Editor's Choice - Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy.

OBJECTIVES: The aim of this review was to carry out primary and secondary analyses of 20 randomised controlled trials (RCTs) comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS). METHODS: A systematic review and meta-analysis of data from 20 RCTs (126 publications) was carried out. RESULTS: Compared with CEA, the 30 day death/stroke rate was significantly higher after CAS in seven RCTs involving 3467 asymptomatic patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.02-2.64) and in 10 RCTs involving 5797 symptomatic patients (OR 1.71, 95% CI 1.38-2.11). Excluding procedural risks, late ipsilateral stroke was about 4% at 9 years for both CEA and CAS, i.e., CAS was durable. Reducing procedural death/stroke after CAS may be achieved through better case selection, e.g., performing CEA in (i) symptomatic patients aged > 70 years; (ii) interventions within 14 days of symptom onset; and (iii) situations where stroke risk after CAS is predicted to be higher (segmental/remote plaques, plaque length > 13 mm, heavy burden of white matter lesions [WMLs], where two or more stents might be needed). New WMLs were significantly more common after CAS (52% vs. 17%) and were associated with higher rates of late stroke/transient ischaemic attack (23% vs. 9%), but there was no evidence that new WMLs predisposed towards late cognitive impairment. Restenoses were more common after CAS (10%) but did not increase late ipsilateral stroke. Restenoses (70%-99%) after CEA were associated with a small but significant increase in late ipsilateral stroke (OR 3.87, 95% CI 1.96-7.67; p < .001). CONCLUSIONS: CAS confers higher rates of 30 day death/stroke than CEA. After 30 days, ipsilateral stroke is virtually identical for CEA and CAS. Key issues to be resolved include the following: (i) Will newer stent technologies and improved cerebral protection allow CAS to be performed < 14 days after symptom onset with risks similar to CEA? (ii) What is the optimal volume of CAS procedures to maintain competency? (iii) How to deliver better risk factor control and best medical treatment? (iv) Is there a role for CEA/CAS in preventing/reversing cognitive impairment?

Defining Patient Safety: a Student Perspective.

BACKGROUND: Patient safety is recognised as an important aspect of the undergraduate medical curriculum. However, packed medical curricula have been slow to evolve despite repeated mandates and large-scale tragedies resulting from unlearnt lessons. The aim of this work was to explore students' perspectives on patient safety to inform curriculum re-design. METHODS: Using a qualitative approach, medical students from year 2 and year 4 of the undergraduate course were invited to participate in focus groups to consider: their personal conceptualisation of patient safety, their perceptions of patient safety education in the existing curriculum and their collective preferences for future teaching in this area. Transcripts of the focus groups were subjected to thematic analysis. RESULTS: Six focus groups were convened with a total of 77 students. Thirteen major themes were identified which included conceptual ambiguity, healthcare culture, error theory, specific safety topics (such as infection prevention and control, medication safety, technical/procedural safety, communication and other non-technical skills), self-awareness, patient-centredness, low student morale and raising concerns. Students were more aware of technical than non-technical competence. They wanted learning aligned to the realities of practice, a clearer concept of patient safety and improved visibility of patient safety topics within an integrated curriculum. CONCLUSIONS: Students are keen to engage with safety topics but frequently feel disempowered as future change agents. Educators need to advocate a clear definition of patient safety and consider the implication of the theory-practice gap on students' evolving attitudes.

The evolution of minimally invasive bariatric surgery.

BACKGROUND: Obesity is a pandemic associated with significant morbidity and mortality. This historical article charts the progress of successful strategies that have been used to tackle weight loss from dietary modifications to the development of surgical interventions that have subsequently evolved. It also provides a précis of the reported outcome data following minimally invasive bariatric procedures. METHODS: A literature review was performed. All articles relevant to the progression of bariatric surgery and minimally invasive surgery were assessed, as were those articles that described the ultimate evolution, combination, and establishment of the two techniques. RESULTS: This article charts the progression of early weight loss strategies, from early dietary modifications and pharmacologic interventions to initial techniques in small bowel bypass procedures, banding techniques, and sleeve gastrectomies. It also describes the simultaneous developments of endoscopic interventions and laparoscopic procedures. CONCLUSIONS: A range of procedures are described, which differ in their success in terms of loss of excess weight and in their complication rates. Weight loss is greatest for biliopancreatic diversion followed by gastric bypass and sleeve gastrectomy and least for adjustable gastric banding. Bariatric surgery is an evolving field, which will continue to expand given current epidemiologic trends. Developments in instrumentation and surgical techniques, including single access and natural orifice approaches, may offer further benefit in terms of patient acceptability.

The role of students as teachers: four years' experience of a large-scale, peer-led programme.

AIM: This study set out to explore whether a teaching programme developed and delivered by medical students yielded an improvement of attendees' examination performance or their experience of preparing for the target assessment. METHODS: Over 4 years all students were invited to consent to use of their official examination data. Students were ranked for baseline performance and again for performance in the target assessment. Change in rank was compared for attendees and non-attenders. Additionally, a questionnaire was distributed to students before and after the peer-led programme. Attendees' responses were compared to those of non-attenders. RESULTS: No statistically significant difference in change in rank was observed between the two groups on evaluation of quantitative performance data. The majority of students (81.0%) scored the programme four or five in terms of perceived usefulness on a five-point Likert scale. Attendees reported statistically significant increases in preparedness for the examination (p=0.001) and in familiarity with the style of examination questions (p=0.004) compared to students who did not attend. CONCLUSION: This study suggests that teaching from peers may improve students' perception of their preparedness for official assessments. However, such interventions may be limited in their ability to produce a demonstrable benefit in terms of examination performance.

Pre-discharge duplex ultrasound scans detect endoleaks not seen on completion angiography after endovascular aneurysm repair.

PURPOSE: To determine whether a pre-discharge duplex ultrasound scan detects early endoleaks that would not otherwise have been identified. METHODS: A retrospective review was conducted of all patients undergoing elective infrarenal endovascular aneurysm repair (EVAR) at our center. These patients underwent intraoperative completion angiography, had a duplex ultrasound scan prior to hospital discharge, and were followed at 1, 3, and 6 months and at 6-month intervals thereafter. The outcome of any patients found to have an endoleak on a pre-discharge scan was studied. RESULTS: There were 52 EVAR patients (50 men; mean age 76 years, range 61-87) with endoleak on the pre-discharge duplex: 17 (2.8%) type I, 28 (4.6%) type II, and 8 (1.3%) type III. Of these, only 7 of the type I and 2 of the type II leaks had been detected on completion angiography. Among the patients with type I endoleaks, 5 had resolution of the leak, 10 required further endovascular interventions, and 2 had open repair (1 died of aneurysm rupture). Two patients with failed endovascular repairs of the leak also had open repair. Fifteen of the 28 type II endoleaks resolved, 4 were treated with endovascular procedures, 1 had open repair, 7 are being observed, and 1 was lost to follow-up. Six of the 8 type III leaks resolved, 1 required open repair for an enlarging sac, and 1 is being observed. CONCLUSION: Despite routine completion angiography, new endoleaks may be identified postoperatively, which suggests that more rigorous imaging at the point of completion angiography is required.