RESUMO
EDUCATIONAL CHALLENGE: Electronic dance music (EDM) festivals - crowded, loud, low-resource environments - pose unique challenges to event medical teams. Simulation can prepare teams to manage clinical presentations in this unconventional context. Without access to simulation infrastructure, a low-technological, low-fidelity simulation modality is warranted. SOLUTION: Draw & Doodle Simulation (D&D SIM) is a low-fidelity simulation where patients are hand-drawn (i.e. on paper, whiteboard, or digitally) instead of utilizing manikins or live actors. Facilitators draw all patient findings, while participants doodle any possible interventions. SOLUTION IMPLEMENTATION: Two D&D SIM cases (serotonin toxicity and refractory anaphylaxis) were piloted in classrooms. Participants included paramedics, medical students, lifeguards, and first aiders. Facilitators conducted simulations using chart paper, with each participant doodling contributions using differently colored markers. LESSONS LEARNED: Participants responded positively, rating the serotonin toxicity case 4.31/5 (n = 13) and refractory anaphylaxis case 4.53/5 (n = 15). Participants appreciated the 'low-stakes', useful 'visual' representation of progress, 'fun and [interactivity]', and appropriate '[realism]' of D&D SIM. However, D&D SIM was perceived as 'less life threatening', would not be appropriate for physical skills (e.g. CPR), required everyone to be 'oriented in the same direction to see the drawing', and the chart paper risked becoming cluttered. NEXT STEPS: Next steps include writing new cases, implementing D&D SIM in other teaching contexts, exploring its use in digital platforms, and studying its effectiveness against higher-fidelity simulation.
RESUMO
Ketamine is a promising therapeutic option in treatment-resistant depression (TRD). The acute efficacy of ketamine in TRD has been demonstrated in replicated randomised-controlled trials (RCTs), but the generalizability of RCT data to real-world practice is limited. To this end, we conducted a systematic review (Search date: 25/12/2021; 1482 records identified) and meta-analysis of studies evaluating the real-world clinical effectiveness of ketamine in TRD patients. Four overlapping syntheses (Total n = 2665 patients; k = 79 studies) and 32 meta-regressions (Total n = 2050; k = 37) were conducted. All results suggest that the mean antidepressant effect is substantial (mean ± 95% CI, % responded = 45 ± 10%; p< 0.0001, % remitted = 30 ± 5.9%; p< 0.0001, Hedges g of symptomatological improvement = 1.44 ± 0.609; p < 0.0001), but the effect varies considerably among patients. The more treatment-resistant cases were found to remit less often (p < 0.01), but no such effect on response was evident (p > 0.05). Meta-regressions also confirmed that the therapeutic effect does not significantly decline with repeated treatments (p > 0.05). These results demonstrate that even the most treatment-resistant patients may benefit from ketamine, and that mid-to-long term treatment is effective in many patients.