Improvement in medical students' knowledge on chronic pain assessment through integrative learning approaches: a randomized controlled trial.

Introduction: This study aimed to compare the knowledge and skills of medical students in chronic pain assessment after being trained using the PQRST (P, provoke and palliate; Q, quality; R, region and radiation; S, severity; T, time) and ACT-UP (A, activity; C, coping; T, think; U, upset; P, people) mnemonics with those using only the PQRST mnemonic. Methods: A double-blind, randomized controlled trial was conducted at the Faculty of Medicine, Universitas Indonesia, including forty students who participated in a simulation-based chronic pain assessment workshop. Pre- and post-test scores were used to assess participants' knowledge. Two independent raters assessed the students' skills. Results: No significant differences in knowledge or skills were observed between the groups; however, a significant improvement in the post-test scores (85.71 [71.43-95.24]) compared to the pre-test scores (61.90 [25.87-90.48]) was observed. The students reported high satisfaction with the workshop. Conclusions: Training with the PQRST and ACT-UP mnemonics is not better than training with the PQRST mnemonic alone in improving students' knowledge and skills in chronic pain assessment. Nevertheless, this pain education workshop was beneficial for student learning. Learning of patient-oriented chronic pain assessment should be provided in a repetitive and integrative fashion using different approaches, such as lectures, demonstrations, simulations, and interactions with patients experiencing chronic pain. To conclude, mnemonics are helpful but not a primary learning tool.

Assessing clinical reasoning in airway related cases among anesthesiology fellow residents using Script Concordance Test (SCT).

INTRODUCTION: Clinical reasoning is a core competency for physicians. In the field of anesthesia, many situations require residents to use their clinical reasoning to make quick and appropriate decisions such as during emergency airway cases. The Script Concordance Test (SCT) is a test developed in recent years and validated that objectively assess clinical reasoning ability. However, studies involving SCT to assess clinical reasoning in airway management is scarce. AIM: To evaluate SCT in assessing clinical reasoning for airway management in anesthesiology residents. METHOD: A cross-sectional study involving residents and anesthesiology consultants from the Department of Anesthesiology and Intensive Care, Faculty of Medicine Universitas Indonesia was conducted to complete SCT. A panel of five anesthesiology consultants with more than 15 years of work experience constructed 20 SCT vignettes based on prevalent airway cases in our center from the past 10 years. Each SCT has three nested questions, with a total of 60 questions, to be answered within 120 min. RESULTS: The SCT of 20 case vignettes with three nested questions were tested on 99 residents from the junior, intermediate, and senior residents, compared to answers from the expert group consisting of ten anesthesiology consultants with more than 5 years of experience. There were significant differences in mean SCT scores in the junior, intermediate, senior and expert groups, 59.3 (46.1-72.8), 64.7 (39.9-74.9), 67.5 (50.6-78.3), and 79.6 (78.4-84.8); p < 0,001 consecutively. Cronbach Alpha 0.69 was obtained, indicating good reliability. CONCLUSION: Our SCT was proven to be a valid and reliable test instrument to assess the clinical reasoning in airway management for anesthesiology residents. SCT was able to discriminate between groups of different clinical experiences and should be included to evaluate airway competencies in anesthesiology residents.

Dose response relationship between D-dimer level and mortality in critically ill COVID-19 patients: a retrospective observational study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a global pandemic. Coagulopathy is one of the most common complications characterized by increased D-dimer level. We aimed to investigate the dose-response relationship between elevated D-dimer level and mortality in critically ill COVID-19 patients. METHODS: This was a retrospective observational study in 259 critically ill COVID-19 patients requiring intensive care unit admission between March and December 2020. We compared the mortality rate between patients with and without elevated D-dimer. Receiver operating characteristic (ROC) curve analysis, Fagan's nomogram, and dose-response relationship were performed to determine the association between D-dimer level and mortality. RESULTS: Overall mortality rate was 40.9% (106 patients). Median D-dimer level was higher in non-survivor group (10,170 ng/mL vs 4,050 ng/mL, p=0.028). The association remained significant after multivariate logistic regression analysis (p=0.046). The optimal cut-off for D-dimer level to predict mortality from ROC curve analysis was 9,020 ng/mL (OR (odds ratio) 3.73 [95% CI (confidence interval) 1.91 - 7.28], p<0.001). D-dimer level >9,020 ng/mL confers 67% posterior probability of mortality and D-dimer level <9,020 ng/mL had 35% probability of mortality. CONCLUSIONS: There was a non-linear dose-response relationship between D-dimer level and mortality with P nonlinearity of 0.004. D-dimer level was associated with mortality in critically ill COVID-19 patients in the non-linear dose-response relationship.

Can Near-Infrared Spectroscopy (NIRS) monitoring prevent post-operative cognitive dysfunction following open- heart surgery?

OBJECTIVE: This study aimed to evaluate the relationship between Post-operative Cognitive Dysfunction (POCD) and regional Oxygen saturation (rSOs) determined by NIRS monitoring during Open-heart surgery. METHODS: This was a prospective cohort study of all patients about to undergo Open-heart surgery at Cipto Mangunkusumo National Referral Hospital, Jakarta. Subjects who fulfilled the selection criteria underwent cognitive assessment one day before the surgery. Basal rSO2 was registered prior to anaesthetic induction, and this value was reported every 10 minutes throughout the procedure as the lowest rSO2 and total desaturation (drop >20%) duration. On postoperative day 5, cognitive function was reassessed. We declared a drop in the cognitive function if the score dropped to >20% from the baseline in at least two cognitive tests. RESULTS: The incidence of POCD was 51.7%. Basal rSO2 values between POCD and non-POCD subjects were relatively similar. A significant difference was noted in the duration of total rSO2 desaturation between the two groups. Total rSO2 desaturation was longer in subjects with than without POCD. The ROC (receiver operating characteristic) curve showed a cut-off point of 20.5 minutes, with an AUC (area under curve) size of 126.5 minutes %. CONCLUSIONS: Absolute rSO2 values did not correlate with POCD. However, a drop in rSO2 value >20% from baseline may correlate with POCD. The use of NIRS in Open-heart surgery may, be beneficial for POCD prevention.

Cardiopulmonary Bypass Alone Does Not Cause Postoperative Cognitive Dysfunction Following Open Heart Surgery.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is commonly observed following cardiac surgery. The utilization of cardiopulmonary bypass (CPB) is associated with many possible mechanisms to cause POCD. However, there is no evidence confirming that CPB alone is the cause of POCD. OBJECTIVES: The current study aimed at evaluating several factors suspected to cause POCD following cardiac surgery in Cipto Mangunkusumo Hospital, Jakarta, Indonesia. METHODS: The current prospective cohort study was conducted on 54 patients who were candidates for cardiac surgery. The assessment of memory, attention, and executive functions was performed by neuropsychological tests, before and after the surgery. Cognitive decline was defined as a 20% decrease in cognitive function in at least one of the tests. Inclusion criteria were adults spokeing Bahasa Indonesia fluently, literate, and giving consent to participate in the study. The analyzed risk factors included age, diabetes, educational level, duration of aortic cross clamp, and duration of cardio-pulmonary bypass. RESULTS: POCD occured in 40.7% of subjects that underwent cardiac surgery using cardiopulmonary bypass. Age was the only influential factor through bivariate test and logistic regression analysis (P = 0.001). The current study conducted a logistic regression test on age variable; the obtained result indicated an increasing trend of POCD in accordance with age group. CONCLUSIONS: Durations of CPB, cross clamp, diabetes, and educational level were not the main risks of POCD. Old age was a significant predictor to POCD.