Knowledge of and attitudes towards medical research ethics among first year doctoral students in Slovenia at the Faculty of Medicine, University of Ljubljana.

BACKGROUND: Research ethics and attitudes should be the main concern of those who are conducting and publishing research in medicine. METHODS: A cross-sectional study was conducted using a questionnaire among first year postgraduate doctoral students in Biomedicine at the Faculty of Medicine, University of Ljubljana during the academic year 2022/2023. RESULTS: There were 54 out of 57 doctoral students included in the study, with a mean age (SD) of 29.7 (4.7) years, with predominantly female doctoral students, 66.7%. The number of correct answers out of 39 considered to illustrate students' knowledge of medical research ethics was 31, meaning that they gave correct answers to 80% of all the questions. The mean number (SD) of correct answers was 18.9 (5.8), which significantly differed from 31 (p < 0.001). The previous experience of the doctoral students in research was significantly correlated with their knowledge of medical research ethics, even when controlling for the age, gender and workplace of respondents. CONCLUSION: This study clearly showed that insufficient knowledge and a poor level of attitudes exist about the main questions pertaining to medical research ethics. Overall knowledge is well below the expected positive answers. Further studies are needed to compare the knowledge of doctoral students with that of their tutors and what implications this might have for further teaching of research ethics.

Evaluation of continuous monitoring of stroke volume and cardiac output in patients supported by an intra-aortic balloon pump.

BACKGROUND: Currently available minimally invasive devices cannot provide continuous determination of stroke volume (SV) or cardiac output (CO) in patients supported with an intra-aortic balloon pump (IABP). Our aim was to evaluate the accuracy of Dat-con™ monitor for continuous SV and CO determination in such patients. METHODS: SV (SVdat-con) and CO (COdat-con) were determined by Dat-con™ monitor in 35 patients supported by IABP, at baseline and after 103 therapeutic interventions. Echocardiography was used to measure SV (SVecho) and CO (COecho) from velocity time integral and cross-sectional area of left ventricular outflow tract. Monitored and echocardiographic values were compared using Bland-Altman's statistics. RESULTS: Bias in baseline SVdat-con compared to SVecho was 0.2 mL, with 1.96 limits of agreement (SD) of ±4.8 mL and with percentage error of 11%. Bias of baseline COdat-con compared to COecho was 0.03 l/min, with 1.96 SD of ±0.435 l/min with percentage error of 10.9%. After therapeutic interventions, bias of SVdat-con compared to SVecho was -0.3 mL, with 1.96 SD of ±4.8 mL and with percentage error of 10.5%. Agreement for SV changes was >95% (exclusion zone: changes <10%). Bias of COdat-con compared to COecho after therapeutic interventions was -0.03 L/min, with 1.96 SD of ±0.45 L/min. CONCLUSION: The accuracy and trending of continuous determination of SV and CO with Dat-con™ monitor in patients supported by IABP is equivalent to echocardiography.

A triad algorithm for analysing individual ante- and post-mortem findings to improve the quality of intensive care.

Autopsy is an important source of data for education and quality control. The aim of this study was comparison of ante- to post-mortem findings to detect weak points of intensive care unit (ICU) care. Patients who died in our 14-bed university medical ICU care and underwent an autopsy examination over 20 months (September 2007 to May 2009) were included. Modified Goldman's criteria were used to categorise discrepancies between diagnoses and post-mortem findings. A triad algorithm was constructed to analyse individual ante- to post-mortem findings. One hundred and seventy post-mortem examinations were conducted (45.6% autopsy rate). Major diagnostic discrepancies were detected in 20 patients (11.8%); four class I (2.4%) and 16 class II (9.4%). Massive pulmonary embolism with cardiac arrest was the most common class I discrepancy (75%). Triad analysis of major class I discrepancies showed that all patients had a history of chronic disease; the majority (75%) had a short ICU length of stay. In 75% adequate tests were used to detect disorders. There were interpretation problems of bedside data in complex emergency clinical conditions, especially with less experienced ICU physicians. Inappropriate or incorrectly interpreted diagnostic procedures were performed in more than half of cases with class II discrepancies (9/16, 56%). Abdominal ultrasonography was misleading in 31% (5/16) cases with class II discrepancies. In conclusion, triad algorithm analysis revealed problematic interpretation of bedside diagnostics in emergency cases by inexperienced physicians in class I major discrepancies detected at autopsy. No correct test and wrong interpretation of abdominal ultrasonography were major causes of class II discrepancies.

Effect of selective and non-selective beta-blockers on body weight, insulin resistance and leptin concentration in chronic heart failure.

BACKGROUND: Chronic heart failure (CHF) is characterized by increased insulin resistance and hyperleptinaemia. We aimed to study effects of selective and non-selective beta-blockers on body weight, insulin resistance, plasma concentrations of leptin and resistin in patients with CHF. METHODS: Twenty-six non-cachectic beta-blocker-naive patients with CHF were randomized and treated with either carvedilol or bisoprolol. Body weight, plasma concentrations of leptin, resistin, fasting glucose and insulin were measured at baseline and after 6 months of therapy. Insulin resistance was estimated by homeostasis model assessment- estimated insulin resistance (HOMA-IR). RESULTS: Body weight increased significantly in the carvedilol group (mean change + 2.30 kg, p = 0.023) while it did not change in the bisoprolol group (mean change -0.30 kg, p = 0.623) (ns between groups). Plasma leptin concentration increased only in the carvedilol group (mean change + 4.20 ng/ml, p = 0.019) (ns between groups). Fasting glucose and resistin remained unchanged in both groups. After 6 months, mean plasma insulin concentration changed significantly differently (p = 0.015) in the bisoprolol (mean change +3.1 microU/ml) compared to the carvedilol group (mean change -6.3 microU/ml) and HOMA-IR was consequently higher in the bisoprolol compared to the carvedilol group (5.2 +/- 4.2 vs 2.8 +/- 1.6, p = 0.046). CONCLUSION: This study found different metabolic effects of carvedilol and bisoprolol in non-cachectic patients with CHF. With unchanged fasting plasma glucose concentration after 6 months of treatment, carvedilol significantly decreased plasma insulin concentration and insulin resistance compared to bisoprolol.

Predicting defibrillation success by 'genetic' programming in patients with out-of-hospital cardiac arrest.

BACKGROUND: In some patients with ventricular fibrillation (VF) there may be a better chance of successful defibrillation after a period of chest compression and ventilation before the defibrillation attempt. It is therefore important to know whether a defibrillation attempt will be successful. The predictive power of a model developed by 'genetic' programming (GP) to predict defibrillation success was studied. METHODS AND RESULTS: 203 defibrillations were administered in 47 patients with out-of-hospital cardiac arrest due to a cardiac cause. Maximal amplitude, a total energy of power spectral density, and the Hurst exponent of the VF electrocardiogram (ECG) signal were included in the model developed by GP. Positive and negative likelihood ratios of the model for testing data were 35.5 and 0.00, respectively. Using a model developed by GP on the complete database, 120 of the 124 unsuccessful defibrillations would have been avoided, whereas all of the 79 successful defibrillations would have been administered. CONCLUSION: The VF ECG contains information predictive of defibrillation success. The model developed by GP, including data from the time-domain, frequency-domain and nonlinear dynamics, could reduce the incidence of unsuccessful defibrillations.

Conversion of atrial fibrillation into a sinus rhythm by coronary angioplasty in a patient with acute myocardial infarction.

Atrial tachyarrhythmias are important complications occurring in more than 8% of acute myocardial infarctions (AMI). Atrial fibrillation (AFi) during the early phase of AMI is caused by atrial ischaemia, atrial distension due to the left ventricular failure or significant diastolic left ventricular dysfunction. AFi in patients with inferior and posterior AMI indicates at least two vessel coronary diseases, a circumflex coronary artery (CX) occlusion before taking off of the left atrial branches as well as significant stenosis or occlusion of the right coronary artery (RCA). In this article the case of a 67-year-old woman with an acute infero-posterior AMI is described. AMI was complicated with a left heart failure, acute AFi with tachyarrhythmia, transient arterial hypotension and ischaemic mitral regurgitation. Emergency coronary angiography disclosed occlusion of the CX, myocardial infarct related artery, and significant stenoses of the RCA. After opening the occluded CX during the PTCA, AFi with a tachyarrhythmia of 160 beats per minute (bpm) immediately converted into a sinus rhythm with 80 bpm, followed by a normalization of blood pressure and cardiac recompensation. Our case report supports the opinion that AFi in patients with inferior and posterior AMI indicates at least a two-vessel coronary disease. Reopening of the occluded atrial coronary branches during urgent medical treatment was casual and effective treatment of both ischaemic heart disease and consequent AFi.

Should we confirm our clinical diagnostic certainty by autopsies?

OBJECTIVE: To evaluate the frequency of diagnostic errors assessed by autopsies. DESIGN AND SETTING: Retrospective review of medical and pathological records in an 11-bed closed medical intensive care unit (ICU) at a 860-bed general hospital. PATIENTS AND INTERVENTIONS: Patients who died in the ICU between January 1998 and December 1999. Medical diagnoses were rated into three levels of clinical diagnostic certainty: complete certainty (group L1), minor diagnostic uncertainty (group L2), and major diagnostic uncertainty (group L3). The patients were divided into three error groups: group A, the autopsy confirmed the clinical diagnosis; group B, the autopsy demonstrated a new relevant diagnosis which would probably not have influenced the therapy and outcome; group C, the autopsy demonstrated a new relevant diagnosis which would probably have changed the therapy and outcome. RESULTS: The overall mortality was 20.3% (270/1331 patients). Autopsies were performed in 126 patients (46.9% of deaths), more often in younger patients (66.6+/-13.9 years vs 72.7+/-12.0 years, p<0.001), in patients with shorter ICU stay (4.7+/-5.6 days vs 6.7+/-8.7 days, p=0.054), and in patients in group L3 without chronic diseases (15/126 vs 1/144, p<0.001). Fatal but potentially treatable errors [group C, 12 patients (9.5%)] were found in 8.7%, 10.0%, and 10.5% of patients in groups L1, L2, and L3, respectively (NS between groups). An ICU length of stay shorter than 24 h was not related to the frequency of group C errors. CONCLUSIONS: Autopsies are performed more often in younger patients without chronic disease and in patients with a low clinical diagnostic certainty. No level of clinical diagnostic certainty could predict the pathological findings.

Bolus versus continuous low dose of enalaprilat in congestive heart failure with acute refractory decompensation.

The first dose of angiotensin-converting enzyme (ACE) inhibitors may trigger a considerable fall of blood pressure in chronic heart failure. The response may be dose-related. To determine hemodynamic and systemic oxygenation effects of low-dose enalaprilat, we administered intravenous enalaprilat (0.004 mg/kg) as bolus (group B) or continuous 1-hour infusion (group C) in 20 patients with congestive heart failure due to ischemic heart disease with acute decompensation refractory to inotropic, vasodilator and diuretic therapy. Hemodynamic and systemic oxygenation variables were recorded at baseline (+0 min), +30, +60, +120, +180, and +360 min after the start of intervention. Mean arterial pressure (MAP) (p < 0. 001), mean pulmonary artery pressure (MPAP) (p < 0.001), pulmonary artery occlusion pressure (PAOP) (p < 0.001), oxygen extraction ratio (ER) (p < 0.026) decreased regardless of enalaprilat application. Compared to group B, there was in group C prolonged decrease of MAP, MPAP, PAOP, ER and increase of pulmonary artery oxyhemoglobin saturation in regard to baseline values. Cardiac index, heart rate, central venous pressure and oxygen consumption index did not change. A low dose of intravenous enalaprilat (0.004 mg/kg) can be used to safely improve hemodynamics and systemic oxygenation in congestive heart failure due to ischemic heart disease with acute refractory decompensation.

Diagnosis and treatment of shock due to massive pulmonary embolism: approach with transesophageal echocardiography and intrapulmonary thrombolysis.

STUDY OBJECTIVES: To evaluate the diagnostic value of transesophageal echocardiography (TEE) as an initial diagnostic tool in shocked patients. The second objective was to study therapeutic impact of intrapulmonary thrombolysis in patients with diagnosed massive pulmonary embolism. DESIGN: Prospective observational study. SETTING: Medical ICU in 800-bed general hospital. PATIENTS: Twenty-four consecutive patients with unexplained shock and distended jugular veins. MEASUREMENTS AND MAIN RESULTS: In 18 patients, right ventricular dilatation with global or segmental hypokinesis was documented. In addition, central pulmonary thromboemboli (12 patients), reduced contrast flow in right pulmonary artery (one patient), and right ventricular free wall akinesis (one patient) were found. No additional echocardiographic findings were apparent in four patients. According to pulmonary scintigraphy or autopsy, sensitivity of TEE for diagnosis of massive pulmonary embolism (MPE) in patients with right ventricular dilatation was 92% and specificity was 100%. In patients without right ventricular dilatation, left ventricular dysfunction (four patients) or cardiac tamponade (two patients) was confirmed. Intrapulmonary thrombolysis was evaluated in 11 of 13 patients with MPE. Two patients died prior to attempted thrombolysis. Three patients received streptokinase and eight received urokinase. Twenty-four hours after beginning of treatment, total pulmonary resistance index significantly decreased for 59% and mean pulmonary artery pressure for 31%. Cardiac index increased for 74%. Nine of 11 patients receiving thrombolysis survived to hospital discharge. CONCLUSION: Bedside TEE is a valuable tool for diagnosis of MPE. It enables immediate intrapulmonary thrombolysis, which seems to be an effective therapeutic alternative in our group of patients with obstructive shock.