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Analysis of the 2010/11 Longitudinal Destinations of Leavers from Higher Education survey shows that overly-simplistic conceptions of graduate success underestimate the value of obtaining a degree in some subjects. Using a skills-based classification of graduate jobs the research finds that maths and vocationally-oriented subjects associated with higher earnings returns (Belfield et al., 2018a, 2018b) – engineering, architecture, computer science and nursing – increase the chances of having an 'Expert' job compared to the average for all graduates. However, more generalist subjects that have been linked with lower earnings such as creative arts, languages and mass communication and documentation are better for accessing graduate jobs where creativity and ability to communicate is key. The research demonstrates the value of using a more nuanced conception of graduate jobs and shows that debate about the value of higher education needs to move away from a narrow focus on earnings. [ABSTRACT FROM AUTHOR]

Left bundle branch block (LBBB) causes immediate electrical and mechanical dyssynchrony of the left ventricle (LV) and gradual structural damages in the Purkinje cells and myocardium. Mechanical dyssynchrony reduces the LV ejection fraction (EF) instantly, but only to ≈55% in an otherwise normal heart. Because of the heart's in-built functional redundancy, a patient with LBBB does not always notice the heart's reduced efficiency straightaway. After a variable period of time (which could be from days to decades), the patient may become symptomatic with heart failure (HF), which classifies as HF with preserved EF ≥50% (HFpEF). The LVEF drops further because of continuous adverse remodeling and inefficient cardiac contraction. The patient transits to HF with moderately reduced EF 35%-50% (HFmrEF) and then reduced EF ≤35% (HFrEF) over 5-21 years. Cardiac resynchronization therapy (CRT) is currently only indicated in guidelines for HFrEF and LBBB. LBBB shortens the median survival of patients with HFmrEF by 5.5 years. Randomized controlled trials have shown that CRT improves echocardiographic indices for HFmrEF with LBBB. CRT in HFpEF with LBBB is a promising but underexplored/underused therapy. There have been anecdotal reports that CRT produced symptom relief in patients debilitated by HFpEF with LBBB, who constitute ≈6% of all patients with HF and an adequate pool of potential randomized controlled trial participants. Conduction system pacing in the form of left bundle branch area pacing is an emerging pacing strategy that might reverse and forestall the deleterious effects of LBBB., Competing Interests: Disclosures Open access publishing for this article was supported through a transformative agreement between the DEAL Consortium and Elsevier., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

The placement of cardiovascular implantable electronic devices (CIED) comes with a risk of adverse events (AE). AE comprise complications associated with the procedure and the device. CIED infection is a severe AE. Reported CIED infection rates are regionally differing and publications of contemporary large cohort data regarding CIED infections for Germany are lacking. This investigation provides rates of CIED infection related hospital admission and CIED infection related mortality in Germany. Data from Germany's largest healthcare insurance fund was screened for CIED procedures during the period: January to December 2015. These data included placement, revision with aim to up- or downgrade, generator substitution, early revision and partial or complete extraction using specific procedure codes for reimbursement. Among the total population of beneficiaries undergoing CIED procedures, International Classification of Diseases codes (ICD 10 GM), operational and procedural codes for partial or complete hardware removal were used to identify CIED infections and lead related endocarditis. To report the corresponding mortality rates, the hospital discharge status was documented. In 2015, from a population of more than 27 million beneficiaries, we identified the cohort of 60,296 patients (57.3% male) who underwent any invasive CIED procedure. Within three months from the index procedure, 1,595 patients developed a major CIED infection. 1,129 (1.87%) were related to the generator pocket and 466 (0.8%) were related to the transvenous proportions of the leads, mortality after those infections was 8.4% and 15.24%, respectively. In summary, our data reveals a higher prevalence of acute CIED infection than previously noted. The elevated number of additional procedures in cases of CIED infection implies a deficiency in infection awareness., Competing Interests: Declarations. Competing interests: BB currently holds or held the following positions during the last three years - medical consultant/ part of the advisory board of: Abbott, BiolineSupply, Boston Scientific, CRM Microport, CrosstecGmbH, DrugsalesLtd., Implicity, Kappamed, KimalPLC, M3 Medical/EcclipseMedical, Medival SRL, Medtronic, Philips/Spectranetics, SintecSRL, Tauro-ImplantGmbH, Tauropharm GmbH, Transcutan The other authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Infection is a significant complication of cardiac implantable electronic device (CIED) therapy. The European TauroPace™ Registry investigates the safety and efficacy of TauroPace™ (TP), an antimicrobial solution containing taurolidine, designed to prevent CIED infections., Methods: This multicenter study included patients undergoing CIED procedures at participating centers where TP was used as a disinfectant for external hardware surfaces and an antiseptic for irrigating surgical sites. All patients eligible for CIED placement with adjunctive TP as the standard of care were included. Other aspects of CIED procedures adhered to current guidelines. Data on CIED-related infective endocarditis, CIED pocket infection, device and procedure-related complications, adverse events, and all-cause mortality were prospectively collected for 12 months. In cases of revision, the previous procedure was censored, and a new procedure was created. Binomial and Kaplan-Meier statistics were employed to analyze event rates., Results: From January 2020 to November 2022, TP was used in 822 out of 1170 CIED procedures. Among patients who completed the 3-month follow-up, no CIED pocket infections were observed, and one case of CIED-related infective endocarditis was reported. In the 12-month follow-up cohort, two additional local pocket CIED infections were observed, resulting in a total of three major CIED infections within 1 year after the CIED placement procedure. The 3-month and 12-month major CIED infection rates were 0.125% and 0.51%, respectively. During the observation a complication rate of 4.4% was reported. No adverse events related to TP were observed., Conclusions: TP appears to be effective and safe in preventing CIED infections., Clinicaltrials: gov Identifier: NCT04735666., (© 2024. The Author(s).)

Introduction: Cardiac implantable electronic device (CIED) complications present significant challenges in clinical practice, especially in elderly patients with multiple comorbidities. Common adverse events include infection, lead malfunction, and device migration. Twiddler's Syndrome, a rare but serious CIED complication characterised by patient manipulation causing lead displacement and device malfunction, is often underreported. The literature consists mainly of case reports and small series, providing limited guidance on prevention and management. As CIEDs are critical for managing cardiac arrhythmias and heart failure, understanding and addressing Twiddler's Syndrome is essential. This case report aims to contribute to the literature by detailing a case of Twiddler's Syndrome, emphasising the importance of a multidisciplinary approach for optimal management., Case Presentation: A 59-year-old male presented with discomfort around his implantable cardioverter defibrillator (ICD) site and the sternal area over the past two days. He denied pain, dyspnoea, or dizziness. Clinical examination revealed a normal heart rhythm and no peripheral pulse deficit. Ultrasound revealed a reduced left ventricular ejection fraction. The atrial lead was not visible, and the shock coil was misplaced. ICD interrogation showed inappropriate shocks due to sensing artifacts and exit block in both leads, with no arrhythmias detected. An X-ray confirmed lead dislodgement and significant entanglement in the pocket. The patient was diagnosed with Twiddler's Syndrome and scheduled for surgical revision., Discussion/conclusions: Dilated cardiomyopathy (DCM), characterised by left ventricular dilatation and dysfunction, accounts for a significant proportion of systolic heart failure cases. Despite advancements in heart failure management, DCM patients remain at high risk for sudden cardiac death (SCD), making ICD implantation crucial. However, CIED placement carries risks of complications, including Twiddler's Syndrome. This condition can lead to lead dislodgement and device malfunction, resulting in inappropriate shocks and potential patient harm. In this case, a single-session extraction and re-implantation were successfully performed using a multidisciplinary approach, emphasising the importance of comprehensive management strategies to address such complications effectively. Regular follow-up showed no adverse events, highlighting the procedure's success and the potential benefits of using advanced antimicrobial adjuncts to prevent infections. This case underscores the need for awareness and standardised protocols for managing Twiddler's Syndrome to improve patient outcomes in the growing population of CIED recipients., (© 2024. The Author(s).)

Competing Interests: Benito Baldauf: Medical consultant/part of the advisory board: Abbott, Bioline Supply, Biotronik, Cablon NL, CRM Microport, Crosstec GmbH, Drugsales Limited, Kappamed, Kimal PLC, M3 Medical/Ecclipse Medical, Medival SRL, Medtronic, Philips/Spectranetics, Sintec SRL, Tauro-Implant GmbH, Tauropharm GmbH, Transcutan. The other authors have nothing to declare.

Aims: TauroPace (Tauropharm, Bavaria Germany), a taurolidine solution for combating cardiac implantable electronic device (CIED) infection, was compared with a historical control of 3% hydrogen peroxide (H2O2) in a prospective observational study., Methods and Results: The device pocket was irrigated, and all hardware accessible within (leads, suture sleeves, pulse generator) was wiped with H2O2, TauroPace, or taurolidine in a galenic formulation during any invasive CIED procedure at the study centre. Only CIED procedures covered by TauroPace or H2O2 from 1 January 2017 to 28 February 2022 were included for analysis. Patients who underwent >1 procedure were censored for the last treatment group and reassigned at the next procedure. The primary endpoint was major CIED infection within 3 months. The secondary endpoints were CIED infection beyond 3 months, adverse events potentially related to the antimicrobial solutions, CIED system, procedure, and death, till the end of follow-up. TauroPace covered 654 procedures on 631 patients, and H2O2 covered 551 procedures on 532 patients. The TauroPace group had more patient risk factors for infection than the H2O2 group (P = 0.0058) but similar device and procedure-specific risk factors (P = 0.17). Cardiac implantable electronic device infection occurred in 0/654 (0%) of the TauroPace group and 6/551 (1.1%) of the H2O2 group (P = 0.0075). Death occurred in 23/654 (3.5%) of the TauroPace group and 14/551 (2.5%) of the H2O2 group (P = 0.33). Non-infection related adverse events were rarer in the TauroPace (3.8%) than the H2O2 (6.0%) group (P = 0.0802)., Conclusion: TauroPace is safe but more effective than H2O2 in reducing CIED infection., Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT05576194., Competing Interests: Conflict of interest: B.B.: consultant/advisor: Abbott, Bioline Supply, Crosstec GmbH, Kapamed, Kimal PLC, M3 Medical/Ecclipse Medical, Medival SRL, Philips/Spectranetics, Sintec SRL, Tauro-Implant GmbH, Tauropharm GmbH, Transcutan; the other authors declare no conflict of interest in relation to this manuscript., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Cardiac implantable electronic device (CIED) placement comes with certain complications. CIED infection is a severe adverse event related to CIED placement. In randomised controlled trials, the preoperative intravenous administration of antibiotics and the adjunctive use of an antibiotic mesh envelope resulted in significant reduction in infections related to cardiac implantable electronic devices. The adjunctive use of taurolidine for this purpose is relatively novel and not considered in the guidelines. The required evidence may consist of a set of clinical studies., Methods: The European TauroPace TM registry (ETPR) prospectively evaluates every consecutive invasive procedure involving any CIED with adjunct TauroPace™ use in the contributing centres. As the estimation of the infection rate needs to be defensible, only interventions registered prior to the procedure will be followed-up. The endpoint is a major cardiac implantable electronic device infection according to the novel CIED infection criteria (1). Secondary endpoints comprise all-cause mortality, complications, adverse events of all grades, and major CIED infections during all follow-up examinations. The follow-up times are three months, twelve months, and eventually 36 months, as acute, subacute, and long-term CIED infections are of interest., Results: As the rate of CIED infections is expected to be very low, this registry is a multicentre, international project that will run for several years. Several reports are planned. The analyses will be included in the case number calculations for future randomised controlled trials., Conclusions: The ETPR will accumulate large case numbers to estimate small event rates more precisely; we intend to follow up on participants for years to reveal possible late effects.

We report the successful salvage of cardiac implantable electronic device pulse generator protrusion sealed by the surrounding skin in a frail patient presenting 5 months after the last surgical revision. ( Level of Difficulty: Advanced. )., Competing Interests: Dr Baldauf is a medical consultant/advisor for the manufacturer of TauroPace. Dr Borov received a research grant through his employer in relation to another manuscript studying the impact of TauroPace in rhythm surgery. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Ethical review and approval were waived for this case. According to the current Italian version of the Italian Data Protection Authority article 110 paragraph 1 and European Union General Data Protection Regulation recital 26, the principles of data protection do not apply. Written informed consent has been obtained from the patient to publish this paper., (© 2023 The Authors.)

We reported the novel use of a taurolidine-containing antimicrobial solution in the successful salvage of a partially exposed and polymicrobially infected cardiac implantable electronic device pulse generator in a frail patient unfit for lead extraction. The old, salvaged device was entirely internalized, and there were no signs of recurrent infection at 9 months follow-up.

Ventricular assist devices (VADs) are used to provide mechanical circulatory support to patients with end-stage heart failure. The driveline connecting the external power source to the pump(s) of the intra-corporal VAD breaches the protective skin barrier and provides a track for microbes to invade the interior of the patient's body. Driveline infection constitutes a major and potentially fatal vulnerability of VAD therapy. Driveline infection cannot traditionally be salvaged and requires the extraction of the entire VAD system. We report here the successful eradication of a VAD driveline infection with a taurolidine-containing antimicrobial solution used for preventing the infection of cardiac implantable electronic devices. If replicated in more cases, the novel treatment concept described here may provide a valuable alternative management strategy of salvage rather than explantation for VAD driveline infection.

(1) Background: The athlete's heart may develop permanent vessel enlargement. The purpose of our study was to define normal values for coronary artery dimensions of endurance athletes by coronary computed tomography angiography (CTA). (2) Methods: Ninety-eight individuals (56.2 ± 11 years) were included into this retrospective matched case-controlled-study. Endurance athletes had regular training volumes of ≥1 h per unit, ≥3-7 times per week (either cycling, running or mountain-endurance). Athletes were matched for age and gender with sedentary controls using propensity score. Quantitative CTA analysis included coronary vessel dimensions (two diameters and area) of the LM, LAD, CX and RCA for all AHA-16-segments. (3) Results: Proximal LAD area and diameter ( p = 0.019); proximal/mid CX (diameter and area; p = 0.026 and p = 0.018/ p = 0.008 and p = 0.009); mid RCA diameter and area; and proximal RCA diameter were significantly larger in endurance athletes ( p < 0.05). The left main area ( p = 0.708) and diameter ( p = 0.809) as well as the mid LAD and distal segments were not different. We present the histograms and data for normal values ±1 and ± 2 SD. (4) Conclusions: Endurance athletes have larger proximal LAD, proximal/mid CX and RCA vessel dimensions, while LM and distal segments are similar. Hence, dilated coronary arteries in endurance athletes (" Athlete's arteries ") have to be distinguished from diffuse ectatic segments developing during Kawasaki disease or multisystemic inflammation syndrome after COVID-19.

Background: The aim was to assess the effect of endurance exercise on coronary vasodilatory capacity and atherosclerosis by coronary computed tomography angiography (CTA) and computational fluid dynamic (CFD) modelling., Methods: 100 subjects (age 56.2y±11, 29 females) who underwent coronary CTA were included into this retrospectively matched cohort study. Endurance athletes (≥1 h per unit and ≥3 times per week training) were compared to controls with a sedentary lifestyle, and within subgroups with and without sublingual nitroglycerin preparation. CTA image analysis included coronary stenosis severity (CADRADS), total (segment involvement score = SIS) and mixed plaque burden (G-score), high-risk plaque criteria, the coronary artery calcium score (CACS) and CFD analysis including Fractional Flow Reserve (FFR CT ), myocardial mass (M), total vessel lumen volume (V) and volume-to-mass (V/M) ratio., Results: The prevalence of atherosclerosis by CTA was 65.4 % and >50 % coronary stenosis was found in 17.3 % of athletes. Coronary stenosis severity (CADRADS), total and mixed non-calcified plaque burden (SIS and G-score) were lower in athletes (p = 0.003 and p < 0.001) but not CACS (p = 0.055) and less high-risk plaques were found (p < 0.001). The G-score was correlated with distal FFR CT (p = 0.025). V/M-ratio was different between athletes who received nitroglycerin compared with those who did not (V/M: 21.1 vs. 14.8; p < 0.001), but these differences were not observed in the control subjects., Conclusion: Endurance training improves coronary vasodilatory capacity and reduces high-risk plaque and mixed non-calcifed plaque burden as assessed by coronary CTA angiography. Our study may advocate coronary CTA with FFR CT for evaluation of coronary artery disease in endurance athletes., (Copyright © 2020. Published by Elsevier B.V.)

Newly qualified doctors spend much of their time with nurses, but little research has considered informal learning during that formative contact. This article reports findings from a multiple case study that explored what newly qualified doctors felt they learned from nurses in the workplace. Analysis of interviews conducted with UK doctors in their first year of practice identified four overarching themes: attitudes towards working with nurses, learning about roles, professional hierarchies and learning skills. Informal learning was found to contribute to the newly qualified doctors' knowledge of their own and others' roles. A dynamic hierarchy was identified: one in which a "pragmatic hierarchy" recognising nurses' expertise was superseded by a "normative structural hierarchy" that reinforced the notion of medical dominance. Alongside the implicit learning of roles, nurses contributed to the explicit learning of skills and captured doctors' errors, with implications for patient safety. The findings are discussed in relation to professional socialisation. Issues of power between the professions are also considered. It is concluded that increasing both medical and nursing professions' awareness of informal workplace learning may improve the efficiency of education in restricted working hours. A culture in which informal learning is embedded may also have benefits for patient safety.

Aim: This aim of this paper was to explore new doctors' preparedness for prescribing., Methods: This was a multiple methods study including face-to-face and telephone interviews, questionnaires and secondary data from a safe prescribing assessment (n= 284). Three medical schools with differing curricula and cohorts were included: Newcastle (systems-based, integrated curriculum); Warwick (graduate entry) and Glasgow [problem-based learning (PBL)], with graduates entering F1 in their local deanery. The primary sample consisted of final year medical students, stratified by academic quartile (n= 65) from each of the three UK medical schools. In addition an anonymous cohort questionnaire was distributed at each site (n= 480), triangulating interviews were conducted with 92 clinicians and questionnaire data were collected from 80 clinicians who had worked with F1s., Results: Data from the primary sample and cohort data highlighted that graduates entering F1 felt under-prepared for prescribing. However there was improvement over the F1 year through practical experience and support. Triangulating data reinforced the primary sample findings. Participants reported that learning in an applied setting would be helpful and increase confidence in prescribing. No clear differences were found in preparedness to prescribe between graduates of the three medical schools., Conclusion: The results form part of a larger study 'Are medical graduates fully prepared for practice?'. Prescribing was found to be the weakest area of practice in all sources of data. There is a need for more applied learning to develop skill-based, applied aspects of prescribing which would help to improve preparedness for prescribing., (© 2011 The Authors. British Journal of Clinical Pharmacology © 2011 The British Pharmacological Society.)

Background: Earlier research indicated that medical graduates feel unprepared to start work, and that this varies with medical school., Aims: To examine the extent to which graduates from different UK medical schools differed in their perceptions of preparedness for practice, and compare their perceptions with those of clinical team members., Method: An anonymous questionnaire assessing perceptions of 53 aspects of preparedness was devised, and administered to the graduating cohorts of three medical schools: Newcastle (systems-based, integrated curriculum); Warwick (graduate-entry) and Glasgow (problem-based learning). In addition, a triangulating questionnaire was cascaded via ward managers to doctors, nurses and pharmacists who worked with new graduates in their first posts., Results: The response rate for the cohort questionnaire was 69% (479/698). The overall mean preparedness score was 3.5 (on a five-point scale), with no significant difference between schools. On individual items, there were large differences within each site, but smaller differences between sites. Graduates felt most prepared for aspects of working with patients and colleagues, history taking and examination. They felt least prepared for completing a cremation form, some aspects of prescribing, complex practical procedures and for applying knowledge of alternative and complementary therapies, and of the NHS. A total of 80 clinical team questionnaires were completed, similarly showing substantial variation within each site, but smaller differences between sites., Conclusions: New doctors feel relatively unprepared for a number of aspects of practice, a perception shared by their colleagues. Although medical school has some effect on preparedness, greater differences are common across sites. Differences may reflect hidden influences common to all the schools, unintended consequences of national curriculum guidance or common traits in the graduate populations sampled. Further research is needed to identify the causes.