Using 360-degree multi-source feedback to evaluate professionalism in surgery departments: an Iranian perspective

Background: Medical professionalism helps physicians adopt a proper and good healing action for the patients based on their particular circumstance. This study was conducted to assess professionalism in surgical residents, using a 360-degree evaluation technique in several teaching hospitals in Tehran, Iran. Methods: This study was conducted on all the second and third year surgery residents from three university teaching hospitals in Tehran. Multi-source feedback questionnaire contained 10 questions on the residents’ professional behavior and was completed by the faculty and staff members (nurses, operation room staff, and medical assistants) as well as other surgery residents, interns and patients to evaluate each resident. Response rates were used to determine feasibility for each of the respondent groups and the mean and standard deviation score for each question was computed to determine the viability of the items. Reliability was assessed using alpha Cronbach coefficient for each respondent group. The correlation between these scores and the residents’ final and OSCE grade was also assessed. Results: The internal consistency reliability for 360-degree rating was 0.889. There was no significant difference in the residents’ score in different hospitals. While male residents obtained higher total score, there was no significant difference between them. The residents, however, obtained lower scores compared to the staff. The highest score was recorded for question 6, suggesting that the residents treated the patients regardless of their socioeconomic status. Conclusion: This study revealed a strong agreement between the results gathered from different respondents, confirming the reliability of the questionnaire and the respondents’ unbiased response. It also revealed that the residents did well in the whole test, showing they were conscientious and learning to become medical professionals

Role of Imaging in Left Atrial Appendage Occlusion

Percutaneous left atrial appendage (LAA) occlusion is now a valid alternative to long-term oral anticoagulation in patients with non-valvular atrial fibrillation at high thrombo-embolism risk, especially for patients who are considered ineligible for anticoagulation. The most frequently used occluders worldwide include the WATCHAMN (Boston Scientific, Natick, MA, USA) and the Amplatzer Cardiac Plug or Amulet (St. Jude Medical/Abbott, St Paul, MN, USA) devices. Multimodality imaging is key in the understanding of 3D aspects of the LAA and surrounding structures anatomy. Imaging is essential for procedural planning, during each step of the procedure and for device surveillance after implantation. Multimodality imaging, including 2D/3D echocardiography, fluoroscopy, and cardiac computed tomography can increase the safety and efficacy of the procedure

Imaging of Left Main Coronary Artery; Untangling the Gordian Knot

Left Main Coronary Artery (LMCA) disease is considered a standout manifestation of coronary artery disease (CAD), because it is accompanied by the highest mortality. Increased mortality is expected, because LMCA is responsible for supplying up to 80% of total blood flow to the left ventricle in a right-dominant coronary system. Due to the significant progress of biomedical technology, the modern drug-eluting stents have remarkably improved the prognosis of patients with LMCA disease treated invasively. In fact, numerous randomized trials provided similar results in one- and five-year survival of patients treated with percutaneous coronary interventions (PCI) -guided with optimal imaging and coronary artery bypass surgery (CABG). However, interventional treatment requires optimal imaging of the LMCA disease, such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT). The aim of this manuscript is to review the main pathophysiological characteristics, to present the imaging techniques of LMCA, and, last, to discuss the future directions in the depiction of LMCA disease.</p

Distal Versus Conventional Radial Access for Coronary Angiography and Intervention The DISCO RADIAL Trial

BACKGROUND Currently, transradial access (TRA) is the recommended access for coronary procedures because of increased safety, with radial artery occlusion (RAO) being its most frequent complication, which will increasingly affect patients undergoing multiple procedures during their lifetimes. Recently, distal radial access (DRA) has emerged as a promising alternative access to minimize RAO risk. A large-scale, international, randomized trial comparing RAO with TRA and DRA is lacking. OBJECTIVES The aim of this study was to assess the superiority of DRA compared with conventional TRA with respect to forearm RAO. METHODS DISCO RADIAL (Distal vs Conventional Radial Access) was an international, multicenter, randomized controlled trial in which patients with indications for percutaneous coronary procedure using a 6-F Slender sheath were randomized to DRA or TRA with systematic implementation of best practices to reduce RAO. The primary endpoint was the incidence of forearm RAO assessed by vascular ultrasound at discharge. Secondary endpoints include crossover, hemostasis time, and access site-related complications. RESULTS Overall, 657 patients underwent TRA, and 650 patients underwent DRA. Forearm RAO did not differ between groups (0.91% vs 0.31%; P = 0.29). Patent hemostasis was achieved in 94.4% of TRA patients. Crossover rates were higher with DRA (3.5% vs 7.4%; P = 0.002), and median hemostasis time was shorter (180 vs 153 minutes; P < 0.001). Radial artery spasm occurred more with DRA (2.7% vs 5.4%; P = 0.015). Overall bleeding events and vascular complications did not differ between groups. CONCLUSIONS With the implementation of a rigorous hemostasis protocol, DRA and TRA have equally low RAO rates. DRA is associated with a higher crossover rate but a shorter hemostasis time. (C) 2022 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation

Bioresorbable Polymer-Coated Orsiro Versus Durable Polymer-Coated Resolute Onyx Stents (BIONYX):Rationale and design of the randomized TWENTE IV multicenter trial

Aim: The aim was to compare in a noninferiority trial the efficacy and safety of 2 contemporary drug-eluting stents (DESs): a novel, durable polymer-coated stent versus an established bioabsorbable polymer-coated stent. Methods and results: The BIONYX trial (ClinicalTrials.gov-no.NCT02508714) is an investigator-initiated, prospective, randomized, patient- and assessor-blinded, international, multicenter study in all-comer patients with all types of clinical syndromes and lesions who require percutaneous coronary interventions with DES. Patients at 7 study sites in the Netherlands, Belgium, and Israel were randomly assigned (1:1, stratified for gender and diabetes mellitus) to treatment with the novel, zotarolimus-eluting, durable polymer-coated Resolute Onyx stent that has a radiopaque, thin-strut, CoreWire stent platform versus the sirolimus-eluting, bioresorbable polymer-coated Orsiro stent (reference device) that has a very thin-strut, cobalt-chromium stent backbone. The primary end point is the 1-year incidence of the composite clinical end point target vessel failure consisting of cardiac death, target vessel–related myocardial infarction, or clinically indicated target vessel revascularization. A power calculation, assuming a target vessel failure rate of 6.0% (noninferiority margin 2.5%), revealed that 2,470 study patients would give the study 80% power (α level 5%), allowing for up to 3% loss to follow-up. The first patient was enrolled on October 7, 2015; on December 23, 2016, the last patient entered the study. Conclusions: BIONYX is a large-scale, prospective, randomized, international, multicenter trial comparing a novel DES with durable coating versus a reference DES with biodegradable coating in all-comers. The study is the first randomized assessment of the Resolute Onyx stent, which is an often-used DES outside the United States

Influence of Bleeding Risk on Outcomes of Radial and Femoral Access for Percutaneous Coronary Intervention: An Analysis From the GLOBAL LEADERS Trial

Background: Radial artery access has been shown to reduce mortality and bleeding events, especially in patients with acute coronary syndromes. Despite this, interventional cardiologists experienced in femoral artery access still prefer that route for percutaneous coronary intervention. Little is known regarding the merits of each vascular access in patients stratified by their risk of bleeding. Methods: Patients from the Global Leaders trial were dichotomized into low or high risk of bleeding by the median of the PRECISE-DAPT score. Clinical outcomes were compared at 30 days. Results: In the overall population, there were no statistical differences between radial and femoral access in the rate of the primary end point, a composite of all-cause mortality, or new Q-wave myocardial infarction (MI) (hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.42-1.15). Radial access was associated with a significantly lower rate of the secondary safety end point, Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding (HR 0.55, 95% CI 0.36-0.84). Compared by bleeding risk strata, in the high bleeding score population, the primary (HR 0.47, 95% CI 0.26-0.85; P = 0.012; Pinteraction = 0.019) and secondary safety (HR 0.57, 95% CI 0.35-0.95; P = 0.030; Pinteraction = 0.631) end points favoured radial access. In the low bleeding score population, however, the differences in the primary and secondary safety end points between radial and femoral artery access were no longer statistically significant. Conclusions: Our findings suggest that the outcomes of mortality or new Q-wave MI and BARC 3 or 5 bleeding favour radial access in patients with a high, but not those with a low, risk of bleeding. Because thisContexte : Il a et e d emontr e que l ’accès par l’artère radiale reduit la mortalite et les h emorragies, en particulier chez les patients presentant un syndrome coronarien aigu. Malgr e cela, les cardiologues interventionnels qui ont acquis de l’experience en matière d ’accès par l’artère femorale pr efèrent encore utiliser cette voie lorsqu ’ils doivent pratiquer une intervention coronarienne percutanee. On connaît mal l’interêt de chacune de ces techniques d ’accès vasculaire au regard du risque d’hemorragie. Methodologie : Les patients de l’essai GLOBAL LEADERS ont et e repartis en deux groupes, selon qu ’ils presentaient un risque d’hemorragie faible ou elev e d ’après le score PRECISE-DAPT median, puis les resultats cliniques ont et e compar es à 30 jours. Resultats : Dans l’ensemble de la population, aucune difference sta- tistiquement significative n’a et e observ ee entre l ’accès radial et l’accès femoral quant au critère d ’evaluation principal, compos e de la mortalite toutes causes confondues et d ’un nouvel infarctus du myocarde (IM) avec onde Q (rapport des risques instantanes [RRI] de 0,70; intervalle de confiance [IC] à 95 % : 0,42-1,15). L’accès radial a et e associe à un taux signi ficativement plus faible de survenue du critère secondaire d’evaluation de l ’innocuite, c ’est-à-dire une hemorragie de type 3 ou 5 selon la classification du BARC (Bleeding Academic Research Consortium) (RRI de 0,55; IC à 95 % : 0,36-0,84). Lorsqu’on compare les sujets en fonction du risque d’hemorragie, les critères d’evaluation de l ’innocuite principal (RRI de 0,47; IC à 95 % : 0,26- 0,85; p ¼ 0,012; pinteraction ¼ 0,019) et secondaire (RRI de 0,57; IC à 95 % : 0,35-0,95; p ¼ 0,030; pinteraction ¼ 0,631) sont favorables à l’accès radial au sein de la population presentant un risque d ’hemor- ragie elev e. Dans la population pr esentant un risque d ’hemorragie faible, les differences entre l ’accès radial et l’accès femoral quant aux critères d’evaluation de l ’innocuite principal et secondaire ne sont toutefois plus statistiquement significatives. Conclusions : Selon ces observations, les resultats concernant la mortalite ou la survenue d ’un nouvel IM avec onde Q et le risque d’hemorragie de type 3 ou 5 selon la classi fication du BARC indiquent que l’accès radial serait à privilegier lorsque le risque d ’hemorragie est elev e, mais pas lorsqu ’il est faible. Comme il ne s’agissait pas d’une analyse principale, il convient de considerer ces observations comme etant g en eratrices d ’hypothèses

Outcomes and regional differences in practice in a worldwide coronary stent registry

Objective: The primary objective was to assess the performance of a new generation thin-strut sirolimus-eluting coronary stent with abluminal biodegradable polymer in an all comer population. The secondary objective was to detail differences in contemporary percutaneous coronary intervention (PCI) practice worldwide. Methods: e-Ultimaster was an all-comer, prospective, global registry (NCT02188355) with independent event adjudication enrolling patients undergoing PCI with the study stent. The primary outcome measure was target lesion failure (TLF) at 1 year, defined as the composite of cardiac death, target vessel myocardial infarction and clinically driven target lesion revascularisation. Data were stratified according to 4 geographical regions. Results: A total of 37 198 patients were enrolled (Europe 69.2%, Asia 17.8%, Africa/Middle East 6.6% and South America/Mexico 6.5%) and 1-year follow-up was available for 35 389 patients (95.1%). One-year TLF occurred in 3.2% of the patients, ranging from 2% (Africa/Middle East) to 4.1% (South America/Mexico). In patients with acute coronary syndrome, potent P2Y(12) inhibitors were prescribed in 48% of patients at discharge, while at 1 year 72% were on any dual antiplatelet therapy. Lipid-lowering treatment was administered in 80.9% and 75.5% of patients at discharge and 1 year, respectively. Regional differences in the profile of the treated patients as well as in PCI practice were reported. Conclusions: In this investigation with worldwide representation, contemporary PCI using a new generation thin-strut sirolimus-eluting coronary stent with abluminal biodegradable polymer was associated with low 1-year TLF across clinical presentations and continents. Suboptimal adherence to current recommendations around antiplatelet and lipid lowering treatments was detected