RESUMO
INTRODUCTION: All graduating physicians should be competent with the basic principles of contagious disease outbreak detection and management. In order to educate our students and residents on this important topic, we created a three-hour workshop that included a case-based simulation exercise, and we offered a two-week medical student course in Emerging Infections and Bioterrorism. METHODS: Twenty-two emergency medicine residents and sixty-four senior medical students rotating in the emergency department of an urban university tertiary referral center participated in a three-hour workshop between July 2005 and April 2006. Pre- and post- workshop surveys given immediately before and immediately following each session were used to determine participant satisfaction and self-reported knowledge and confidence in outbreak response. In March 2006 we offered a medical student elective course in Emerging Infections and Bioterrorism. Thirteen fourth-year medical students from a variety of specialties attended the two-week course. The course focused on selected topics in emerging and re-emerging infections and addressed general principles of infection control and biological disaster planning for healthcare facilities. A survey was given to all graduating fourth-year medical students in 2005 and 2006, before and after creation of the didactic course, to evaluate their comfort and perceived knowledge of outbreak detection and containment. RESULTS: Overall, both students who participated in the workshop and those who participated in the didactic course (with or without the workshop) showed improvement in self-reported knowledge of outbreak detection and management, although the effect was statistically significant only for those participating in the didactic course. Due to the small numbers of emergency medicine residents who completed the surveys, we cannot comment on the effectiveness of the resident workshop, although there was a trend toward improved self-reported knowledge after the workshop. Students pursuing internal medicine, pediatrics, emergency medicine, and ENT were most likely to report that outbreak education was very important. Nearly all participants felt outbreak preparedness was not covered in existing curricula, and 92% thought the workshop was beneficial. CONCLUSIONS: Most participants felt that outbreak preparedness was not adequately addressed in their curricula and almost all wanted more instruction. In addition, the didactic course and workshop improved self-reported student knowledge of the basic principles of contagious disease outbreak detection and management. Based on the results of our study, we propose integration of a three-hour simulation-based workshop with other instructional endeavors in emerging infections and biopreparedness into medical education curricula. We recommend the offering of a more comprehensive course for those pursuing emergency medicine and the primary care specialties, as they will be the most likely to encounter an outbreak. A web-based course may be a desirable alternative for institutions that could not otherwise add this training to their curriculum due to logistical reasons or time constraints. Further research is needed to determine the feasibility and effectiveness of these educational strategies.
RESUMO
BACKGROUND: Gynecological laparoscopic surgery procedures are often complicated by postoperative pain resulting in an unpleasant experience for the patient, delayed discharge, and increased cost. Glucocorticosteroids have been suggested to reduce the severity and incidence of postoperative pain. METHODS: This study examines the efficacy of a sustained release betamethasone preparation to reduce postoperative pain and the requirement for pain relief drugs after either diagnostic laparoscopy or tubal ligation. Patients were recruited, as presenting, after obtaining informed consent. Prior to surgery, patients were randomly selected by a computer generated table to receive either pharmacy-coded betamethasone (12 mg IM Celestone trade mark ) or an optically identical placebo injection of Intralipid trade mark and isotonic saline mixture. The effect of non-controlled prophylactic intraoperative treatment with either fentanyl or ketorolac per surgeon's orders was also noted in this study. Blood samples taken at recovery and at discharge times were extracted and analyzed for circulating betamethasone. Visual analog scale data on pain was gathered at six post-recovery time points in a triple blind fashion and statistically compared. The postoperative requirement for pain relief drugs was also examined. RESULTS: Although the injection achieved a sustained therapeutic concentration, no beneficial effect of IM betamethasone on postoperative pain or reduction in pain relief drugs was observed during the postoperative period. Indeed, the mean combined pain scores during the 2 hour postoperative period, adjusted for postoperative opioids as the major confounding factor, were higher approaching statistical significance (P = 0.056) in the treatment group. Higher pain scores were also observed for the tubal ligation patients relative to diagnostic laparoscopy. Intraoperative fentanyl treatment did not significantly lower the average pain score during the 2 hour postoperative period. Intraoperative ketorolac treatment significantly lowered (P = 0.027) pain scores and reduced the postoperative requirement for additional pain relief drugs. CONCLUSIONS: There was a lack of efficacy of preoperative sustained release betamethasone in reducing postoperative pain despite maintaining a therapeutic concentration during the postoperative period. Intraoperative Ketorolac did afford some short-term pain relief in the postoperative period and reduced the need for additional pain relief drugs.
