Can virtual-reality simulation ensure transthoracic echocardiography skills before trainees examine patients?

Objectives: This study aimed to develop and gather the validity evidence for a standardised simulation-based skills test in transthoracic echocardiography and to establish a credible pass/fail score. Methods: Experts developed a virtual-reality simulator test in cardiology, medical education and simulation-based education. Thirty-six physicians with different experiences in transthoracic echocardiography completed the test at Odense University Hospital, Denmark. The performances of novice, intermediate and experienced participants were compared using the Bonferroni post hoc test. Cronbach's alpha was used to determine the internal consistency reliability of the test. The consistency of performance was analysed using the intraclass correlation coefficient. A pass/fail score was established using the contrasting groups' standard-setting method. Results: We developed a test with high consistent reliability (Alpha = .81), 95% CI [.69, .89]. In both cases, the performers' level was consistent, fitting others at the same level of experience (intraclass correlation r(35)=.81, p<.001). A pass/fail score of 48/50 points was established based on the mean test score of novice and experienced physicians. Conclusions: We developed a standardised virtual-reality simulation-based test of echocardiography skills with the ability to distinguish between participants with different levels of transthoracic echocardiography experience. This test could direct a mastery learning training program where trainees practise until they reach the pre-defined level and secure a higher level of competency to ensure quality and safety for patients.

Eight weeks of mineralocorticoid blockade does not improve insulin sensitivity in type 2 diabetes.

Individuals with type 2 diabetes have an increased risk of cardiovascular disease. A correlation between plasma aldosterone and hyperinsulinemia has been demonstrated in vivo, and hyperinsulinemia and insulin resistance are independently associated with the development of cardiovascular complications. We investigated if mineralocorticoid blockade (Eplerenone) improves insulin sensitivity in individuals with type 2 diabetes compared to healthy controls. We included 13 participants with type 2 diabetes (<5 years; male/female, Caucasians) and 10 healthy control participants (male/female, Caucasians). On 2 experimental days, before and at the end of the 8 weeks of treatment with mineralocorticoid blockade, a two-stage hyperinsulinemic-isoglycemic clamp (20 and 50 mU∙m-2 min-1 ) was performed for the determination of insulin sensitivity. No change in insulin sensitivity was detected at the end of the mineralocorticoid blockade in the individuals with type 2 diabetes or the healthy controls. Both before and at the end of the treatment with mineralocorticoid blockade, the individuals with type 2 diabetes had a lower insulin sensitivity compared to healthy controls. In conclusion, mineralocorticoid receptor blockade does not appear to improve insulin sensitivity in individuals with type 2 diabetes. CLINICAL TRIAL REGISTRATION: NCT03017703. https://clinicaltrials.gov/ct2/show/NCT03017703.

[Iatrogenic clinically cardiac arrest after administration of nitroglycerin].

This case report highlights the importance of preload in cardiac tamponade, as cardiac arrest with pulseless electrical activity was unintentionally induced after sublingual administration of nitroglycerin in an 83-year-old woman with unrecognised haemopericardium. Cardiac tamponade is a life-threatening condition, as accumulation of fluids in the pericardial sac diminishes preload which can ultimately lead to cardiac arrest. Primary elements in the development of critical haemodynamic tamponade are rate of fluid-accumulation and compensatory mechanisms, mainly tachycardia and vasoconstriction.

Colloids in Cardiac Surgery-Friend or Foe?

OBJECTIVE: The right choice of fluid replacement still is a matter of debate. Recently, two large-scale studies on the use of hydroxyethyl starches (HES) in the intensive care setting have been published, which have caused a huge shift in the daily practice of volume therapy. These results have been applied to patients outside intensive care. The aim of this study was to evaluate the impact this change has had on the outcomes in a large population of cardiac surgery patients, with a focus on the type of colloid infusion. DESIGN: A prospective, registered, observational study, using propensity score matching. SETTING: Cohort study from 3 university hospitals using a common registry. PARTICIPANTS: The study comprised 17,742 patients who were referred for cardiac surgery from 2007 to 2014. INTERVENTIONS: Patients were divided in groups according to perioperative fluid replacement with either crystalloids or colloids. The colloid group was further divided into HES or human albumin (HA). Analyses were based on the following 3 subsections: HES versus crystalloids, HA versus crystalloids, and HES versus HA, with use of propensity score matching or direct matching of cases. Primary outcome parameters were 30-day and 6-month mortality, new postoperative renal replacement therapy, and new cardiac ischemic events. MEASUREMENTS AND MAIN RESULTS: The groups were fully comparable in individual analyses. The use of HES had no impact on new dialysis and 30-day mortality. A Cox proportional regression analysis showed that HES had no impact on 6-month mortality and new postoperative ischemic events. When comparing HA with crystalloid use, a significantly increased risk in crude analysis was demonstrated on all outcome parameters; and when comparing HA with HES, a significantly higher risk was observed in HA patients in mortality parameters and new postoperative, but after adjustment, only the risk of new postoperative dialysis persisted. CONCLUSION: This study underlined the difficulties in establishing hardcore outcome data, even in large cohort studies. The findings seemed to diminish the magnitude of risk when using HES in cardiac surgery patients and seriously questioned the choice of HA when a plasma expander is needed.

[Assessment of the prognosis in patients who remain comatose after resuscitation from cardiac arrest]. / Vurdering af prognose hos patienter med manglende opvågning efter hjertestop

In Denmark there are around 3,500 unexpected cardiac arrests (CA) out of hospital each year. There is an unknown number of CA in hospitals. The survival rate after CA outside a hospital in Denmark is 10% after 30 days. There are varying data for the neurological outcome in this group of patients. The purpose of this work is to disseminate new knowledge and to help standardizing the treatment in the group of patients who remain comatose after being resuscitated from CA. Assessment of the prognosis for a patient in this group can be made after 72 hours and a multi-modal approach to the patient is required.