Safety and efficiency assessment of training Canadian cardiac surgery residents to perform aortic valve surgery.

BACKGROUND: Research has demonstrated equivalent patient safety outcomes for various cardiac procedures when the primary surgeon was a supervised trainee. However, cardiac surgery cases have become more complex, and the Canadian cardiac surgery education model has undergone some changes. We sought to compare patient safety and efficiency of aortic valve replacement (AVR) between Canadian patients treated by senior cardiac trainees and those treated by certified cardiac surgeons. METHODS: We completed a single-centre, case-matched, prospectively collected and retrospectively analyzed study of AVR. Patients were matched between trainees and consultants for age, sex, New York Heart Association and Canadian Cardiovascular Society status, urgency of operation and diabetes status. RESULTS: We analyzed 1102 procedures: 624 isolated AVRs and 478 AVRs with coronary artery bypass graft (CABG). For isolated AVR, there was no significant difference in 30-d mortality (p = 0.13) or in major adverse events (p = 0.38) between the groups. In the AVR+CABG group, there was no significant difference in 30-day mortality (p = 0.10) or in the rates of major adverse events (p = 0.37) between the groups. Secondary outcomes (hospital and intensive care unit lengths of stay, valve size and type) did not differ significantly between the groups for isolated AVR or AVR+CABG. CONCLUSION: Despite a higher-risk patient population and changes in the cardiac surgery training model, it appears that outcomes are not negatively affected when a senior trainee acts as the primary surgeon in cases of AVR.

CONTEXTE: La recherche a fait état de résultats équivalents au plan de la sécurité des patients lors de diverses interventions cardiaques lorsque le chirurgien principal était un résident supervisé. Toutefois, la chirurgie cardiaque se complexifie et le modèle de formation canadien en chirurgie cardiaque a subi quelques transformations. Nous avons voulu comparer la sécurité de patients canadiens et l'efficience du remplacement de la valvule aortique (RVA) selon que les patients étaient traités par des résidents séniors en chirurgie cardiaque ou par des chirurgiens certifiés. MÉTHODES: Nous avons procédé à une collecte prospective de cas assortis, dans 1 seul centre, puis à une analyse rétrospective des cas de RVA. Les patients ont été répartis entre résidents et experts et assortis selon l'âge, le sexe, la classification de la NYHA (New York Heart Association) et de la Société canadienne de cardiologie, le caractère urgent de l'intervention et le statut à l'égard du diabète. RÉSULTANTS: Nous avons analysé 1102 interventions : 624 RVA isolés et 478 RVA avec pontage aorto-coronarien (PAC). Dans les cas de RVA isolés, on n'a noté aucune différence significative pour ce qui est de la mortalité à 30 jours (p = 0,13) ou des effets indésirables majeurs (p = 0,38) entre les groupes. Pour ce qui est du groupe RVA+PAC, on n'a noté aucune différence significative quant à la mortalité à 30 jours (p = 0,10) ou quant aux taux d'effets indésirables majeurs (p = 0,37) entre les groupes. Les paramètres secondaires (durée du séjour à l'hôpital et à l'unité des soins intensifs, taille et type de valvule) n'ont pas été significativement différents entre les groupes qu'il s'agisse de RVA isolé ou de RVA+PAC. CONCLUSIONS: Malgré une population de patients à risque plus élevé et les transformations apportées au modèle de formation en chirurgie cardiaque, il semble que les résultats ne soient pas affectés négativement lorsqu'un résident sénior agit à titre de chirurgien principal dans les cas de RVA.

Experience of introducing an electronic health records station in an objective structured clinical examination to evaluate medical students' communication skills in Canada: a descriptive study.

PURPOSE: There is limited literature related to the assessment of electronic medical record (EMR)-related competencies. To address this gap, this study explored the feasibility of an EMR objective structured clinical examination (OSCE) station to evaluate medical students' communication skills by psychometric analyses and standardized patients' (SPs) perspectives on EMR use in an OSCE. METHODS: An OSCE station that incorporated the use of an EMR was developed and pilot-tested in March 2020. Students' communication skills were assessed by SPs and physician examiners. Students' scores were compared between the EMR station and 9 other stations. A psychometric analysis, including item total correlation, was done. SPs participated in a post-OSCE focus group to discuss their perception of EMRs' effect on communication. RESULTS: Ninety-nine 3rd-year medical students participated in a 10-station OSCE that included the use of the EMR station. The EMR station had an acceptable item total correlation (0.217). Students who leveraged graphical displays in counseling received higher OSCE station scores from the SPs (P=0.041). The thematic analysis of SPs' perceptions of students' EMR use from the focus group revealed the following domains of themes: technology, communication, case design, ownership of health information, and timing of EMR usage. CONCLUSION: This study demonstrated the feasibility of incorporating EMR in assessing learner communication skills in an OSCE. The EMR station had acceptable psychometric characteristics. Some medical students were able to efficiently use the EMRs as an aid in patient counseling. Teaching students how to be patient-centered even in the presence of technology may promote engagement.

The impact of learner involvement in emergency department patient assessments on short-term return visits requiring hospital admission: a cross-sectional study.

PURPOSE: Learners, either medical students or residents, often perform the initial assessment of patients visiting the emergency department (ED). It is unclear, however, if learners affect the rate of short-term unscheduled return visits. The objective of this study was to determine if the involvement of learners in ED visits increases the rate of return visits. METHODS: This was a retrospective cross-sectional analysis of ED visit data at a single tertiary care centre over a 1-year period. Return visits were defined as those presenting within 72 h of discharge from an initial non-admit ED visit and resulting in an admission on the second visit. A generalized linear mixed model was used to determine the odds ratios of return visits, adjusting for prespecified co-variates, with and without learners involved during the initial visit. Secondary analyses assessed for associations between learner level of training, program of study and return visits. RESULTS: Return visits occurred after 658 (1.3%) of 51,149 encounters involving learners and 701 (0.8%) of 83,310 encounters with no learner involvement. Involvement of learners in ED initial visits was not associated with increased odds of return visits (adjusted OR 1.13 [95% CI 0.71-1.81]), although the point estimates were heterogeneous over learner level of training, with clerkship students (medical student years 3 and 4) and senior residents (post-graduate years 4 and 5) trending towards reduced odds of a return visit. Resident program of study did not independently predict return visits. CONCLUSIONS: This study demonstrated that the involvement of learners in ED patient assessments is not associated with increased odds of short-term unscheduled return visits.

RéSUMé: OBJECTIF: Les apprenants, qu'ils soient étudiants en médecine ou résidents, procèdent souvent à l'évaluation initiale des patients qui se rendent au service des urgences (SU). Il n'est pas clair, cependant, si les apprenants ont une incidence sur le taux de visites de retour imprévues à court terme. L'objectif de cette étude était de déterminer si la participation des apprenants dans les visites aux urgences augmentait le taux de retour des visites. MéTHODES: Il s'agissait d'une analyse transversale rétrospective des données sur les visites à l'urgence dans un seul centre de soins tertiaires sur une période d'un an. Les visites de retour ont été définies comme celles qui se sont présentées dans les 72 heures suivant la sortie d'une première visite à l'urgence sans admission et qui ont donné lieu à une admission lors de la deuxième visite. Un modèle linéaire mixte généralisé a été utilisé pour déterminer les rapports de cotes des visites de retour, en tenant compte des co-variables préétablies, avec et sans participation des apprenants pendant la visite initiale. Des analyses secondaires ont évalué les associations entre le niveau de formation de l'apprenant, le programme d'études et les visites de retour. RéSULTATS: Les visites de retour ont eu lieu après 658 (1,3%) des 51 149 rencontres impliquant des apprenants et 701 (0,8%) des 83 310 rencontres sans participation de l'apprenant. L'implication des apprenants dans les visites initiales à l'urgence n'était pas associée à une probabilité accrue de visites ultérieures (OR ajusté = 1,13 [IC à 95% 0,71­1,81]), bien que les estimations ponctuelles aient été hétérogènes selon le niveau de formation de l'apprenant, les étudiants en externat (années d'études en médecine 3 et 4) et les résidents seniors (années 4 et 5 des études supérieures) ont tendance à réduire les risques de visite de retour. Le programme d'études des résidents n'a pas prédit de manière indépendante les visites de retour. CONCLUSIONS: Cette étude a démontré que la participation des apprenants aux évaluations des patients à l'urgence n'est pas associée à une probabilité accrue de visites de retour imprévues à court terme.

Critical Predictors for the Early Detection of Conversion From Unipolar Major Depressive Disorder to Bipolar Disorder: Nationwide Population-Based Retrospective Cohort Study.

BACKGROUND: Unipolar major depressive disorder (MDD) and bipolar disorder are two major mood disorders. The two disorders have different treatment strategies and prognoses. However, bipolar disorder may begin with depression and could be diagnosed as MDD in the initial stage, which may later contribute to treatment failure. Previous studies indicated that a high proportion of patients diagnosed with MDD will develop bipolar disorder over time. This kind of hidden bipolar disorder may contribute to the treatment resistance observed in patients with MDD. OBJECTIVE: In this population-based study, our aim was to investigate the rate and risk factors of a diagnostic change from unipolar MDD to bipolar disorder during a 10-year follow-up. Furthermore, a risk stratification model was developed for MDD-to-bipolar disorder conversion. METHODS: We conducted a retrospective cohort study involving patients who were newly diagnosed with MDD between January 1, 2000, and December 31, 2004, by using the Taiwan National Health Insurance Research Database. All patients with depression were observed until (1) diagnosis of bipolar disorder by a psychiatrist, (2) death, or (3) December 31, 2013. All patients with depression were divided into the following two groups, according to whether bipolar disorder was diagnosed during the follow-up period: converted group and nonconverted group. Six groups of variables within the first 6 months of enrollment, including personal characteristics, physical comorbidities, psychiatric comorbidities, health care usage behaviors, disorder severity, and psychotropic use, were extracted and were included in a classification and regression tree (CART) analysis to generate a risk stratification model for MDD-to-bipolar disorder conversion. RESULTS: Our study enrolled 2820 patients with MDD. During the follow-up period, 536 patients were diagnosed with bipolar disorder (conversion rate=19.0%). The CART method identified five variables (kinds of antipsychotics used within the first 6 months of enrollment, kinds of antidepressants used within the first 6 months of enrollment, total psychiatric outpatient visits, kinds of benzodiazepines used within one visit, and use of mood stabilizers) as significant predictors of the risk of bipolar disorder conversion. This risk CART was able to stratify patients into high-, medium-, and low-risk groups with regard to bipolar disorder conversion. In the high-risk group, 61.5%-100% of patients with depression eventually developed bipolar disorder. On the other hand, in the low-risk group, only 6.4%-14.3% of patients with depression developed bipolar disorder. CONCLUSIONS: The CART method identified five variables as significant predictors of bipolar disorder conversion. In a simple two- to four-step process, these variables permit the identification of patients with low, intermediate, or high risk of bipolar disorder conversion. The developed model can be applied to routine clinical practice for the early diagnosis of bipolar disorder.

Applying natural language processing techniques to develop a task-specific EMR interface for timely stroke thrombolysis: A feasibility study.

OBJECTIVE: To reduce errors in determining eligibility for intravenous thrombolytic therapy (IVT) in stroke patients through use of an enhanced task-specific electronic medical record (EMR) interface powered by natural language processing (NLP) techniques. MATERIALS AND METHODS: The information processing algorithm utilized MetaMap to extract medical concepts from IVT eligibility criteria and expanded the concepts using the Unified Medical Language System Metathesaurus. Concepts identified from clinical notes by MetaMap were compared to those from IVT eligibility criteria. The task-specific EMR interface displays IVT-relevant information by highlighting phrases that contain matched concepts. Clinical usability was assessed with clinicians staffing the acute stroke team by comparing user performance while using the task-specific and the current EMR interfaces. RESULTS: The algorithm identified IVT-relevant concepts with micro-averaged precisions, recalls, and F1 measures of 0.998, 0.812, and 0.895 at the phrase level and of 1, 0.972, and 0.986 at the document level. Users using the task-specific interface achieved a higher accuracy score than those using the current interface (91% versus 80%, p = 0.016) in assessing the IVT eligibility criteria. The completion time between the interfaces was statistically similar (2.46 min versus 1.70 min, p = 0.754). DISCUSSION: Although the information processing algorithm had room for improvement, the task-specific EMR interface significantly reduced errors in assessing IVT eligibility criteria. CONCLUSION: The study findings provide evidence to support an NLP enhanced EMR system to facilitate IVT decision-making by presenting meaningful and timely information to clinicians, thereby offering a new avenue for improvements in acute stroke care.

Presentation and outcomes of necrotizing soft tissue infections.

BACKGROUND: Necrotizing soft tissue infections (NSTIs) are aggressive infections associated with significant morbidity, including amputation and organ failure, and high mortality. The rapid progression and significant risk of morbidity and mortality associated with NSTIs makes quick diagnosis and treatment critical. The objective of this study was to determine the presentation of patients diagnosed with NSTIs and their in-hospital outcomes. METHODS: This was a retrospective review of adult (>17 years) patients with a discharge diagnosis of necrotizing fasciitis at London Health Sciences Centre (annual census 125,000) over a 5-year period (April 2008-March 2013). RESULTS: Sixty patients with confirmed NSTI were included in this study. Common comorbidities at presentation included immunocompromise (58.3%), diabetes mellitus (41.7%), vascular disease (45.0%), and obesity (24.6%). Initial presentations included swelling (91.7%), erythema (86.7%), bullae (28.3%), petechiae (8.3%), and bruising (45.0%). Fifty (83.3%) underwent surgery, with a median (interquartile range) time from initial emergency department presentation to surgery of 15.5 hours (7.8, 74.9). In-hospital mortality among those who had surgical intervention was 14.0%, compared to 60.0% for patients who did not have surgery (Δ46.0%; 95% CI: 14.8% to 70.2%). CONCLUSION: Diabetes mellitus, immune-compromise, vascular disease, and obesity are common comorbidities of NSTIs. Survival is higher among patients who receive surgical treatment. Patients presenting with this clinical picture warrant a high degree of suspicion.

Constrictive pericarditis associated with atypical antipsychotics.

We report the successful surgical intervention in a case of constrictive pericarditis after long-term use of atypical antipsychotics. Pericarditis developed in our patient with a longstanding history of schizophrenia treated with atypical antipsychotics. Pericardiectomy was undertaken, and the patient's presenting symptom of shortness of breath resolved subsequently with an uneventful postoperative course.

Successful Intraoperative Reversal of Heparin With Factor VII in a Patient With Protamine Reaction.

Factor VII has been utilized to treat post-operative bleeding after cardiac surgery refractory to other intervention. We report the case of a patient who developed intractable bleeding after a severe protamine reaction following emergency repair of type A aortic dissection and was successfully treated with factor VII.

Introduction of a novel teaching paradigm for head and neck anatomy.

INTRODUCTION: Didactic head and neck anatomy teaching has been replaced by a novel self-directed, multimodal, and multidisciplinary approach at the Schulich School of Medicine and Dentistry (SSMD). OBJECTIVES: To describe the use of a novel teaching paradigm at SSMD and to enable readers to determine how this methodology may benefit medical students at other academic institutions and disciplines. DESIGN: Prospective cohort study. METHODS: The paradigm consists of multimedia learning modules to guide independent anatomy learning. Students received a case-based assignment based on the content of the learning modules to guide them through cadaveric dissections facilitated by a multidisciplinary team of surgeons and anatomists. PRIMARY OUTCOME: Postcourse survey and mean scores comparison. The survey collected data, including demographics and previous anatomic and computer-assisted learning (CAL) experiences, and focused on measuring student perception of the proposed paradigm. Secondary outcome: Correlation of demographics. RESULTS: The paradigm was successfully implemented and warmly received, but it still requires further development. Although CAL allows increased individual engagement, students still enjoy and value lectures. In addition, students view instruction by surgeons in laboratories as the most valuable component of their anatomy teaching as it not only deepened the students' understanding of anatomic structures but also provided them with the clinical relevance. Technological innovations were welcomed by the students but have not replaced their appreciation of dissection and lecures.

Robotic coronary artery bypass for aberrant right coronary artery stenosis.

Anomalous coronary arteries that course between the aorta and pulmonary artery are subject to compressive forces and can manifest angina, myocardial infarction and sudden death. The current report presents a young, female patient who presented with a short duration of severe, rapidly progressive angina despite optimal medical therapy. Combined computed tomography and myocardial perfusion scanning identified an anomalous dominant right coronary artery that appeared kinked at its origin between the aorta and main pulmonary artery. A robot-assisted right internal thoracic artery to right coronary artery bypass was performed, which was confirmed to be widely patent (FitzGibbon grade A) on routine intraoperative angiography. The procedure completely resolved the patient's angina symptoms.