Simulation-based medical education can be used to improve the mental health competency of emergency physicians.

OBJECTIVE: We explored the feasibility of developing, running and evaluating a simulation-based medical education (SBME) workshop to improve the knowledge, skills and attitudes of emergency department (ED) doctors when called on to assess patients in psychiatric crisis. METHOD: We designed a four-hour workshop incorporating SBME and a blend of pre-reading, short didactic elements and multiple-choice questions (MCQs). Emergency department nurses (operating as SBME faculty) used prepared scripts to portray patients presenting in psychiatric crisis. They were interviewed in front of, and by, ED doctors. We collected structured course evaluations, Debriefing Assessment for Simulation in Healthcare (DASH) scores, and pre- and post-course MCQs. RESULTS: The pilot workshop was delivered to 12 ED registrars using only existing resources of the Psychiatry and Emergency Departments. Participants highly valued both 'level of appropriateness' (Likert rating µ = 4.8/5.0) and 'overall usefulness' (µ = 4.7/5.0) of the programme. They reported an improved understanding of the mental state and of relevant legal issues and rated the debriefings highly (participant DASH rating: n = 193; score µ = 6.3/7.0). Median MCQ scores improved non-significantly pre- and post-course (7.5/12 vs 10/12, p = 0.261). CONCLUSION: An SBME workshop with these aims could be delivered and evaluated using the existing resources of the Psychiatry and Emergency Departments.

The role of the renin-angiotensin system blocking in the management of atrial fibrillation.

OBJECTIVE: To review current available evidence for the role of renin-angiotensin system blockade in the management of atrial fibrillation. METHOD: We conducted a PubMed and Medline literature search (January 1980 through July 2011) to identify all clinical trials published in English concerning the use of angiotensin converting enzyme inhibitors or angiotensin II receptor blockers for primary and secondary prevention of atrial fibrillation. We also discussed renin-angiotensin system and its effects on cellular electrophysiology. CONCLUSION: The evidence from the current studies discussed does not provide a firm definitive indication for the use of angiotensin converting enzyme inhibitors or angiotensin II receptor blockers in the primary or secondary prevention of atrial fibrillation. Nevertheless, modest benefits were observed in patients with left ventricular dysfunction. In view of the possible benefits and the low incidence of side-effects with angiotensin converting enzyme inhibitors and angiotensin II receptor blockers, they can be given to patients with recurrent AF, specifically those with hypertension, heart failure and diabetes mellitus.

The effects of bolus and continuous nasogastric feeding on gastro-oesophageal reflux and gastric emptying in healthy volunteers: a randomised three-way crossover pilot study.

BACKGROUND & AIMS: Nasogastric feeding may result in gastro-oesophageal reflux and, therefore, increase the risk of aspiration. This may be greater when feeds are administered via a bolus than by infusion. We aimed to measure gastric emptying time and quantify gastro-oesophageal reflux in healthy volunteers given a liquid feed via an oral bolus (OB), a nasogastric tube bolus (TB) and a nasogastric tube drip (TD). METHODS: Twelve male volunteers participated in three separate studies (OB, TB and TD) in random order, each 3 days apart. The feed consisted of 220 ml Ensure Plus (1.5 kcal/ml), labelled with 12 MBq (99m)Tc DTPA. The OB and TB were given over 5 min and the infusion rate for the TD was 55 ml/h. Gastric emptying time was measured using gamma scintigraphy. Gastro-oesophageal reflux was observed continuously until the stomach was empty, using a multichannel intraluminal impedance catheter. RESULTS: Mean (95% CI) T(50) gastric emptying times for the OB and TB studies were 41.3 (36.5-46.2) min and 36.2 (30.6-41.8) min respectively (p=0.19). The stomach emptied at a rate equal to the infusion rate in the TD studies. Median (IQR) number of reflux episodes for the OB, TB and TD studies were 4.5 (2.0-6.0), 3.0 (2.0-4.75) and 2.0 (0.25-6.25) respectively. Median (IQR) total duration of reflux for the OB, TB and TD studies were 38 (20-242), 49 (17-71) and 36 (1-125) s respectively (p=NS). CONCLUSIONS: The lack of difference in gastro-oesophageal reflux between bolus and continuous feeding indicates that in healthy volunteers both methods are equally safe with respect to the risk of aspiration.