Azacytidine plus olaparib for relapsed acute myeloid leukaemia, ineligible for intensive chemotherapy, diagnosed with a synchronous malignancy.

Patients with relapsed/refractory acute myeloid leukaemia (AML), ineligible for intensive chemotherapy and allogeneic stem cell transplantation, have a dismal prognosis. For such cases, hypomethylating agents are a viable alternative, but with limited success. Combination chemotherapy using a hypomethylating agent plus another drug would potentially bring forward new alternatives. In the present manuscript, we present the cell and molecular background for a clinical scenario of a 44-year-old patient, diagnosed with high-grade serous ovarian carcinoma, diagnosed, and treated with a synchronous AML. Once the ovarian carcinoma relapsed, maintenance treatment with olaparib was initiated. Concomitantly, the bone marrow aspirate showed 30% myeloid blasts, consistent with a relapse of the underlying haematological disease. Azacytidine 75 mg/m2 treatment was started for seven days. The patient was administered two regimens of azacytidine monotherapy, additional to the olaparib-based maintenance therapy. After the second treatment, the patient presented with leucocytosis and 94% myeloid blasts on the bone marrow smear. Later, the patient unfortunately died. Following this clinical scenario, we reproduced in vitro the combination chemotherapy of azacytidine plus olaparib, to accurately assess the basic mechanisms of leukaemia progression, and resistance to treatment. Combination chemotherapy with drugs that theoretically target both malignancies might potentially be of use. Still, further research, both pre-clinical and clinical, is needed to accurately assess such cases.

A cross-sectional evaluation of knowledge among Chinese dentists regarding the treatment of traumatic injuries in primary teeth.

BACKGROUND/AIM: Injuries to the primary dentition affect children's esthetics, function, and mental health. They may also affect the development of the permanent teeth. The knowledge of dentists about deciduous tooth trauma is rarely evaluated. The aim of this study was to evaluate the knowledge and attitude of dentists in China regarding traumatic dental injuries to primary teeth. MATERIAL AND METHODS: A self-administered online questionnaire containing questions on demographic data and knowledge based on a clinical scenario was given to a purposive sample of dentists, recruited by a non-probability convenience sampling method. The chi-square test was used for statistical analysis, with the significance level set at P <.05. RESULTS: A total of 394 out of 409 dentists provided valid data. There was no significant difference in demographic data. Questions about the treatment of hard dental tissue injuries in primary teeth presented a correct-response rate of 66.4%, with the highest correct-response rate for enamel fracture (n = 368, 93.4%) and lowest for complicated crown-root fracture with pulp exposure (n = 104, 26.4%). Questions about treatment of luxation injuries in primary teeth presented a correct-response rate of 66.6%, with subluxation presenting the highest correct-response rate (n = 391, 99.2%). Factors associated with higher correct-response rates were specialist disciplines, educational qualifications, workplaces, experience of injured teeth treated, and educational experience about primary tooth trauma. No significant differences were found in the correct-response rates of dentists with different years of work experience. Lack of cooperation from children was considered a major obstacle for treatment. Special lectures and Internet courses were the most preferred methods of obtaining knowledge. CONCLUSION: The results suggest that it is necessary to enhance dental trauma education for dentists in China. More attention needs to be paid to trauma in primary dentition to ensure adequate treatment for traumatized primary teeth.

Cardio-ankle vascular index predicts the 1-year prognosis of heart failure patients categorized in clinical scenario 1.

The sudden increase in blood pressure by vascular dysfunction is associated with the development of acute decompensated heart failure (ADHF) categorized in clinical scenario (CS) 1. However, the relationship between vascular function and prognosis in ADHF patients with CS1 is unclear. 3239 consecutive ADHF patients between January 2012 and June 2018 were enrolled. ADHF patients with CS1 undergoing ankle brachial index/cardio-ankle vascular index (CAVI) were included and patients with peripheral artery disease were excluded. Finally, 113 patients were analyzed. The primary endpoint of the present study was composite endpoint at 1 year (the cardiac death or re-hospitalization by ADHF). Cox proportional hazard analysis was conducted to identify independent predictors of composite endpoint. 25 patients (22.1%) were developed composite endpoint. CAVI in patients who have composite endpoint were significantly higher than without non-composite endpoint (composite endpoint group: 9.9 ± 1.3 non-composite endpoint group 8.7 ± 1.7, P = 0.001). The composite endpoint group was elderly and had higher ejection fraction, lower hemoglobin, and less used beta blockers, and renin angiotensin aldosterone system inhibitors. After adjustment by these confounding factors, CAVI was independently associated with the occurrence of composite endpoint (hazard ratio 1.69, 95% CI 1.05-2.73, P = 0.032). A cut-off value of CAVI for predicting composite endpoint was 8.65 (sensitivity 0.444, specificity 0.920, area under the curve 0.724, 95% CI 0.614-0.834). High CAVI was associated with the occurrence of composite endpoint after CS1 ADHF.

Effectiveness of clinical scenario dramas to teach doctor-patient relationship and communication skills.

BACKGROUND: The doctor-patient relationship in China has deteriorated in recent years, and poor doctor-patient communication is one of the main reasons. How to effectively carry out doctor-patient communication training originated from the West among Chinese medical students still to be studied. In the past decade, Peking Union Medical College has adopted clinical scenario drama to teach doctor-patient relationship and clinical communication skills. The aim of this study was to introduce clinical scenario dramas and evaluate its effectiveness in promoting doctor-patient relationships and clinical communication skills through students' self-perceptions in Chinese medical students. METHODS: This study was a retrospective, self-controlled study and conducted from March 2009 to October 2018. Doctor-patient relationship and communication skills training were administered to all sixth-year medical students, which involved lectures and various clinical scenario dramas. The program totaled 24 h, of which each class session was 3 h, with 8 sessions in total. All students were requested to complete an anonymous 5 likert self-rating survey including self-confidence in using communication skills and self-perceived learning attitude and ability before and at the end of the course. In addition, they were requested to evaluate the curriculum after completion of the course. RESULTS: Clinical scenario dramas helped students improve their self-confidence in clinical communication skills except for psychosomatic history taking (p < 0.05). The interests for participation in clinical scenario dramas were higher compared to attending lectures (4.39 ± 0.610 Vs 4.07 ± 0.831, p<0.01). Study participants were highly satisfied in the course setting, teaching instructors and content (4.61 ± 0.546, 4.65 ± 0.535, 4.63 ± 0.534). The self-evaluation results demonstrated that clinical scenario dramas improved the learning ability of medical students (p < 0.05). CONCLUSION: The use of clinical scenario dramas was helpful in teaching doctor-patient communication skills.

Penalty-based approaches to evaluating multiplicity adjustments in clinical trials: Traditional multiplicity problems.

Given the importance of addressing multiplicity issues in confirmatory clinical trials, several recent publications focused on the general goal of identifying most appropriate methods for multiplicity adjustment in each individual setting. This goal can be accomplished using the Clinical Scenario Evaluation approach. This approach encourages trial sponsors to perform comprehensive assessments of applicable analysis strategies such as multiplicity adjustments under all plausible sets of statistical assumptions using relevant evaluation criteria. This two-part paper applies a novel class of criteria, known as criteria based on multiplicity penalties, to the problem of evaluating the performance of several candidate multiplicity adjustments. The ultimate goal of this evaluation is to identify efficient and robust adjustments for each individual trial and optimally select parameters of these adjustments. Part I deals with traditional problems with a single source of multiplicity. Two case studies based on recently conducted Phase III trials are used to illustrate penalty-based approaches to evaluating candidate multiple testing methods and constructing optimization algorithms.

Penalty-based approaches to evaluating multiplicity adjustments in clinical trials: Advanced multiplicity problems.

Given the importance of addressing multiplicity issues in confirmatory clinical trials, several recent publications focused on the general goal of identifying most appropriate methods for multiplicity adjustment in each individual setting. This goal can be accomplished using the Clinical Scenario Evaluation approach. This approach encourages trial sponsors to perform comprehensive assessments of applicable analysis strategies such as multiplicity adjustments under all plausible sets of statistical assumptions using relevant evaluation criteria. This two-part paper applies a novel class of criteria, known as criteria based on multiplicity penalties, to the problem of evaluating the performance of several candidate multiplicity adjustments. The ultimate goal of this evaluation is to identify efficient and robust adjustments for each individual trial and optimally select parameters of these adjustments. Part II focuses on advanced settings with several sources of multiplicity, for example, clinical trials with several endpoints evaluated at two or more doses of an experimental treatment. A case study is given to illustrate a penalty-based approach to evaluating candidate multiple testing procedures in advanced multiplicity problems.

Tradeoff-based optimization criteria in clinical trials with multiple objectives and adaptive designs.

The article discusses clinical trial optimization problems in the context of mid- to late-stage drug development. Using the Clinical Scenario Evaluation approach, main objectives of clinical trial optimization are formulated, including selection of clinically relevant optimization criteria, identification of sets of optimal and nearly optimal values of the parameters of interest, and sensitivity assessments. The paper focuses on a class of optimization criteria arising in clinical trials with several competing goals, termed tradeoff-based optimization criteria, and discusses key considerations in constructing and applying tradeoff-based criteria. The clinical trial optimization framework considered in the paper is illustrated using two case studies based on a clinical trial with multiple objectives and a two-stage clinical trial which utilizes adaptive decision rules.

Preferred Place of End-of-Life Care Based on Clinical Scenario: A Cross-Sectional Study of a General Japanese Population.

In Japan, which has an aging society with many deaths, it is important that people discuss preferred place for end-of-life care in advance. This study aims to investigate whether the preferred place of end-of-life care differs by the assumed clinical scenario. This clinical scenario-based survey used data from a nationwide survey conducted in Japan in December 2017. Participants aged 20 years and older were randomly selected from the general population. The survey contained questions based on three scenarios: cancer, end-stage heart disease, and dementia. For each scenario, respondents were asked to choose the preferred place of end-of-life care among three options: home, nursing home, and medical facility. Eight hundred eighty-nine individuals participated in this study (effective response rate: 14.8%). The proportions of respondents choosing home, nursing home, and medical facility for the cancer scenario were 49.6%, 10.9%, and 39.5%, respectively; for the end-stage heart disease scenario, 30.5%, 18.9%, and 50.6%; and for the dementia scenario, 15.2%, 54.5%, and 30.3% (p < 0.0001, chi-square test). The preferred place of end-of-life care differed by the assumed clinical scenario. In clinical practice, concrete information about diseases and their status should be provided during discussions about preferred place for end-of-life care to reveal people's preferences more accurately.

Screening, diagnosis and monitoring of sarcopenia: When to use which tool?

BACKGROUND & AIMS: Sarcopenia is a muscle disorder associated with loss of muscle mass, strength and function. Early screening, diagnosis and treatment may improve outcome in different disease conditions. A wide variety of tools for estimation of muscle mass is available and each tool has specific technical requirements. However, different investigational settings and lack of homogeneity of populations influence the definition of gold standards, proving it difficult to systematically adopt these tools. Recently, the European Working Group on Sarcopenia in Older People (EWGSOP) published a revised recommendation (EWGSOP-2) and algorithm for using tools for screening and diagnosing sarcopenia. However, agreement of the EWGSOP2 criteria with other classifications is poor and although an overview of available tools is valuable, for the purpose of clinical decision-making the reverse is useful; a given scenario asks for the most suitable tools. RESULTS: Tools were identified for screening, diagnostics and longitudinal monitoring of muscle mass. For each of these clinical scenarios the most appropriate tools were listed and for each technique their usability is specified based on sensitivity and specificity. Based on this information a specific recommendation is made for each clinical scenario. CONCLUSION: This narrative review provides an overview of currently available tools and future developments for different clinical scenarios such as screening, diagnosis and longitudinal monitoring of alterations in muscle status. It supports clinical decision-making in choosing the right tools for muscle mass quantification depending on the need within a given clinical scenario as well as the local availability and expertise.

Limited evidence exists on determinants of physiotherapists' adherence to high value interventions in nonspecific low back pain management: A scoping review.

BACKGROUND: Examining the emerging body of evidence investigating what drives physiotherapist's clinical decisions in the management of low back pain can guide future research into identifying barriers and facilitators of their adherence to evidence recommended interventions. OBJECTIVE: To establish the body of evidence regarding factors that improve or hinder physiotherapists' adherence to high-value interventions on the management of non-specific low back pain. DESIGN: Scoping review. METHODS: We conducted a Scoping review by searching MEDLINE, CINAHL, and SPORTDiscus databases on 13 February 2021. Two reviewers independently screened the retrieved literature and selected articles for inclusion. We included quantitative research that investigated an association between physiotherapists' personal characteristics or setting related characteristics with their clinical management of patients with non-specific low back pain. RESULTS: Twelve studies reported in 13 publications were included. The majority of the studies were conducted in high-income countries including, the United States, Canada and UK. Twenty-six factors were investigated as potentially influencing physiotherapists' adherence to high value interventions in low back pain management. The most commonly examined physiotherapists' attributes were educational qualification that is postgraduate or certification course (58%, N = 7 studies), years of experience (41%, N = 5 studies), and beliefs and attitude about low back pain (41%, N = 5 studies). Work setting (N = 4) and workload (N = 3) were frequently investigated setting related factors. CONCLUSION: Currently, there is limited evidence available to understand determinants controlling practice behaviours of physiotherapists' management of nonspecific low back pain. Future researches conceptualized within contemporary theories of clinician behaviour change and models of knowledge translation are needed.

What is known about factors improving physiotherapists' adherence to high value interventions in nonspecific low back pain? A scoping review protocol.

INTRODUCTION: Despite multiple guidelines providing best practice treatment recommendations for managing low back pain (LBP), current evidence suggests that physiotherapists across the world often provide costly, ineffective, unnecessary, even harmful care. The purpose of this scoping review is to establish the body of evidence regarding factors that improve or hinder physiotherapist's adherence to high-value interventions in the management of non-specific LBP. METHODS: This scoping review will be conducted based on the methodological framework for scoping review recommended by Arksey & O'Malley's and Levac. Three electronic databases will be searched: MEDLINE, CINAHL and SPORTDiscus. A search of grey literature will also be performed. The search will cover studies published in English from the inception of each database to the present date. The reference lists of all included reports and articles will be hand-searched for additional results. Two independent reviewers will screen titles and abstracts for assessment against the eligibility criteria. Data will be extracted and presented in tabular form and a narrative summary that aligns with the review's aim. ETHICS AND DISSEMINATION: This scoping review does not require ethics approval. Results of this scoping review will be disseminated via conference presentation and/or publication in a scientific journal. We will also disseminate the results as part of stakeholder meetings with physiotherapists including clinicians, academicians, researchers and administrators managing non-specific LBP. A summary of the key results will be shared across social networking sites in the form of infographics.

Scenario-based clinical simulation: Bridging the gap between intern-students' anxiety and provision of holistic nursing care for preterm neonates.

AIM: This study aimed to determine the effect of Scenario-Based Clinical Simulation (SBCS) on nursing students' anxiety and skills related to providing holistic nursing care for preterm neonates. BACKGROUND: Nursing students who are caring for preterm neonates experience high level of anxiety that might negatively influence their clinical performance. Clinical nurse educators face the challenge of preparing skilful and competent students within the constraints of limited orientation time in the Neonatal Intensive Care Unit (NICU). The application of SBCS provides students with opportunities to practice critical thinking, problem-solving and communication skills, pose questions and remediate their clinical deficiencies in non-threatening learning enviroment. DESIGN: A quasi-experimental, two groups, pre-post test study was carried out in the NICU of Specialized Hospital at Smouha, Alexandria. METHOD: Sixty students completed a baseline skills assessment, as students' clinical skills were scored on a 148-item checklist and participants rated their anxiety. All participants received a didactic lecture and demonstrated nursing procedures. Research team facilitated an interactive SBCS session for the intervention group focused on the holistic care of preterm neonates and the common health problems affecting them. Two weeks later, two independent raters re-assessed the students' skills on the admitted preterms, and participants completed the anxiety questionnaire again. RESULTS: It is revealed that all participants in the intervention group (100%) had good skills after two weeks of SBCS compared to 20% of the control group (P < 0.001). Moreover, 43.3% of the nursing students in control group experienced severe anxiety compared to only 6.7% of those in the intervention group who attended the SBCS (P < 0.001). CONCLUSION: The application of SBCS in NICU provided an interactive learning experience, improved and sustained students' clinical skills. They reflected on their performance and remediated their skills in a conducive environment. So, they encountered less anxiety while providing holistic care for preterm neonates.

Is Clinical Scenario Simulation Teaching Effective in Cultivating the Competency of Nursing Students to Recognize and Assess the Risk of Pressure Ulcers?

OBJECTIVE: To evaluate the effectiveness of a clinical scenario simulation method among nursing students for assessing the risk of patients developing pressure ulcers compared with the traditional didactic method. METHODS: This experimental study was a controlled trial with single-blind assessments. Nursing students (n = 47) were randomly assigned to either a control or an experimental group. The control group (n = 21) was instructed using traditional didactic methods that only delivered knowledge of pressure ulcers, while the experimental group (n = 26) received a clinical scenario simulation-based method for cultivating the competence to assess the risk of pressure ulcers. Participants underwent pre- and post-intervention based on the objective structured clinical examination (OSCE) comprising objective performance criteria. Data were analyzed using a t-test in the SPSS Statistics software program at a significance level of 0.05. RESULTS: No significant differences were observed regarding age or the mean scores of the OSCE in pre-intervention between the two groups. Following the intervention, the mean score of the experimental group's performance was higher (29.04 ± 6.00) compared with the control group (12.38 ± 4.15) (P = 0.000). There were statistical differences between the two groups. Nursing students in the clinical scenario simulation group performed significantly better in recognizing and assessing the risk of pressure ulcers. CONCLUSION: This study demonstrates that a clinical scenario simulation approach is more effective than employing the traditional didactic method for cultivating students' assessment ability regarding pressure ulcers. This student-centered, clinical scenario simulation method can help to effectively develop students' competency in recognizing and assessing the risk of pressure ulcers, thereby providing a solid foundation for their clinical practice towards enhanced patient safety.

Acute coronary syndromes and acute heart failure: a diagnostic dilemma and high-risk combination. A statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology.

Acute coronary syndrome is a precipitant of acute heart failure in a substantial proportion of cases, and the presence of both conditions is associated with a higher risk of short-term mortality compared to acute coronary syndrome alone. The diagnosis of acute coronary syndrome in the setting of acute heart failure can be challenging. Patients may present with atypical or absent chest pain, electrocardiograms can be confounded by pre-existing abnormalities, and cardiac biomarkers are frequently elevated in patients with chronic or acute heart failure, independently of acute coronary syndrome. It is important to distinguish transient or limited myocardial injury from primary myocardial infarction due to vascular events in patients presenting with acute heart failure. This paper outlines various clinical scenarios to help differentiate between these conditions and aims to provide clinicians with tools to aid in the recognition of acute coronary syndrome as a cause of acute heart failure. Interpretation of electrocardiogram and biomarker findings, and imaging techniques that may be helpful in the diagnostic work-up are described. Guidelines recommend an immediate invasive strategy for patients with acute heart failure and acute coronary syndrome, regardless of electrocardiographic or biomarker findings. Pharmacological management of patients with acute coronary syndrome and acute heart failure should follow guidelines for each of these syndromes, with priority given to time-sensitive therapies for both. Studies conducted specifically in patients with the combination of acute coronary syndrome and acute heart failure are needed to better define the management of these patients.

Clinical Scenario Classification for Characterization and Outcome Prediction of Acute Decompensated Heart Failure Under Contemporary Phenotyping.

Background: The concept of Clinical Scenario (CS) classification has been widely utilized to aid in choosing appropriate management strategies for acute decompensated heart failure (ADHF). Methods and Results: The West Tokyo-Heart Failure (WET-HF) Registry is a multicenter, prospective cohort registry enrolling consecutive hospitalized ADHF patients. Based on systolic blood pressure (SBP) at admission, 4,000 patients enrolled between 2006 and 2017 were classified into 3 groups: CS1, SBP ≥140 mmHg; CS2, 100≤SBP<140 mmHg; and CS3, SBP <100 mmHg. The CS1 group had a high rate of fluid retention such as leg edema, and the largest reduction in body weight at discharge. In-hospital diuretics use was the most frequent in CS1. Although the primary endpoint of long-term all-cause death and/or ADHF re-hospitalization was more common in more advanced CS, there was no significant difference between the 3 CS groups in patients with HF with preserved ejection fraction (HFpEF; P=0.10). Although more advanced CS was associated with larger left ventricular (LV) chamber size in HF with reduced EF (HFrEF), it was associated with smaller LV size in HFpEF. Conclusions: The long-term prognostic value of CS classification was limited in HFpEF. Whereas CS was closely associated with degree of LV remodeling in HFrEF, a smaller LV chamber might be associated with a lower cardiovascular functional reserve in HFpEF.

Systolic blood pressure on admission as a marker of fluid re-distribution in acute heart failure.

BACKGROUND: The relation between systolic blood pressure (sBP) on admission and the extent of fluid re-distribution in patients with acute heart failure (AHF) remains unclear. This study aimed to investigate this relation. METHODS: We enrolled consecutive patients who were admitted for AHF in our cardiology department and divided them into three groups according to the tertiles of sBP on admission as follows: low, intermediate, and high sBP groups. Weight changes and estimated relative plasma volume changes (ΔePV) on admission and 24h later were determined in each patient. ΔePV were calculated with the Strauss formula using hemoglobin and hematocrit levels. Univariate and multiple regression analyses were performed to investigate the relation between sBP and ΔePV. RESULTS: The ΔePV of low, intermediate, and high sBP groups were 104.3%, 108.2%, and 121.3%, respectively. High sBP group showed a significantly larger ΔePV than the other two groups (p<0.001 and 0.004, respectively). The body weight of patients in the high sBP group slightly but significantly decreased within 24h (-0.64±0.92kg, p=0.002). The initial sBP had a significant correlation with ΔePV (R2, 0.295; p<0.001). Multiple regression analysis showed significant association between initial sBP with ΔePV. CONCLUSIONS: These results indicate that large amounts of extravasated fluid existed on admission in patients with a high initial sBP. The sBP on admission could be a simple and useful indicator for the extent of fluid re-distribution in AHF.

Simulation Clinical Scenario Design Workshop for Practicing Clinicians.

Introduction: Faculty development is important to developing skilled faculty members who are able to effectively design and deliver educational content. There has been an increase in courses designed to help faculty better teach at the bedside, but fewer options for those interested in developing their skills as simulation-based educators. Our goal was to create a workshop to train prospective simulation educators on the skills and knowledge necessary to design a clinical scenario. Methods: Learners participate in a 90-minute workshop utilizing short, didactic teaching and practical hands-on practice. Faculty guide learners through the process of developing targeted goals and learning outcomes, setting the scene for a clinical scenario, and storyboarding the main action. Learners work individually, but engage in peer-to-peer feedback, as well as instructor feedback, throughout the session. Results: We have run four iterations of this workshop at our institution in the past year, and developed a modified version for an international meeting. A total of 51 learners from our hospital have completed the workshop. Overall, learners agree that the workshop is informative and increases their knowledge. For each educational objective, more than 70% of participants indicated the workshop increased their competence in the area either "extremely" or "quite a bit." Discussion: This workshop provides learners hand-on practice in developing a scenario for simulation-based education. Learners leave with the tools and knowledge necessary to take the work developed in the session and create a complete scenario that can be used at our simulation center or at another facility.

A comparison of clinical-scenario (case cluster) versus stand-alone multiple choice questions in a problem-based learning environment in undergraduate medicine.

OBJECTIVES: To compare stand-alone multiple choice questions (MCQs) and integrated clinical-scenario (case cluster) multiple choice questions (CS-MCQs) in a problem-based learning (PBL) environment. METHODS: A retrospective descriptive analysis of MCQ examinations was conducted in a course that integrates the subspecialties of anatomical pathology, chemical pathology, hematology, immunology, microbiology and pharmacology. The MCQ items were analyzed for their reliability (Kuder-Richardson-20, KR-20), level of difficulty (Pi), discrimination index (Di), item distractors and student performances. The statistical analysis of the results was extracted from the integrity online item-analysis programme. The results of the standard stand-alone and CS multiple choice questions were compared. RESULTS: KR-20 for the CS-MCQs and stand-alone MCQs was consistently high. KR-20 and Pi were higher for the CS-MCQs. There was no significant difference between the CS-MCQs and stand-alone MCQs in Pi and Di. A range of difficulty levels was found based on Bloom's taxonomy. The mean scores for the class were higher for the CS-MCQ examination. The compilation of the CS-MCQ examination was more challenging. CONCLUSIONS: CS-MCQs compare favorably to stand-alone MCQs and provide opportunities for the integration of sub-specialties and assessment in keeping with PBL. They assess students' cognitive skills and are reliable and practical. Different levels of item difficulty promote multi-logical and critical thinking. Students' scores were higher for the CS-MCQ examination, which may suggest better understanding of the material and/or better question clarity. The scenarios have to flow logically. Increasing the number of scenarios ensures the examination of more course content.