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Correspondence to: P McGettigan p.mcgettigan@qmul.ac.uk Because a physician has possessed himself of an electrocardiograph, a polygraph, an x-ray machine, a blood pressure instrument, or some ingenious form of stethoscope, it does not at all follow that he has become competent to judge a patient’s condition; not infrequently the very reverse is the case, for more often than not the limitations of these devices are far from being comprehended. Ventricular fibrillation, with chaotic electrical activity, for which DC cardioversion can be life saving ECG 5 A: ICC, JHM, and A-MS contributed to image selection and interpretation, composition and editing of the answer options, and approved the final draft.

The transthoracic colour Doppler imaging shows turbulent colour flow suggestive of aortic regurgitation and further flow between the non-coronary cusp and the right atrium. [...]of these images, the patient was transferred to a cardiothoracic surgical centre.

Young men often view themselves under the scope of a “Hero’s Journey” due to various forms of entertainment equating a “hero” with the traditionally masculine. Using drawing, painting, and printmaking I was able to explore the auto-biographical and social implications of hero complexes through compositions creating light humor along with titles hinting at the implications of the imagery. As well looking into traditional fantasy myths (i.e. King Arthur) and fantasy entertainment (Video games, movies, role playing games) as a mode of satiating the desire to become a hero. Believing oneself to be a hero can create a feeling of being only a force of good on the world without understanding the potential of discomfort one can cause when treating yourself as such. The desire to become a hero can become a source of anxiety for young men, creating feelings as though they are not living up to the standards for a heroic male. Viewing oneself as a hero can have both positive and negative impact on a person, most want to be liked and remembered but it is important to remember the people around you in that pursuit.

The excimer laser has several potential advantages over conventional balloon angioplasty in the management of stenoses of the native coronary arteries and of the ostia of saphenous vein grafts. Its use in nine patients, eight of whom were classed as high risk, is described. Four lesions involved the ostia of saphenous vein grafts, three of protected left main stems, and two of native right coronary arteries. Stand alone laser was used in seven cases and laser with additional balloon angioplasty was used in two vein graft stenoses. Acute laser success was achieved in all cases, with a mean reduction of stenosis from 82% to 34% after laser alone and to 28% when balloon angioplasty was used as well. One patient died during laser angioplasty to a non-ostial lesion (procedural success rate 89%) and a second died ten weeks after the procedure. In one patient recurrent angina developed (clinical recurrence rate 25%) and restenosis was confirmed on angiography. Follow up angiography was also performed on the other six surviving patients, all of whom were symptom free and none of whom showed evidence of significant restenosis (restenosis rate 14%). With a mean follow up of 19.7 months the overall success rate was 67%.

In a randomized trial, 798 patients with varicose veins were assigned to undergo laser ablation, foam sclerotherapy, or surgery. At 5 years, disease-specific quality of life was better after laser ablation or surgery than after foam sclerotherapy, and cost-effectiveness analysis favored laser ablation.

Background: Caregivers experience high rates of occupational injuries, especially during wheelchair transfers, which often result in back pain and musculoskeletal disorders due to the physical demands of lifting and repositioning. While mechanical floor lifts, the current standard, reduce back strain, they are time-consuming and require handling techniques that subject caregivers to prolonged and repeated non-neutral trunk postures, increasing the risk of long-term back injuries. Aims: The aim was to assess the time efficiency and ergonomics of the powered personal transfer system (PPTS), a robotic transfer device designed for bed-to/from-wheelchair transfers. Methods: We evaluated transfers with the PPTS and mechanical lift with eight able-bodied participants who assisted with transfers between a bed and a wheelchair. Inertial measurement units (IMUs) were placed on participants to track their motion and assess trunk joint angles during transfers. Results: The PPTS significantly reduced the transfer time (144.31 s vs. 525.82 s, p < 0.001) and required significantly less range of motion for trunk flexion (p < 0.001), lateral bending (p = 0.008), and axial rotation (p = 0.001), all of which have been associated with back injuries. Additionally, the PPTS significantly reduced the time caregivers spent in non-neutral trunk postures, potentially lowering injury risks. Conclusions: These findings suggest that the PPTS improves transfer efficiency and caregiver safety, offering a promising alternative to the current standard of care for wheelchair-to/from-bed transfers.

In a multicenter, open-label, randomized trial in patients with immune thrombocytopenia, 91.5% of patients who received mycophenolate mofetil plus glucocorticoids had platelet levels above 100,000 per microliter, as compared with 63.9% of patients who received glucocorticoids only. Quality-of-life measures of physical function and fatigue were worse in the mycophenolate mofetil group.

Bivalirudin, with selective use of glycoprotein (GP) IIb/IIIa inhibitor agents, is an accepted standard of care in primary percutaneous coronary intervention (PPCI). We aimed to compare antithrombotic therapy with bivalirudin or unfractionated heparin during this procedure. In our open-label, randomised controlled trial, we enrolled consecutive adults scheduled for angiography in the context of a PPCI presentation at Liverpool Heart and Chest Hospital (Liverpool, UK) with a strategy of delayed consent. Before angiography, we randomly allocated patients (1:1; stratified by age [<75 years vs ≥75 years] and presence of cardiogenic shock [yes vs no]) to heparin (70 U/kg) or bivalirudin (bolus 0·75 mg/kg; infusion 1·75 mg/kg per h). Patients were followed up for 28 days. The primary efficacy outcome was a composite of all-cause mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularisation. The primary safety outcome was incidence of major bleeding (type 3–5 as per Bleeding Academic Research Consortium definitions). This study is registered with ClinicalTrials.gov, number NCT01519518. Between Feb 7, 2012, and Nov 20, 2013, 1829 of 1917 patients undergoing emergency angiography at our centre (representing 97% of trial-naive presentations) were randomly allocated treatment, with 1812 included in the final analyses. 751 (83%) of 905 patients in the bivalirudin group and 740 (82%) of 907 patients in the heparin group had a percutaneous coronary intervention. The rate of GP IIb/IIIa inhibitor use was much the same between groups (122 patients [13%] in the bivalirudin group and 140 patients [15%] in the heparin group). The primary efficacy outcome occurred in 79 (8·7%) of 905 patients in the bivalirudin group and 52 (5·7%) of 907 patients in the heparin group (absolute risk difference 3·0%; relative risk [RR] 1·52, 95% CI 1·09–2·13, p=0·01). The primary safety outcome occurred in 32 (3·5%) of 905 patients in the bivalirudin group and 28 (3·1%) of 907 patients in the heparin group (0·4%; 1·15, 0·70–1·89, p=0·59). Compared with bivalirudin, heparin reduces the incidence of major adverse ischaemic events in the setting of PPCI, with no increase in bleeding complications. Systematic use of heparin rather than bivalirudin would reduce drug costs substantially. Liverpool Heart and Chest Hospital, UK National Institute of Health Research, The Medicines Company, AstraZeneca, The Bentley Drivers Club (UK).