A Clinical Diagnostic Test for Calcium Release Deficiency Syndrome.

Importance: Sudden death and cardiac arrest frequently occur without explanation, even after a thorough clinical evaluation. Calcium release deficiency syndrome (CRDS), a life-threatening genetic arrhythmia syndrome, is undetectable with standard testing and leads to unexplained cardiac arrest. Objective: To explore the cardiac repolarization response on an electrocardiogram after brief tachycardia and a pause as a clinical diagnostic test for CRDS. Design, Setting, and Participants: An international, multicenter, case-control study including individual cases of CRDS, 3 patient control groups (individuals with suspected supraventricular tachycardia; survivors of unexplained cardiac arrest [UCA]; and individuals with genotype-positive catecholaminergic polymorphic ventricular tachycardia [CPVT]), and genetic mouse models (CRDS, wild type, and CPVT were used to define the cellular mechanism) conducted at 10 centers in 7 countries. Patient tracings were recorded between June 2005 and December 2023, and the analyses were performed from April 2023 to December 2023. Intervention: Brief tachycardia and a subsequent pause (either spontaneous or mediated through cardiac pacing). Main Outcomes and Measures: Change in QT interval and change in T-wave amplitude (defined as the difference between their absolute values on the postpause sinus beat and the last beat prior to tachycardia). Results: Among 10 case patients with CRDS, 45 control patients with suspected supraventricular tachycardia, 10 control patients who experienced UCA, and 3 control patients with genotype-positive CPVT, the median change in T-wave amplitude on the postpause sinus beat (after brief ventricular tachycardia at ≥150 beats/min) was higher in patients with CRDS (P < .001). The smallest change in T-wave amplitude was 0.250 mV for a CRDS case patient compared with the largest change in T-wave amplitude of 0.160 mV for a control patient, indicating 100% discrimination. Although the median change in QT interval was longer in CRDS cases (P = .002), an overlap between the cases and controls was present. The genetic mouse models recapitulated the findings observed in humans and suggested the repolarization response was secondary to a pathologically large systolic release of calcium from the sarcoplasmic reticulum. Conclusions and Relevance: There is a unique repolarization response on an electrocardiogram after provocation with brief tachycardia and a subsequent pause in CRDS cases and mouse models, which is absent from the controls. If these findings are confirmed in larger studies, this easy to perform maneuver may serve as an effective clinical diagnostic test for CRDS and become an important part of the evaluation of cardiac arrest.

ICD Implantation Rates in Cardiac Arrest Survivors in Canada.

Background: Patients resuscitated from out-of-hospital cardiac arrest (OHCA) are at high risk of recurrence, posing a substantial burden on healthcare systems. Despite the established benefit of implantable cardioverter defibrillator (ICD) therapy in many such patients, and recommendations by guidelines, few studies have described the proportion of OHCA patients who receive guideline-concordant care. Methods: The Canadian Institute for Health Information Discharge Abstract Database dataset was used to identify OHCA patients admitted to hospitals across Canada, excluding Quebec. We analyzed all patients without a probable ischemic or bradycardia etiology of cardiac arrest, who survived to discharge, to estimate the ICD implantation rates in patients who were potentially eligible to have an ICD. Results: Between 2013 and 2017, a total of 10,435 OHCA patients who were admitted to the hospital were captured in the database; 4486 (43%) survived to hospital discharge, and 2580 survivors (57.5%) were potentially eligible to receive an ICD. Among these potentially eligible patients, 757 (29.3%) received an ICD during their index admission or within 30 days after discharge from the hospital. The ICD implantation rate during index admission increased from 13.8% in 2013 to 19.6% in 2017 (P-value for time trend < 0.05). The rate of ICD implantations in potentially eligible patients was higher in urban than in rural settings (19.5% vs 11.1%) and in teaching vs community hospitals (34.7% vs 9.8%). Conclusions: Although ICD implantation rates show an increasing trend among patients with OHCA who are likely eligible for secondary prevention, significant underutilization of ICDs persists in these patients.

Contexte: Les patients ayant survécu à un arrêt cardiaque extra-hospitalier (ACEH) présentent un risque élevé de récidive, ce qui impose un lourd fardeau aux systèmes de soins de santé. Malgré l'avantage établi de la mise en place d'un défibrillateur cardioverteur implantable (DCI) chez un grand nombre de ces patients, et les recommandations des lignes directrices, peu d'études décrivent la proportion de patients victimes d'un ACEH ayant reçu des soins conformes aux lignes directrices. Méthodologie: Nous avons recensé les admissions à l'hôpital de patients ayant subi un ACEH au Canada, à l'exception du Québec à partir de l'ensemble de données de la Base de données sur les congés des patients de l'Institut canadien d'information sur la santé. Nous avons inclus dans notre analyse tous les patients pour lesquels la cause de l'arrêt cardiaque n'était probablement pas ischémique ou bradycardique et qui avaient survécu jusqu'à leur congé de l'hôpital, afin d'estimer les taux d'implantation d'un DCI chez les patients potentiellement admissibles à cette intervention. Résultats: Entre 2013 et 2017, un total de 10 435 patients ayant subi un ACEH ont été hospitalisés selon la base de données; 4 486 (43 %) avaient survécu jusqu'à leur congé de l'hôpital, et 2 580 survivants (57,5 %) étaient potentiellement admissibles à l'implantation d'un DCI. Parmi les patients potentiellement admissibles, 757 (29,3 %) avaient reçu un DCI au moment de leur admission initiale ou dans les 30 jours suivant leur congé de l'hôpital. Le taux d'implantation de DCI lors de l'admission initiale est passé de 13,8 % en 2013 à 19,6 % en 2017 (valeur p pour la tendance au fil du temps < 0,05). Le taux d'implantation d'un DCI chez les patients potentiellement admissibles était plus élevé en milieu urbain qu'en milieu rural (19,5 % contre 11,1 %) et dans les hôpitaux d'enseignement/universitaires par comparaison avec les hôpitaux communautaires (34,7 % contre 9,8 %). Conclusions: Bien que les taux d'implantation de DCI affichent une tendance à la hausse chez les patients ayant subi un ACEH qui sont probablement admissibles à des interventions de prévention secondaire, les DCI demeurent largement sous-utilisés chez ces patients.

Evaluation of prognostic scores for status epilepticus in the neurology ICU: A retrospective study.

OBJECTIVE: Status epilepticus (SE) in the neurology intensive care unit (ICU) is associated with significant morbidity. We aimed to evaluate the utility of existing prognostic scores, namely the Status Epilepticus Severity Score (STESS), Epidemiology Based Mortality Score in Status Epilepticus (EMSE)-EACE and Encephalitis-Nonconvulsive Status Epilepticus-Diazepam Resistance-Image Abnormalities-Tracheal Intubation (END-IT), among SE patients in the neurology ICU. METHODS: Neurology ICU patients with SE requiring continuous electroencephalography (cEEG) monitoring over a 10 year period were included. The STESS, EMSE-EACE and END-IT scores were applied retrospectively. Receiver operating characteristic (ROC) analysis was performed to assess the discriminatory value of the scores for inpatient mortality and functional decline, as measured by increase in the modified Rankin Scale (mRS) on discharge. RESULTS: Eighty-five patients were included in the study, of which 71 (83.5%) had refractory SE. Inpatient mortality was 36.5%. Sixty - seven (78.8%) of patients suffered functional decline, with a median mRS of 5 upon hospital discharge. The AUCs of the STESS, EMSE-EACE and END-IT scores associated with inpatient mortality were 0.723 (95% CI 0.613-0.833), 0.722 (95% CI 0.609-0.834) and 0.560 (95% CI 0.436-0.684) respectively. The AUCs of the STESS, EMSE-EACE and END-IT scores associated with functional decline were 0.604 (95% CI 0.468-0.741), 0.596 (95% CI 0.439-0.754) and 0.477 (95% CI 0.331-0.623). SIGNIFICANCE: SE was associated with high mortality and morbidity in this cohort of neurology ICU patients requiring cEEG monitoring. The STESS and EMSE-EACE scores had acceptable AUCs for prediction of inpatient mortality. However, the STESS, EMSE-EACE and END-IT were poorly-correlated with discharge functional outcomes. Further refinements of the scores may be necessary among neurology ICU patients for predicting discharge functional outcomes.

Temporal Trends of Enrollment by Sex and Race in Major Cardiovascular Randomized Clinical Trials.

Background: Women and racialized minorities continue to be underrepresented in cardiovascular (CV) trial outcomes data, despite comprising a significant global burden of CV disease. This study evaluated the impact of trial characteristics on the temporal enrollment of women and racialized minorities in prominent CV trials published in the period 1986-2023. Methods: MEDLINE was searched for CV trials published in The Lancet, the Journal of the American Medical Association, and the New England Journal of Medicine. Participant and investigator demographics, types of interventions, clinical indications, and funding sources were compared according to the enrollment of women or racialized minorities. Results: From 799 studies, including 4,071,921 patients, the enrollment of women and racialized minorities significantly increased from 1986 to 2023 (both P ≤ 0.001). Although the enrollment of women varied by trial indication, comprising 25.0% of coronary artery disease, 35.2% of noncoronary and/or vascular disease, 13.8% of heart failure, 17.0% of arrhythmia, and 28.7% of other CV trials (P ≤ 0.001), it did not differ by peer-reviewed vs industry funding. First authors who were women were more likely than first authors who were men to enroll significantly more women (P = 0.01). Conclusions: Active efforts to increase diverse enrollment, along with improved reporting, including of sex and race, in future CV trials may increase the generalizability of their findings and applicability to global populations.

Contexte: Les femmes et les groupes racisés demeurent sous-représentés dans les données de résultats d'essais cliniques sur les maladies cardiovasculaires (CV) malgré l'important fardeau global associé à ces maladies. Cette étude visait à évaluer l'effet des caractéristiques des essais sur la sélection temporelle des femmes et des membres de groupes racisés dans les essais portant principalement sur les maladies CV durant la période de 1986 à 2023. Méthodologie: La base de données MEDLINE a été consultée à la recherche d'essais sur les maladies CV publiés dans The Lancet, Journal of the American Medical Association et New England Journal of Medicine. Les données démographiques des participants et des chercheurs, les types d'interventions, les indications cliniques et les sources de financement ont été comparés en fonction de la sélection des femmes ou des membres de groupes racisés. Résultats: Dans 799 études cumulant 4 071 921 patients, la sélection des femmes et des membres de groupes racisés a augmenté significativement entre 1986 et 2023 (p ≤ 0,001 dans les deux cas). Bien que la sélection des femmes variait en fonction des indications des essais, soit 25,0 % dans les essais portant sur les coronaropathies, 35,2 % pour les maladies non coronariennes et/ou vasculaires, 13,8 % pour l'insuffisance cardiaque, 17,0 % pour l'arythmie et 28,7 % pour d'autres maladies CV (p ≤ 0,001), elle ne différait pas selon que les études étaient révisées par des pairs ou qu'elles étaient financées par l'industrie. Lorsqu'une femme était l'autrice principale, le nombre de femmes sélectionnées était susceptible d'être plus élevé que lorsque l'auteur principal était un homme (p = 0,01). Conclusions: Des efforts actifs pour diversifier davantage la sélection des participants et mieux rendre compte des différences, notamment en ce qui concerne le sexe et la race, pourraient élargir la portée des conclusions des futurs essais sur les maladies CV et leur application à l'ensemble de la population.

Case report: From palliative to potentially curative - the advent of immunotherapy providing hope to advanced gallbladder adenocarcinoma.

Introduction: Biliary tract cancers (BTC) are often diagnosed at an advanced stage where prognosis is poor and curative-intent surgery is infeasible. First-line cisplatin-gemcitabine chemotherapy for advanced gallbladder cancer has remained unchanged over more than a decade, but recent developments in immunotherapy such as durvalumab have highlighted promise as a combination treatment regime with current standard chemotherapy. Methods: In this case description, we present a case of locally-advanced gallbladder adenocarcinoma involving the biliary confluence that was initially planned for an extended right hepatectomy after portal vein embolization. Interval imaging revealed peritoneal metastasis, which was confirmed on diagnostic laparoscopy and biopsy. The patient underwent 8 cycles of cisplatin 25 mg/m2 and gemcitabine 1,000 mg/m2 chemotherapy on days 1 and 8 of each 21-day cycle, with durvalumab (Imfinzi®) 1,500 mg immunotherapy on day 1 of every cycle, in accordance with the treatment protocol of the TOPAZ-1 trial. Repeat imaging demonstrated a stable primary lesion with no further evidence of peritoneal disease. The patient subsequently underwent curative-intent conversion surgery with an extended right hepatectomy and Roux-en-Y hepaticojejunostomy, which were completed through a fully minimally-invasive laparoscopic approach. Results: Final pathological TNM classification was ypT1aN0, with near-complete pathological response to pre-surgical therapy, uninvolved margins (R0 resection) and tumour shrinkage from 2.5 centimetres on pre-operative cross-sectional imaging to 0.5 centimetres on final histology. The patient had an uneventful post-operative course, and was fit for discharge by the fourth post-operative day. He remained well after three months of routine post-operative follow-up, with no significant post-operative complications and biochemical or radiological evidence of disease recurrence. Conclusion: Our case description highlights the immense potential of combination durvalumab immunotherapy with cisplatin-gemcitabine chemotherapy in the treatment of advanced gallbladder adenocarcinoma. The patient's locally advanced disease was initially planned for complex open surgery, prior to discovery of peritoneal metastasis rendering it inoperable. This was successfully down-staged with combination therapy to eventual R0 resection via minimally-invasive surgery. In addition, this case description demonstrates the feasibility of a fully laparoscopic approach with postulated benefits of diagnostic re-evaluation of peritoneal disease, reduced wound pain and shorter length of hospital stay.

Prognostic Value of Different Thresholds for Myocardial Scar Quantification on Cardiac MRI Late Gadolinium Enhancement Images in Patients Receiving Implantable Cardioverter Defibrillators.

Purpose: To compare the predictive value of different myocardial scar quantification thresholds using cardiac MRI for appropriate implantable cardioverter defibrillator (ICD) shock and mortality. Materials and Methods: In this retrospective, two-center observational cohort study, patients with ischemic or nonischemic cardiomyopathy underwent cardiac MRI prior to ICD implantation. Late gadolinium enhancement (LGE) was first determined visually and then quantified by blinded cardiac MRI readers using different SDs above the mean signal of normal myocardium, full-width half-maximum, and manual thresholding. The intermediate signal "gray zone" was calculated as the differences between different SDs. Results: Among 374 consecutive eligible patients (mean age, 61 years ± 13 [SD]; mean left ventricular ejection fraction, 32% ± 14; secondary prevention, 62.7%), those with LGE had a higher rate of appropriate ICD shock or death than those without (37.5% vs 26.6%, log-rank P = .04) over a median follow-up of 61 months. In multivariable analysis, none of the thresholds for quantifying scar was a significant predictor of mortality or appropriate ICD shock, while the extent of gray zone was an independent predictor (adjusted hazard ratio per 1 g = 1.025; 95% CI: 1.008, 1.043; P = .005) regardless of the presence or absence of ischemic heart disease (P interaction = .57). Model discrimination was highest for the model incorporating the gray zone (between 2 SD and 4 SD). Conclusion: Presence of LGE was associated with a higher rate of appropriate ICD shock or death. Although none of the scar quantification techniques predicted outcomes, the gray zone both in infarct and nonischemic scar was an independent predictor and may refine risk stratification.Keywords: MRI, Scar Quantification, Implantable Cardioverter Defibrillator, Sudden Cardiac Death Supplemental material is available for this article. © RSNA, 2023.

Trial watch: immunotherapeutic strategies on the horizon for hepatocellular carcinoma.

The use of immune checkpoint inhibitors (ICIs) targeting PD-L1/PD-1 and CTLA-4 has transformed the oncology practice of hepatocellular carcinoma. However, only 25-30% of the patients with advanced HCC treated with atezolizumab-bevacizumab or tremelimumab-durvalumab (STRIDE) respond initially, and mechanistic biomarkers and novel treatment strategies are urgently needed for patients who present with or acquire resistance to first-line ICI-based therapies. The recent approval of the STRIDE regimen has also engendered new questions, such as patient selection factors (e.g. portal hypertension and history of variceal bleed) and biomarkers, and the optimal combination and sequencing of ICI-based regimens. Triumphs in the setting of advanced HCC have also galvanized considerable interest in the broader application of ICIs to early- and intermediate-stage diseases, including clinical combination of ICIs with locoregional therapies. Among these clinical contexts, the role of ICIs in liver transplantation - which is a potentially curative strategy unique to HCC management - as a bridge to liver transplant in potential candidates or in the setting of post-transplant recurrence, warrants investigation in view of the notable theoretical risk of allograft rejection. In this review, we summarize and chart the landscape of seminal immuno-oncology trials in HCC and envision future clinical developments.

Measuring Interprofessional Collaboration's Impact on Healthcare Services Using the Quadruple Aim Framework: A Protocol Paper.

Despite decades of research on the impact of interprofessional collaboration (IPC), we still lack definitive proof that team-based care can lead to a tangible effect on healthcare outcomes. Without return on investment (ROI) evidence, healthcare leaders cannot justifiably throw their weight behind IPC, and the institutional push for healthcare manpower reforms crucial for facilitating IPC will remain variable and fragmentary. The lack of proof for the ROI of IPC is likely due to a lack of a unifying conceptual framework and the over-reliance on the single-method study design. To address the gaps, this paper describes a protocol which uses as a framework the Quadruple Aim which examines the ROI of IPC using four dimensions: patient outcomes, patient experience, provider well-being, and cost of care. A multimethod approach is proposed whereby patient outcomes are measured using quantitative methods, and patient experience and provider well-being are assessed using qualitative methods. Healthcare costs will be calculated using the time-driven activity-based costing methodology. The study is set in a Singapore-based national and regional center that takes care of patients with neurological issues.

In symptomatic AF, cryoballoon ablation reduced progression to persistent AF vs. antiarrhythmic therapy at 3 y.

SOURCE CITATION: Andrade JG, Deyell MW, Macle L, et al. Progression of atrial fibrillation after cryoablation or drug therapy. N Engl J Med. 2023;388:105-16. 36342178.

A framework for evaluating predictive models.

Predictive models provide estimates on an individual's probability of having a disease or developing a disease/disease outcome. Clinicians often use them to support clinical decision-making. Many prediction models are published annually; online versions of models (such as MDCalc and QxMD) facilitate their use at the point of care. However, before using a model, the clinician should first establish that the model has undergone external validation demonstrating satisfactory predictive performance. Ideally, the model should also demonstrate improved outcomes from an impact analysis. This article summarizes the basic steps of predictive model evaluation, and is followed by an application example.

Current practice in diagnostic genetic testing of the epilepsies

Epilepsy genetics is a rapidly developing field, in which novel disease-associated genes, novel mechanisms associated with epilepsy, and precision medicine approaches are continuously being identified. In the past decade, advances in genomic knowledge and analysis platforms have begun to make clinical genetic testing accessible for, in principle, people of all ages with epilepsy. For this reason, the Genetics Commission of the International League Against Epilepsy (ILAE) presents this update on clinical genetic testing practice, including current techniques, indications, yield of genetic testing, recommendations for pre- and post-test counseling, and follow-up after genetic testing is completed. We acknowledge that the resources vary across different settings but highlight that genetic diagnostic testing for epilepsy should be prioritized when the likelihood of an informative finding is high. Results of genetic testing, in particular the identification of causative genetic variants, are likely to improve individual care. We emphasize the importance of genetic testing for individuals with epilepsy as we enter the era of precision therapy.

Effective online large-group teaching in health professions education.

Online large-group teaching (OLGT), employed to reach a large group of learners in separate physical locations, allows asynchronous learning and facilitates social distancing. While online large-groups can be a powerful and resource-lean means of health professions education, it has challenges and potential pitfalls that may affect the learning process and outcomes. Through a sociomateriality framework, this article describes strategies for effective online large-group teaching in health professions education in three key strands. Firstly, to optimize learning, OLGT sessions should match learning needs with appropriate OLGT platforms, incorporate strategies to sustain learner attention, and accommodate learners of different abilities. Secondly, to develop a learning culture, OLGT must not only focus on cognitive aspects of learning but also build a community of practice, nurture digital professionalism and professional identity. Thirdly, we discuss the avoidance of pitfalls such as cognitive overload of both tutors and learners, technical issues and security risks, mitigating inequities in access to online learning, and the use of program evaluation to plan for sustained improvements. We conclude with a case vignette that discusses the challenges of OLGT and the application of the above strategies in a teaching scenario.

Viewing interprofessional collaboration through the lens of networked ecological systems theory.

Interprofessional collaboration (IPC) is key to ensuring safe quality care for patients. However, IPC intervention outcomes are variable, leading to calls for systems theories to understand complex interactions in healthcare. Using networked ecological systems theory (NEST), we aimed to uncover facilitators and barriers impacting the interactions between nurses and physicians in a specialty healthcare center. A qualitative study involving 55 non-participant observations and 17 individual semi-structured interviews was conducted at the National Neuroscience Institute of Singapore from April 2019 to March 2021. Template analysis was used to analyze the data. The most important IPC facilitators were exosystemic institutional support and physicians' willingness to engage in IPC in the microsystems that together enabled the establishment of disease-based outpatient programs fostering patient-centered interactions among different healthcare professionals (HCP). We also found that patient-, disease-, and systems-related knowledge played an important role in facilitating IPC. Macrosystemic entrenchments such as intraprofessional composition of ward rounds emerged as a significant barrier. However, microsystemic efforts such as chat groups connecting all HCP involved in the care of the patients in the wards have fostered IPC. Although still preliminary, these findings suggest NEST can be useful to inform systematic interventions to improve IPC.

Differential effects of team-based learning on clinical reasoning.

BACKGROUND: Clinical reasoning (CR) is the ability to integrate information, knowledge and contextual factors for patient care. Few studies have explored effects of team-based learning (TBL) on neurological CR. This study compared simplified TBL (sTBL) against interactive lectures (IL) for teaching CR in neuroanatomical localisation (NL) and neurological emergencies (NE), assessed using a validated Script Concordance Test (SCT). METHODS: A crossover study was conducted with third- and fifth-year undergraduates, randomly assigned to two groups, from the Yong Loo Lin School of Medicine in Singapore. Group 1 was taught NE with sTBL and NL with IL, whereas Group 2 was taught NL with sTBL and NE with IL. Teaching was conducted sequentially over 3 h followed immediately by the SCT. The primary outcome was the difference in mean SCT scores of NE and NL taught with sTBL versus IL. FINDINGS: A total of 179 students (Group 1, n = 81; Group 2, n = 98) participated. Mean NL SCT scores for students taught with sTBL were significantly higher compared with IL (64.8% vs. 61.7%, mean difference 3.1%, 95% confidence interval [CI] 0.6%-5.5%, p = 0.013); effect size was 0.38. Mean NE SCT scores were similar between students taught with sTBL or IL (66.6% vs. 67.0%, mean difference -0.4%, 95% CI -2.2% to 3.1%, p = 0.75). CONCLUSIONS: sTBL was superior to IL for teaching NL, whereas both methods were comparable for teaching NE. TBL may be suitable for teaching more complex neurological topics involving diagnostic reasoning through development of problem representation, hypothesis generation and illness script selection.

Personal protective equipment training for non-healthcare workers in the Covid-19 pandemic: Effectiveness of an evidence-based skills training framework.

BACKGROUND: Large-scale quarantine facilities staffed with non-healthcare workers (NHCW) were instrumental in preventing community spread of COVID-19 (coronavirus disease of 2019). The objective of this study was to determine the effectiveness of a newly developed procedural skills training framework in ensuring personal protective equipment (PPE) compliance of PPE-naïve NHCWs. METHODS: We developed a PPE procedural skills training framework for NHCWs using the Learn, See, Practice, Prove, Do, and Maintain (LSPPDM) framework and international guidelines on PPE for healthcare workers. The NHCWs underwent PPE training using this framework, conducted by a team of Infection Prevention nurses, prior to being stationed within the CCF. Effectiveness of the LSPPDM PPE training framework was assessed using: 1) competency assessment scores for NHCWs, 2) PPE compliance rates from daily audit findings, and, 3) healthcare-associated COVID-19 infection rates of NHCWs. RESULTS: A total of 883 NHCWs had completed the PPE training and demonstrated competency in PPE compliance, fulfilling 100% of the checklist requirements. Mean PPE compliance of all NHCWs during the 11-week study period was noted to be >96%. The post-implementation improvement was statistically significant when the compliance was expressed in 3-days blocks) and in bed management staff (P = < 0.05). None of the 883 NHCWs who underwent PPE training via the LSPPDM framework were diagnosed with healthcare-associated COVID-19 infection. CONCLUSION: An evidence-based skills training framework is effective in PPE training of large numbers of NHCWs, resulting in high compliance of appropriate PPE use and prevention of healthcare-associated COVID-19 infection.

Is Virtual Team-Based Learning Feasible and Effective in Teaching Neurolocalisation?

We investigated the feasibility and effectiveness of virtual team-based learning (TBL) in teaching neurolocalisation (NL) in a sample of 18 student volunteers. Student satisfaction and knowledge outcomes were evaluated using the modified TBL Student Assessment Instrument and Extended Matching Questionnaire (EMQ), respectively. Mean student satisfaction rating was good at 3.9 out of 5.0 (SD 0.3). Participants achieved high mean EMQ scores of 84.2% (SD 2.9) with moderate correlation between individual assessment scores and EMQ scores (ρ = 0.587, p = 0.01). Virtual TBL is feasible for teaching NL with good student satisfaction and knowledge outcomes.

Myocardial strain assessment using cardiovascular magnetic resonance imaging in recipients of implantable cardioverter defibrillators.

BACKGROUND: Cardiovascular magnetic resonance (CMR) is increasingly used in the evaluation of patients who are potential candidates for implantable cardioverter-defibrillator (ICD) therapy to assess left ventricular (LV) ejection fraction (LVEF), myocardial fibrosis, and etiology of cardiomyopathy. It is unclear whether CMR-derived strain measurements are predictive of appropriate shocks and death among patients who receive an ICD. We evaluated the prognostic value of LV strain parameters on feature-tracking (FT) CMR in patients who underwent subsequent ICD implant for primary or secondary prevention of sudden cardiac death. METHODS: Consecutive patients from 2 Canadian tertiary care hospitals who underwent ICD implant and had a pre-implant CMR scan were included. Using FT-CMR, a single, blinded, reader measured LV global longitudinal (GLS), circumferential (GCS), and radial (GRS) strain. Cox proportional hazards regression was performed to assess the associations between strain measurements and the primary composite endpoint of all-cause death or appropriate ICD shock that was independently ascertained. RESULTS: Of 364 patients (mean 61 years, mean LVEF 32%), 64(17.6%) died and 118(32.4%) reached the primary endpoint over a median follow-up of 62 months. Univariate analyses showed significant associations between GLS, GCS, and GRS and appropriate ICD shocks or death (all p < 0.01). In multivariable Cox models incorporating LVEF, GLS remained an independent predictor of both the primary endpoint (HR 1.05 per 1% higher GLS, 95% CI 1.01-1.09, p = 0.010) and death alone (HR 1.06 per 1% higher GLS, 95% CI 1.02-1.11, p = 0.003). There was no significant interaction between GLS and indication for ICD implant, presence of ischemic heart disease or late gadolinium enhancement (all p > 0.30). CONCLUSIONS: GLS by FT-CMR is an independent predictor of appropriate shocks or mortality in ICD patients, beyond conventional prognosticators including LVEF. Further study is needed to elucidate the role of LV strain analysis to refine risk stratification in routine assessment of ICD treatment benefit.