BACKGROUND: The administration of intravenous cangrelor at reperfusion achieves faster onset of platelet P2Y12 inhibition than oral ticagrelor and has been shown to reduce myocardial infarction (MI) size in the preclinical setting. We hypothesized that the administration of cangrelor at reperfusion will reduce MI size and prevent microvascular obstruction in patients with ST-segment–elevation MI undergoing primary percutaneous coronary intervention. METHODS: This was a phase 2, multicenter, randomized, double-blind, placebo-controlled clinical trial conducted between November 2017 to November 2021 in 6 cardiac centers in Singapore. Patients were randomized to receive either cangrelor or placebo initiated before the primary percutaneous coronary intervention procedure on top of oral ticagrelor. The key exclusion criteria included presenting <6 hours of symptom onset; previous MI and stroke or transient ischemic attack; on concomitant oral anticoagulants; and a contraindication for cardiovascular magnetic resonance. The primary efficacy end point was acute MI size by cardiovascular magnetic resonance within the first week expressed as percentage of the left ventricle mass (%LVmass). Microvascular obstruction was identified as areas of dark core of hypoenhancement within areas of late gadolinium enhancement. The primary safety end point was Bleeding Academic Research Consortium–defined major bleeding in the first 48 hours. Continuous variables were compared by Mann-Whitney U test (reported as median [first quartile–third quartile]), and categorical variables were compared by Fisher exact test. A 2-sided P <0.05 was considered statistically significant. RESULTS: Of 209 recruited patients, 164 patients (78%) completed the acute cardiovascular magnetic resonance scan. There were no significant differences in acute MI size (placebo, 14.9% [7.3–22.6] %LVmass versus cangrelor, 16.3 [9.9–24.4] %LVmass; P =0.40) or the incidence (placebo, 48% versus cangrelor, 47%; P =0.99) and extent of microvascular obstruction (placebo, 1.63 [0.60–4.65] %LVmass versus cangrelor, 1.18 [0.53–3.37] %LVmass; P =0.46) between placebo and cangrelor despite a 2-fold decrease in platelet reactivity with cangrelor. There were no Bleeding Academic Research Consortium–defined major bleeding events in either group in the first 48 hours. CONCLUSIONS: Cangrelor administered at the time of primary percutaneous coronary intervention did not reduce acute MI size or prevent microvascular obstruction in patients with ST-segment–elevation MI given oral ticagrelor despite a significant reduction of platelet reactivity during the percutaneous coronary intervention procedure. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03102723.

Background: Spontaneous hemopneumothorax is rare, accounting for only 1%–12% of patients presenting with spontaneous pneumothorax. The optimal management of these patients remains controversial with no definitive guidelines on patient selection and timing of surgery. The aim of this study was to review our institution’s surgical experience in the management of patients with spontaneous hemopneumothorax. Methods: We performed a retrospective review of all patients with spontaneous hemopneumothorax who underwent surgery from January 2000 to June 2013. Patient data were obtained from our institution’s primary spontaneous pneumothorax database. Results: Of 510 patients who underwent surgery for spontaneous pneumothorax, 33 (6.4%) developed spontaneous hemopneumothorax. The mean age was 24.0 years (range 16–40 years). In 30 (90.9%) patients, it was their first presentation of pneumothorax. There were 25 (75.8%) patients with Vanderschueren stage III spontaneous pneumothorax. Blood loss ranged from 250 to 3000 mL (mean 1280 mL). In 28 patients, a torn adhesion band was the source of bleeding. Thoracotomy was the surgical approach in 9 (27.3%) patients, and video-assisted thoracic surgery was used in 24 (72.7%). One patient required reoperation for retained clots. There was no mortality. Conclusion: Our results suggest that surgical management of spontaneous hemopneumothorax can be undertaken with minimal morbidity and mortality. With the increasing use of video-assisted thoracic surgery, definitive surgical management of spontaneous hemopneumothorax can be instituted earlier.

Falls due to hypoglycaemia in the elderly is usually a complication of diabetic treatment. In the absence of diabetes, hypoglycaemia may be due to insulin or insulin-like producing tumours. The Doege-Potter syndrome is a rare paraneoplastic syndrome, characterised by non-islet cell tumour hypoglycaemia (NICTH) secondary to a solitary fibrous tumour that secretes insulin-like growth factor (IGF) 2. Definitive treatment of hypoglycaemia due to NICTH is by tumour resection. Our patient was a 78-year-old woman admitted after a fall with a facial injury and a history of significant weight loss. Her blood sugar was persistently low despite intravenous dextrose infusion. CT of the thorax revealed a large heterogeneous mass measuring 11.6×16.3×15.6 cm in the right hemithorax. A biopsy of the mass was reported as a solitary fibrous tumour. Biochemical investigations revealed low insulin, C-peptide, IGF-1 and a high IGF-2:IGF-1 ratio, consistent with NICTH. The patient underwent tumour resection and the hypoglycaemia normalised completely immediately after surgery.