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Background: The COVID-19 pandemic has resulted in worldwide kidney transplantation (KT) moratoriums. The impacts of these moratoriums on the life expectancy of KT candidates remain unclear., Methods: We simulated the evolution of several French candidate populations for KT using a multistate semi-Markovian approach and according to moratorium durations ranging from 0 to 24 mo. The transition rates were modeled from the 63 927 French patients who began dialysis or were registered on the waiting list for KT between 2011 and 2019., Results: Among the 8350 patients active on the waiting list at the time of the French KT moratorium decided on March 16, 2020, for 2.5 mo, we predicted 4.0 additional months (confidence interval [CI], 2.8-5.0) on the waiting list and 42 additional deaths (CI, -70 to 150) up to March 16, 2030, compared with the scenario without moratorium. In this population, we reported a significant impact for a 9-mo moratorium duration: 135 attributable deaths (CI, 31-257) up to March 16, 2030. Patients who became active on the list after March 2020 were less impacted; there was a significant impact for an 18-mo moratorium (175 additional deaths [CI, 21-359]) in the 10 862 prevalent end-stage renal disease patients on March 16, 2020 and for a 24-mo moratorium (189 additional deaths [CI, 10-367]) in the 16 355 incident end-stage renal disease patients after this date., Conclusion: The temporary moratorium of KT during a COVID-19 peak represents a sustainable decision to free up hospitals' resources if the moratorium does not exceed a prolonged period., Competing Interests: The authors declared no conflict of interest for this study., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Adverse events (AEs) in health care are a public health issue. Although mandatory, error disclosure is experienced by health providers as a difficult task., Methods: In this prospective study, the primary objective was to assess performance in disclosing AEs to simulated parents using a validated scale before and after training among a pediatric residents' population. Secondary objectives were to assess correlation with year of residency, sex, and previous experience and to analyze gain in knowledge (theoretical pretest/posttest scores) and satisfaction. Two evaluation simulations (simulation [SIM] 1 and SIM 2) were scheduled at 3-week interval. In the intervention group, mastery learning was offered after SIM 1 including a didactic approach and a training session using role-playing games. For the control group, the course was carried out after SIM 2. Assessments were performed by 2 independent observers and simulated parents., Results: Forty-nine pediatric residents performed 2 scenarios of AE disclosure in front of simulated parents. In the intervention group, performance scores on SIM 2 (72.36 ± 5.40) were higher than on SIM 1 (65.08 ± 9.89, P = 0.02). In the control group, there was no difference between SIM 1 and SIM 2 (P = 0.62). The subjective scores from simulated parents showed the same increase on SIM 2 (P < 0.01). There was no correlation with the residents' previous experience or their residency year. There was an increase in self-confidence (P = 0.04) for SIM 2. There was also an increase in posttest theoretical scores (P = 0.02), and residents were satisfied with the training., Conclusions: This study showed the benefits of simulation-based training associated with mastery learning in AE disclosure among pediatric residents. It is important to train residents for these situations to avoid traumatic disclosure generating a loss of confidence of the family regarding physicians and possible lawsuits., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The primary objective was to determine whether technical and nontechnical performances were in some way correlated during immersive simulation. Performance was measured among French Emergency Medical Service workers at an individual and a team level. Secondary objectives were to assess stress response through collection of physiologic markers (salivary cortisol, heart rate, the proportion derived by dividing the number of interval differences of successive normal-to-normal intervals > 50 ms by the total number of normal-to-normal intervals [pNN50], low- and high-frequency ratio) and affective data (self-reported stress, confidence, and dissatisfaction), and to correlate them to performance scores., Design: Prospective observational study performed as part of a larger randomized controlled trial., Setting: Medical simulation laboratory., Subjects: Forty-eight participants distributed among 12 Emergency Medical System teams., Interventions: Individual and team performance measures and individual stress response were assessed during a high-fidelity simulation. Technical performance was assessed by the intraosseous access performance scale and the Team Average Performance Assessment Scale; nontechnical performance by the Behavioral Assessment Tool for leaders, and the Clinical Teamwork Scale. Stress markers (salivary cortisol, heart rate, pNN50, low- and high-frequency ratio) were measured both before (T1) and after the session (T2). Participants self-reported stress before and during the simulation, self-confidence, and perception of dissatisfaction with team performance, rated on a scale from 0 to 10., Measurements and Main Results: Scores (out of 100 total points, mean ± SD) were intraosseous equals to 65.6 ± 14.4, Team Average Performance Assessment Scale equals to 44.6 ± 18.1, Behavioral Assessment Tool equals to 49.5 ± 22.0, Clinical Teamwork Scale equals to 50.3 ± 18.5. There was a strong correlation between Behavioral Assessment Tool and Clinical Teamwork Scale (Rho = 0.97; p = 0.001), and Behavioral Assessment Tool and Team Average Performance Assessment Scale (Rho = 0.73; p = 0.02). From T1 to T2, all stress markers (salivary cortisol, heart rate, pNN50, and low- and high-frequency ratio) displayed an increase in stress level (p < 0.001 for all). Self-confidence was positively correlated with performance (Clinical Teamwork Scale: Rho = 0.47; p = 0.001, Team Average Performance Assessment Scale: Rho = 0.46; p = 0.001). Dissatisfaction was negatively correlated with performance (Rho = -0.49; p = 0.0008 with Behavioral Assessment Tool, Rho = -0.47; p = 0.001 with Clinical Teamwork Scale, Rho = -0.51; p = 0.0004 with Team Average Performance Assessment Scale). No correlation between stress response and performance was found., Conclusions: There was a positive correlation between leader (Behavioral Assessment Tool) and team (Clinical Teamwork Scale and Team Average Performance Assessment Scale) performances. These performance scores were positively correlated with self-confidence and negatively correlated with dissatisfaction.

Objectives: In patients with acute hypoxemic respiratory failure, noninvasive ventilation and high-flow nasal cannula oxygen are alternative strategies to conventional oxygen therapy. Endotracheal intubation is frequently needed in these patients with a risk of delay, and early predictors of failure may help clinicians to decide early. We aimed to identify factors associated with intubation in patients with acute hypoxemic respiratory failure treated with different noninvasive oxygenation techniques., Design: Post hoc analysis of a randomized clinical trial., Setting: Twenty-three ICUs., Patients: Patients with a respiratory rate greater than 25 breaths/min and a PaO2/FIO2 ratio less than or equal to 300 mm Hg., Intervention: Patients were treated with standard oxygen, high-flow nasal cannula oxygen, or noninvasive ventilation., Measurement and Main Results: Respiratory variables one hour after treatment initiation. Under standard oxygen, patients with a respiratory rate greater than or equal to 30 breaths/min were more likely to need intubation (odds ratio, 2.76; 95% CI, 1.13-6.75; p = 0.03). One hour after high-flow nasal cannula oxygen initiation, increased heart rate was the only factor associated with intubation. One hour after noninvasive ventilation initiation, a PaO2/FIO2 ratio less than or equal to 200 mm Hg and a tidal volume greater than 9 mL/kg of predicted body weight were independent predictors of intubation (adjusted odds ratio, 4.26; 95% CI, 1.62-11.16; p = 0.003 and adjusted odds ratio, 3.14; 95% CI, 1.22-8.06; p = 0.02, respectively). A tidal volume above 9 mL/kg during noninvasive ventilation remained independently associated with 90-day mortality., Conclusions: In patients with acute hypoxemic respiratory failure breathing spontaneously, the respiratory rate was a predictor of intubation under standard oxygen, but not under high-flow nasal cannula oxygen or noninvasive ventilation. A PaO2/FIO2 below 200 mm Hg and a high tidal volume greater than 9 mL/kg were the two strong predictors of intubation under noninvasive ventilation.

Objective: To evaluate whether early administration of high-dose methylprednisolone limits the fall of platelets in preeclampsia., Methods: A randomized trial of 180 mg methylprednisolone or placebo administered in divided doses over 36 hours was conducted in women admitted for preeclampsia and platelet counts below 150×10/L in four French academic centers. Patients were not included when platelet counts were below 50×10/L or when immediate delivery was required. The primary study outcome was the proportion of patients with platelet counts above 100×10/L 36 hours after the first dose of study medication. The total sample size needed to detect a 23% difference in the rate of this outcome between groups with a one-tailed α of 0.05 and 90% power was 94 patients., Results: Thirty-six patients were randomly assigned to receive methylprednisolone and 34 placebo between October 2007 and May 2011. Platelet counts above 100×10/L at 36 hours after the first dose of study medication were recorded in 30 (83%) in the active group and 29 (85%) in the placebo group (relative risk 0.98, 95% confidence interval 0.80-1.20; P=.82). The only adverse potentially study-related event was hyperglycemia in one woman allocated to methylprednisolone., Conclusion: In women with preeclampsia and platelet counts under 150×10/L, methylprednisolone was not effective in maintaining platelet counts above 100×10/L., Clinical Trial Registration: EU Clinical Trials Register, http://clinicaltrialsregister.eu, EudraCT 2006-004881-15-FR.

Diabetic macular edema (DME) is the main cause of visual loss associated with diabetes but any association between DME and cardiovascular events is unclear.This study aims to describe the possible association between DME and cardiovascular events in a multicenter cross-sectional study of patients with type 2 diabetes.Two thousand eight hundred seven patients with type 2 diabetes were recruited from diabetes and nephrology clinical institutional centers participating in the DIAB 2 NEPHROGENE study focusing on diabetic complications. DME (presence/absence) and diabetic retinopathy (DR) classification were based on ophthalmological report and/or on 30° color retinal photographs. DR was defined as absent, nonproliferative (background, moderate, or severe) or proliferative. Cardiovascular events were stroke, myocardial infarction, and lower limb amputation.Details regarding associations between DME and cardiovascular events were evaluated.The study included 2807 patients with type 2 diabetes, of whom 355 (12.6%) had DME. DME was significantly and independently associated with patient age, known duration of diabetes, HbA1c, systolic blood pressure, and DR stage. Only the prior history of lower limb amputation was strongly associated with DME in univariate and multivariate analyses, whereas no association was found with regard to myocardial infarction or stroke. Moreover, both major (n = 32) and minor lower limb (n = 96) amputations were similarly associated with DME, with respective odds ratio of 3.7 (95% confidence interval [CI], 1.77-7.74; P = 0.0012) and of 4.29 (95% CI, 2.79-6.61; P < 0.001).DME is strongly and independently associated with lower limb amputation in type 2 diabetic patients.

Study Design: This is a biomechanical study., Objective: Measuring changes in foraminal size after L4-L5 interspinous devices implantation., Summary of Background Data: Low-back pain aetiologies include foraminal stenoses. A niche is developing for interspinal implants that are minimally invasive with few harmful side effects. At present, we do not have sufficient understanding about their impact on the foraminal opening., Methods: Six fresh L2-S1 columns were prepared with preservation of the capsuloligamentary and discal structures. The L4-L5 foramen was particularly carefully prepared. A 2-dimensional photographic analysis measured the length and width of the foramen and the extraforaminal surface, both before and after the implantation of a supple interspinal device that preserves the supraspinal ligaments. Photographic calibration and the use of precise and identical photographic landmarks (pixels) permitted the calculation of the foraminal deformity. A Wilcoxon test was performed for statistical analysis with P<0.05 for significance., Results: The average foraminal length was 15.7±2.8 mm and the average width was 9.4±1.2 mm. After the implantation of an interspinal device, it was 16.8±2.5 and 10.1±1.3 mm, respectively. The increase in the average foraminal opening was 7.45% and 7.63%, respectively (P=0.02). The average foraminal surface area was 150.4±35.8 mm and following intervention, this was 165.1±28.3 mm, that is an average gain of 14.65 mm (5.3-26.9) (P=0.03)., Conclusions: Few interspinal devices have been the subject of studies on the foraminal opening after implantation. Among the initial strict indications on root compressions for which conventional surgery is too invasive, these implants could present a true therapeutic alternative. This supple implant significantly opened the L4-L5 foramen on the cadavers. Nevertheless, biomechanical data are lacking on its effects on the 3 planes following stress. Even if the impact on the foraminal opening is of interest, kinematic studies are needed to determine the exact effects before clinical implantation.

We propose an intraosseous (IO) procedure scale for evaluating the insertion process during simulation. A 12-item scale for assessing the performance of IO insertion into the proximal tibia reproduces all the steps of a manual procedure. The performance of 31 emergency physicians was evaluated with this scale on a mannequin simulating a decompensated shock in a 6-month-old infant.Our IO procedure scale was reliable, with a very high interobserver reproducibility. The application of this scale to procedures yielded higher scores for successful than for unsuccessful procedures (P < 10), a 93.5% success rate, and a mean placement time of 2 minutes 23 seconds. Although designed for a manual insertion of an IO needle during simulation, this scale may be also suitable for use in clinical settings.

The main advantages of ambulatory blood pressure monitoring (ABPM) over clinic blood pressure measurements are the following: the lack of an alarm reaction and of observer bias; repeated readings during 24 h in the customary environment of the patient, instead of a single measurement in the doctor's office; superior reproducibility, allowing the sample size of study groups to be reduced substantially; and multiple data, likely to be analysed by several complementary methods. The different non-pharmacological interventions could be classified as follows: probably ineffective (sodium intake restriction, caffeine intake restriction, abstinence from alcohol consumption), probably effective (potassium supplementation, magnesium supplementation, weight reduction by overweight patients, cessation of smoking) and requiring further investigation (psychological interventions, physical activity, dietary lipid level modifications). The effects of pharmacological treatment may be accurately assessed by using ABPM: detailed information is given concerning the duration of action of the antihypertensive drugs; different regimens of the same treatment mayi be compared with each other or with placebo; and the trough: peak ratio can be determined for each drug. It is noteworthy that all of these subtle measurements have to be performed in patients the blood pressure of whom seems to respond adequately to the drug under evaluation. An additional key role for ABPM in clinical trials could be to establish selection criteria both for trial entry and for dose adjustment.