MedShr: improving patient care through clinical case discussion.

Case discussion is an essential part of clinical practice and medical education, and as part of patient care takes place both informally between medical staff and formally in case conferences and other meetings. Case presentations are often the most popular sessions at medical congresses and increasingly have moved to digital channels and social media. MedShr was developed to help doctors improve patient care: to empower doctors to use their own smartphones to share and discuss clinical cases, whilst protecting patient privacy and confidentiality.

Cost implications of implementing NICE guideline on chest pain in rapid access chest pain clinics: an audit and cost analysis.

Background: Implementing the recently published National Institute for Health and Clinical Excellence (NICE) clinical guideline on chest pain (CG95) in rapid access chest pain clinics (RACPCs) could significantly impact on overall cost, while introducing new technology like cardiac computed tomography (CT) scanning. With the National Health Service (NHS) under pressure to make £20 billion savings, applying CG95 in RACPCs could be challenging. An audit enabled us to assess the cost implications.

An unusual case of massive subcutaneous chest wall haemorrhage with enoxaparin.

Enoxaparin is used in the treatment of acute coronary syndromes and offers improved outcome in the composite endpoint of death, myocardial infarction and major bleeding when compared with unfractionated heparin (UFH). Our report describes a rare case of massive life-threatening subcutaneous chest wall haemorrhage, distant to the injection site. Clinicians should be aware of atypical presentations of haemorrhage when using combination antiplatelet and antithrombotic therapy.

Coronary steal with unstable angina secondary to a coronary artery fistula.

Background: A 62-year old man with progressive deterioration of stable angina presented with an unstable episode and was referred for diagnostic coronary angiography.

Investigations: Physical examination, electrocardiography, myocardial perfusion scan, coronary angiography, cardiac CT.

Diagnosis: Left coronary main stem to pulmonary artery fistula.

Sirolimus-eluting and paclitaxel-eluting stents for the treatment of coronary bifurcations.

Background: The aim of the study was to compare the outcomes of sirolimus-eluting (SES) and paclitaxel-eluting (PES) stent implantation in coronary bifurcations treated with either a 1-stent or 2-stent strategy.

Methods: The study used a retrospective cohort analysis of consecutive de novo bifurcations, excluding left main, treated with SES or PES between April 2003 and June 2005.

Results: We identified 170 bifurcations in 161 patients treated with SES and 119 bifurcations in 112 patients treated with PES.

Protamine usage following implantation of drug-eluting stents: a word of caution.

The treatment of hemorrhagic complications of percutaneous interventions with protamine is an accepted practice. Concerns exist about the increased thrombo-genicity of drug-eluting stents. We report two cases of acute stent thrombosis following drug-eluting stent implantation related to protamine administration.

Long-term follow-up of drug-eluting stents when inserted for on- and off-label indications.

This study reports long-term follow-up of the on- and off-label implantation of drug-eluting stents (DESs) in a retrospective study of 1,044 patients. Off-label implantation of DESs was performed for left main coronary artery lesions, bifurcation lesions, bare metal stent restenosis, ostial disease, chronic total occlusions, saphenous vein graft lesions, internal mammary artery graft lesions, left ventricular ejection fraction <30%, and acute myocardial infarction. End points examined were procedural complications, in-hospital myocardial infarction, and acute stent thrombosis; end points examined at follow-up were subacute stent thrombosis, late stent thrombosis, target vessel revascularization, myocardial infarction, death, and major adverse clinical events (MACEs; a composite of death, myocardial infarction, and target vessel revascularization).

Incidence and predictors of drug-eluting stent thrombosis during and after discontinuation of thienopyridine treatment.

Background: The need for prolonged aspirin and thienopyridine therapy and the risk of stent thrombosis (ST) remain as drawbacks associated with drug-eluting stents.

Methods And Results: A prospective observational cohort study was conducted between June 2002 and January 2004 on 3021 patients consecutively and successfully treated in 5389 lesions with drug-eluting stents. Detailed patient information was collected on antiplatelet therapy.

Induction, differentiation, and remodeling of blood vessels after transplantation of Bcl-2-transduced endothelial cells.

Implants of collagen-fibronectin gels containing Bcl-2-transduced human umbilical vein endothelial cells (Bcl-2-HUVECs) induce the formation of human endothelial cell (EC)/murine vascular smooth muscle cell (VSMC) chimeric vessels in immunodeficient mice. Microfil casting of the vasculature 60 d after implantation reveals highly branched microvascular networks within the implants that connect with and induce remodeling of conduit vessels arising from the abdominal wall circulation. Approximately 85% of vessels within the implants are lined by Bcl-2-positive human ECs expressing VEGFR1, VEGFR2, and Tie-2, but not integrin alpha(v)beta(3).

Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction.

Problem: Delay in starting thrombolytic treatment in patients arriving at hospital with chest pain who are diagnosed as having acute myocardial infarction.

Design: Audit of "door to needle times" for patients presenting with chest pain and an electrocardiogram on admission that confirmed acute myocardial infarction. A one year period in each of three phases of development was studied.