Streptococcus oralis meningitis in pregnancy

While pregnancy is a time of relative immunosuppression, infective endocarditis and bacterial meningitis remain rare. We present a case of a pregnant woman with Streptococcus oralis endocarditis and meningitis. This is the first reported case of Streptococcus oralis meningitis in a patient without predisposing risk factors. This case highlights the importance of collecting blood cultures in febrile illness during pregnancy and illustrates that effective management plans can be formulated without performing invasive diagnostic tests such as transesophageal echocardiography.

Management of pulmonary arterial hypertension during pregnancy

INTRODUCTION

Pulmonary arterial hypertension (PAH) is defined as a mean pulmonary artery pressure >20 mmHg and pulmonary vascular resistance >2 Wood Units (WU) on right-heart catheterization. Pregnancy is generally contraindicated in PAH, it is associated with high maternal mortality. Despite current recommendations, the number of women with PAH wishing to become pregnant is increasing. Specialist care is essential for preconception counseling, and the management of pregnancy and delivery in such patients.

AREAS COVERED

We cover the physiology of pregnancy, and its effects on the cardiovascular system in PAH. We also discuss optimal management based on available evidence and guidance.

EXPERT OPINION

Pregnancy should be avoided in most patients with PAH. Counseling on appropriate contraception should be offered routinely. Education of women with childbearing potential is essential and should start at the time of diagnosis of PAH, or the time of transition from pediatric to adult services in patients developing PAH in childhood. Women wishing to become pregnant should receive individualized risk assessment and optimization of PAH therapies via a dedicated specialist pre-pregnancy counseling service, to minimize risk and improve outcomes. Pregnant PAH patients should receive expert multidisciplinary management in a PH center, including close monitoring and early initiation of therapies.

Transthoracic Echocardiographic Assessment of the Heart in Pregnancy-a position statement on behalf of the British Society of Echocardiography and the United Kingdom Maternal Cardiology Society

Pregnancy is a dynamic process associated with profound hormonally mediated haemodynamic changes which result in structural and functional adaptations in the cardiovascular system. An understanding of the myocardial adaptations is important for echocardiographers and clinicians undertaking or interpreting echocardiograms on pregnant and post-partum women. This guideline, on behalf of the British Society of Echocardiography and United Kingdom Maternal Cardiology Society, reviews the expected echocardiographic findings in normal pregnancy and in different cardiac disease states, as well as echocardiographic signs of decompensation. It aims to lay out a structure for echocardiographic scanning and surveillance during and after pregnancy as well as suggesting practical advice on scanning pregnant women.

Prevalence of pre-eclampsia and adverse pregnancy outcomes in women with pre-existing cardiomyopathy: a multi-centre retrospective cohort study

Pre-eclampsia is associated with postnatal cardiac dysfunction; however, the nature of this relationship remains uncertain. This multicentre retrospective cohort study aimed to determine the prevalence of pre-eclampsia in women with pre-existing cardiac dysfunction (left ventricular ejection fraction < 55%) and explore the relationship between pregnancy outcome and pre-pregnancy cardiac phenotype. In this cohort of 282 pregnancies, pre-eclampsia prevalence was not significantly increased (4.6% [95% C.I 2.2-7.0%] vs. population prevalence of 4.6% [95% C.I. 2.7-8.2], p = 0.99); 12/13 women had concurrent obstetric/medical risk factors for pre-eclampsia. The prevalence of preterm pre-eclampsia (< 37 weeks) and fetal growth restriction (FGR) was increased (1.8% vs. 0.7%, p = 0.03; 15.2% vs. 5.5%, p < 0.001, respectively). Neither systolic nor diastolic function correlated with pregnancy outcome. Antenatal ß blockers (n = 116) were associated with lower birthweight Z score (adjusted difference - 0.31 [95% C.I. - 0.61 to - 0.01], p = 0.04). To conclude, this study demonstrated a modest increase in preterm pre-eclampsia and significant increase in FGR in women with pre-existing cardiac dysfunction. Our results do not necessarily support a causal relationship between cardiac dysfunction and pre-eclampsia, especially given the population's background risk status. The mechanism underpinning the relationship between cardiac dysfunction and FGR merits further research but could be influenced by concomitant ß blocker use.

Medical leadership training varies substantially between UK medical schools: Report of the leadership in undergraduate medical education national survey (LUMENS)

BACKGROUND

Doctors are increasingly expected to demonstrate medical leadership and management (MLM) skills. The Faculty of Medical Leadership and Management (FMLM) has published an indicative undergraduate curriculum to guide the development of MLM content at UK medical schools.

METHOD

Students from 30 medical schools were surveyed to determine their understanding of MLM teaching at their school. Timetables for 21 schools were searched for MLM-related keywords. Student-reported teaching and timetabled teaching were coded according to predefined themes. Aggregated demographic and postgraduate performance data were obtained through collaboration with the Medical Student Investigators Collaborative (msico.org).

RESULTS

Whilst 88% of medical students see MLM teaching as relevant, only 18% believe it is well integrated into their curriculum. MLM content represented ∼2% of timetabled teaching in each 5-year undergraduate medical course. Most of this teaching was dedicated to teamwork, performance/reflection and communication skills. There was minimal association between how much of a topic students believed they were taught, and how much they were actually taught. We found no association between the volume of MLM teaching and performance in postgraduate examinations, trainee career destinations or fitness to practice referrals.

CONCLUSION

Our findings demonstrate limited and variable teaching of MLM content. Delivery was independent of broader teaching and assessment factors.

Population burst propagation across interacting areas of the brain

For many perceptual and behavioral tasks, a prominent feature of neural spike trains involves high firing rates across relatively short intervals of time. We call these events "population bursts." Because during a population burst information is, presumably, transmitted from one part of the brain to another, burst timing should reveal activity related to the flow of information across neural circuits. We developed a statistical method (based on a point process model) of determining, accurately, the time of the maximum (peak) population firing rate on a trial-by-trial basis and used it to characterize burst propagation across areas. We then examined the tendency of peak firing rates in distinct brain areas to shift earlier or later in time, together, across repeated trials, and found this trial-to-trial coupling of peak times to be a sensitive indicator of interaction across populations. In the data we examined, from the Allen Brain Observatory, we found many very strong correlations (95% confidence intervals above 0.75) in cases where standard methods were unable to demonstrate cross-area correlation. The statistical model introduced cross-area covariation only through population-level trial-dependent time shifts and gain constants (values of which were learned from the data), yet it provided very good fits to data histograms, including histograms of spike count correlations within and across visual areas. Our results demonstrate the utility of carefully assessing timing and propagation, across brain regions, of transient bursts in neural population activity, based on multiple spike train recordings.NEW & NOTEWORTHY We developed a novel statistical method for identifying coordinated propagation of activity across populations of spiking neurons, with high temporal accuracy. Using simultaneous recordings from three visual areas we document precise timing relationships on a trial-by-trial basis, and we show how previously existing techniques can fail to discover coordinated activity in cases where the new approach finds very strong cross-area correlation.

256 Implementing and Reinforcing Positive Change to Regional Hand Trauma Service with Introduction of the Golden Patient Initiative

Introduction

Significant theatre delays were identified in hand trauma lists at our regional adult hand surgery unity. We aimed to improve theatre delays by implementing a golden patient initiative.

Method

Literature review identified the golden patient initiative, which ensures first patient on the list is identified, communicated to multidisciplinary team, and is optimized for theatre.

Multi-stage intervention according to change management models (ADKAR and McKinsey 7s) was used. This included (1) a new protocol, (2) educational intervention, 3) poster and (4) a variety of information dissemination methods. To ensure multidisciplinary staff engagement and reinforce positive change, we used multiple verbal, visual and written prompts: trauma co-ordinator-led daily reminders, senior involvement, new column in handover list, verbal reminders at departmental meetings, posters in key areas and widely-accessible reference booklet.

Prospective analysis of theatre utilisation pre- and post-intervention to measure impact of intervention.

Results

Analysis of emergency general list (EG) and local anaesthetic list (LA) start times identified an average 40 and 20-minute-long delays respectively. Following introduction of golden patient there was a reduction in delays by 9 minutes in LA and 5 minutes in EG. The latest start time improvement by 8 minutes in LA and 50 minutes in EG. There was also a reduction in operation delays by 2.8% in LA and 14.3% in EG. The estimated annual cost saved in EG is approximately £45,200.

Conclusions

We believe that implementing sustainable change is a complex and challenging process. Implementing the golden patient initiative resulted in a positive impact on hand trauma services.

One year outcomes of heart failure multispecialty multidisciplinary team virtual meetings

 

Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model.

This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings.

A total of 189 patients were discussed from January-December 2020. This was uninterrupted during the COVID-19 pandemic. The mean age was 70.3±18.1 years and median follow-up 6 months (range 1–13 months). The mean Charlson Co-morbidity score was 5.3±1.2 and Rockwood Frailty Score was 4.9±1. The mean number of outpatient clinic attendances avoided was 1.7±0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p&lt;0.01) with a saving of around 730 bed days (estimated cost-saving £260,000).

The HF multispecialty virtual MDT approach provides seamless integration of primary care community services with secondary and tertiary care. Consensus decision from MDT meetings provides holistic approach for HF patients with comorbidities and frailty, and reduces inconvenience to patients by preventing the need to attend multiple specialty clinics. This approach can also lead to significant cost-savings to the healthcare system.

Funding Acknowledgement

Type of funding sources: None.

Ivabradine-sensitive incessant atrial tachycardia during pregnancy: a case report

Background 

Automaticity is the dominant mechanism in maternal focal atrial tachycardia (FAT) during pregnancy and if incessant, can cause tachycardia-induced cardiomyopathy. Medication failure for FATs is common, however, for the subgroup due to increased automaticity ivabradine sensitivity has been described and may represent a valuable treatment option. Little data are available regarding the safety profile of ivabradine during pregnancy.

Case Summary 

We report the case of a 38-year-old woman with background of peripartum cardiomyopathy and incessant atrial tachycardia with deteriorating ventricular function during her second pregnancy unresponsive to betablockade and demonstrating the immediate successful rate-controlling effect of ivabradine.

Discussion 

Early recognition of persistent maternal FAT is essential due to its frequent association with tachycardia-mediated cardiomyopathy. Our case report highlights the challenges of providing an equally safe and effective treatment of these notoriously difficult to treat arrhythmias during pregnancy. Ivabradine in combination with a betablocker can be effective for abnormal automaticity but its safety profile during pregnancy remains uncertain.

The Human Gut Microbiota: A Key Mediator of Osteoporosis and Osteogenesis

An expanding body of research asserts that the gut microbiota has a role in bone metabolism and the pathogenesis of osteoporosis. This review considers the human gut microbiota composition and its role in osteoclastogenesis and the bone healing process, specifically in the case of osteoporosis. Although the natural physiologic processes of bone healing and the pathogenesis of osteoporosis and bone disease are now relatively well known, recent literature suggests that a healthy microbiome is tied to bone homeostasis. Nevertheless, the mechanism underlying this connection is still somewhat enigmatic. Based on the literature, a relationship between the microbiome, osteoblasts, osteoclasts, and receptor activator of nuclear factor-kappa-Β ligand (RANKL) is contemplated and explored in this review. Studies have proposed various mechanisms of gut microbiome interaction with osteoclastogenesis and bone health, including micro-RNA, insulin-like growth factor 1, and immune system mediation. However, alterations to the gut microbiome secondary to pharmaceutical and surgical interventions cannot be discounted and are discussed in the context of clinical therapeutic consideration. The literature on probiotics and their mechanisms of action is examined in the context of bone healing. The known and hypothesized interactions of common osteoporosis drugs and the human gut microbiome are examined. Since dysbiosis in the gut microbiota can function as a biomarker of bone metabolic activity, it may also be a pharmacological and nutraceutical (i.e., pre- and probiotics) therapeutic target to promote bone homeostasis.

Do Rockwood frailty score and Charlson comorbidity index help to risk stratify outpatient versus inpatient management of acute decompensated heart failure?

Introduction

Acute decompensated heart failure (ADHF) is associated with frailty and co-morbidities which influence prognosis. The Rockwood Frailty Score (RFS) and age-adjusted Charlson co-morbidity index (CCI) have been used to predict outcomes in hospitalised ADHF patients.

Purpose

To describe the relationship of CCI, RFS and clinical risk score -Get With The Guidelines Score (GWTG) with mortality in ADHF treated as outpatients (OP) versus hospitalised inpatients (IP).

Methods

This retrospective analysis compared 2 cohorts of consecutive ADHF patients - hospitalised in-patients (IP) versus outpatients (OP) who were treated with bolus intravenous diuretics in a specialist heart failure nurse delivered OP HF unit (Ambulatory HF Unit -AHFU) with input from various specialties (renal, palliative, ascitic, pleural teams) from Nov 16 to Dec 17. Mean follow-up duration was similar for both groups (IP=19.5±4.1 months; OP=19.3±3.9 months, p=0.6). Mortality was compared at 1, 3 and 12 months based on RFS (no frailty &lt;5, mild to moderate frailty 5/6, severe frailty - 7 to 9). Results were expressed as mean±SD and analysed using One-Way ANOVA and Chi-squared with Fisher's exact test test.

Results

410 consecutive patients (482 admissions) were hospitalised (inpatients -IP) and 231 OP (289 OP visits) were treated in the AHFU. IP group had significantly higher mean CCI (IP=6.55±2; OP=6.10±1.9; p=0.006) and mean RFS (IP 5.2±1.2; OP 4.9±1.1; p=0.002). Mean Clinical Risk Score GWTG was similar (IP=38.9±7.2; OP=38.4±6.6; p=0.44). Mean survival was significantly lower in IP (IP=378±270 days; OP=437±228; P=0.003). As shown in the table higher RFS predicts increased mortality risk (1 month, 3 month and 12 month).

Conclusions

Rockwood Frailty Score predicts mortality in ADHF and assessment of RFS can play an important role in risk stratifying and decision-making in addition to clinical risk-scores, with regards to suitability for outpatient treatment of ADHF.

Funding Acknowledgement

Type of funding source: None

Mechanisms of the Osteogenic Switch of Smooth Muscle Cells in Vascular Calcification: WNT Signaling, BMPs, Mechanotransduction, and EndMT

Characterized by the hardening of arteries, vascular calcification is the deposition of hydroxyapatite crystals in the arterial tissue. Calcification is now understood to be a cell-regulated process involving the phenotypic transition of vascular smooth muscle cells into osteoblast-like cells. There are various pathways of initiation and mechanisms behind vascular calcification, but this literature review highlights the wingless-related integration site (WNT) pathway, along with bone morphogenic proteins (BMPs) and mechanical strain. The process mirrors that of bone formation and remodeling, as an increase in mechanical stress causes osteogenesis. Observing the similarities between the two may aid in the development of a deeper understanding of calcification. Both are thought to be regulated by the WNT signaling cascade and bone morphogenetic protein signaling and can also be activated in response to stress. In a pro-calcific environment, integrins and cadherins of vascular smooth muscle cells respond to a mechanical stimulus, activating cellular signaling pathways, ultimately resulting in gene regulation that promotes calcification of the vascular extracellular matrix (ECM). The endothelium is also thought to contribute to vascular calcification via endothelial to mesenchymal transition, creating greater cell plasticity. Each of these factors contributes to calcification, leading to increased cardiovascular mortality in patients, especially those suffering from other conditions, such as diabetes and kidney failure. Developing a better understanding of the mechanisms behind calcification may lead to the development of a potential treatment in the future.

The Analysis of Teaching of Medical Schools (AToMS) survey: an analysis of 47,258 timetabled teaching events in 25 UK medical schools relating to timing, duration, teaching formats, teaching content, and problem-based learning

BACKGROUND

What subjects UK medical schools teach, what ways they teach subjects, and how much they teach those subjects is unclear. Whether teaching differences matter is a separate, important question. This study provides a detailed picture of timetabled undergraduate teaching activity at 25 UK medical schools, particularly in relation to problem-based learning (PBL).

METHOD

The Analysis of Teaching of Medical Schools (AToMS) survey used detailed timetables provided by 25 schools with standard 5-year courses. Timetabled teaching events were coded in terms of course year, duration, teaching format, and teaching content. Ten schools used PBL. Teaching times from timetables were validated against two other studies that had assessed GP teaching and lecture, seminar, and tutorial times.

RESULTS

A total of 47,258 timetabled teaching events in the academic year 2014/2015 were analysed, including SSCs (student-selected components) and elective studies. A typical UK medical student receives 3960 timetabled hours of teaching during their 5-year course. There was a clear difference between the initial 2 years which mostly contained basic medical science content and the later 3 years which mostly consisted of clinical teaching, although some clinical teaching occurs in the first 2 years. Medical schools differed in duration, format, and content of teaching. Two main factors underlay most of the variation between schools, Traditional vs PBL teaching and Structured vs Unstructured teaching. A curriculum map comparing medical schools was constructed using those factors. PBL schools differed on a number of measures, having more PBL teaching time, fewer lectures, more GP teaching, less surgery, less formal teaching of basic science, and more sessions with unspecified content.

DISCUSSION

UK medical schools differ in both format and content of teaching. PBL and non-PBL schools clearly differ, albeit with substantial variation within groups, and overlap in the middle. The important question of whether differences in teaching matter in terms of outcomes is analysed in a companion study (MedDifs) which examines how teaching differences relate to university infrastructure, entry requirements, student perceptions, and outcomes in Foundation Programme and postgraduate training.

Exploring UK medical school differences: the MedDifs study of selection, teaching, student and F1 perceptions, postgraduate outcomes and fitness to practise

BACKGROUND

Medical schools differ, particularly in their teaching, but it is unclear whether such differences matter, although influential claims are often made. The Medical School Differences (MedDifs) study brings together a wide range of measures of UK medical schools, including postgraduate performance, fitness to practise issues, specialty choice, preparedness, satisfaction, teaching styles, entry criteria and institutional factors.

METHOD

Aggregated data were collected for 50 measures across 29 UK medical schools. Data include institutional history (e.g. rate of production of hospital and GP specialists in the past), curricular influences (e.g. PBL schools, spend per student, staff-student ratio), selection measures (e.g. entry grades), teaching and assessment (e.g. traditional vs PBL, specialty teaching, self-regulated learning), student satisfaction, Foundation selection scores, Foundation satisfaction, postgraduate examination performance and fitness to practise (postgraduate progression, GMC sanctions). Six specialties (General Practice, Psychiatry, Anaesthetics, Obstetrics and Gynaecology, Internal Medicine, Surgery) were examined in more detail.

RESULTS

Medical school differences are stable across time (median alpha = 0.835). The 50 measures were highly correlated, 395 (32.2%) of 1225 correlations being significant with p < 0.05, and 201 (16.4%) reached a Tukey-adjusted criterion of p < 0.0025. Problem-based learning (PBL) schools differ on many measures, including lower performance on postgraduate assessments. While these are in part explained by lower entry grades, a surprising finding is that schools such as PBL schools which reported greater student satisfaction with feedback also showed lower performance at postgraduate examinations. More medical school teaching of psychiatry, surgery and anaesthetics did not result in more specialist trainees. Schools that taught more general practice did have more graduates entering GP training, but those graduates performed less well in MRCGP examinations, the negative correlation resulting from numbers of GP trainees and exam outcomes being affected both by non-traditional teaching and by greater historical production of GPs. Postgraduate exam outcomes were also higher in schools with more self-regulated learning, but lower in larger medical schools. A path model for 29 measures found a complex causal nexus, most measures causing or being caused by other measures. Postgraduate exam performance was influenced by earlier attainment, at entry to Foundation and entry to medical school (the so-called academic backbone), and by self-regulated learning. Foundation measures of satisfaction, including preparedness, had no subsequent influence on outcomes. Fitness to practise issues were more frequent in schools producing more male graduates and more GPs.

CONCLUSIONS

Medical schools differ in large numbers of ways that are causally interconnected. Differences between schools in postgraduate examination performance, training problems and GMC sanctions have important implications for the quality of patient care and patient safety.

Perceptions of water insecurity from urban and peri-urban Haiti: A quantitative analysis

Safe drinking water access has continued to be a growing issue in Haiti. Water accessibility, availability, and quality can have severe implications on health and safety, with those in urban areas often having more access. Key differences relating to water accessibility can be seen between the urban and peri-urban areas of Haiti. One major objective of this research is to examine the disparities between the two areas and determine limiting and enabling factors that are contributing to the perceived access to clean water. A cross-cultural household water insecurity experiences (HWISE) survey (n = 499) was distributed to determine barriers and accessibility to sufficient water quality and quantity at the household level. This paper explores the relationship between water insecurity between two urban and peri-urban communes in Haiti using this data. Fisher’s Exact and Kruskal-Wallis tests were used to identify significant differences between strata, and logistic regression was used to determine significant associations with water security outcomes. Results indicated there were differences in both the costs and the sources of drinking and non-drinking water between urban and peri-urban Haiti. Certain demographic and behavioral characteristics were associated with increased water insecurity, including a household size greater than five and experiencing injury during collection.

One-year outcomes after successful chronic total occlusion percutaneous coronary intervention: The impact of dissection re-entry techniques

We aimed to determine clinical outcomes 1 year after successful chronic total occlusion (CTO) PCI and, in particular, whether use of dissection and re-entry strategies affects clinical outcomes. Hybrid approaches have increased the procedural success of CTO percutaneous coronary intervention (PCI) but longer-term outcomes are unknown, particularly in relation to dissection and re-entry techniques. Data were collected for consecutive CTO PCIs performed by hybrid-trained operators from 7 United Kingdom (UK) centres between 2012 and 2014. The primary endpoint (death, myocardial infarction, unplanned target vessel revascularization) was measured at 12 months along with angina status. One-year follow up data were available for 96% of successful cases (n = 805). In total, 85% of patients had a CCS angina class of 2-4 prior to CTO PCI. Final successful procedural strategy was antegrade wire escalation 48%; antegrade dissection and re-entry (ADR) 21%; retrograde wire escalation 5%; retrograde dissection and re-entry (RDR) 26%. Overall, 47% of CTOs were recanalized using dissection and re-entry strategies. During a mean follow up of 11.5 ± 3.8 months, the primary endpoint occurred in 8.6% (n = 69) of patients (10.3% (n = 39/375) in DART group and 7.0% (n = 30/430) in wire-based cases). The majority of patients (88%) had no or minimal angina (CCS class 0 or 1). ADR and RDR were used more frequently in more complex cases with greater disease burden, however, the only independent predictor of the primary endpoint was lesion length. CTO PCI in complex lesions using the hybrid approach is safe, effective and has a low one-year adverse event rate. The method used to recanalize arteries was not associated with adverse outcomes. © 2017 Wiley Periodicals, Inc.

Aspergillus infection in pulmonary cavitating lesions with right atrial myxoma

Cardiac myxomas are rare primary tumors with varied clinical presentations that may pose a diagnostic challenge. Here, we describe the case of a 21-year-old man with multiple cavitating lung lesions with aspergillosis and underlying right atrial myxoma, who presented with hemoptysis and weight loss. He was successfully treated with right atrial myxoma resection and antifungal agents, with no recurrence or complications after one year of follow-up.

Comparison of radiation dose and the effect of operator experience in femoral and radial arterial access for coronary procedures

Radial access coronary procedures are associated with fewer access site complications compared to femoral access. There is controversy regarding greater radiation exposure to patient and operator using radial access. We aimed to compare radiation dose during coronary procedures for the 2 access routes and assess the effect of operator experience with radial access on radiation dose. Fluoroscopy time (FT) and dose-area product (DAP) were recorded for all radial access and femoral access procedures during default femoral access, transition phase (femoral access and early radial access), and default radial access. Femoral access cases (n = 848, 412 diagnostic, 436 percutaneous coronary interventions [PCIs]) and radial access cases (n = 965, 459 diagnostic, 506 PCIs) were assessed. For diagnostics, median FT for radial access was longer than for femoral access (4.43 minutes, interquartile range [IQR] 2.55 to 8.18, vs 2.34 minutes, IQR 1.49 to 4.18, p <0.001) and associated with larger DAP (radial access 1,837 μGy·m(2), IQR 1,172 to 2,783, vs femoral access 1,657 μGy·m(2), IQR 1,064 to 2,376, p <0.001). For PCI, FT was longer for radial access (median 12.02 minutes, IQR 7.57 to 17.54, vs femoral access 9.36 minutes, IQR 6.13 to 14.27, p <0.001)-this did not translate into an increased DAP (femoral access median 3,392 μGy·m(2), IQR 2,139 to 5,193, vs radial access 3,682 μGy·m(2), IQR 2,388 to 5,314, p = NS). For diagnostic radial access, FT decreased from the transition phase (n = 134) to the default radial access phase (n = 323, 5.12 minutes, IQR 3.07 to 9.40, vs 4.21 minutes, IQR 2.49 to 7.52, p = 0.03). This was not observed for PCI. In conclusion, transition from femoral access to radial access for diagnostics and PCI increased FT. DAP increased for diagnostic radial access but not PCI compared with femoral access. FTs for radial access diagnostic cases decreased with experience.

Are we there yet? The state of the evidence base for guidelines on breaking bad news to cancer patients

The way clinicians break bad news to cancer patients has been retrospectively associated with poor psychosocial outcomes for patients. Education and practice in breaking bad news may be ineffective for improving patients' well-being unless it is informed by a sound evidence base. In the health field, research efforts are expected to advance evidence over time to inform evidence-based practice. Key characteristics of an advancing evidence base are a predominance of new data, and rigorous intervention studies which prospectively demonstrate improved outcomes. This review aimed to examine the progress of the evidence base in breaking bad news to cancer patients. Manual and computer-based searches (Medline and PsycINFO) were performed to identify publications on the topic of breaking bad news to cancer patients published between January 1995 and March 2009. Relevant publications were coded in terms of whether they provided new data, examined psychosocial outcomes for patients or tested intervention strategies and whether intervention studies met criteria for design rigour. Of the 245 relevant publications, 55.5% provided new data and 16.7% were intervention studies. Much of the intervention effort was directed towards improving provider skills rather than patient outcomes (9.8% of studies). Less than 2% of publications were rigorous intervention studies which addressed psychosocial outcomes for patients. Rigorous intervention studies which evaluate strategies for improving psychosocial outcomes in relation to breaking bad news to cancer patients are needed. Current practice and training regarding breaking bad news cannot be regarded as evidence-based until further research is completed.