James McKinney

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.

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.

Simulation in Non-Invasive Cardiology

Simulation training for noninvasive cardiology has a rich history, beginning with heart sound simulators to the current era of multimedia simulations and full-scale cardiopulmonary simulators for learning cardiac physical examination. More recently, part-task trainers and mannequin-based simulators have been developed for training in transthoracic and transesophageal echocardiography. In this chapter, the range of simulation modalities for cardiac physical examination and echocardiography are reviewed. Recommendations regarding curricular implementation are highlighted.

Perspectives on pre-participation cardiovascular screening in young competitive athletes: U SPORTS

ABSTRACT Objectives: To investigate the pre-participation cardiovascular screening (PPS) protocols currently implemented at U SPORTS (the governing body of university sport in Canada) sanctioned schools as well as the attitudes toward PPS as reported by Canadian University medical and athletic personnel. Methods: A 15-question survey was sent to the U SPORTS athletic directors in both French and English. The survey focused on the current practices of PPS within the respondents’ universities as well as attitudes regarding PPS. Athletic directors distributed the instructions to participate in the voluntary survey at their own discretion to coaches, athletic therapists, physicians, and associated personnel working within U SPORTS-sanctioned schools. Results: Twenty-three athletic therapists, 12 coaches, 6 physicians, and 5 associated personnel completed the survey (46 in total). Half of the respondents (52%) reported that some form of PPS was conducted at their institution. Eighty percent of respondents agreed with the implementation of mandatory PPS, and 60% reported that they believe their athletes have a neutral attitude toward PPS. Three respondents documented having witnessed an athlete’s sudden cardiac arrest/death. Conclusion: Members of the athletic care teams at U SPORTS-sanctioned schools display an overall positive attitude toward the implementation of mandatory PPS. Based on concerns raised by survey respondents, PPS procedures would need to be developed in a time- and cost-effective manner if PPS were to be expanded.

Automated external defibrillator and emergency action plan preparedness amongst Canadian university athletics

Sudden cardiac death is the leading medical cause of death in athletes. The use of an automated external defibrillator (AED) and an emergency action plan (EAP) are effective strategies for improving outcomes of sudden cardiac arrest. The availability of an AED and the presence of an EAP amongst Canadian universities (U-SPORTS) are unknown. Surveys were sent to the athletic directors from U-SPORTS representing the universities within Canada. Questions were directed towards AED and EAP preparedness. All schools reported an on-site AED for sanctioned events. However, less than half of schools reported bringing the AED on-site for field sports. A total of 89% of U-SPORTS universities estimated that their EAP is capable of delivering defibrillation within 5 minutes of collapse. The majority of U-SPORTS universities have accessible AEDs and satisfactory EAP strategies. However, AED availability and EAPs during sport require continuous improvement.

Assessment of cardiovascular risk and preparticipation screening protocols in masters athletes: the Masters Athlete Screening Study (MASS): a cross-sectional study

Background Underlying coronary artery disease (CAD) is the primary cause of sudden cardiac death in masters athletes (>35 years). Preparticipation screening may detect cardiovascular disease; however, the optimal screening method is undefined in this population. The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and the American Heart Association (AHA) Preparticipation Screening Questionnaire are often currently used; however, a more comprehensive risk assessment may be required. We sought to ascertain the cardiovascular risk and to assess the effectiveness of screening tools in masters athletes. Methods This cross-sectional study performed preparticipation screening on masters athletes, which included an ECG, the AHA 14-element recommendations and Framingham Risk Score (FRS). If the preparticipation screening was abnormal, further evaluations were performed. The effectiveness of the screening tools was determined by their positive predictive value (PPV). Results 798 athletes were included in the preparticipation screening analysis (62.7% male, 54.6±9.5 years, range 35–81). The metabolic equivalent task hours per week was 80.8±44.0, and the average physical activity experience was 35.1±14.8 years. Sixty-four per cent underwent additional evaluations. Cardiovascular disease was detected in 11.4%, with CAD (7.9%) being the most common diagnosis. High FRS (>20%) was seen in 8.5% of the study population. Ten athletes were diagnosed with significant CAD; 90% were asymptomatic. A high FRS was most indicative of underlying CAD (PPV 38.2%). Conclusion Masters athletes are not immune to elevated cardiovascular risk and cardiovascular disease. Comprehensive preparticipation screening including an ECG and FRS can detect cardiovascular disease. An exercise stress test should be considered in those with risk factors, regardless of fitness level.

Prevalence and Associated Clinical Characteristics of Exercise-Induced ST-Segment Elevation in Lead aVR

Background Exercise-induced ST-segment elevation (STE) in lead aVR may be an important indicator of prognostically important coronary artery disease (CAD). However, the prevalence and associated clinical features of exercise-induced STE in lead aVR among consecutive patients referred for exercise stress electrocardiography (ExECG) is unknown. Methods All consecutive patients receiving a Bruce protocol ExECG for the diagnosis of CAD at a tertiary care academic center were included over a two-year period. Clinical characteristics, including results of coronary angiography, were compared between patients with and without exercise-induced STE in lead aVR. Results Among 2227 patients undergoing ExECG, exercise-induced STE ≥1.0mm in lead aVR occurred in 3.4% of patients. Patients with STE in lead aVR had significantly lower Duke Treadmill Scores (DTS) (-0.5 vs. 7.0, p<0.01) and a higher frequency of positive test results (60.2% vs. 7.3%, p<0.01). Furthermore, patients with STE in lead aVR were more likely to undergo subsequent cardiac catheterization than those without STE in lead aVR (p<0.01, odds ratio = 4.2). Conclusions Among patients referred for ExECG for suspected CAD, exercise-induced STE in lead aVR was associated with a higher risk DTS, an increased likelihood of a positive ExECG, and referral for subsequent coronary angiography. These results suggest that exercise-induced STE in lead aVR may represent a useful ECG feature among patients undergoing ExECG in the risk stratification of patients.

A NOVEL PRE-PARTICIPATION SCREENING QUESTIONNAIRE FOR YOUNG COMPETITIVE ATHLETES

The sudden cardiac death (SCD) of a young competitive athlete (YCA) is a tragic event. The best way to screen YCAs is controversial. The AHA and ESC recommend history and physical with the ESC endorsing an ECG as a part of the screening algorithm. Young competitive athletes ages (12-35) were

The Resilience of Women: Atrial Fibrillation Resistance.

Atrial fibrillation (AF) is facilitated by atrial remodeling, atrial ectopy, and an imbalance of the autonomic nervous system. Participation in endurance sport has an impact on all of these factors and may therefore act as a promoter of this arrhythmia.1 AF generally represents a final common pathway for a number of predisposing cardiac and noncardiac conditions.2 Emerging risk factors for AF development include tall stature, obstructive sleep apnea, and a history of endurance exercise.3 To place the “potency” of risk of endurance exercise as a risk factor for AF into perspective, the odds ratios (OR) for endurance exercise is 3, in comparison with significant daily alcohol consumption (>36 g/day, OR 1.4), hypertension (OR 1.5), and LV systolic dysfunction (OR 5.9).2 The preliminary case-control studies that demonstrated the positive association between endurance exercise and AF incidence were small in participant number, and dominated by or limited to male participants.4 Nonetheless, these initial studies formed the basis for further exploration examining the link between physical activity and AF, and fostered discussions about the “U-shaped” or “J-shaped” curve with respect to physical activity and cardiovascular events. Some studies showed a linear response while others suggested a “U-shaped” curve.5 In this issue of the Journal of Cardiovascular Electrophysiology, Mohanty et al.5 set forth to improve the granularity and accuracy of prior small case-control studies to identify the veracity of the association between physical activity and incident AF, and to ascertain the effect of gender and physical activity on incident AF. They present the results of a metaanalysis examining the effect that varying levels of physical activity have on the development of AF. The most important conclusions from their study are: (1) moderate intensity exercise is protective regardless of gender, (2) a sedentary lifestyle or minimal activity was associated with an increased risk of AF (OR 2.47), and (3) there is a gender-specific effect of high-intensity physical activity on AF development. Compared with sedentary counterparts, men who exercised

PREVALENCE OF EXERCISE INDUCED ST-SEGMENT ELEVATION IN LEAD AVR

The exercise stress test (EST) is a valuable tool for the detection of coronary artery disease (CAD). Preliminary studies suggest that exercise induced ST-segment elevation (STE) in lead aVR may be an important indicator of prognostically important CAD. However, studies have been limited by their