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One patient required surgical pericardioplasty. The remaining seven patients had a median follow-up of 17.3 months (5-144.9 months) and all remained asymptomatic. Conclusion CPDs are more likely to be partial on the left side and patients often have RV dilation on the TTE and levocardia on CMR. Most patients remain stable and do not require surgical intervention. TTE and CMR play an important role in making the diagnosis of this anomaly. © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Background It is still uncertain whether coronary bifurcations with lesions involving a large side branch (SB) should be treated by stenting the main vessel and provisional stenting of the SB (simple) or by routine two-stent techniques (complex). We aimed to compare clinical outcome after treatment of lesions in large bifurcations by simple or complex stent implantation. Methods The study was a randomised, superiority trial. Enrolment required a SB≥2.75 mm, ≥50% diameter stenosis in both vessels, and allowed SB lesion length up to 15 mm. The primary endpoint was a composite of cardiac death, non-procedural myocardial infarction and target lesion revascularisation at 6 months. Two-year clinical follow-up was included in this primary reporting due to lower than expected event rates. Results A total of 450 patients were assigned to simple stenting (n=221) or complex stenting (n=229) in 14 Nordic and Baltic centres. Two-year follow-up was available in 218 (98.6%) and 228 (99.5%) patients, respectively. The primary endpoint of major adverse cardiac events (MACE) at 6 months was 5.5% vs 2.2% (risk differences 3.2%, 95% CI -0.2 to 6.8, p=0.07) and at 2 years 12.9% vs 8.4% (HR 0.63, 95% CI 0.35 to 1.13, p=0.12) after simple versus complex treatment. In the subgroup treated by newer generation drug-eluting stents, MACE was 12.0% vs 5.6% (HR 0.45, 95% CI 0.17 to 1.17, p=0.10) after simple versus complex treatment. Conclusion In the treatment of bifurcation lesions involving a large SB with ostial stenosis, routine two-stent techniques did not improve outcome significantly compared with treatment by the simpler main vessel stenting technique after 2 years. Trial registration number NCT01496638. © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Aim In Japan, the number of facilities introducing a rapid response system (RRS) has been increasing. However, many institutions have had unsuccessful implementations. In order to implement RRS smoothly, a plan that meets the needs of each hospital is needed. Methods Rapid response system teams from each hospital, including a physician and staff in charge of medical safety, from the RRS online registry were invited to attend a workshop. The workshop aimed to develop and implement RRS. The course curriculum was based on the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) developed in the USA. Participating facilities were required to formulate an RRS introduction plan referring to Kotter's 8-step change model to overcome barriers in the implementation of RRS. The change in medical emergency team activations comparing the intervention and control group hospitals was compared. Results Sixteen institutions were eligible for this study. After participating in the workshop, there was a tendency toward more frequent activation of medical emergency teams in the intervention group (P = 0.075). According to a self-evaluation from each facility, there is great difficulty in overcoming the 5th step of Kotter's model (empower people to act the vision). this website Conclusion This step-by-step evaluation clearly identified a problem with implementation and provided measures for resolution corresponding to each facility. There was a major barrier to overcome the 5th step of Kotter's model in leading change, which represents the attitude toward implementing RRS in institutions. © 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.Aim To describe the epidemiology of patients on extracorporeal membrane oxygenation (ECMO) and investigate the possible association between outcomes for respiratory ECMO patients and hospital volume of ECMO treatment for any indications. Methods Using data from the Diagnosis Procedure Combination database, a nationwide Japanese inpatient database, between 1 July 2010 and 31 March 2018, we identified inpatients aged ≥18 years who underwent ECMO. Institutional case volume was defined as the mean annual number of ECMO cases; eligible patients were categorized into institutional case volume tertile groups. The primary outcome was in-hospital mortality. For ECMO patients with respiratory failure, the association between institutional case volume group and in-hospital mortality rate was analyzed using a multilevel logistic regression model including multiple imputation. Results Extracorporeal membrane oxygenation was carried out on 25,384 patients during the study period; of those, 1,227 cases were for respiratory failure. Respiratory cases were categorized into low- ( less then 8 cases/year), medium- (8-16 cases/year), and high-volume groups (≥17 cases/year). The overall in-hospital mortality rate for respiratory ECMO was 62.5% in low-, 54.7% in medium-, and 50.4% in high-volume institutions. With reference to low-volume institutions, the adjusted odds ratios (95% confidence interval) of the medium- and high-volume institutions for in-hospital mortality were 0.72 (0.50-1.04; P = 0.082) and 0.65 (0.45-0.95; P = 0.024), respectively. Conclusions The present study showed that accumulating the experience of using ECMO for any indications could positively affect the outcome of ECMO treatment for respiratory failure, which suggests the effectiveness of consolidating ECMO cases in high-volume centers in Japan. © 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.