Search

Laura Rechtien,1,2 Maximilian Gradel,1 Martin R Fischer,1 Tanja Graupe,1 Konstantinos Dimitriadis1,3 1Institute for Didactics and Educational Research in Medicine, Ludwig Maximilian University of Munich, Munich, Germany; 2Department of Dermatology, Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen, Germany; 3Department of Neurology, Ludwig Maximilian University of Munich, Munich, GermanyCorrespondence: Konstantinos Dimitriadis, Email konstantin.dimitriadis@med.uni-muenchen.deIntroduction: Physicians are increasingly confronted with new requirements in their daily job, which go beyond the mere treatment of patients. The aim of this Mixed-Method-Study is to better understand management as it relates to physicians’ daily work, to clarify the physicians’ perception of their management role and to examine physician’s self-assessed competence in these functions.Methods: We used three different instruments: Semi-structured interviews, a self-assessment survey and direct observations to evaluate managerial activities performed by residents. Both latter were based on instruments established for management research.Results: Interviewed residents were familiar with the term “Management” but had difficulties in defining it. Concerning managerial functions in context of their daily work, we identified three main categories: Self-management, Patient-management and Management of the ward. In this context, physicians named numerous examples of management tasks and for which they felt ill prepared. Eighty-eight residents participated in the self-assessment survey and rated the majority of the management tasks as necessary for the residents’ work. Although physicians estimated the proportion of managerial work to comprise only 40.6%, a much higher number of mere management tasks could be identified through direct observations (n = 12). Activities related to management were more often observed than genuine physician tasks.Discussion: This study illustrates the prominent role of management activities in context of the residents’ work, while at the same time showing that residents do not feel sufficiently educated, prepared nor competent in management tasks.Keywords: medical curriculum, medical education, physician’s leadership, physician’s managerial skills, physician’s manager role

Full medical registration in Germany requires passing three medical state examinations. The first state exam (M1) regarding pre-clinical subjects consists of a written exam and a viva voce exam. The second state exam (M2) is a written test and comprises the medical specialties. The third state exam (M3)is an oral/viva voce practical exam. The written test questions are published by the German Institute for Medical and Pharmaceutical Examination Questions (IMPP).Both written tests consist of 320 single choice questions with five possible answers each. Recently, artificial intelligence (AI) in the form of ChatGPT passed examinations of the US Medical License exam (USMLE) (1). ChatGPT is a large language model (LLM), which is based on the transformer network architecture "general pre-trained transformer" (GPT) with more than 170 billion parameters (2, 3). It recognizes speech patterns and responds in a context appropriate way to user queries/questions. We investigated whether Chat GPT could pass the first and second state examinations in Germany and thus is able to answer complex medical questions in the German language. [ABSTRACT FROM AUTHOR]

Objective: Space for personality development as well as for the development of critical, creative and interdisciplinary thinking is rarely found in medical curricula in Germany. To be prepared for the challenges of modern medicine, future physicians need a visionary mindset. The aim of this study is to determine the need for teaching such content among medical students in the context of visionary elective curricula and to examine these with regard to the desired topics and organizational structure.Methods: This is a cross-sectional study with 236 medical students from all semesters of the Ludwig-Maximilians-University Munich. The survey consists of 50 questions and includes single choice, multiple choice, matrix questions, open-ended questions and Likert scales. Responses were examined using descriptive statistics and compared parametrically in sub-aspects.Results: Three-quarters of respondents would like to see curricular content on interdisciplinary interfaces with other disciplines. A suitable framework for this is seen by 87% of the respondents in a visionary elective curriculum. Students would like to see a broad range of specific content such as global health, politics, business, and computer science. The majority of respondents would like to see 1 unit of instruction per week and would participate in an appropriate program. Such an offering would promote creative (53.6%), critical (63.7%), and interdisciplinary thinking (69.0%) and train to become better physicians (87%).Conclusion: Participants in this study are positive toward the introduction of visionary content in medical school. Faculties should build visionary elective curricula according to the graduate profile requirements of the new NKLM 2.0 to make medical education sustainable.

A circular, nature-based solution has been implemented in the drought-prone zone of the Mediterranean Island of Mykonos (Greece) to demonstrate how a residential rainwater collection system can be upgraded to enable optimal use of low-cost rainwater while making use of the natural services provided by the subsurface. The overall purpose is to develop a novel distributed intervention for rainwater harvesting, storage and recovery, by collecting excess water during the winter season and reusing it in the summer, thus increasing its management efficiency. The functioning of the entire system is flexible and adaptable, as it can be adjusted according to specific environmental conditions (rainfall, temperature) for each hydrological year. The configuration is highly replicable as it can be implemented in similar water scarce areas of the Mediterranean region and beyond and scalable as it can be applied to various scales (e.g. residential, touristic, municipal) of water demanding systems. [ABSTRACT FROM AUTHOR]

Patients suffering from chronic kidney disease (CKD) have higher ischemic and bleeding risk compared with patients with normal renal function. The aim of our systematic review and meta-analysis is to compare shortened (≤3 months) dual antiplatelet therapy (DAPT) with longer DAPT in patients with CKD undergoing percutaneous coronary interventions. We systematically screened three major databases (Medline, Cochrane Central Register of Controlled Trials, and Scopus) searching for randomized-controlled trials or subanalyses of them, which compared shortened (S-DAPT) to longer (L-DAPT) regimens of DAPT in patients with CKD. The primary endpoint is the net adverse clinical events (NACE) and the secondary is major adverse cardiac events (MACE), and bleedings. Subgroup analyses included studies using only P2Y12 monotherapy, ticagrelor-based regimens, 1- and 3-month duration of DAPT. A total of 10 studies and 6688 patients were included in our analysis. No significant differences regarding NACE (RR: 0.97, 95% CI: 0.84-1.12, I2 = 0%), MACE (RR: 1.00, 95% CI: 0.85-1.117, I2 = 0%), and bleedings (RR: 0.78, 95% CI: 0.59-1.03, I2 = 25%) were observed between S-DAPT and L-DAPT in our meta-analysis. The findings from the subgroup analyses were in accordance with total findings; bleedings were significantly reduced in S-DAPT when only studies with 3-month duration of DAPT were analyzed (RR: 0.58, 95% CI: 0.40-0.85, I2 = 0%). Our systematic review and meta-analysis showed that no significant differences were observed between patients treated with S-DAPT or L-DAPT in the terms of MACE, NACE, and bleedings in patients with CKD. When it is required, S-DAPT could be considered in patients with CKD., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

In the modern era of structural heart interventions, the total number of transseptal procedures is growing exponentially, thus increasing the rate and need for management of iatrogenic atrial septal defects (iASDs). To date, there are no official guidelines on the assessment and management of iASDs, due to inconclusive evidence on whether patients benefit more from the percutaneous closure of iASD than from conservative management and vigorous follow-up. Despite the abundance of observational studies on iASDs, there is still a lack of randomized studies. Evidence so far show that percutaneous closure is no superior over conservative treatment in patients with iASDs, however, it has been demonstrated that patients with spontaneous closure of iASDs experience less heart failure (HF) hospitalizations. On the other hand, researchers have investigated the beneficial nature of interatrial shunt therapy in patients with HFpEF and, more recently, with HFrEF, due to the presumed hemodynamic benefits. Herein, we provide an updated review of relevant literature, focusing on iASD persistence rates, predicting factors for their persistence, and clinical outcomes of iASD persistence, to summarize available evidence and discuss future directions in the field., (© 2024 Wiley Periodicals LLC.)

Heart failure (HF) has become even more prevalent in recent years, as a result of improved diagnostics and an increase in the risk factors predisposing to its pathology. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) emerged as one of the key pharmacotherapy options for both reduced and preserved ejection fraction, providing cardio- and renoprotection and improving mortality and cardiovascular (CV) outcomes. The pleiotropism of SGLT2i has led to multiple efforts to understand their distinct pathophysiological interactions with various pathways, including microcirculation, endothelial dysfunction, and inflammation. More recently, the role of SGLT2i on the sympathetic nervous system (SNS) is starting to be recognized, especially as observations of retained or reduced heart rate (HR) despite volume contraction have been noted by investigators in the large clinical trials testing the safety and efficacy of these agents. Both preclinical and clinical studies have been performed, with conflicting results. Interestingly, in both settings, whilst there are indications of SNS modulation by SGLT2i, other studies contradict such findings, without showing, however, worsening of the autonomic homeostasis. Given the importance of neuromodulation in HF, in both pharmacological and interventional therapies, in this review, we aim to describe the role of SNS in CV disease, focusing on HF, analyse preclinical and clinical data regarding the efficacy of SGLT2i in modulating autonomic dysfunction by examining various markers of SNS activation, as well as provide the most plausible theoretical backgrounds on the mechanism of benefit of SNS from the inhibition of SGLT2 receptors., Competing Interests: Funding: None, Conflict of Interest: None, (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Hypertension, characterized by elevated blood pressure levels, remains a global health concern due to its association with cardiovascular complications, notably thrombosis. Thrombosis, the formation of blood clots within blood vessels, poses a significant risk for myocardial infarction, stroke, and limb ischemia, leading to adverse patient outcomes. Understanding the pathophysiological mechanisms underlying thrombosis in hypertension is crucial for developing effective preventive and therapeutic strategies. Hypertension induces structural and functional alterations in the vasculature, endothelium, and platelets, creating a prothrombotic milieu. Endothelial dysfunction, increased platelet activation, and alterations in coagulation factors contribute to the heightened thrombotic risk observed in hypertensive individuals. Biomarkers associated with thrombotic events, such as mean platelet volume, D-Dimer, and fibrinogen offer valuable insights into the pathogenesis of thrombosis and may serve as prognostic indicators for cardiovascular events in hypertensive populations. Investigating the impact of antihypertensive treatment on thrombotic risk is essential, as these medications exert pleiotropic effects on the vasculature and hemostatic system. By elucidating the intricate interplay between hypertension and thrombosis, this review aims to enhance our understanding of cardiovascular risk in hypertensive individuals and identify novel therapeutic targets for preventing thrombotic complications., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Introduction: Contrast-induced acute kidney injury (CI-AKI) is a common complication of iodinated contrast administration during coronary procedures, especially in patients with diabetes mellitus (DM). Besides periprocedural hydration and statins, there are no other pharmacological strategies with consistent results to prevent CI-AKI up to date. This study aims to evaluate the efficacy of chronic use of sodium-glucose co-transporter 2 (SGLT2) inhibitors on the prevention of CI-AKI in patients with type 2 DM following coronary procedures., Methods: A systematic literature search of MEDLINE, Google Scholar, Embase, and Cochrane Library was performed. Relevant observational studies and randomized controlled studies (RCTs) were identified. Results were pooled using a random-effect model meta-analysis. Subgroup analyses were performed to evaluate the potential benefit of SGLT2 inhibitors on the prevention of CI-AKI in patients undergoing urgent or elective coronary angiography/percutaneous coronary interventions (CAG/PCI)., Results: Seven observational studies and one randomized controlled trial with 2740 patients were included. Chronic treatment (minimum duration 2 weeks to 6 months) with an SGLT2 inhibitor was associated with a significantly reduced risk of CI-AKI in diabetic patients undergoing coronary procedures compared with the control group [risk ratio (RR) 0.48; 95% confidence interval (CI) 0.39-0.59; p < 0.001). Results of subsequent subgroup analysis showed a significant reduction in the incidence of CI-AKI in diabetic patients undergoing both elective CAG/PCI (RR 0.49; 95% CI 0.35-0.68; p<0.001) and urgent CAG/PCI (RR 0.48; 95% Cl 0.35-0.66; p < 0.001)., Discussion: Chronic use of SGLT2 inhibitors may be preventative against the incidence of CI-AKI in patients with type 2 DM undergoing coronary interventions. Further RCTs are needed to confirm our findings., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Heart failure with preserved ejection fraction (HFpEF) represents an entity with complex pathophysiologic pathways, among which coronary microvascular dysfunction (CMD) is believed to be an important orchestrator. Research in the field of CMD has highlighted impaired vasoreactivity, capillary rarefaction, and inflammation as potential mediators of its development. CMD can be diagnosed via several noninvasive methods including transthoracic echocardiography, cardiac magnetic resonance, and positron emission tomography. Moreover, invasive methods such as coronary flow reserve and index of microcirculatory resistance are commonly employed in the assessment of CMD. As far as the association between CMD and HFpEF is concerned, numerous studies have highlighted the coexistence of CMD in the majority of HFpEF patients. Additionally, patients affected by both conditions may be facing an adverse prognosis. Finally, there is limited evidence suggesting a beneficial effect of renin-angiotensin-aldosterone system blockers, ranolazine, and sodium-glucose cotransporter-2 inhibitors in CMD, with further evidence being awaited regarding the impact of other pharmacotherapies such as anti-inflammatory agents., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

In the dynamic field of interventional cardiology, significant strides have been made in reducing periprocedural complications. Echocardiography, particularly transesophageal echocardiography, plays a key role in ensuring the safety and success of structural heart interventions. Its real-time imaging capabilities allow for precise monitoring of device positioning, deployment, and procedural outcomes. By adhering to established imaging protocols and acquiring standard imaging planes, periprocedural echocardiography has become an essential tool for the successful performance of many structural heart interventions. In this manuscript, we present a series of unusual yet significant complications that we encountered during structural interventional procedures in our catheter laboratory. These complications, detected through echocardiography, underscore the critical role of imaging guidance in recognizing, and addressing unforeseen challenges, such as device malposition, thrombus formation in cardiac chambers during structural heart interventions, and cardiac tamponade during transcatheter mitral valve procedures. Through these cases, we highlight the effectiveness of transesophageal echocardiography in promptly identifying complications, allowing for timely intervention and resolution., (© 2024 The Author(s). Journal of Clinical Ultrasound published by Wiley Periodicals LLC.)

Lately, a large number of stable ischemic patients, with no obstructed coronary arteries are being diagnosed. Despite this condition, which is being described as angina with no obstructive coronary arteries (ANOCA), was thought to be benign, recent evidence report that it is associated with increased risk for adverse cardiovascular outcomes. ANOCA is more frequent in women and, pathophysiologically, it is predominantly related with microvascular dysfunction, while other factors, such as endothelial dysfunction, inflammation and autonomic nervous system seem to also play a major role to its development, while other studies implicate ANOCA and microvascular dysfunction in the pathogenesis of heart failure with preserved ejection fraction. For establishing an ANOCA diagnosis, measurement including coronary flow reserve (CFR), microvascular resistance (IMR) and hyperemic microvascular resistance (HMR) are mostly used in clinical practice. In addition, new modalities, such as optical coherence tomography (OCT) are being tested and show promising results for future diagnostic use. Regarding management, pharmacotherapy consists of a wide selection of drugs, according to the respected pathophysiology of the disease (vasospastic angina or microvascular dysfunction), while research for new treatment options including interventional techniques, is currently ongoing. This review, therefore, aims to provide a comprehensive analysis of all aspects related to ANOCA, from pathophysiology to clinical managements, as well as clinical implications and suggestions for future research efforts, which will help advance our understanding of the syndrome and establish more, evidence-based, therapies., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Early revascularization for patients with acute myocardial infarction (AMI) is of outmost importance in limiting infarct size and associated complications, as well as for improving long-term survival and outcomes. However, reperfusion itself may further damage the myocardium and increase the infarct size, a condition commonly recognized as myocardial reperfusion injury. Several strategies have been developed for limiting the associated with reperfusion myocardial damage, including hypothermia. Hypothermia has been shown to limit the degree of infarct size increase, when started before reperfusion, in several animal models. Systemic hypothermia, however, failed to show any benefit, due to adverse events and potentially insufficient myocardial cooling. Recently, the novel technique of intracoronary selective hypothermia is being tested, with preclinical and clinical results being of particular interest. Therefore, in this review, we will describe the pathophysiology of myocardial reperfusion injury and the cardioprotective mechanics of hypothermia, report the animal and clinical evidence in both systemic and selective hypothermia and discuss the potential future directions and clinical perspectives in the context of cardioprotection for myocardial reperfusion injury.

Meropenem penetration into the cerebrospinal fluid (CSF) is subject to high interindividual variability resulting in uncertain target attainment in CSF. Recently, several authors recommended administering meropenem as a continuous infusion (CI) to optimize CSF exposure. This study aimed to compare the concentrations and pharmacokinetics of meropenem in CSF after intermittent infusion (II) and CI. This prospective, observational study (NCT04426383) included critically ill patients with external ventricular drains who received either II or CI of meropenem. Meropenem pharmacokinetics in plasma and CSF were characterized using population pharmacokinetic modeling (NONMEM 7.5). The developed model was used to compare the concentration-time profile and probability of target attainment (PTA) between II and CI. A total of 16 patients (8 CI, 8 II; samples: n plasma = 243, n CSF = 263) were recruited, with nine patients (5 CI, 4 II) suffering from cerebral and seven patients from extracerebral infections. A one-compartment model described the plasma concentrations adequately. Meropenem penetration into the CSF (partition coefficient (KP), c CSF /c plasma ) was generally low (6.0%), exhibiting substantial between-subject variability (coefficient of variation: 84.0%). There was no correlation between the infusion mode and KP, but interleukin (IL)-6 measured in CSF showed a strong positive correlation with KP ( P < 0.001). Dosing simulations revealed no relevant differences in CSF concentrations and PTA in CSF between CI and II. Our study did not demonstrate increased penetration rates or higher concentrations of meropenem in the CSF with CI compared with II., Clinical Trials: This study is registered with ClinicalTrials.gov as NCT04426383., Competing Interests: S.G.W. received research support from Boehringer Ingelheim and AqVida GmbH; consultancy fees from Medicine for Malaria Venture, Utility Therapeutics, and Merck KGaA; and speaker honoraria from GlaxoSmithKline. C.S. received speaker honoraria from CytoSorbents Europe GmbH. M.Z. received research support from CytoSorbents Europe GmbH, consulting fees from Gilead, and speaker honoraria from MSD. U.L. received consulting honoraria from CytoSorbents Europe GmbH and was part of an advisory board of Roche Diagnostics International Ltd. All other authors declare no conflict of interest.

Atrial fibrillation (AF) is the most common arrhythmia in patients with valvular heart disease, and it can be associated with adverse patient outcomes. However, the need for anticoagulation to counterbalance AF-associated stroke risk may further lead to suboptimal outcomes via increasing bleeding events, especially in high-risk individuals. Because the vast majority of thrombi occur in the left atrial appendage, left atrial appendage occlusion (LAAO) is an established procedure for preventing ischemic stroke in patients with AF, while limiting anticoagulation-related bleeding events. Thus, the concept of combining an index procedure for structural heart disease (SHD) with LAAO seems promising for preventing future stroke events. A combined procedure has been described in aortic stenosis (transcatheter aortic valve implantation + LAAO), mitral regurgitation (transcatheter edge-to-edge repair + LAAO), and atrial septal defects (patent foramen ovale/atrial septal defect + LAAO). Evidence shows that a combined procedure can be safely performed in a "1-stop shop" fashion, without increased rates of procedural adverse events, with the potential to limit bleeding risk and provide prophylaxis against stroke events. This review analyses indications and clinical evidence regarding the safety and efficacy of combined SHD+LAAO procedures, while also providing insights into gaps in knowledge and future directions for the evolution of this field., (Copyright © 2024 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)