An Evaluation of the Use of Student Response Systems in Teaching Diagnostic Reasoning for Physicians.

BACKGROUND: Feedback is an aspect of teaching strategy that facilitates the learners to achieve expertise in the necessary skills for effective diagnostic reasoning. Several studies have demonstrated that student response systems (SRSs) are useful for enhancing learner engagement and obtaining immediate feedback. We aimed to examine the experiences of learners who used SRSs in a diagnostic reasoning class. METHODS: In 2016, an observational study was conducted on a 4-hour training course on "improving physicians' diagnostic process" that included 34 physicians. The Zuvio multimedia online interactive system was used. The learners could use smartphones to respond to the questions. A 5-point Likerttype scale quantitative questionnaire was designed to explore the viewpoints of the learners regarding the students' engagement, feedback, and outcomes. The learners were requested to complete a brief qualitative feedback form that included the following two sections: (1) the benefi ts and (2) the challenges of using SRSs. Qualitative and quantitative methods were used for data analyses. RESULTS: Total 32 participants (response rate: 94%) completed the questionnaire. Most respondents reported that using the SRSs enabled them to concentrate more effectively, express themselves in a stressfree environment, strengthen their interactions with peers and teachers, improve their participation in discussions, and obtain useful feedback. Three themes were identified from the qualitative results: (1) facilitating learning, (2) hardware limitations, and (3) question-development skills. CONCLUSION: The SRSs can be easily implemented and positively affect the teaching of diagnostic reasoning. However, teachers should develop question-development skills so that the systems function more effectively in the instruction of diagnostic reasoning.

Use of a Modified Fishbone Diagram to Analyze Diagnostic Errors in Emergency Physicians.

INTRODUCTION: Reilly et al. described a structured approach to the analysis of diagnostic errors by using a novel modifi ed fi shbone diagram. The application of this tool in emergency medicine had not previously been reported. The objective of this study is to use the modified fishbone diagram analysis method in examining the causes of common diagnostic errors committed by emergency physicians and the circumstances associating errors in cognitive processes. METHODS: Sixty-one cases of diagnostic errors involving ten board-certified emergency physicians (EPs) were identifi ed through a peer review process. Using a qualitative study approach, in-depth semi structured interviews with EPs was conducted. All interview audiotapes were transcribed verbatim. Content analysis was performed on all textual data to identify the factors underlying errors using the modified fishbone diagram. RESULTS: In 61 cases, 165 diagnostic errors were identified (2.7 per case). The underlying contributions to errors fell into 7 categories: cognitive process (54/61, 89%), specific presentation (32/61, 52%), clinical data gathering (24/61, 39%), organization issues (12/61, 20%), affective factors (9/61, 15%), context of care (9/61, 15%), and communication (5/61, 8%). Of these cognitive errors were the most common. However, only six cases occurred in isolation (6/54, 11%), with the remaining 48 cases (48/54, 89%) occurring with other types of errors, the most common being specific presentation (28/54, 52%) and clinical data gathering (24/54, 44%). CONCLUSIONS: The modified fishbone diagram is a useful tool to identify various categories of errors on diagnostic process in emergency department (ED). These fi ndings provide a basis on which to build a framework for teaching EPs how to avoid misdiagnoses in the ED setting.

Effect of preceding medications on resuscitation outcome of out-of-hospital cardiac arrest.

As evidence regarding the impact of preceding medications on resuscitation outcomes has been inconsistent, this study aimed to analyze the association between preceding medications and resuscitation outcomes in patients experiencing out-of-hospital cardiac arrest (OHCA). This retrospective study included patients with OHCA presenting to a tertiary care hospital by emergency medical service (EMS) between January 2006 and June 2011. Using the Utstein template, data were collected from EMS and hospital medical records for prehospital care, in-hospital care, and medications which were taken continuously for at least 2 weeks preceding OHCA. Primary outcome was the proportion of patients with a survived event. Multivariable logistic regression analyses were performed to evaluate the predictors of survived events. Among the 1381 included patients with OHCA, 552 (40.0%) patients achieved sustained return of spontaneous circulation and 463 (33.5%) patients survived after resuscitation, 96 (7.0%) patients survived until discharge, and 20 (1.4%) patients had a favorable neurological outcome at discharge. The multivariable analyses revealed that use of statins preceding OHCA was independently associated with a greater probability of a survived events (OR=2.09, 95% CI 1.08 to 4.03, p=0.028).Use of digoxin was adversely associated with survived events (OR=0.39, 95% CI 0.16 to 0.90, p=0.028) in patients with OHCA. The continuous use of statins preceding OHCA was positively associated with survived events, while use of digoxin was adversely related. It deserves more attention on medications preceding OHCA because of their potential effect on resuscitation outcomes.

Transient hyperammonemia in seizures: a prospective study.

PURPOSE: To investigate the incidence and duration of transient hyperammonemia in seizures and to verify the significant confounders related to transient hyperammonemia in seizures. METHODS: One hundred twenty-one noncirrhotic adult patients with seizures admitted to the emergency department were enrolled in the study. Laboratory examination was performed, including plasma ammonia level assessment. In addition, the basic parameters, underlying systemic diseases, and seizure-related conditions were assessed. The patients were classified into a group with hyperammonemia on arrival and a group without, in order to compare seizure-related adverse events that occurred during a 9-month period. KEY FINDINGS: The incidence of hyperammonemia in patients with seizures was 67.77%. Plasma ammonia levels in patients with generalized tonic-clonic (GTC) seizures were significantly higher than those in patients in the non-GTC seizure group (median 174.5 vs. 47 µg/dl; proportion 76.5% vs. 21.1%; p < 0.001). Median plasma ammonia levels decreased spontaneously from 250 to 54 µg/dl (p < 0.00001) in an average interval of 466.79 min. GTC seizures (p < 0.0001), male gender (p < 0.0001), bicarbonate (p < 0.0001), diabetes (p = 0.0139), and alcohol-related seizures (p = 0.0002) were significant factors associated with hyperammonemia on arrival. No significant differences related to admission rates or mortalities were found between the two groups. SIGNIFICANCE: The presence of transient hyperammonemia in patients with seizures is significantly related to GTC seizures, male gender, bicarbonate, diabetes, and alcohol-related seizures. The appropriate period to study ammonia levels following a seizure event is within 8 h. Because these phenomena are self-limited, ammonia-lowering management are not necessary. Hyperammonemia on arrival is not necessarily related to adverse outcomes.