Masters Athlete Screening Study (MASS): Insights Into the Psychological Impact of Cardiovascular Preparticipation Screening.

OBJECTIVE: To determine the psychological impact of a cardiovascular disease (CVD) diagnosis identified during preparticipation screening (PPS) of masters athletes. DESIGN: Cross-sectional study. SETTING: Masters athletes diagnosed with CVD through the Masters Athletes Screening Study. PARTICIPANTS: Sixty-seven athletes (89.6% male, mean age at diagnosis 60.1 ± 7.1 years, range 40-76) with diagnoses of coronary artery disease (CAD) (73.1%), high premature ventricular contraction burden (9.0%), mitral valve prolapse (7.5%), atrial fibrillation (AF) (3.0%), bicuspid aortic valve (3.0%), aortic dilatation (1.5%), coronary anomaly (1.5%), and rheumatic heart disease (1.5%). Three participants had multiple diagnoses. INTERVENTION: Online survey distributed to masters athletes identified with CVD. MAIN OUTCOME MEASURES: Assessment of psychological distress [Impact of Event Scale-Revised (IES-R)], perceptions of screening, and preferred support by CVD type. RESULTS: The median total IES-R and subscale scores were within the normal range {median [interquartile range (IQR)] total 2.0 [0-6.0]; intrusion 1.0 [0-3.0]; avoidance 0 [0-3.0]; hyperarousal 0 [0-1.0]}. Athletes with bicuspid aortic valve [20.5 (IQR, 4.0-37.0)], AF [7.0 (IQR, 0-14.0)], and severe CAD [5.5 (IQR, 1.0-12.0)] had the highest total IES-R scores. One individual with bicuspid aortic valve reported a significant stress reaction. Ten athletes (14.9%) had scores >12. Ninety-three percent of athletes were satisfied having undergone PPS. Preferred type of support varied by cardiovascular diagnosis. CONCLUSIONS: The majority of masters athletes diagnosed with CVD through PPS do not experience significant levels of psychological distress. Athletes diagnosed with more severe types of CVD should be monitored for psychological distress. Support should be provided through a multidisciplinary and individualized approach.

Clinical assessment of AF pattern is poorly correlated with AF burden and post ablation outcomes: A CIRCA-DOSE sub-study.

BACKGROUND: Contemporary guidelines recommend that atrial fibrillation (AF) be classified into paroxysmal and persistent AF based on clinical assessment, with these categorizations forming the basis of therapeutic recommendations. While pragmatic, clinical assessment may introduce misclassification errors, which may impact treatment decisions. We sought to determine the relationship between AF classification, baseline AF burden, and post-ablation arrhythmia outcomes. DESIGN: The current study is a sub-analysis of a prospective, parallel-group, multicenter, single-blinded randomized clinical trial. All 346 patients enrolled in CIRCA-DOSE received an implantable cardiac monitor a median of 72 days prior to ablation. AF was classified as low burden paroxysmal, high burden paroxysmal, or persistent based on clinical assessment prior to device implantation. Prior to ablation patients were re-classified using the same definitions based on device monitoring data. Correlation between classifications, AF burden, and post-ablation arrhythmia outcomes were assessed. RESULTS: There was poor agreement between clinical and device-based AF classification (Cohen's kappa: 0.192). AF classification derived from pre-ablation continuous monitoring reflected baseline and post-ablation AF burden with greater accuracy and with less overlap between the AF classes (P < 0.01 for all categorical comparisons). Patients objectively classified as "Low Burden" paroxysmal by continuous monitoring data had significantly greater freedom from recurrent AF/AT/AFL compared to those classified as "High Burden" paroxysmal (hazard ratio [HR] 0.57 for AF/AT/AFL recurrence) or persistent AF (HR 0.19 for AF/AT/AFL recurrence). CONCLUSIONS: Classification of AF pattern based on pre-ablation continuous cardiac rhythm monitoring better predicted AF burden and freedom from recurrent AF post ablation. Despite the use of standardized definitions, classification of AF based on clinical assessment did not predict baseline AF burden, post ablation AF burden, or freedom from recurrent AF post ablation. TRIAL REGISTRATION: ClinicalTrials.govNCT01913522.

Point-of-Care Ultrasound as a Component of Preparticipation Screening of Athletes: A Systematic Review.

This review examined whether the addition of point-of-care ultrasound (POCUS) to electrocardiography (ECG)-inclusive preparticipation screening strategies has the potential to reduce false-positive results and detect diseases associated with sudden cardiac death that may not be identified through current modalities. Five studies, representing 2646 athletes, demonstrated that ECG-inclusive preparticipation screening strategies resulted in positive results in 19.9% of the cohort. With the addition of POCUS, positive results were reduced to 4.9%, and 1 additional condition potentially associated with sudden cardiac death was identified. The magnitude of positive results with POCUS may be reduced if current ECG criteria were applied.

Safety of Endovascular Intervention for Stroke on Therapeutic Anticoagulation: Multicenter Cohort Study and Meta-Analysis.

INTRODUCTION: Intravenous (IV) tissue plasminogen activator (tPA) is contraindicated in therapeutically anti-coagulated patients. Such patients may be considered for endovascular intervention. However, there are limited data on its safety. PATIENTS AND METHODS: We performed a multicenter retrospective study of patients undergoing endovascular intervention for acute ischemic stroke while on therapeutic anticoagulation. We compared the observed rate of National Institute of Neurological Disorders and Stroke defined symptomatic intracerebral hemorrhage (sICH) with risk-adjusted historical control rates of sICH after IV tPA using weighted averages of the hemorrhage after thrombolysis (HAT) and Multicenter Stroke Survey (MSS) prediction scores. We also performed a metaanalysis of studies assessing risk of sICH with endovascular intervention in patients on anticoagulation. RESULTS AND DISCUSSION: Of 94 cases, mean age was 73 years and median National Institutes of Health Stroke Scale was 19. Anticoagulation consisted of warfarin (n = 51), dabigatran (n = 6), rivaroxaban (n = 13), apixaban (n = 1), IV heparin (n = 19), low molecular weight heparin (n = 3), and combined warfarin and IV heparin (n = 3). sICH was seen in 7 patients (7%, 95% confidence interval 4-15), all on warfarin. Predicted sICH rates for the cohort based on HAT and MSS scoring were 12% and 7%, respectively. Meta-analysis of 6 studies showed no significant difference in sICH between patients undergoing endovascular intervention on anticoagulation and comparator groups. CONCLUSIONS: Endovascular intervention in subjects on therapeutic anticoagulation appears reasonably safe, with a sICH rate similar to patients not on anticoagulation receiving IV tPA.

New Insights and Recommendations for Athletes With Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) has long been considered to be a high-risk cardiac condition for which exercise was thought to increase the risk of sudden cardiac death (SCD). This was founded in part by initial autopsy studies reporting HCM to be a leading medical cause of SCD among young athletes. Most forms of competitive sport and exercise were therefore thought to increase the risk of SCD to a prohibitive level. Resultant expert consensus guideline recommendations universally restricted athletes with HCM from participation in moderate- to vigourous-intensity sport and exercise in a binary "yes" or "no" clinical decision making process with the goal of reducing the risk of sports-related SCD. HCM is, however, a heterogeneous genetic condition with variable penetrance and risk. The degree to which sports and exercise increases the risk of SCD at an individual patient level continues to be an area of clinical uncertainty. Emerging data and clinical experience from the past several decades have provided important new insights into exercise-related risks and have brought into question the appropriateness of overly restrictive binary clinical decision making for exercise recommendations in HCM. This includes an improved understanding of the overall prevalence of HCM in the general population, improved observational estimates of the risk of SCD related to continued sport and exercise participation, and a general shift toward improved patient-centred approaches to care through shared decision making processes. The rules by which the game is played may be changing for athletes with HCM.

Combined approach to lysis utilizing eptifibatide and recombinant tissue plasminogen activator in acute ischemic stroke-enhanced regimen stroke trial.

BACKGROUND AND PURPOSE: In a previous study, 0.3 and 0.45 mg/kg of intravenous recombinant tissue plasminogen activator (rt-PA) were safe when combined with eptifibatide 75 mcg/kg bolus and a 2-hour infusion (0.75 mcg/kg per minute). The Combined Approach to Lysis Utilizing Eptifibatide and rt-PA in Acute Ischemic Stroke-Enhanced Regimen (CLEAR-ER) trial sought to determine the safety of a higher-dose regimen and to establish evidence for a phase III trial. METHODS: CLEAR-ER was a multicenter, double-blind, randomized safety study. Ischemic stroke patients were randomized to 0.6 mg/kg rt-PA plus eptifibatide (135 mcg/kg bolus and a 2-hour infusion at 0.75 mcg/kg per minute) versus standard rt-PA (0.9 mg/kg). The primary safety end point was the incidence of symptomatic intracranial hemorrhage within 36 hours. The primary efficacy outcome measure was the modified Rankin Scale (mRS) score ≤1 or return to baseline mRS at 90 days. Analysis of the safety and efficacy outcomes was done with multiple logistic regression. RESULTS: Of 126 subjects, 101 received combination therapy, and 25 received standard rt-PA. Two (2%) patients in the combination group and 3 (12%) in the standard group had symptomatic intracranial hemorrhage (odds ratio, 0.15; 95% confidence interval, 0.01-1.40; P=0.053). At 90 days, 49.5% of the combination group had mRS ≤1 or return to baseline mRS versus 36.0% in the standard group (odds ratio, 1.74; 95% confidence interval, 0.70-4.31; P=0.23). After adjusting for age, baseline National Institutes of Health Stroke Scale, time to intravenous rt-PA, and baseline mRS, the odds ratio was 1.38 (95% confidence interval, 0.51-3.76; P=0.52). CONCLUSIONS: The combined regimen of intravenous rt-PA and eptifibatide studied in this trial was safe and provides evidence that a phase III trial is warranted to determine efficacy of the regimen. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00894803.

Simulation-based training for cardiac auscultation skills: systematic review and meta-analysis.

OBJECTIVES: The current review examines the effectiveness of simulation-based medical education (SBME) for training health professionals in cardiac physical examination and examines the relative effectiveness of key instructional design features. METHODS: Data sources included a comprehensive, systematic search of MEDLINE, EMBASE, CINAHL, PsychINFO, ERIC, Web of Science, and Scopus through May 2011. Included studies investigated SBME to teach health profession learners cardiac physical examination skills using outcomes of knowledge or skill. We carried out duplicate assessment of study quality and data abstraction and pooled effect sizes using random effects. RESULTS: We identified 18 articles for inclusion. Thirteen compared SBME to no-intervention (either single group pre-post comparisons or SBME added to other instruction common to all learners, such as traditional bedside teaching), three compared SBME to other educational interventions, and two compared two SBME interventions. Meta-analysis of the 13 no-intervention comparison studies demonstrated that simulation-based instruction in cardiac auscultation was effective, with pooled effect sizes of 1.10 (95 % CI 0.49-1.72; p < 0.001; I(2) = 92.4 %) for knowledge outcomes and 0.87 (95 % CI 0.52-1.22; p < 0.001; I(2) = 91.5 %) for skills. In sub-group analysis, hands-on practice with the simulator appeared to be an important teaching technique. Narrative review of the comparative effectiveness studies suggests that SBME may be of similar effectiveness to other active educational interventions, but more studies are required. LIMITATIONS: The quantity of published evidence and the relative lack of comparative effectiveness studies limit this review. CONCLUSIONS: SBME is an effective educational strategy for teaching cardiac auscultation. Future studies should focus on comparing key instructional design features and establishing SBME's relative effectiveness compared to other educational interventions.

Reversible cerebral vasoconstriction syndrome: a review of recent research.

Reversible cerebral vasoconstriction syndrome (RCVS) is a collective term used for transient noninflammatory, nonatherosclerotic segmental constriction of cerebral arteries. The angiopathies of RCVS have previously been defined by several nomenclatures. Current opinion favors the unification of these pathophysiologically related angiopathies because of their similar angiographic features and clinical course. RCVS typically presents acutely as headache, delirium, seizure, cerebral ischemia, and/or hemorrhage. The angiographic features make RCVS an important mimic of CNS vasculitides. In contrast to CNS vasculitis, RCVS is typically a transient condition with relatively good clinical outcomes. Although a complete understanding of the etiological and pathological features of RCVS has not yet been achieved, alterations in vascular tone lead to the observed arterial changes. In this review, we aim to provide a summary of RCVS and provide insight into current perspectives of the underlying pathophysiological processes, diagnosis, and treatment.

Cardiac examination and the effect of dual-processing instruction in a cardiopulmonary simulator.

Use of dual-processing has been widely touted as a strategy to reduce diagnostic error in clinical medicine. However, this strategy has not been tested among medical trainees with complex diagnostic problems. We sought to determine whether dual-processing instruction could reduce diagnostic error across a spectrum of experience with trainees undertaking cardiac physical exam. Three experiments were conducted using a similar design to teach cardiac physical exam using a cardiopulmonary simulator. One experiment was conducted in each of three groups: experienced, intermediate and novice trainees. In all three experiments, participants were randomized to receive undirected or dual-processing verbal instruction during teaching, practice and testing phases. When tested, dual-processing instruction did not change the probability assigned to the correct diagnosis in any of the three experiments. Among intermediates, there was an apparent interaction between the diagnosis tested and the effect of dual-processing instruction. Among relative novices, dual processing instruction may have dampened the harmful effect of a bias away from the correct diagnosis. Further work is needed to define the role of dual-processing instruction to reduce cognitive error. This study suggests that it cannot be blindly applied to complex diagnostic problems such as cardiac physical exam.

Hospital prenotification of stroke patients by emergency medical services improves stroke time targets.

BACKGROUND: Prenotification to hospitals by emergency medical services of patients with suspected stroke is recommended to reduce delays in time-dependent therapies. We hypothesized that hospital prenotification would reduce recommended stroke time targets. METHODS: We used the Robert Wood Johnson University Hospital (RWJUH) Brain Attack Database, which includes demographic and clinical data on all emergency department (ED) patients alerted as a Brain Attack between January 1, 2009 and June 30, 2010. Outcome variables included the time from door to stroke team arrival, computed tomographic (CT) scan completion, CT scan interpretation, electrocardiogram, laboratory results, treatment decision, and intravenous (IV) tissue plasminogen activator (tPA) administration. The primary independent variable was brain attack activation before arrival to the emergency department (ED; prenotification) versus on or after ED arrival (no prenotification). Analysis of covariance was used with patient predictors as covariates in addition to the one of interest (prenotification vs no prenotification). P ≤ .05 was considered statistically significant. RESULTS: There were 229 patients (114 prenotification and 115 no prenotification) alerted as having a brain attack within the study period. Patients with prehospital notification were older (69.5 years vs 61.5 years; P = .0002), had more severe strokes (National Institutes of Health Stroke Scale score of 11.1 vs 6.9; P < .0001), and received IV tPA twice as often (27% vs 15%; P = .024). Prenotification resulted in a significant reduction in all stroke time targets except door to treatment decision and tPA administration. CONCLUSIONS: Prehospital notification of suspected stroke patients reduces time to stroke team arrival, CT scan completion, and CT scan interpretation. IV thrombolysis occurred twice as often in the prenotification group.

Stimulus Sensitive Constant Micro Macro Square-Wave Jerks in a Comatose Patient.

Saccades are generally thought of as being cortically generated and not seen in comatose patients. We describe a patient, comatose secondary to a large intracerebral hemorrhage, who developed constant rhythmic small amplitude square-wave jerks with an intersaccadic interval of 130 ms. Despite the patient's comatose state the eye movements would stop transiently in response to auditory or tactile stimulation and then quickly regain their previous amplitude. The case suggests that the presence of repetitive saccades in the form of square-wave jerks does not indicate consciousness.

Viral Heart Disease: Diagnosis, Management, and Mechanisms.

"Viral heart disease" is a term encompassing numerous virus-triggered heart conditions, wherein cardiac myocytes are injured, causing contractile dysfunction, cell death, or both. Cardiotropic viruses may also damage interstitial cells and vascular cells. Clinical presentation of the disorder varies widely. In most cases, patients are asymptomatic. Presentation includes-but is not limited to-flu-like symptoms, chest pain, cardiac arrhythmias, heart failure, cardiogenic shock, and sudden cardiac death. Laboratory studies, including blood-based heart injury indicators and cardiac imaging, may be needed. Management of viral heart disease requires a graded approach. Watchful observation at home may be the first step. Closer observation, with additional testing such as echocardiography in the clinic or hospital is less common yet may inform the use of cardiac magnetic resonance imaging. Intensive care may be indicated in severe acute illness. Viral heart disease mechanisms are complex. Initially, damage is predominantly virus mediated, whereas, in the second week, immune responses bring unintended obverse consequences for the myocardium. Innate immunity is largely beneficial in initial attempts to quell viral replication, whereas adaptive immunity brings helpful and antigen-specific mechanisms to fight the pathogen but also introduces the capability of autoimmunity. Each cardiotropic virus family has its own pathogenesis signature, including attack on myocytes, vascular cells, and other constitutive cells of myocardial interstitium. The stage of disease and preponderant viral pathways lend opportunities for potential intervention but also the likelihood of uncertainty about management. Overall, this review provides a novel glimpse into the depth of and need for solutions in viral heart disease.

Automated external defibrillator and emergency action plan preparedness amongst masters athletes.

OBJECTIVES: Sudden cardiac arrest/death (SCA/D) is the leading medical cause of death in athletes. Masters athletes (≥35 years old) are increasing in numbers and are responsible for the vast majority of sport-related SCDs. Automated external defibrillators (AEDs) and emergency action plans (EAPs) have been shown to unequivocally reduce SCD, however, their prevalence in masters athletics remains unknown. We sought to identify the perceived AED accessibility and EAP preparedness amongst a group of masters athletes. METHODS: A 40-item survey was sent to 735 master athletes identified through the Masters Athlete Screening Study. Participants were athletes with no known significant cardiac history. The survey inquired on the availability and location of AEDs within exercise settings, the presence of EAPs, and participants' cardiac concerns. RESULTS: Sixty-eight percent of athletes completed the survey. Ninety-seven percent and 99% of athletes believed CPR and AEDs were effective at saving lives, respectively. Thirty-eight percent of athletes were aware of an AED in proximity to where they exercise, with 40% aware of one available during competition events, and 28% during training events. Only 10% of athletes were aware of an EAP active in their place of exercise. Half of the athletes perceive their risk of cardiac arrest during exercise to be ≤0.5 in 100,000. CONCLUSIONS: These findings indicate that nearly all athletes believe CPR and AED are effective at saving lives, but only a minority are aware of an AED near their place of exercise, with even fewer aware of an active EAP. Master athletes underestimate their own risk for exercise-related cardiac events, affirming the importance of educating masters athletes on their increased cardiac risk and the importance of EAPs.

Masters athlete screening study (MASS): incidence of cardiovascular disease and major adverse cardiac events and efficacy of screening over five years.

BACKGROUND: The efficacy of cardiovascular screening in Masters athletes (MAs) (≥35 y), and whether screening decreases their risk of major adverse cardiac events (MACEs) is unknown. PURPOSE: To evaluate the effectiveness of yearly cardiovascular screening, and the incidence of cardiovascular disease (CVD) and MACE over five years. METHODS AND RESULTS: MAs (≥35 y) without previous history of CVD underwent yearly cardiovascular screening. Participants with an abnormal screen underwent further evaluations. In the initial year, 798 MAs (62.7% male, 55 ± 10 y) were screened; 11.4% (n = 91) were diagnosed with CVD. Coronary artery disease (CAD) was the most common diagnosis (n = 64; 53%). During follow-up, there were an additional 89 CVD diagnoses with an incidence rate of 3.58/100, 4.14/100, 3.74/100, 1.19/100, for years one to four, respectively. The most common diagnoses during follow-up were arrhythmias (n = 33; 37%). Increasing age (OR = 1.047, 95% confidence interval (CI): 1.003-1.094; P = 0.0379), Framingham Risk Score (FRS) (OR = 1.092, 95% CI: 1.031-1.158; P = 0.003), and LDL cholesterol (OR = 1.709, 95% CI: 1.223-2.401; P = 0.002) were predictive of CAD, whereas moderate intensity activity (min/wk) (OR = 0.997, 95% CI: 0.996-0.999; P = 0.002) was protective. Ten MACE (2.8/1000 athlete-years) occurred. All of these MAs were male, and 90% had ≥10% FRS. All underwent further evaluations with only two identified to have obstructive CAD. CONCLUSION: MACE occurred despite yearly screening. All MAs who had an event had an abnormal screen; however, cardiac functional tests failed to detect underlying CAD in most cases. It may be appropriate to offer computed coronary tomography angiography in MAs with ≥10% FRS to overcome the limitations of functional testing, and to assist with lifestyle and treatment modifications.

The efficacy of heart screening in Masters athletes (MAs) (≥35 y) is not well understood. This study of 798 MAs reported 10 major adverse cardiac event (MACE) over 5 years (2.8/1000 athlete-years), despite undergoing yearly screening. The MAs who had a MACE occurred only in males whom had an abnormal screen with 90% having an intermediate or higher cardiovascular risk. All of these MAs underwent further testing, however, stress tests (i.e. echocardiogram, electrocardiogram, nuclear) failed to detect underlying heart disease in most cases. Therefore, it may be appropriate to offer computed coronary tomography angiography in MAs with intermediate or higher cardiovascular risk to overcome the limitations of functional testing in this population, and to assist with lifestyle and treatment modifications.

Exercise-induced arterial hypoxemia in female masters athletes.

The purpose of the study was to characterize exercise induced arterial hypoxemia (EIAH) in female masters athletes (FMA). We hypothesized that FMA would experience EIAH during treadmill running. Eight FMA (48-57 years) completed pulmonary function testing and an incremental exercise test until exhaustion (V̇O2max⁡ = 45.7 ± 6.5, range:35-54 ml/kg/min). On a separate day, the participants were instrumented with a radial arterial catheter and an esophageal temperature probe. Participants performed three to four constant load exercise tests at 60-70 %, 75 %, 90 %, 95 %, and 100 % of maximal oxygen uptake while sampling arterial blood and recording esophageal temperature. We found that FMA decrease their partial pressure of oxygen (86.0 ± 7.6, range:73-108 mmHg), arterial saturation (96.2 ± 1.2, range:93-98 %), and widen their alveolar to arterial oxygen difference (23.2 ± 8.8, range:5-42 mmHg) during all exercise intensities however, with variability in terms of severity and pattern. Our findings suggest that FMA experience EIAH however aerobic fitness appears unrelated to occurrence or severity (r = 0.13, p = 0.756).

Shared Decision-Making in Athletes Diagnosed With a Cardiovascular Condition: A Scoping Review.

This scoping review summarizes existing approaches, benefits, and barriers to shared decision-making (SDM) in the context of sports cardiology. Among 6,058 records screened, 37 articles were included in this review. Most included articles defined SDM as an open dialogue between the athlete, healthcare team, and other stakeholders. The benefits and risks of management strategies, treatment options, and return-to-play were the focus of this dialogue. Key components of SDM were described through various themes, such as emphasizing patient values, considering nonphysical factors, and informed consent. Benefits of SDM included enhancing patient understanding, implementing a personalized management plan, and considering a holistic approach to care. Barriers to SDM included pressure from institutions, consideration of multiple perspectives in decision-making, and the potential liability of healthcare providers. The use of SDM when discussing management, treatment, and lifestyle modification for athletes diagnosed with a cardiovascular condition is necessary to ensure patient autonomy and engagement.

Statin therapy and the risk of intracerebral hemorrhage: a meta-analysis of 31 randomized controlled trials.

BACKGROUND AND PURPOSE: Statin therapy decreases the risk of ischemic stroke. An increased risk of intracerebral hemorrhage (ICH) has been observed in some studies. To investigate this issue, we performed a meta-analysis of randomized controlled trials using statins that reported ICH. METHODS: We performed a literature search of Medline, Web of Science, and The Cochrane Library through January 25, 2012, and identified additional randomized controlled trials by reviewing reference lists of retrieved studies and prior meta-analyses. All randomized controlled trials of statin therapy that reported ICH or hemorrhagic stroke were included. The primary outcome variable was ICH. Thirty-one randomized controlled trials were included. All analyses used random effects models and heterogeneity was not observed in any of the analyses. RESULTS: A total of 91,588 subjects were included in the active group and 91,215 in the control group. There was no significant difference in incidence of ICH observed in the active treatment group versus control (OR, 1.08; 95% CI, 0.88-1.32; P=0.47). ICH risk was not related to the degree of low-density lipoprotein reduction or achieved low-density lipoprotein cholesterol. Total stroke (OR, 0.84; 95% CI, 0.78-0.91; P<0.0001) and all-cause mortality (OR, 0.92; CI, 0.87-0.96; P=0.0007) were significantly reduced in the active therapy group. There was no evidence of publication bias. CONCLUSIONS: Active statin therapy was not associated with significant increase in ICH in this meta-analysis of 31 randomized controlled trials of statin therapy. A significant reduction in all stroke and all-cause mortality was observed with statin therapy.

Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis.

INTRODUCTION: The Glidescope(®) video-laryngoscopy appears to provide better glottic visualization than direct laryngoscopy. However, it remains unclear if it translates into increased success with intubation. METHODS: We systematically searched electronic databases, conference abstracts, and article references. We included trials in humans comparing Glidescope(®) video-laryngoscopy to direct laryngoscopy regarding the glottic view, successful first-attempt intubation, and time to intubation. We generated pooled risk ratios or weighted mean differences across studies. Meta-regression was used to explore heterogeneity based on operator expertise and intubation difficulty. RESULTS: We included 17 trials with a total of 1,998 patients. The pooled relative risk (RR) of grade 1 laryngoscopy (vs ≥ grade 2) for the Glidescope(®) was 2.0 [95% confidence interval (CI) 1.5 to 2.5]. Significant heterogeneity was partially explained by intubation difficulty using meta-regression analysis (P = 0.003). The pooled RR for nondifficult intubations of grade 1 laryngoscopy (vs ≥ grade 2) was 1.5 (95% CI 1.2 to 1.9), and for difficult intubations it was 3.5 (95% CI 2.3 to 5.5). There was no difference between the Glidescope(®) and the direct laryngoscope regarding successful first-attempt intubation or time to intubation, although there was significant heterogeneity in both of these outcomes. In the two studies examining nonexperts, successful first-attempt intubation (RR 1.8, 95% CI 1.4 to 2.4) and time to intubation (weighted mean difference -43 sec, 95% CI -72 to -14 sec) were improved using the Glidescope(®). These benefits were not seen with experts. CONCLUSION: Compared to direct laryngoscopy, Glidescope(®) video-laryngoscopy is associated with improved glottic visualization, particularly in patients with potential or simulated difficult airways.

Twelve tips for teaching in a provincially distributed medical education program.

BACKGROUND: As distributed undergraduate and postgraduate medical education becomes more common, the challenges with the teaching and learning process also increase. AIM: To collaboratively engage front line teachers in improving teaching in a distributed medical program. METHOD: We recently conducted a contest on teaching tips in a provincially distributed medical education program and received entries from faculty and resident teachers. RESULTS: Tips that are helpful for teaching around clinical cases at distributed teaching sites include: ask "what if" questions to maximize clinical teaching opportunities, try the 5-min short snapper, multitask to allow direct observation, create dedicated time for feedback, there are really no stupid questions, and work with heterogeneous group of learners. Tips that are helpful for multi-site classroom teaching include: promote teacher-learner connectivity, optimize the long distance working relationship, use the reality television show model to maximize retention and captivate learners, include less teaching content if possible, tell learners what you are teaching and make it relevant and turn on the technology tap to fill the knowledge gap. CONCLUSION: Overall, the above-mentioned tips offered by front line teachers can be helpful in distributed medical education.