A Systematic Scoping Review on Pedagogical Strategies of Interprofessional Communication for Physicians in Emergency Medicine.

BACKGROUND: Interprofessional communication (IPC) is integral to interprofessional teams working in the emergency medicine (EM) setting. Yet, the coronavirus disease 2019 pandemic has laid bare gaps in IPC knowledge, skills and attitudes. These experiences underscore the need to review how IPC is taught in EM. PURPOSE: A systematic scoping review is proposed to scrutinize accounts of IPC programs in EM. METHODS: Krishna's Systematic Evidence-Based Approach (SEBA) is adopted to guide this systematic scoping review. Independent searches of ninedatabases (PubMed, Embase, CINAHL, Scopus, PsycINFO, ERIC, JSTOR, Google Scholar and OpenGrey) and "negotiated consensual validation" were used to identify articles published between January 1, 2000 and December 31, 2020. Three research teams reviewed the data using concurrent content and thematic analysis and independently summarized the included articles. The findings were scrutinized using SEBA's jigsaw perspective and funneling approach to provide a more holistic picture of the data. IN TOTAL: 18,809 titles and abstracts were identified after removal of duplicates, 76 full-text articles reviewed, and 19 full-text articles were analyzed. In total, four themes and categories were identified, namely: (a) indications and outcomes, (2) curriculum and assessment methods, (3) barriers, and (4) enablers. CONCLUSION: IPC training in EM should be longitudinal, competency- and stage-based, underlining the need for effective oversight by the host organization. It also suggests a role for portfolios and the importance of continuing support for physicians in EM as they hone their IPC skills. HIGHLIGHTS: • IPC training in EM is competency-based and organized around stages.• IPC competencies build on prevailing knowledge and skills.• Longitudinal support and holistic oversight necessitates a central role for the host organization.• Longitudinal, robust, and adaptable assessment tools in the EM setting are necessary and may be supplemented by portfolio use.

Real-World Assessment of Acute Left Ventricular Lead Implant Success and Complication Rates: Results from the Attain Success Clinical Trial.

BACKGROUND: Left ventricular lead (LVL) implant success rates have historically ranged between 70.5% and 95.5%. To date, there are few large studies that evaluate LVL implant success utilizing a single family of delivery catheters and leads. The Attain Success study was a prospective nonrandomized multicenter global study with the main objectives of assessing single-system LVL implant success and complication rates. METHODS: Patients undergoing cardiac resynchronization therapy implantation were eligible for enrollment. There was no prespecified level of experience for investigator participation. LVL implant success and complication rates were assessed though 3 months of follow-up. RESULTS: A total of 2,014 patients (69.1 ± 12.0 years, 71% male and 38% atrial fibrillation) were enrolled from 114 centers with a follow-up of 3.5 ± 2.1 months. Coronary sinus cannulation success rate was 96.4% with Attain Family delivery catheters. Implant success rate for Attain Family leads using Attain Family catheters was 94.0%; overall LVL implant success rate was 97.1%. Median procedure time was 4 minutes for cannulation and 9 minutes for LVL placement. Median fluoroscopy time was 17 minutes and median contrast used was 25 cc. There were 55 catheter or LVL-related complications in 53 subjects; the majority were LVL dislodgements (34, 1.7%) and extracardiac stimulation (11, 0.5%). The Kaplan-Meier estimate of the 3-month complication probability was 2.6%. CONCLUSION: This study represents the largest prospective evaluation of LVL implantation to date, revealing a high LVL implant success rate and low complication rate using a single family of leads and delivery catheters.

Deleterious effect of right ventricular apical pacing on left ventricular diastolic function and the impact of pre-existing diastolic disease.

AIMS: Right ventricular apex (RVA) pacing may have deleterious effects on left ventricular (LV) systolic function, but its impact on LV diastolic function has not been explored. METHODS AND RESULTS: Ninety-seven patients with sinus node dysfunction and ejection fraction (EF) ≥ 50% with permanent RVA pacing were randomly programmed to V-sense and V-pace modes and examined by echocardiography. Tissue Doppler imaging was employed to assess myocardial systolic velocity (S') and early diastolic velocity (E') at the mitral annulus. Systolic dyssynchrony was assessed using 12 LV segmental model (Ts-SD). Switching from V-sense to V-pace resulted in the worsening of both diastolic and systolic functions as shown by the decreased EF, reduced mean E' and S' velocities, as well as increase in LV volume and Ts-SD (all P< 0.001). Reduction of mean E' and S' of ≥ 1 cm/s occurred in 35 (36%) and 45 (46%) patients, respectively. In pre-defined subgroup analysis, only patients with pre-existing LV diastolic dysfunction had a significant reduction of mean E' and S' (both P< 0.001) even after age adjustment. Multivariate logistic regression analysis showed that independent factors for the reduction of mean E' ≥ 1 cm/s or mean S' ≥ 1 cm/s at V-pace were pre-existing LV diastolic dysfunction [odds ratio (OR): 4.735, P= 0.007 for E'; OR: 3.307, P= 0.022 for S'] and systolic dyssynchrony at V-pace (OR: 5.459, P= 0.007 for E'; OR: 2.725, P= 0.035 for S'). CONCLUSION: In patients with preserved EF, RVA pacing is associated with the deterioration of both LV diastolic and systolic functions, which is particularly obvious in those with pre-existing LV diastolic dysfunction and V-pace-induced systolic dyssynchrony.

Multicenter clinical experience with an atrial lead designed to minimize far-field R-wave sensing.

AIMS: To evaluate a novel atrial lead designed to reduce far-field sensing. METHODS AND RESULTS: Sixty-three patients with standard pacing indications were randomized to receive an OptiSense 1699T (St Jude Medical, USA) or conventional pacing lead in the right atrium. Post-implant follow-up was conducted for all patients at 90 days and for a subset at 360 days. Standard electrical parameters were measured. Thresholds of sensing were determined for far-field ventricular signals. The number of inappropriate mode switches was determined from the stored intracardiac electrogram (IEGM). At 90 days, an IEGM Holter recorded 24 h of IEGM. With atrial sensitivity programmed at 0.3 mV, no far-field sensing occurred in the OptiSense group, but it did occur in 20% and 30% of the control group at 90 and 360 days, respectively. Inappropriate mode switching was observed in 4% of the OptiSense group in contrast to 23% of the control group. The IEGM Holter found no far-field sensing in the OptiSense group, but did find 83 023 far-field events from 22% of control patients. The standard electrical parameters of the OptiSense leads were acceptable. CONCLUSION: The OptiSense lead reduced ventricular far-field sensing in the atrium while maintaining satisfactory pacing and sensing performance, resulting in less inappropriate mode switch.

Incremental prognostic value of combining left ventricular lead position and systolic dyssynchrony in predicting long-term survival after cardiac resynchronization therapy.

The efficacy of CRT (cardiac resynchronization therapy) can be affected by a number of factors; however, the prognostic significance of the LV (left ventricular) lead position has not been explored. The aim of the present study was to examine whether a PL (posterolateral) lead position has an additional value to systolic dyssynchrony in predicting a better survival after CRT. Patients (n=134) who received CRT were followed-up for 39+/-24 months. The LV lead position was determined by cine fluoroscopy, and baseline dyssynchrony was assessed by TDI (tissue Doppler imaging). The relationship between the LV lead position/dyssynchrony and mortality was compared using Kaplan-Meier curves, followed by Cox regression analysis. The all-cause and cardiovascular mortalities were 38 and 31% respectively. The presence of dyssynchrony and a PL lead position predicted a lower all-cause mortality (29 compared with 47%; log-rank chi2=5.38, P=0.02) and cardiovascular mortality (21 compared with 41%; log-rank chi2=6.75, P=0.009) than when absent. The all-cause mortality was as high as 62% when patients had neither dyssynchrony nor a PL lead position, but was reduced to 29% when both criteria were present, and was between 45 and 46% when only one criterion was present (chi2=6.79, P=0.01). The corresponding values for cardiovascular mortality were 62% when patients had neither dyssynchrony nor a PL lead position, 36-38% when patients had either dyssynchrony or a PL lead position, and 21% when patients had both criteria present (chi2=9.54, P=0.004). Combining dyssynchrony and a PL lead position independently predicted a lower all-cause morality {HR (hazard ratio), 0.496 [95% CI (confidence interval), 0.278-0.888]; P=0.018} and cardiovascular mortality [HR, 0.442 (95% CI, 0.232-0.844); P=0.013]. In conclusion, the placement of the LV lead at a PL position provides additional value to baseline dyssynchrony in predicting a lower all-cause and cardiovascular mortality during long-term follow-up after CRT.

Effect of left ventricular lead concordance to the delayed contraction segment on echocardiographic and clinical outcomes after cardiac resynchronization therapy.

INTRODUCTION: The optimal left ventricular (LV) pacing site for cardiac resynchronization therapy (CRT) is unclear. The current study aims to explore the clinical significance of LV lead concordance to delayed contraction segment in CRT. METHODS AND RESULTS: Concordant LV lead position was defined as the lead tip located by fluoroscopy at or immediately adjacent to the LV segment with latest contraction determined by tissue Doppler imaging. Echocardiographic and clinical outcomes among 101 consecutive patients with or without concordant LV lead positions were compared. There was no significant difference in changes in LV volumes and clinical parameters between patients with concordant (n = 46) or nonconcordant (n = 55) LV lead positions at 3 and 6 months. In multivariate analysis, the baseline asynchrony index (beta= 1.092, 95% CI: 1.050-1.114; P < 0.001), but not LV lead concordance, was the only independent predictor of LV reverse remodeling. By Cox regression analysis, ischemic etiology, and LV reverse remodeling, but not LV lead concordance, were independent predictors of mortality (beta= 2.475, 95% CI: 1.183-5.178; P = 0.016, and beta= 0.272, 95% CI: 0.130-0.567; P < 0.001, respectively), cardiovascular hospitalization (beta= 1.551, 95% CI: 1.032-2.333; P = 0.035, and beta= 0.460, 95% CI: 0.298-0.708; P < 0.001, respectively), and heart failure hospitalization (beta= 0.486, 95% CI: 0.320-0.738; P = 0.001 for LV reverse remodeling). CONCLUSION: LV lead concordance to the delayed contraction segment may not be a major determining factor for favorable echocardiographic and clinical outcomes after CRT.

Reversible left ventricular dyssynchrony and heart failure induced by right ventricular pacing.

Right ventricular (RV) pacing related heart failure is reported in some patients after long term pacing. The exact mechanism is not yet clear but may be related to left ventricular (LV) dyssynchrony induced by RV apical pacing. We report one case with baseline normal LV ejection fraction but complicated by heart failure and ventricular tachycardia after 4 months of pacing for complete heart block together with illustration of LV dyssynchrony demonstrated by tissue Doppler imaging.

Left ventricular systolic dyssynchrony is a predictor of cardiac remodeling after myocardial infarction.

OBJECTIVES: We sought to determine whether early assessment of left ventricular (LV) dyssynchrony by tissue Doppler imaging may predict progressive ventricular enlargement and cardiac dysfunction after acute myocardial infarction (MI). METHODS: Forty-seven patients (mean age 59.9 +/- 11.6 years) with normal QRS duration underwent tissue Doppler imaging and contrast-enhanced cardiac magnetic resonance imaging (Ce-MRI) at days 2 to 6, 3 months, and at 1 year after the index MI. Systolic dyssynchrony index (Ts-SD) was calculated from 12 LV segments, and infarct size (IS) by Ce-MRI. RESULTS: The remodeling group (n = 16) (defined as an increase in end-systolic volume > or =10% between 1 year and baseline) had greater initial IS (27.2 +/- 9.6 vs 13.7 +/- 4.1%, P < .001) and Ts-SD (50.9 +/- 12.8 vs 33.6 +/- 7.7 milliseconds, P < .001) than nonremodeling group (n = 31). At 1 year, the remodeling group had progressive increase in Ts-SD and decrease in LV ejection fraction (57.3 +/- 18.5 and 36.0 +/- 7.6%, respectively; both P < .05 vs baseline). Both Ts-SD (odds ratio 1.19 [1.07-1.32], P = .001) and IS (odds ratio 1.65 [1.19-2.29], P = .003) were shown to be independent predictors of progressive LV remodeling. A cutoff value of Ts-SD > or =45 milliseconds predicted LV remodeling at 1 year (sensitivity 90.5%, specificity 90.9%, Area-under-curve 0.907) (P = .0005). CONCLUSIONS: Left ventricular systolic dyssynchrony is a newly identified predictor of chronic LV remodeling after acute MI, which is independent and incremental to conventional assessment and IS as measured by Ce-MRI.

Improvement of left atrial function is associated with lower incidence of atrial fibrillation and mortality after cardiac resynchronization therapy.

BACKGROUND: Left atrial (LA) volume is a predictor of cardiovascular events in patients with heart failure. Improvement of LA function and reverse remodeling was observed after cardiac resynchronization therapy (CRT). OBJECTIVE: The purpose of this study was to explore the clinical significance of improvement in LA function after CRT. METHODS: Echocardiographic studies were performed before and 3 months after CRT in 97 patients (72 men and 25 women; age 63.8 +/- 13.3 years) with standard CRT indication but no history of atrial fibrillation (AF). LA active emptying fraction based on the change in volumes (LAV-EF) were calculated, and significant improvement in LA function (LA responder) was defined as a relative increase >/=50% from baseline LAV-EF. The primary end-points were newly developed AF detected by ECG or device and all-cause mortality. RESULTS: After 1,200 +/- 705 days of follow-up, LA responders (n = 47 [48.5%]) had a significantly lower incidence of AF (12.8% vs 40%, P = .002) and mortality (17% vs 44%, P = .004) than did LA nonresponders. In Cox proportional hazard analysis, LA responders was the only independent predictor of lower risk of new-onset AF (hazard ratio 0.22, 95% confidence interval 0.08-0.61, P = .003), whereas both LA responders (hazard ratio 0.22, 95% confidence interval 0.09-0.53, P <.001) and left ventricular reverse remodeling (>10% reduction in left ventricular end-systolic volume at 3 months; hazard ratio 0.96, 95% confidence interval 0.93-0.99, P = .03) were independent predictors of lower risk of death after CRT. CONCLUSION: Improvement of LA function after CRT was associated with a lower incidence of AF and mortality in AF naïve patients with severe heart failure.

Effects of photochemical transformations of dissolved organic matter on bacterial metabolism and diversity in three contrasting coastal sites in the Northwestern Mediterranean Sea during summer.

The effects of phototransformation of dissolved organic matter (DOM) on bacterial growth, production, respiration, growth efficiency, and diversity were investigated during summer in two lagoons and one oligotrophic coastal water samples from the Northwestern Mediterranean Sea, differing widely in DOM and chromophoric DOM concentrations. Exposure of 0.2-microm filtered waters to full sun radiation for 1 d resulted in small changes in optical properties and concentrations of DOM, and no changes in nitrate, nitrite, and phosphate concentrations. After exposure to sunlight or dark (control) treatments, the water samples were inoculated with the original bacterial community. Phototransformation of DOM had contrasting effects on bacterial production and respiration, depending on the water's origin, resulting in an increase of bacterial growth efficiency for the oligotrophic coastal water sample (120%) and a decrease for the lagoon waters (20 to 40%) relative to that observed in dark treatments. We also observed that bacterial growth on DOM irradiated by full sun resulted in changes in community structure of total and metabolically active bacterial cells for the three locations studied when compared to the bacteria growing on un-irradiated DOM, and that changes were mainly caused by phototransformation of DOM by UV radiation for the eutrophic lagoon and the oligotrophic coastal water and by photosynthetically active radiation (PAR) for the mesoeutrophic lagoon. These initial results indicate that phototransformation of DOM significantly alters both bacterial metabolism and community structure in surface water for a variety of coastal ecosystems in the Mediterranean Sea. Further studies will be necessary to elucidate a more detailed appreciation of potential temporal and spatial variations of the effects measured.

Impact of atrial fibrillation in heart failure with normal ejection fraction: a clinical and echocardiographic study.

BACKGROUND: The clinical significance of atrial fibrillation (AF) in heart failure with normal ejection fraction (HFNEF) remains undetermined. METHODS AND RESULTS: We compared the clinical and echocardiographic characteristics among 238 patients hospitalized for HF. Using the cutoff of left ventricular EF of 50%, there were 146 patients with HFNEF (AF = 42) and 92 with systolic HF (AF = 30). When compared among HFNEF, the New York Heart Association (NYHA) class (2.61 +/- 0.51 versus 2.21 +/- 0.46; P < .05), 6-minute walk distance (279.7 +/- 66.0 versus 338.0 +/- 86.1 m; P < .01), quality of life score (26.1 +/- 14.3 versus 19.5 +/- 10.3; P < .05), and previous HF hospitalization were significantly worse in the AF group. These variables were significantly better in HFNEF than systolic HF with sinus rhythm, but the differences were not detected among those with AF. Patients with HFNEF and AF were associated with more severe diastolic dysfunction when compared to sinus rhythm. With a median follow-up of 10.5 months, the proportion of HFNEF patients in AF with recurrent HF hospitalization or death was significantly higher than those in sinus rhythm (28.6% versus 10.6%; P < .01). Both AF and restrictive diastolic dysfunction were independent predictors of HF hospitalization or death in HFNEF. CONCLUSION: Patients with HFNEF and AF were associated with more severe diastolic dysfunction and worse clinical outcomes than those in sinus rhythm.

Effect of left ventricular endocardial activation pattern on echocardiographic and clinical response to cardiac resynchronization therapy.

OBJECTIVE: To explore the left ventricular (LV) electrical activation pattern in heart failure (HF) and its implication to cardiac resynchronization therapy (CRT). DESIGN AND SETTING: Observational study at the University Teaching Hospital. PATIENTS: 23 optimally treated patients with HF with New York Heart Association class III, QRS duration >120 ms and LV ejection fraction <35%. INTERVENTIONS: The LV endocardial activation pattern and total activation time (Tat) was determined by non-contact mapping and the LV mechanical dys-synchrony was determined by standard deviation (Ts-SD) and maximal difference (Ts-diff) of time to peak systolic contraction (Ts) among 12 LV segments using tissue Doppler imaging before receiving CRT. MAIN OUTCOME MEASURES: Correlation between electrical and mechanical dys-synchrony; volumetric responder to CRT at 3 months; HF hospitalisation or death by Kaplan-Meier analysis. RESULTS: Homogenous (type I, n = 8) and presence of conduction block (type II, n = 15) patterns were identified. Significant correlation between Tat and Ts-SD/Ts-diff was noted only in type II (r = 0.73/0.56, p = 0.002/0.03). Ts-SD and Ts-diff in type II were significantly longer than type I. 12 patients in type II and 2 in type I were CRT responders (p = 0.01). After 487 (447) days, patients with type II pattern had significantly lower risk of HF hospitalisation or death than those with type I (log rank chi(2) = 5.25; p = 0.02). CONCLUSION: Patients with type II LV endocardial activation pattern had a more favourable echocardiographic and clinical response to CRT than those with type I pattern.

Atrial strain rate echocardiography can predict success or failure of cardioversion for atrial fibrillation: a combined transthoracic tissue Doppler and transoesophageal imaging study.

AIMS: The purpose of this study was to assess the feasibility of measuring left atrial dysfunction with tissue Doppler imaging derived strain rate and to explore its role in predicting the maintenance of sinus rhythm after cardioversion for atrial fibrillation. METHODS AND RESULTS: Strain rate (SR) and tissue Doppler imaging (TDI) were performed with offline analysis of the basal left atrial wall (LA). SR detected a systolic (Ssr) and early diastolic (Esr) deformation induced by ventricular motion. LA dimensions and volume were measured. Left atrial appendage emptying (LAA_EV) and filling (LAA_FV) velocities were also obtained by transesophageal echocardiography. 27 healthy age-matched controls and 42 patients with AF before cardioversion were studied. Patients were grouped into (1): those who remained in sinus rhythm (group S, n=12) and (2) those who either failed cardioversion or reverted to AF within 4 weeks (group F, n=30). LA dimensions were significantly larger and atrial Esr was significantly lower in group F than group S (all p<0.01). LAA_EV and LAA_FV were not different between groups S and F. Multivariate regression analysis showed that a lower Esr and larger transverse LA diameter (LADtr) were independent predictors of failure of cardioversion (HR, 95% CI: 0.36, 0.14-0.88 and 2.85, 1.33-6.10, respectively). Esr combined with LADtr improved the sensitivity and specificity for predicting successful cardioversion. CONCLUSIONS: SR can be measured in the basal LA wall in atrial fibrillation and the magnitude of the early diastolic SR could predict the success of cardioversion and the likelihood of maintenance of sinus rhythm.

Suboptimal medical therapy in patients with systolic heart failure is associated with less improvement by cardiac resynchronization therapy.

BACKGROUND: Proven medical therapy is under-prescribed in heart failure (HF) for various reasons. Cardiac resynchronization therapy (CRT) is of proven value in selected patients with HF; however, the degree of benefit in those without the optimal therapy is not clear. METHODS: This is a retrospective study comparing the effect of CRT in 30 patients without optimal combination therapy (group 1; 10 (33%) without ACEi or equivalent and 25 (83%) without beta-blockers) to an age, sex, ejection fraction (EF) and New York Heart Association (NYHA) class matched control but with the combination (group 2; n=30) at baseline. All patients were in NYHA class III or IV with EF < or = 35% and QRS interval > or = 120 ms. Echocardiographic examination and N-terminal pro-brain natriuretic peptide (NT pro-BNP) levels before and 3 months after CRT were compared between the two groups. The composite endpoints of HF hospitalization or death during follow-up were compared by Kaplan-Meier analysis. RESULTS: There were significantly less improvement in EF (+4.0+/-2.5% vs +10.1+/-3.2%; p<0.05) and degree of reverse remodeling in group 1 after 3 months. Patients in group 1 had significantly higher level of NT pro-BNP levels at 3 months (2221+/-2001 pg/mL vs 1038+/-905 pg/mL; p<0.001) and higher rates of HF hospitalization or death (53.3% vs 23.3%; Log rank chi2 5.52; p=0.019). CONCLUSION: Patients receiving CRT but without optimal medical therapy were associated with less echocardiographic and clinical improvement. Optimal medical therapy, if tolerated, before CRT is necessary.