Academic outcome and moderator of flipped classroom learning program "Teaching on the Run".

BACKGROUND: Flipped classroom (FC) style Australian faculty development program Teaching on the Run (TOTR) was introduced into Chang Gung Memorial Hospital since 2014. However, its effectiveness in Taiwan has not been formally assessed. This work intended to examine the learning gain of TOTR and identify the moderators of FC outcome by using TOTR as a representative model of FC. METHODS: A non-controlled before-after study was undertaken by retrospective analysis of learning data collected during TOTR workshop. Multiple choice questions were tested at baseline (pre-test), after pre-class learning (mid-test) and after classroom activity (post-test) to assess the learning gain. All available demographic and learning variables were included in the moderator analysis. RESULTS: Stepwise and significant improvement in exam scores was noted from pre-test to mid-test and post-test (p < 0.001 for both). Univariate analysis showed pre-test scores, mid-test scores, class participation and session of TOTR were significantly associated with post-test scores. However, multivariate analysis by general linear model showed only mid-test scores and session of TOTR were significant predictor of post-test score. Generalized estimating equations analysis showed that class participation is a significant moderator that influence the scores change from mid-test to post-test. CONCLUSION: TOTR is effective in improving knowledge of teaching skills for clinical teachers in Taiwan. Achievement in pre-class learning, class participation and learner factor are potential moderators of the FC outcome. Thus, facilitators should try their best to promote a good achievement in pre-class learning and engagement in classroom activity in FC style learning.

Lead thrombus under standard-dose edoxaban in a patient with normal to high creatinine clearance and protein S deficiency.

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOACs) are as effective and safe as warfarin for thromboembolic prevention and treatment. The efficacy of NOACs lacks evidence from large and randomized studies in patients with inherited severe thrombophilia, including protein S deficiency. Further, some concerns still exist regarding the relative efficacy of edoxaban in preventing arterial thromboembolism in patients with normal to high creatinine clearance (CrCl). We present a case of a rare complication of lead thrombus under standard-dose edoxaban in a patient with protein S deficiency and supernormal renal function. CASE PRESENTATION: A 65-year-old man experienced persistent chest tightness and a high level of D-dimer. Chest computed tomography (CT) showed a lead thrombus at the superior vena cava. He had a medical history including, paroxysmal atrial fibrillation (PAf), sick sinus syndrome after permanent pacemaker implantation, and transient ischemic attack. He received standard-dose edoxaban (60 mg daily) after PAf was diagnosed. His estimated CrCl was 98.6-102.1 mL/min. However, protein S deficiency (22.8%; normal range: 55-130%) was diagnosed. After switching to dabigatran (150 mg twice daily) for 3 months, the chest CT showed lead thrombus resolution and no symptoms were seen during the follow-up period. CONCLUSIONS: This case was a rare complication of lead thrombus in a protein S deficient patient with normal renal function receiving standard-dose edoxaban. Edoxaban efficacy is uncertain in patients with protein S deficiency, and intracardiac devices also increase the risk of thromboembolic events.

Multiple intracardiac masses: myxoma, thrombus or metastasis: a case report.

INTRODUCTION: The incidence of multiple intracardiac mass is rare. The differential diagnosis of intracavitary mass lesions includes benign, malignant primary, secondary metastatic cardiac tumors, or thrombus. CASE PRESENTATION: We report the case of a 49-year-old Asian woman, who experienced a 2-week history of progressive exertional dyspnea, orthopnea, bilateral lower limb edema and palpitations. Transthoracic echocardiography showed one fixed round hyperechoic mass with central necrosis over the left ventricular apex, one oscillating hyperechoic nodule over the anterior mitral annulus and one irregularly heterogeneous mass bulging out from the lateral wall of the right atrium. The incidence of multiple myxomas is rare. Unfortunately, high tumor marker, serum lactic dehydrogenase and serum uric acid levels were also present. We could not differentiate between diagnoses of multiple myxomas with thrombi or multiple metastatic tumors. CONCLUSIONS: Primary intracardiac tumors are rare. Approximately 75% are benign, and approximately 50% are myxomas, which have an incidence of 0.0017% in the general population. Multiple intracardiac myxomas account for less than 5% of all cases of myxoma. Our case was an atypical picture of right atrial (RA) myxoma, as it was located in the RA lateral wall and extended to the RA auricle at the junction among the superior and inferior vena cava. Two masses in the left ventricle (LV) were thrombi and resolved after heparinization. Initially, elevated tumor markers and high serum uric acid and high serum lactic dehydrogenase levels were related to necrotic tumor-derived tissue, decompensated heart failure with pleural effusion and renal insufficiency. We share our experience of multiple intracardiac masses. Whether the intracardiac mass is benign or malignant, we recommend surgery due to the possibilities of systemic or pulmonary massive embolism, infection, arrhythmia and sudden death if the thrombus ruptures or the mass dislodges.

Long-term Outcomes of Carotid Artery Stenting for Radiation-Associated Stenosis.

BACKGROUND: In Taiwan, the prevalence of head and neck cancer is relatively high. Because radiation-associated carotid stenosis is a significant risk factor for stroke, carotid artery stenting (CAS), instead of carotid endarterectomy, is indicated in patients with radiation-associated carotid stenosis. We sought to evaluate the effect of neck radiotherapy (XRT) on the long-term outcome of patients undergoing CAS. METHODS: From March 2001 to November 2011, 147 CAS procedures were performed on 129 patients (n = 43 for XRT, n = 86 for non-XRT). Mean follow-up was 42.7 ± 20.5 months (median: 52 months; range: 1-60 months). Duplex velocity criterion for > 50% restenosis after CAS was defined as peak systolic velocity > 175 cm/s. Endpoints included 5-year freedom from mortality, ipsilateral recurrent stroke, and major adverse cardiovascular events (MACE). RESULTS: The mean age of XRT patients was significantly lesser than that of non-XRT patients (61 ± 8 vs. 71 ± 8, p < 0.001). There was significantly less coronary artery disease and other cardiovascular co-morbidities in XRT patients. No significant differences were noted in the composite 30-day ipsilateral stroke/myocardial infarction/mortality (XRT: 8.6% vs. non-XRT: 6%, p > 0.05) and 5-year freedom from mortality, ipsilateral recurrent stroke, and MACE (p > 0.05) between the two groups. Intra-stent carotid restenosis > 50% was significantly higher in the XRT group on follow-up. CONCLUSION: Long-term outcomes of CAS for radiation-associated stenosis were not altered by a history of neck XRT, except for asymptomatic carotid restenosis.