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(1) Background and Objectives : Flow assessment using cardiovascular magnetic resonance (CMR) provides important implications in determining physiologic parameters and clinically important markers. However, post-processing of CMR images remains labor- and time-intensive. This study aims to assess the validity and repeatability of fully automated segmentation of phase contrast velocity-encoded aortic root plane. (2) Materials and Methods: Aortic root images from 125 patients are segmented by artificial intelligence (AI), developed using convolutional neural networks and trained with a multicentre cohort of 160 subjects. Derived simple flow indices (forward and backward flow, systolic flow and velocity) and complex indices (aortic maximum area, systolic flow reversal ratio, flow displacement, and its angle change) were compared with those derived from manual contours. (3) Results : AI-derived simple flow indices yielded excellent repeatability compared to human segmentation ( p < 0.001), with an insignificant level of bias. Complex flow indices feature good to excellent repeatability ( p < 0.001), with insignificant levels of bias except flow displacement angle change and systolic retrograde flow yielding significant levels of bias ( p < 0.001 and p < 0.05, respectively). (4) Conclusions : Automated flow quantification using aortic root images is comparable to human segmentation and has good to excellent repeatability. However, flow helicity and systolic retrograde flow are associated with a significant level of bias. Overall, all parameters show clinical repeatability.

Objective: Chronic pain in inflammatory bowel disease (IBD) is common and detrimental to quality of life. Recent Cochrane reviews identified a multitude of randomised controlled trial interventions, but the certainty of the findings is low or very low. We set out to reach a patient and professional co-produced Delphi consensus on treatment priorities, key outcomes and propose a model for understanding our findings., Methods: An online survey was co-produced with Crohn's and Colitis UK and sent to patients and healthcare professionals in two phases, for prioritisation of treatments and outcome measures. Phase three consisted of four online group interviews, where patients and healthcare professionals discussed the rationale of their choices. Transcripts were combined with the free text data from the Delphi surveys and analysed through a three-phase qualitative technique., Results: The phase 1 survey was completed by 128 participants (73 patients, 3 carers and 53 health professionals). Diet was the top priority for both patients (n=26/73, 36.1%) and healthcare professionals (n=29/52, 56.9%). Phase 2 was completed by 68 participants. FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet, stress management therapy and relaxation therapy were the top three consensus priorities. Phase 3 group interviews were attended by 13 patients and 5 healthcare professionals. Key themes included: The patient as an individual, beliefs and experiences, disease activity influencing therapy choice, accessibility barriers and quality of life., Conclusion: Low FODMAP diet, followed by psychological therapies were the highest-rated research priorities for healthcare professionals and patients. Funding bodies and researchers should consider these findings, alongside the model for understanding our findings, when making research decisions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Aortic conduit and reservoir functions can be directly measured by four-dimensional flow (4D flow) cardiovascular magnetic resonance (CMR)., Methods: Twenty healthy controls (10 young and 10 age-gender-matched old controls) and 20 patients with heart failure with preserved ejection fraction (HFpEF) were recruited. All had 4D flow CMR. Flow was quantified at the ascending and descending aorta levels. In addition, at the ascending aorta level, we quantified systolic flow displacement (FDs) and systolic flow reversal ratio (sFRR). The aortic conduit function was defined as the relative drop in systolic flow from the ascending to the descending aorta (∆Fs). Aortic reservoir function was defined as descending aortic diastolic stroke volume (DAo SV d )., Results: Both ∆Fs (R=0.51, p=0.001) and DAo SV d (R=-0.68, p=0.001) were significantly associated with ageing. Native T1 (R=0.51, p=0.001) and extracellular volume (R=0.51, p=0.001) showed maximum association with ∆Fs. ∆Fs significantly increased in HFpEF versus age-gender-matched controls (41±8% vs 52±12%, p=0.02). In multiple regression, only ∆Fs and DAo SV d were independent predictors of the estimated glomerular filtration rate (model R=0.77, p=0.0001). FDs was significantly associated with ∆Fs (R=0.4, p=0.01) and DAo SV d (R=-0.48, p=0.002), whereas sFRR was mainly associated with DAo SV d (R=-0.46, p=0.003)., Conclusion: Both aortic conduit and reservoir function decline with age and this decline in aortic function is also independently associated with renal functional decline. Ascending aortic turbulent flow signatures are associated with loss of aortic conduit and reservoir functions. Finally, in HFpEF, aortic conduit and reservoir function demonstrate progressive decline., Trials Registration Number: NCT05114785., Competing Interests: Competing interests: PG is a clinical advisor for Neosoft, Pie Medical Imaging and Medis Medical Imaging. PG consults for Anteris and Edward Life Sciences. All other authors have no competing interests to declare., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Cardiovascular magnetic resonance (CMR) imaging shows promise in estimating pulmonary capillary wedge pressure (PCWP) non-invasively. At the population level, the prognostic role of CMR-modelled PCWP remains unknown. Furthermore, the relationship between CMR-modelled PCWP and established risk factors for cardiovascular disease has not been well characterized., Objective: The main aim of this study was to investigate the prognostic value of CMR-modelled PCWP at the population level., Methods: Employing data from the imaging substudy of the UK Biobank, a very large prospective population-based cohort study, CMR-modelled PCWP was calculated using a model incorporating left atrial volume, left ventricular mass and sex. Logistic regression explored the relationships between typical cardiovascular risk factors and raised CMR-modelled PCWP (≥15 mmHg). Cox regression was used to examine the impact of typical risk factors and CMR-modelled PCWP on heart failure (HF) and major adverse cardiovascular events (MACE)., Results: Data from 39 163 participants were included in the study. Median age of all participants was 64 years (inter-quartile range: 58 to 70), and 47% were males. Clinical characteristics independently associated with raised CMR-modelled PCWP included hypertension [odds ratio (OR) 1.57, 95% confidence interval (CI) 1.44-1.70, P < 0.001], body mass index (BMI) [OR 1.57, 95% CI 1.52-1.62, per standard deviation (SD) increment, P < 0.001], male sex (OR 1.37, 95% CI 1.26-1.47, P < 0.001), age (OR 1.33, 95% CI 1.27-1.41, per decade increment, P < 0.001) and regular alcohol consumption (OR 1.10, 95% CI 1.02-1.19, P = 0.012). After adjusting for potential confounders, CMR-modelled PCWP was independently associated with incident HF [hazard ratio (HR) 2.91, 95% CI 2.07-4.07, P < 0.001] and MACE (HR 1.48, 95% CI 1.16-1.89, P = 0.002)., Conclusions: Raised CMR-modelled PCWP is an independent risk factor for incident HF and MACE. CMR-modelled PCWP should be incorporated into routine CMR reports to guide HF diagnosis and further management., (© 2024 The Author(s). ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Cardiac magnetic resonance (CMR) in the four-chamber plane offers comprehensive insight into the volumetrics of the heart. We aimed to develop an artificial intelligence (AI) model of time-resolved segmentation using the four-chamber cine., Methods: A fully automated deep learning algorithm was trained using retrospective multicentre and multivendor data of 814 subjects. Validation, reproducibility, and mortality prediction were evaluated on an independent cohort of 101 subjects., Results: The mean age of the validation cohort was 54 years, and 66 (65%) were males. Left and right heart parameters demonstrated strong correlations between automated and manual analysis, with a ρ of 0.91-0.98 and 0.89-0.98, respectively, with minimal bias. All AI four-chamber volumetrics in repeatability analysis demonstrated high correlation (ρ = 0.99-1.00) and no bias. Automated four-chamber analysis underestimated both left ventricular (LV) and right ventricular (RV) volumes compared to ground-truth short-axis cine analysis. Two correction factors for LV and RV four-chamber analysis were proposed based on systematic bias. After applying the correction factors, a strong correlation and minimal bias for LV volumetrics were observed. During a mean follow-up period of 6.75 years, 16 patients died. On stepwise multivariable analysis, left atrial ejection fraction demonstrated an independent association with death in both manual (hazard ratio (HR) = 0.96, p = 0.003) and AI analyses (HR = 0.96, p < 0.001)., Conclusion: Fully automated four-chamber CMR is feasible, reproducible, and has the same real-world prognostic value as manual analysis. LV volumes by four-chamber segmentation were comparable to short-axis volumetric assessment., Trials Registration: ClinicalTrials.gov: NCT05114785., Relevance Statement: Integrating fully automated AI in CMR promises to revolutionise clinical cardiac assessment, offering efficient, accurate, and prognostically valuable insights for improved patient care and outcomes., Key Points: • Four-chamber cine sequences remain one of the most informative acquisitions in CMR examination. • This deep learning-based, time-resolved, fully automated four-chamber volumetric, functional, and deformation analysis solution. • LV and RV were underestimated by four-chamber analysis compared to ground truth short-axis segmentation. • Correction bias for both LV and RV volumes by four-chamber segmentation, minimises the systematic bias., (© 2024. The Author(s).)

Background: Constipation that is prolonged and does not resolve with conventional therapeutic measures is called intractable constipation. The treatment of intractable constipation is challenging, involving pharmacological or non-pharmacological therapies, as well as surgical approaches. Unresolved constipation can negatively impact quality of life, with additional implications for health systems. Consequently, there is an urgent need to identify treatments that are efficacious and safe., Objectives: To evaluate the efficacy and safety of treatments used for intractable constipation in children., Search Methods: We searched CENTRAL, MEDLINE, Embase, and two trials registers up to 23 June 2023. We also searched reference lists of included studies for relevant studies., Selection Criteria: We included randomised controlled trials (RCTs) comparing any pharmacological, non-pharmacological, or surgical treatment to placebo or another active comparator, in participants aged between 0 and 18 years with functional constipation who had not responded to conventional medical therapy., Data Collection and Analysis: We used standard Cochrane methods. Our primary outcomes were symptom resolution, frequency of defecation, treatment success, and adverse events; secondary outcomes were stool consistency, painful defecation, quality of life, faecal incontinence frequency, abdominal pain, hospital admission for disimpaction, and school absence. We used GRADE to assess the certainty of evidence for each primary outcome., Main Results: This review included 10 RCTs with 1278 children who had intractable constipation. We assessed one study as at low risk of bias across all domains. There were serious concerns about risk of bias in six studies. One study compared the injection of 160 units botulinum toxin A (n = 44) to unspecified oral stool softeners (n = 44). We are very uncertain whether botulinum toxin A injection improves treatment success (risk ratio (RR) 37.00, 95% confidence interval (CI) 5.31 to 257.94; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Frequency of defecation was reported only for the botulinum toxin A injection group (mean interval of 2.6 days). The study reported no data for the other primary outcomes. One study compared erythromycin estolate (n = 6) to placebo (n = 8). The only primary outcome reported was adverse events, which were 0 in both groups. The evidence is of very low certainty due to concerns with risk of bias and serious imprecision. One study compared 12 or 24 μg oral lubiprostone (n = 404) twice a day to placebo (n = 202) over 12 weeks. There may be little to no difference in treatment success (RR 1.29, 95% CI 0.87 to 1.92; low certainty evidence). We also found that lubiprostone probably results in little to no difference in adverse events (RR 1.05, 95% CI 0.91 to 1.21; moderate certainty evidence). The study reported no data for the other primary outcomes. One study compared three-weekly rectal sodium dioctyl sulfosuccinate and sorbitol enemas (n = 51) to 0.5 g/kg/day polyethylene glycol laxatives (n = 51) over a 52-week period. We are very uncertain whether rectal sodium dioctyl sulfosuccinate and sorbitol enemas improve treatment success (RR 1.33, 95% CI 0.83 to 2.14; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). Results of defecation frequency per week was reported only as modelled means using a linear mixed model. The study reported no data for the other primary outcomes. One study compared biofeedback therapy (n = 12) to no intervention (n = 12). We are very uncertain whether biofeedback therapy improves symptom resolution (RR 2.50, 95% CI 1.08 to 5.79; very low certainty evidence, downgraded due to serious concerns with risk of bias and imprecision). The study reported no data for the other primary outcomes. One study compared 20 minutes of intrarectal electromotive botulinum toxin A using 2800 Hz frequency and botulinum toxin A dose 10 international units/kg (n = 30) to 10 international units/kg botulinum toxin A injection (n = 30). We are very uncertain whether intrarectal electromotive botulinum toxin A improves symptom resolution (RR 0.96, 95% CI 0.76 to 1.22; very low certainty evidence) or if it increases the frequency of defecation (mean difference (MD) 0.00, 95% CI -1.87 to 1.87; very low certainty evidence). We are also very uncertain whether intrarectal electromotive botulinum toxin A has an improved safety profile (RR 0.20, 95% CI 0.01 to 4.00; very low certainty evidence). The evidence for these results is of very low certainty due to serious concerns with risk of bias and imprecision. The study did not report data on treatment success. One study compared the injection of 60 units botulinum toxin A (n = 21) to myectomy of the internal anal sphincter (n = 21). We are very uncertain whether botulinum toxin A injection improves treatment success (RR 1.00, 95% CI 0.75 to 1.34; very low certainty evidence). No adverse events were recorded. The study reported no data for the other primary outcomes. One study compared 0.04 mg/kg oral prucalopride (n = 107) once daily to placebo (n = 108) over eight weeks. Oral prucalopride probably results in little or no difference in defecation frequency (MD 0.50, 95% CI -0.06 to 1.06; moderate certainty evidence); treatment success (RR 0.96, 95% CI 0.53 to 1.72; moderate certainty evidence); and adverse events (RR 1.15, 95% CI 0.94 to 1.39; moderate certainty evidence). The study did not report data on symptom resolution. One study compared transcutaneous electrical stimulation to sham stimulation, and another study compared dietitian-prescribed Mediterranean diet with written instructions versus written instructions. These studies did not report any of our predefined primary outcomes., Authors' Conclusions: We identified low to moderate certainty evidence that oral lubiprostone may result in little to no difference in treatment success and adverse events compared to placebo. Based on moderate certainty evidence, there is probably little or no difference between oral prucalopride and placebo in defecation frequency, treatment success, or adverse events. For all other comparisons, the certainty of the evidence for our predefined primary outcomes is very low due to serious concerns with study limitations and imprecision. Consequently, no robust conclusions could be drawn., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Aims: Heart failure (HF) with preserved ejection fraction disproportionately affects women. There are no validated sex-specific tools for HF diagnosis despite widely reported differences in cardiac structure. This study investigates whether sex, as assigned at birth, influences cardiac magnetic resonance (CMR) assessment of left ventricular filling pressure (LVFP), a hallmark of HF agnostic to ejection fraction., Methods and Results: A derivation cohort of patients with suspected pulmonary hypertension and HF from the Sheffield centre underwent invasive right heart catheterization and CMR within 24 h of each other. A sex-specific CMR model to estimate LVFP, measured as pulmonary capillary wedge pressure (PCWP), was developed using multivariable regression. A validation cohort of patients with confirmed HF from the Leeds centre was used to evaluate for the primary endpoints of HF hospitalization and major adverse cardiovascular events (MACEs). Comparison between generic and sex-specific CMR-derived PCWP was undertaken. A total of 835 (60% female) and 454 (36% female) patients were recruited into the derivation and validation cohorts respectively. A sex-specific model incorporating left atrial volume and left ventricular mass was created. The generic CMR PCWP showed significant differences between males and females (14.7 ± 4 vs. 13 ± 3.0 mmHg, P > 0.001), not present with the sex-specific CMR PCWP (14.1 ± 3 vs. 13.8 mmHg, P = 0.3). The sex-specific, but not the generic, CMR PCWP was associated with HF hospitalization (hazard ratio 3.9, P = 0.0002) and MACE (hazard ratio 2.5, P = 0.001) over a mean follow-up period of 2.4 ± 1.2 years., Conclusion: Accounting for sex improves precision and prognostic performance of CMR biomarkers for HF., Competing Interests: Conflict of interest: P.G. is a clinical advisor for Pie Medical Imaging and Medis Medical Imaging. All other authors have no conflicts of interest to declare., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Artificial Intelligence (AI) is rapidly transforming healthcare, and there is a critical need for a nuanced understanding of how AI is reshaping teaching, learning, and educational practice in medical education. This review aimed to map the literature regarding AI applications in medical education, core areas of findings, potential candidates for formal systematic review and gaps for future research., Methods: This rapid scoping review, conducted over 16 weeks, employed Arksey and O'Malley's framework and adhered to STORIES and BEME guidelines. A systematic and comprehensive search across PubMed/MEDLINE, EMBASE, and MedEdPublish was conducted without date or language restrictions. Publications included in the review spanned undergraduate, graduate, and continuing medical education, encompassing both original studies and perspective pieces. Data were charted by multiple author pairs and synthesized into various thematic maps and charts, ensuring a broad and detailed representation of the current landscape., Results: The review synthesized 278 publications, with a majority (68%) from North American and European regions. The studies covered diverse AI applications in medical education, such as AI for admissions, teaching, assessment, and clinical reasoning. The review highlighted AI's varied roles, from augmenting traditional educational methods to introducing innovative practices, and underscores the urgent need for ethical guidelines in AI's application in medical education., Conclusion: The current literature has been charted. The findings underscore the need for ongoing research to explore uncharted areas and address potential risks associated with AI use in medical education. This work serves as a foundational resource for educators, policymakers, and researchers in navigating AI's evolving role in medical education. A framework to support future high utility reporting is proposed, the FACETS framework.

Background: Left atrial (LA) assessment is an important marker of adverse cardiovascular outcomes. Cardiovascular magnetic resonance (CMR) accurately quantifies LA volume and function based on biplane long-axis imaging. We aimed to validate single-plane-derived LA indices against the biplane method to simplify the post-processing of cine CMR., Methods: In this study, 100 patients from Leeds Teaching Hospitals were used as the derivation cohort. Bias correction for the single plane method was applied and subsequently validated in 79 subjects., Results: There were significant differences between the biplane and single plane mean LA maximum and minimum volumes and LA ejection fraction (EF) (all p < 0.01). After correcting for biases in the validation cohort, significant correlations in all LA indices were observed (0.89 to 0.98). The area under the curve (AUC) for the single plane to predict biplane cutoffs of LA maximum volume ≥ 112 mL was 0.97, LA minimum volume ≥ 44 mL was 0.99, LA stroke volume (SV) ≤ 21 mL was 1, and LA EF ≤ 46% was 1, (all p < 0.001)., Conclusions: LA volumetric and functional assessment by the single plane method has a systematic bias compared to the biplane method. After bias correction, single plane LA volume and function are comparable to the biplane method.

Purpose: The main objective of this study was to develop two-dimensional (2D) phase contrast (PC) methods to quantify the helicity and vorticity of blood flow in the aortic root., Methods: This proof-of-concept study used four-dimensional (4D) flow cardiovascular MR (4D flow CMR) data of five healthy controls, five patients with heart failure with preserved ejection fraction and five patients with aortic stenosis (AS). A PC through-plane generated by 4D flow data was treated as a 2D PC plane and compared with the original 4D flow. Visual assessment of flow vectors was used to assess helicity and vorticity. We quantified flow displacement (FD), systolic flow reversal ratio (sFRR) and rotational angle (RA) using 2D PC., Results: For visual vortex flow presence near the inner curvature of the ascending aortic root on 4D flow CMR, sFRR demonstrated an area under the curve (AUC) of 0.955, p<0.001. A threshold of >8% for sFRR had a sensitivity of 82% and specificity of 100% for visual vortex presence. In addition, the average late systolic FD, a marker of flow eccentricity, also demonstrated an AUC of 0.909, p<0.001 for visual vortex flow. Manual systolic rotational flow angle change (ΔsRA) demonstrated excellent association with semiautomated ΔsRA (r=0.99, 95% CI 0.9907 to 0.999, p<0.001). In reproducibility testing, average systolic FD (FDsavg) showed a minimal bias at 1.28% with a high intraclass correlation coefficient (ICC=0.92). Similarly, sFRR had a minimal bias of 1.14% with an ICC of 0.96. ΔsRA demonstrated an acceptable bias of 5.72°-and an ICC of 0.99., Conclusion: 2D PC flow imaging can possibly quantify blood flow helicity (ΔRA) and vorticity (FRR). These imaging biomarkers of flow helicity and vorticity demonstrate high reproducibility for clinical adoption., Trials Registration Number: NCT05114785., Competing Interests: Competing interests: PG is a clinical advisor for Pie Medical Imaging and Medis Medical Imaging and has done consultancy for Edwards Life Sciences and Anteris. All other authors have no competing interests to declare., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Aims: Turbulent aortic flow makes the cardiovascular system less effective. It remains unknown if patients with heart failure with preserved ejection fraction (HFpEF) have disturbed aortic flow. This study sought to investigate advanced markers of aortic flow disturbances in HFpEF., Methods: This case-controlled observational study used four-dimensional flow cardiovascular magnetic resonance derived, two-dimensional phase-contrast reformatted plane data at an orthogonal plane just above the sino-tubular junction. We recruited 10 young healthy controls (HCs), 10 old HCs and 23 patients with HFpEF. We analysed average systolic aortic flow displacement (FDsavg), systolic flow reversal ratio (sFRR) and pulse wave velocity (PWV). In a sub-group analysis, we compared old HCs versus age-gender-matched HFpEF (N=10)., Results: Differences were significant in mean age (P<0.001) among young HCs (22.9±3.5 years), old HCs (60.5±10.2 years) and HFpEF patients (73.7±9.7 years). FDsavg, sFRR and PWV varied significantly (P<0.001) in young HCs (8±4%, 2±2%, 4±2m/s), old HCs (16±5%, 7±6%, 11±8m/s), and HFpEF patients (23±10%, 11±10%, 8±3). No significant PWV differences existed between old HCs and HFpEF.HFpEF had significantly higher FDsavg versus old HCs (23±10% vs 16±5%, P<0.001). A FDsavg > 17.7% achieved 74% sensitivity, 70% specificity for differentiating them. sFRR was notably higher in HFpEF (11±10% vs 7±6%, P<0.001). A sFRR > 7.3% yielded 78% sensitivity, 70% specificity in differentiating these groups. In sub-group analysis, FDsavg remained distinctly elevated in HFpEF (22.4±9.7% vs 16±4.9%, P=0.029). FDsavg of >16% showed 100% sensitivity and 70% specificity (P=0.01). Similarly, sFRR remained significantly higher in HFpEF (11.3±9.5% vs 6.6±6.4%, P=0.007). A sFRR of >7.2% showed 100% sensitivity and 60% specificity (P<0.001)., Conclusion: Aortic flow haemodynamics namely FDsavg and sFRR are significantly affected in ageing and HFpEF patients., Competing Interests: Competing interests: PG is a clinical advisor for Pie Medical Imaging, Neosoft and Medis Medical Imaging; he provides consultancy to Edwards Lifesciences and Anteris. SEP provides Consultancy to Circle Cardiovascular Imaging Inc., Calgary, Alberta, Canada. All other authors have no competing interests to declare., (Copyright: © 2024 Mehmood Z et al.)

Aims: Blood pressure (BP) is a crucial factor in cardiovascular health and can affect cardiac imaging assessments. However, standard outpatient cardiovascular MR (CMR) imaging procedures do not typically include BP measurements prior to image acquisition. This study proposes that brachial systolic BP (SBP) and diastolic BP (DBP) can be modelled using patient characteristics and CMR data., Methods: In this multicentre study, 57 patients from the PREFER-CMR registry and 163 patients from other registries were used as the derivation cohort. All subjects had their brachial SBP and DBP measured using a sphygmomanometer. Multivariate linear regression analysis was applied to predict brachial BP. The model was subsequently validated in a cohort of 169 healthy individuals., Results: Age and left ventricular ejection fraction were associated with SBP. Aortic forward flow, body surface area and left ventricular mass index were associated with DBP. When applied to the validation cohort, the correlation coefficient between CMR-derived SBP and brachial SBP was (r=0.16, 95% CI 0.011 to 0.305, p=0.03), and CMR-derived DBP and brachial DBP was (r=0.27, 95% CI 0.122 to 0.403, p=0.0004). The area under the curve (AUC) for CMR-derived SBP to predict SBP>120 mmHg was 0.59, p=0.038. Moreover, CMR-derived DBP to predict DBP>80 mmHg had an AUC of 0.64, p=0.002., Conclusion: CMR-derived SBP and DBP models can estimate brachial SBP and DBP. Such models may allow efficient prospective collection, as well as retrospective estimation of BP, which should be incorporated into assessments due to its critical effect on load-dependent parameters., Competing Interests: Competing interests: PG is a clinical advisor for Pie Medical Imaging and Medis Medical Imaging. PG is consultant for Anteris and Edwards Lifesciences. All other authors have no competing interests to declare., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background and objectives : Evaluating left ventricular filling pressure (LVFP) plays a crucial role in diagnosing and managing heart failure (HF). While traditional assessment methods involve multi-parametric transthoracic echocardiography (TTE) or right heart catheterisation (RHC), cardiovascular magnetic resonance (CMR) has emerged as a valuable diagnostic tool in HF. This study aimed to assess a simple CMR-derived model to estimate pulmonary capillary wedge pressure (PCWP) in a cohort of patients with suspected or proven heart failure and to investigate its performance in risk-stratifying patients. Materials and methods : A total of 835 patients with breathlessness were evaluated using RHC and CMR and split into derivation (85%) and validation cohorts (15%). Uni-variate and multi-variate linear regression analyses were used to derive a model for PCWP estimation using CMR. The model's performance was evaluated by comparing CMR-derived PCWP with PCWP obtained from RHC. Results : A CMR-derived PCWP incorporating left ventricular mass and the left atrial area (LAA) demonstrated good diagnostic accuracy. The model correctly reclassified 66% of participants whose TTE was 'indeterminate' or 'incorrect' in identifying raised filling pressures. On survival analysis, the CMR-derived PCWP model was predictive for mortality (HR 1.15, 95% CI 1.04-1.28, p = 0.005), which was not the case for PCWP obtained using RHC or TTE. Conclusions : The simplified CMR-derived PCWP model provides an accurate and practical tool for estimating PCWP in patients with suspected or proven heart failure. Its predictive value for mortality suggests the ability to play a valuable adjunctive role in echocardiography, especially in cases with unclear echocardiographic assessment.

Background and Objectives : Cardiovascular magnetic resonance (CMR) is emerging as an important imaging tool for sub-phenotyping and estimating left ventricular (LV) filling pressure (LVFP). The N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) is released from cardiac myocytes in response to mechanical load and wall stress. This study sought to investigate if CMR-derived LVFP is associated with the serum levels of NT-proBNP and, in addition, if it provides any incremental prognostic value in heart failure (HF). Materials and Methods : This study recruited 380 patients diagnosed with HF who underwent same-day CMR and clinical assessment between February 2018 and January 2020. CMR-derived LVFP was calculated, as previously, from long- and short-axis cines. During CMR assessment, serum NT-proBNP was measured. The pathological cut-offs were defined as follows: NT-proBNP ≥ 125 pg/mL and CMR LVFP > 15 mmHg. The incidence of HF hospitalisation was treated as a clinical outcome. Results : In total, 305 patients had NT-proBNP ≥ 125 pg/mL. Patients with raised NT-proBNP were older (54 ± 14 vs. 64 ± 11 years, p < 0.0001). Patients with raised NT-proBNP had higher LV volumes and mass. In addition, CMR LVFP was higher in patients with raised NT-proBNP (13.2 ± 2.6 vs. 15.4 ± 3.2 mmHg, p < 0.0001). The serum levels of NT-proBNP were associated with CMR-derived LVFP (R = 0.42, p < 0.0001). In logistic regression analysis, this association between NT-proBNP and CMR LVFP was independent of all other CMR variables, including LV ejection fraction, LV mass, and left atrial volume (coefficient = 2.02, p = 0.002). CMR LVFP demonstrated an independent association with the incidence of HF hospitalisation above NT-proBNP (hazard ratio 2.7, 95% confidence interval 1.2 to 6, p = 0.01). Conclusions: A CMR-modelled LVFP is independently associated with serum NT-proBNP levels. Importantly, it provides an incremental prognostic value over and above serum NT-proBNP levels.

Aims: Left ventricular filling pressure (LVFP) can be estimated from cardiovascular magnetic resonance (CMR). We aimed to investigate whether CMR-derived LVFP is associated with signs, symptoms, and prognosis in patients with recently diagnosed heart failure (HF)., Methods and Results: This study recruited 454 patients diagnosed with HF who underwent same-day CMR and clinical assessment between February 2018 and January 2020. CMR-derived LVFP was calculated, as previously, from long- and short-axis cines. CMR-derived LVFP association with symptoms and signs of HF was investigated. Patients were followed for median 2.9 years (interquartile range 1.5-3.6 years) for major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, HF hospitalization, non-fatal stroke, and non-fatal myocardial infarction. The mean age was 62 ± 13 years, 36% were female (n = 163), and 30% (n = 135) had raised LVFP. Forty-seven per cent of patients had an ejection fraction < 40% during CMR assessment. Patients with raised LVFP were more likely to have pleural effusions [hazard ratio (HR) 3.2, P = 0.003], orthopnoea (HR 2.0, P = 0.008), lower limb oedema (HR 1.7, P = 0.04), and breathlessness (HR 1.7, P = 0.01). Raised CMR-derived LVFP was associated with a four-fold risk of HF hospitalization (HR 4.0, P < 0.0001) and a three-fold risk of MACE (HR 3.1, P < 0.0001). In the multivariable model, raised CMR-derived LVFP was independently associated with HF hospitalization (adjusted HR 3.8, P = 0.0001) and MACE (adjusted HR 3.0, P = 0.0001)., Conclusions: Raised CMR-derived LVFP is strongly associated with symptoms and signs of HF. In addition, raised CMR-derived LVFP is independently associated with subsequent HF hospitalization and MACE., (© 2023 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: The widespread introduction of minimally invasive endovascular techniques in cardiovascular surgery has necessitated a transition in the psychomotor skillset of trainees and surgeons. Simulation has previously been used in surgical training; however, there is limited high-quality evidence regarding the role of simulation-based training on the acquisition of endovascular skills. This systematic review aimed to systematically appraise the currently available evidence regarding endovascular high-fidelity simulation interventions, to describe the overarching strategies used, the learning outcomes addressed, the choice of assessment methodology, and the impact of education on learner performance., Methods: A comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using relevant keywords to identify studies evaluating simulation in the acquisition of endovascular surgical skills. References of review articles were screened for additional studies., Results: A total of 1,081 studies were identified (474 after removal of duplicates). There was marked heterogeneity in methodologies and reporting of outcomes. Quantitative analysis was deemed inappropriate due to the risk of serious confounding and bias. Instead, a descriptive synthesis was performed, summarizing key findings and quality components. Eighteen studies were included in the synthesis (15 observational, 2 case-control and 1 randomized control studies). Most studies measured procedure time, contrast usage, and fluoroscopy time. Other metrics were recorded to a lesser extent. Significant reductions were noted in both procedure and fluoroscopy times with the introduction of simulation-based endovascular training., Conclusions: The evidence regarding the use of high-fidelity simulation in endovascular training is very heterogeneous. The current literature suggests simulation-based training leads to improvements in performance, mostly in terms of procedure and fluoroscopy time. High-quality randomized control trials are needed to establish the clinical benefits of simulation training, sustainability of improvements, transferability of skills and its cost-effectiveness., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To investigate whether left atrial (LA) volume and left ventricular filling pressure (LVFP) assessed by cardiovascular magnetic resonance (CMR) change during adenosine delivered myocardial hyperaemia as part of a first-pass stress perfusion study., Methods and Results: We enrolled 33 patients who had stress CMR. These patients had a baseline four-chamber cine and stress four-chamber cine, which was done at peak myocardial hyperaemic state after administering adenosine. The left and right atria were segmented in the end ventricular diastolic and systolic phases. Short-axis cine stack was segmented for ventricular functional assessment. At peak hyperaemic state, left atrial end ventricular systolic volume just before mitral valve opening increased significantly from baseline in all (91 ± 35ml vs. 81 ± 33ml, P = 0.0002), in males only (99 ± 35ml vs. 88 ± 33ml, P = 0.002) and females only (70 ± 26ml vs. 62 ± 22ml, P = 0.02). The right atrial end ventricular systolic volume increased less significantly from baseline (68 ± 21ml vs. 63 ± 20ml, P = 0.0448). CMR-derived LVFP (equivalent to pulmonary capillary wedge pressure) increased significantly at the peak hyperaemic state in all (15.1 ± 2.9mmHg vs. 14.4 ± 2.8mmHg, P = 0.0002), females only (12.9 ± 2.1mmHg vs. 12.3 ± 1.9mmHg, P = 0.029) and males only (15.9 ± 2.8mmHg vs. 15.2 ± 2.7mmHg, P = 0.002) cohorts., Conclusion: Left atrial volume assessment by CMR can measure acute and dynamic changes in preloading conditions on the left ventricle. During adenosine administered first-pass perfusion CMR, left atrial volume and LVFP rise significantly., (© 2023. The Author(s).)

Background: The reproducibility of mitral regurgitation (MR) quantification by cardiovascular magnetic resonance (CMR) imaging using different software solutions remains unclear. This research aimed to investigate the reproducibility of MR quantification between two software solutions: MASS (version 2019 EXP, LUMC, Netherlands) and CAAS (version 5.2, Pie Medical Imaging). Methods: CMR data of 35 patients with MR (12 primary MR, 13 mitral valve repair/replacement, and ten secondary MR) was used. Four methods of MR volume quantification were studied, including two 4D-flow CMR methods (MR MVAV and MR Jet ) and two non-4D-flow techniques (MR Standard and MR LVRV ). We conducted within-software and inter-software correlation and agreement analyses. Results: All methods demonstrated significant correlation between the two software solutions: MR Standard (r=0.92, p<0.001), MR LVRV (r=0.95, p<0.001), MR Jet (r=0.86, p<0.001), and MR MVAV (r=0.91, p<0.001). Between CAAS and MASS, MR Jet and MR MVAV , compared to each of the four methods, were the only methods not to be associated with significant bias. Conclusions: We conclude that 4D-flow CMR methods demonstrate equivalent reproducibility to non-4D-flow methods but greater levels of agreement between software solutions., Competing Interests: Competing interests: Dr P Garg is a clinical advisor for Pie Medical Imaging and Medis Medical Imaging., (Copyright: © 2023 Grafton-Clarke C et al.)

There remains a debate whether the ventricular volume within prolapsing mitral valve (MV) leaflets should be included in the left ventricular (LV) end-systolic volume, and therefore factored in LV stroke volume (SV), in cardiac magnetic resonance (CMR) assessments. This study aims to compare LV volumes during end-systolic phases, with and without the inclusion of the volume of blood on the left atrial aspect of the atrioventricular groove but still within the MV prolapsing leaflets, against the reference LV SV by four-dimensional flow (4DF). A total of 15 patients with MV prolapse (MVP) were retrospectively enrolled in this study. We compared LV SV with (LV SV MVP ) and without (LV SV standard ) MVP left ventricular doming volume, using 4D flow (LV SV 4DF ) as the reference value. Significant differences were observed when comparing LV SV standard and LV SV MVP ( p < 0.001), and between LV SV standard and LV SV 4DF ( p = 0.02). The Intraclass Correlation Coefficient (ICC) test demonstrated good repeatability between LV SV MVP and LV SV 4DF (ICC = 0.86, p < 0.001) but only moderate repeatability between LV SV standard and LV SV 4DF (ICC = 0.75, p < 0.01). Calculating LV SV by including the MVP left ventricular doming volume has a higher consistency with LV SV derived from the 4DF assessment. In conclusion, LV SV short-axis cine assessment incorporating MVP dooming volume can significantly improve the precision of LV SV assessment compared to the reference 4DF method. Hence, in cases with bi-leaflet MVP, we recommend factoring in MVP dooming into the left ventricular end-systolic volume to improve the accuracy and precision of quantifying mitral regurgitation.

Background: Measurement of peak velocities is important in the evaluation of heart failure. This study compared the performance of automated 4D flow cardiac MRI (CMR) with traditional transthoracic Doppler echocardiography (TTE) for the measurement of mitral inflow peak diastolic velocities., Methods: Patients with Doppler echocardiography and 4D flow cardiac magnetic resonance data were included retrospectively. An established automated technique was used to segment the left ventricular transvalvular flow using short-axis cine stack of images. Peak mitral E-wave and peak mitral A-wave velocities were automatically derived using in-plane velocity maps of transvalvular flow. Additionally, we checked the agreement between peak mitral E-wave velocity derived by 4D flow CMR and Doppler echocardiography in patients with sinus rhythm and atrial fibrillation (AF) separately., Results: Forty-eight patients were included (median age 69 years, IQR 63 to 76; 46% female). Data were split into three groups according to heart rhythm. The median peak E-wave mitral inflow velocity by automated 4D flow CMR was comparable with Doppler echocardiography in all patients (0.90 ± 0.43 m/s vs 0.94 ± 0.48 m/s, P = 0.132), sinus rhythm-only group (0.88 ± 0.35 m/s vs 0.86 ± 0.38 m/s, P = 0.54) and in AF-only group (1.33 ± 0.56 m/s vs 1.18 ± 0.47 m/s, P = 0.06). Peak A-wave mitral inflow velocity results had no significant difference between Doppler TTE and automated 4D flow CMR (0.81 ± 0.44 m/s vs 0.81 ± 0.53 m/s, P = 0.09) in all patients and sinus rhythm-only groups. Automated 4D flow CMR showed a significant correlation with TTE for measurement of peak E-wave in all patients group (r = 0.73, P < 0.001) and peak A-wave velocities (r = 0.88, P < 0.001). Moreover, there was a significant correlation between automated 4D flow CMR and TTE for peak-E wave velocity in sinus rhythm-only patients (r = 0.68, P < 0.001) and AF-only patients (r = 0.81, P = 0.014). Excellent intra-and inter-observer variability was demonstrated for both parameters., Conclusion: Automated dynamic peak mitral inflow diastolic velocity tracing using 4D flow CMR is comparable to Doppler echocardiography and has excellent repeatability for clinical use. However, 4D flow CMR can potentially underestimate peak velocity in patients with AF., (© 2023. The Author(s).)

Aims: The levels of abstraction, vast vocabulary and high cognitive load present significant challenges in undergraduate histopathology education. Self-determination theory describes three psychological needs which promote intrinsic motivation. This paper describes, evaluates and justifies a remotely conducted, post-COVID-19 histopathology placement designed to foster intrinsic motivation., Methods: 90 fourth-year medical students took part in combined synchronous and asynchronous remote placements integrating virtual microscopy into complete patient narratives through Google Classroom, culminating in remote, simulated multidisciplinary team meeting sessions allowing participants to vote on 'red flag' signs and symptoms, investigations, histological diagnoses, staging and management of simulated virtual patients. The placement was designed to foster autonomy, competence and relatedness, generating authenticity, transdisciplinary integration and clinical relevance. A postpositivistic evaluation was undertaken with a validated preplacement and postplacement questionnaire capturing quantitative and qualitative data., Results: There was a significant (p<0.001) improvement in interest, confidence and competence in histopathology. Clinical integration and relevance, access to interactive resources and collaborative learning promoted engagement and sustainability post-COVID-19. Barriers to online engagement included participant lack of confidence and self-awareness in front of peers., Conclusions: Fostering autonomy, competence and relatedness in post-COVID-19, remote educational designs can promote intrinsic motivation and authentic educational experiences. Ensuring transdisciplinary clinical integration, the appropriate use of novel technology and a focus on patient narratives can underpin the relevance of undergraduate histopathology education. The presentation of normal and diseased tissue in this way can serve as an important mode for the acquisition and application of clinically relevant knowledge expected of graduates., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The COVID-19 pandemic caused graduate medical education (GME) programs to pivot to virtual interviews (VIs) for recruitment and selection. This systematic review synthesizes the rapidly expanding evidence base on VIs, providing insights into preferred formats, strengths, and weaknesses., Methods: PubMed/MEDLINE, Scopus, ERIC, PsycINFO, MedEdPublish, and Google Scholar were searched from 1 January 2012 to 21 February 2022. Two authors independently screened titles, abstracts, full texts, performed data extraction, and assessed risk of bias using the Medical Education Research Quality Instrument. Findings were reported according to Best Evidence in Medical Education guidance., Results: One hundred ten studies were included. The majority (97%) were from North America. Fourteen were conducted before COVID-19 and 96 during the pandemic. Studies involved both medical students applying to residencies (61%) and residents applying to fellowships (39%). Surgical specialties were more represented than other specialties. Applicants preferred VI days that lasted 4-6 h, with three to five individual interviews (15-20 min each), with virtual tours and opportunities to connect with current faculty and trainees. Satisfaction with VIs was high, though both applicants and programs found VIs inferior to in-person interviews for assessing 'fit.' Confidence in ranking applicants and programs was decreased. Stakeholders universally noted significant cost and time savings with VIs, as well as equity gains and reduced carbon footprint due to eliminating travel., Conclusions: The use of VIs for GME recruitment and selection has accelerated rapidly. The findings of this review offer early insights that can guide future practice, policy, and research.

Objective: We aim to validate four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) peak velocity tracking methods for measuring the peak velocity of mitral inflow against Doppler echocardiography., Method: Fifty patients were recruited who had 4D flow CMR and Doppler Echocardiography. After transvalvular flow segmentation using established valve tracking methods, peak velocity was automatically derived using three-dimensional streamlines of transvalvular flow. In addition, a static-planar method was used at the tip of mitral valve to mimic Doppler technique., Results: Peak E-wave mitral inflow velocity was comparable between TTE and the novel 4D flow automated dynamic method (0.9 ± 0.5 vs 0.94 ± 0.6 m/s; p = 0.29) however there was a statistically significant difference when compared with the static planar method (0.85 ± 0.5 m/s; p = 0.01). Median A-wave peak velocity was also comparable across TTE and the automated dynamic streamline (0.77 ± 0.4 vs 0.76 ± 0.4 m/s; p = 0.77). A significant difference was seen with the static planar method (0.68 ± 0.5 m/s; p = 0.04). E/A ratio was comparable between TTE and both the automated dynamic and static planar method (1.1 ± 0.7 vs 1.15 ± 0.5 m/s; p = 0.74 and 1.15 ± 0.5 m/s; p = 0.5 respectively). Both novel 4D flow methods showed good correlation with TTE for E-wave (dynamic method; r = 0.70; P < 0.001 and static-planar method; r = 0.67; P < 0.001) and A-wave velocity measurements (dynamic method; r = 0.83; P < 0.001 and static method; r = 0.71; P < 0.001). The automated dynamic method demonstrated excellent intra/inter-observer reproducibility for all parameters., Conclusion: Automated dynamic peak velocity tracing method using 4D flow CMR is comparable to Doppler echocardiography for mitral inflow assessment and has excellent reproducibility for clinical use., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: To validate the k-adaptive-t autocalibrating reconstruction for Cartesian sampling (kat-ARC), an exclusive sparse reconstruction technique for four-dimensional (4D) flow cardiac magnetic resonance (CMR) using conservation of mass principle applied to transvalvular flow., Methods: This observational retrospective study (2020/21-075) was approved by the local ethics committee at the University of East Anglia. Consent was waived. Thirty-five patients who had a clinical CMR scan were included. CMR protocol included cine and 4D flow using Kat-ARC acceleration factor 6. No respiratory navigation was applied. For validation, the agreement between mitral net flow (MNF) and the aortic net flow (ANF) was investigated. Additionally, we checked the agreement between peak aortic valve velocity derived by 4D flow and that derived by continuous-wave Doppler echocardiography in 20 patients., Results: The median age of our patient population was 63 years (interquartile range [IQR] 54-73), and 18/35 (51%) were male. Seventeen (49%) patients had mitral regurgitation, and seven (20%) patients had aortic regurgitation. Mean acquisition time was 8 ± 4 min. MNF and ANF were comparable: 60 mL (51-78) versus 63 mL (57-77), p = 0.310). There was an association between MNF and ANF (rho = 0.58, p < 0.001). Peak aortic valve velocity by Doppler and 4D flow were comparable (1.40 m/s, [1.30-1.75] versus 1.46 m/s [1.25-2.11], p = 0.602) and also correlated with each other (rho = 0.77, p < 0.001)., Conclusions: Kat-ARC accelerated 4D flow CMR quantified transvalvular flow in accordance with the conservation of mass principle and is primed for clinical translation., (© 2022. The Author(s) under exclusive licence to European Society of Radiology.)

Background: The COVID-19 pandemic has necessitated the need to develop teaching innovations that provide safe, authentic clinical encounters which facilitate experiential learning. In tandem with the dissemination of teleconsultation and online teaching, this pilot study describes, evaluates and justifies a multi-camera live-streaming teaching session to medical students from the clinical environment., Approach: Multiple audio and video inputs capturing an outpatient clinic setting were routed through Open Broadcast Software (OBS) to create a customised feed streamed to remote learners through a videoconferencing platform. Sessions were conducted between September 2020 and March 2021. Twelve students sequentially interacted with a patient who held an iPad. Higher quality Go-Pro cameras captured the scene, allowing students to view the consultation from the patient and doctor's perspective. A consultant then conducted a 'gold standard' patient consultation observed by students. A faculty member remotely facilitated the session, providing pre-clinic teaching and debriefing. The equipment required with costing for a standard and low-cost version is described, as well as a set-up schematic and overview of ideal conditions and barriers encountered during trials., Evaluation: All students completed a post-participation questionnaire, rating the overall quality of the sessions as 9.7/10. The quality of online facilitation, utility of observing peers' and consultant interaction with the patient, opportunity for peer-to-peer learning and availability of multiple camera angles were particularly valued by students., Implications: This innovation permits an authentic clinical interaction to be experienced by multiple students remotely, promoting equitable access to high-quality teaching, while maintaining the safety of students and patients., (© 2022 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Background: Antibiotics have been considered to treat ulcerative colitis (UC) due to their antimicrobial properties against intestinal bacteria linked to inflammation. However, there are concerns about their efficacy and safety., Objectives: To determine whether antibiotic therapy is safe and effective for the induction and maintenance of remission in people with UC., Search Methods: We searched five electronic databases on 10 December 2021 for randomised controlled trials (RCTs) comparing antibiotic therapy to placebo or an active comparator., Selection Criteria: We considered people with UC of all ages, treated with antibiotics of any type, dose, and route of administration for inclusion. Induction studies required a minimum duration of two weeks for inclusion. Maintenance studies required a minimum duration of three months to be considered for inclusion., Data Collection and Analysis: We used standard methodological procedures expected by Cochrane. Our primary outcome for induction studies was failure to achieve remission and for maintenance studies was relapse, as defined by the primary studies., Main Results: We included 12 RCTs (847 participants). One maintenance of remission study used sole antibiotic therapy compared with 5-aminosalicylic acid (5-ASA). All other trials used concurrent medications or standard care regimens and antibiotics as an adjunct therapy or compared antibiotics with other adjunct therapies to examine the effect on induction of remission. There is high certainty evidence that antibiotics (154/304 participants) compared to placebo (175/304 participants) result in no difference in failure to achieve clinical remission (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.06). A subgroup analysis found no differences when steroids, steroids plus 5-ASA, or steroids plus 5-ASA plus probiotics were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (102/168 participants) compared to placebo (121/175 participants) may result in no difference in failure to achieve clinical response (RR 0.75, 95% CI 0.47 to 1.22). A subgroup analysis found no differences when steroids or steroids plus 5-ASA were used as additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (6/342 participants) compared to placebo (5/349 participants) may result in no difference in serious adverse events (RR 1.19, 95% CI 0.38 to 3.71). A subgroup analysis found no differences when steroids were additional therapies to antibiotics and placebo. There is low certainty evidence that antibiotics (3/342 participants) compared to placebo (1/349 participants) may result in no difference in withdrawals due to adverse events (RR 2.06, 95% CI 0.27 to 15.72). A subgroup analysis found no differences when steroids or steroids plus 5-ASA were additional therapies to antibiotics and placebo. It is unclear if there is any difference between antibiotics in combination with probiotics compared to no treatment or placebo for failure to achieve clinical remission (RR 0.68, 95% CI 0.39 to 1.19), serious adverse events (RR 1.00, 95% CI 0.07 to 15.08), or withdrawals due to adverse events (RR 1.00, 95% CI 0.07 to 15.08). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5-ASA for failure to achieve clinical remission (RR 2.20, 95% CI 1.17 to 4.14). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to probiotics for failure to achieve clinical remission (RR 0.47, 95% CI 0.23 to 0.94). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to 5-ASA for failure to maintain clinical remission (RR 0.71, 95% CI 0.47 to 1.06). The certainty of the evidence is very low. It is unclear if there is any difference between antibiotics compared to no treatment for failure to achieve clinical remission in a mixed population of people with active and inactive disease (RR 0.56, 95% CI 0.29 to 1.07). The certainty of the evidence is very low. For all other outcomes, no effects could be estimated due to a lack of data., Authors' Conclusions: There is high certainty evidence that there is no difference between antibiotics and placebo in the proportion of people who achieve clinical remission at the end of the intervention period. However, there is evidence that there may be a greater proportion of people who achieve clinical remission and probably a greater proportion who achieve clinical response with antibiotics when compared with placebo at 12 months. There may be no difference in serious adverse events or withdrawals due to adverse events between antibiotics and placebo. No clear conclusions can be drawn for any other comparisons. A clear direction for future research appears to be comparisons of antibiotics and placebo (in addition to standard therapies) with longer-term measurement of outcomes. Additionally. As there were single studies of other head-to-head comparisons, there may be scope for future studies in this area., (Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Objectives: Mitral regurgitation (MR) and microvascular obstruction (MVO) are common complications of myocardial infarction (MI). This study aimed to investigate the association between MR in ST-elevation MI (STEMI) subjects with MVO post-reperfusion. STEMI subjects undergoing primary percutaneous intervention were enrolled. Cardiovascular magnetic resonance (CMR) imaging was performed within 48-hours of initial presentation. 4D flow images of CMR were analysed using a retrospective valve tracking technique to quantify MR volume, and late gadolinium enhancement images of CMR to assess MVO., Results: Among 69 patients in the study cohort, 41 had MVO (59%). Patients with MVO had lower left ventricular (LV) ejection fraction (EF) (42 ± 10% vs. 52 ± 8%, P < 0.01), higher end-systolic volume (98 ± 49 ml vs. 73 ± 28 ml, P < 0.001) and larger scar volume (26 ± 19% vs. 11 ± 9%, P < 0.001). Extent of MVO was associated with the degree of MR quantified by 4D flow (R = 0.54, P = 0.0003). In uni-variate regression analysis, investigating the association of CMR variables to the degree of acute MR, only the extent of MVO was associated (coefficient = 0.27, P = 0.001). The area under the curve for the presence of MVO was 0.66 (P = 0.01) for MR > 2.5 ml. We conclude that in patients with reperfused STEMI, the degree of acute MR is associated with the degree of MVO., (© 2022. The Author(s).)

Background: Prior reviews investigated medical education developments in response to COVID-19, identifying the pivot to remote learning as a key area for future investigation. This review synthesized online learning developments aimed at replacing previously face-to-face 'classroom' activities for postgraduate learners., Methods: Four online databases (CINAHL, Embase, PsychINFO, and PubMed) and MedEdPublish were searched through 21 December 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction, and assessed risk of bias. The PICRAT technology integration framework was applied to examine how teachers integrated and learners engaged with technology. A descriptive synthesis and outcomes were reported. A thematic analysis explored limitations and lessons learned., Results: Fifty-one publications were included. Fifteen collaborations were featured, including international partnerships and national networks of program directors. Thirty-nine developments described pivots of existing educational offerings online and twelve described new developments. Most interventions included synchronous activities ( n  Fif5). Virtual engagement was promoted through chat, virtual whiteboards, polling, and breakouts. Teacher's use of technology largely replaced traditional practice. Student engagement was largely interactive. Underpinning theories were uncommon. Quality assessments revealed moderate to high risk of bias in study reporting and methodology. Forty-five developments assessed reaction; twenty-five attitudes, knowledge or skills; and two behavior. Outcomes were markedly positive. Eighteen publications reported social media or other outcomes, including reach, engagement, and participation. Limitations included loss of social interactions, lack of hands-on experiences, challenges with technology and issues with study design. Lessons learned highlighted the flexibility of online learning, as well as practical advice to optimize the online environment., Conclusions: This review offers guidance to educators attempting to optimize learning in a post-pandemic world. Future developments would benefit from leveraging collaborations, considering technology integration frameworks, underpinning developments with theory, exploring additional outcomes, and designing and reporting developments in a manner that supports replication.

Objectives: The management of severe aortic stenosis mandates consideration of aortic valve intervention for symptomatic patients. However, for asymptomatic patients with severe aortic stenosis, recent randomised trials supported earlier intervention. We conducted a systematic review and meta-analysis to evaluate all the available data comparing the two management strategies., Methods: PubMed, Cochrane and Web of Science databases were systematically searched from inception until 10 January 2022. The search key terms were 'asymptomatic', 'severe aortic stenosis' and 'intervention'., Results: Meta-analysis of two published randomised trials, AVATAR and RECOVERY, included 302 patients and showed that early intervention resulted in 55% reduction in all-cause mortality (HR=0.45, 95% CI 0.24 to 0.86; I 2 0%) and 79% reduction in risk of hospitalisation for heart failure (HR=0.21, 95% CI 0.05 to 0.96; I 2 15%). There was no difference in risk of cardiovascular death between the two groups (HR=0.36, 95% CI 0.03 to 3.78; I 2 78%). Additionally, meta-analysis of eight observational studies showed improved mortality in patients treated with early intervention (HR=0.38, 95% CI 0.26 to 0.56; I 2 77%)., Conclusion: This meta-analysis provides evidence that, in patients with severe asymptomatic aortic stenosis, early intervention reduces all-cause mortality and improves outcomes compared with conservative management. While this is very encouraging, further randomised controlled studies are needed to draw firm conclusions and identify the optimal timing of intervention., Prospero Registration Number: CRD42022301037., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objective: Doppler echocardiographic aortic valve peak velocity and peak pressure gradient assessment across the aortic valve (AV) is the mainstay for diagnosing aortic stenosis. Four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) is emerging as a valuable diagnostic tool for estimating the peak pressure drop across the aortic valve, but assessment remains cumbersome. We aimed to validate a novel semi-automated pipeline 4D flow CMR method of assessing peak aortic value pressure gradient (AVPG) using the commercially available software solution, CAAS MR Solutions, against invasive angiographic methods., Results: We enrolled 11 patients with severe AS on echocardiography from the EurValve programme. All patients had pre-intervention doppler echocardiography, invasive cardiac catheterisation with peak pressure drop assessment across the AV and 4D flow CMR. The peak AVPG was 51.9 ± 35.2 mmHg using the invasive pressure drop method and 52.2 ± 29.2 mmHg for the 4D flow CMR method (semi-automated pipeline), with good correlation between the two methods (r = 0.70, p = 0.017). Assessment of AVPG by 4D flow CMR using the novel semi-automated pipeline method shows excellent agreement to invasive assessment when compared to doppler-based methods and advocate for its use as complementary to echocardiography., (© 2022. The Author(s).)

Background: The novel coronavirus disease was declared a pandemic in March 2020, which necessitated adaptations to medical education. This systematic review synthesises published reports of medical educational developments and innovations that pivot to online learning from workplace-based clinical learning in response to the pandemic. The objectives were to synthesise what adaptations/innovation were implemented (description), their impact (justification), and 'how' and 'why' these were selected (explanation and rationale)., Methods: The authors systematically searched four online databases up to December 21, 2020. Two authors independently screened titles, abstracts and full-texts, performed data extraction, and assessed the risk of bias. Our findings are reported in alignment with the STORIES (STructured apprOach to the Reporting in healthcare education of Evidence Synthesis) statement and BEME guidance., Results: Fifty-five articles were included. Most were from North America ( n  = 40), and nearly 70% focused on undergraduate medical education (UGME). Key developments were rapid shifts from workplace-based learning to virtual spaces, including online electives, telesimulation, telehealth, radiology, and pathology image repositories, live-streaming or pre-recorded videos of surgical procedures, stepping up of medical students to support clinical services, remote adaptations for clinical visits, multidisciplinary team meetings and ward rounds. Challenges included lack of personal interactions, lack of standardised telemedicine curricula and need for faculty time, technical resources, and devices. Assessment of risk of bias revealed poor reporting of underpinning theory, resources, setting, educational methods, and content., Conclusions: This review highlights the response of medical educators in deploying adaptations and innovations. Whilst few are new, the complexity, concomitant use of multiple methods and the specific pragmatic choices of educators offers useful insight to clinical teachers who wish to deploy such methods within their own practice. Future works that offer more specific details to allow replication and understanding of conceptual underpinnings are likely to justify an update to this review.

Background: The COVID-19 pandemic spurred an abrupt transition away from in-person educational activities. This systematic review investigated the pivot to online learning for nonclinical undergraduate medical education (UGME) activities and explored descriptions of educational offerings deployed, their impact, and lessons learned., Methods: The authors systematically searched four online databases and conducted a manual electronic search of MedEdPublish up to December 21, 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction and assessed risk of bias. A third author resolved discrepancies. Findings were reported in accordance with the STORIES (STructured apprOach to the Reporting in healthcare education of Evidence Synthesis) statement and BEME guidance., Results: Fifty-six articles were included. The majority ( n  = 41) described the rapid transition of existing offerings to online formats, whereas fewer ( n  = 15) described novel activities. The majority ( n  = 27) included a combination of synchronous and asynchronous components. Didactics ( n  = 40) and small groups ( n  = 26) were the most common instructional methods. Teachers largely integrated technology to replace and amplify rather than transform learning, though learner engagement was often interactive. Thematic analysis revealed unique challenges of online learning, as well as exemplary practices. The quality of study designs and reporting was modest, with underpinning theory at highest risk of bias. Virtually all studies ( n  = 54) assessed reaction/satisfaction, fewer than half ( n  = 23) assessed changes in attitudes, knowledge or skills, and none assessed behavioral, organizational or patient outcomes., Conclusions: UGME educators successfully transitioned face-to-face instructional methods online and implemented novel solutions during the COVID-19 pandemic. Although technology's potential to transform teaching is not yet fully realized, the use of synchronous and asynchronous formats encouraged virtual engagement, while offering flexible, self-directed learning. As we transition from emergency remote learning to a post-pandemic world, educators must underpin new developments with theory, report additional outcomes and provide details that support replication.

Objectives: Four-dimensional flow CMR allows for a comprehensive assessment of the blood flow kinetic energy of the ventricles of the heart. In comparison to standard two-dimensional image acquisition, 4D flow CMR is felt to offer superior reproducibility, which is important when repeated examinations may be required. The objective was to evaluate the inter-observer and intra-observer reproducibility of blood flow kinetic energy assessment using 4D flow of the left ventricle in 20 healthy volunteers across two centres in the United Kingdom and the Netherlands., Data Description: This dataset contains 4D flow CMR blood flow kinetic energy data for 20 healthy volunteers with no known cardiovascular disease. Presented is kinetic energy data for the entire cardiac cycle (global), the systolic and diastolic components, in addition to blood flow kinetic energy for both early and late diastolic filling. This data is available for reuse and would be valuable in supporting other research, such as allowing for larger sample sizes with more statistical power for further analysis of these variables., (© 2021. The Author(s).)

Background : Four-dimensional (4D) flow cardiovascular magnetic resonance imaging (MRI) is an emerging technique used for intra-cardiac blood flow assessment. The role of 4D flow cardiovascular MRI in the assessment of trans-valvular flow in patients with atrial fibrillation (AF) has not previously been assessed. The purpose of this study was to assess the feasibility, image quality, and internal validity of 4D flow cardiovascular MRI in the quantification of trans-valvular flow in patients with AF. Methods : Patients with AF and healthy controls in sinus rhythm underwent cardiovascular MRI, including 4D flow studies. Quality assurance checks were done on the raw data and streamlines. Consistency was investigated by trans-valvular flow assessment between the mitral valve (MV) and the aortic valve (AV). Results : Eight patients with AF (88% male, mean age 62±13 years, mean heart rate (HR) 83±16 beats per minute (bpm)) were included and compared with ten healthy controls (70% male, mean age 41±20 years, mean HR 68.5±9 bpm). All scans were of either good quality with minimal blurring artefacts, or excellent quality with no artefacts. No significant bias was observed between the AV and MV stroke volumes in either healthy controls (-4.8, 95% CI -15.64 to 6.04; P=0.34) or in patients with AF (1.64, 95% CI -4.7 to 7.94; P=0.56). A significant correlation was demonstrated between MV and AV stroke volumes in both healthy controls (r=0.87, 95% CI 0.52 to 0.97; P=0.001) and in AF patients (r=0.82, 95% CI 0.26 to 0.97; P=0.01). Conclusions : In patients with AF, 4D flow cardiovascular MRI is feasible with good image quality, allowing for quantification of trans-valvular flow., Competing Interests: Competing interests: P.G. reports clinical advisor role to Medis Medical Imaging and Pie Medical Imaging., (Copyright: © 2021 Mills MT et al.)

Background Rates of oropharyngeal (OP) cancer are increasing and mortality is related to stage at diagnosis. Early diagnosis is vital to improving patient outcomes.Aim To describe current general practice pathways and time intervals in OP cancer and: a) compare to current National Institute for Health and Care Excellence guidance to refer from general practitioners (GPs) to general medical dentists (dentists); and b) referral pathways for pharyngeal cancers.Design and setting A ten-year retrospective study of patients diagnosed with OP cancer in one suburban general practice in England using GP notes, including secondary care correspondence.Results There were 12 cases of OP cancer; six oral and six pharyngeal. There were marked differences in referral pathways and time intervals for people with visible, or palpable, oral cancers and those with non-visible, or impalpable, pharyngeal cancers. No one had GP to dentist referral. General practice 'safety-netting' or follow-up was not commonly recorded.Conclusion GPs are pivotal in diagnosing symptomatic OP cancers. General practice and dental teams encountering symptoms of uncertain aetiology (for example, pharyngitis) should offer safety-netting to shorten patient intervals to re-attendance. Pathways for oral cancer referral were usually clear and linear. Pathways for pharyngeal cancer were usually complex, with much longer time intervals in primary and secondary care, and would benefit from a single national referral pathway to ENT.

Background: Medical schools differ, particularly in their teaching, but it is unclear whether such differences matter, although influential claims are often made. The Medical School Differences (MedDifs) study brings together a wide range of measures of UK medical schools, including postgraduate performance, fitness to practise issues, specialty choice, preparedness, satisfaction, teaching styles, entry criteria and institutional factors., Method: Aggregated data were collected for 50 measures across 29 UK medical schools. Data include institutional history (e.g. rate of production of hospital and GP specialists in the past), curricular influences (e.g. PBL schools, spend per student, staff-student ratio), selection measures (e.g. entry grades), teaching and assessment (e.g. traditional vs PBL, specialty teaching, self-regulated learning), student satisfaction, Foundation selection scores, Foundation satisfaction, postgraduate examination performance and fitness to practise (postgraduate progression, GMC sanctions). Six specialties (General Practice, Psychiatry, Anaesthetics, Obstetrics and Gynaecology, Internal Medicine, Surgery) were examined in more detail., Results: Medical school differences are stable across time (median alpha = 0.835). The 50 measures were highly correlated, 395 (32.2%) of 1225 correlations being significant with p < 0.05, and 201 (16.4%) reached a Tukey-adjusted criterion of p < 0.0025. Problem-based learning (PBL) schools differ on many measures, including lower performance on postgraduate assessments. While these are in part explained by lower entry grades, a surprising finding is that schools such as PBL schools which reported greater student satisfaction with feedback also showed lower performance at postgraduate examinations. More medical school teaching of psychiatry, surgery and anaesthetics did not result in more specialist trainees. Schools that taught more general practice did have more graduates entering GP training, but those graduates performed less well in MRCGP examinations, the negative correlation resulting from numbers of GP trainees and exam outcomes being affected both by non-traditional teaching and by greater historical production of GPs. Postgraduate exam outcomes were also higher in schools with more self-regulated learning, but lower in larger medical schools. A path model for 29 measures found a complex causal nexus, most measures causing or being caused by other measures. Postgraduate exam performance was influenced by earlier attainment, at entry to Foundation and entry to medical school (the so-called academic backbone), and by self-regulated learning. Foundation measures of satisfaction, including preparedness, had no subsequent influence on outcomes. Fitness to practise issues were more frequent in schools producing more male graduates and more GPs., Conclusions: Medical schools differ in large numbers of ways that are causally interconnected. Differences between schools in postgraduate examination performance, training problems and GMC sanctions have important implications for the quality of patient care and patient safety.

Background: What subjects UK medical schools teach, what ways they teach subjects, and how much they teach those subjects is unclear. Whether teaching differences matter is a separate, important question. This study provides a detailed picture of timetabled undergraduate teaching activity at 25 UK medical schools, particularly in relation to problem-based learning (PBL)., Method: The Analysis of Teaching of Medical Schools (AToMS) survey used detailed timetables provided by 25 schools with standard 5-year courses. Timetabled teaching events were coded in terms of course year, duration, teaching format, and teaching content. Ten schools used PBL. Teaching times from timetables were validated against two other studies that had assessed GP teaching and lecture, seminar, and tutorial times., Results: A total of 47,258 timetabled teaching events in the academic year 2014/2015 were analysed, including SSCs (student-selected components) and elective studies. A typical UK medical student receives 3960 timetabled hours of teaching during their 5-year course. There was a clear difference between the initial 2 years which mostly contained basic medical science content and the later 3 years which mostly consisted of clinical teaching, although some clinical teaching occurs in the first 2 years. Medical schools differed in duration, format, and content of teaching. Two main factors underlay most of the variation between schools, Traditional vs PBL teaching and Structured vs Unstructured teaching. A curriculum map comparing medical schools was constructed using those factors. PBL schools differed on a number of measures, having more PBL teaching time, fewer lectures, more GP teaching, less surgery, less formal teaching of basic science, and more sessions with unspecified content., Discussion: UK medical schools differ in both format and content of teaching. PBL and non-PBL schools clearly differ, albeit with substantial variation within groups, and overlap in the middle. The important question of whether differences in teaching matter in terms of outcomes is analysed in a companion study (MedDifs) which examines how teaching differences relate to university infrastructure, entry requirements, student perceptions, and outcomes in Foundation Programme and postgraduate training.

The exponential growth of the systematic review methodology within health has been mirrored within medical education, allowing large numbers of publications on a topic to be synthesized to guide researchers and teachers. The robust, transparent and reproducible search methodologies employed offer scholarly rigor. The scope and scale of many reviews in education have only been matched by the size of the commitment needed to complete them and occasional lack of utility of reports. As such, we have noticed a growth in reviews across journals in the field that have questions that are more focused in scope. The authors propose 12 tips for performing a focused review in the right settings for the right reasons and discuss why such "focused reviews" may be more beneficial in those circumstances. Focused reviews allow researchers to formulate answers to specific local issues that have explicit utility of findings. Such reviews are equipped to identify what works for specific groups in specific circumstances and even question how and why this may occur. An additional impact of a focused approach can be a rapid turnaround. This article explains the purpose and benefits of focused review and provides guidance on how to produce them.

A best evidence topic in cardiovascular surgery was written in accordance to a structured protocol. The question addressed was: in patients undergoing endovascular repair of abdominal aortic aneurysm (EVAR), is local anaesthetic (LA) superior to general anaesthetic in terms of perioperative outcomes? Altogether, 630 publications were found using the reported search protocol, of which 3 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type and primary outcomes were tabulated. The 3 included studies are systematic reviews with meta-analyses, with no randomized trials identified. Within the studies, there is a degree of heterogeneity in terms of surgical case-mix (elective or emergency EVAR or both) and anaesthetic technique (LA, regional anaesthetic, local-regional anaesthetic and general anaesthetic). With 1 study not providing pooled estimates, the second study demonstrated statistical significance in favour of local-regional anaesthetic within the elective setting in terms of mortality [pooled odds ratio (OR) 0.70, 95% confidence interval (CI) 0.52-0.95; P = 0.02], morbidity (pooled OR 0.73, 95% CI 0.55-0.96; P = 0.0006) and total length of hospital admission (pooled mean difference: -1.53, 95% CI -2.53 to -0.53; P = 0.00001). The third study failed to demonstrate a statistically significant mortality benefit with LA (pooled OR 0.54, 95% CI 0.21-1.41; P = 0.211). While the results of these studies fail to provide a clear answer to a complex surgical problem, it would be appropriate, in the light of current evidence, to recommend LA as non-inferior to general anaesthetic in both emergency and elective settings., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in a patient undergoing thoracic aortic surgery, is innominate artery cannulation superior to axillary artery cannulation in terms of postoperative outcomes? Five hundred and thirty-one papers were found using the reported search strategy, of which 5 represented the best evidence to answer the clinical question. A total of 1338 participants were included across the 5 studies. Seven hundred and twenty-two patients were cannulated via the axillary artery and 616 were cannulated via the innominate artery. The included 5 studies were 2 prospective observational cohorts, 2 retrospective case-series analysis and a single-blinded randomized trial. Thirty-day or in-hospital mortality rates were reported in all 5 studies. There were no significant differences in mortality with innominate artery cannulation compared to axillary artery cannulation (P > 0.05), with slightly lower mortality rates in 2 studies, slightly higher mortality rates in 2 and equal in 1 study. Though statistical significance was not demonstrated (P > 0.05), a stroke occurred slightly less frequently in patients receiving innominate artery cannulation compared to axillary artery cannulation in 3 of the 4 studies. Innominate artery cannulation is non-inferior to axillary artery cannulation for thoracic aortic surgery, with a similar level of neuroprotection and is not associated with increased levels of mortality., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Coronary artery bypass grafting is a key cardiac surgery procedure and is the main treatment for patients with multivessel coronary artery disease. The most frequently used conduit for this procedure is the long saphenous vein (LSV). The technique of harvesting the LSV has evolved over the last 30 years from total open harvesting to endoscopic with minimal access technique. The most important determining factor for success in coronary artery surgery is the graft patency rate. The literature evidence behind each technique has been reported at different levels and there is an ongoing debate about which technique can provide optimum vein patency over the long term. This literature review aims to summarize the current evidence, the implications involved with the use of each technique for harvesting LSV and the patency rate at variable follow-up intervals., (© 2019 Wiley Periodicals, Inc.)

Objective: To systematically compare outcomes between patients with asymptomatic carotid artery diseases (>80% stenosis) that had undergone staged carotid endarterectomy (CEA) before coronary artery bypass grafting (CABG) vs simultaneous CEA and CABG., Methods: A comprehensive electronic search of MEDLINE, Scopus, EMBASE, and Ovid from their inception up till August 2018 was performed to identify all studies comparing staged CEA followed by CABG to simultaneous CEA and CABG. Primary outcome measure was postoperative stroke, and secondary measures were myocardial infarction (MI) and 30-day mortality rates., Results: A total of 67 953 patients were analyzed from 11 articles. There was higher rate of previous stroke in the staged cohort (2.64% vs 2.32%; odds ratio [OR], 0.81; 95% confidence interval [CI; 0.66, 0.99]; P = .040). There was no difference in previous MI (P = .57) or unstable angina (P = .08) among both cohorts. Postoperatively, there were higher stroke rates (3.64% vs 2.83%; OR, 0.72; 95% CI [0.62-0.89]; P < .0001), operative mortality (4.32% vs 3.58%; OR, 0.90; 95% CI [0.83-0.98]; P = .02), and 30-day mortality (4.40% vs 3.58%; OR, 0.86; 95% CI [0.78-0.96]; P = .006) in the simultaneous cohort. However, length of stay was significantly shorter in the simultaneous cohort (11.9 days vs 12.6 days; weighted mean difference 3.14 [0.77-5.51]; P = .009). There were no significant differences in 1-year mortality (P = .33), MI rates (P = .08), and rates of transient neurological deficits (P = .06)., Conclusion: The results from this study favors staged CEA with CABG with lower incidence of postoperative stroke, operative, and 30-day mortality. A larger study, ideally a randomized controlled trial, is required to address the superiority of each technique., (© 2019 Wiley Periodicals, Inc.)

Consensus on how to assess non-technical skills is lacking. This systematic review aimed to evaluate the evidence regarding non-technical skills assessments in undergraduate medical education, to describe the tools used, learning outcomes and the validity, reliability and psychometrics of the instruments. A standardized search of online databases was conducted and consensus reached on included studies. Data extraction, quality assessment, and content analysis were conducted per Best Evidence in Medical Education guidelines. Nine papers met the inclusion criteria. Assessment methods broadly fell into three categories: simulated clinical scenarios, objective structured clinical examinations, and questionnaires or written assessments. Tools to assess non-technical skills were often developed locally, without reference to conceptual frameworks. Consequently, the tools were rarely validated, limiting dissemination and replication. There were clear themes in content and broad categories in methods of assessments employed. The quality of this evidence was poor due to lack of theoretical underpinning, with most assessments not part of normal process, but rather produced as a specific outcome measure for a teaching-based study. While the current literature forms a good starting position for educators developing materials, there is a need for future work to address these weaknesses as such tools are required across health education.

This article was migrated. The article was marked as recommended. Poor standards of handover threaten patient safety and continuity of care, contributing significantly to morbidity and mortality. Handover practices has risen to the forefront of the patient safety agenda, with a call to develop and implement undergraduate handover modules into undergraduate healthcare education. Recent systematic reviews demonstrate a common failure of educational interventions to demonstrate a theoretical and pedagogical framework underpinning the delivery of education and method of assessment. The authors developed and piloted a multi-disciplinary evidence-based undergraduate handover training program to health care students studying at a UK university. The intervention was designed based on underpinning educational theories. It has been developed in a manner that supports dissemination and replication, with a model that is cost effective. The intervention was designed to assess learner reaction, attitudes and confidence, and knowledge and skills. This was achieved through a pre- and post-intervention attitude questionnaire, and an externally validated pre- and post-intervention knowledge assessment. 46 undergraduate students participated, with a statistically significant increase in self-reported attitudes (p < 0.001) and knowledge (p < 0.001) following the handover intervention. Students participated from the disciplines of medicine, adult nursing, pharmacy, mental health nursing, paramedic practice and operating department practioners. This intervention serves as a significant resource for those looking to develop local interventions and stands as a truly multi-disciplinary approach to handover education, mirroring the clinical reality. The introduction of this handover intervention immediately improves the attitudes, knowledge and skills of undergraduate healthcare students. Future work should sample beyond the selected 6 professions, investigating the transference of outcomes to the workplace, as well as the impact on patient safety., (Copyright: © 2019 Gordon M et al.)

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: In patients undergoing cardiac surgery, is postoperative music therapy effective in reducing pain and anxiety? Altogether, 153 papers were found using the reported search method, of which 7 represented the best evidence to answer the clinical question. Six of the included studies were randomized trials, with 1 further non-randomized trial. The specific music protocols utilized widely varied, ranging from 1 short session on day 1 postoperatively to multiple sessions per day over a 72-h period. Most therapies involved music of a relaxing type, typically between 50 and 60 dB. All 7 studies reported on pain, with 4 demonstrating significant differences in pain score; however, 3 of these were not associated with reduction in analgesia requirements. Five studies reported on anxiety, with 2 demonstrating a statistically significant improvement in levels of anxiety. These results need to be contextualized by the small number of participants within each study and the heterogeneity in the therapy protocols utilized. The current best available evidence fails to support the benefits of music therapy as an effective non-pharmacological option in reducing pain and anxiety following open-heart surgery. While there is scarce evidence demonstrating efficacy, the current literature contains very small-sample-sized studies in utilizing music therapy protocols which in turn have wide range of variability in terms of duration, frequency, timing in the postoperative period and specific choice of music utilized in each protocol., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)