Gamification has gained popularity in medical education, but key elements have not been formally identified. This study aimed to generate and prioritize a list of key elements of gamification in medical education. This study utilized a two-stage approach, including the Delphi method and qualitative interview. Nineteen medical educators with expertise in gamification participated in the Delphi method stage. Experts who had more than three years of experience with gamification in medical education constituted the expert panel. The experts were then asked to rate the gamification elements using the Likert five-point scale through at least two consensus-seeking rounds. Consensus for key elements was predefined as ≥ 51% of respondents rating an element as 'important' or"very important." In the qualitative interview stage, 10 experts provided feedback on the application of these key gamification elements. Eighteen participants (11 males and 7 females) completed the entire Delphi process for this study. After two rounds of surveys, the consensus was reached on all elements. Thirteen elements scored more than 4 points (37%) and reached the criteria of key elements of gamification in medical education. The top five key elements were integration with instruction objectives, game rules, rapid feedback, fairness, and points/scoring. The thirteen key elements for successful gamification in medical education were further organized into two main categories: (1) gamification design principles and (2) game mechanisms. Integration with educational objectives, gamification in curriculum design and teaching methods, and balancing between the mechanisms and principles were the three key components for successful gamification. This study explored the gamification key elements, providing practical tips for medical educators in their efforts to gamify medical education. Future studies involving learners could be performed to examine the efficacy of these key elements in gamification.

Background: Methods: Results: Conclusions:

The effects of tranexamic acid (TXA) in the setting of shoulder arthroplasty are unclear. The objective of this study was to examine the effects of TXA in reducing the need for blood transfusions and blood loss in patients undergoing primary total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and retrospective cohort studies (RCS) that compared outcomes of patients who did and did not receive TXA during TSA or RTSA. We searched Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE for relevant studies. We assessed the risk of bias of the included studies and calculated pooled risk estimates. The primary outcome was transfusion rate, and secondary outcomes were changes in hemoglobin, estimated total blood loss (ETBL), blood loss via drainage, operative time, hospital stay, overall complications, and thromboembolic events. We identified 3 RCTs and 3 RCS including 677 patients with 680 shoulders (343 TXA and 337 non-TXA). The random-effects model meta-analysis showed that TXA group had a lower transfusion rate (risk ratio (RR) 0.34, 95% CI 0.14 to 0.79), less change in hemoglobin (mean difference (MD) -0.64 g/dl, 95% CI -0.81 to − 0.46), and reduced ETBL (MD -249.24 ml, 95% CI -338.74 to − 159.74). In patients with RTSA, the TXA group had a lower transfusion rate (RR 0.28, 95% CI 0.14 to 0.79), less ETBL (MD -249.15 ml, 95% CI -426.60 to − 71.70), less change in hemoglobin (MD − 0.64 g/dl, 95% CI -0.86 to − 0.42), and less blood loss via drainage (MD − 84.56 ml, 95% CI -145.72.14 to − 23.39) than non-TXA group. The use of TXA in primary shoulder arthroplasty appears safe, and can reduce transfusion rate, changes in hemoglobin, and perioperative total blood loss, especially in patients with RTSA. Level of Evidence: Systematic Review and meta-analysis, III.

Background: Monomicrobial necrotizing fasciitis is rapidly progressive and life-threatening. This study was undertaken to ascertain whether the clinical presentation and outcome for patients with this disease differ for those infected with a gram-positive as compared to gram-negative pathogen. Methods: Forty-six patients with monomicrobial necrotizing fasciitis were examined retrospectively from November 2002 to January 2008. All patients received adequate broad-spectrum antibiotic therapy, aggressive resuscitation, prompt radical debridement and adjuvant hyperbaric oxygen therapy. Eleven patients were infected with a gram-positive pathogen (Group 1) and 35 patients with a gram-negative pathogen (Group 2). Results: Group 2 was characterized by a higher incidence of hemorrhagic bullae and septic shock, higher APACHE II scores at 24 h post-admission, a higher rate of thrombocytopenia, and a higher prevalence of chronic liver dysfunction. Gouty arthritis was more prevalent in Group 1. For non-survivors, the incidences of chronic liver dysfunction, chronic renal failure and thrombocytopenia were higher in comparison with those for survivors. Lower level of serum albumin was also demonstrated in the non-survivors as compared to those in survivors. Conclusions: Pre-existing chronic liver dysfunction, chronic renal failure, thrombocytopenia and hypoalbuminemia, and post-operative dependence on mechanical ventilation represent poor prognostic factors in monomicrobial necrotizing fasciitis. Patients with gram-negative monobacterial necrotizing fasciitis present with more fulminant sepsis.

Patients with knee osteoarthritis (OA) were reported to have quadriceps weakness, and impaired proprioception, both related to pain and swelling. It is unclear whether pain alone a causal factor to above findings over the knee joint. The purpose of this study was to assess the effects of knee pain alone on the quadriceps strength, proprioception and dynamic balance in subjects with bilateral knee OA without joint swelling. Fourty females with mean age of 68.3 years were involved in this cross-sectional study. The inclusion criteria were bilateral knee OA without joint swelling, with a visual analogue pain scale difference (> 1) between each knee. Patients all underwent assessment of the isokinetic strength of knee muscles, knee proprioceptive acuity, and dynamic balance. Patients’ more painful knee had weaker isokinetic quadriceps strength than less painful knee at both 60 °/s and 180 °/s (p = 0.01, p = 0.01, respectively). There were no differences in proprioceptive acuity between both knees in all three knee positions. Meanwhile, there was a significant difference in the dynamic balance index measurement between both knees (more painful versus less painful: 3.88 ± 1.15 vs. 3.30 ± 1.00, p = 0.01). Quadriceps strength was associated with dynamic balance stability (60 °/s, r = − 0.578, p < 0.01; 180 °/s, r = − 0.439, p < 0.01). For patients with knee OA, the more painful knee was associated with weaker quadriceps and poor balance ability. To improve lower limb function and balance stability of the older persons having knee OA, physicians should take the optimal pain management strategy.

Stoma reversal is a surgical procedure commonly used following temporary defunctioning stoma surgery. Surgical site infection is one of the most common postoperative morbidities. A few skin closure methods have been developed to decrease surgical site infection. However, the optimal skin closure method is still in debate. The aim of this study was to compare the surgical site infection rate and other postoperative outcomes between the pursestring closure and conventional primary closure techniques. We searched the MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for relevant trials. We conducted a meta-analysis of randomized controlled trials that compared the surgical outcomes following pursestring closure and conventional primary closure techniques. We conducted the meta-analysis by using the random-effects model. The primary outcome of interest was surgical site infection following stoma reversal within 30 days after operation. This meta-analysis included 4 randomized controlled trials with a total of 319 participants (162 in the pursestring closure group and 157 in the conventional primary closure group). Compared with the conventional primary closure group, the pursestring closure group had a significant decrease in surgical site infection (risk difference, -0.25; 95% CI, -0.36 to -0.15; p < 0.00001; number needed to treat = 4) and higher satisfaction with cosmetic outcomes (standard mean difference, 0.7; 95% CI, 0.13-1.27; p = 0.02). No other significant differences in operative time, length of hospital stay, and wound healing time were found between the 2 groups. This study was limited to the lack of double blinding and long-term follow-up in the included trials. Pursestring closure has significantly fewer surgical site infections and achieves better cosmetic outcomes following stoma reversal than conventional primary closure.