Acute Spontaneous Subdural Hematoma in a Patient With an End-Stage Renal Disease After Starting Dual Antiplatelet Therapy Post Drug-Eluting Stent Insertion: A Case Report

Dual antiplatelet therapy (DAPT) has been widely utilized for secondary prevention in patients with cardiovascular diseases, such as post-drug eluting stent insertion, stroke, and peripheral vascular disease. The occurrence of bleeding complications, including intracranial hemorrhage, has been extensively studied in relation to DAPT. However, the occurrence of acute spontaneous subdural hematomas in this context is relatively rare. These hematomas can manifest through various symptoms, including altered mental status (AMS) and confusion. The risk of intracranial hemorrhage is particularly higher in patients receiving aspirin with ticagrelor, especially in those with reduced estimated glomerular filtration rate (eGFR) and liver disease. In this case report, we present the case of a patient with end-stage renal disease undergoing peritoneal hemodialysis and a remote history of liver transplant. The patient presented to the hospital with chest pain, subsequently underwent drug-eluting stent placement, and was initiated on DAPT. Following the initiation of DAPT, the patient developed confusion and was diagnosed with an acute spontaneous subdural hematoma. The patient underwent middle meningeal artery embolization to manage the hematoma.

Acute Mitral Regurgitation: An Unusual Cause of Unilateral Pulmonary Consolidation

Unilateral pulmonary consolidation generally indicates infectious pneumonia. In this case report, we describe a patient with infective endocarditis and acute mitral valve regurgitation who developed acute unilateral pulmonary consolidation that resolved dramatically after mechanical ventilation and diuretic therapy. The prompt resolution of the consolidation with treatment suggests pulmonary edema. This case report highlights that rare conditions such as acute pulmonary edema should be considered in the differential diagnosis of patients who present with unilateral pulmonary consolidation to avoid delay in appropriate treatment.

Metabolic Modulators for Chronic Cardiac Ischemia

Many patients with ischemic heart disease continue to experience anginal symptoms despite revascularization and treatment with antianginal medications. The effectiveness of current anti-ischemic medications is limited by their hemodynamic side effects, such as hypotension and bradycardia, which result in compromised organ perfusion. In this article, we review five novel agents (ranolazine, trimetazidine, L-carnitine, ribose, and dichloroacetate) under investigation for treatment of ischemic heart disease that work by enhancing the efficiency of the myocardium, rather than decreasing its work. This new paradigm promises to eliminate these side effects.

Coronary vein graft disease: pathogenesis and prevention

Not long after coronary artery bypass grafting surgery was described, several reports presented follow-up angiographic data on large cohorts of patients, demonstrating that approximately one-half of saphenous vein grafts fail within 10 to 15 years of surgery and that graft failure is associated with worse clinical outcomes. Three processes are responsible for vein graft failure. Thrombosis, intimal hyperplasia and accelerated atherosclerosis contribute to graft failure in the acute, subacute and late postoperative periods, respectively. Studies have shown that perioperative antiplatelet therapy can reduce early thrombosis and graft failure. As in native coronaries, intensive lipid lowering can attenuate the process of atherosclerosis in vein grafts. Intimal hyperplasia in the vein graft is thought to be an adaptation of the vein to higher pressures in the arterial circulation. This process is further promoted by the loss of inhibition from the endothelial layer, which is injured during surgery. A new 'no-touch' technique for harvesting grafts may be effective in preventing disruption to the endothelial layer, and subsequent intimal hyperplasia and graft loss. Off-pump surgery and endoscopic vein harvesting, which are known to reduce surgical morbidity, have been shown to be no worse than on-pump surgery and open vein harvesting, respectively, in terms of vein graft patency. Various gene therapies can prevent intimal hyperplasia in animal models, but human data obtained so far have been disappointing. Placing an external stent around a vein graft may reduce tangential wall stress and subsequent intimal hyperplasia.

Can computer autoacquisition of medical information meet the needs of the future? A feasibility study in direct computation of the fine grained electronic medical record

The project describes feasibility testing of a two-year clinical deployment of an electronic record keeping system for primary care medicine that allowed financial medical management and clinical disease study without the encumbrance of human encoding. The software used an expert system for acquisition of historical information and automatic database encoding of each independent fact. The historical acquisition system was combined with a screen-based physician data entry system to create a fine-grained medical record. Fine-grained data allowed direct computer processing to mimic the ends that presently require human encoding--gatekeeping, disease characterization and remote disease surveillance. The project demonstrated the possibility of real time gatekeeping through direct analysis of data. Detection and characterization of disease states using statistical methods within the database was possible, however, limited in this study because of the large numbers of patient interviews required. The possibilities for remote disease monitoring and clinical studies are also discussed.