Chronic Total Occlusion Interventions in Patients with Reduced Ejection Fraction.

PURPOSE OF THE REVIEW: The goal of this paper is to review the current evidence surrounding CTO PCI in patients with low EF, the most high-risk population to treat. We also present pertinent case examples and offer practical tips to increase success and lower complications when performing CTO PCI in patients with low EF. RECENT FINDINGS: In a prospective randomized control study, greater improvement in angina frequency and quality of life, assessed by the Seattle Angina Questionnaire, was achieved by CTO PCI compared to optimal medical therapy. Furthermore, after successful CTO PCI, improvements in health status were similar in patients with both low and normal EF. CTO PCI can not only ameliorate symptoms of angina in patients with low EF but may also potentially improve EF in carefully selected populations. However, information regarding treatment of this high-risk population is lacking and large-scale studies targeting patients with severely reduced EF remain necessary.

A microanalysis of expert-student dialogue videos: Supporting preparation and learning for clinical competence assessment.

INTRODUCTION: The aim of this qualitative study was to analyse students' perceptions and impact of using a novel video genre designed to support their learning and preparation for a clinical competence assessment. The videos demonstrate expert-student dialogue (ESD) of authentic, one-on-one discourse between the teacher and student, relating to the case presentation and self-evaluation of the assessment. METHODS: Students who were about to perform a competence assessment were invited to participate in the study. Students were asked to watch a relevant ESD video they had not previously had access to, which showed the examiner-examinee dialogue relating to a peer's tooth preparation for the competence assessment. Immediately after watching the video, a video simulated recall approach was performed to analyse students' perceptions. Thematic analysis was performed to induce relevant themes. RESULTS: Five themes were identified: analysis and judgement, observational learning from expert dialogue, observational learning from student dialogue, self-efficacy and empathy. Positive responses from interviews suggested high cognitive engagement with this video genre with an affective component that was also valued as an informative learning resource. Students reported the video could stimulate them to think, make it easier to remember knowledge, avoid errors observed, and gain insights into assessment process and examiner's expectations. Empathy was also reported towards the examinee in the video. CONCLUSIONS: The ESD videos facilitated students' active and analytical thinking as well as improved their assessment preparedness. This video genre has shown how observing ESD can support students' learning and preparation for a clinical competence assessment.

The relation of online learning analytics, approaches to learning and academic achievement in a clinical skills course.

INTRODUCTION: This study examined relationships of students' access of e-learning (learning analytics) for a healthcare psychomotor skills course, approaches to learning (R-SPQ-2F psychometric) and academic achievement (summative examination results). An understanding of the relationships may help in supporting students learning. METHODS: Two consecutive cohorts of 5th year dental students were asked to complete the R-SPQ-2F questionnaire and permission to access data of online videos and associated quizzes and two summative written examination results were examined. The summative assessments were an OSCA and a written-paper question both in prosthodontics. Multiple linear regression and correlation analysis were performed. RESULTS: Students (n=98) performed a total of 10470 video access events and 7714 attempts in online quizzes. Deep learning approach was the strongest predictor variable (ß=0.270; P=.004) on written-paper question result. While video and quiz access were moderately correlated (r=0.600; P<.001) to each other, video access was not a significant predictor to either of the examination results. Quiz access was negatively associated with academic achievement for the written-paper question results (ß=-0.349; P<.001). CONCLUSIONS: Only deep approach to learning appeared to be relevant for the written-paper question examination grades. Conversely, the number of video and quiz access did not relate to either examination results. This suggests e-learning access and examinations do not appear to relate under the conditions explored. Other attributes of learning management access may need to be explored to determine if access to learning management systems may be useful in offering remedial support to students.

An exploration of student access to a learning management system-challenges and recommendations for educators and researchers.

INTRODUCTION: This study examined student access to online resources of a faculty's learning management system (LMS). Issues relating to current e-learning resources usage were identified and formed the basis for recommendations to help assist stakeholders in teaching, learning and research. METHODS: Learning analytics from four cohorts of undergraduate dental students were extracted from the database of a LMS spanning between 2012 and 2016. Individual datasets were combined into one master file, re-categorised, filtered and analysed based on cohort, year of study, course and nature of online resource. RESULTS: A total of 157,293 access events were documented. The proportion of administrative to learning data varied across cohorts, with oldest cohort having the highest ratio (82:18) in their final year and most recent cohort having a ratio of 33:67 in their 4th year demonstrating a higher proportion to learning. Seven Learning domains were identified in the access data: access to problem-based learning resources was the highest and next was fixed prosthodontics videos. The prosthodontics discipline had the highest access across the curriculum while some others had very limited or even no learning access events. CONCLUSION: A number of limitations have been identified with the analytics and learning resources in this LMS and engagement with learning resource provision. More detailed data capture of access use and unique identifiers to resources as well as keyword tagging of the resources are required to allow accurate mapping and support of students learning. Moreover, motivation or nudging of students behaviour to more actively engage with learning content needs exploration.

Analysis of insulin pump settings in children and adolescents with type 1 diabetes mellitus.

AIM: To characterize current insulin pump settings used in young patients with type 1 diabetes mellitus (T1DM) and to assess their relationship to glycemic control. METHODS: This retrospective study included patients aged <18 yr old with T1DM >1 yr using a Medtronic pump device. Pump data including number of blood glucose (BG) tests per day, basal and bolus insulin parameters, carbohydrate ratio (CR), and insulin sensitivity factors (ISFs) were averaged over 14 d for statistical analyses. Anthropometric data and recent glycosylated hemoglobin A1c (HbA1c) were recorded. RESULTS: A total of 292 patients (144 males and 148 females) were included in the study. Participants had a median age (interquartile range, IQR) of 12.9 yr (10.0-15.1 yr) and pump duration of 2.8 yr (1.5-4.2 yr). No significant differences in median HbA1c (IQR) were observed in preschool [n = 14; HbA1c 7.8% (7.3-8.3%)], prepubertal [n = 105; HbA1c 8.1% (7.7-8.9%)], and adolescent subjects [n = 173; HbA1c 8.4% (7.7-9.0%)]. Adolescents took significantly fewer boluses and BG tests per day compared with younger children (p < 0.05). Age-specific diurnal variation in basal insulin delivery was noted. Additionally, stronger carbohydrate cover and weaker corrections were used in real-life compared with theoretical 500 and 100 rules, respectively. Lower HbA1c was associated with higher number of daily boluses, greater number of BG tests per day, lower average CR/500 rule ratio, and higher average ISF/100 rule ratio adjusted for age (R(2) = 0.22; p < 0.01). CONCLUSION: Insulin pump therapy requires continuous adjustments and glycemic targets are achieved by a minority. We believe this is the first study in pediatric cohort looking at association between CR and ISF with glycemic control.

Prognostic variables for clinical outcomes in valvular heart disease patients with moderate to severe secondary tricuspid regurgitation.

BACKGROUND AND AIM OF THE STUDY: Secondary tricuspid regurgitation (STR) is frequently seen in cardiology practice. Currently, few data are available on the prognostic variables associated with moderate or severe STR on death and progression to valve surgery. Hence, the study aim was to identify these prognostic variables. METHODS: In this retrospective study, patients with at least moderate STR were identified from an ongoing database and followed until death, any valvular heart surgery, or the end of the study. Clinical and echocardiographic variables including age, gender, coronary artery disease, device implantation (defibrillator or pacemaker), pulmonary disease, left ventricular ejection fraction, right ventricular size, right ventricular systolic pressure (RVSP), STR severity and concomitant valve disease were recorded. End-points were death and valve surgery. RESULTS: The average age of the 92 study participants was 68 +/- 16 years. During a mean follow up of 43 +/- 24 months, there were 13 deaths (14%) and 12 surgeries (13%). In multivariate analysis, both an elevated RVSP and device implantation were significant predictors of death (p = 0.0038 and 0.0487, respectively). Only an elevated RVSP was predictive of surgery (p = 0.05) and surgery-free survival (p = 0.0005). A RVSP > 48 mmHg had a hazard ratio of 3.93 (p = 0.0012) and a high diagnostic accuracy for predicting death, with an area under the receiver operating characteristic curve of 0.73. CONCLUSION: In patients with valvular heart disease and at least moderate STR, an elevated RVSP of at least 48 mmHg was associated with significantly increased mortality and decreased surgery-free survival.

Thirty-Year Time Trends in Diabetic Retinopathy and Macular Edema in Youth With Type 1 Diabetes.

OBJECTIVE: To examine trends in diabetic retinopathy (DR) and diabetic macular edema (DME) in adolescents with type 1 diabetes between 1990 and 2019. RESEARCH DESIGN AND METHODS: We analyzed 5,487 complication assessments for 2,404 adolescents (52.7% female, aged 12-20 years, diabetes duration >5 years), stratified by three decades (1990-1999, 2000-2009, 2010-2019). DR and DME were graded according to the modified Airlie House classification from seven-field stereoscopic fundal photography. RESULTS: Over three decades, the prevalence of DR was 40, 21, and 20% (P < 0.001) and DME 1.4, 0.5, and 0.9% (P = 0.13), respectively, for 1990-1999, 2000-2009, and 2010-2019. Continuous subcutaneous insulin infusion (CSII) use increased (0, 12, and 55%; P < 0.001); mean HbA1c was bimodal (8.7, 8.5, and 8.7%; P < 0.001), and the proportion of adolescents meeting target HbA1c <7% did not change significantly (8.3, 7.7, and 7.1%; P = 0.63). In multivariable generalized estimating equation analysis, DR was associated with 1-2 daily injections (odds ratio 1.88, 95% CI 1.42-2.48) and multiple injections in comparison with CSII (1.38, 1.09-1.74); older age (1.11, 1.07-1.15), higher HbA1c (1.19, 1.05-1.15), longer diabetes duration (1.15, 1.12-1.18), overweight/obesity (1.27, 1.08-1.49) and higher diastolic blood pressure SDS (1.11, 1.01-1.21). DME was associated with 1-2 daily injections (3.26, 1.72-6.19), longer diabetes duration (1.26, 1.12-1.41), higher diastolic blood pressure SDS (1.66, 1.22-2.27), higher HbA1c (1.28, 1.03-1.59), and elevated cholesterol (3.78, 1.84-7.76). CONCLUSIONS: One in five adolescents with type 1 diabetes had DR in the last decade. These findings support contemporary guidelines for lower glycemic targets, increasing CSII use, and targeting modifiable risk factors including blood pressure, cholesterol, and overweight/obesity.

Myocardial perfusion imaging analysis in patients with regurgitant valvular heart disease.

BACKGROUND/AIM: We noticed that there was decreased correlation of the findings from myocardial perfusion imaging (MPI) and cardiac catheterization (CATH) in patients with mitral regurgitation (MR) and aortic regurgitation (AR) compared to patients without valve disease. METHODS: Through a systematic review of MPI records at the Harry S. Truman Memorial Veterans' Hospital between 1998 and 2008, we identified 58 patients with at least moderate MR or AR by echocardiogram who underwent cardiac catheterization within 6 months of the MPI study. A control group was formulated with 60 patients who did not have significant MR or AR on echocardiogram and who had both MPI and CATH. Correlation between MPI and CATH was graded as complete, partial, or absent. RESULTS: Correlation between MPI and CATH was lower in the valve disease patients (study group) when compared to controls. Correlation was complete in 76% of study patients and 90% of controls, partial in 15% of study patients and 5% of controls, and absent in 9% of study patients and 5% of controls. Differences between the groups were significant (P < .05). CONCLUSIONS: Patients with regurgitant valvular heart disease may have myocardial perfusion abnormalities that are not associated with angiographic critical coronary stenosis.

Dobutamine stress echocardiography Doppler estimation of cardiac diastolic function: a simultaneous catheterization correlation study.

BACKGROUND: Doppler echocardiography using the ratio of early diastolic transmitral velocity to early diastolic mitral annular tissue velocity (E/E') is routinely used to evaluate left ventricular (LV) filling pressures at rest. We tested the hypothesis that measurement of E/E' in patients undergoing dobutamine stress echocardiography (DSE) will detect changes in LV filling pressures. METHODS: In this prospective study, 16 patients with normal LV ejection fraction and normal coronary arteries by angiography underwent a standard DSE protocol with simultaneous LV filling pressure monitoring with a fluid filled pigtail catheter. Doppler echocardiographic assessment of LV diastolic function was performed using E/E' at rest and during DSE. RESULTS: The average age of the study participants was 57 ± 8 years. Average heart rate was 61 ± 11 bpm at baseline and 141 ± 12 bpm at peak stress. LV mean diastolic pressure decreased from 12.3 ± 2.6 mmHg at baseline to 9.0 ± 2.3 mmHg at peak stress (P = 0.0001). Baseline E/E' at the septum and lateral annulus were 8.7 ± 2.2 and 7.5 ± 1.9 and during peak stress were 8.3 ± 3.1 and 7.9 ± 3.5, respectively. There was no significant change in E/E' at either the septum or the lateral annulus (P = 0.55, P = 0.66). There was no significant correlation between LV mean diastolic pressure and E/E' with dobutamine stress. CONCLUSIONS: In patients with normal LV ejection fraction and no significant coronary artery disease undergoing DSE, the ratio of early diastolic transmitral velocity to early diastolic tissue velocity (E/E') at peak stress with dobutamine does not predict changes in LV filling pressures.