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Introduction: Sleep deprivation impacts clinical performance. However, literature is conflicting, with insufficient focus on patient outcomes. The aim of this study was to assess if patient satisfaction and prescription errors in outpatient clinics were adversely affected when consulting post-call versus non-post-call registrars. Methods: This prospective, quantitative study was set in a large teaching hospital in Singapore. Between November 2015 and February 2016, patients from clinics run by a registrar after 24-hour shift were recruited to post-call group. Patients from non-post-call clinics run by the same registrar were controls. Outcome measures were patient satisfaction, using 5-item 4-point Likert scale questionnaire, and prescribing error rate, defined as number of errors over number of orders. Differences were analysed using chi-squared test. Results: 103 of 106 (97%) patients in 9 post-call clinics and 93 of 105 (90%) patients in 9 non-post-call clinics were recruited. Questionnaire completion rate was 99%. 536 and 526 prescriptions were ordered in post-call and non-post-call groups, respectively. Percentage of top-box responses (greatest satisfaction) was higher in post-call group overall (79.3% versus 62.4%, p

Background Stress cardiovascular magnetic resonance (CMR) offers assessment of ventricular function, myocardial perfusion and viability in a single examination to detect coronary artery disease (CAD). We developed an in-scanner exercise stress CMR (ExCMR) protocol using supine cycle ergometer and aimed to examine the diagnostic value of a multiparametric approach in patients with suspected CAD, compared with invasive fractional flow reserve (FFR) as the reference gold standard. Methods In this single-centre prospective study, patients who had symptoms of angina and at least one cardiovascular disease risk factor underwent both ExCMR and invasive angiography with FFR. Rest-based left ventricular function (ejection fraction, regional wall motion abnormalities), tissue characteristics and exercise stress-derived (perfusion defects, inducible regional wall motion abnormalities and peak exercise cardiac index percentile-rank) CMR parameters were evaluated in the study. Results In the 60 recruited patients with intermediate CAD risk, 50% had haemodynamically significant CAD based on FFR. Of all the CMR parameters assessed, the late gadolinium enhancement, stress-inducible regional wall motion abnormalities, perfusion defects and peak exercise cardiac index percentile-rank were independently associated with FFR-positive CAD. Indeed, this multiparametric approach offered the highest incremental diagnostic value compared to a clinical risk model (χ2 for the diagnosis of FFR-positive increased from 7.6 to 55.9; P Conclusion The study demonstrates the clinical potential of using in-scanner multiparametric ExCMR to accurately diagnose CAD. Trial registration: ClinicalTrials.gov, NCT03217227, Registered 11 July 2017–Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03217227?id=NCT03217227&draw=2&rank=1&load=cart

While brachial mean blood pressure (MBP) and left ventricular mass (LVM) measured from CTCA are the two CFD simulation input parameters, their effects on noninvasive fractional flow reserve (FFRB) have not been systematically investigated. We demonstrate that inaccurate MBP and LVM inputs differing from patient-specific values could result in misclassification of borderline ischemic lesions. This is important in the clinical application of noninvasive FFR in coronary artery disease diagnosis.

Background: Resident attrition is costly but literature studying the motivations behind it in obstetrics and gynaecology (OBGYN) is lacking. Objectives: We aimed to study the relationship between prior specialty-appropriate work experience and risk of attrition amongst OBGYN residents in Singapore, and identify factors placing residents at greater risk of attrition. Methods: This nationwide mixed methods case control study studied all OBGYN residents in Singapore for the 2011 and 2012 intakes. A pre-piloted questionnaire was used to identify work experience and risk factors related to resident attrition. Structured interviews were conducted with a subgroup of participants chosen for diversity of educational background, work experience, and position towards residency. Results: 28 of 33 (84.8%) eligible residents participated in this study. Female (40.9% vs. 0%), married (50.0% vs. 22.2%) and Singaporean (38.1% vs.14.3%) residents more often considered attrition from training. Those accepted into residency after graduation were 33% less likely to have considered leaving. No statistical difference was observed between residents with prior work experience and those without (38.9% vs. 20.0%, p=0.417). All interviewees believed that prior experience informs expectations and eases initial learning. Low job satisfaction related to mismatched expectations was the most quoted reason for considering attrition. 85.7% of interviewed residents were concerned about competing work and family demands. Conclusions: Lack of specialty-appropriate work experience contributes to misinformed training expectations and increased attrition risk. Residents who have considered attrition may still desire career longevity in their specialty. Reduction in mismatched expectations promises to improve job satisfaction and translate to career longevity.

We compared real-world clinical outcomes of patients receiving intravascular lithotripsy (IVL) versus rotational atherectomy (RA) for heavily calcified coronary lesions.Fifty-three patients who received IVL from January 2017 to July 2020 were retrospectively compared to 271 patients who received RA from January 2017 to December 2018. Primary endpoints were in-hospital and 30-day major adverse cardiovascular events (MACE).IVL patients had a higher prevalence of acute coronary syndrome (56.6% vs 24.4, p0.001), multivessel disease (96.2% vs 73.3%, p0.001) and emergency procedures (17.0% vs 2.2%, p0.001) compared to RA. In-hospital MACE (11.3% vs 5.9%, p=0.152), MI (7.5% vs 3.3%, p=0.152), and mortality (5.7% vs 3.0%, p=0.319) were not statistically significant. 30-day MACE was higher in the IVL cohort vs RA (17.0% vs 7.4%, p=0.035). Propensity score adjusted regression using IVL was also performed on in-hospital MACE (odds ratio [OR], 1.677; 95% confidence interval [CI], 0.588-4.779) and 30-day MACE (OR, 1.910; 95% CI, 0.774-4.718).These findings represent our initial IVL experience in a high-risk, real-world cohort. Although the event rate in the IVL arm was numerically higher compared to RA, the small numbers and retrospective nature of this study preclude definitive conclusions. These clinical outcomes are likely to improve with greater experience and better case selection, allowing IVL to effectively treat complex calcified coronary lesions.

This article was migrated. The article was not marked as recommended. The 2019 novel coronavirus disease (COVID-19) spreads outside China rapidly and became a global pandemic. Recognising its severity and with experiences from the Severe Acute Respiratory Syndrome coronavirus (SARS-CoV) outbreak in 2003, the Singapore government promptly and decisively implemented measures to contain the disease. Many of them have direct effects on our healthcare workers (HCW), and our graduate medical education, which is modelled after the US residency training system, has invariably been impacted to a large degree. Strategies aimed at minimising unnecessary contact between HCW, and directives to step up on human resources as healthcare institutions prepare to cope with a disease outbreak called for modifications to residents' training routine. Residents are affected by curtailment of leave and reallocation of manpower to meet the demands at various frontlines and have to cope with significant physical and emotional stress from anxiety and even pessimism as the situation unfolds with unpredictability. Nevertheless, the pandemic also presents a rare opportunity for residents to learn about healthcare in an international and interdisciplinary context, and develop qualities like resilience, adaptability and solidarity in the face of a medical crisis.

Culprit lesion identification in ST elevation myocardial infarction (STEMI) is often guided by electrocardiogram (ECG) changes. However, in the setting of multi-vessel coronary artery occlusion, this can be challenging. We describe an interesting case of dual territory STEMI with unanticipated ECG changes that bring forth the concept of ‘balanced ischaemia’. These seemingly bizarre findings are well explained using the fundamentals of electrocardiography reinstating its relevance in modern day cardiology.

Near-infrared spectroscopy (NIRS) has been employed to assess the composition of the atherosclerotic plaques in native coronary arteries. However, little is known about the detection of neoatherosclerosis by NIRS in in-stent restenosis (ISR). The aim of the study was to assess the relationship between the distribution of lipid determined by NIRS and morphology of ISR on optical coherence tomography (OCT).We performed both NIRS and OCT in 39 drug-eluting stents with ISR. Values of lipid-core burden index (LCBI) derived by NIRS were compared with the OCT-derived thickness of the fibrous cap covering neoatherosclerotic lesions. A total of 22 (49%) in-stent neointimas were identified as lipid rich by both NIRS and OCT. There was good agreement between OCT and NIRS in identifying lipid within in-stent neointima (kappa = 0.60, 95% CI: 0.34-0.86). OCT identified thin-cap neoatheromas (TCNA) (65 µm) in 12 stents (23%). The minimal cap thickness of in-stent neoatherosclerotic plaque measured by OCT correlated with the maxLCBI4mm (maximal LCBI per 4 mm) within the stent (r = -0.77, P0.01). Moreover, maxLCBI4mm was able to accurately predict TCNA with a cut-off value of144.NIRS correlates with OCT identification of lipids in stented vessels and is able to predict the presence of thin fibrous cap neoatheroma.

High-definition 60-MHz intravascular ultrasound (IVUS) represents the current state of the art in IVUS imaging, offering superior spatial resolution of

Patient initials or identifier number STK ### Relevant clinical history and physical exam A 67-year-old man has experienced recurrent unstable angina pectoris (Canadian Cardiovascular Society angina class IV) in the last six months. He had a 30-year history of smoking twenty cigarettes per

Mechanisms and patterns of in-stent restenosis (ISR) comparing bare metal stents (BMS) and 1st and 2nd generation drug-eluting stent (DES) as evaluated by optical coherence tomography (OCT) have not been well delineated. OCT evaluation of ISR (minimum lumen area

To the Editor:Patients with systemic lupus erythematosus (SLE) are at in-creased risk of premature atherosclerosis, mediated by endothelialdysfunction and increased arterial stiffness[1]. The latter, mostcommonly assessed using carotid-femoralpulse wave velocity, isincreased in patients with SLE and is associated with cardiovascu-lar risk factors[1]. Recently, a more sensitive measure of arterialstiffness (effective arterial elastance; Ea), and ventricular-arterialcoupling (ratio of arterial and end-systolic ventricular elastance;Ea/Ees) demonstrated incremental prognostic value in patientswith chronic heart failure[2]. We aimed to assess the potential ofEa and Ea/Ees as novel biomarkers of cardiovascular risk in SLEwomen without ischemic heart disease.Women whosatisfiedtherevised American College of Rheumatolo-gy classification criteria for SLE were prospectively recruited from therheumatology clinics, as described previously [3]. Patients with recentactive flares, ischemic heart disease (all patients underwent nuclearstress perfusion imaging as part of the study), cardiomyopathies(including myocarditis) and valvular heart disease of≥ moderateseverity were excluded. Cardiovascular risk was defined as historyof hypertension, hyperlipidemia, diabetes mellitus, current tobacco use,cerebrovascularevents,familyhistoryofcoronaryarterydiseaseandsec-ondary anti-phospholipid syndrome. Age-matched control women wererecruited from the community. Left ventricular mass, diastolic functionand systolic ejection fraction were assessed with echocardiography;Ea was estimated as 0.9 x (arm-cuff systolic pressure/Doppler strokevolume) and Ees was calculated by the well-validated approach ofusing arm-cuff pressures, Doppler stroke volumes, ejection fraction,pre-ejection and systolic periods [4,5]. The study was conducted inaccordance with the Declaration of Helsinki and approved by the localresearch ethics committee. Written informed consent was obtainedfrom all participants.Continuousvariableswerepresentedinmean±SDormedian[inter-quartile range] and compared using either the Student t test or Mann-Whitney U test, as appropriate. The mean differences in Ea and Ea/Eeswere adjusted for age,systolic ejection fraction and systolicblood pres-sure. We assessed associations using the Pearson (r) or Spearman (ρ)correlation, as appropriate. All statistical analyses were performedwiththeSPSSversion19(SPSSInc,Chicago,USA).Atwo-sidedP b0.05 was considered statistically significant.Forty-eight patients with SLE (43±9 years old; disease durationof 14±6 years; 1 [0,2] risk factors) and 20 control women (42±9years old) were recruited. There were no differences in left ventricu-lar mass, diastolic function and Ees between SLE and control women(PN0.50 for all;Table 1). Compared to control individuals, patientswithSLEhadlowersystolicejectionfraction,albeitasmalldifference(71±8 versus 75±7%; P=0.04). Despite similar systolic blood pres-sure compared with control women (116±12 versus 119±16mmHg; P=0.52), patients with SLE had increased Ea (1.77±0.56versus 1.37±0.27 mmHg/mL; adjusted mean difference 0.30mmHg/mL, 95% confidence interval [CI] 0.08 to 0.53 mmHg/mL,Pb0.001) and Ea/Ees (0.61±0.18versus 0.50±0.07; adjusted meandifference 0.06, 95% CI 0.01 to 0.12, P=0.04). Furthermore, Ea wasassociated with increasing cardiovascular risk (ρ=0.35; P=0.02),systolic blood pressure (r=0.55, Pb0.001) and duration of predniso-lone use (ρ=0.33, P=0.03).Over 3 years of follow-up (median 31 [17,37] months), 8% ofpatients with SLE developed cardiovascular events (event rate 3.2 per100 person-years; non-fatal myocardial infarction, n=2; stroke, n=1