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Abstract Introduction: The primary purpose of this study was to compare the effect of high fidelity simulation versus a computer-based case solving self-study, in skills acquisition about malignant hyperthermia on first year anesthesiology residents. Methods: After institutional ethical committee approval, 31 first year anesthesiology residents were enrolled in this prospective randomized single-blinded study. Participants were randomized to either a High Fidelity Simulation Scenario or a computer-based Case Study about malignant hyperthermia. After the intervention, all subjects' performance in was assessed through a high fidelity simulation scenario using a previously validated assessment rubric. Additionally, knowledge tests and a satisfaction survey were applied. Finally, a semi-structured interview was done to assess self-perception of reasoning process and decision-making. Results: 28 first year residents finished successfully the study. Resident's management skill scores were globally higher in High Fidelity Simulation versus Case Study, however they were significant in 4 of the 8 performance rubric elements: recognize signs and symptoms (p = 0.025), prioritization of initial actions of management (p = 0.003), recognize complications (p = 0.025) and communication (p = 0.025). Average scores from pre- and post-test knowledge questionnaires improved from 74% to 85% in the High Fidelity Simulation group, and decreased from 78% to 75% in the Case Study group (p = 0.032). Regarding the qualitative analysis, there was no difference in factors influencing the student's process of reasoning and decision-making with both teaching strategies. Conclusion: Simulation-based training with a malignant hyperthermia high-fidelity scenario was superior to computer-based case study, improving knowledge and skills in malignant hyperthermia crisis management, with a very good satisfaction level in anesthesia residents.
Resumo Introdução: O objetivo primário deste estudo foi comparar o efeito da simulação de alta-fidelidade versus autoestudo baseado em resolução de casos no computador, a aquisição de habilidades sobre hipertermia maligna em residentes de anestesiologia do primeiro ano. Métodos: Após a aprovação do Comitê de Ética institucional, 31 residentes de anestesiologia do primeiro ano foram inscritos neste estudo prospectivo, randômico e encoberto. Os participantes foram randomizados para um ambiente de simulação de alta-fidelidade (SAF) ou um estudo de caso (EC) em computador sobre hipertermia maligna. Após a intervenção, o desempenho de todos os indivíduos foi avaliado através de um ambiente de simulação de alta-fidelidade utilizando uma rubrica de avaliação previamente validada. Além disso, uma pesquisa de satisfação e testes de conhecimento foram aplicados. Por fim, uma entrevista semiestruturada foi realizada para avaliar a autopercepção do processo de raciocínio e da tomada de decisão. Resultados: Vinte e oito residentes do primeiro ano concluíram o estudo com sucesso. Os escores dos residentes na aquisição de habilidades no manejo da hipertermia maligna foram globalmente maiores no Grupo SAF que no Grupo EC, mas a significância foi em quatro dos oito elementos da rubrica de desempenho: reconhecer os sinais e sintomas (p = 0,025), priorizaras ações iniciais do manejo (p = 0,003), reconhecer complicações (p = 0,025) e comunicação (p = 0,025). As médias dos escores nos questionários de conhecimento pré- e pós-teste melhoraram de 74% para 85% no Grupo SAF e diminuíram de 78% para 75% no Grupo EC (p = 0,032). Em relação à análise qualitativa, não houve diferença nos fatores que influenciaram o processo de raciocínio e de tomada de decisão dos alunos com ambas as estratégias de ensino. Conclusão: O treinamento baseado em simulação com um ambiente de alta-fidelidade de hipertermia maligna foi superior ao estudo de caso em computador, melhorou o conhecimento e as habilidades no manejo de crises de hipertermia maligna, com um nível de satisfação muito bom entre os residentes de anestesia.
Assuntos
Simulação de Paciente , Educação Médica , Hipertermia Maligna/fisiopatologia , Estudos Prospectivos , Treinamento por Simulação , Anestesistas , Corpo Clínico HospitalarRESUMO
INTRODUCTION: The primary purpose of this study was to compare the effect of high fidelity simulation versus a computer-based case solving self-study, in skills acquisition about malignant hyperthermia on first year anesthesiology residents. METHODS: After institutional ethical committee approval, 31 first year anesthesiology residents were enrolled in this prospective randomized single-blinded study. Participants were randomized to either a High Fidelity Simulation Scenario or a computer-based Case Study about malignant hyperthermia. After the intervention, all subjects' performance in was assessed through a high fidelity simulation scenario using a previously validated assessment rubric. Additionally, knowledge tests and a satisfaction survey were applied. Finally, a semi-structured interview was done to assess self-perception of reasoning process and decision-making. RESULTS: 28 first year residents finished successfully the study. Resident's management skill scores were globally higher in High Fidelity Simulation versus Case Study, however they were significant in 4 of the 8 performance rubric elements: recognize signs and symptoms (p = 0.025), prioritization of initial actions of management (p = 0.003), recognize complications (p = 0.025) and communication (p = 0.025). Average scores from pre- and post-test knowledge questionnaires improved from 74% to 85% in the High Fidelity Simulation group, and decreased from 78% to 75% in the Case Study group (p = 0.032). Regarding the qualitative analysis, there was no difference in factors influencing the student's process of reasoning and decision-making with both teaching strategies. CONCLUSION: Simulation-based training with a malignant hyperthermia high-fidelity scenario was superior to computer-based case study, improving knowledge and skills in malignant hyperthermia crisis management, with a very good satisfaction level in anesthesia residents.
RESUMO
BACKGROUND: It is unknown whether warfarin or aspirin therapy is superior for patients with heart failure who are in sinus rhythm. METHODS: We designed this trial to determine whether warfarin (with a target international normalized ratio of 2.0 to 3.5) or aspirin (at a dose of 325 mg per day) is a better treatment for patients in sinus rhythm who have a reduced left ventricular ejection fraction (LVEF). We followed 2305 patients for up to 6 years (mean [±SD], 3.5±1.8). The primary outcome was the time to the first event in a composite end point of ischemic stroke, intracerebral hemorrhage, or death from any cause. RESULTS: The rates of the primary outcome were 7.47 events per 100 patient-years in the warfarin group and 7.93 in the aspirin group (hazard ratio with warfarin, 0.93; 95% confidence interval [CI], 0.79 to 1.10; P=0.40). Thus, there was no significant overall difference between the two treatments. In a time-varying analysis, the hazard ratio changed over time, slightly favoring warfarin over aspirin by the fourth year of follow-up, but this finding was only marginally significant (P=0.046). Warfarin, as compared with aspirin, was associated with a significant reduction in the rate of ischemic stroke throughout the follow-up period (0.72 events per 100 patient-years vs. 1.36 per 100 patient-years; hazard ratio, 0.52; 95% CI, 0.33 to 0.82; P=0.005). The rate of major hemorrhage was 1.78 events per 100 patient-years in the warfarin group as compared with 0.87 in the aspirin group (P<0.001). The rates of intracerebral and intracranial hemorrhage did not differ significantly between the two treatment groups (0.27 events per 100 patient-years with warfarin and 0.22 with aspirin, P=0.82). CONCLUSIONS: Among patients with reduced LVEF who were in sinus rhythm, there was no significant overall difference in the primary outcome between treatment with warfarin and treatment with aspirin. A reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage. The choice between warfarin and aspirin should be individualized. (Funded by the National Institute of Neurological Disorders and Stroke; WARCEF ClinicalTrials.gov number, NCT00041938.).
