A permanent pacemaker is a mainstay treatment for symptomatic bradyarrhythmia, including atrioventricular node blocks and sick sinus syndrome. Although this device was introduced to aid electrical recovery, pacemakers can cause mechanical dysfunction of the tricuspid valve, resulting in significant tricuspid regurgitation (TR). Because pacemaker-related TR is a correctable cause of right heart failure, it is of paramount importance to assess the presence or severity of TR and its association with pacemakers. However, acoustic shadowing from the pacemaker wire hampers the accurate visualization of TR jets, and increases the risk of failing to detect severe TR. Accordingly, goal-directed imaging with a high index of clinical suspicion should be performed when patients present with right heart failure after pacemaker implantation. In this issue of the Journal, the authors sought to investigate the frequency of aggravated TR in patients after pacemaker implantation. They also explored the predictors of TR aggravation, which might provide valuable information for identification of patients who require meticulous follow-up to allow timely intervention. These data regarding the predictive variables for pacemaker-related TR can serve as a roadmap for future studies to identify strategies for reducing the risk of significant TR, such as a tailored approach based on heart rhythm (bradyarrhythmia only vs. combined atrial fibrillation), pacemaker mode (VVI vs. DDD), the location of the pacemaker lead (apical vs. base), and the use of state-of-the art techniques (classical lead vs. leadless).
Acoustics ; Atrioventricular Node ; Bradycardia ; Follow-Up Studies ; Heart ; Heart Failure ; Humans ; Shadowing (Histology) ; Sick Sinus Syndrome ; Tricuspid Valve ; Tricuspid Valve Insufficiency*

No abstract available.
Atherosclerosis* ; Carotid Arteries* ; Coronary Artery Disease* ; Coronary Vessels* ; Risk Assessment*

PURPOSE: Team-based learning (TBL) is increasingly employed in medical education because of its potential to promote active group learning. In TBL, learners are usually asked to assess the contributions of peers within their group to ensure accountability. The purpose of this study is to assess the validity and reliability of a peer evaluation instrument that was used in TBL classes in a single medical school. METHODS: A total of 141 students were divided into 18 groups in 11 TBL classes. The students were asked to evaluate their peers in the group based on evaluation criteria that were provided to them. We analyzed the comments that were written for the highest and lowest achievers to assess the validity of the peer evaluation instrument. The reliability of the instrument was assessed by examining the agreement among peer ratings within each group of students via intraclass correlation coefficient (ICC) analysis. RESULTS: Most of the students provided reasonable and understandable comments for the high and low achievers within their group, and most of those comments were compatible with the evaluation criteria. The average ICC of each group ranged from 0.390 to 0.863, and the overall average was 0.659. There was no significant difference in inter-rater reliability according to the number of members in the group or the timing of the evaluation within the course. CONCLUSION: The peer evaluation instrument that was used in the TBL classes was valid and reliable. Providing evaluation criteria and rules seemed to improve the validity and reliability of the instrument.
Education, Medical ; Humans ; Learning* ; Methods* ; Reproducibility of Results* ; Schools, Medical ; Social Responsibility

The longitudinal integrated clerkship is an innovative approach in medical education that emphasizes continuity as a key principle to provide student-centered experiences and learning. Seoul National University College of Medicine decided to adapt longitudinal integrated clerkships to the new curriculum beginning in 2018, and therefore conducted pilot studies in 2016 and 2017. This study aimed to analyze the program evaluation results of the two pilot programs and discuss issues related to the successful implementation of longitudinal integrated clerkships in Korea. We conducted a focus group interview with nine students who participated in the 2016 pilot program and 13 students who participated in the 2017 pilot program. We also conducted a focus group interview with 11 faculty members who either participated in the pilot program or will participate in the main program. From the 2016 experience, we found that it is not appropriate to assign each patient to a single student and let the students contact their patients personally for feasibility and safety reasons. In the 2017 pilot program, we assigned each patient to a group of students, which made it more feasible for the students to follow-up with their patients. The students were satisfied with their new experience of longitudinal patient follow-up and regular meetings in the pilot program. Faculty emphasized the importance of establishing the course objectives and holding an orientation for the students and the faculty. Further study is planned to evaluate the early outcomes of the main longitudinal integrated clerkship.
Curriculum ; Education, Medical ; Focus Groups ; Follow-Up Studies ; Humans ; Korea ; Learning ; Linear Energy Transfer ; Pilot Projects ; Program Evaluation ; Seoul

OBJECTIVE: To investigate the diagnostic validity of coronary computed tomography angiography (cCTA) in vasospastic angina (VA) and factors associated with discrepant results between invasive coronary angiography with the ergonovine provocation test (iCAG-EPT) and cCTA. MATERIALS AND METHODS: Of the 1397 patients diagnosed with VA from 2006 to 2016, 33 patients (75 lesions) with available cCTA data from within 6 months before iCAG-EPT were included. The severity of spasm (% diameter stenosis [%DS]) on iCAG-EPT and cCTA was assessed, and the difference in %DS (Δ%DS) was calculated. Δ%DS was compared after classifying the lesions according to pre-cCTA-administered sublingual nitroglycerin (SL-NG) or beta-blockers. The lesions were further categorized with %DS ≥ 50% on iCAG-EPT or cCTA defined as a significant spasm, and the diagnostic performance of cCTA on identifying significant spasm relative to iCAG-EPT was assessed. RESULTS: Compared to lesions without SL-NG treatment, those with SL-NG treatment showed a higher Δ%DS (39.2% vs. 22.1%, p = 0.002). However, there was no difference in Δ%DS with or without beta-blocker treatment (35.1% vs. 32.6%, p = 0.643). The significant difference in Δ%DS associated with SL-NG was more prominent in patients who were aged < 60 years, were male, had body mass index < 25 kg/m2, and had no history of hypertension, diabetes, or dyslipidemia. Based on iCAG-EPT as the reference, the per-lesion-based sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cCTA for VA diagnosis were 7.5%, 94.0%, 60.0%, 47.1%, and 48.0%, respectively. CONCLUSION: For patients with clinically suspected VA, confirmation with iCAG-EPT needs to be considered without completely excluding the diagnosis of VA simply based on cCTA results, although further prospective studies are required for confirmation.
Angina Pectoris, Variant ; Angiography ; Body Mass Index ; Constriction, Pathologic ; Coronary Angiography ; Diagnosis ; Dyslipidemias ; Ergonovine ; Humans ; Hypertension ; Male ; Nitroglycerin ; Prospective Studies ; Sensitivity and Specificity ; Spasm

Background and Objectives: Few studies have addressed the predictive implications of right ventricular (RV) and pulmonary arterial (PA) coupling as assessed by echocardiography in patients with acute heart failure (AHF). This study aimed to ascertain the prognostic importance of RV-PA coupling in AHF cases and discern any divergence in its prognostic efficacy based on different heart failure (HF) phenotypes. Methods: We evaluated RV-PA coupling by measuring the ratio of right ventricular global longitudinal strain (RVGLS) to pulmonary arterial systolic pressure (PASP), termed the RVGLS/PASP ratio, and assessed its prognostic role using the STrain for Risk Assessment and Therapeutic Strategies in Patients with Acute Heart Failure registry. Results: From an AHF registry of 4312 patients, we analyzed the RVGLS/PASP ratio in 2,865 patients (1,449 men; age, 71.1±13.5 years). At a median follow-up of 35.0 months, 1,199 (41.8%) patients died. Remarkably, PASP (hazard ratio [HR], 1.012; p<0.001), RVGLS (HR, 1.019;p<0.001), and the RVGLS/PASP ratio (HR, 2.426; p<0.001) were statistically significant predictors of all-cause mortality in the univariate analysis. The RVGLS/PASP ratio was a significant predictor of all-cause mortality in all the HF phenotypes, including HF with reduced ejection fraction (HR, 2.124; p=0.002), HF with mildly reduced ejection fraction (HR, 2.733; p=0.021), and HF with preserved ejection fraction (HR, 2.134; p=0.006). Multivariate analysis after adjusting for clinical and echocardiographic variables revealed that the RVGLS/PASP ratio ≤0.32 was associated with a 36% increase in all-cause mortality (HR, 1.365; p<0.001). Conclusions Impaired RV-PA coupling, defined as an RVGLS/PASP ratio (≤0.32) was associated with an increased risk of mortality in patients with AHF across all HF phenotypes.

BACKGROUND: It is critical to develop remedial education for underperforming medical students, but little is known about how to create an effective remediation program. Deliberate practice (DP) is a structured and reflective activity that is designed to optimize performance. Here we applied the concept of DP to create remedial education to improve the clinical practices of medical students. We also analyzed the effectiveness of the remediation program. METHODS: Based on the expert performance approach of DP, we designed a 4-week remedial program for clinical performance that included feedback and reflection. There were 74 student participants in this program from 2014 to 2017. Their clinical performance was re-evaluated after completion, and changes in their clinical performance scores were analyzed. RESULTS: Students who completed the remediation program showed significant improvements in clinical performance scores (P < 0.001). Most students found the program to be instructive and helpful for improving their clinical performance. They reported that role play with peers was the most helpful for improving their skills. CONCLUSION: The DP-based remediation program improved the clinical performance of failing medical students. This remediation program should continue to be offered to underperforming students to ensure that medical school graduates are competent.
Clinical Competence ; Education ; Education, Medical ; Humans ; Longitudinal Studies ; Prospective Studies ; Schools, Medical ; Students, Medical

Purpose: Longitudinal integrated clerkships (LICs) have been introduced in medical schools, as learning relationships with clinical faculty or peers are important components of medical education. The purpose of this study was to investigate the characteristics of student-faculty and student-student interactions in the LIC and to identify other factors related to whether students understood and acquired the program’s main outcomes. Methods: The study was conducted among the 149 third-year students who participated in the LIC in 2019. We divided the students into groups of eight. These groups were organized into corresponding discussion classes, during which students had discussions with clinical faculty members and peers and received feedback. Clinical faculty members and students were matched through an e-portfolio, where records were approved and feedback was given. A course evaluation questionnaire was completed and analysed. Results: A total of 144 valid questionnaires were returned. Logistic regression analysis showed that relevant feedback in discussion classes (adjusted odds ratio [AOR], 5.071; p<0.001), frequency of e-portfolio feedback (AOR, 1.813; p=0.012), and motivation by e-portfolio feedback (AOR, 1.790; p=0.026) predicted a greater likelihood of understanding the continuity of the patient’s medical experience. Relevant feedback from faculty members in discussion classes (AOR, 3.455; p<0.001) and frequency of e-portfolio feedback (AOR, 2.232; p<0.001) also predicted a greater likelihood of understanding the concept of patient-centered care. Conclusion Student-faculty interactions, including relevant feedback in discusstion classes, frequency of e-portfolio feedback, and motivation by e-portfolio feedback were found to be important factors in the LIC program.