Background: In the past several years, gamified learning has been growing in popularity in various medical educational contexts including cardiopulmonary resuscitation (CPR) training. Furthermore, prior work in Basic Life Support (BLS) training has demonstrated the benefits of serious games as a method for pretraining among medical students. However, there is little evidence to support these benefits with regard to Advanced Life Support (ALS) training. Objective: We compare the effects of a brief precourse ALS preparation using a serious smartphone game on student knowledge, skills, and perceptions in this area with those of conventional ALS training alone. Methods: A serious game (Resus Days) was developed by a Thai physician based on global ALS clinical practice guidelines. Fifth-year medical students were enrolled and randomized to either the game group or the control group. Participants in both groups attended a traditional ALS lecture, but the game group was assigned to play Resus Days for 1 hour before attending the lecture and were allowed to play as much as they wished during the training course. All students underwent conventional ALS training, and their abilities were evaluated using multiple-choice questions and with hands-on practice on a mannequin. Subject attitudes and perceptions about the game were evaluated using a questionnaire. Results: A total of 105 students participated in the study and were randomly assigned to either the game group (n=52) or the control group (n=53). Students in the game group performed better on the ALS algorithm knowledge posttest than those in the control group (17.22 [SD 1.93] vs 16.60 [SD 1.97], P=.01; adjusted mean difference [AMD] 0.93; 95% CI 0.21-1.66). The game group’s pass rate on the skill test was also higher but not to a statistically significant extent (79% vs 66%, P=.09; adjusted odds ratio [AOR] 2.22; 95% CI 0.89-5.51). Students indicated high satisfaction with the game (9.02 [SD 1.11] out of 10). Conclusions: Engaging in game-based preparation prior to an ALS training course resulted in better algorithm knowledge scores for medical students than attending the course alone. Trial Registration: Thai Clinical Trials Registry HE611533; https://tinyurl.com/wmbp3q7

Background Severe hyperlactatemia (lactate level >= 10 mmol/L) is associated with high mortality rates in critically ill patients. However, there is limited data on emergency department (ED) patients. We aimed to investigate the clinical characteristics, etiology and outcomes of patients with severe hyperlactatemia in the ED setting. Methods A retrospective cohort study was conducted at a tertiary care hospital in Thailand. We included adult patients with a venous lactate sample taken in the ED within one hour. We excluded patients after out-of-hospital cardiac arrest, transferred to/from another hospital or those with missing clinical data. Mortality rates were evaluated among patients with increasing degrees of lactate elevation and among patients with severe hyperlactatemia, stratified by causative etiology. Results We analyzed venous lactate levels in 40,047 patients, with 26,680 included in the analysis. Among these, 1.7% had severe hyperlactatemia (lactate >= 10 mmol/L), 10.5% moderate (4-9.99 mmol/L), 28.8% mild (2-3.99 mmol/L), and 59.0% normal levels (< 2 mmol/L). Severe hyperlactatemia was associated with high mortality rates of 29%, 37%, and 38% at 7, 28, and 60 days respectively, significant ICU admissions and mechanical ventilation rates. Patients with severe hyperlactatemia were stratified into high (> 50% mortality), moderate (21-50%), and low (< 20%) 28-day mortality risk groups. High-risk conditions included non-septic shock, traumatic injuries/burns, and neurological issues, with mortality rates of 51.1%, 61.8%, and 57.1%, respectively. In the moderate risk group, namely infection without shock showed a high prevalence, with a mortality rate of 36%. In the low-risk group, seizures and fainting were associated with lower mortality, exhibiting mortality rates of 0%. Conclusions Severe hyperlactatemia is associated with higher rates of ICU admission and mortality compared to other degrees of lactate elevation in a general ED population. However, mortality rates can vary considerably, depending on the underlying etiology associated with different primary diagnoses.

Background: Escherichia coli is a common bloodstream infection pathogen in the emergency department (ED). Patients with extended-spectrum beta-lactamase (ESBL) E. coli have a higher risk of morbidity. However, there is still debate surrounding ESBL E. coli-associated mortality in community, intensive care unit, and tertiary care settings. In addition, there have been few studies regarding mortality in ESBL E. coli in ED settings, and results have been contradictory. Methods: This was a retrospective cohort study conducted at the Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University in Thailand aimed at evaluating the possible association between ESBL E. coli bacteremia and mortality in the ED. The inclusion criteria were age 18 years or over, clinical presentation suspicious of infection, and positive blood culture for E. coli. Predictors for mortality were analyzed by logistic regression analysis. Results: During the study period, 273 patients presented at the ED with hemoculture positive for E. coli. Of those, 27 (9.89%) died. Five factors remained in the final model, of which plasma glucose levels, serum lactate levels, and ESBL E. coliwere significantly associated with 28-day mortality in the ED with adjusted odds ratios of 0.970, 1.258, and 12.885, respectively. Plasma glucose of less than 113 mg/dL yielded a sensitivity of 80.95% and specificity of 64.29%, while serum lactate over 2.4 mmol/L had a sensitivity of 81.48% and specificity of 45.50%. Conclusion: ESBL E. coli, plasma glucose, and serum lactate levels were associated with 28-day mortality in patients with E. coli bacteremia presenting at the ED.

To report on prevalence of gout flare in emergency departments and to report the quality of gout care in emergency departments and causes of admission at emergency departments. A retrospective chart review of visits that had a primary diagnosis in gout by the International Classification of Diseases, the tenth revision, at emergency departments from 6 universities in Thailand over a 5 year period from 1 January 2012 to 31 December 2016. Six hundred thirty-two visits were included to the study. Prevalence of gout flare in emergency departments was 0.04. Only 29.3% of the visits had arthrocentesis. 628/632 (99.4%) and 519/585 (88.7%) of the visits were prescribed medications in emergency departments and had home medications, respectively. Although all visits that were prescribed colchicine in emergency departments received adequate doses of colchicine, it was also found that more than 2.4 mg/day of colchicine was prescribed (3/394, 0.8%) for home medications. In addition, 183/343 (53.4%) of the visits with normal renal function were prescribed non-steroidal anti-inflammatory drugs (NSAIDs). However, prescribed NSAIDs in abnormal renal function (42/343, 12.2%) was also found. The interruption of dosing, including increase, decrease, addition or discontinuance of urate lowing therapy in a gout flare period was 42/632 (6.6%). The most common cause of admission was acute gouty arthritis (31/47, 66.0%). Quality of gout care in the emergency departments was not good. Inappropriate management of gout flare in emergency departments was demonstrated in our study, particularly with regard to investigations and pharmacological management. Gaps between clinicians and guidelines, the knowledge of clinicians, and overcrowding in emergency departments were hypothesized in the results.