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Pulmonary vein isolation and atrial substrate modification using catheter ablation have been developed as a standard treatment for atrial fibrillation (AF). However, the standard end‐point for these procedures is still not well established. This study aimed to investigate the characteristics among positive and negative AF vulnerability patients with normal structural heart, in order to define the endpoint of the atrial substrate modification. Fifty supraventricular tachycardia patients with normal heart structure referred for electrophysiological study and catheter ablation were enrolled. After eliminating the underling arrhythmias, the basic cycle length, effective refractory period of the right atrium, and the P wave indices in 12‐lead electrocardiograms were measured. The AF vulnerability test was performed by atrial burst decremental pacing with a pacing cycle length decreasing from 290 ms to 200 ms. The AF vulnerability test was considered as positive when the duration of the induced AF or atrial tachyarrhythmias (ATs) was longer than 10 seconds. The parameters of atrial substrates were compared between patients with positive and negative values of the AF vulnerability test. ATs or AF were induced in 24 (48%) patients. Among these patients, 12 (24%) induced ATs or AF were found to be sustained (duration more than 10 seconds). However, only two of these patients could reproduce the positive result after 10 minutes of the first induced protocol. Comparing the patient baseline characteristics, P wave characteristics and cardiac echo parameters, there were no significant differences between the positive and negative AF vulnerability groups. In conclusion, AF and ATs could be induced in patients with a structurally normal heart. The traditional clinical indices of atrial substrates were not significantly different between the positive and negative AF vulnerability patients. Protocols other than atrial burst decremental pacing should be investigated to evaluate the endpoint of the atrial substrate modification.

Pulmonary vein isolation and atrial substrate modification using catheter ablation have been developed as a standard treatment for atrial fibrillation (AF). However, the standard end-point for these procedures is still not well established. This study aimed to investigate the characteristics among positive and negative AF vulnerability patients with normal structural heart, in order to define the endpoint of the atrial substrate modification. Fifty supraventricular tachycardia patients with normal heart structure referred for electrophysiological study and catheter ablation were enrolled. After eliminating the underling arrhythmias, the basic cycle length, effective refractory period of the right atrium, and the P wave indices in 12-lead electrocardiograms were measured. The AF vulnerability test was performed by atrial burst decremental pacing with a pacing cycle length decreasing from 290 ms to 200 ms. The AF vulnerability test was considered as positive when the duration of the induced AF or atrial tachyarrhythmias (ATs) was longer than 10 seconds. The parameters of atrial substrates were compared between patients with positive and negative values of the AF vulnerability test. ATs or AF were induced in 24 (48%) patients. Among these patients, 12 (24%) induced ATs or AF were found to be sustained (duration more than 10 seconds). However, only two of these patients could reproduce the positive result after 10 minutes of the first induced protocol. Comparing the patient baseline characteristics, P wave characteristics and cardiac echo parameters, there were no significant differences between the positive and negative AF vulnerability groups. In conclusion, AF and ATs could be induced in patients with a structurally normal heart. The traditional clinical indices of atrial substrates were not significantly different between the positive and negative AF vulnerability patients. Protocols other than atrial burst decremental pacing should be investigated to evaluate the endpoint of the atrial substrate modification.

A rising trend of incidence and prevalence of ulcerative colitis (UC) had been noticed in Asian countries. We conducted this study to investigate the epidemiology and medical burden of UC in Taiwan.

Inducible atrioventricular nodal reentrant tachycardia was demonstrated by electrophysiological studies in a 55‐year‐old female who suffered from intermittent palpitation, in which paroxysmal atrial fibrillation (AF) was consistently documented by electrocardiogram recordings. After ablation of the slow pathway, the atrioventricular nodal reentrant tachycardia and AF were not inducible. During 2 years of follow‐up, there were no recurrences of AF in terms of symptoms or findings from Holter electrocardiograms. We suggest that the AF was triggered by the atrioventricular nodal reentrant tachycardia and the successful ablation of atrioventricular nodal reentrant tachycardia was associated with freedom arising from ablation of AF.

Cardiac memory (CM) can alter the configuration of action potentials and the transmural repolarization gradient in ventricular tissue. This study evaluated the effects of CM on ventricular arrhythmogenicity. A total of 20 patients (12 females, 8 males; mean age, 46 ± 13 years) were enrolled. The following indicators were measured to evaluate ventricular arrhythmogenicity: (1) the action potential duration at 90% repolarization (APD 90) recorded from the right ventricular apex (RVA); (2) the maximal slope of the action potential duration restitution curve (APDR) constructed by programmed extra stimuli from RVA; and (3) the maximal corrected QT interval (QTc) and QT interval dispersion (QTd). The short‐term CM was induced by constant pacing from the RVA at a pacing cycle length (PCL) of 400 ms for 20 minutes. After induction of CM, the mean APD 90were significantly shortened at both PCLs of 600 ms and 400 ms (252.9 ± 6.4 ms vs. 235.6 ± 6.4 ms and 231.2 ± 6.4 ms vs. 214.4 ± 7.3 ms, respectively; p= 0.001). No significant change regarding the maximal slopes of APDR were found at both PCLs of 600 ms and 400 ms (1.05 ± 0.09 vs. 0.96 ± 0.11 and 0.85 ± 0.08 vs. 0.84 ± 0.09, respectively). QTc (417.3 ± 9.1 ms vs. 454.7 ± 8.3 ms; p= 0.001), but not QTd (63.4 ± 5.4 ms vs. 65.7 ± 6.1 ms), was significantly shortened. Short‐term CM significantly decreased ventricular APD 90and QTc, but did not significantly change the maximal slope of APDR or QTd. These results suggest that CM might not have a significant effect on ventricular arrhythmogenicity.

Objective structured clinical examination (OSCE) is an effective assessment method to evaluate medical students' clinical competencies performance. Postgraduate year 1 (PGY1) residents have been initiated in a general medicine training program in Taiwan since 2003. However, little is known about the learning effectiveness of trainees from this program. This pilot study aimed to evaluate the clinical core competencies of PGY1 residents using OSCE, and to reflect on the strengths and weaknesses of this pilot assessment project. OSCE was conducted for five PGY1 examinees (4 men, 1 woman) with five stations covering core themes, including history taking, physical examination, clinical procedure of airway intubation, clinical reasoning, and communication skills for informing bad news. Itemized checklists and five‐point Likert scale global ratings were used for evaluating performance. The results showed that the performance of our PGY1 residents on history taking was significantly better after about 2 months of postgraduate training on general internal medicine. Self‐evaluation on performance by examinees revealed significantly lower global ratings on post‐course OSCE (4.14 ± 0.80 vs. 3.68 ± 0.66; p< 0.02). Surveys from tutors and standardized patients (SPs) completed at pre‐ and post‐course OSCEs showed consistently favorable responses on the purposes, content, process, and environment of this assessment (4.0 ± 0.17 vs. 4.0 ± 0.12, nonsignificant). However, a survey of the examinees completed at preand post‐course OSCEs showed relatively unfavorable responses to the same aspects, and to tutors and SPs (4.1 ± 0.09 vs. 3.7 ± 0.18; p< 0.05). Qualitative information revealed that tutors and SPs remarked that PGY1 residents' medical knowledge performance was satisfactory but their clinical reasoning performance, communication skills (giving bad news) and self‐confidence were unsatisfactory. In conclusion, this pilot study has demonstrated that OSCE is a rational and feasible assessment method for evaluating the effectiveness of our PGY general medicine training program. The quantitative data and qualitative information provide a foundation to improve the quality of the program design and evaluation in implementing postgraduate general medicine training.

Atrial electrical remodeling (ER) after spontaneous or pacing‐induced atrial fibrillation has been previously described in humans. We investigated atrial ER induced by a 5‐minute period of rapid atrial pacing and the pharmacologic effects of verapamil and procainamide on this atrial ER phenomenon. The atrial effective refractory periods (ERPs) at drive cycle lengths of 400 (ERP400) and 600 (ERP600) ms, at five representative atrial sites (high right atrium [HRA]; proximal, middle and distal coronary sinus; interarrial septum), were determined in 20 patients at baseline and immediately after cessation of a 5‐minute period of rapid pacing from the HRA at a rate of 150 bpm. The degrees of atrial ERP400and ERP600shortening after pacing were calculated as acute atrial ER. The same protocol was repeated in another 15 patients after intravenous administration of verapamil (0.15 mg/kg) and in another 15 patients after intravenous administration of procainamide (15 mg/kg). The results demonstrated that, in the control state acute atrial ER can be significantly demonstrated at each atrial representative site (p<0.001). The mean ERP400and ERP600shortenings were 9+4% and 8+4%, respectively. After procainamide infusion, but not after verapamil, baseline ERP400and ERP600values were significantly prolonged at the five representative atrial sites (p < 0.01). Acute atrial ER could still be demonstrated at each atrial site after procainamide or verapamil infusion (p < 0.001). In conclusion, acute atrial ER can be demonstrated after only a 5‐minute period of rapid atrial pacing in humans. Intravenous verapamil or procainamide does not abolish this ER process.

Emerging evidence suggests that statins have a favorable impact on the reduction of arrhythmia events and sudden cardiac death in patients with structural heart disease. We aimed to investigate the possibly and directly favorable effects of statins on ventricular late potentials, QT dispersion, and transmural dispersion of repolarization attained by analyzing clinical electrocardiography (ECG) risk stratification parameters in patients with hypercholesterolemia without structural heart disease. In total, 82 patients (45 females; mean age, 62 ± 10 years) with hypercholesterolemia were enrolled in this prospective study to examine the effects of statin therapy (atorvastatin 10mg/day for 3 months) on ECG risk stratification parameters. Surface 12‐lead ECG and signal‐average ECG (SAECG) were recorded before and after statin treatment. The SAECG parameters, QT dispersion, Bazett‐corrected QT (QTc) dispersion, T wave peak‐to‐end interval (Tpe), and percentage of Tpe/QT interval were calculated and compared before and after statin therapy. Twelve‐lead ambulatory 24‐hour ECGs were recorded in 12 patients. The results demonstrated that after statin therapy for 3 months, serum levels of total cholesterol and low‐density lipoprotein cholesterol were significantly reduced (both pvalues < 0.001). However, neither significant changes of each SAECG parameter nor the frequency of late potentials were demonstrated after atorvastatin therapy. In addition, no significant changes in QT dispersion, QTc dispersion, Tpe, or Tpe/QT were found. However, 24‐hour ambulatory ECG revealed a flattening effect of circadian variation of QTc dispersion after atorvastatin therapy. In conclusion, the favorable antiarrhythmia effect of atorvastatin (10 mg/day) therapy cannot be directly reflected by analyzing these noninvasive ECG risk stratification parameters in low‐risk patients with hypercholesterolemia.

Objective— The aim of this study is to evaluate and compare the impact of preload alterations by haemodialysis (HD) on the Tei index obtained by pulsed Doppler echocardiography (PDE-Tei index) and tissue Doppler echocardiography (TDE-Tei index).Methods and results— Thirty-eight uraemic patients underwent echocardiography 1hour before and 1hour after HD was studied. Before HD, PDE- and TDE-Tei indices had a weak correlation (r=0.439, P=0.006). After HD, the correlation became stronger (r=0.794, P <0.001). After HD, body weight (P<0.001), early transmitral filling wave peak velocity (E) (P<0.001), early diastolic mitral annular velocity (Em) (P<0.001), and E/Em (P=0.001) decreased and PDE- (P<0.001) and TDE-Tei indices (P=0.022) increased significantly. In addition, after HD, body weight reduction had a significant correlation with E decrease and PDE- and TDE-Tei index increase (P<0.001, P=0.005, and P=0.016, respectively).A subgroup comparison showed that in patients with body weight reduction< 3kg, the PDE-Tei index (P=0.003) increased significantly but TDE-Tei index (P=0.209) did not change after HD. In patients with body weight reduction ≥ 3kg, both the PDE- and TDE-Tei indices (P=0.003 and 0.042, respectively) increased significantly after HD.Conclusions— Both the PDE- and TDE-Tei indices are preload-dependent indicators. However, TDE-Tei index is less preload-dependent and is more accurate in assessing global left ventricular function in patients with body weight reduction<3kg after HD.

Emerging evidence suggests that statins have a favorable impact on the reduction of arrhythmia events and sudden cardiac death in patients with structural heart disease. We aimed to investigate the possibly and directly favorable effects of statins on ventricular late potentials, QT dispersion, and transmural dispersion of repolarization attained by analyzing clinical electrocardiography (ECG) risk stratification parameters in patients with hypercholesterolemia without structural heart disease. In total, 82 patients (45 females; mean age, 62 ± 10 years) with hypercholesterolemia were enrolled in this prospective study to examine the effects of statin therapy (atorvastatin 10mg/day for 3 months) on ECG risk stratification parameters. Surface 12-lead ECG and signal-average ECG (SAECG) were recorded before and after statin treatment. The SAECG parameters, QT dispersion, Bazett-corrected QT (QTc) dispersion, T wave peak-to-end interval (Tpe), and percentage of Tpe/QT interval were calculated and compared before and after statin therapy. Twelve-lead ambulatory 24-hour ECGs were recorded in 12 patients. The results demonstrated that after statin therapy for 3 months, serum levels of total cholesterol and low-density lipoprotein cholesterol were significantly reduced (both pvalues < 0.001). However, neither significant changes of each SAECG parameter nor the frequency of late potentials were demonstrated after atorvastatin therapy. In addition, no significant changes in QT dispersion, QTc dispersion, Tpe, or Tpe/QT were found. However, 24-hour ambulatory ECG revealed a flattening effect of circadian variation of QTc dispersion after atorvastatin therapy. In conclusion, the favorable antiarrhythmia effect of atorvastatin (10 mg/day) therapy cannot be directly reflected by analyzing these noninvasive ECG risk stratification parameters in low-risk patients with hypercholesterolemia.

Laparoscopic surgery is usually considered to be less invasive when compared to traditional laparotomy, and is regarded as a relatively low‐risk procedure for postoperative complications because of the reduced surgical stress and earlier mobilization. However, we describe a 47‐year‐old woman who presented with acute respiratory distress, drowsy consciousness, and circulatory collapse shortly after gynecologic laparoscopic ovariectomy for removing an ovarian teratoma at a local hospital. After resuscitation, the patient was transferred to our emergency department. Immediate bedside electrocardiographic and echocardiographic examination results led to acute pulmonary embolism being quickly diagnosed. The patient received subsequent intensive care with smooth course. Although pulmonary embolism is rare after laparoscopic surgery, early detection and quick treatment are important in the management of this life‐threatening complication and offer good prognosis. The risk of pulmonary embolism after gynecologic laparoscopic surgery remains unclear. Therefore, the decision to provide prophylaxis is up to the individual physician, and should take into consideration the patient's individual risk factors and comorbidities.

Patients with infective endocarditis usually developed persistent fever and heart failure, especially when the valve structures are invaded and destroyed. Persistent bacteremia often leads to severe sepsis or overwhelming septic shock. Septic emboli from the vegetation will possibly result in systemic thromboembolism with multiple organ infarction. Patients with infective endocarditis have been reported to present with either ruptured sinus of Valsalva or complete atrioventricular block. However, both of these serious complications occurring in a single patient is rare. In this case report, we present a 54‐year‐old man with a previous history of alcoholic cirrhosis and chronic renal failure who suffered from a fulminant course of infective endocarditis. Simultaneously, ruptured sinus of Valsalva and complete atrioventricular block further complicated the preexisting septic shock and multiple organ failure.

Objective— Beyond lipid lowering, statins have pleiotropic effects with favourable benefits against atherogenesis.Withdrawal of statin therapy has been demonstrated to abrogate vascular protective activity and even increase the incidence of thrombotic vascular events.The purpose of this study is to investigate the serial changes of soluble CD40 ligand (sCD40L) and two adipocytokines, adiponectin and resistin, after short-term atorvastatin therapy and withdrawal in patients with hypercholesterolaemia.Methods and results— Thirty-two patients with hypercholesterolaemia received atorvastatin 10 mg/day for 3 months. Serum lipid profiles, and levels of sCD40L, adiponectin and resistin, were assessed before and immediately after 3 months’ statin therapy. Serum levels of sCD40L and adiponectin were also measured on the 3 consecutive days after statin withdrawal. After 3 months’ statin therapy, levels of sCD40L (1.93 ± 1.13 vs. 1.30 ± 0.97 ng/mL), total cholesterol and low-density lipoprotein cholesterol (LDL-C) were all reduced significantly (p < 0.05). However, sCD40L level tended to increase towards baseline on the first and second days after statin withdrawal, but was not significantly elevated until the third day after withdrawal (1.89 ± 1.28 vs. 1.30 ± 0.97 ng/mL, p < 0.05).Total cholesterol and LDL-C levels did not increase during the 3 days of statin withdrawal. No significant changes of adiponectin and resistin levels were shown after statin therapy.Conclusions— These results indicate that the effect of statin on sCD40L level was abrogated after therapy withdrawal, and was independent of serum cholesterol level. Statin therapy did not significantly alter levels of adiponectin and resistin.

Background: Atrioventricular nodal reentry tachycardia (AVNRT) is based on the concept of dual AV node pathways that are functionally and anatomically distinct. The bigger coronary sinus ostium (CSO) in patients with AVNRT compared to other supraventricular tachycardias (SVTs) may produce separation of atrial inputs into the AV node or create anisotropic conduction, thus giving rise to a different AV nodal physiology. Previous studies measuring the size of the CSO using CS angiography between patients with AVNRT and other SVTs showed conflicting results. Besides, no previous studies have compared the CS morphology of the different forms of AVNRT.

Background: Atrioventricular nodal reentrant tachycardia (AVNRT) can be usually induced by atrial pacing or extrastimulation. However, it is less commonly induced only by ventricular pacing or extrastimulation.

Coronary stent dislodgment or embolization before deployment is a rare but challenging complication in interventional cardiology. Intracoronary embolization of the dislodged stent is associated with a high risk of coronary occlusion, due to thrombus formation and subsequent myocardial infarction. Furthermore, systemic embolization may cause severe cerebrovascular events. Nonsurgical retrieval strategies for this complication have been suggested, but bailout cardiac surgery may be indicated if percutaneous retrieval attempts fail. To our knowledge, this is the first case report of intracoronary drug‐eluting stent dislodgment, and successful retrieval was accomplished by a loop snare technique. With the increasing trend of using drug‐eluting stents in percutaneous coronary intervention, the likelihood of stent dislodgment or embolization may increase. It should be kept in mind, especially by coronary interventionists, how to manage this complication.

The Heart Outcomes Prevention Evaluation (HOPE) study demonstrated that the angiotensin‐converting enzyme inhibitor, ramipril, significantly reduces mortality, myocardial infarction and stroke in high‐risk cardiovascular patients, beyond the benefits from blood pressure lowering. The tolerability of ramipril 10 mg/day has been an important concern when applying these results. Following the same criteria as the HOPE study, we investigated the adverse effects profile and tolerability of 10 mg ramipril in high‐risk patients at our institution. In total, 92 patients with high cardiovascular risk were eligible for this study. Initially, ramipril was prescribed 2.5 mg orally once daily, and then titrated up to 5.0, 7.5, and 10.0 mg/day at 1‐month intervals. The target maintenance dose was 10 mg/day. All adverse events were recorded during at least 3 months of follow‐up. After 4‐6 months of the titration protocol, only 18 patients (25.3%) reached and remained on ramipril 10 mg/day; 11 (15.5%), 22 (30.9%), and 20 patients (28.2%) remained on 2.5, 5.0, and 7.5 mg/day, respectively. Twenty‐one patients (22.6%) had at least one adverse event. Twelve patients (13.0%) stopped treatment because of adverse effects. A total of 23 episodes of adverse events were reported, including cough (15.1%), dizziness (6.0%), and hypotension (2.4%). Ramipril was relatively well tolerated in our study population. However, only one‐quarter of our patients reached the target maintenance dose of 10 mg/day. Dry cough, dizziness, and hypotension were the major side effects. About 15% of our patients discontinued ramipril treatment, which is comparable with previous reports.

Atrioesophageal fistulas have been reported to be a lethal complication following catheter ablation of atrial fibrillation (AF). The purpose of this study was to investigate the relationship between the esophagus and posterior left atrium (LA) and provide the anatomic information necessary to minimize the risk of esophageal injury during AF ablation.

Typical atrial flutter is characterized by its sawtooth flutter wave in leads II, III, aVF, and V1. Atrioventricular reciprocating tachycardia is characterized by its small retrograde P wave after completion of QRS complex, where sawtooth flutter‐like P waves are rarely seen in the electrocardiogram during atrioventricular reciprocating tachycardia. We report on a 62‐year‐old patient who presented the characteristic sawtooth flutter‐like P waves in the electrocardiogram during attack of supraventricular tachycardia. By electrophysiologic study, the mechanism of his supraventricular tachycardia was atrioventricular reciprocating tachycardia using the left posterior lateral concealed accessory pathway for retrograde conduction. The accessory pathway was successfully ablated by radiofrequency ablation therapy.

Acute ST‐segment elevation myocardial infarction after the administration of terlipressin in patients with hemorrhagic esophageal varices is a rare but life‐threatening complication. We report the case of a 73‐year‐old female patient with esophageal variceal bleeding complicated with acute ST‐segment elevation myocardial infarction after intravenous injection of terlipressin. We discuss the underlying mechanisms of terlipressin‐related acute myocardial infarction and review the literature.

Electrocardiographic changes in neurovascular disease are not rare. Patients with subarachnoid hemorrhage have electrocardiographic (ECG) abnormalities that may mimic ischemic heart disease and acute myocardial infarction. Outflow of catecholamines in the early stage of subarachnoid hemorrhage contributes to elevated blood pressure in most patients. Hypotension is a rare presentation in subarachnoid hemorrhage. We report a case of subarachnoid hemorrhage with transient ST elevation and intractable shock simulating acute myocardial infarction, and review the mechanism of ECG changes in subarachnoid hemorrhage.

Ankle‐brachial pressure index (ABI) measured using a conventional Doppler method is an independent predictor of the number of coronary vessels affected in coronary artery disease (CAD). Recently, a new clinical device has been developed to measure ABI using an oscillometric method. It is unclear whether ABI measured using this device is a significant predictor of the severity of coronary atherosclerosis. We retrospectively included 87 patients from our outpatient clinic who had ever undergone coronary angiography. ABI was determined in all subjects using the new ABI‐form device. The lower value of ABI in either limb was used for analysis. We divided our subjects into two groups, with either ABI less than 0.9 or at least 0.9, and compared basal characteristics between groups. We analyzed the relationship between ABI and the severity of CAD. In addition, we calculated the sensitivity, specificity, and positive and negative predictive values of ABI less than 0.9 in predicting multivessel (two‐vessel + three‐vessel) involvement in our patients. There were 15 patients with ABI less than 0.9 and 72 with ABI at least 0.9. Patients with ABI less than 0.9 were older and had higher plasma levels of uric acid. The prevalence of diabetes mellitus, hypertension, smoking, and diuretic use was significantly higher in patients with ABI less than 0.9. In addition, the group with ABI less than 0.9 had a lower prevalence of one‐vessel CAD and higher prevalence of three‐vessel or multivessel CAD. The sensitivity, specificity, and positive and negative predictive values of ABI less than 0.9 in predicting multivessel CAD were 22%, 96%, 93%, and 34%, respectively. In conclusion, ABI measured using the automated oscillometric method can be used to predict the severity of coronary atherosclerosis in patients with CAD.

Coronary artery dissection is a devastating disease, but spontaneous left main coronary artery dissection is extremely rare. We present the case of a 58‐year‐old diabetic man who was found to have primary spontaneous left main coronary artery dissection during a coronary angiography examination. Although the dissecting lesion persisted, he had no peri‐procedural chest discomfort or electrocardiographic change. We performed urgent coronary artery bypass grafting, which was uneventful. The patient received regular cardiovascular follow‐up and did not complain of any postoperative chest discomfort. He had an uneventful recovery.

Antiphospholipid syndrome (APS) is an uncommon prothrombotic disorder that has been increasingly recognized in recent years. The diagnosis of APS must be associated with venous or arterial thrombosis or both. Patients with APS usually present with recurrent deep vein thrombosis, pulmonary thromboembolism, thromboembolic stroke, or myocardial infarction. Here, we report a case of a 61‐year‐old female who presented with a 3‐month history of increasingly frequent retrosternal chest tightness. After treadmill test and thallium‐201 myocardial perfusion scan, she was admitted and underwent elective coronary angiography but developed acute thrombosis after direct intracoronary stenting. She was successfully rescued with repeat percutaneous transluminal coronary angioplasty and prolonged heparin and glycoprotein IIb/IIIa antagonist use. Laboratory data showed prolongation of partial thromboplastin time and positive anti‐cardiolipin antibody. These findings satisfied the criteria for APS; the patient was diagnosed with primary APS because she had neither typical symptoms nor signs of systemic lupus erythematosus or other immunologic disorders. Thereafter, long‐term oral anticoagulant appeared to be effective. To our knowledge, this is the first report of acute stent thrombosis in a patient with primary APS.

The objective, structured clinical examination (OSCE) is a method to assess clinical competency based on objective testing, through direct observation in a formal setting. The Kaohsiung Medical University (KMU) has pioneered OSCEs in Taiwan. In KMU, three groups of examinees—medical students in years 3 and 4, medical students in years 5 and 6, and medical students in year 7—were assessed using different OSCEs. Each OSCE was set up using the following five steps: (1) create cases; (2) decide on the items or clinical skills to be evaluated; (3) train standardized patients; (4) run the OSCE and (5) review videos to improve the curriculum. We expect that KMU will become the premier OSCE center in Taiwan.