A guide to the management of atrial fibrillation in Santa Claus.

•In view of his advanced age and risk factors, Santa Claus is at high risk of developing atrial fibrillation. Despite this, no guidelines exist on the subject. •Following a review of the literature, we present our position on the management of atrial fibrillation in Santa Claus, and propose the use of the SANTA CLAUS mnemonic to aid clinicians: Screen for atrial fibrillation; Anticoagulate; Normalise heart rate; Treat comorbidities; Anti-arrhythmic drugs; Cardioversion; Lifestyle measures; Ablation treatment; Understand emotional and psychological impact; Save Santa Claus.

Sex-Dependent QRS Guidelines for Cardiac Resynchronization Therapy Using Computer Model Predictions.

Cardiac resynchronization therapy (CRT) is an important treatment for heart failure. Low female enrollment in clinical trials means that current CRT guidelines may be biased toward males. However, females have higher response rates at lower QRS duration (QRSd) thresholds. Sex differences in the left ventricle (LV) size could provide an explanation for the improved female response at lower QRSd. We aimed to test if sex differences in CRT response at lower QRSd thresholds are explained by differences in LV size and hence predict sex-specific guidelines for CRT. We investigated the effect that LV size sex difference has on QRSd between male and females in 1093 healthy individuals and 50 CRT patients using electrophysiological computer models of the heart. Simulations on the healthy mean shape models show that LV size sex difference can account for 50-100% of the sex difference in baseline QRSd in healthy individuals. In the CRT patient cohort, model simulations predicted female-specific guidelines for CRT, which were 9-13 ms lower than current guidelines. Sex differences in the LV size are able to account for a significant proportion of the sex difference in QRSd and provide a mechanistic explanation for the sex difference in CRT response. Simulations accounting for the smaller LV size in female CRT patients predict 9-13 ms lower QRSd thresholds for female CRT guidelines.

An Alternative View of Self-Discharge Against Medical Advice: An Opportunity to Demonstrate Empathy, Empowerment, and Care.

In this article, we present the experiences of discharging against medical advice from the perspectives of 17 hospital and community-based health care practitioners, and 16 patients, and relatives from a range of medical and surgical wards. Semistructured, in-depth interviews were conducted and thematically analyzed. We identified that practitioners, patients, and relatives frequently expressed empathy for each other during the interviews, and discharge against medical advice was presented as a way for patients to have control over their health. Contrary to predominantly negative framings that highlight increased mortality and morbidity, and portray people who discharge against medical advice as poor decision makers, we conclude discharge against medical advice can be framed positively. It can be an opportunity to empathize, empower, and care. We recommend that the vocabulary used in hospital discharge against medical advice policies and documents should be updated to reflect a culture of medicine that values patient autonomy, patient centeredness, and shared decision making.

Computer model for the cardiovascular system: development of an e-learning tool for teaching of medical students.

BACKGROUND: This study combined themes in cardiovascular modelling, clinical cardiology and e-learning to create an on-line environment that would assist undergraduate medical students in understanding key physiological and pathophysiological processes in the cardiovascular system. METHODS: An interactive on-line environment was developed incorporating a lumped-parameter mathematical model of the human cardiovascular system. The model outputs were used to characterise the progression of key disease processes and allowed students to classify disease severity with the aim of improving their understanding of abnormal physiology in a clinical context. Access to the on-line environment was offered to students at all stages of undergraduate training as an adjunct to routine lectures and tutorials in cardiac pathophysiology. Student feedback was collected on this novel on-line material in the course of routine audits of teaching delivery. RESULTS: Medical students, irrespective of their stage of undergraduate training, reported that they found the models and the environment interesting and a positive experience. After exposure to the environment, there was a statistically significant improvement in student performance on a series of 6 questions based on cardiovascular medicine, with a 33% and 22% increase in the number of questions answered correctly, p < 0.0001 and p < 0.001 respectively. CONCLUSIONS: Considerable improvement was found in students' knowledge and understanding during assessment after exposure to the e-learning environment. Opportunities exist for development of similar environments in other fields of medicine, refinement of the existing environment and further engagement with student cohorts. This work combines some exciting and developing fields in medical education, but routine adoption of these types of tool will be possible only with the engagement of all stake-holders, from educationalists, clinicians, modellers to, most importantly, medical students.

End-stage heart failure non-pharmacological therapy: recent advances in pacemakers, pressure monitors, pumps and other devices.

Heart failure is a common, expensive and fatal condition and yet, until recently, there was a paucity of treatment options for patients with end-stage heart failure (ESHF), other than pharmacotherapy or heart transplant. Recent advances mean there is now an array of non-pharmacological therapies available for such patients; two such examples are cardiac resynchronisation therapy (CRT) and implantable cardioverter defibrillators (ICDs), which improve pump function, symptoms, exercise capacity or reduce the risk of arrhythmic death, respectively. Furthermore, prior to transplant or if they are deemed unsuitable, patients now have the option of a left ventricular assist device (LVAD) or total artificial heart (TAH), where available, before heart transplant needs to be considered. The concept of remote monitoring is increasingly popular, and while recording parameters such as blood pressure and weight are not new, what is new is how implantable remote monitoring devices are now able to detect clinical decompensation before even the patient is symptomatic and relay this information onto the clinician. Other more novel therapies for ESHF include nerve stimulators to reduce sympathetic tone, the risk of arrhythmia and augment reverse cardiac remodelling and, perhaps the most novel of all, cardiac contractility modulation, stimulating the heart paradoxically during the absolute refractory period that serves to improve cardiac contractility.

Differences in level of confidence in diabetes care between different groups of trainees: the TOPDOC diabetes study.

BACKGROUND: There is an increasing prevalence of diabetes. Doctors in training, irrespective of specialty, will have patients with diabetes under their care. The aim of this further evaluation of the TOPDOC Diabetes Study data was to identify if there was any variation in confidence in managing diabetes depending on the geographical location of trainees and career aspirations. METHODS: An online national survey using a pre-validated questionnaire was administered to trainee doctors. A 4-point confidence rating scale was used to rate confidence in managing aspects of diabetes care and a 6-point scale used to quantify how often trainees would contribute to the management of patients with diabetes. Responses were grouped depending on which UK country trainees were based and their intended career choice. RESULTS: Trainees in Northern Ireland reported being less confident in IGT diagnosis, use of IV insulin and peri-operative management and were less likely to adjust oral treatment, contact specialist, educate lifestyle, and optimise treatment. Trainees in Scotland were less likely to contact a specialist, but more likely to educate on lifestyle, change insulin, and offer follow-up advice. In Northern Ireland, Undergraduate (UG) and Postgraduate (PG) training in diagnosis was felt less adequate, PG training in emergencies less adequate, and reporting of need for further training higher. Trainees in Wales felt UG training to be inadequate. In Scotland more trainees felt UG training in diagnosis and optimising treatment was inadequate. Physicians were more likely to report confidence in managing patients with diabetes and to engage in different aspects of diabetes care. Aspiring physicians were less likely to feel the need for more training in diabetes care; however a clear majority still felt they needed more training in all aspects of care. CONCLUSIONS: Doctors in training have poor confidence levels dealing with diabetes related care issues. Although there is variability between different groups of trainees according to geographical location and career aspirations, this is a UK wide issue. There should be a UK wide standardised approach to improving training for junior doctors in diabetes care with local training guided by specific needs.

Cardiogeriatrics: the current state of the art.

It is estimated that by 2050, 17% of the world's population will be greater than 85 years old, which, combined with cardiovascular disease (CVD) being the leading cause of death and disability, sets an unprecedented burden on our health and care systems. This perfect storm will be accompanied by a rise in the prevalence of CVD due to increased survival of patients with pre-existing CVD and the incidence of CVD that is associated with the process of ageing. In this review, we will focus on the diagnosis and management of common CVD conditions in old age, namely: heart failure (HF), coronary artery disease (CAD), atrial fibrillation (AF) and valvular heart disease (VHD). Despite limited evidence, clinical guidelines are increasingly considering the complexity of management of these conditions in the older person, which often coexist, for example, AF and HF or CAD and VHD. Furthermore, they, in turn, need specific consideration in the context of comorbidities, polypharmacy, frailty and impaired cognition found in this age group. Hence, the emerging role of the geriatric cardiologist is therefore vital in performing comprehensive geriatric assessment, attending multidisciplinary team meetings and ultimately considering the patient and the sum of their diseases in their totality. There have been recent advances in CVD management but how we apply these to deliver integrated care to the elderly population is key. This review article aims to bring together emerging studies and guidelines on assessment and management of CVD in the elderly, summarising latest definitions, diagnostics, therapeutics and future challenges.

Adult congenital heart disease: a review of the simple lesions.

There has been a dramatic improvement in mortality rates among children with congenital heart disease with advances in neonatal screening and surgical techniques, resulting in a significant increase in the prevalence of adults living with congenital heart disease. The most common simple lesions of congenital heart disease include atrial and ventricular septal defects, patent ductus arteriosus and coarctation of the aorta, which are typically detected and treated in childhood. However, they may also present in adulthood with non-specific symptoms or incidental findings, such as refractory hypertension. As the adult population of those living with congenital heart disease grows, it is imperative that all clinicians remain abreast of these common cardiac conditions, irrespective of their specialty, as patients may present with sequelae of their congenital heart disease or other non-cardiac conditions.

Changes and advances in the field of infective endocarditis.

Infective endocarditis is a rare but deadly disease, with a highly variable presentation. The clinical manifestations of the condition are often multisystemic, ranging from dermatological to ophthalmic, and cardiovascular to renal. Thus, patients with infective endocarditis may first present to the acute or general physician, who may have a variable knowledge of the condition. The diagnosis of infective endocarditis can be challenging, relying on clinical, imaging and microbiological features. Recent decades have seen a transformation in the epidemiology and microbiology of infective endocarditis and yet, despite advances in diagnostics and therapeutics, mortality rates remain high. This review outlines the emerging studies and guidelines on the assessment and management of infective endocarditis, focusing on the evolving epidemiology of the condition, the role of new imaging modalities, updated diagnostic criteria, the latest on antimicrobial and surgical management, and the role of a multidisciplinary approach in the management of patients with infective endocarditis.

Drive-by collection and self-fitting of ambulatory electrocardiogram monitoring.

Ambulatory electrocardiogram (AECG) monitoring is a common cardiovascular investigation. Traditionally, this requires a face-to-face appointment. In order to reduce contact during the COVID-19 pandemic, we investigated whether drive-by collection and self-fitting of the device by the patient represents an acceptable alternative. A prospective, observational study of consecutive patients requiring AECG monitoring over a period of one month at three hospitals was performed. Half underwent standard (face-to-face) fitting, and half attended a drive-by service to collect their monitor, fitting their device at home. Outcome measures were quality of the recordings (determined as good, acceptable or poor), and patient satisfaction. A total of 375 patients were included (192 face-to-face, 183 drive-by). Mean patient age was similar between the two groups. The quality of the AECG recordings was similar in both groups (52.6% good in face-to-face vs. 53.0% in drive-by; 34.9% acceptable in face-to-face vs. 32.2% in drive-by; 12.5% poor in face-to-face vs. 14.8% in drive-by; Chi-square statistic 0.55, p=0.76). Patient satisfaction rates were high, with all patients in both groups satisfied with the care they received. In conclusion, drive-by collection and self-fitting of AECG monitoring yields similar AECG quality to conventional face-to-face fitting, with high levels of patient satisfaction.

Is there a beneficial role for a flexible bronchoscopic approach to oesophageal tumour-related tracheobronchial stenosis?

BACKGROUND: Interventional pulmonology, in particular, tracheobronchial stent insertion, has been well described in the treatment of tracheobronchial malignant disease. Its benefits are particularly obvious in patients with inoperable malignancy or in those unfit for surgery and have been extensively described. Fewer data exist on the benefits of using self-expanding metal stents (SEMS) inserted via flexible bronchoscopy in the treatment of tracheobronchial stenosis due to extrinsic compression or infiltration from primary oesophageal malignancy. METHODS: We retrospectively reviewed all patients who had stent insertion via flexible bronchoscopy from 2002 to 2010 at our institution. RESULTS: We found 14 patients who had Ultraflex™ self-expanding metal stent insertion for this condition. We analysed this group of patients with respect to their presentation; indications for stent insertion over surgery; size, location, and number of stents inserted; sedative dose; complications of therapy; and survival time. CONCLUSION: We conclude that insertion of SEMS via flexible bronchoscopy is a safe and effective therapy for those individuals who require palliation or are too unfit for the general anaesthesia required for surgery. Moreover, this form of stent insertion may be performed by respiratory physicians in the bronchoscopy suite, rather than by their cardiothoracic counterparts in theatre.

Implications of the 2021 National Institute for Health and Care Excellence atrial fibrillation guidelines.

In 2021 the National Institute for Health and Care Excellence updated its guidance for diagnosing and managing atrial fibrillation. This editorial summarises the key changes made in these guidelines and discusses their implementation in UK clinical practice.

Protocol for a national audit on self-reported confidence levels, training requirements and current practice among trainee doctors in the UK: the Trainees Own Perception of Delivery of Care in Diabetes (TOPDOC) Study.

BACKGROUND: As the incidence and prevalence of diabetes increases across the world, resource pressures require doctors without specialist training to provide care for people with diabetes. In the UK, national standards have been set to ensure quality diabetes care from diagnosis to the management of complications. In a multi-centre pilot study, we have demonstrated a lack of confidence among UK trainee doctors in managing diabetes. Suboptimal confidence was identified in a number of areas, including the management of diabetes emergencies. A national survey would clarify whether the results of our pilot study are representative and reproducible. METHODS/DESIGN: Target cohort: All postgraduate trainee doctors in the UK. DOMAINS STUDIED: The self reported online survey questionnaire has 5 domains: (1) confidence levels in the diagnosis and management of diabetes, (2) working with diabetes specialists, (3) perceived adequacy of training in diabetes (4) current practice in optimising glycaemic control and (5) perceived barriers to seeking euglycaemia.Assessment tools: Self-reported confidence is assessed using the 'Confidence Rating' (CR) scale for trainee doctors developed by the Royal College of Physicians. This scale has four points--('not confident' (CR1), 'satisfactory but lacking confidence' (CR2), 'confident in some cases (CR3) and 'fully confident in most cases' (CR4).Frequency of aspects of day-to-day practice is assessed using a six-point scale. Respondents have a choice of 'always' (100%), 'almost always' (80-99%), 'often' (50-79%), 'not very often' (20-49%) and 'rarely' (5-19%) or never (less than 5%). DISCUSSION: It is anticipated that the results of this national study will clarify confidence levels and current practice among trainee doctors in the provision of care for people with diabetes. The responses will inform efforts to enhance postgraduate training in diabetes, potentially improving the quality of care for people with diabetes.

Maternal and neonatal outcomes in women with history of coronary artery disease.

BACKGROUND: Pregnancy outcomes in women with pre-existing coronary artery disease (CAD) are poorly described. There is a paucity of data therefore on which to base clinical management to counsel women, with regard to both maternal and neonatal outcomes. METHOD: We conducted a retrospective multicentre study of women with established CAD delivering at 16 UK specialised cardiac obstetric clinics. We included pregnancies of 24 weeks' gestation or more, delivered between January 1998 and October 2018. Data were collected on maternal cardiovascular, obstetric and neonatal events. RESULTS: 79 women who had 92 pregnancies (94 babies including two sets of twins) were identified. 35.9% had body mass index >30% and 24.3% were current smokers. 18/79 (22.8%) had prior diabetes, 27/79 (34.2%) had dyslipidaemia and 21/79 (26.2%) had hypertension. The underlying CAD was due to atherosclerosis in 52/79 (65.8%), spontaneous coronary artery dissection (SCAD) in 11/79 (13.9%), coronary artery spasm in 7/79 (8.9%) and thrombus in 9/79 (11.4%).There were six adverse cardiac events (6.6% event rate), one non-ST elevation myocardial infarction at 23 weeks' gestation, two SCAD recurrences (one at 26 weeks' gestation and one at 9 weeks' postpartum), one symptomatic deterioration in left ventricular function and two women with worsening angina. 14% of women developed pre-eclampsia, 25% delivered preterm and 25% of infants were born small for gestational age. CONCLUSION: Women with established CAD have relatively low rates of adverse cardiac events in pregnancy. Rates of adverse obstetric and neonatal events are greater, highlighting the importance of multidisciplinary care.

Training tomorrow's doctors in diabetes: self-reported confidence levels, practice and perceived training needs of post-graduate trainee doctors in the UK. A multi-centre survey.

OBJECTIVE: To assess the confidence, practices and perceived training needs in diabetes care of post-graduate trainee doctors in the UK. METHODS: An anonymised postal questionnaire using a validated 'Confidence Rating' (CR) scale was applied to aspects of diabetes care and administered to junior doctors from three UK hospitals. The frequency of aspects of day-to-day practice was assessed using a five-point scale with narrative description in combination with numeric values. Respondents had a choice of 'always' (100%), 'almost always' (80-99%), 'often' (50-79%), 'not very often' (20-49%) and 'rarely' (less than 20%). Yes/No questions were used to assess perception of further training requirements. Additional 'free-text' comments were also sought. RESULTS: 82 doctors completed the survey. The mean number of years since medical qualification was 3 years and 4 months, (range: 4 months to 14 years and 1 month). Only 11 of the respondents had undergone specific diabetes training since qualification.4(5%) reported 'not confident' (CR1), 30 (37%) 'satisfactory but lacked confidence' (CR2), 25 (30%) felt 'confident in some cases' (CR3) and 23 (28%) doctors felt fully confident (CR4) in diagnosing diabetes. 12 (15%) doctors would always, 24 (29%) almost always, 20 (24%) often, 22 (27%) not very often and 4 (5%) rarely take the initiative to optimise gcaemic control. 5 (6%) reported training in diagnosis of diabetes was adequate while 59 (72%) would welcome more training. Reported confidence was better in managing diabetes emergencies, with 4 (5%) not confident in managing hypoglycaemia, 10 (12%) lacking confidence, 22 (27%) confident in some cases and 45 (55%) fully confident in almost all cases. Managing diabetic ketoacidosis, 5 (6%) doctors did not feel confident, 16 (20%) lacked confidence, 20 (24%) confident in some cases, and 40 (50%) felt fully confident in almost all cases. CONCLUSION: There is a lack of confidence in managing aspects of diabetes care, including the management of diabetes emergencies, amongst postgraduate trainee doctors with a perceived need for more training. This may have considerable significance and further research is required to identify the causes of deficiencies identified in this study.

Primary and secondary care integration in delivery of value-based health-care systems.

The Five Year Forward View ( NHS England, 2014 ) endorses outcomes-based approaches and integrated care systems. This article looks at the role and functions of hospitals in value-based health-care systems, following Porter's value-based health-care framework. Changes will be required not only in the way health care is organized within a hospital in the form of so-called integrated practice units, but more importantly primary and secondary care will have to work together to realize value for patients across the health-care pathway and system. It will be necessary to build an enabling IT platform that facilitates an integrated dataset across primary and secondary care to measure outcomes and costs across patient pathways. Finally, new payment models will be required to remove current barriers and allow clinicians to do the right things for their patients without organizations being penalized. The final section describes current maturity of the system, opportunities and challenges in the UK.

Journal clubs in the digital age: Twitter for continuing professional development.

The departmental journal club (JC) is a well-established form of continuing professional development (CPD). Social media offers a range of interactive online platforms, allowing the traditional JC to move from a formal educational meeting with local health professionals to a digital platform with users across the world. The authors created the General Internal Medicine JC (@GIMJClub) on Twitter and following a year of activity retrospectively analysed the participation and impact of this medium of JC delivery. There were 61 different participants across different continents, specialties and levels who participated in the 12 JC sessions and sent 1,543 tweets in total. Factors that appeared to influence the success of an individual JC session included choosing diverse, topical papers to discuss and a wide range of hosts. This work demonstrates the success of a Twitter-based general internal medicine JC for CPD. @GIMJClub facilitated unique and diverse interactions not otherwise available.