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Introduction The COVID-19 pandemic hindered medical education and limited access to clinical skills training for trainee medical doctors, including electrocardiogram (ECG) interpretation. These restrictions prompted a shift towards virtual training environments and online learning. In this study, we assessed the impact of the pandemic on trainees' confidence and their perceived difficulty in independently interpreting ECGs. Additionally, we examined the effectiveness of two online learning approaches, namely lectures and case-solving webinars, in improving their skills. Methods The study was a mixed methods observational study conducted in three phases. In the first phase, a cross-sectional study was conducted to subjectively assess the trainees' confidence levels and the perceived difficulty independently reading ECGs. The second phase involved a cohort study where an online learning module consisting of eight lecture-based sessions was implemented. This module covered all the topics recommended in the foundation doctor training curriculum. The third phase also involved a cohort study where an online case-based discussion learning module with two problem-solving webinars was introduced. We assessed the outcomes on a 1 to 10 Likert scale for confidence and perceived difficulty in independently reading ECGs. Results Sixty-five trainees participated in the initial cross-sectional study. Among them, 100% of the participants reported substantial difficulty in interpreting ECGs (scoring 6 or more on the Likert scale), and 76.5% of the participants did not feel enough confidence to read ECGs independently (scoring 6 or less). Ten trainees attended the second phase. Online lectures significantly increased the mean confidence score by 1.9 points (t(9) = 2.82, p = 0.02, 95% confidence interval (CI) [0.38-3.42]) and significantly reduced the mean of the perceived difficulty score by 2.7 points (t(9) = 5.71, p < 0.001, 95% CI [1.63-3.77]). Compared to the online lectures, the online problem-solving sessions significantly increased the mean of the composite score of confidence and perceived difficulty in reading ECGs (-0.8 vs. 4 points, 95% CI [1.49, 8.26], p = 0.011). Conclusion The COVID-19 pandemic negatively affected the ECG reading skills of junior medical trainees. However, the online teaching approach effectively improved their confidence and the level of difficulty they experienced in ECG interpretation. Applying online case problem-solving was found to be superior to the lecture-based approach in enhancing these parameters.
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Background and objective The Global Registry of Acute Coronary Events (GRACE) study showed poor outcomes in ST-elevation myocardial infarction (STEMI) patients with acute heart failure (AHF) at hospital admission in terms of increased in-hospital and six-month mortality and readmission rates. In this study, we aimed to examine the effects of AHF at the time of admission on the coronary thrombus burden and post-primary percutaneous coronary intervention (PPCI) coronary flow among STEMI patients. Methods We conducted a cohort study involving 210 consecutive STEMI patients who presented to a single PPCI centre between June 2016 and January 2017. We classified them into two groups based on their Killip class at the time of presentation to the emergency department: no heart failure (NHF) and AHF groups. The primary outcome was the incidence of Thrombolysis In Myocardial Infarction (TIMI) flow grade of less than 3 in the stented coronary artery in the absence of mechanical obstruction or dissection (also known as no-reflow). The secondary outcome was the presence of a heavy thrombus burden (TIMI grade 4 or 5) at the time of angiography. Results The AHF group had a significantly higher incidence of no-reflow than the NHF group (25% vs. 8.4%, p=0.019). However, the prevalence of heavy thrombus burden did not differ significantly between the two groups (50% in the AHF group vs. 43.16% in the NHF group, p=0.557). The multivariable logistic regression analysis showed that AHF was an independent predictor of no-reflow in STEMI patients post-PPCI [Odds ratio (OR): 3.59, 95% confidence interval (CI): 1.09-11.83, p=0.035]. Conclusion Based on our findings, AHF is associated with an increased risk of no-reflow in STEMI patients post-PPCI, irrespective of the coronary thrombus load.
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Pheochromocytoma originates from the chromaffin cells of the adrenal medulla. It produces an excess of catecholamines. It is essentially a benign tumour, and the malignant type represents a minority. The malignant behaviour can be unclear in the absence of metastases. Factors of poor prognosis in malignant pheochromocytoma include male sex, old age, large-sized tumours, the presence of metastases at the time of diagnosis and non-surgical treatment. The cornerstone treatment of pheochromocytoma is surgical excision. In the presence of metastases, chemotherapy can control the symptoms and prolong survival. Its reported side effects are usually few and mild. This report presents a rare case of malignant pheochromocytoma in a 26-year-old gentleman that first manifested as a hypertensive urgency. The patient had several recurrences and multiple metastases despite two surgical excisions. Such poor outcome could not be predicted initially by the known risk factors. A non-previously reported complication of treatment was acute lower limb ischaemia after the start of chemotherapy for the tumour, depriving the patient of completing the course. In conclusion, the presence of hypertension in young adults warrants the investigation for pheochromocytoma. Postoperative follow-up is mandatory to pick up early signs of malignancy and metastasis. Tumour breakdown by chemotherapy can cause various cardiovascular problems including acute limb ischaemia. The management can be quite challenging, therefore, a multidisciplinary team should look after the case. A palliative approach can be used in patients with severe symptoms and no chance of cure.
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Background: The Global Registry of Acute Coronary Events (GRACE) study showed that admission HF is associated with longer hospital stay and higher mortality in ST-elevation myocardial infarction (STEMI) patients. No data are available on the effect of heart failure (HF) on the length of cardiac care unit (CCU) stay and in-hospital major adverse cardiac events (MACEs). The link between the severity of HF and the in-hospital prognosis is not established. Therefore, we aimed to investigate the unstudied outcomes in HF patients as well as to compare the outcomes across the spectrum of HF presentations. Methods: We studied 210 STEMI patients presenting to a single primary percutaneous coronary intervention (PPCI) center in a retrospective cohort pattern. We excluded those who received fibrinolysis, those who had chest pain for more than 24 h and those with previous stents and presenting with stent thrombosis. All the procedures followed the ethical standards of Alexandria University and the Helsinki Declaration. Results: STEMI patients with HF had significantly longer CCU stay (mean value of 3.6 vs. 2.87 days, P = 0.009), higher in-hospital MACE (55% vs. 4.7%, P < 0.001) and higher mortality (15% vs. 0.53%, P < 0.001). Multivariate logistic regression analysis revealed that HF is an independent predictor of in-hospital mortality (odds ratio (OR) = 9.11, 95% confidence interval (CI): 1.66 - 49.9, P = 0.01). The patients with severe HF on admission (Killip III and IV) tended to stay longer in the CCU (4.13 ± 1.89 days vs. 3.25 ± 1.54 days, P = 0.069) and the hospital (5.88 ± 3.09 vs. 4.42 ± 2.47 days, P = 0.077), compared to those with mild HF (Killip II). There was a tendency for a higher incidence of in-hospital MACE (75% vs. 33%, P = 0.068) and mortality (16.7% vs. 12.5%, P = 0.798) in the former group compared to the latter. The differences among HF subgroups did not reach the point of statistical significance though. Conclusions: The presence of HF on the admission of STEMI patients undergoing PPCI is associated with longer CCU stay, higher in-hospital MACE and mortality.
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BACKGROUND: Female patients show poorer outcomes after coronary interventions compared to males. This study aims to investigate the role of enhanced inflammatory response in female ST-elevation myocardial infarction (STEMI) patients in poor outcomes post primary percutaneous coronary intervention (PPCI). METHODS: This study included 120 STEMI patients who went to PPCI in two tertiary cardiac centers over 6 months. All STEMI patients who are eligible for PPCI are included. We excluded those who had previous coronary artery bypass grafting (CABG) with venous grafts, previous PCI with in-stent restenosis (ISR), and those who had signs of infection on admission. These are then divided into two groups according to sex (males and females). Impaired coronary flow (also known as no-reflow) is defined as a coronary TIMI (thrombolysis in myocardial infarction) flow less than 3 after PCI in the absence of mechanical coronary occlusion. RESULTS: The studied groups included 88 males and 32 females. The median age in females was higher than males (62 vs. 57.5 years respectively, P = 0.005). The prevalence of hypertension (34 vs. 21 patients, P = 0.01), non-insulin-dependent diabetes mellitus (NIDDM) (22 vs. 16 patients, P = 0.01) and smoking (61 vs. 0 patients, P < 0.001) was higher in male patients. The incidence of impaired coronary flow did not differ significantly between the two groups (10 males and six females, P = 0.363). The median neutrophil to lymphocyte (N/L) ratio showed to be non-significantly higher in females (5 in males vs. 6 in females, P = 0.342). However, the mean N/L ratio was significantly higher in female patients with impaired coronary flow compared to males (9.35 vs. 5.79, P = 0.003). CONCLUSIONS: The enhanced inflammatory response in female STEMI patients may be responsible for poorer outcomes after PPCI. Larger-scale studies are required to define immune mechanisms as a potential target to improve outcomes in STEMI patients.
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Chondroid syringoma is a rare tumor with the potential for malignant transformation and distant metastasis. The site of predilection for benign chondroid syringoma is the head and neck region, and it is less likely to involve the foot. In contrast, malignant chondroid syringoma is more commonly encountered in the extremities and is characterized by rapid growth, local invasion, and distant metastasis. We report an unusual case of benign chondroid syringoma in a 47-year-old female who presented with a 20-year history of a mass in her left foot to bring such cases to the attention of foot and ankle specialists. We highlight the histologic diagnosis and surgical procedures with a 6-month postoperative follow-up period. It is unlikely that a treating physician would anticipate this histologic tumor type, considering the rarity of the condition, the long history of this patient's lesion, and the benign presentation in the extremities.
