Does Cardiac Physical Exam Teaching Using a Cardiac Simulator Improve Medical Students' Diagnostic Skills?

Background Challenges in bedside teaching may be overcome by the use of high-fidelity simulators for teaching the cardiac physical exam. The purpose of this study is to compare the ability of first-year medical students (MS1) to perform a cardiac physical exam and make the correct diagnosis after instruction using standardized patients (SPs) as compared to a cardiac simulator (Harvey, Laerdal Medical Corporation, NY, US). Methods Thirty-two MS1 were randomized to a teaching module on either SPs or Harvey. Their performance and ability to make the correct diagnosis were evaluated during a posttest objective structured clinical examination (OSCE) on real patients. Results No difference in the mean OSCE score was observed (SP: M=62.2% vs. Harvey: M=57.2%, p=0.32). The SP group obtained a higher frequency of correct diagnoses (M=61.5% SP vs. M=21.0% Harvey, p=0.03). Student feedback revealed that Harvey offered superior clinical findings; however, 34.4% of students requested a combination of teaching modalities as opposed to either method alone. Conclusions Performance in examination skills did not differ between the SP and Harvey groups but the SP group demonstrated an improved ability to arrive at a unifying diagnosis. A combined teaching program may be ideal for transferability to patients.

Paging the eCardiologist: insights into referral behaviour of primary care physicians from qualitative analysis of a cardiology eConsult service.

OBJECTIVE: The purpose of this study is to investigate determinants of primary care physician cardiology referrals by performing qualitative analysis of questions asked by primary care physicians in cardiology electronic consultation services (eConsults). SETTING: A health region in eastern Ontario, Canada, where primary care providers have had access to an eConsult service since 2010. PARTICIPANTS: We included all consecutive cardiology eConsults initiated by registered primary care provider users of our eConsult service and who initiated one or more eConsult between July 2014 and January 2015. We excluded eConsults in which the primary care provider attached a document without asking a question. A convenience sample of 100 consecutive eConsults initiated by 61 primary care providers was analysed after excluding 14 eConsults.Primary and secondary outcome measures: Primary care provider eConsult questions are categorised into thematic categories based on the constant comparison method of qualitative analysis with external validation by content experts. Secondary outcomes include sample primary care provider eConsult questions to illustrate each theme and any emergent subthemes. RESULTS: Thematic saturation occurred after analysis of 30 eConsults. An additional 70 eConsults were coded with no new emergent themes. Themes include exceptions to clinical guidelines (n=13), non-cardiac treatment in a cardiac patient (n=13), specific investigation/management (n=18), interpretation of diagnostic testing (n=46), clinical concerns despite normal testing (n=4) and screening for positive family history (n=6). Subthemes include multiple comorbidities and mild abnormalities on cardiac tests. CONCLUSIONS: We report categories of clinical questions that drive primary care provider cardiology eConsults. Multimorbidity leads to cardiology eConsults as primary care providers try to apply treatment guidelines in medically complex patients. Mild test abnormalities unrelated to clinical problems commonly lead to cardiology eConsult requests. Further research is needed to determine how guidelines can better account for multimorbidity, and how cardiologists can better communicate with primary care providers to put cardiac test results in clinical context.

Mother-child interactions in young children with excessive physical aggression and in typically developing young children.

BACKGROUND: Among the multiple risk factors, the emergence of conduct problems in young children may be linked to harsh parenting and child's temperamental difficulties, leading to a reciprocal early discordant relationship. Little is known about the characteristics of early parent-child interactions in young children with physical aggression. OBJECTIVE: The purpose of the current study was to evaluate the characteristics of mother-child interactions in dyads referred for excessive physical aggression in young children under 5 years of age compared to mother-child interactions in typically developing young children. METHOD: Mother-child interactions were assessed during a free-play session in both a clinical sample ( N = 70, child mean age = 3.5 years) and a nonclinical sample ( N = 80, child mean age = 3.5 years) by using the Rating Scale of Interaction Style (Clark and Seifer, adapted by Molitor and Mayes). RESULTS: Significant differences were found between several interactive features in clinical and nonclinical dyads. In clinical dyads, mothers' behaviors were often characterized by intrusiveness and criticism toward children, and poor facilitative positioning. Children with excessive aggressive behavior often displayed poor communication, initiation of bids, and poor responsiveness toward the mother. They displayed fewer sustained bouts of play than typically developing children did. In clinical dyads, strong positive correlations were found between child responsiveness and maternal interest in engagement ( r = .41, p < .001), while the child displaying sustained bouts of play was negatively correlated with the mother's attempts to intrude on the child's activity ( r = .64, p < .05). CONCLUSIONS: These data show that children with excessive aggressive behavior develop disrupted mother-infant interactions from a very young age. Several negative interactive features and correlations between child behavior and maternal behavior were found in clinical samples. The effects of these features add up and probably strengthen each other, thus leading to interactive difficulties from a very young age. More attention should be paid to early parent-child interactions in case of child behavioral problems. The recognition of these interactive dysfunctions is discussed in terms of clinical implications for therapeutic interventions.

Sleep apnea in chronic heart failure.

PURPOSE OF REVIEW: As heart failure continues to carry significant morbidity and mortality it is crucial to pursue new lines of therapy. Addressing sleep apnea, which is highly prevalent in these patients, offers just such an avenue. We discuss how sleep apnea may contribute to the propagation of heart failure, and how understanding its effects and reversing these effects might benefit heart failure patients. RECENT FINDINGS: Continuous positive airway pressure ventilation, atrial pacing, and chronic resynchronization therapy have all been studied in sleep apnea. Some of these therapies have shown benefits in heart failure. This offers hope for improved outcomes, particularly with respect to mortality. Delineating how these therapies affect the heart's energetics and metabolism may also provide further understanding of the relationship between sleep apnea and heart failure. SUMMARY: As both obstructive and central sleep apnea are highly prevalent in heart failure, treating these patients with continuous positive airway pressure, atrial pacing, or chronic resynchronization therapy may offer morbidity and mortality benefits. Much remains to be understood about the relationship between sleep apnea and heart failure, and understanding the interaction between the two at both the myocardial and clinical level is crucial.

New therapies in acute decompensated heart failure.

PURPOSE OF REVIEW: Hospitalization and mortality rates associated with heart failure are persistently high. This is due partly to aging of the population but mostly to delayed progress in the pharmacological treatment of decompensated heart failure. We will review the current recommendations and most recent advancement in the pharmacological treatment of acute decompensated heart failure while providing a systematic approach to the management of this prevalent condition. RECENT FINDINGS: Loop diuretics, nitrates and inotropes such as dobutamine and milrinone are the current mainstay of acute heart failure management although their associated morbidity and possible mortality have raised serious concerns. Recent vasoactive agents such as Nesiritide, Tolvaptan and more recently the inotropic agent Levosimedan could offer improved hemodynamics and congestive relief to patients in acute pulmonary edema. SUMMARY: Despite the promising results of these agents, further clinical trials are required prior to their international approval as first-line therapy. Although we can be optimistic that these vasoactive drugs might have favorable clinical outcomes and improve the intricate management of decompensated heart failure, their associated mortality benefit remains unclear and controversial.

Percutaneous coronary intervention for left main coronary artery disease.

Coronary artery bypass surgery is the currently accepted treatment for unprotected left main coronary artery disease. Currently, the data supporting the safety and efficacy of stents for unprotected left main coronary disease are derived mostly from nonrandomized, single-center studies or registries. These results appear promising but large randomized trials are needed to guide therapy of this potentially lethal disease.