detailed information on the thermal conductivity of diverse materials including aluminum nitride (AlN), silicon carbide (SiC), diamond, a...

  7. ABB high burnup fuel

    Andersson, S.; Helmersson, S.; Nilsson, S.; Jourdain, P.; Karlsson, L.; Limback, M.; Garde, A.M.

    1999-01-01

    Fuel designed and fabricated by ABB is now operating in 40 PWRs and BWRs in Europe, the United States and Korea. An excellent fuel reliability track record has been established. High burnups are proven for both PWR and BWR. Thermal margin improving features and advanced burnable absorber concepts enable the utilities to adopt demanding duty cycles to meet new economic objectives. In particular we note the excellent reliability record of ABB PWR fuel equipped with Guardian TM debris filter proven to meet the 6 rod-cycles fuel failure goal, and the out-standing operating record of the SVEA 10 x 10 fuel, where ABB is the only vendor to date with batch experience to high burnup. ABB is dedicated to maintain high fuel reliability as well as continually improve and develop a broad line of PWR and BWR products. ABB's development and fuel follow-up activities are performed in close co-operation with its utility customers. This paper provides an overview of recent fuel performance and reliability experience at ABB. Selected development and validation activities for PWR and BWR fuel are presented, for which the ABB test facilities in Windsor (TF-2 loop, mechanical test laboratory) and Vaesteras (FRIGG, BURE) are essential. (authors)

  8. High performance data transfer

    Cottrell, R.; Fang, C.; Hanushevsky, A.; Kreuger, W.; Yang, W.

    2017-10-01

    The exponentially increasing need for high speed data transfer is driven by big data, and cloud computing together with the needs of data intensive science, High Performance Computing (HPC), defense, the oil and gas industry etc. We report on the Zettar ZX software. This has been developed since 2013 to meet these growing needs by providing high performance data transfer and encryption in a scalable, balanced, easy to deploy and use way while minimizing power and space utilization. In collaboration with several commercial vendors, Proofs of Concept (PoC) consisting of clusters have been put together using off-the- shelf components to test the ZX scalability and ability to balance services using multiple cores, and links. The PoCs are based on SSD flash storage that is managed by a parallel file system. Each cluster occupies 4 rack units. Using the PoCs, between clusters we have achieved almost 200Gbps memory to memory over two 100Gbps links, and 70Gbps parallel file to parallel file with encryption over a 5000 mile 100Gbps link.

  9. Very high energy colliders

    Richter, B.

    1985-05-01

    The conclusions are relatively simple, but represent a considerable challenge to the machine builder. High luminosity is essential. We may in the future discover some new kind of high cross section physics, but all we know now indicates that the luminosity has to increase as the square of the center of mass energy. A reasonable luminosity to scale from for electron machines would be 10 33 cm -2 s -1 at a center of mass energy of 3 TeV. The required emittances in very high energy machines are small. It will be a real challenge to produce these small emittances and to maintain them during acceleration. The small emittances probably make acceleration by laser techniques easier, if such techniques will be practical at all. The beam spot sizes are very small indeed. It will be a challenge to design beam transport systems with the necessary freedom from aberration required for these small spot sizes. It would of course help if the beta functions at the collision points could be reduced. Beam power will be large - to paraphrase the old saying, ''power is money'' - and efficient acceleration systems will be required

  10. High-voltage picoamperemeter

    Bugl, Andrea; Ball, Markus; Boehmer, Michael; Doerheim, Sverre; Hoenle, Andreas; Konorov, Igor [Technische Universitaet Muenchen, Garching (Germany); Ketzer, Bernhard [Technische Universitaet Muenchen, Garching (Germany); Helmholtz-Institut fuer Strahlen- und Kernphysik, Bonn (Germany)

    2014-07-01

    Current measurements in the nano- and picoampere region on high voltage are an important tool to understand charge transfer processes in micropattern gas detectors like the Gas Electron Multiplier (GEM). They are currently used to e.g. optimize the field configuration in a multi-GEM stack to be used in the ALICE TPC after the upgrade of the experiment during the 2nd long shutdown of the LHC. Devices which allow measurements down to 1pA at high voltage up to 6 kV have been developed at TU Muenchen. They are based on analog current measurements via the voltage drop over a switchable shunt. A microcontroller collects 128 digital ADC values and calculates their mean and standard deviation. This information is sent with a wireless transmitting unit to a computer and stored in a root file. A nearly unlimited number of devices can be operated simultaneously and read out by a single receiver. The results can also be displayed on a LCD directly at the device. Battery operation and the wireless readout are important to protect the user from any contact to high voltage. The principle of the device is explained, and systematic studies of their properties are shown.

  11. High altitude dermatology

    G K Singh

    2017-01-01

    Full Text Available Approximately, 140 million people worldwide live permanently at high altitudes (HAs and approximately another 40 million people travel to HA area (HAA every year for reasons of occupation, sports or recreation. In India, whole of Ladakh region, part of Northwest Kashmir, Northern part of Sikkim and Tenga valley of Arunachal are considered inhabited areas of HAA. The low quantity of oxygen, high exposure of ultraviolet (UV light, very low humidity, extreme subzero temperature in winter, high wind velocity, make this region difficult for lowlanders as well as for tourists. Acute mountain sickness, HA pulmonary edema, HA cerebral edema, and thromboembolic conditions are known to occur in HA. However, enough knowledge has not been shared on dermatoses peculiar to this region. Xerosis, UV-related skin disorders (tanning, photomelanosis, acute and chronic sunburn, polymorphic light eruption, chronic actinic dermatitis, actinic cheilitis, etc., cold injuries (frostbite, chilblains, acrocyanosis, erythrocyanosis, etc. nail changes (koilonychias, airborne contact dermatitis, insect bite reaction, and skin carcinoma (basal cell carcinomas, squamous cell carcinomas, and also rarely malignant melanoma are the dermatoses seen in HAAs. Early diagnosis and knowledge of HA dermatoses may prevent serious consequences of disease and improve the quality of life for the visitors as well as for native of the place.

  12. High power coaxial ubitron

    Balkcum, Adam J.

    In the ubitron, also known as the free electron laser, high power coherent radiation is generated from the interaction of an undulating electron beam with an electromagnetic signal and a static periodic magnetic wiggler field. These devices have experimentally produced high power spanning the microwave to x-ray regimes. Potential applications range from microwave radar to the study of solid state material properties. In this dissertation, the efficient production of high power microwaves (HPM) is investigated for a ubitron employing a coaxial circuit and wiggler. Designs for the particular applications of an advanced high gradient linear accelerator driver and a directed energy source are presented. The coaxial ubitron is inherently suited for the production of HPM. It utilizes an annular electron beam to drive the low loss, RF breakdown resistant TE01 mode of a large coaxial circuit. The device's large cross-sectional area greatly reduces RF wall heat loading and the current density loading at the cathode required to produce the moderate energy (500 keV) but high current (1-10 kA) annular electron beam. Focusing and wiggling of the beam is achieved using coaxial annular periodic permanent magnet (PPM) stacks without a solenoidal guide magnetic field. This wiggler configuration is compact, efficient and can propagate the multi-kiloampere electron beams required for many HPM applications. The coaxial PPM ubitron in a traveling wave amplifier, cavity oscillator and klystron configuration is investigated using linear theory and simulation codes. A condition for the dc electron beam stability in the coaxial wiggler is derived and verified using the 2-1/2 dimensional particle-in-cell code, MAGIC. New linear theories for the cavity start-oscillation current and gain in a klystron are derived. A self-consistent nonlinear theory for the ubitron-TWT and a new nonlinear theory for the ubitron oscillator are presented. These form the basis for simulation codes which, along

  13. High pressure effect for high-Tc superconductors

    Takahashi, Hiroki; Tomita, Takahiro

    2011-01-01

    A number of experimental and theoretical studies have been performed to understand the mechanism of high-T c superconductivity and to enhance T c . High-pressure techniques have played a very important role for these studies. In this paper, the high-pressure techniques and physical properties of high-T c superconductor under high pressure are presented. (author)

  14. High current induction linacs

    Barletta, W.; Faltens, A.; Henestroza, E.; Lee, E.

    1994-07-01

    Induction linacs are among the most powerful accelerators in existence. They have accelerated electron bunches of several kiloamperes, and are being investigated as drivers for heavy ion driven inertial confinement fusion (HIF), which requires peak beam currents of kiloamperes and average beam powers of some tens of megawatts. The requirement for waste transmutation with an 800 MeV proton or deuteron beam with an average current of 50 mA and an average power of 40 MW lies midway between the electron machines and the heavy ion machines in overall difficulty. Much of the technology and understanding of beam physics carries over from the previous machines to the new requirements. The induction linac allows use of a very large beam aperture, which may turn out to be crucial to reducing beam loss and machine activation from the beam halo. The major issues addressed here are transport of high intensity beams, availability of sources, efficiency of acceleration, and the state of the needed technology for the waste treatment application. Because of the transformer-like action of an induction core and the accompanying magnetizing current, induction linacs make the most economic sense and have the highest efficiencies with large beam currents. Based on present understanding of beam transport limits, induction core magnetizing current requirements, and pulse modulators, the efficiencies could be very high. The study of beam transport at high intensities has been the major activity of the HIF community. Beam transport and sources are limiting at low energies but are not significant constraints at the higher energies. As will be shown, the proton beams will be space-charge-dominated, for which the emittance has only a minor effect on the overall beam diameter but does determine the density falloff at the beam edge

  15. High density dispersion fuel

    Hofman, G.L.

    1996-01-01

    A fuel development campaign that results in an aluminum plate-type fuel of unlimited LEU burnup capability with an uranium loading of 9 grams per cm 3 of meat should be considered an unqualified success. The current worldwide approved and accepted highest loading is 4.8 g cm -3 with U 3 Si 2 as fuel. High-density uranium compounds offer no real density advantage over U 3 Si 2 and have less desirable fabrication and performance characteristics as well. Of the higher-density compounds, U 3 Si has approximately a 30% higher uranium density but the density of the U 6 X compounds would yield the factor 1.5 needed to achieve 9 g cm -3 uranium loading. Unfortunately, irradiation tests proved these peritectic compounds have poor swelling behavior. It is for this reason that the authors are turning to uranium alloys. The reason pure uranium was not seriously considered as a dispersion fuel is mainly due to its high rate of growth and swelling at low temperatures. This problem was solved at least for relatively low burnup application in non-dispersion fuel elements with small additions of Si, Fe, and Al. This so called adjusted uranium has nearly the same density as pure α-uranium and it seems prudent to reconsider this alloy as a dispersant. Further modifications of uranium metal to achieve higher burnup swelling stability involve stabilization of the cubic γ phase at low temperatures where normally α phase exists. Several low neutron capture cross section elements such as Zr, Nb, Ti and Mo accomplish this in various degrees. The challenge is to produce a suitable form of fuel powder and develop a plate fabrication procedure, as well as obtain high burnup capability through irradiation testing

  16. [Detecting high risk pregnancy].

    Doret, Muriel; Gaucherand, Pascal

    2009-12-20

    Antenatal care is aiming to reduce maternal land foetal mortality and morbidity. Maternal and foetal mortality can be due to different causes. Their knowledge allows identifying pregnancy (high risk pregnancy) with factors associated with an increased risk for maternal and/or foetal mortality and serious morbidity. Identification of high risk pregnancies and initiation of appropriate treatment and/or surveillance should improve maternal and/or foetal outcome. New risk factors are continuously described thanks to improvement in antenatal care and development in biology and cytopathology, increasing complexity in identifying high risk pregnancies. Level of risk can change all over the pregnancy. Ideally, it should be evaluated prior to the pregnancy and at each antenatal visit. Clinical examination is able to screen for intra-uterin growth restriction, pre-eclampsia, threatened for preterm labour; ultrasounds help in the diagnosis of foetal morphological anomalies, foetal chromosomal anomalies, placenta praevia and abnormal foetal growth; biological exams are used to screen for pre-eclampsia, gestational diabetes, trisomy 21 (for which screening method just changed), rhesus immunisation, seroconversion for toxoplasmosis or rubeola, unknown infectious disease (syphilis, hepatitis B, VIH). During pregnancy, most of the preventive strategies have to be initiated during the first trimester or even before conception. Prevention for neural-tube defects, neonatal hypocalcemia and listeriosis should be performed for all women. On the opposite, some measures are concerning only women with risk factors such as prevention for toxoplasmosis, rhesus immunization (which recently changed), tobacco complications and pre-eclampsia and intra-uterine growth factor restriction.

  17. High Power Density Motors

    Kascak, Daniel J.

    2004-01-01

    With the growing concerns of global warming, the need for pollution-free vehicles is ever increasing. Pollution-free flight is one of NASA's goals for the 21" Century. , One method of approaching that goal is hydrogen-fueled aircraft that use fuel cells or turbo- generators to develop electric power that can drive electric motors that turn the aircraft's propulsive fans or propellers. Hydrogen fuel would likely be carried as a liquid, stored in tanks at its boiling point of 20.5 K (-422.5 F). Conventional electric motors, however, are far too heavy (for a given horsepower) to use on aircraft. Fortunately the liquid hydrogen fuel can provide essentially free refrigeration that can be used to cool the windings of motors before the hydrogen is used for fuel. Either High Temperature Superconductors (HTS) or high purity metals such as copper or aluminum may be used in the motor windings. Superconductors have essentially zero electrical resistance to steady current. The electrical resistance of high purity aluminum or copper near liquid hydrogen temperature can be l/lOO* or less of the room temperature resistance. These conductors could provide higher motor efficiency than normal room-temperature motors achieve. But much more importantly, these conductors can carry ten to a hundred times more current than copper conductors do in normal motors operating at room temperature. This is a consequence of the low electrical resistance and of good heat transfer coefficients in boiling LH2. Thus the conductors can produce higher magnetic field strengths and consequently higher motor torque and power. Designs, analysis and actual cryogenic motor tests show that such cryogenic motors could produce three or more times as much power per unit weight as turbine engines can, whereas conventional motors produce only 1/5 as much power per weight as turbine engines. This summer work has been done with Litz wire to maximize the current density. The current is limited by the amount of heat it

  18. High energy ion implantation

    Ziegler, J.F.

    1985-01-01

    High energy ion implantation offers the oppertunity for unique structures in semiconductor processing. The unusual physical properties of such implantations are discussed as well as the special problems in masking and damage annealing. A review is made of proposed circuit structures which involve deep implantation. Examples are: deep buried bipolar collectors fabricated without epitaxy, barrier layers to reduce FET memory sensitivity to soft-fails, CMOS isolation well structures, MeV implantation for customization and correction of completed circuits, and graded reach-throughs to deep active device components. (orig.)

  19. High-power electronics

    Kapitsa, Petr Leonidovich

    1966-01-01

    High-Power Electronics, Volume 2 presents the electronic processes in devices of the magnetron type and electromagnetic oscillations in different systems. This book explores the problems of electronic energetics.Organized into 11 chapters, this volume begins with an overview of the motion of electrons in a flat model of the magnetron, taking into account the in-phase wave and the reverse wave. This text then examines the processes of transmission of electromagnetic waves of various polarization and the wave reflection from grids made of periodically distributed infinite metal conductors. Other

  20. Theoretical High Energy Physics

    Christ, Norman H.; Weinberg, Erick J.

    2014-07-14

    we provide reports from each of the six faculty supported by the Department of Energy High Energy Physics Theory grant at Columbia University. Each is followed by a bibliography of the references cited. A complete list of all of the publications in the 12/1/2010-04/30/2014 period resulting from research supported by this grant is provided in the following section. The final section lists the Ph.D. dissertations based on research supported by the grant that were submitted during this period.

  1. High resolution backscattering instruments

    Coldea, R.

    2001-01-01

    The principle of operation of indirect-geometry time-of-flight spectrometers are presented, including the IRIS at the ISIS spallation neutron source. The key features that make those types of spectrometers ideally suited for low-energy spectroscopy are: high energy resolution over a wide dynamic range, and simultaneous measurement over a large momentum transfer range provided by the wide angular detector coverage. To exemplify these features are discussed of single-crystal experiments of the spin dynamics in the two-dimensional frustrated quantum magnet Cs 2 CuCl 4 . (R.P.)

  2. ALICE High Level Trigger

    Alt, T

    2013-01-01

    The ALICE High Level Trigger (HLT) is a computing farm designed and build for the real-time, online processing of the raw data produced by the ALICE detectors. Events are fully reconstructed from the raw data, analyzed and compressed. The analysis summary together with the compressed data and a trigger decision is sent to the DAQ. In addition the reconstruction of the events allows for on-line monitoring of physical observables and this information is provided to the Data Quality Monitor (DQM). The HLT can process event rates of up to 2 kHz for proton-proton and 200 Hz for Pb-Pb central collisions.

  3. High frequency asymptotic methods

    Bouche, D.; Dessarce, R.; Gay, J.; Vermersch, S.

    1991-01-01

    The asymptotic methods allow us to compute the interaction of high frequency electromagnetic waves with structures. After an outline of their foundations with emphasis on the geometrical theory of diffraction, it is shown how to use these methods to evaluate the radar cross section (RCS) of complex tri-dimensional objects of great size compared to the wave-length. The different stages in simulating phenomena which contribute to the RCS are reviewed: physical theory of diffraction, multiple interactions computed by shooting rays, research for creeping rays. (author). 7 refs., 6 figs., 3 insets

  4. High Speed Photomicrography

    Hyzer, William G.

    1983-03-01

    One of the most challenging areas in applying high-speed photography and videography in the plant and laboratory is in the recording of rapid events at macro and microscopic scales. Depth of field, exposure efficiency, working distance, and required exposure time are all reduced as optical magnification is increased, which severely taxes the skill and ingenuity of workers interested in recording any fast moving phenomena through the microscope or with magnifying lenses. This paper defines the problems inherent in photographing within macro and microscopic ranges and offers a systematic approach to optimizing the selection of equipment and choice of applicable techniques.

  5. Highly excited atoms

    Kleppner, D.; Littman, M.G.; Zimmerman, M.L.

    1981-01-01

    Highly excited atoms are often called Rydberg atoms. These atoms have a wealth of exotic properties which are discussed. Of special interest, are the effects of electric and magnetic fields on Rydberg atoms. Ordinary atoms are scarcely affected by an applied electric or magnetic field; Rydberg atoms can be strongly distorted and even pulled apart by a relatively weak electric field, and they can be squeezed into unexpected shapes by a magnetic field. Studies of the structure of Rydberg atoms in electric and magnetic fields have revealed dramatic atomic phenomena that had not been observed before

  6. Clojure high performance programming

    Kumar, Shantanu

    2013-01-01

    This is a short, practical guide that will teach you everything you need to know to start writing high performance Clojure code.This book is ideal for intermediate Clojure developers who are looking to get a good grip on how to achieve optimum performance. You should already have some experience with Clojure and it would help if you already know a little bit of Java. Knowledge of performance analysis and engineering is not required. For hands-on practice, you should have access to Clojure REPL with Leiningen.

  7. High energy physics

    Fortney, L.R.; Goshaw, A.T.; Walker, W.D.

    1991-01-01

    This progress report presents a review of research done over the past five years by the Duke High Energy Physics Group. This research has been centered at Fermilab where we have had a continuing involvement with both the Tevatron collider and fixed-target programs. In 1988 we began extensive detector R ampersand D for the SSC through its Major Subsystem Program. Duke has been an active member of the Solenoidal Detector Collaboration (SDC) since its formation. These last five years has also been used to finish the analysis of data from a series of hybrid bubble chamber experiments which formed the core of Duke's research program in the early 1980's

  8. Highly Sensitive Optical Receivers

    Schneider, Kerstin

    2006-01-01

    Highly Sensitive Optical Receivers primarily treats the circuit design of optical receivers with external photodiodes. Continuous-mode and burst-mode receivers are compared. The monograph first summarizes the basics of III/V photodetectors, transistor and noise models, bit-error rate, sensitivity and analog circuit design, thus enabling readers to understand the circuits described in the main part of the book. In order to cover the topic comprehensively, detailed descriptions of receivers for optical data communication in general and, in particular, optical burst-mode receivers in deep-sub-µm CMOS are presented. Numerous detailed and elaborate illustrations facilitate better understanding.

  9. High temperature superconductors

    Paranthaman, Parans

    2010-01-01

    This essential reference provides the most comprehensive presentation of the state of the art in the field of high temperature superconductors. This growing field of research and applications is currently being supported by numerous governmental and industrial initiatives in the United States, Asia and Europe to overcome grid energy distribution issues. The technology is particularly intended for densely populated areas. It is now being commercialized for power-delivery devices, such as power transmission lines and cables, motors and generators. Applications in electric utilities include current limiters, long transmission lines and energy-storage devices that will help industries avoid dips in electric power.

  10. High Power Vanadate lasers

    Strauss

    2006-07-01

    Full Text Available stream_source_info Strauss1_2006.pdf.txt stream_content_type text/plain stream_size 3151 Content-Encoding UTF-8 stream_name Strauss1_2006.pdf.txt Content-Type text/plain; charset=UTF-8 Laser Research Institute... University of Stellenbosch www.laser-research.co.za High Power Vanadate lasers H.J.Strauss, Dr. C. Bollig, R.C. Botha, Prof. H.M. von Bergmann, Dr. J.P. Burger Aims 1) To develop new techniques to mount laser crystals, 2) compare the lasing properties...

  11. High energy cosmic rays

    Stanev, Todor

    2010-01-01

    Offers an accessible text and reference (a cosmic-ray manual) for graduate students entering the field and high-energy astrophysicists will find this an accessible cosmic-ray manual Easy to read for the general astronomer, the first part describes the standard model of cosmic rays based on our understanding of modern particle physics. Presents the acceleration scenario in some detail in supernovae explosions as well as in the passage of cosmic rays through the Galaxy. Compares experimental data in the atmosphere as well as underground are compared with theoretical models

  12. High-nitrogen explosives

    Naud, D. (Darren); Hiskey, M. A. (Michael A.); Kramer, J. F. (John F.); Bishop, R. L. (Robert L.); Harry, H. H. (Herbert H.); Son, S. F. (Steven F.); Sullivan, G. K. (Gregg K.)

    2002-01-01

    The syntheses and characterization of various tetrazine and furazan compounds offer a different approach to explosives development. Traditional explosives - such as TNT or RDX - rely on the oxidation of the carbon and hydrogen atoms by the oxygen carrying nitro group to produce the explosive energy. High-nitrogen compounds rely instead on large positive heats of formation for that energy. Some of these high-nitrogen compounds have been shown to be less sensitive to initiation (e.g. by impact) when compared to traditional nitro-containing explosives of similar performances. Using the precursor, 3,6-bis-(3,5-dimethylpyrazol-1-yl)-s-tetrazine (BDT), several useful energetic compounds based on the s-tetrazine system have been synthesized and studied. The compound, 3,3{prime}-azobis(6-amino-s-tetrazine) or DAAT, detonates as a half inch rate stick despite having no oxygen in the molecule. Using perfluoroacetic acid, DAAT can be oxidized to give mixtures of N-oxide isomers (DAAT03.5) with an average oxygen content of about 3.5. This energetic mixture burns at extremely high rates and with low dependency on pressure. Another tetrazine compound of interest is 3,6-diguanidino-s-tetrazine(DGT) and its dinitrate and diperchlorate salts. DGT is easily synthesized by reacting BDT with guanidine in methanol. Using Caro's acid, DGT can be further oxidized to give 3,6-diguanidino-s-tetrazine-1,4-di-N-oxide (DGT-DO). Like DGT, the di-N-oxide can react with nitric acid or perchloric acid to give the dinitrate and the diperchlorate salts. The compounds, 4,4{prime}-diamino-3,3{prime}-azoxyfurazan (DAAF) and 4,4{prime}-diamino-3,3{prime}-azofurazan (DAAzF), may have important future roles in insensitive explosive applications. Neither DAAF nor DAAzF can be initiated by laboratory impact drop tests, yet both have in some aspects better explosive performances than 1,3,5-triamino-2,4,6-trinitrobenzene TATB - the standard of insensitive high explosives. The thermal stability of DAAz

  13. High dimensional entanglement

    Mc

    2012-07-01

    Full Text Available stream_source_info McLaren_2012.pdf.txt stream_content_type text/plain stream_size 2190 Content-Encoding ISO-8859-1 stream_name McLaren_2012.pdf.txt Content-Type text/plain; charset=ISO-8859-1 High dimensional... entanglement M. McLAREN1,2, F.S. ROUX1 & A. FORBES1,2,3 1. CSIR National Laser Centre, PO Box 395, Pretoria 0001 2. School of Physics, University of the Stellenbosch, Private Bag X1, 7602, Matieland 3. School of Physics, University of Kwazulu...

  14. High Availability of RAPIENET

    Yoon, G.; Oh, J. S.; Kwon, D. H.; Kwon, S. C.; Park, Y. O.

    2012-01-01

    Many industrial customers are no longer satisfies with conventional Ethernet-based communications. They require a more accurate, more flexible, and more reliable technology for their control and measurement systems. Hence, Ethernet-based high-availability networks are becoming an important topic in the control and measurement fields. In this paper, we introduce a new redundant programmable logic controller (PLC) concept, based on real-time automation protocols for industrial Ethernet (RAPIEnet). RAPIEnet has intrinsic redundancy built into its network topology, with hardware-based recovery time. We define a redundant PLC system switching model and demonstrate its performance, including RAPIEnet recovery time

  15. High gradient superconducting quadrupoles

    Lundy, R.A.; Brown, B.C.; Carson, J.A.; Fisk, H.E.; Hanft, R.H.; Mantsch, P.M.; McInturff, A.D.; Remsbottom, R.H.

    1987-07-01

    Prototype superconducting quadrupoles with a 5 cm aperture and gradient of 16 kG/cm have been built and tested as candidate magnets for the final focus at SLC. The magnets are made from NbTi Tevatron style cable with 10 inner and 14 outer turns per quadrant. Quench performance and multipole data are presented. Design and data for a low current, high gradient quadrupole, similar in cross section but wound with a cable consisting of five insulated conductors are also discussed

  16. Knees Lifted High

    2008-08-04

    The Eagle Books are a series of four books that are brought to life by wise animal characters - Mr. Eagle, Miss Rabbit, and Coyote - who engage Rain That Dances and his young friends in the joy of physical activity, eating healthy foods, and learning from their elders about health and diabetes prevention. Knees Lifted High gives children fun ideas for active outdoor play.  Created: 8/4/2008 by National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP).   Date Released: 8/5/2008.

  17. High temperature reaction kinetics

    Jonah, C.D.; Beno, M.F.; Mulac, W.A.; Bartels, D.

    1985-01-01

    During the last year the dependence of the apparent rate of OD + CO on water pressure was measured at 305, 570, 865 and 1223 K. An explanation was found and tested for the H 2 O dependence of the apparent rate of OH(OD) + CO at high temperatures. The isotope effect for OH(D) with CO was determined over the temperature range 330 K to 1225 K. The reason for the water dependence of the rate of OH(OD) + CO near room temperatures has been investigated but no clear explanation has been found. 1 figure

  18. High-multiplicity processes

    Shelkov, G.; Sisakyan, A.; Mandzhavidze, I.

    1999-01-01

    We wish to demonstrate that investigation of asymptotically high multiplicity (AHM) hadron reactions may solve, or at least clear up, a number of problems unsolvable by other ways. We would lean upon the idea: (i) the reactions final state entropy is proportional to multiplicity and, by this reason, just in the AHM domain one may expect the equilibrium final state and (ii) the AHM final state is cold because of the energy-momentum conservation laws. This means that the collective phenomena may become important in the AHM domain. The possibility of hard processes dominance is considered also

  19. ALMA High Frequency Techniques

    Meyer, J. D.; Mason, B.; Impellizzeri, V.; Kameno, S.; Fomalont, E.; Chibueze, J.; Takahashi, S.; Remijan, A.; Wilson, C.; ALMA Science Team

    2015-12-01

    The purpose of the ALMA High Frequency Campaign is to improve the quality and efficiency of science observing in Bands 8, 9, and 10 (385-950 GHz), the highest frequencies available to the ALMA project. To this end, we outline observing modes which we have demonstrated to improve high frequency calibration for the 12m array and the ACA, and we present the calibration of the total power antennas at these frequencies. Band-to-band (B2B) transfer and bandwidth switching (BWSW), techniques which improve the speed and accuracy of calibration at the highest frequencies, are most necessary in Bands 8, 9, and 10 due to the rarity of strong calibrators. These techniques successfully enable increased signal-to-noise on the calibrator sources (and better calibration solutions) by measuring the calibrators at lower frequencies (B2B) or in wider bandwidths (BWSW) compared to the science target. We have also demonstrated the stability of the bandpass shape to better than 2.4% for 1 hour, hidden behind random noise, in Band 9. Finally, total power observing using the dual sideband receivers in Bands 9 and 10 requires the separation of the two sidebands; this procedure has been demonstrated in Band 9 and is undergoing further testing in Band 10.

  20. Giant high occipital encephalocele

    Agrawal Amit

    2016-03-01

    Full Text Available Encephaloceles are rare embryological mesenchymal developmental anomalies resulting from inappropriate ossification in skull through with herniation of intracranial contents of the sac. Encephaloceles are classified based on location of the osseous defect and contents of sac. Convexity encephalocele with osseous defect in occipital bone is called occipital encephalocele. Giant occipital encephaloceles can be sometimes larger than the size of baby skull itself and they pose a great surgical challenge. Occipital encephaloceles (OE are further classified as high OE when defect is only in occipital bone above the foramen magnum, low OE when involving occipital bone and foramen magnum and occipito-cervical when there involvement of occipital bone, foramen magnum and posterior upper neural arches. Chiari III malformation can be associated with high or low occipital encephaloceles. Pre-operatively, it is essential to know the size of the sac, contents of the sac, relation to the adjacent structures, presence or absence of venous sinuses/vascular structures and osseous defect size. Sometimes it becomes imperative to perform both CT and MRI for the necessary information. Volume rendered CT images can depict the relation of osseous defect to foramen magnum and provide information about upper neural arches which is necessary in classifying these lesions.