Re-examining single-moment-in-time high-stakes examinations in specialist training: A critical narrative review.

In this critical narrative review, we challenge the belief that single-moment-in-time high-stakes examinations (SMITHSEx) are an essential component of contemporary specialist training. We explore the arguments both for and against SMITHSEx, examine potential alternatives, and discuss the barriers to change.SMITHSEx are viewed as the "gold standard" assessment of competence but focus excessively on knowledge assessment rather than capturing essential competencies required for safe and competent workplace performance. Contrary to popular belief, regulatory bodies do not mandate SMITHSEx in specialist training. Though acting as significant drivers of learning and professional identity formation, these attributes are not exclusive to SMITHSEx.Skills such as crisis management, procedural skills, professionalism, communication, collaboration, lifelong learning, reflection on practice, and judgement are often overlooked by SMITHSEx. Their inherent design raises questions about the validity and objectivity of SMITHSEx as a measure of workplace competence. They have a detrimental impact on trainee well-being, contributing to burnout and differential attainment.Alternatives to SMITHSEx include continuous low-stakes assessments throughout training, ongoing evaluation of competence in the workplace, and competency-based medical education (CBME) concepts. These aim to provide a more comprehensive and context-specific assessment of trainees' competence while also improving trainee welfare.Specialist training colleges should evolve from exam providers to holistic education sources. Assessments should emphasise essential practical knowledge over trivia, align with clinical practice, aid learning, and be part of a diverse toolkit. Eliminating SMITHSEx from specialist training will foster a competency-based approach, benefiting future medical professionals' well-being and success.

Competency domains of educators in medical, nursing, and health sciences education: An integrative review.

PURPOSE: Competencies for educators of healthcare professionals are important for demonstrating accountability, defining roles and responsibilities, structuring activities for training and development, defining standards, quality assurance, performance reviews, career development, and promoting the professionalisation of teaching. The frameworks and domains of educator competencies have not previously been reviewed or systematically described. Through this integrative review, the authors sought to identify an inclusive structure for competency domains that may be applied to educators. METHODS: Keywords were identified in a pilot search, followed by a multi-database search strategy of records published from 2000 to January 2020 with subsequent backward and forward reference searches. We included all record types that listed or described educator competency domains in medical, nursing and health sciences education. We excluded records that described 'ideal traits' or 'characteristics of good teachers/educators,' presented competencies as part of a larger curricular framework, and teaching assessment tool content. RESULTS: The multi-database search retrieved 2942 initial citations. From a full-text review of 301 records, 67 were identified as describing educator competency domains eligible for analysis. Documents contained a median of six domains (interquartile range = 5-7) and 14.9% incorporated at least one overarching element across their domains. Following an inductive thematic analysis, six distinct domains of educator competence were identified: Teaching and facilitating learning; Designing and planning learning; Assessment of learning; Educational research and scholarship; Educational leadership and management; Educational environment, quality, and safety. The two latter domains contained sub-themes that were able to be further categorised. Documents and frameworks were described for a wide variety of health and allied health disciplines. CONCLUSION: Distinct educator competency domains were identified in this analysis, applicable across a range of healthcare disciplines. Along with the description of design elements, these provide a guide for the development and evaluation of educator competency frameworks.

Percutaneous Coronary Intervention in an Extremely Rare Case of Double Circumflex Coronary Arteries With Acute Myocardial Infarction.

The anomalous origin of the left circumflex (Cx) artery (LCX) from the right coronary sinus or the right coronary artery (RCA) has been reported as one of the most common congenital coronary anomalies. However, the occurrence of double or twin Cx coronary arteries has been sparsely reported in the literature. We describe a rare case of a middle-aged male with acute myocardial infarction (MI) who had double Cx coronary arteries, one arising from the RCA and the other from the left main coronary artery. He underwent successful angioplasty with the stenting of the culprit right Cx artery (RCX).

Double Whammy: Subacute Stent Thrombosis While Being Adherent to Dual Antiplatelet Therapy Including Ticagrelor, Followed by Multiple Coronary Artery Aneurysms in a COVID-19 Patient.

Coronavirus disease 2019 (COVID-19), although predominantly a respiratory illness, can have important cardiovascular implications, which include the development of myocardial injury/myocarditis, acute coronary syndromes, arrhythmias, pericarditis, and the occurrence of arterial and venous thrombosis. We describe a rare case of a middle-aged COVID-19 patient who developed sub-acute stent thrombosis after implantation of second-generation drug-eluting stents (DES) despite being adherent to dual antiplatelet therapy including ticagrelor and who subsequently developed multiple coronary artery aneurysms within a few weeks of the DES implantation.

Isolated right ventricular myocardial infarction caused by occlusion of an anomalous non-dominant right coronary artery: successful management with percutaneous coronary intervention.

Isolated right ventricular myocardial infarction (RVMI) is a rare clinical presentation of acute coronary syndrome. A high index of suspicion is needed for its timely diagnosis and management to prevent serious complications like heart failure, cardiogenic shock, ventricular arrythmias or sudden cardiac death. Coronary anomalies are rare entities with a varied clinical presentation. We report an interesting case of a middle-aged female who presented with isolated RVMI, with a borderline blood pressure and sinus node dysfunction resulting from occlusion of an anomalous right coronary artery. The successful management of this patient with percutaneous coronary intervention using coronary stenting is also discussed.

Sex differences in acute coronary syndrome: insights from an observation study in low socio-economic cohort from India.

Aim: To study sex-related differences in acute coronary syndrome (ACS) presentation, management and in-hospital outcomes. Materials & methods: We studied 621 ACS patients (150 women, 471 men) of low socio-economic status from South India from February 2015 to January 2016. Multivariable logistic regression methods were used to assess sex differences in the in-hospital outcomes. Adjudicated major adverse cardiovascular events (MACE) included in-hospital cardiac arrest, cardiogenic shock, heart failure, re-infarction, stroke, major bleeding and mortality. Results & conclusion: Mean age in women was 60.97 ± 11.23 years versus 54.5 ± 10.87 years in men (p < 0.001). Women had higher prevalence of hypertension and diabetes and presented with more non-ST elevation ACS. There were no differences in the use of antiplatelets, statins and other pharmacotherapy except for the higher use of nitrates in women. There were no differences in MACE rates between women and men (15.3 vs 9.6%; adjusted odds ratio: 1.43; CI: 0.76-2.69).

Interviewer bias in selection of anaesthesia Fellows: A single-institution quality assessment study.

Fellowships are competitive training posts, often in a subspecialty area. We performed a quality assessment of potential interviewer bias on anaesthesia Fellow selection. After research locality approval, we analysed interview scores for all Fellowship applications to our department over six years. Panel interviewers participated in a structured interview process, asking a series of standardised questions to rate applicants. A mixed model analysis of total applicant rating with crossed effects of applicants and interviewers was used. A total of 94 applicants were interviewed by 27 panel members, with between two and four panel members per interview, giving a total of 329 applicant ratings. The random effect of applicants accounted for 45.8% of total variance in ratings (95% confidence intervals (CI) for intraclass correlation (ICC) 35.8%-57.2%) while interviewer effects accounted for 13.4% of total variance (95% CI for ICC 5.3%-30.0%). We found no evidence of bias for most potential sources after analysing multiple applicant and interviewer factors. After adjusting for interviewer training programme, applicants from other training programmes were rated a mean of 1.87 points lower than Australian and New Zealand College of Anaesthetists (ANZCA) applicants (95% CI 0.62-3.12, P = 0.003) and 1.84 points lower than Royal College of Anaesthetists (RCoA) applicants (95% CI 0.37-3.32, P = 0.014). After adjusting for applicant gender, female clinicians rated applicants 1.12 points higher (95% CI 0.19-2.06, P = 0.019) on average than male clinicians. The observed differences in interview scores amongst male and female clinicians and lower scores in applicants from programmes other than ANZCA/RCoA were small, and require confirmation in independent studies.

Clinical Characteristics, Management Strategies, and In-Hospital Outcomes of Acute Coronary Syndrome in a Low Socioeconomic Status Cohort: An Observational Study From Urban India.

BACKGROUND: Coronary artery disease is the leading cause of mortality in India. There is scarcity of data on demographic profile and outcomes of acute coronary syndrome (ACS) in low socioeconomic status (SES) population of India. OBJECTIVES: This study was undertaken to determine the clinical presentation, management strategies, and in-hospital outcomes of ACS in low SES population. METHODS: We conducted 1-year prospective observational cohort study of ACS patients admitted at Employees State Insurance Corporation unit of our tertiary care cardiac center. Clinical parameters, management strategies, and in-hospital outcomes of 621 patients enrolled during the study period from February 2015 to January 2016 were studied. RESULTS: Mean age of patients was 56.06 ± 11.29 years. Majority (62%) of the patients had ST elevation myocardial infarction (STEMI), whereas Non-ST elevation acute coronary syndrome (NSTE-ACS) was seen in 38% of the patients. Median time from symptom onset to hospital admission was 285 min with wide range from 105 to 1765 min. Coronary angiography was performed in 81% of patient population. Single-vessel disease (SVD) was the most common pattern (seen in 43.3%) of coronary artery involvement with left anterior descending coronary artery (LAD) being the most frequently involved vessel (62.8%). Pharmaco-invasive approach was the preferred strategy. Overall percutaneous coronary intervention (PCI) rates were 59.1% (62.1% in STEMI and 54.2% in NSTE-ACS). Overall in-hospital mortality was 3.2%, being significantly higher in STEMI (4.2%) as compared with NSTE-ACS (1.7%). CONCLUSIONS: With implementation of evidence-based pharmacotherapy and interventions, outcomes comparable with developed countries can be achieved even in low SES populations of developing world.

Gender effects in anaesthesia training in Australia and New Zealand.

BACKGROUND: Women face gender-based challenges in their medical education and career. Inequitable access to procedural training, a confidence gap, and professional identity deficit have been shown. We made a gender comparison of procedural case volume, confidence for independent practice, perceived gender and ethnic bias, and professional identity in Australasian anaesthesia trainees. METHODS: An online, voluntary, anonymous survey using SurveyMonkey® was delivered to Australasian anaesthesia trainees. Information collected included demographics, experience and confidence in 12 anaesthetic procedures, assessments relating to confidence and professional identity, and perceived gender and ethnic bias. Gender differences were evaluated. RESULTS: Three hundred and fifty-six trainees (22.2%) of the Australian and New Zealand College of Anaesthetists (ANZCA) responded. Male trainees reported a higher number (standard deviation) of procedures performed greater than 10 times (men 4.45 [2.55], women 3.78 [1.95]; P<0.001 adjusted for training level). Men were more likely to rate themselves at a training competency above their actual training level (men 18.6%, women 7.8%; P=0.004) and exaggerate procedural experience to supervisors (men 30.8%, women 11.8%; P<0.001). Final-year male trainees felt significantly more prepared for independent practice (P=0.021, trend across ordered responses). Women reported significantly higher levels of gender bias exhibited by patients (men 1.1%, women 84.5%; P<0.001) and in training overall (men 10.3%, women 55.3%; P<0.001), which was compounded in women with an ethnic minority background. CONCLUSIONS: A discrepancy exists between the number of procedures performed by male and female anaesthesia trainees in Australia and New Zealand. Relative male overconfidence may be a major contributing factor to the gender confidence gap.

Incidence, Characteristics and Atherosclerotic Involvement of Coronary Artery Anomalies in Adult Population Undergoing Catheter Coronary Angiography.

BACKGROUND: Coronary artery anomalies (CAAs) are rare disorders of coronary anatomy with varied clinical presentations. There are widespread geographic variations in incidence and patterns of these anomalies, with limited data from North Indian population. We performed a retrospective study to evaluate the incidence, characteristics and atherosclerotic involvement of CAAs in adult population undergoing catheter coronary angiography. METHODS: Serial coronary angiographies performed at our institution over a period of 2.5 years (from January 2017 to June 2019) were retrospectively analyzed. We identified patients with anomalous coronaries and studied their clinical characteristics and angiographic profiles. RESULTS: Among 3,233 coronary angiograms analyzed, CAAs were found in 99 patients with an incidence of 3.06%. Mean age of the patients was 56.2 ± 12.9 years (range: 20 - 86 years), with 74.75% being males and 25.25% females. Split right coronary artery (RCA) was the most common coronary anomaly, being seen in 27 patients; with an angiographic incidence of 0.84%. Dual left anterior descending artery (LAD) was the second most common anomaly and was seen in 22 cases with an angiographic incidence of 0.68%. Absent left main trunk was noted in 14 patients (0.43%). Ectopic origin of RCA from left sinus was seen in 12 patients (0.37%), while ectopic origin of RCA from ascending aorta was seen in four patients (0.12%). Ectopic origin of left circumflex artery (LCX) from right sinus or RCA was noted in 13 patients (0.40%). One patient (0.03%) had a superdominant LAD supplying the posterior descending artery (PDA). Coronary artery fistulae were seen in six patients (0.18%). Significant coronary artery disease (CAD) was seen in 89 of 268 (33.21%) normal vessels, whereas it was seen in 56 of 114 (49.12%) of anomalous vessels. This difference was statistically significant (P = 0.003). CONCLUSIONS: The incidence of CAAs in our study was slightly higher than many of the previous angiographic series. The patterns of coronary anomalies in our study were different from most of the previous studies. Our study had higher incidence of atherosclerotic involvement of anomalous vessels as compared to normal vessels.

Prevalence and characteristics of dual left anterior descending artery in adult patients undergoing coronary angiography.

Aim: To determine the prevalence and characteristics of dual left anterior descending artery (LAD) in adults undergoing catheter coronary angiography. Materials & methods: We identified cases with dual LAD by retrospectively analyzing 3233 angiograms done from January 2017 to June 2019. Results: Dual LAD was seen in 22 patients (0.68%). We identified type I dual LAD in 14 cases, type II in 7 cases and type III in 1 case. Significant stenosis was seen in proximal part of long LAD in 12 cases, in LAD proper in 7 cases and in proximal part of short LAD in 4 cases. Conclusion: Dual LAD is a rare anomaly. Its sound knowledge is essential for proper management of patients with coronary artery disease.

Deliberate teaching tools for clinical teaching encounters: A critical scoping review and thematic analysis to establish definitional clarity.

PURPOSE AND METHOD: We conducted a scoping review of tools designed to add structure to clinical teaching, with a thematic analysis to establish definitional clarity. RESULTS: Six thousand and forty nine citations were screened, 434 reviewed for eligibility, and 230 identified as meeting study inclusion criteria. Eighty-nine names and 51 definitions were identified. Based on a post facto thematic analysis, we propose that these tools be named "deliberate teaching tools" (DTTs) and defined as "frameworks that enable clinicians to have a purposeful and considered approach to teaching encounters by incorporating elements identified with good teaching practice." We identified 46 DTTs in the literature, with 38 (82.6%) originally described for the medical setting. Forty justification articles consisted of 16 feedback surveys, 13 controlled trials, seven pre-post intervention studies with no control group, and four observation studies. Current evidence of efficacy is not entirely conclusive, and many studies contain methodology flaws. Forty-nine clarification articles comprised 12 systematic reviews and 37 narrative reviews. The most number of DTTs described by any review was four. A common design theme was identified in approximately three-quarters of DTTs. CONCLUSIONS: Applicability of DTTs to specific alternate settings should be considered in context, and appropriately designed justification studies are warranted to demonstrate efficacy.

Developing and validating a tool for measuring the educational environment in clinical anesthesia.

PURPOSE: We aimed to develop a contemporary measure for anesthesia teaching and learning in the operating theatre that was applicable to a variety of training jurisdictions, the Measure for the Anaesthesia Theatre Educational Environment (MATE). METHODS: A systematic review of the literature and modified Delphi approach was used to identify items for content validity. Reliability and exploratory factor analyses were conducted after a pilot survey of trainees to show construct validity, with removal of redundant items. Item domains were identified through a global assessment of factor structure accuracy and relation to real-world constructs. RESULTS: Literature review generated an initial 73-item list. A modified Delphi approach with 24 experts identified 44 relevant items. The pilot survey generated 390 responses. Reliability analysis, exploratory factor analysis, and global assessment refined the measure to 33 items. Four domains were identified according to factor structure: teaching preparation and practice, assessment and feedback, procedures and responsibility, and overall atmosphere. The educational environment was rated by trainees at 74.6 ± 15.6% with excellent internal consistency (Cronbach's α = 0.975). CONCLUSION: The MATE survey tool generated valid and reliable scores when measuring the educational environment in the operating theatre. Further research is required to investigate possible differences between the training countries and age of junior doctors and the associated underlying factors. Other researchers are invited to administer the survey and share results within a central database.

Successful balloon mitral valvotomy in a rare coexistence of Ebstein's anomaly and rheumatic mitral stenosis.

Co-existence of Ebstein's anomaly of the tricuspid valve with rheumatic mitral stenosis is a very rare occurrence. We report the case of a young man who presented with progressive dyspnoea and was found to have rheumatic mitral stenosis with pulmonary hypertension and Ebstein's anomaly of the tricuspid valve. The patient underwent successful balloon mitral valvotomy resulting in marked improvement of symptoms.

Aspherical-atom modeling of coordination compounds by single-crystal X-ray diffraction allows the correct metal atom to be identified.

Single-crystal X-ray diffraction (XRD) is often considered the gold standard in analytical chemistry, as it allows element identification as well as determination of atom connectivity and the solid-state structure of completely unknown samples. Element assignment is based on the number of electrons of an atom, so that a distinction of neighboring heavier elements in the periodic table by XRD is often difficult. A computationally efficient procedure for aspherical-atom least-squares refinement of conventional diffraction data of organometallic compounds is proposed. The iterative procedure is conceptually similar to Hirshfeld-atom refinement (Acta Crystallogr. Sect. A- 2008, 64, 383-393; IUCrJ. 2014, 1,61-79), but it relies on tabulated invariom scattering factors (Acta Crystallogr. Sect. B- 2013, 69, 91-104) and the Hansen/Coppens multipole model; disordered structures can be handled as well. Five linear-coordinate 3d metal complexes, for which the wrong element is found if standard independent-atom model scattering factors are relied upon, are studied, and it is shown that only aspherical-atom scattering factors allow a reliable assignment. The influence of anomalous dispersion in identifying the correct element is investigated and discussed.

Molecular architecture with carbohydrate functionalized ß-peptides adopting 314-helical conformation.

Carbohydrate recognition is essential in cellular interactions and biological processes. It is characterized by structural diversity, multivalency and cooperative effects. To evaluate carbohydrate interaction and recognition, the structurally defined attachment of sugar units to a rigid template is highly desired. ß-Peptide helices offer conformationally stable templates for the linear presentation of sugar units in defined distances. The synthesis and ß-peptide incorporation of sugar-ß-amino acids are described providing the saccharide units as amino acid side chain. The respective sugar-ß-amino acids are accessible by Michael addition of ammonia to sugar units derivatized as α,ß-unsaturated esters. Three sugar units were incorporated in ß-peptide oligomers varying the sugar (glucose, galactose, xylose) and sugar protecting groups. The influence of sugar units and the configuration of sugar-ß-amino acids on ß-peptide secondary structure were investigated by CD spectroscopy.