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Objective: To systematically compare outcomes between patients with asymptomatic carotid artery diseases (>80% stenosis) that had undergone staged carotid endarterectomy (CEA) before coronary artery bypass grafting (CABG) vs simultaneous CEA and CABG., Methods: A comprehensive electronic search of MEDLINE, Scopus, EMBASE, and Ovid from their inception up till August 2018 was performed to identify all studies comparing staged CEA followed by CABG to simultaneous CEA and CABG. Primary outcome measure was postoperative stroke, and secondary measures were myocardial infarction (MI) and 30-day mortality rates., Results: A total of 67 953 patients were analyzed from 11 articles. There was higher rate of previous stroke in the staged cohort (2.64% vs 2.32%; odds ratio [OR], 0.81; 95% confidence interval [CI; 0.66, 0.99]; P = .040). There was no difference in previous MI (P = .57) or unstable angina (P = .08) among both cohorts. Postoperatively, there were higher stroke rates (3.64% vs 2.83%; OR, 0.72; 95% CI [0.62-0.89]; P < .0001), operative mortality (4.32% vs 3.58%; OR, 0.90; 95% CI [0.83-0.98]; P = .02), and 30-day mortality (4.40% vs 3.58%; OR, 0.86; 95% CI [0.78-0.96]; P = .006) in the simultaneous cohort. However, length of stay was significantly shorter in the simultaneous cohort (11.9 days vs 12.6 days; weighted mean difference 3.14 [0.77-5.51]; P = .009). There were no significant differences in 1-year mortality (P = .33), MI rates (P = .08), and rates of transient neurological deficits (P = .06)., Conclusion: The results from this study favors staged CEA with CABG with lower incidence of postoperative stroke, operative, and 30-day mortality. A larger study, ideally a randomized controlled trial, is required to address the superiority of each technique., (© 2019 Wiley Periodicals, Inc.)

Consensus on how to assess non-technical skills is lacking. This systematic review aimed to evaluate the evidence regarding non-technical skills assessments in undergraduate medical education, to describe the tools used, learning outcomes and the validity, reliability and psychometrics of the instruments. A standardized search of online databases was conducted and consensus reached on included studies. Data extraction, quality assessment, and content analysis were conducted per Best Evidence in Medical Education guidelines. Nine papers met the inclusion criteria. Assessment methods broadly fell into three categories: simulated clinical scenarios, objective structured clinical examinations, and questionnaires or written assessments. Tools to assess non-technical skills were often developed locally, without reference to conceptual frameworks. Consequently, the tools were rarely validated, limiting dissemination and replication. There were clear themes in content and broad categories in methods of assessments employed. The quality of this evidence was poor due to lack of theoretical underpinning, with most assessments not part of normal process, but rather produced as a specific outcome measure for a teaching-based study. While the current literature forms a good starting position for educators developing materials, there is a need for future work to address these weaknesses as such tools are required across health education.

This article was migrated. The article was marked as recommended. Poor standards of handover threaten patient safety and continuity of care, contributing significantly to morbidity and mortality. Handover practices has risen to the forefront of the patient safety agenda, with a call to develop and implement undergraduate handover modules into undergraduate healthcare education. Recent systematic reviews demonstrate a common failure of educational interventions to demonstrate a theoretical and pedagogical framework underpinning the delivery of education and method of assessment. The authors developed and piloted a multi-disciplinary evidence-based undergraduate handover training program to health care students studying at a UK university. The intervention was designed based on underpinning educational theories. It has been developed in a manner that supports dissemination and replication, with a model that is cost effective. The intervention was designed to assess learner reaction, attitudes and confidence, and knowledge and skills. This was achieved through a pre- and post-intervention attitude questionnaire, and an externally validated pre- and post-intervention knowledge assessment. 46 undergraduate students participated, with a statistically significant increase in self-reported attitudes (p < 0.001) and knowledge (p < 0.001) following the handover intervention. Students participated from the disciplines of medicine, adult nursing, pharmacy, mental health nursing, paramedic practice and operating department practioners. This intervention serves as a significant resource for those looking to develop local interventions and stands as a truly multi-disciplinary approach to handover education, mirroring the clinical reality. The introduction of this handover intervention immediately improves the attitudes, knowledge and skills of undergraduate healthcare students. Future work should sample beyond the selected 6 professions, investigating the transference of outcomes to the workplace, as well as the impact on patient safety., (Copyright: © 2019 Gordon M et al.)

Objective: The purpose of this study was to compare perioperative and mortality outcomes of endovascular aortic repair against open repair in acute type B thoracic aortic dissection., Methods: A comprehensive search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all published data comparing open vs endovascular repair in management of acute type B aortic dissection. Databases where evaluated and assessed to July 2017. The 95% confidence intervals were analyzed from the extracted data using relevant statistical methods., Results: Overall, 18,193 patients were found in a combination of nine studies. Patients undergoing open repair were younger (mean, 61.3 ± 9.3 years vs 66.6 ± 12.5 years; P < .00001). Postoperative stroke and paraplegia were similar in both groups (P = .71 and P = .81 respectively); however, the rate of all neurologic complications were more common in the traditional open repair group (6.9% vs 4.8%; P = .006). The all-cause operative and 1-year death was reported as higher in the open repair group (18.6% vs 7.4% [P < .0001] and 24.3% vs 14.3% [P < .0001], respectively); however, at 5 years this rate is almost similar between both groups (46.7% vs 49.7%; P = .21). At 1 year, the rate of reintervention was reported to be higher in endovascular repair group of patients (15.4% vs 5.5%; P = .004)., Conclusions: This study concludes that endovascular repair, in the setting of acute type B thoracic aortic dissection, provides an early surgical benefit; however, this finding has not yet been supported by long-term data. There seems to be a benefit with respect to all-neurologic events in favor of endovascular repair. Long-term comparative data and studies are required to give a better understanding of these two approaches., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: In patients undergoing cardiac surgery, is postoperative music therapy effective in reducing pain and anxiety? Altogether, 153 papers were found using the reported search method, of which 7 represented the best evidence to answer the clinical question. Six of the included studies were randomized trials, with 1 further non-randomized trial. The specific music protocols utilized widely varied, ranging from 1 short session on day 1 postoperatively to multiple sessions per day over a 72-h period. Most therapies involved music of a relaxing type, typically between 50 and 60 dB. All 7 studies reported on pain, with 4 demonstrating significant differences in pain score; however, 3 of these were not associated with reduction in analgesia requirements. Five studies reported on anxiety, with 2 demonstrating a statistically significant improvement in levels of anxiety. These results need to be contextualized by the small number of participants within each study and the heterogeneity in the therapy protocols utilized. The current best available evidence fails to support the benefits of music therapy as an effective non-pharmacological option in reducing pain and anxiety following open-heart surgery. While there is scarce evidence demonstrating efficacy, the current literature contains very small-sample-sized studies in utilizing music therapy protocols which in turn have wide range of variability in terms of duration, frequency, timing in the postoperative period and specific choice of music utilized in each protocol., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, 'In patients undergoing cardiac surgery, is postoperative massage therapy effective in reducing pain, anxiety and physiological parameters?' Altogether, 287 papers were found using the reported search, of which 7 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and the results of these papers are tabulated. The specific therapy protocols widely varied between studies, with differences in frequency, specific timing in the postoperative period, techniques used and experience of therapy provider. These variations limit the generalization and transferability of the conclusions. The effect of massage therapy on anxiety levels was reported in 5 studies. All but one demonstrated a significant improvement in anxiety. Pain was also reported in 5 studies, with significant improvement demonstrated in 4 studies. Importantly, a number of these studies failed to report on analgesic requirements nor demonstrate a reduction in opioid requirements, thus limiting the validity of the drawn conclusions. There is significant heterogeneity in randomized trials reporting on the effects of massage therapy. Although there is evidence to suggest that massage therapy reduces pain and anxiety following cardiac surgery, there are often caveats to the conclusions drawn with other studies reporting no significant difference. Therefore, in light of this, it would not be logical to recommend massage therapy as an effective therapy. There is no current evidence to suggest that massage therapy improves physiological parameters, including the onset of atrial fibrillation postoperatively., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The incidence of oral cancer is increasing. Guidance for oral cancer from the National Institute for Health and Care Excellence (NICE) is unique in recommending cross-primary care referral from GPs to dentists., Aim: This review investigates knowledge about delays in the diagnosis of symptomatic oral squamous cell carcinoma (OSCC) in primary care., Design and Setting: An independent multi-investigator literature search strategy and an analysis of study methodologies using a modified data extraction tool based on Aarhus checklist criteria relevant to primary care., Method: The authors conducted a focused systematic review involving document retrieval from five databases up to March 2018. Included were studies looking at OSCC diagnosis from when patients first accessed primary care up to referral, including length of delay and stage of disease at time of definitive diagnosis., Results: From 538 records, 16 articles were eligible for full-text review. In the UK, more than 55% of patients with OSCC were referred by their GP, and 44% by their dentist. Rates of prescribing between dentists and GPs were similar, and both had similar delays in referral, though one study found greater delays attributed to dentists as they had undertaken dental procedures. On average, patients had two to three consultations before referral. Less than 50% of studies described the primary care aspect of referral in detail. There was no information on inter-GP-dentist referrals., Conclusion: There is a need for primary care studies on OSCC diagnosis. There was no evidence that GPs performed less well than dentists, which calls into question the NICE cancer option to refer to dentists, particularly in the absence of robust auditable pathways., (© British Journal of General Practice 2019.)

Background: Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are a major development in the prevention of cardiovascular disease (CVD) and is one of the most significant discoveries since the development of statin therapy. Administration of two human monoclonal antibodies to PCSK9 (alirocumab and evolocumab) can significantly reduce low-density lipoprotein cholesterol (LDL-c) concentrations, thus improving lipid management. Accordingly, guidelines on the specific indications for alirocumab and evolocumab usage have been released. This multicentre study aimed to estimate the proportion of patients treated for an acute myocardial infarction (MI) who could be considered for PCSK9 inhibitors under the current National Institute for Health and Care Excellence (NICE) lipid targets criteria., Methods: The records of 596 patients in two large hospitals in Liverpool, UK were analysed. Information was collected on lipid profiles during and after admission, lipid-lowering therapy and previous CVD., Results: At least 2.2% of patients were eligible for PCSK9 inhibitors post-MI under the current NICE guidance. Additionally, 29% of patients failed to achieve LDL-c concentrations <2.0 mmol/L despite maximum statin therapy and failed to meet eligibility for PCSK9 inhibitors as per the NICE criteria. This cohort represents a group of patients 'in limbo', in which statin therapy alone is not sufficient to reduce LDL-c., Conclusions: PCSK9 inhibitors are expensive and so their use must be highly selective. At present, in a real-world setting with ezetimibe underprescribing, ~2% of patients are eligible and a further 30% are deprived of benefit and improved outcomes by lack of optimisation and/or potential use of PCSK9 inhibitors., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Intraventricular conduction abnormalities following cardiac surgery have been thoroughly described, especially after valvular surgery. It is also widely known that several anesthetic factors can cause autonomic disturbances resulting in the unmasking of sinus node dysfunction, significant bradycardia, and cardiovascular collapse during the intraoperative period. However, little is known about asymptomatic episodes, especially those occurring prior to coronary artery bypass grafting (CABG). We report a rare occurrence of an intraventricular conduction defect that presented in an asymptomatic patient following non-ST-elevation myocardial infarction prior to urgent CABG. Our patient presented with sudden-onset chest pain, and following coronary angiography he was found to have triple-vessel coronary disease. During anesthetic induction for inpatient CABG surgery, he developed episodes of acute sinus tachy-brady episodes, requiring a stat dose of adrenaline to maintain the heart rate prior to the establishment of cardiopulmonary bypass. The arrhythmia persisted postoperatively, necessitating the insertion of a permanent dual-chamber pacemaker for complete heart block. The patient was later discharged without further complications, and upon follow-up 12 months later, he remains in good health.