How Will New Bioabsorbable Polymer Drug Eluting Stents...

How Will New Bioabsorbable Polymer Drug Eluting Stents...
How will new bioabsorbable polymer drug–eluting stents impact DAPT duration? Ian J Sarembock,
MB, ChB, MD, FACC; Dean J Kereiakes, MD, FACC The Heart & Vascular Service Line and The
Lindner Center for Research and Education, The Christ Hospital Health Network, Cincinnati, Ohio
The evolution of percutaneous coronary intervention (PCI) from plain old balloon angioplasty
(POBA) in 1977, to bare metal stents (BMS) in 1986, through the revolutionary introduction of
drug–eluting stents (DES) in 2003 which successfully treated the "Achilles heal" of BMS
(neointimal proliferation and restenosis) has provided significant iterative improvement in platform
design and performance. Adverse clinical events to 1–year following stent ... Show more content on
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Stents that deliver anti–proliferative drugs from durable polymer, have reduced both clinical and
angiographic restenosis compared with bare metal stents without increasing adverse events (AEs)
including death or myocardial infarction (MI) (1–2). However, permanent polymers may be
associated with hypersensitivity reactions, delayed and/or incomplete vascular healing which may
contribute to an increased risk of both late (30 days to 1 year) and very late (beyond 1 year) stent
thrombosis (ST) which was particularly evident following first generation DES (5,6). Even newer
durable polymers with enhanced biocompatibility and improved clinical outcomes have still been
incriminated in chronic inflammation, thrombosis and neoatherosclerosis (which occurs earlier and
with increased prevalence following both 1st and 2nd generation DES (7,8,9). To reduce the risk of
stent thrombosis and MI, the 2016 ACC/AHA Guideline Focused Update on Duration of Dual
Antiplatelet Therapy in Patients With Coronary Artery Disease provides guidance regarding the
duration of dual antiplatelet therapy following DES deployment for both stable coronary artery
disease (CAD) as well as acute coronary syndromes (ACS) (10). Patients should receive clopidogrel
(or an alternative P2Y12 inhibitor) in addition to aspirin for a minimum of 6 months (stable CAD)
or 12 months (ACS) unless there is high bleeding risk (10). Longer treatment duration may be
prescribed on an individualized basis for
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Cardiovascular Disease, Atherosclerosis Essay
One source of great mortality and morbidity in Europe and North America is the cardiovascular
disease, Atherosclerosis. It is recognized as a chronic inflammatory disease of the intermediate and
large arteries characterized by the thickening of the arterial wall and is the primary cause of
coronary and cerebrovascular heart disease (Wilson, 2005). It accounts for 4.35 million deaths in
Europe and 35% death in the UK each year. Mortality rate are generally higher in men than pre–
menopausal woman. Past the menopause, a woman's risk is similar to a man's (George and Johnston,
2010). Clinical trials have confirmed that lipid accumulation, endothelial dysfunction, cell
proliferation, inflammation matrix alteration and foam cell formation are ... Show more content on
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Macrophage which is now foam–like accumulates on the blood vessel to form visible fatty streak
which then undergoes apoptosis. The plaque continues to grow and hardens narrowing the arteries.
This ruptures and causes a blood clot which limits the flow of oxygen–rich blood to the body
causing a heart attack, stroke or even death. Factors that are known to predispose to atherosclerosis
are physical inactivity, diabetes mellitus, hyperlipidemia, cigarette smoking and hypertension which
increase the chances by two–fold by damaging the vascular endothelium. Experimental studies have
just shown that excess blood levels of iron can lead to atherosclerosis (Guyton and Hall, 2011).
2.0 Molecular and Cell–based therapies
Presently, the treatment strategies used are risk factor modification, conventional pharmacology and
surgical revascularization. These strategies have hitherto not been of enormous solution as the
disease progression still result in recurrent symptoms. This has now led to the exploitation of
advances in comprehending the vascular biology of atherogenesis to introduce novel cell and
molecular–based therapies. The application of immunomodulation, lipid–lowering agents like
statins, gene transfer, antisense technology and so on has resulted in new therapeutic strategies to
interrupt cell proliferation and disorder of the vessel wall. In this essay, immunomudulation and
lipid–lowering agent shall be discussed.
2.1 Immunomodulation

The Human Heart Of Cardiology
Cardiology The human heart has a special characteristic, it has its own electrical impulse, which
allows it to beat normally outside of the human body as long as it has sufficient oxygen levels. The
term cardiology refers to the medical branch which focuses on disease and irregularities of the heart.
A cardiologist focuses on the individual area of the body that is the heart and these doctors focus on
preventing and treating illnesses of the whole heart or single vessels or arteries. Technology in all
medical fields are constantly improving and becoming reliable. Within the past two decades there
has been a multitude of advancements in the field of cardiology. An example of the improvement
made in the field of cardiology include the invention of artificial organs. According to Yukiyasu
Sezai, "Progress in several types of artificial organs in the cardiovascular field ... have significantly
contributed to advancements in cardiac surgery" (318). Examples of these artificial organs include
the following: percutaneous cardiopulmonary systems, ventricular assist devices, nonpulsatile flow
pumps, and artificial hearts. Percutaneous cardiopulmonary systems allows the patient to regulate
pressure and temperature of blood, as well as oxygen levels. This method of control is used widely
due to the cost, both the device used and instillation, being significantly lower than the cost of an
artificial heart, and the uncomplicated form of control. Two types of ventricular assist devices–

Primary Angioplasty For Acute Myocardial Afarction
Primary angioplasty for Acute Myocardial infarction
The treatment of myocardial infarction has evolved considerably over the past decades. Reported
mortality rates have fallen as a result of early diagnosis and treatment along with improved
management of its complications. Primary importance has been given to restore antegrade coronary
blood flow in the offending artery of the patient with evolving acute myocardial infarction. The two
methods to achieve this goal are thrombolytic treatment and immediate coronary angiography
followed by primary angioplasty.
The formation of coronary thrombus on an atherosclerotic plaque, leading to total or sub–total
occlusion of the coronary artery, is the key event that causes acute ischemic syndromes as ... Show
more content on Helpwriting.net ...
In terms of safety, incidence of stroke was reduced from 2.0% with thrombolysis to 0.7% with
angioplasty.
It has been found that costs are not higher and maybe even lower for primary angioplasty.
After the development of safe and effective antiplatelet agents, stenting has a profound effect on the
performance and results of primary angioplasty both in the acute phase and during follow–up. The
use of drug eluting stents are cost–effective by reducing the rate of restenosis. Patients who need
stents have a reduced need for repeat hospitalization and

Improving Health And Self Care For Multiple Reasons
In a research article by Johnson (2010), elderly individuals may not be able to maintain health and
self–care for multiple reasons, such as cognitive limitations, mobility issues, living conditions, and
other comorbidities. Language barriers may also affect the understanding of discharge instructions.
This has significance when looking at Australians in 2006, almost three million, aged 15–74 years of
age, spoke English as a second language. Karliner and colleagues conducted a study to focus on
language barriers and the understanding of discharge instructions among patients with limited
English proficiency from 2 large urban hospitals. The sample consisted of 308 random Spanish,
Chinese, and English–speaking patients recruited from medical surgical floors who were used in the
study. Although the patients were provided with interpreters in their appropriate languages, the
results of the study discovered low understanding for follow–up appointments (56%) and
medication outcomes such as the purpose of medication (41%).
In another study, focus group participants discussed their most common obstacles faced when trying
to manage their care on their own appropriately. Having insufficient information and ''know–how''
about their health and health care were the primary barriers that patients revealed when they talked
about managing their own care (Holly). Participants mentioned about how overwhelmed they felt
trying to cope with a chronic condition, especially after their initial

Combination Products : What Are They? How Do Design A...
Combination Products: What are they? How do we design a suitable trial?
BME 5950 Special topics in BME – FDA regulation
Zhenlin Huang
Outline
I. What is the combination product?
1. Definitions of combination product
2. The major three components: drug, device, and biologics.
II. Case study: drug–eluting stent
1. History of drug–eluting stent
2. The first FDA approved drug–eluting stent
3. Review responsibility of FDA approval on the DES
4. Other further investigations
5. Discussions
III. Case study: regenerative medicine
1. Combination product in regenerative medicine
2. The first FDA approved ....
3. Review responsibility
4. Others consideration
5. Discussions
IV. Discussions and future challenges
I. What is the combination product?
1. ... Show more content on Helpwriting.net ...
The other is the combination products with other types of FDA–regulated articles, such as foods,
nutraceuticals, or cosmetics called cosmeceuticals. Figure 1. Combination Product.
2. The major three components: drug, device, and biologics
FDA categorizes three classes of product: (1) Drug, (2) Device, and (3) Biologics. Drug is the
product intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease,
which is regulated by the Center for drug evaluation and research (CDER). The second category–
Device is the product which does not achieve its intended purposes through chemical reaction in
human, and it is not dependent upon being metabolized to achieve its primary purposes. This
product is called an instrument, apparatus, implement, machine, contrivance, implant, in vitro
reagent, or similar. Device is regulated by the center for devices and radiological health (CDRH),
and the biologics are regulated by the center for biologics evaluation and research (CBER). For now,
there is not a specific center to review the combination product.

II. Case study: Drug–eluting stent (DES)
1. History of Drug–eluting Stent
In the 1970s, coronary angioplasty was first introduced as the minimally invasive way of re–opening
coronary arteries that had been narrowed by the plaque. Physicians inserted a balloon via the
catheter into the peripheral artery and then inflated the balloon to compress the plaque against the
artery wall. However, the

Aortic Smooth Muscle Thesis
"Influence of low shear and cyclic strain on hyperglycemic rat aortic smooth muscle cells: An In
Vitro dynamic disease model"
____________________________________________________________________________ A
Thesis Presented to The Graduate School of Clemson University
____________________________________________________________________________ In
Partial Fulfillment of the Requirements for the Degree Masters of Science Bioengineering
____________________________________________________________________________ By
Varun Chawla July 2015
____________________________________________________________________________
Thesis committee Dr. Martine LaBerge, Committee Chair Dr. Agneta Simionescu Dr. Dan
Simionescu Abstract Vascular complications are the leading cause of morbidity and mortality
amongst diabetic patients which represent a major proportion of patients undergoing coronary artery
revascularization. Major advances in drug eluting stent technologies have reduced the overall rates
of restenosis in general however diabetic patients still remain at a high risk thus requiring target
lesion revascularization more commonly as compared to non–diabetic cohort. Phenotypic
modulation demonstrated by smooth ... Show more content on Helpwriting.net ...
Lumen loss after balloon angioplasty can be separated into 3 distinct stages: Early loss associated
with elastic recoil, late loss due to negative remodeling, and neointimal hyperplasia. Elastic recoil
occurs immediately following angioplasty with reports of 34% loss in lumen diameter within 15
minutes of balloon inflation and may account for up to 50% of loss in the acute lumen gain after
angioplasty

Rush University Personal Statement Sample
The belief that an education is valuable when it is used to serve your community was instilled in me
at a very young age. Growing up in a small village in Nigeria, West Africa, I was surrounded by an
African culture with a rural rustic lifestyle. I saw poverty, sickness, death and suffering on a daily
basis. I learned to build deep relationships with people of all age groups; from kids who were my
playmates, to moms whose babies I helped care for, and grandmas cooking over firewood or selling
in market stalls. I learned to value and treat all people with respect, appreciate them, and to always
take the time to help others.
During these formative years, I learned and accepted hard work and determination as essential
components of life. Having to walk miles to my father's farm after school; planting and harvesting
crops all year round; helping my mother make "soya milk" to sell at the market; tending to the
household chores; caring for my younger siblings; were all accomplished while studying to make
good grades in school. Soon discipline, ... Show more content on Helpwriting.net ...
My research interest lies in the field of cardiology. More specifically, I am interested in studying
several aspects of treatment for coronary artery and peripheral vascular disease, new anticoagulant
drugs, drug eluting stents, and devices to prevent blood clot in patients with atrial fibrillation. Other
areas that interest me are racial and gender disparity in heart and vascular conditions. At Rush
University, I am particularly excited to interact with, and interested in the research efforts of Dr
Lynne Braun, "Reducing Health disparity in African American women"; Dr Rami Doukky, "Left
atrial appendage thrombus in patients with nonvavular atrial fibrillation"; and Dr Jeffrey Snell,
"STOP–PAD Study". As a physician, I have learned the importance of working closely with mentors
and faculty who are already experts in the field

Testing Methods, Witnessing Of Data And Calculations
Spectranetics was founded in 1984, they provide expert tools, training and support designed to help
successfully manage every cardiac lead and to eradicate restenosis and amputation, saving time,
money and, most importantly, lives. For my co–op my day to day responsibilities include
performing daily testing for the new product at both the CA and MN site using new equipment
currently in the MN site. I will be also helping to manage the flow of the Fremont, CA lab,
reviewing of testing methods, witnessing of data and calculations. For this project, I will be working
directly with Timothy Hom as he is the manager of the Fremont lab. I will also be working closely
with the Maple Grove R&D team and Ying Yang (a Sr. Analytical Development Manager here at
Spectranetics, Fremont, CA) for the validation work required for completion of the project. Since
we are an FDA regulated facility, I must follow the FDA validation protocols in order to have this
equipment ready to be used for our testing purposes.
Project
Objective
The objective of this test method was to evaluate catheter preparation, deployment and retraction in
an iliofemoral tortuous path model and measure the total quantity and size of particulates generated
from the simulated use of Stellarex 035 paclitaxel–coated balloon catheters after catheter
preparation, deployment and retraction. The transferring and validation of particulate testing method
for our new product line from our Maple grove, Minnesota site to our

Causes Of Death For Men And Women During The United States
One of the leading causes of death for men and women in the United States can be attributed to
Coronary Artery Disease. In the medical world, treatments are ever–changing and improving the
chance of survival from this disease. One such treatment, Percutaneous Coronary Intervention (PCI)
with stent placement, is now used in more than 80% of CAD cases with an exceedingly high success
rate (http://emedicine.medscape.com/article/161446–overview). With any procedure, there is a
number of tools at the doctor's fingertips, and a new experimental technology in the stent world has
risen with temporary bio–absorbable stents. The following document will briefly explain the
procedure and their use in percutaneous coronary intervention.
First, we ... Show more content on Helpwriting.net ...
Such contraindications could be an intolerance to long–term antiplatelet therapy or significant
conditions leading to a reduced lifespan in the patient. If there is a lack of cardiac surgical support or
the artery has suffered less than 50% or complete occlusion, the procedure may be voided. The
patient also must not have received a bypass graft to the left anterior descending artery.
(http://www.merckmanuals.com/professional/cardiovascular–disorders/cardiovascular–tests–and–
procedures/percutaneous–coronary–interventions). Careful approach should be used in cases where
patients suffer from diabetes and coronary artery disease or have left main disease without collateral
flow and a high Syntax score. (http://emedicine.medscape.com/article/ 161446–overview).
As with any medical procedure, risks are taken into precaution when preforming a Percutaneous
Coronary Intervention. Complications generally arise from three types: contrast administration,
catheter/tool related issues, and access site situations (bleeding, hematoma, limb ischemia, etc.) A
patient may have an allergic reaction to the contrast media administered of which there is a course of
action to counteract the reaction with diphenhydramine, albuterol, or epinephrine. Contrast
nephropathy, one of the highest risks of PCI, is presented as an insufficiency of the renal system
clearing the blood. This risk can be reduced by using

The Synthesis Of Nannomaterials
Chemical synthesis of nanomaterials for drug delivery most commonly involves the synthesis of
nanometal compounds, polymer nanocomposites and quantum dots. The original synthesis
techniques for these nanomedicine applications involve toxic reagents and waste products. Green
chemistry initiatives are attempting to produce nanometals, composites and quantum dots without
the toxicity and waste associated with early methods.
Nanometals are an area of high interest in for drug delivery due to their magnetic properties.
Nanometals such as iron oxides have the desired traits of nanoparticles such as high surface to
volume ratios while also allowing for manipulation of drug delivery using magnetic fields.
Therapeutics are linked to the outside of ... Show more content on Helpwriting.net ...
In addition to injectable applications, nanometals are also synthesized for medical stent drug
delivery. This type of drug delivery vehicle involves the permanent fixture of a nanoparticle
apparatus that releases therapeutics in vivo over time. Nanometal stents are fundamentally green as
they are constructed to biodegrade in vivo and excreted through the renal system as they degrade.
The original construction of nanometal stents involved iron; however, iron stents have caused
inflammation in vivo.
Polyphenol–coated porous nanomaterials such as silica are some of the most commonly studied
nanomaterials for stents. Self–assembling, silica scaffolding with PEG coating is a natural choice for
drug delivery stents because it is biodegradable and allows for controlled release of therapeutics to
targeted sites in vivo via a pH–sensitive release. Such scaffolding is meets green chemistry goals of
clean synthesis and avoided waste production; however, patient efficacy must still be improved.
Current in vivo studies demonstrate PEG coatings contributing to "pleural effusion, pericardial
effusion and pulmonary fibrosis and granuloma" as a result of the high–concentration of
nanoparticles in the region of the scaffolding.
Construction of silica scaffolding has led to toxicity in researchers and patients. According to
Jahangirian x–ray and electron microscopy have discovered silica

A Brief Note On Coronary Heart Of Diabetic Patients
Coronary Revascularisation in Diabetic Patients
Introduction
Diabetes Mellitus (DM) increases the risk of coronary artery disease (CAD) by two to four folds,
which may manifest as a silent myocardial infarct in diabetic patients. It is therefore of no surprise
that ischaemic coronary artery disease is responsible for ¾ of diabetes related deaths. The
pathophysiology of atherosclerosis differs greatly in patients with diabetes, resulting in a more
progressive and accelerated form of vascular disease. Revascularisation is required to reverse the
damage, however studies have shown that DM acts as a strong risk factor for restenosis following
successful angioplasty or coronary stenting. Therefore, choosing the most optimal revascularisation
... Show more content on Helpwriting.net ...
With respect to his family history, his mother is diabetic and his father died of IHD at 50 years of
age. The patient is a social drinker and an ex smoker with a pack year history of 20, quitting 6
months ago.
Examination
On examination, the patient had a GCS of 15/15, good colour and was well perfused. A BMI of
28.5, Blood pressure of 110/70 and a vivid regular pulse of 80 bpm with a normal temperature was
noted. Peripheral pulses were present at all focuses. There was no peripheral oedema and JVP was
not elevated. On cardiorespiratory examination no additional heart sound was heard. There was
bilateral symmetrical chest expansion of the lungs. On auscultation bronchial vesicular sounds were
heard bilaterally with few crackles at the lung bases. Aorta was pulsatile and non–expansible and
bowel sounds were present. System review was unremarkable.
Investigations
On ECG, ischaemic signs were noted; T wave inversion in D1, avL, v4, v5 and v6. Such changes
were absent in the previous ECG that was taken five months ago.
Chest X–ray showed a cardiothoracic index was within the physiological limit. The size and shape
of the heart and aorta were normal. Lung fields were clear with no opacity.
Echocardiogram showed an ejection fraction of 50%, within lower bounds of normal. However,
slight hypokinesia was noted at the apex. Raised pulmonary arterial systolic

Medical Case Study
A 60 year old male presented in the ED with a history of chronic alcoholism, diabetes mellitis type
2, aortic valve stenosis and shortness of breath. He states that he cannot catch his breath and has
constant burning chest discomfort for one week without substernal chest pressure. He reports
coughing with production of sputum and denies having these symptoms before. He does drink
alcohol (including today) and admitted to drug use (marijuana). He developed worsening respiratory
distress in the ED and was placed on a Bipap, but his oxygenation worsened and he was intubated.
He was hypotensive and started on a norepinephrine drip after central line placed in right IJ. A chest
x ray showed evidence of fluid overload. He shows signs of CHF, ... Show more content on
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If the heart is compromised, it can compensate for a time by pumping harder and faster, but at a
certain point, it is so over worked that it can no longer over exert the force of contraction and pump
more volume out to the tissues. "The stroke volume of the heart increases in response to an increase
in the volume of blood in the ventricles, before contraction (the end diastolic volume), when all
other factors remain constant (Frank Starling law)" . There are four one way valves that keep the
blood flowing in the correct direction throughout the body. Ther e are the mitral, tricuspid,
pulmonary and aortic valve. During each beat of the heart, they open and close, allowing blood to
flow through the vasculature. When the aortic valve between the left ventricle of the heart and the
main artery (aorta) became stenosed, it no longer allowes the blood to pump through properly. When
the left ventricle has to overcome the higher pressures (due to constriction or disfunction of the
aortic valve) to force blood into the aorta. Feeding oxygen rich blood to the tissues. The extra work
can cause enlargement or thickening of the heart muscle and over time, becomes weakened.
What caused aortic valve stenosis? Most likely having a history of cardiovascular risk factors, such
as diabetes type 2, high cholesterol and high blood pressure! Untreated aortic valve stenosis can lead
to weakening of the heart muscle, which could

Balloon Angioplasty Essay
1. Introduction Cardiovascular disease is the leading cause of death in the world accounting for 17.5
million people, or more than 30% of all deaths. Atherosclerosis leads to coronary artery disease,
which is a manifestation of ischemic heart disease [1,2]. When an artery narrows, or becomes
blocked, intervention is required to restore normal blood flow. In patients with multi–vessel
coronary artery disease, coronary artery bypass graft surgery in generally accepted as a better
method due to the greater risk of developing recurrent ischemic events. However, in those with a
single vessel obstruction, the non–surgical procedure known as percutaneous coronary intervention
(PCI) has been shown to be as effective in treating stenosis [2]. PCI is achieved using balloon
angioplasty, which was first introduced in 1977 [1]. 1.1 – Bare Metal Stents (BMS) By the mid
1980's, bare metal stents (BMS) were developed to overcome the limitations of balloon angioplasty
[1]. Coronary stents are metal lattices that hold the vessel open, which prevents recoil following
angioplasty [2]. They are delivered using a catheter–mounted balloon inserted either in the brachial
or femoral artery, which is then threaded to the site of blockage in the coronary artery. The balloon
is inflated, and the stent is released covering the stenosed lesion ... Show more content on
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Out of 744 cases, eight main reasons for using BMS were found to be: large vessel diameter
(32.4%); ST–segment elevation MIs (17.7%); reimbursement/other reasons (9.4%); advanced age
(12.4%); concomitant oral coagulant treatment (11.3%); increased bleeding risk, cancer, or anemia
(9.5%); planned surgery within 12 months (5.5%); and anticipated poor dual antiplatelet therapy
(DAPT) compliance (1.7%). Patients often receive BMS over DES to avoid long term DAPT; this
reduces treatment from 1 year for DES to 1 month for BMS

Case Based Approach : Patient Information
Percutaneous Coronary Intervention Chloe McSherry Cardiology in Practice SSC Report – Case
Based Approach Patient Information: The Patient: Patient X was a 77–year–old gentleman who
agreed to speak to me on 26/ 06/16 I wanted to write about patient X as I had watched his
emergency PCI on 22/06/16 I spoke to the patient in CCU whilst his wife was here. This proved
useful as the patient has Alzheimer's disease, and although it is only mild he did struggle to piece
together what actually brought him into hospital. Presenting Complaint: Epigastric Pain History of
Presenting Complaint: Presented to PRI with epigastric pain Was present for around 2 hours before
going to PRI, scored 7/10 in pain scale and had presented very suddenly, the pain did not radiate and
the patient described it as dull and constant The pain was not exaggerated by movement The patient
did not collapse The patient did not experience any nausea or vomiting When questioned the patient
remembered being SOB during the incident The patient denied having any chest or calf pain The
patient claimed he had previously experienced this pain on a number of occasion, but usually it
resolved itself Whilst in hospital the pain worsened and troponin and ECG tests (which originally
were normal) showed signs of a STEMI – raised troponin and ST–elevation suggesting an
anterolateral myocardial infarction Past Medical History: Alzheimer's Disease –

Cardiovascular Health Risk Factors Among Americans
Cardiovascular disease has gained a global attention due to the overwhelming number of cases
reported annually. Stakeholders from various health monitoring agencies, health care providers, and
government agencies have come together to tackle the disease, and reduce morbidity and mortality.
Organizations such as the Million Hearts Initiative, the American Heart Association (AHA) 2020
Goals, and the Healthy People 2020 goals have established public health objectives aimed at
targeting cardiovascular risk factors, and improving the outcome of the disease (Sidney, Rosamond,
Howard & Luepker, 2013). The aspirations of the AHA 2020 objectives are to enhance the
cardiovascular well–being of all Americans by 20%, as well as decrease related deaths from
cardiovascular diseases and stroke by 20% (Sidney et al., 2013). Statistical analysis of the
predominance of cardiovascular health risk factors among Americans is overwhelming and therefore
needs immediate action. According to Go et al. (2013), about 31.9 million adults 20 years or older
have total serum cholesterol levels greater than or equals to 240 mg/dL. According to a statistical
data recorded between 2007 to 2010, 33% of United States adults aged 20 years of age or older are
hypertensive, that is about 78 million US adults, and 44% globally (Go et al., 2013). In 2010, an
overwhelming 19.7 million people in the United States were diagnosed with diabetes mellitus, in
addition to 8.2 million unconfirmed cases, and 38.2% people

Procedure For Laparoscopic Appendicectomy ( Emergency...
A 54–year–old man presents acutely with anterior NSTEMI and is treated with PCI (Drug eluting
stent) to the LAD and placed on DAPT (aspirin 300mg and ticagrelor 75 mg bd). He subsequently
develops abdominal pain, which is confirmed as acute appendicitis on CT scan and is referred by the
surgical unit for laparoscopic appendicectomy.
Discuss the timing of any surgery for this man generally, and more specifically with reference to the
pharmacology (kinetics and dynamics) of aspirin and ticagrelor. Include the advantages that
ticagrelor may have over clopidogrel in the management of percutaneous coronary intervention
(PCI) and acute coronary syndrome (ACS)?
Factors affecting surgical outcome:
1. Patient factors:
a. Middle aged man
b. Acute anterior NSTEMI, treated with PCI (Percutaneous Coronary Intervention with a Drug
Eluting Stent) to LAD
c. Subsequent acute abdominal pain (diagnosis of acute appendicitis confirmed by CT abdomen)
2. Surgical factors: For laparoscopic appendicectomy (emergency surgery).
3. Drug factors: On aspirin 300 mg and ticagrelor 75 mg bd.
When we think of the ideal time to operate on this patient, two facts leap to attention: first, it might
be unwise to proceed with surgery immediately as he has had a recent myocardial infarction, and
second, that the antiplatelets need to be managed optimally to get the best outcomes possible– there
is a fine line between the risk of stent thrombosis if they are stopped too early and excessive intra–
and

Literature Review On Atherosclerosis
Literature Review Draft
Atherosclerosis is characterised by gradual decrease in the luminal diameter of large arteries, it has
major health implications and contributes to around 50% of all deaths within westernized countries
(7). Patients can undergo coronary artery stenting to prolong the effects of this. Treatments for this
have undergone major developments over the past 40 years, including balloon angioplasty in 1977,
development of bare–metal stents (BMS) in the 1980's, introduction of drug–eluting stents (DES) in
2000 (43) and current research into incorporating NO donors into stents. The first stent implantation
performed on a human was conducted in 1986 (13), since then they have become one of the most
common ways of intervention due to atherosclerosis. In the US there are 500,000 people who
undergo stenting annually (42). The success of stenting is inhibited by the reoccurrence of
restenosis. Multiple things can affect the rate of in–stent restenosis, elevated LDL levels, increased
levels of plasminogen activator inhibitor I, type 2 diabetes and enhanced platelet aggergability (10).
Therefore the severity of restenosis will differ between patients.
Nobuyoshi et al, (1) and Serruys et al (2) found that restenosis is not an instantaneous development
after stent implantation, it develops between the 1st and 3rd month after implantation, although the
greatest change in luminal diameter occurred between the 2nd and 3rd month. These studies suggest
that restenosis is

Essay about Cardiac Catheterization
Cardiac catheterization is often referred to as coronary angiography or a coronary angiogram. It is a
radiographic procedure that is used to look at and visualize the heart and the coronary arteries.
During a cardiac catheterization it is possible for the cardiologist performing the procedure to see
how effectively blood is flowing through the coronary arteries. In addition, this procedure allows the
cardiologists to see how blood is moving through the chambers of the heart and how effective the
heart valves are functioning. A cardiac catheterization can also allow for the visualization of the
movement of the walls of the heart to see if the pumping action of the heart is normal. The primary
application of cardiac catheterization is to ... Show more content on Helpwriting.net ...
The stent will be placed where it can be expanded to hold the artery open. Some stents are designed
to simply keep the artery held open. Other stents used are drug–eluting stents. These stents are
coated with pharmacologic agents that work to prevent restenosis of the artery. Another form of PCI
is artherectomy. This is a procedure that has a cardiologist using a cutting blade that spins rapidly or
a laser beam to cut away or burn away plaque that is blocking a branch of the coronary arteries. To
perform a cardiac catheterization the patient is brought to the cardiac catheterization lab. These
procedures are performed by specially trained cardiologists, nurses and radiologic technologists. The
procedure is performed on a specialized table with fluoroscopy equipment, cardiac monitoring
equipment, and the use of computerized technology to assist in data and image collection and
analysis. To perform a cardiac catheterization the cardiologist will insert a sheath, or a short tube
usually into the femoral artery. A long very thin catheter will then be fed through the sheath and
guided through the arteries until it is in the heart and coronary arteries. The physician uses
fluoroscopy equipment to guide the catheter into the coronary arteries. To allow for clear viewing of
the coronary arteries, contrast material is injected into the catheter. As the contrast material flows
through the heart chambers and coronary arteries x–rays are taken. The

Dual Antiplatelet Therapy Case
Case 3
Mrs JL is a 78 year old who is being discharged from your ward after being admitted following a
severe bout of gastroenteritis. She has made a full recovery and is about to be discharged. You took a
medication history from her when she was admitted and recorded that she was taking aspirin 100mg
daily and clopidogrel 75mg daily after having had a drug eluting stent inserted 6 months previously.
Her other admission medications include metformin 1g daily, perindopril 5mg daily. Mrs JL's
discharge script includes all the medications on admission except the clopidogrel. Is it Ok to cease
the clopidogrel in this patient?
A. Generate a PICO table and an answerable question for the given case
Patient/Population Elderly diabetic patient ... Show more content on Helpwriting.net ...
[7] However, diabetes still remains a major risk factor for restenosis after both bare–metal stents and
DESs. [10] Diabetes mellitus is regarded as a proinflammatory and prothrombotic condition, and
patients with diabetes mellitus are more frequently resistant to aspirin and clopidogrel than those
without diabetes mellitus. [2] The minimum necessary duration of DAPT may be longer in diabetic
than in nondiabetic patients. [2] Among diabetic patients, target vessel failure occurred more
frequently with 6–month DAPT than with 12–month DAPT. [2] Prolonged DAPT for >6 months
might be needed to prevent late stent thrombosis because of delayed vascular healing and
inflammatory reaction after implantation of drug–eluting stents.

Structure Of A Bare-Metal Stent (BMS)
When it comes to structure, a bare–metal stent (BMS) is an elaborate mesh–like tube having a thin
wall (stent platform) without a drug coating. The first stents that were licensed were made up of bare
metal (316L stainless steel). The second generation of stents was composed of cobalt chromium
alloy. There is another stent which called A drug–eluting stent (DES) that involves a stent platform
with the drug to help the patient prevent from having the abnormally narrowed arteries again. The
stent platform is an expandable mesh–like tube. The polymer coated on the stent has one to more
than three layers and take the drug out. The first DES were also comprised of stainless steel alloys,
and the next generation DES used cobalt chromium alloy.While ... Show more content on
Helpwriting.net ...
DAPT had to have long enough time after implanting the stent into arteries to prevent stent
thrombosis.Premature discontinuation of anticoagulation therapy, also known as premature
discontinuation of DAPT, means discontinuation of DAPT for less than three months for sirolimus–
eluting stents (SES) and shorter than six months for paclitaxel–eluting stents (PES). The outcome of
the premature discontinuation of DAPT can increase the risk of stent thrombosis, myocardial
infarction, and death. Bare–metal stents (BMS) do not relate to blood clotting issues after stent
implantation such as stent thrombosis. Therefore, it can be said that BMS do not need anti–clotting
therapies. On the contrary, drug–eluting stents have been involved with late stent thrombosis. To
prevent this issue, optimal conditions of several factors should be considered. Those factors can be
stent position and expansion, the number of stents, stent size, stent design, patient and lesion, and
premature discontinuation of antiplatelet medicines. Revascularization can be defined that produce
the healthy blood circulation to a body part again under the situation carrying depletion of oxygen to
an organ. The terminology, revascularization, is usually used by surgical

Johnson and Johnson Analysis
INTRODUCTION
Johnson and Johnson have revolutionized the way people think about health care, and has easily
become the pinnacle of success by doing so. Pioneers of the health care industry and overall human
health and well being, Johnson and Johnson is guided by its "Our Credo" and founding principle
that "doctors and nurses should use sterile sutures, dressings and bandages to treat peoples wounds"
(Johnson and Johnson – Our History).
Most of Johnson and Johnson's success can be attributed to its emphasis on decentralized
management, which allows for greater focus as the company blankets 250 countries across the world
(Johnson and Johnson – Strategic Planning). For the last 120 years, Johnson and Johnson have been
on the forefront of ... Show more content on Helpwriting.net ...
[pic]
Figure 2. 2006–2009 Revenue, Expenses, And Income Figures For All Business Segments
Ratio Analysis
Financial ratios provide a means to analyze the operations of a company in comparison to its
industry and its historical results.
Liquidity Ratios
Johnson and Johnson has a current ratio of 1.8X which is the same as the current ratio for the
industry. The quick ratio is 1.6X compared to the industry's 1.4X provides further evidence of the
company's liquidity. This will provide needed working capital necessary to develop new products
and finance potential acquisitions. (Ventureline)
Johnson and Johnson's receivables turnover ratio is currently 6.4X and mirrors the current industry
average. It is also higher that it's three major competitors: Merck & Company, Novartis AG, and
Pfizer, Inc. This high ratio indicates an efficient collection of credit sales, which minimizes the wait
before funds are received and available for use.
Inventory turnover is currently at 3.6X and slightly better than the industry average of 3.5X. It is
also nearly twice as high as its three major competitors. This provides a competitive advantage since
there is not a high level of inventory that could be deemed obsolete due to new drug developments

or decreased potency. In addition, capital is not tied up in maintaining inventories that do not
provide any return.
Debt Ratios
The current times interest earned ratio for Johnson and Johnson is 25.1X compared to the

The Implantable Medical Device Industry
In the implantable medical devices industry, substitute products exist for some types but not all.
According to Michael Porter's "Competitive Strategy: Techniques for Analyzing Industries and
Competitors", in order for a product to be a viable substitute, it must achieve similar function as the
product that it is replacing by a different means. Porter considers four categories for analyzing a
substitute: "performance, cost of change, buyer inclination to substitute and price–performance
trade–off" (Porter, 1998). When comparing medical therapies for coronary artery disease,
musculoskeletal disorders, degenerative disc disease, spinal tumors and fractures, the present day
implantable medical devices are a minimally invasive form of treatment than former ones. They are
the new products and services and there are not many direct substitutes besides generic products. In
fact, many doctors argue that "medical therapy should be viewed as complementary rather than as an
opposing strategy" (Blumenthal et al., 2000). In many cases, substitute products can be drugs
prescribed to a patient in lieu of an operation to implant a medical device. For example, with
coronary artery disease, two therapies are commonly used: stents (implantable devices) and
coronary artery bypass graft (CABG) surgery. Differences between outcomes with stenting and with
CABG are a point of controversy (Hannan et al., 2008; Ryan et al., 2006). However, a recent study
comparing the treatment outcomes of all

Homework Summary And Analysis
Sidrah Ali
Homework #3
BME 501
5 November 2014
1. a. Bare–metal stents (BMS) and drug eluding stents (DES) essentially have the same tube like
structure and generally consist of the same metal alloy composition of the wires. However, unlike
the bare metal stents (BMS), the drug eluting stents (DES) are coated with a polymer which holds
and eludes a drug such as paclitaxel or sirolimus which aids in the inhibition of restenosis.
http://en.wikipedia.org/wiki/Drug–eluting_stent b. "Off–label" use of drug eluding stents (DES)
constitutes the fact that the stent is not particularly approved or designed for the certain application
it is being used for even if it has showed promise in treatment. Where as "on–label" use is the use of
the stent for ... Show more content on Helpwriting.net ...
The stent is inserted into the artery by balloon angioplasty, to expand the vessel walls in order to
return blood flow back to normal. There are two types of stents, bare–metal stents and drug–eluting
stents. Once a BMS is inserted into the vessel, it become fully endothelialized.. However, The
animation explains that in about 1/3 of BMS implants, restenosis occurs. On the other hand DES
were developed to combat this issue. The polymer coating on the DES contains a drug which aids in
the inhibition of restenosis. However, the endothelialization process for drug–eluting stents has
shown to be problematic, which can in time cause stent thrombosis, which can possibly lead to
myocardial infarction. It is important to note that these stents should be used in patients how do not
have complex coronary stenosis because the off–label use is not completely understood and has a
higher risk of

Characteristics Of A Stable Angina
Stable Angina
What is stable angina?
Stable angina is another term for chest pain that occurs with activity and improves with rest or a
medication called nitroglycerine. This is an extremely common condition that typically affects older
individuals with high blood pressure, diabetes, and elevated cholesterol. People with angina are at
increased risk for cardiovascular conditions such as heart attack, peripheral vascular disease, and
stroke. As opposed to stable angina, unstable angina is an emergency that can lead to heart attack
very quickly.
Since stable angina is so important, it is critical that patients be educated about the causes and
treatment of this condition. By the end of this article you will know the answers to these ... Show
more content on Helpwriting.net ...
Other symptoms that may occur during angina attacks include:
Difficulty breathing
Low energy
Exercise intolerance
Profuse sweating
Nausea or vomiting
There are no specific signs on physical examination that can diagnose angina.
How is angina diagnosed?
Angina is suspected based on symptoms and the diagnosis is typically confirmed with a stress test.
There are various types of stress tests. Your doctor may have you exercise on a treadmill while
monitoring your symptoms, blood pressure, heart rate, and electrocardiogram (stress EKG). If you
have an abnormal EKG at baseline, they might not be able to interpret the EKG during exercise, so
they may perform other tests that provide similar information – a stress echocardiogram or nuclear
stress test.
During a stress echocardiogram, your doctor will look at an ultrasound of your heart before and after
exercise. Similarly, during a nuclear stress test, you doctor will evaluate your heart before and after
exercise using nuclear imaging. If your heart pumps abnormally with exercise, this can suggest that
it is not receiving enough blood during physical activity.
Sometimes, individuals might not be able to use a treadmill due to severe arthritis in the hips or
knees, or because they are paraplegic or unable to walk. During these circumstances, your doctor
can administer an intravenous medication (eg, adenosine, dobutamine) to mimic physical activity. In
other words, your doctor will

In-Stent Restenosis: A Case Study
A 78 year old female with hypertension appear with stable angina pectoris. An angiogram of the left
anterior descending coronary artery revealed a lesion near the bifurcation vessel. The lesion was
bifurcated with a ballon catheter and an endeavor drug eluting stent was deployed in the blood
vessel. The patient left without any complications on a medical therapy. Ten months later, the
angiogram of the patient revealed a Grade IV Stent Fracture and a substantial in–stent restenosis
(Appendix 1). Problem Description: We believe that the endeavor stent failed and led to a substantial
in–stent restenosis because the 316L stainless steel material used in the stent, wasn't strong enough
to bear the radial load in the struts. Additionally, we believe that the standard PC + zatrolimus drug
on the endeavor ... Show more content on Helpwriting.net ...
Firstly, the main function of the implanted stent is to prevent arteries from clogging back up and
allowing blood to flow through. Secondly, we believe that our implant material should be fatigue
resistant because it experience pulsatile flow due to the presence of a pulsatile blood pressure. The
implant should be stronger in radial than shear because the implant will have to withstand
significant amount of force from the fatty deposits of the vessels. Additionally, the implant should
have minimum reactivity with blood constituents because we don't want to induce unnecessary
thrombosis or any sort of inflammation. Thirdly, we believe that class 1 biomaterial are ideal for our
implant because our material requires failure loads of 10–50 times the body weights, meaning it has
to be extremely strong. Furthermore, we believe that our material should have extremely high
resistance to compressive deformation as well as little reactivity with the environment, in order to
accomplish the necessary

Nursing Case Study Phentermine
Introduction
In the 1990's, phentermine was marketed in combination with fenfluramine as Fen–Phen. The
combination therapy was subsequently well documented to lead to valve abnormalities resulting in
aortic valve replacements, as well as pulmonary hypertension, in patients younger than expected.
This led to its ultimate removal from the market in 1997. 1–3 However, phentermine alone was
deemed safe and continued to be sold as a weight loss aid, either on its own or in combination with,
other medications.4 There are no known reports of ischemia induced by phentermine alone or other
associated weight loss agents. Particular consideration should be given to patients who present for
surgery and anesthesia who have previously been prescribed phentermine. We describe a case of
phentermine–induced myocardial infarction in a young female who was previously healthy.
Clinical Presentation ... Show more content on Helpwriting.net ...
To date, there are only two documented case reports in otherwise healthy women who presented
with ST segment elevation myocardial infarctions (STEMI) associated with the use of phentermine
or sibutramine, another similar weight loss agent.7 However, unlike in our case, the coronary
angiographies were normal. Further investigations for the etiology of those events, including
toxicology for cocaine abuse and a hypercoagulable state, were negative. The authors concluded that
due to the absence of cardiovascular risk factors, the appetite suppressants were responsible for the
myocardial infarctions in those two patients. In our case, the only identifiable cardiovascular risk
factor for this otherwise healthy, young woman was tobacco use. Therefore, we suspect that her use
of the appetite suppressant, phentermine, may have accelerated coronary atherosclerotic disease,
thus precipitating her acute coronary

Pricing Of A Variable For Health System
Pricing Regression–CABG Like the case for colectomy, Table 6 shows the results of two pricing
regressions. An indicator variable for health system was included in model 1, while different types
of health system variables were included in model 2. The number of comorbid conditions was
significantly associated with the risk–adjusted CABG price. Having one comorbidity condition
increased the risk–adjusted CABG price by 3.2 percent (model 1) and 3 percent (model 2). In
addition, three or more comorbidity conditions were associated with a 14 percent (model 2) increase
in the risk–adjusted CABG price. In addition, an increase in the number of venous treated was
significantly associated with the risk–adjusted CABG price. The risk–adjusted CABG ... Show more
content on Helpwriting.net ...
The possible reasons behind the different results among system and network affiliated hospitals are
discussed later. The magnitude of price differences was varied across system/network types. IHS
affiliated hospitals showed the lowest risk–adjusted CABG price, which was 15.6 percent (model 2)
lower than non–system hospitals. The CABG prices in MCHS and DHS affiliated hospitals were
significantly lower than the CABG price in non–system hospitals by 7.8 percent and 8.5 percent
respectively. The CABG price for HMO enrollees was significantly lower than the CABG price that
for fee–based plans by 8.2 percent (model 1) and 8 percent (model 2). The CABG prices for patients
with CDHPs and HDHPs were 23.5 percent higher than the CABG prices for other fee–based plan
enrollees (model 2). Health market concentration and HMO penetration rate was not significantly
associated with the risk–adjusted CABG price. Descriptive Statistics–PCI The PCI sample included
111,668 patients who went through a hospitalization due to PCI (Table 7). The average unadjusted
PCI price for this sample was $24,397. The mean age of patients for this PCI sample was 54.16 and
76.4 percent of the PCI patients were male. As measured by Elixhauser index, 45.5 percent of
patients did not have any comorbid

Symptoms And Treatment Of Acute Coronary Syndrome
CLINICAL CLARIFICATION Acute coronary syndrome refers to several potentially life–
threatening conditions associated with acute myocardial ischemia and/or infarction most commonly
resulting from a sudden decrease in coronary blood flow8, 2 Includes ST–elevation myocardial
infarction (STEMI), non–ST–elevation myocardial infarction (NSTEMI), and unstable angina
CLASSIFICATION Based on electrocardiogram (ECG) 8 ○ Acute chest pain and persistent (>20
min) ST–segment elevation – Defined as ST–elevation acute coronary syndrome (STEACS) and
generally indicates acute total coronary occlusion. – Most developed ST–segment elevation
myocardial infarction ○ Acute chest pain without persistent ST–segment elevation – Accounts for
75% of all cases of acute coronary syndrome 2 – Defined as non–ST–elevation acute coronary
syndrome (NSTEACS), further diagnostically refined as: □ Non–ST–segment elevation myocardial
infarction (elevated biomarkers) □ Unstable angina – At presentation, ECG reveals: □ Persistent or
transient ST–segment depression, or □ T–wave inversion □ Flat T waves □ Pseudo–normalization of
T waves □ No ECG changes DIAGNOSIS CLINICAL PRESENTATION History ○ Thorough past
medical history essential for suring appropriate diagnosis and management. 2 ○ Factors that should
be evaluated include: – Nature of angina symptoms □ Location, duration, radiation, quality, intensity
□ Provocative factors (ie. activity, emotional stress) □ Palliating factors (ie. rest, sublingual

Balloon Agioplasty Essay
Article Evaluation and APA Citation
Source 1
Stenting is a minimally invasive surgical procedure that implements the use of synthetic mesh
material to clear vascular obstruction and improve blood flow ("Balloon Angioplasty and Stents",
2015). Angioplasty involves using a balloon to compress the plaque against the arterial wall in order
to clear the blockage, but there is debate as to which procedure is optimal in minimizing risk of
complications after the procedure ("Balloon Angioplasty and Stents", 2015). According to "Balloon
Angioplasty and Stents" (2015) these two procedures often go hand in hand, in fact, "about 80% of
patients who have balloon angioplasty will have a stent placed as well." This procedure can be
implemented in any ... Show more content on Helpwriting.net ...
Volume Number: 65
6. Issue Number: 8
7. Page Numbers: 777–786
8. Yes, it has been peer–reviewed.
9. The problem is that the current recommendation for DAPT in stenting patients is one year, but
there may be no difference in risk factor in shortening the duration of treatment. The researchers
hypothesize that a six month treatment is noninferior to a 24 month treatment.
10. The research is conducted in an attempt to reevaluate current medical practice and potentially
introduce a more efficient treatment method.
11. There was no mention of research conducted by other scientists.
12. The researchers performed a randomized study of patients with drug–eluting stents that
underwent 6 or 24 month DAPT treatment. The researchers began by performing an aspirin–
resistant test and separated those that responded well to aspirin. The researchers collected data from
6– 12–24– and 36– month follow ups with the patients' doctors.
13. The measurements of any bleeding within 36 months after the procedure were appropriate
because the researchers were looking for the presence of any complications with each treatment.
14. Bleeding indicated the lack of effectiveness of a certain treatment. Otherwise, no indicators are

Essay On Coronary Intervention
Abstract:
Aim: Combined PCI and TAVR placement through a non conventional access in an elderly male
with multiple co–morbidities along with difficult access.
Methods and Results: 68 year old male with Society for Thoracic Surgeons score 4.55% and Euro
score II 2.92% due to the presence of myriad of diseases such as severe aortic stenosis, NYHA class
II, CCS class III angina, HIV, stage III COPD, severe peripheral vascular disease with prior right
axillary–femoral and femoral– femoral artery bypass with occluded abdominal aorta and
cerebrovascular disease with carotid stenosis underwent transaortic valve replacement through a
nonconforming transaxillary route simultaneously with a percutaneous coronary intervention with
immensely enhanced quality of life objectively one month post procedure.
Conclusion: Percutaneous coronary intervention and TAVR execution as a single procedure can
occur in discerning patient population as it does not increase the risk of mortality even in the setting
of severe multi–organ involvement.
Introduction:
In a ... Show more content on Helpwriting.net ...
His past medical history was remarkable for hypertension, stage III COPD by GOLD criteria, HIV,
severe peripheral vascular disease with prior right axillary to femoral and femoral to femoral artery
bypass with occluded "lead–pipe" abdominal aorta, cerebrovascular disease with moderate–to–
severe carotid stenosis, pulmonary hypertension, spinal stenosis and several previous orthopedic
procedures. Moreover he had an elevated Charlson Comorbidity Score and a prolonged 5–meter
walk test. The predicted operative mortality for surgical aortic valve replacement based on the
Society for Thoracic Surgeons score and Euro score II was 4.55% and 2.92% respectively. He was
deemed inoperable in light of his history and predicted surgical

Myocardial Infaraction
Aldosterone: Role in Edematous Disorders, Hypertension, Chronic Renal Failure, and Metabolic
Syndrome. Schrier RW, Masoumi A, Elhassan E. University of Colorado Denver, Aurora, Colorado.
Abstract The role of aldosterone has expanded from the hormone's genomic effects that involve
renal sodium transport to nongenomic effects that are independent of the effect of aldosterone on
sodium transport. The nongenomic effects of aldosterone to increase fibrosis, collagen deposition,
inflammation, and remodeling of the heart and blood vessels, however, are markedly increased in
the presence of high sodium intake. The genomic effect of aldosterone increases renal sodium
transport, but the administration of large doses of aldosterone to normal ... Show more content on
Helpwriting.net ...
Diabetic patients with ACS derive a greater benefit from established therapies, particularly platelet–
inhibiting therapies, including clopidogrel pretreatment, and glycoprotein IIb/IIIa inhibitor use.
Recent data show intense ADP–P2Y12 platelet receptor inhibition with prasugrel is of particular
clinical value in the diabetic patient with ACS, without excessive bleeding. Diabetic patients with
ACS also benefit more from aggressive revascularization strategies. Recent data show the benefit of
drug–eluting stents in the setting of primary percutaneous coronary intervention for ST–segment
elevation myocardial infarction in decreasing target vessel revascularization up to 2 years,
particularly in patients at highest risk for restenosis with bare metal stents (likely diabetic patients).
This review summarizes the data supporting the key pharmacologic and revascularization
management strategies to guide the clinician in taking care of diabetic patients who present with an
ACS event. PMID: 20446120 [PubMed – as supplied by publisher 2010 Mar;7(1):9–14. ST2: a
novel remodeling biomarker in acute and chronic heart failure. Shah RV, Januzzi JL Jr. Cardiology
Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55
Fruit Street, Boston, MA, 02114, USA. Abstract ST2, a member of the interleukin–1 receptor
family, is a novel biomarker of mechanical stress measurable

Computed Tomography Advantages And Disadvantages
Computed Tomography (CT)
A CT scan, also called as X–ray Computed Tomography (X–ray CT) or Computerized Axial
Tomography (CAT ), makes use of computer–processed combinations of many X–ray images taken
from different angles to produce cross–sectional (tomographic) images (virtual 'slices') of specific
areas of a scanned object, allowing the user to see inside the object without cutting them.
Digital geometry processing is used to generate a three–dimensional image of the inside of the
object from a large series of two–dimensional radiographic images taken around a single axis of
rotation. Most common application of X–ray CT is Medical Imaging. Its cross–sectional images are
used for diagnostic and therapeutic purposes in various medical disciplines. ... Show more content
on Helpwriting.net ...
Now, we were able to view the tomographic anatomy of the human body, noninvasively.
2. Also, we were able to view density differences. But there were a few disadvantages:
1. The anatomic structures were superimposed.
2. Soft tissue couldn't be differentiated.
3. It was time consuming.
4. The resolution of the image was not very good.
Sir Godfrey N. Hounsfield of EMI Laboratories and Alan M. Cormack of Tufts University were
awarded with Nobel Prize in the field of Physiology and Medicine in 1979.
A Prototype CT scanner
Generation of CT scanners
The general classification of CT scanners is based upon the arrangement of the components and the
mechanical motion required collecting the data.
The first commercially viable CT scanner was invented by Sir Godfrey Hounsfield in Hayes, United
Kingdom, at EMI Central Research Laboratories using X–rays. He conceived his idea in 1967. The
first EMI–Scanner was installed in Atkinson Morley Hospital in Wimbledon, England, and the first
patient brain–scan was done on 1 October, 1971. It was publicly announced in 1972.
First Generation = Translate – Rotate –One Detector
Second Generation = Translate – Rotate – Multiple detectors
Third Generation = Rotate –

Medieval Medicine Research Paper
Middle Ages to Modern
Medieval medicine and procedures have transformed drastically over time from the middle ages to
modern day. During the medieval era, medicine was multi–faced, relying on the skills of several
practitioners. Leonardo da Vinci stated, ?Medicine is the restoration of discordant element; sickness
is the discord of the elements infused into the living body.? Educational requirements, procedures,
and diseases have evolved since the medieval era to present day, due to major breakthroughs.
In the middle ages, doctors had limited knowledge (BBC). Doctors were developed through
practicing, not schooling. Beginning in the 15th century, doctors were required to have a minimum
amount of schooling to even be considered a doctor. The ... Show more content on Helpwriting.net
...
Pneumonia was present during the winter months because of the cold drafty dwellings. Skin
diseases were common due to the rough worn that peasants wore, and the lack of nutrition
(Diseases). The major disease concern in the middle era was the Black Death. It was spread by rats
that were present on the long journeys of the trading ships (Black).
As I refer back to the ninth paragraph, the Black Death killed over twenty million people in the
Middle Ages. Girolama Fracstora, however, was the first to discover that plaques and epidemics
were not caused by the body. He was also the first person to say that there was an outside source
(Wikipedia). Scientists are led to believe that the spread of the plaque could have been prevented by
the simple use of soap and water. Not all diseases have cures today. Cancer is the leading cause of
death internationally, and is predicted to keep on rising. The second leading cause of death is
cardiovascular disease or CVD. Physicians have proven that patients who lack of exercise and have
poor dietary habits are more at risk to be diagnosed with this disease. For decades they have tried to
discover a cure for diabetes, but have been unsuccessful. Type 1 is thought to be caused by genetics.
Food processing is blamed for type 2 diabetes (Torres). Diseases are evolving every

Critical Limb Ischemi Acute Presentation Of Peripheral...
Background
Critical limb ischemia is severe presentation of peripheral arterial disease. The incidence of Critical
limb ischemia could increase with age and atherosclerotic risk factors such as, diabetes, cigarette
smoking, obesity or hypertension .The prevalence of critical limb ischemia is approximately 12% in
the adult population especially men compared to women (Davies 2012). Critical limb ischemia
could lead to insufficient blood and oxygen supply to the affected tissues compromising limb
viability. Manifestation of this disease include, claudication, rest pain or tissue loss.
Critical limb ischemia could affect the functional capacity a decrease in overall well–being and
quality of life due to reduced blood flow and a typical ... Show more content on Helpwriting.net ...
2013). Nevertheless, Percutaneous transluminal angioplasty and Bare–metal stents failed to
demonstrate durability because of the high rate of restenosis following endovascular procedure
which could occur early after treatment (Falkowski et al. 2009)
The lack of recognized durable antirestontic result after plain balloon angioplasty lead to the
investigation of alternative procedures. After the success of drug–eluting stents in decreasing
coronary restenosis after percutaneous coronary interventions, drug–eluting stent was recommended
as salvage procedure in case of Percutaneous transluminal angioplasty failure (Rosales,
Mathewkutty & Gnaim 2008).
Stent devices were invented in the 1980s and refined in the 1990s. Stenting techniques have
transformed and expanded the therapeutic capabilities of angioplasty. There are two classification
for stents based on their mode of deployment balloon–expandable and self–expandable. Stents are
small mesh tubes which inserted to keep arteries open after angioplasty procedure. Drug –eluting
stents have a polymer coating over mesh. This Polymer coatings have been proven to be durable and
deliver drug in a uniform and controlled way ( White, Hollier 2007).
This essay is aim to assess the effectiveness of Drug–eluting stent on long–term limb preservation of
infrapopliteal vessel patency in patients with Critical limb ischemia due to below the knee arterial
obstructive disease.

Coronary Artery Disease Research Paper
Coronary artery disease (CAD), or heart disease, is the leading cause of death for both men and
women in the United States. CAD is usually caused by the development of atherosclerosis, the
condition in which plaques made up of cholesterol–containing deposits build up in the arteries.
When plaque buildup narrows or blocks the coronary arteries that supply the heart muscle, there is a
decrease in blood flow, oxygen and nutrients to the heart. This decreased blood flow can cause
angina pectoris or chest pain, shortness of breath, or a heart attack. CAD weakens the heart muscle
and leads to heart failure, in which the heart cannot pump enough blood the way it should to satisfy
the body's demands, or cardiac arrhythmias, in which the heartbeat is irregular. ... Show more
content on Helpwriting.net ...
PCI restores blood flow through narrowed or blocked coronary arteries. During PCI, a balloon–
tipped catheter –– a thin, flexible tube –– is inserted into an artery in the groin or the arm and
threaded to the diseased coronary artery. Then, the balloon is inflated to compress the plaque and
widen the artery. A stent usually made of metal mesh may be placed to help keep the artery open.
Bare metal stents (BMS) prevent the risk of the artery collapsing, but they do not reduce the risk of
restenosis, the reoccurrence of the artery becoming narrowed and leading to decreased blood flow.
The development of drug–eluting stents (DES) has improved the risk of restenosis. However, DES
are associated with the risk of stent thrombosis, the formation of a blood clot inside the artery that
can lead to decreased blood flow. Innovations in heart stents are continuing, and second–generation
DES and new stents are under

Our Comprehensive Synthesis Of Available Evidence Showed A...
Our comprehensive synthesis of available evidence showed a strong association between the LISA
and the risk of late/very late ST and MI during the post imaging follow up. The low incidence of ST
events over 18,145 person–months follow up (≈1.4% ST per person–year) in LISA group explains
the limited power of previous studies evaluating this association. Our results are consistent with a
prior meta–analysis of five studies which found LISA to be associated with increased risk of late ST
(OR = 6.51; 95% CI 1.34–34.91)(13). We extended these findings by including 11 additional studies
and longer follow up of previous studies published subsequently. Also, we accounted for variable
follow up period of included studies by using person–months as offset rather than the number of
patients in each group. Moreover, as recommended in literature (17–18), we used multiple statistical
methods as part of our sensitivity analysis to assess the robustness of our findings. Our finding stood
the test of these sensitivity analysis confirming a strong association between LISA ( and LAISA)
and late/very late ST. Although we found a significant association between LISA and clinical events
(ST and MI), our results do not establish a cause and effect relationship. The two cohorts, LISA and
control, were unbalanced on one or more characteristics in all included studies. For instance, LISA
group had longer stents and more commonly associated with acute coronary syndrome as the
indication for PCI in

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