Twelve tips for teaching in virtual reality.

Virtual reality (VR) is a technology that is seeing increasing use in medical education as a means to complement or prepare students for clinical practice in a safe space. Whilst effective for learning, it can be difficult to use effectively and requires significant planning to avoid the technological tail wagging the educational dog. We have run educational sessions using the technology to teach anatomy and clinical reasoning that have been well received by students at Queen Mary, University of London. In this article, we share 12 practical tips from our experiences on how to create and deliver learning using VR.

Diagnostic coronary angiography and percutaneous coronary intervention practices in New Zealand: The All New Zealand Acute Coronary Syndrome-Quality Improvement CathPCI registry 3-year study (ANZACS-QI 37).

BACKGROUND: Coronary heart disease remains one of the leading causes of mortality and morbidity in New Zealand (NZ) and globally. The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) programme includes the CathPCI registry which records all those referred for diagnostic coronary angiography (DCA) and percutaneous coronary intervention (PCI) in NZ. We present the methods and three-years of data from the ANZACS-QI CathPCI registry. METHODS: The data was extracted from the ANZACS QI CathPCI registry from 01/09/2014 to 24/09/2017. The ANZACS-QI data dictionary defines all the clinical, procedural and outcomes variables collected, and standard statistical analyses were applied. RESULTS: 40,870 patients underwent cardiac catheterisation, with a mean age of 65 years, and males making up 67% of the cohort. Indications included acute coronary syndrome 55%, angina with suspected stable coronary disease 28%, valve surgery workup 8%, planned PCI 3%, heart failure/cardiomyopathy 3%, arrhythmia 1% and other 2%. For those undergoing DCA alone, radial access was used in 85% and two-thirds had at least one major artery with >50% stenosis. PCI was performed in 39% of patients. Drug-eluting stents were used in 97%. CONCLUSION: The CathPCI registry records the characteristics and outcomes of all patients undergoing DCA and PCI in NZ hospitals. As part of the ANZACS-QI programme the registry provides an important platform for quality improvement, research and to inform clinical practice.

The impact of a national COVID-19 lockdown on acute coronary syndrome hospitalisations in New Zealand (ANZACS-QI 55).

BACKGROUND: Countries with a high incidence of coronavirus 2019 (COVID-19) reported reduced hospitalisations for acute coronary syndromes (ACS) during the pandemic. This study describes the impact of a nationwide lockdown on ACS hospitalisations in New Zealand (NZ), a country with a low incidence of COVID-19. METHODS: All patients admitted to a NZ Hospital with ACS who underwent coronary angiography in the All NZ ACS Quality Improvement registry during the lockdown (23 March - 26 April 2020) were compared with equivalent weeks in 2015-2019. Ambulance attendances and regional community troponin-I testing were compared for lockdown and non-lockdown (1 July 2019 to 16 February 2020) periods. FINDINGS: Hospitalisation for ACS was lower during the 5-week lockdown (105 vs. 146 per-week, rate ratio 0•72 [95% CI 0•61-0•83], p = 0.003). This was explained by fewer admissions for non-ST-segment elevation ACS (NSTE-ACS; p = 0•002) but not ST-segment elevation myocardial infarction (STEMI; p = 0•31). Patient characteristics and in-hospital mortality were similar. For STEMI, door-to-balloon times were similar (70 vs. 72 min, p = 0•52). For NSTE-ACS, there was an increase in percutaneous revascularisation (59% vs. 49%, p<0•001) and reduction in surgical revascularisation (9% vs. 15%, p = 0•005). There were fewer ambulance attendances for cardiac arrests (98 vs. 110 per-week, p = 0•04) but no difference for suspected ACS (408 vs. 420 per-week, p = 0•44). Community troponin testing was lower throughout the lockdown (182 vs. 394 per-week, p<0•001). INTERPRETATION: Despite the low incidence of COVID-19, there was a nationwide decrease in ACS hospitalisations during the lockdown. These findings have important implications for future pandemic planning. FUNDING: The ANZACS-QI registry receives funding from the New Zealand Ministry of Health.

Acute reperfusion for ST-elevation myocardial infarction in New Zealand (2015-2017): patient and system delay (ANZACS-QI 29).

AIM: Prompt access to cardiac defibrillation and reperfusion therapy improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The study aim was to describe the 'patient' and 'system' delay in patients who receive acute reperfusion therapy for ST-elevation myocardial infarction (STEMI) in New Zealand. METHODS: In 2015-17, 3,857 patients who received acute reperfusion therapy were captured in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. 'Patient delay' is the time from symptom onset to first medical contact (FMC), and 'system delay' the time from FMC until reperfusion therapy (primary percutaneous coronary intervention (PCI) or fibrinolysis). RESULTS: Seventy percent of patients received primary PCI and 30% fibrinolysis. Of those receiving fibrinolysis, 122 (10.5%) received pre-hospital fibrinolysis. Seventy-seven percent were transported to hospital by ambulance. After adjustment, people who were older, male and presented to a hospital without a routine primary PCI service were less likely to travel by ambulance. Patient delay: The median delay was 45 minutes for ambulance-transported patients and 97 minutes for those self-transported to hospital, with a quarter delayed by >2 hours and >3 hours, respectively. Delay >1 hour was more common in older patients, Maori and Indian patients and those self-transported to hospital. System delay: For ambulance-transported patients who received primary PCI, the median time was 119 minutes. For ambulance-transported patients who received fibrinolysis, the median system delay was 86 minutes, with Maori patients more often delayed than European/Other patients. For patients who received pre-hospital fibrinolysis the median delay was 46 minutes shorter. For the quarter of patients treated with rescue PCI after fibrinolysis, the median needle-to-rescue time was prolonged-four hours. CONCLUSIONS: Nationwide implementation of the NZ STEMI pathway is needed to reduce system delays in delivery of primary PCI, fibrinolysis and rescue PCI. Ongoing initiatives are required to reduce barriers to calling the ambulance early after symptom onset.

The Association between Arterial Oxygen Tension, Hemoglobin Concentration, and Mortality in Mechanically Ventilated Critically Ill Patients.

BACKGROUND: Hypoxemia and anemia are common findings in critically ill patients admitted to Intensive Care Units. Both are independently associated with significant morbidity and mortality. However, the interaction between oxygenation and anemia and their impact on mortality in critically ill patients has not been clearly defined. We undertook this study to determine whether hemoglobin (Hb) level would modify the association between hypoxemia and mortality in mechanically ventilated critically ill patients. METHODS: We performed a retrospective cohort study of all mechanically ventilated adult patients (aged >16 years) in the Australian and New Zealand Intensive Care Society Adult Patient Database (APD) admitted over a 10-year period. Multivariate hierarchical logistic regression was used to assess the relationship between hypoxemia and hospital mortality stratified by Hb. RESULTS: Of 1,196,089 patients in the APD, 219,723 satisfied our inclusion and exclusion criteria. There was a linear negative relationship between hypoxemia and hospital mortality which was significantly modified when stratified by Hb. Hb independently increased the risk of mortality in patients with arterial oxygen tension <102. CONCLUSIONS: Hb is an effect modifier on the association between oxygenation and mortality.

The natural theology of Victorian industry.

As clergymen in Britain celebrated the Great Exhibition in the summer of 1851 and drew appropriate moral lessons, there was widespread agreement that the triumphs of industry on display represented the fulfilment of God's will. The basic assumption was that overcoming God's curse on Adam had been possible only through sustained hard work - industry in the early Victorian sense - and that this imperative work ethic had always been God's intention for mankind. In elaborating the details, preachers combined the British tradition of natural theology with the Scottish Enlightenment's progressive science of man to paint a picture of the slow recovery of man from the Fall through his own industry. This was the very story of civilization itself, with God the driving force. The celebrants were quite clear that it was divine providence that had ordained the greatness of Great Britain.

The Great Exhibition of 1851: the struggle to describe the indescribable.

Despite efforts to lay out the Great Exhibition in a rational arrangement, it was so vast and variegated and overwhelming in its single 18-acre building that it was literally indescribable. Robert Hunt in his Synopsis argued that every visitor needed to find a thread - any thread - through the labyrinth; but this proved elusive, even for professional journalists, who must overall be judged to have failed. With description impossible, journalists tried other strategies, notably epistolary form, and also fiction, which excused the writer from providing any more than a few personal impressions. The legacy of the Exhibition is ambiguous: judged at the time an overwhelming success, it proved to be all too easily forgettable and ephemeral.

Molecular basis of resistance to cytochrome bc1 inhibitors.

Inhibitors of the mitochondrial respiratory chain enzyme cytochrome bc1 (respiratory complex III) have been developed as antimicrobial agents. They are used in agriculture to control plant pathogenic fungi and in medicine against human pathogens, such as the malaria parasite Plasmodium falciparum, or Pneumocystis jiroveci (an opportunistic pathogenic fungus life-threatening in immuno-compromised patients). These respiratory inhibitors are thus effective against a broad range of important pathogens. Unfortunately, the problem of acquired resistance has rapidly emerged. A growing number of pathogen isolates resistant to inhibitor treatment have been reported, and this resistance is often linked to mutation within cytochrome b, one of the essential catalytic subunits of the complex. Saccharomyces cerevisiae is an invaluable model in order to assess the impact of the mutations on the sensitivity to the drugs, on the respiratory capacity and the fitness of cells. In this minireview, the inhibitors, their mode of action, and the mutations implicated in resistance and studied in yeast are briefly reviewed. Four mutations that are of particular importance in medicine and in agriculture are briefly reviewed and described in more detail and the molecular basis of resistance and of evolution of the mutations is discussed succinctly.

Ecological conservation through aesthetic landscape planning: a case study of the Lower Wisconsin State Riverway.

A consequence of expanding residential development into rural areas is the potential alteration of ecological communities. Certain novel land-use policies seek practical solutions by accommodating social needs for housing while conserving biodiversity. This study investigates whether regulations designed to protect the aesthetic characteristics of a river corridor simultaneously mitigate negative effects of development on avian biodiversity, despite the absence of explicit conservation objectives. Using housing data from the US Census (1990 and 2000) and the Audubon Christmas Bird Count (1987-2000), we examined changes in housing density, avian communities, and the relationship between these two variables in a location that has adopted aesthetic landscape planning, the Lower Wisconsin State Riverway. We found that overall species diversity increased in the Riverway, but remained constant in reference areas, although the relative increase in housing density in the two areas did not differ. We also found that omnivore populations decreased in the Riverway and increased in reference sites. On the whole, our study provides preliminary evidence that aesthetic landscape planning, such as employed in the Lower Wisconsin State Riverway, might constitute a politically viable approach to conserve ecological resources.

Further insights into the no-reflow phenomenon after primary angioplasty in acute myocardial infarction: the role of microthromboemboli.

We tested the hypothesis that when acute coronary occlusion is caused by thrombus, part of the no-reflow phenomenon may result from spontaneous or coronary angioplasty-induced microthromboemboli, and that this phenomenon may be partly or wholly reversible. Accordingly, a thrombus was created in the left anterior descending coronary artery of 6 dogs and was labeled in vivo with (99m)Tc-DMP-444 that binds to the IIb/IIIa platelet receptor. Angioplasty was then performed to obtain thrombolysis in myocardial infarction grade-3 flow. Myocardial contrast echocardiography was performed 15 and 60 minutes after recanalization to define perfusion defect size. (99m)Tc-autoradiography and infarct size (IS) measurement were performed postmortem. An additional 5 dogs with coronary artery ligation followed by reperfusion served as control animals. These dogs also underwent myocardial contrast echocardiography and in vivo labeling with (99m)Tc-DMP-44. (99m)Tc uptake was significantly higher in the reperfused bed in dogs with thrombus compared with control dogs (2.7 +/- 0.9 vs 1.4 +/- 0.3 counts/pixel(-1)/min(-1), P =.01) indicating the presence of microthromboemboli. Perfusion defect size early (15 minutes) after recanalization was smaller than the hot spot on autoradiography and overestimated IS in dogs with thrombus. Perfusion defect size decreased with time and was closer to IS 60 minutes after recanalization. The dogs with thrombi demonstrated larger IS/risk area ratios compared with the 5 control dogs (46 +/- 6% vs 27 +/- 12%, P =.04). We conclude that part of the no-reflow phenomenon seen after angioplasty in acute coronary thrombosis is a result of microthromboemboli and is mostly reversible. No reflow late after reperfusion is a result of tissue necrosis. The thrombus burden also affects ultimate IS.

Perfusion versus function: the ischemic cascade in demand ischemia: implications of single-vessel versus multivessel stenosis.

BACKGROUND: We hypothesized that during demand ischemia, abnormal perfusion will precede abnormal function, the spatial extent of perfusion abnormality will be greater than that of functional abnormality, and the spatiotemporal disparity between abnormal perfusion and abnormal function will be more marked in the presence of single-vessel stenosis (SVS) versus multivessel stenosis (MVS). METHODS AND RESULTS: Nine dogs each underwent either SVS or MVS placement. These noncritical stenoses were classified as mild, moderate, or severe on the basis of the transstenotic pressure gradient (10 to 14, 15 to 20, or >20 mm Hg). Dobutamine was infused starting at 10 and reaching 40 microg/kg(-1) x min(-1). Wall thickening (WT) and myocardial perfusion (myocardial contrast echocardiography) were assessed at each stage. Resting perfusion and function were normal in all dogs. In SVS, abnormal perfusion (delayed rate of microbubble replenishment) was seen at the lowest dose of dobutamine irrespective of the stenosis severity, whereas WT abnormality was seen only at high doses of dobutamine and was influenced by the stenosis severity. The spatial extent of abnormal perfusion exceeded that of WT abnormality at all but the highest dobutamine dose. This spatiotemporal discordance between abnormal perfusion and function was significantly less in MVS, where it was possible to identify separate regions with abnormal function at lower doses of dobutamine. CONCLUSIONS: These data support the occurrence of the ischemic cascade during demand ischemia. They also explain the higher sensitivity of abnormal perfusion compared with abnormal function for the detection of coronary stenosis as well as the higher sensitivity of dobutamine echocardiography for MVS compared with SVS.