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Introduction Script concordance tests (SCTs) have been developed to assess clinical reasoning in uncertain situations. Their reliability for the evaluation of undergraduate medical students has not been evaluated. Methods Twenty internal medicine SCT cases were implemented in undergraduate students of two programs. The results obtained on the SCTs were compared to those obtained by the same students on clinical-based classical multiple-choice questions (MCQs). Results A total of 551/883 students (62%) answered the SCTs. The mean aggregate score (based on a total 20 points) was 11.54 (3.29). The success rate and mean score for each question did not differ depending on the modal response but the discrimination rate did. The results obtained by the students on the SCT test correlated with their scores on the MCQ tests. Among students, 446/517 (86%) considered the SCTs to be more difficult than classical MCQs, although the mean score did not differ between the SCT and MCQ tests. Conclusion The use of SCTs is a feasible option for the evaluation of undergraduate students. The SCT scores correlated with those obtained on classical MCQ tests.

Resume Contexte Les referentiels des societes savantes de medecine et des colleges des enseignants des specialites medicales sont utilises comme des references officielles pour les examens facultaires et les epreuves nationales. L’oncologie est une discipline transdisciplinaire, pratiquee et enseignees par les oncologues mais egalement des specialistes d’organe. Ce travail avait pour objectif d’identifier les discordances entre les chapitres traitant du cancer dans les referentiels des colleges d’enseignants en medecine et d’en evaluer l’impact chez les etudiants. Materiel et methodes Les discordances entre les chapitres traitant du cancer dans les referentiels des colleges d’enseignants en medecine ont ete recensees par des etudiants, volontaires, en sixieme annee a la faculte de medecine Sorbonne universite. Il leur etait egalement demande d’evaluer, de maniere individuelle, l’impact de ces discordances sur leur apprentissage. Resultats En mars 2017, les 17 items de cancerologie du programme officiel du deuxieme cycle des etudes medicales etaient traites dans 14 referentiels de colleges d’enseignants en medecine (deux a quatre referentiels par localisation tumorale). Soixante-dix-huit des 390 etudiants de sixieme annee se sont portes volontaires et ont travaille en binomes. Chaque localisation etait analysee par trois binomes (un a deux cancers par binome). Cent cinquante-quatre discordances ont ete relevees (quatre a dix-huit par cancer). L’ensemble des etudiants declarait que l’existence de ces discordances etait source de doute et d’anxiete. Quatre-vingt-cinq pour cent d’entre eux consideraient qu’une harmonisation des referentiels devrait etre recherchee dans l’ensemble des domaines du programme des etudes medicales. Conclusions Les discordances entre referentiels des colleges d’enseignants sont frequentes, generant une anxiete chez les etudiants avec un impact ressenti sur leur apprentissage.

International audience; Objectives: To evaluate the impact of nonviolent communication (NVC) training on five aspects of medical students' empathy skills using implicit and explicit measures. Methods: 312 third-year French medical students were randomly allocated to an intervention group (n = 123) or a control group (n = 189). The intervention group received 2.5 days of NVC training. For each group, empathy-related skills were measured implicitly using three cognitive tests (Visuo-Spatial Perspective Taking, Privileged Knowledge, Empathy for Pain evaluation) and explicitly using two self-rating questionnaires (Jefferson Scale of Physician Empathy, Empathy Quotient). Both groups completed tests and questionnaires before (pre-test) and three months after training (post-test). Responses were collected via online software, and data were analyzed using paired linear mixed models and Bayes Factors. Results: We found a significant increase in the Jefferson Scale of Physician Empathy (JSPE) score between pre-and post-tests in the intervention group compared to the control group (linear mixed models: 0.95 points [0.17, 1.73], t(158) = 2.39, p < 0.05), and an expected gender effect whereby females had higher JSPE scores (1.57 points [0.72, 2.42], t(262) =-3.62, p < 0.001). There was no interaction between these two factors. Conclusions: Our results show that brief training in nonviolent communication improves subjective empathy three months after training. These results are promising for the long-term effectiveness of NVC training on medical students' empathy and call for the introduction of NVC training in medical school. Further studies should investigate whether longer training will produce larger and longer-lasting benefits.

STUDY DESIGN Prospective study. OBJECTIVE Determine risk factors and consider impact of low back pain for medical students. SUMMARY OF BACKGROUND DATA Low back pain (LBP) is one of the most prevalent complaints among students. The vulnerability of medical students due to stress and numerous hours of studying and training makes them at risk of LBP. METHODS We submitted an online self-administered modified version of the Standardized Nordic Questionnaire to 1800 medical students from 2nd to 6th year from December 2017 to March 2018. RESULTS A total of 1243/1800 (68.9%) students responded to our survey. Mean age was 23.3 ± 2.9 years ranging from 18 to 44 years. 835 (72.1%) students reported suffering from LBP. In multivariate analysis with logistic regression analysis model, the third year of medical studies (odds ratio [OR]: 0.558, 95% confidence interval [CI] 0.387-0.805; P = 0.002) was identified as an independent prognostic factor of LBP. Moreover, exercising weekly (OR: 1.835, 95% CI 0.933-2.5; P = 0.01) and walking at least 30 minutes a day (OR: 1.458, 95% CI 1.129-1.876; P = 0.01) significantly improve LBP. LBP generate higher monthly consumption of an analgesic (OR: 32.8, 95% CI 4.271-252.2; P

BackgroundWhereas first-line bronchial artery embolisation (BAE) is considered standard of care for the management of severe haemoptysis, it is unknown whether this approach is warranted for non-severe haemoptysis.Research questionTo assess the efficacy on bleeding control and the safety of first-line BAE in non-severe haemoptysis of mild abundance.Study design and methodsThis multicentre, randomised controlled open-label trial enrolled adult patients without major comorbid condition and having mild haemoptysis (onset ResultsBleeding recurrence at day 30 after randomisation (primary outcome) occurred in 4 (11.8%) of 34 patients in the BAE strategy and 17 (44.7%) of 38 patients in the medical strategy (difference −33%; 95% CI −13.8% to −52.1%, p=0.002). The 90-day bleeding recurrence-free survival rates were 91.2% (95% CI 75.1% to 97.1%) and 60.2% (95% CI 42.9% to 73.8%), respectively (HR=0.19, 95% CI 0.05 to 0.67, p=0.01). No death occurred during follow-up and no bleeding recurrence needed surgery.Four adverse events (one major with systemic emboli) occurred during hospitalisation, all in the BAE strategy (11.8% vs 0%; difference 11.8%, 95% CI 0.9 to 22.6, p=0.045); all eventually resolved.ConclusionIn non-severe haemoptysis of mild abundance, BAE associated with medical therapy had a superior efficacy for preventing bleeding recurrences at 30 and 90 days, as compared with medical therapy alone. However, it was associated with a higher rate of adverse events.Trial registration numberNCT01278199

In France, at the end of the sixth year of medical studies, students take a national ranking examination including progressive clinical case-based multiple-choice questions (MCQs). We aimed to evaluate the ability of these MCQs for testing higher-order thinking more than knowledge recall, and to identify their characteristics associated with success and discrimination.We analysed the 72 progressive clinical cases taken by the students in the years 2016-2019, through an online platform.A total of 72 progressive clinical cases (18 for each of the 4 studied years), corresponding to 1059 questions, were analysed. Most of the clinical cases (n=43, 60%) had 15 questions. Clinical questions represented 89% of all questions, whereas basic sciences questions accounted for 9%. The most frequent medical subspecialties were internal medicine (n=90, 8%) and infectious diseases (n=88, 8%). The most frequent question types concerned therapeutics (26%), exams (19%), diagnosis (14%), and semiology (13%). Level 2 questions ("understand and apply") accounted for 59% of all questions according to the Bloom's taxonomy. The level of Bloom's taxonomy significantly changed over time with a decreasing number of level 1 questions ("remember") (P=0.04). We also analysed the results of the students among 853 questions of training ECNi. Success and discrimination significantly decreased when the number of correct answers increased (P0.0001 both). The success, discrimination, mean score, and mean number of discrepancies did not differ according to the diagnosis, exam, imaging, semiology, or therapeutic type of questions.Progressive clinical case-based MCQs represent an innovative way to evaluate undergraduate students.

OBJECTIVES To determine whether real-time video communication between the first responder and a remote intensivist via Google Glass improves the management of a simulated in-hospital pediatric cardiopulmonary arrest before the arrival of the ICU team. DESIGN Randomized controlled study. SETTING Children's hospital at a tertiary care academic medical center. SUBJECTS Forty-two first-year pediatric residents. INTERVENTIONS Pediatric residents were evaluated during two consecutive simulated pediatric cardiopulmonary arrests with a high-fidelity manikin. During the second evaluation, the residents in the Google Glass group were allowed to seek help from a remote intensivist at any time by activating real-time video communication. The residents in the control group were asked to provide usual care. MEASUREMENTS AND MAIN RESULTS The main outcome measures were the proportion of time for which the manikin received no ventilation (no-blow fraction) or no compression (no-flow fraction). In the first evaluation, overall no-blow and no-flow fractions were 74% and 95%, respectively. During the second evaluation, no-blow and no-flow fractions were similar between the two groups. Insufflations were more effective (p = 0.04), and the technique (p = 0.02) and rate (p < 0.001) of chest compression were more appropriate in the Google Glass group than in the control group. CONCLUSIONS Real-time video communication between the first responder and a remote intensivist through Google Glass did not decrease no-blow and no-flow fractions during the first 5 minutes of a simulated pediatric cardiopulmonary arrest but improved the quality of the insufflations and chest compressions provided.

Introduction Neurological disorders are frequently being managed by general practitioners. It is therefore critical that future physicians become comfortable with neurological examination and physical diagnosis. Graduating medical students often consider neurological examination as one of the clinical skills they are least comfortable with, and they even tend to be neurophobic. One way to improve the learning of neurological semiology is to design innovative learner-friendly educational methods, including simulation training. Methods The feasibility of mime-based roleplaying was tested by a simulation training program in neurological semiology called ‘The Move’. The program was proposed to third-year medical students at Pierre and Marie Curie University in Paris during their neurology rotation. Students were trained to roleplay patients by miming various neurological syndromes (pyramidal, vestibular, cerebellar, parkinsonian) as well as distal axonopathy, chorea and tonic–clonic seizures. Using an anonymous self-administered questionnaire, the students’ and teachers’ emotional experience and views on the impact of the program were then investigated. Results A total of 223/365 students (61%) chose to participate in the study. Both students and teachers felt their participation was pleasant. Students stated that The Move increased their motivation to learn neurological semiology (78%), and improved both their understanding of the subject (77%) and their long-term memorization of the teaching content (86%). Although only a minority thought The Move was likely to improve their performance on their final medical examination (32%), a clear majority (77%) thought it would be useful for their future clinical practice. Both students (87%) and teachers (95%) thought The Move should be included in the medical curriculum. Conclusion Mime-based roleplaying simulation may be a valuable tool for training medical students in neurological semiology, and may also help them to overcome neurophobia.

Resume Objectifs L’objectif du deuxieme cycle des etudes medicales (DCEM) est « l’acquisition des competences generiques permettant aux etudiants d’exercer par la suite les fonctions du troisieme cycle ». Aucune etude, a notre connaissance, ne s’est interessee aux competences des internes de pediatrie a l’aube de leur prise de fonction. Materiels et methodes Les internes de pediatrie d’Ile-de-France nommes a l’issue des epreuves classantes nationales (ECN) 2014 ont ete evalues par simulateur sur un scenario d’arret cardiorespiratoire (ACR) de l’enfant. Le score de competence (respect de l’algorithme et technique de la reanimation) et les fractions de temps sans ventilation et sans compression ont ete recueillis. Resultats principaux Quarante-deux des 79 nouveaux internes ont ete evalues 15 jours avant leur prise de fonction. Le score de competence median a ete de 4 sur 13. Les fractions de temps sans ventilation et sans compression ont ete respectivement de 55 et 81 %. Il n’existait pas de correlation entre les resultats et le classement des internes aux ECN. Conclusions La prise en charge de l’ACR de l’enfant n’est pas maitrisee par les internes de pediatrie a quelques jours de leur prise de fonction. L’introduction de la simulation au cours du DCEM devrait favoriser l’acquisition des competences.

Background Although oversedation has been associated with increased morbidity in ventilated critically ill patients, it is unclear whether prevention of oversedation improves mortality. We aimed to assess 90-day mortality in patients receiving a bundle of interventions to prevent oversedation as compared to usual care. Methods In this randomized multicentre trial, all adult patients requiring mechanical ventilation for more than 48 h were included. Two groups were compared: patients managed according to usual sedation practices (control), and patients receiving sedation according to an algorithm which provided a gradual multilevel response to pain, agitation, and ventilator dyssynchrony with no specific target to alter consciousness and no use of sedation scale and promoted the use of alternatives to continuous infusion of midazolam or propofol (intervention). Results Inclusions were stopped before reaching the planned enrolment. Between 2012 and 2014, 584 patients were included in the intervention group and 590 in the control group. Baseline characteristics were well balanced between groups. Although the use of midazolam and propofol was significantly lower in the intervention group, 90-day mortality was not significantly lower (39.4 vs. 44.2% in the control group, p = 0.09). There were no significant differences in 1-year mortality between the two groups. The time to first spontaneous breathing trial and time to successful extubation were significantly shorter in the intervention group than in the control group. These last results should be interpreted with precaution regarding the several limitations of the trial including the early termination. Conclusions This underpowered study of severely ill patients was unable to show that a strategy to prevent oversedation could significantly reduce mortality. Trial registration NCT01617265

We tested whether dreams can anticipate a stressful exam and how failure/success in dreams affect next-day performance. We collected information on students' dreams during the night preceding the medical school entrance exam. Demographic, academic, sleep and dream characteristics were compared to the students' grades on the exam. Of the 719 respondents to the questionnaire (of 2324 total students), 60.4% dreamt of the exam during the night preceding it. Problems with the exam appeared in 78% of dreams and primarily involved being late and forgetting answers. Reporting a dream about the exam on the pre-exam night was associated with better performance on the exam (p=.01). The frequency of dreams concerning the exam during the first term predicted proportionally higher performance on the exam (R=0.1, p=.01). These results suggest that the negative anticipation of a stressful event in dreams is common and that this episodic simulation provides a cognitive gain.

Introduction Pres de 8000 etudiants en medecine sont amenes a passer chaque annee, en juin, les Epreuves classantes nationales informatisees (ECNi), a la fin de leur deuxieme cycle de formation des etudes medicales (DFASM). Le classement aux ECNi est determinant pour le choix de leur specialite et lieu de formation du 3e cycle. Les modalites de passation des epreuves ont ete modifiees pour aboutir, depuis 2016, a une passation totalement informatisee sur tablette, des questions a reponses multiples (QRM) isolees au sein de dossiers progressifs, ou pour l’analyse d’articles scientifiques, la notation s’effectuant par discordance. Il n’y a pas de donnees sur les facteurs associes a la reussite depuis la mise en place de ces nouvelles modalites de passation. Materiels et methodes L’objectif de cette etude etait de determiner les facteurs associes avec un classement dans la premiere moitie (M1), le premier quart (Q1) et le dernier quart (Q4) des etudiants en medecine. Il s’agissait d’une etude longitudinale monocentrique a partir des donnees de la scolarite de 460 etudiants ayant ete inscrits a la Faculte de medecine Pierre-et-Marie-Curie (Paris VI ), respectivement de la DFGSM2 a la DFASM3 entre les annees universitaires 2012 a 2016. Les facteurs predictifs suivants etaient etudies dans un modele multivarie : le fait d’avoir passe des UE en deuxieme session au cours de sa scolarite, le fait d’etre primant pour le concours de PAES, le sexe, et l’âge. Une seconde analyse visait a etudier le parcours des etudiants au cours de leur 6e annees d’etudes, en particulier, l’association a la presence aux conferences de preparation aux ECNi proposees par la Faculte. Resultats Parmi les 369 etudiants de cette faculte ayant passe les ECNi en 2017, 273 etudiants avaient suivi une scolarite sans interruption ni redoublement et ont ete analyses. Parmi eux, 48 % etaient situes dans le premier quart,77 % dans la premiere moitie des etudiants classes, et 6 %dans le dernier quart. L’âge moyen lors des ECNi etait de 25 ans (±1,5) et 62 % des etudiants etaient des femmes. Les facteurs predictifs les plus associes a la reussite aux ECNi 2017 etaient le fait de ne pas avoir passe d’UE lors d’epreuves de seconde session (OR 0,018 [0,07–0,47] p Conclusion Le classement aux ECNi est un evenement complexe mettant en jeu de nombreux facteurs interagissant entre eux. La reussite aux ECNi etait dans cette etude associee a un âge plus jeune, une reussite en PAES a la premiere tentative, la presence aux conferences de preparation facultaires, la reussite aux epreuves blanches et l’absence d’UE validees en deuxieme session au cours de sa scolarite.

Summary Background Ultrasonography is a non-invasive imaging modality that offers the opportunity to teach living cardiac anatomy and physiology. Aims The objectives of this study were to assess the feasibility of integrating an ultrasound-based course into the conventional undergraduate medical teaching programme and to analyse student and teacher feedback. Methods An ultrasound-based teaching course was implemented and proposed to all second-year medical students ( n = 348) at the end of the academic year, after all the conventional modules at our faculty. After a brief theoretical and practical demonstration, students were allowed to take the probe and use the ultrasound machine. Students and teachers were asked to complete a survey and were given the opportunity to provide open feedback. Results Two months were required to implement the entire module; 330 (95%) students (divided into 39 groups) and 37 teachers participated in the course. Student feedback was very positive: 98% of students agreed that the course was useful; 85% and 74% considered that their understanding of cardiac anatomy and physiology, respectively, was improved. The majority of the teachers (97%) felt that the students were interested, 81% agreed that the course was appropriate for second-year medical students and 84% were willing to participate to future sessions. Conclusions Cardiac anatomy and physiology teaching using ultrasound is feasible for undergraduate medical students and enhances their motivation to improve their knowledge. Student and teacher feedback on the course was very positive.

Aim Before implementing new workshops and teaching in our faculty for performing basic life support (BLS), we aimed to determine the level of self-confidence of medical students with regard to the management of cardiac arrest (CA). Methods We conducted a preinterventional study. A questionnaire was sent to third-year to sixth-year medical students. We recorded sex, year of training, and personal witnessing of CA. We asked them about their theoretical knowledge on 10 main items of BLS and their self-perception of qualification to conduct a CA situation. We tested the respective influence of sex, year of training, and personal witnessing of CA. Results In total, 592 (37%) students completed the questionnaire, 42% of them were men. Less than a third of the students (30%) thought of themselves as being sufficiently qualified to conduct BLS. After the third year, the level of study did not influence their theoretical knowledge or their self-perception of qualification. Male sex and the number of CAs witnessed were the only factors positively associated with better self-confidence regarding qualification. Conclusion Self-perception of qualification in BLS is poor in our faculty. In our study, personal witnessing of CA greatly influenced confidence, whereas level of study did not.

International audience; Importance Acetazolamide has been used for decades as a respiratory stimulant for patients with chronic obstructive pulmonary disease (COPD) and metabolic alkalosis, but no large randomized placebo-controlled trial is available to confirm this approach.Objective To determine whether acetazolamide reduces mechanical ventilation duration in critically ill patients with COPD and metabolic alkalosis.Design, Setting, and Participants The DIABOLO study, a randomized, double-blind, multicenter trial, was conducted from October 2011 through July 2014 in 15 intensive care units (ICUs) in France. A total of 382 patients with COPD who were expected to receive mechanical ventilation for more 24 hours were randomized to the acetazolamide or placebo group and 380 were included in an intention-to treat analysis.Interventions Acetazolamide (500-1000 mg, twice daily) vs placebo administered intravenously in cases of pure or mixed metabolic alkalosis, initiated within 48 hours of ICU admission and continued during the ICU stay for a maximum of 28 days.Main Outcomes and Measures The primary outcome was the duration of invasive mechanical ventilation via endotracheal intubation or tracheotomy. Secondary outcomes included changes in arterial blood gas and respiratory parameters, weaning duration, adverse events, use of noninvasive ventilation after extubation, successful weaning, the duration of ICU stay, and in-ICU mortality.Results Among 382 randomized patients, 380 (mean age, 69 years; 272 men [71.6%]; 379 [99.7%] with endotracheal intubation) completed the study. For the acetazolamide group (n = 187), compared with the placebo group (n = 193), no significant between-group differences were found for median duration of mechanical ventilation (−16.0 hours; 95% CI, −36.5 to 4.0 hours; P = .17), duration of weaning off mechanical ventilation (−0.9 hours; 95% CI, −4.3 to 1.3 hours; P = .36), daily changes of minute-ventilation (−0.0 L/min; 95% CI, −0.2 to 0.2 L/min; P = .72), or partial carbon-dioxide pressure in arterial blood (−0.3 mm Hg; 95% CI, −0.8 to 0.2 mm Hg; P = .25), although daily changes of serum bicarbonate (between-group difference, −0.8 mEq/L; 95% CI, −1.2 to −0.5 mEq/L; P \textless .001) and number of days with metabolic alkalosis (between-group difference, −1; 95% CI, −2 to −1 days; P \textless .001) decreased significantly more in the acetazolamide group. Other secondary outcomes also did not differ significantly between groups.Conclusions and Relevance Among patients with COPD receiving invasive mechanical ventilation, the use of acetazolamide, compared with placebo, did not result in a statistically significant reduction in the duration of invasive mechanical ventilation. However, the magnitude of the difference was clinically important, and it is possible that the study was underpowered to establish statistical significance.Trial Registration clinicaltrials.gov Identifier: NCT01627639

International audience; Objective: Simulation-based teaching offers promising and diverse teaching possibilities. We aim to assess whether the death of the manikin increased anxiety amongst learner compared to similar simulation-based course where the manikin stays alive. Methods: We conducted a cluster randomized study amongst multidisciplinary teams of emergency workers. Teams of physicians, nurses, and healthcare assistants were randomly assigned to participate in a simulation-based course where the simulated patient died (death group) or not (life group). We assessed anxiety at 1 month after the teaching using Spielberger STAI-state anxiety questionnaire. We compared reduction of anxiety when facing a life-threatening situation in both groups. Results: We included 25 teams for a total of 129 participants. We analysed 63 participants in the death group and 57 in the life group. Baseline characteristics were similar in both groups, including baseline anxiety (STAI-state score 39.6 (7.8) in the death group vs 38.6 (7.1) in the life group). We report a significant reduction in both groups 1 month after the training: 6.6 (7.8) vs 6 (8.0), mean difference 0.5 (−2.4; 3.4). At 3 months, we report a significant greater reduction of anxiety in the death group (mean difference 4 [0.1; 7.9]). Conclusion: We observed in our sample that unexpected simulated patient death did not increase anxiety amongst multidisciplinary emergency workers.

Background Phrenic pacing is an alternative to positive-pressure ventilation in selected patients, mostly in cases of upper spinal cord injury. We evaluated results of phrenic pacing performed by video-assisted thoracic surgery (VATS). Method Between 1997 and 2007, after complete neuromuscular investigations, 20 patients requiring full-time ventilation were selected for phrenic pacing (19 with posttraumatic tetraplegia and 1 with congenital central hypoventilation syndrome). Quadripolar cuff electrodes were fixed around each intrathoracic phrenic nerve via bilateral VATS. They were connected to a subcutaneous radiofrequency receiver coupled to an external radiofrequency transmitter. All patients participated in a reconditioning program beginning 2 weeks after implantation and continued until ventilatory weaning. Results Phrenic pacing was successful in all cases. No intraoperative complications or perioperative mortality were observed. Intraoperative testing detected stimulation thresholds in 19 patients (range, 0.05-2.9 mA). Ventilatory weaning was obtained in 18 patients. Median diaphragm reconditioning time was 6 weeks (2 weeks–11 months). Reconditioning was still in process in a young woman and was not achieved in an elderly woman with a 4-year history of tetraplegia. All the patients weaned from mechanical ventilation reported improved quality of life. Failure or delay in recovery of effective diaphragm contraction was due to nonreversible amyotrophy. Conclusions VATS implantation of 4-pole electrodes around the intrathoracic phrenic nerve is a safe procedure. Ventilatory weaning correlates with the degree of diaphragmatic amyotrophy. Phrenic pacing, performed as soon as neurologic and orthopedic stabilization is achieved, is the most important prognostic factor for successful weaning.

Le plan sante au travail 2016–2020 prevoit dans le cadre de l’objectif operationnel 8 II-1 de renforcer les acteurs de la prevention en entreprise. L’action 3.5 preconise de renforcer les services de sante au travail ; renforcer l’attractivite de la filiere medecine du travail, en developpant des actions d’information et de communication en direction des eleves en medecine pour valoriser et accroitre l’attractivite de la profession et en ameliorant l’attractivite de la carriere hospitalo-universitaire avec une forte influence sur la recherche universitaire. Depuis 2013 l’universite de medecine Pierre-et-Marie-Curie a commence une collaboration avec le CIAMT proposant aux etudiants en medecine de 4e annee une matinee de stage de decouverte en service de sante au travail. Les etudiants ont assiste a une consultation avec le medecin du travail et parfois avec l’infirmier en sante au travail. A la fin de ce stage les etudiants ont repondu a un questionnaire d’evaluation du stage. Nous vous presentons les resultats de ces evaluations et l’interet porte par les etudiants participants entre 2013 et 2017. Huit cent vingt et un etudiants en 4e annee de medecine ont effectue un stage d’une matinee dans le service de sante au travail. Seulement 796 questionnaires ont pu etre exploites. A la question « ce stage est utile pour l’item no 178. Environnement professionnel et sante au travail » 82,3 % des etudiants ont repondu favorablement (d’accord et tout a fait d’accord). A la question « ce stage est utile pour l’item no 179. Organisation de la medecine du travail. Prevention des risques professionnels » 84,55 % des etudiants ont repondu favorablement (d’accord et tout a fait d’accord). A la question « ce stage est utile pour l’item no 180. Accidents du travail et maladies professionnelles : definitions et enjeux » 67,21 % des etudiants ont repondu favorablement (d’accord et tout a fait d’accord). A la question « ce stage aide a comprendre le role du medecin du travail » 96,86 % des etudiants ont repondu favorablement (d’accord et tout a fait d’accord). Concernant la question « ce stage fait decouvrir une pratique de la medecine peu connue » 94,97 % des etudiants ont repondu favorablement (d’accord et tout a fait d’accord). A remarquer qu’a la question « Ce stage donne envie d’approfondir mes connaissances en medecine du travail » 45 % des etudiants ont repondu favorablement (d’accord et tout a fait d’accord) et 54,6 % ne sont pas d’accord. En conclusion a l’item « Ce stage a change mon regard sur la medecine du travail » 62 % des etudiants ont repondu favorablement (d’accord et tout a fait d’accord).

Background Neurally adjusted ventilatory assist (NAVA) is a partial ventilatory support mode where positive pressure is provided in relation to diaphragmatic electrical activity (EAdi). Central inspiratory activity is normally not monotonous, but it demonstrates short-term variability and complexity. The authors reasoned that NAVA should produce a more "natural" or variable breathing pattern than other modes. This study compared respiratory variability and complexity during pressure support ventilation (PSV) and NAVA. Methods Flow and EAdi were recorded during routine PSV (tidal volume approximately 6-8 ml/kg) and four NAVA levels (1-4 cm H2O/microVEAdi) in 12 intubated patients. Breath-by-breath variability of flow and EAdi-related variables was quantified by the coefficient of variation (CV) and autocorrelation analysis. Complexity of flow and EAdi was described using noise titration, largest Lyapunov exponent, Kolmogorov-Sinai entropy, and three-dimensional phase portraits. Results Switching from PSV to NAVA increased the CV and decreased the autocorrelation for most flow-related variables in a dose-dependent manner (P < 0.05, partial eta for the CV of mean inspiratory flow 0.642). The changes were less marked for EAdi. A positive noise limit was consistently found for flow and EAdi. Largest Lyapunov exponent and Kolmogorov-Sinai entropy for flow were greater during NAVA than PSV and increased with NAVA level (P < 0.05, partial eta 0.334 and 0.312, respectively). Largest Lyapunov exponent and Kolmogorov-Sinai entropy for EAdi were not influenced by ventilator mode. Conclusions Compared with PSV, NAVA increases the breathing pattern variability and complexity of flow, whereas the complexity of EAdi is unchanged. Whether this improves clinical outcomes remains to be determined.

Introduction Deploye au niveau national durant l’annee 2013, le Systeme Informatique Distribue d’Evaluation en Sante (SIDE S) permet a plusieurs dizaines de milliers d’etudiants en deuxieme cycle des etudes de medecine de s’entrainer et d’etre evalues sur leurs connaissances theoriques. SIDE S permet la generation de statistiques de reponses aux questions, en particulier la moyenne de points pour chaque question a reponses multiples (QRM), le pourcentage de reussite a la question et le potentiel de discrimination de la question (difference entre le pourcentage d’etudiants classes dans le premier quart de l’epreuve ayant repondu correctement a la QRM et le pourcentage d’etudiants classes dans le dernier quart de l’epreuve ayant repondu correctement a cette meme question). On dispose cependant de peu d’elements d’analyse docimologiques de ces nouvelles modalites d’evaluation. En decembre 2016 puis en avril 2017, des epreuves regionales d’entrainement ont eu lieu dans la region Paris-ile de France en vue de la preparation aux Epreuves classantes nationales informatisees (ECNi) par l’intermediaire de la plate-forme SIDE S. Sept facultes de medecine y ont participe, soit 1591 etudiants. Materiels et methodes L’objectif de cette etude etait de determiner la nature des questions posees aux etudiants de DFASM3 ainsi que les elements predictifs de bonne ou mauvaise reussite a une question. Il s’agissait d’une etude transversale portant sur les donnees docimologiques des 2 epreuves d’entrainement aux ECNide decembre 2016 et avril 2017 proposees aux etudiants de DFASM3. Seuls les QRM des dossiers progressifs (DP) ont ete analysees. Ont ete notes le pourcentage de reussite a la QRM, la faculte d’origine, le nombre de propositions valides a chaque question, la categorie de la question, la discipline sur laquelle portaient les questions. Parallelement, une analyse docimologique portant sur les epreuves de juin 2016 et 2017 des ECNi, ainsi que les epreuves complementaires de ces 2 annees ayant eu lieu en mars et servi d’entrainement pour tous les etudiants de DFASM3 des facultes de France. Resultats Nous avons analyse 260 questions reparties dans 17 DP. Le nombre moyen de questions par DP etait de 15,1. Le taux de reussite moyen par question etait de 42 %. Dix questions etaient a reponse unique (QRU) (3,9 %) et 246 etaient des QRM (96,1 %). Quatre-vingt questions (32,6 %) presentaient un taux de reussite compris entre 0 et 25 %, 67 (27,3 %) entre 25 et 50 %, 68 (27,7 %) entre 50 et 75 % et 30 (12,2 %) entre 75 et 100 %. Le nombre de DP pluridisciplinaires etait de 5 (29,4 %) et leurs questions etaient moins bien reussies que celles des dossiers uni-disciplinaires (28,7 % versus 47,5 %, student p ou = 40 %) etait plus frequente lorsque le nombre de propositions valides etait faible et le pourcentage de reussite global intermediaire. La discipline et la faculte d’origine n’etaient pas associees avec une meilleure discrimination. Au cours des 4 epreuves des ECNi, 3 DP de medecine interne ont ete proposes aux etudiants : l’un portant sur une sarcoidose (syndrome de Lofgren), l’un sur une lupus systemique (avec anemie hemolytique auto-immune) et l’un sur un syndrome de Raynaud (dans un contexte de sclerodermie systemique). Parallelement 12 QRM isolees de medecine interne ont ete proposees, 6 en 2016 et 6 en 2017. Conclusion La medecine interne est une discipline presente aux ECNi et peu reussie lors des epreuves d’entrainement franciliennes. L’analyse docimologique a permis d’identifier que le pourcentage de reussite a une question depend du nombre de propositions valides. Les questions d’imagerie et de therapeutique sont globalement moins bien reussies et peuvent constituer des points sur lesquels insister pour les enseignants.

High cervical spinal cord injuries induce extreme handicap and tactile isolation. Tracheotomised tetraplegic patients are also bound to be olfaction deprived. By restoring negative pressure inspiration, diaphragm pacing (DP) should improve olfaction. We tested olfaction in 10 consecutive tetraplegics during positive pressure mechanical ventilation and DP, using the University of Pennsylvania Smell Identification Test (UPSIT). Quality of life was assessed using the Satisfaction with Life Scale (SWLS). Self-perceived benefits of DP were studied using an in-house questionnaire. Olfaction was very poor during positive pressure mechanical ventilation (UPSIT, mean+/-SD 17.1+/-6.4, anosmia or severe microsmia). It improved during DP (35.2+/-1.9, normosmia or mild microsmia; p0.0001) and SWLS was 18.5+/-4.2. Nine patients stated that DP had improved their quality of life. This was driven by better mobility (ranked first), improved self-image and relationships with others (ranked second), improved olfaction and better feeling of security (both ranked third). Improved olfaction is among the benefits of DP and should be mentioned to patients considered for this therapy. Furthermore, attention to olfaction is warranted in tracheotomised ventilator-dependent patients, as a putative path towards improvement of quality of life.

Compliance by residents in pediatrics to pediatric resuscitation guidelines is low. In many French faculties, a 1-h traditional lecture is still used to educate medical students about pediatric cardiopulmonary arrest (CPA). We developed an innovative pedagogic course combining a 23-min video and 3-h simulation exercises to improve knowledge and skills of medical students. A prospective controlled study was conducted. Medical student knowledge was tested before, just after, and 6-12 months after the innovative course and compared to that of a cohort who attended the traditional lecture. A high-fidelity mannequin simulator simulating cardiopulmonary arrest was used to assess and compare the skills of the study and control groups. Costs of the courses were evaluated; 809 of 860 (94 %) medical students were assessed for knowledge. Six to 12 months after the courses, the median score was significantly higher for the innovative group than that for the traditional lecture group (p 0.001). In terms of skills, student in the innovative group scored higher on the performance score than the control group (p 0.01). The innovative course was 24 times more expensive.Combination of video and simulation allows better retention of knowledge than a traditional lecture and leads to better compliance to resuscitation guidelines.• Compliance by residents to pediatric resuscitation guidelines is low. • We developed an innovative pedagogic course combining an educational video and simulation. What is new: • Knowledge retention after the innovative course was better than after a traditional lecture. • Sixty-six students tested on their skills demonstrated better compliance to resuscitation guidelines.

To assess whether the quality of chest compressions (CC) differs before and after a night shift. We carried out a cluster randomized study in three Emergency Departments and three ICUs in Paris, France. Physicians were assessed on a control day and immediately following after a night shift. The primary endpoint was the proportion of CC with a depth greater than 50 mm. We analyzed 67 participants. The proportion of CC with a depth greater than 50 mm was similar on a control day and after a night shift [52% in both groups, mean difference of 0 (95% confidence interval: -17 to 17)]. Other indicators of CC quality were unchanged after a night shift, except for the mean depth of CC (51 vs. 48 mm, P=0.01). We report in our sample that the quality of CC after a night shift is not inferior to a control day.

To evaluate the efficacy of a simple mechanical device to maintain constant endotracheal cuff pressure (Pcuff) during mechanical ventilation (large encased inflatable cuff connected to the endotracheal cuff and receiving constant pressure from a heavy mass attached to an articulated arm).Single-center, prospective, randomized, crossover, pilot study in a medical intensive care unit.Nine consecutive mechanically ventilated patients (age 62+/-20 years, SAPS II score 39+/-15).Control day: Pcuff monitored and adjusted with a manometer (Hi-Lo, Tyco Healthcare) according to current recommendations (twice a day and after each intervention on the tracheal tube); initial target Pcuff 22-28 cmH20. Prototype day: test device connected to the endotracheal cuff; same initial target. Continuous Pcuff recording during both days. Control and prototype days in random order.Pcuff values over 50 cmH20 were recorded in six patients during the control day (178+/-159min), never during the prototype day. During the control day, Pcuff was between 30 and 50 cmH20 for 29+/-25% of the time, vs 0.3+/-0.3% during the prototype day (p0.01). Pcuff was between 15 and 30 cmH20 for 56+/-36% of the time during the control day, vs 95+/-14% during the prototype day p0.01). During the control day, Pcuff was below 15 cmH20 for 15+/-17% of the time, vs 4.7+/-15% during the prototype day (p0.05).The tested device successfully controlled Pcuff with minimal human resource consumption. Prospective studies are required to assess its clinical impact.

We evaluated the use of plasma B-type natriuretic peptide (BNP) levels for risk stratification in elderly patients with acute pulmonary embolism (PE).Bedside BNP assay was performed blindly at admission in consecutive patients older than 65 years with acute PE. A complicated PE was defined as any of the following: death, cardiopulmonary resuscitation, mechanical ventilation, use of vasopressors, thrombolysis, surgical embolectomy, or admission in intensive care unit.Fifty-one patients (age, 79 +/- 9 years) were included. Thirteen patients had adverse events: 11 were admitted in the intensive care unit and 3 died. The median BNP level (95% confidence interval [CI]) was higher in the group of patients with complicated PE, 274 pg/mL (95% CI, 142-581 pg/mL) vs 78 pg/mL (95% CI, 33-230 pg/mL) (P.05), respectively. The receiver operating characteristic curve showed that BNP significantly predicted a complicated PE with an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.58-0.83) (P.05). The best threshold value was 200 pg/mL with a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 0.69 (0.43-0.87), 0.63 (0.47-0.77), 0.39 (0.22-0.59), 0.86 (0.69-0.94), and 0.65 (0.51-0.77), respectively.Our study suggests that BNP is not a reliable marker of complicated PE in elderly patients.

Objective: To assess the value of the diaphragmatic response to transcranial magnetic stimulation (TMS) in predicting the recovery of ventilatory activity after CNS lesions responsible for central respiratory paralysis. Methods: The authors studied 11 long-term ventilator-dependent patients with central respiratory paralysis (description group: spinal trauma 10, medullary ischemia 1) and 16 patients with central respiratory paralysis for less than 10 weeks (prognostic group, evaluated after a 1-year follow-up: spinal trauma 8, medullary ischemia 4, radiation myelitis 1, subdural hematoma 1, complication of neurosurgery 2). Results: In the description group, all the patients had a bilaterally abolished diaphragm response. In the prognostic group, six patients were fully ventilator dependent because of a complete absence of ventilatory activity at follow-up time. They lacked any diaphragm response. The 10 other patients had recovered ventilatory activity and full (n = 9) or partial (n = 1) ventilatory autonomy. In nine cases, diaphragm response was present at least on one side, with a normal latency (right: 15.6 ± 1.5 milliseconds; left: 16.2 ± 2.2 milliseconds). The test had 100% specificity (95% CI 52 to 100) and 90% sensitivity (95% CI 54 to 99) to predict the recovery of ventilatory activity. Conclusion: Electrophysiologic studies of the diaphragm in response to transcranial magnetic stimulation may help predict the recovery of central respiratory paralysis within 1 year.

Resume Position du probleme La ventilation par tracheotomie est efficace chez des patients atteints de maladies neuromusculaires, mais contraignante. Le « retour » a une ventilation au masque (VNI) peut etre envisage, mais cette pratique n’est pas repandue, en partie faute de procedures standardisees permettant une transition sure. Methodes Une procedure de relais tracheotomie-ventilation au masque a ete elaboree a partir de la litterature et de l’experience locale (faisabilite de la ventilation non-invasive : absence de lesions laryngo-tracheales, compensation de fuites adequate ; efficacite de la toux). Elle a ete testee chez trois patients atteints de maladies neuromusculaires severes mais stables (polyradiculonevrite chronique dans deux cas, amyotrophie spinale progressive dans un cas), a titre preliminaire. Resultats Les trois patients ont pu etre decanules et adaptes a une ventilation a domicile en 6, 7, et 10 jours, au terme desquels ils etaient tous rentres a leur domicile. Apres 4 mois dans 2 cas, 6 mois dans l’autre, aucune complication significative n’etait relevee, l’etat respiratoire sous ventilation au masque etait comparable a l’etat anterieur (tracheotomie), et les patients etaient satisfaits du changement. Conclusion L’algorithme propose semble permettre un passage rapide et sur de la tracheotomie a la ventilation au masque. Il reste, par des etudes a grande echelle, a verifier cette notion, et, au-dela, a identifier dans quelle population une telle demarche peut raisonnablement etre appliquee.

This paper presents an efficient method for pricing discrete Asian options. Its contribution to the existing literature consists in targeting at smile and non proportional dividend effects. Using an homogeneity property, we show how to reduce an n +1 dimensional problem to a 2 or 3 dimensional one. We derive a PDE for the Asian option and solve it with the standard Crank Nicholson method. The dimension reduction imposes us to interpolate and extrapolate our conditional price at each fixing date. Within a deterministic volatility structure consistent with the smile, the homogeneity property is roughly conserved, thanks to a vega correction term. This allows us to stay in a two dimensional framework as in the Black Scholes case. We examine different numerical specifications of our finite difference (interpolation method, grid boundaries, time and space steps) as well as the extension to the case of non proportional discrete dividends, using a jump condition. We benchmark our results with Quasi Monte-Carlo simulation and a multi-dimensional PDE.

Resume Le diaphragme est le principal muscle de l'inspiration normale. La production d'une ventilation alveolaire adaptee a la production de dioxyde de carbone par l'organisme implique une capacite diaphragmatique suffisante pour surmonter la charge que represente l'impedance du systeme respiratoire et une endurance correcte. Si ces conditions ne sont pas remplies, il existe un risque de faillite ventilatoire avec hypercapnie. Explorer la fonction diaphragmatique commence par l'examen clinique de la dynamique thoraco-abdominale dans le volume courant. Un bilan comprenant spirometrie, mesure des pressions inspiratoires statique et dynamique ( sniff-test ) et gazometrie est indispensable. La stimulation phrenique permet de quantifier l'importance d'une dysfonction diaphragmatique et d'en cerner le mecanisme. La stimulation magnetique transcrânienne peut detecter des dysfonctions diaphragmatiques d'origine centrale. Une evaluation precise de la fonction diaphragmatique peut etre utile dans le bilan d'affections comportant une atteinte neuromusculaire respiratoire pouvant impliquer une assistance ventilatoire, en cas de difficulte du sevrage de la ventilation mecanique ou dans le bilan du retentissement respiratoire des neuro-myopathies acquises en reanimation. Il est vraisemblable que les techniques modernes, non invasives et simples a mettre en œuvre, d'exploration du diaphragme permettent d'inclure l'evaluation de sa fonction a grande echelle dans ces indications.

Recently, it has been suggested that peak expiratory flow (PEF) may be determined by the wave speed flow-limiting mechanism. In six normal male subjects (age = 33 +/- 8 years) performing expiratory forced vital capacity (FVC) maneuvers, a negative expiratory pressure (NEP) of -10 cm H2O was randomly applied at the beginning of maximal expiration to assess changes in PEF as compared with baseline. During FVC maneuvers, the expiratory effort was measured by changes in esophageal pressure (Pes), as either peak expiratory Pes-Pes at end expiratory lung volume (DeltaPes(peak)) or maximal rate of rise of Pes (dPes/dt(max)). In each experimental condition, at least three FVC maneuvers with comparable expiratory effort were selected for analysis for each subject. With similar DeltaPes(peak) (107.2 +/- 34.9 versus 111.7 +/- 40.5 cm H2O) and dPes/dt(max) (1181 +/- 518 versus 1177 +/- 546 cm H2O/second) PEF amounted to 10.84 +/- 1.08 L/second and to 10.82 +/- 1.03 L/second with and without NEP, respectively. These data show that PEF obtained by normal subjects to the best of their abilities (best PEF) does not increase with NEP and indicate that the best PEF is a flow-limited and effort-independent parameter, reflecting only lung and airways mechanics as the other subsequent maximal expiratory flows achieved during the FVC maneuver.

International audience; Background: Oral presentations of clinical cases by medical students during medical rounds in hospital wards are a source of anxiety and little is known about how this anxiety can be alleviated. The objective of this study was to investigate whether video-based feedback of public oral presentations can reduce anxiety in 4th year medical students. Methods: Multicentre randomized study conducted in six intensive care units (ICU) and emergency departments (ED) in France over a 9-month period in 2012. One hundred and forty two 4th year medical students were randomized to two groups: intervention and control. Students in the intervention group were recorded while making an oral presentation of a patient during morning ward rounds, followed by video-based feedback. Students in the control group conducted presented classical oral presentations without being filmed and with no formal feedback. Anxiety levels during a public oral presentation were assessed using the Spielberger State Anxiety Inventory (STAI-S). The primary outcome was the difference in STAI-S scores between groups at the beginning and at the end of a 3-month ICU or ED internship. Results: Seventy four students were randomized to the 'video-based feedback' group and 68 were randomized to the control group. In both groups, STAI-S scores were significantly lower after 3 months of internship. However, the reduction in STAI-S scores was significantly greater in the " video-based feedback " group than in controls (−9.2 ± 9.3 vs. –4.6 ± 8.2, p = 0.024. Compared to the control group, significantly fewer students with high-level anxiety were observed in the " video-based feedback " group after 3 months of internship (68 vs. 28%, p

The eosinophilic inflammatory response in asthma is associated with protein nitration, detected as immunostaining for 3-nitrotyrosine (3NT). As the presence of 3NT is strongly correlated with upregulation of the inducible form of nitric oxide synthase (NOS II), it has been hypothesized that 3NT formation results from the action of peroxynitrite (ONOO-), a highly reactive NO derivative produced from the reaction of molecular NO and O2-. However, recent observations have suggested that the action of peroxidases, including eosinophil peroxidase (EPO), may be responsible for protein nitration. In this study, we used murine models of allergic asthma to address the relative contribution of EPO and NOS II to protein nitration. We studied EPO-deficient New Zealand White (NZW) mice, which were sensitized and challenged intranasally with ovalbumin (OVA). Despite comparable levels of eosinophilia, NO, and superoxide production, NZW mice exhibited markedly decreased 3NT staining around the airways after OVA challenge when compared with two other strains (A/J and C57BL/6J). Immunocytochemical analysis of bronchoalveolar lavage (BAL) cells and lung sections suggested that 3NT staining was largely confined to eosinophils. This was confirmed by Western Blot analysis of proteins from different subsets of BAL cells that demonstrated a marked decrease in 3NT formation in eosinophils from NZW mice. These results contrast with those obtained in OVA-sensitized and -challenged NOS II deficient mice, which despite decreased NO production, exhibited similar 3NT staining in the airways after OVA challenge as in wild-type control mice. In this model, protein nitration was thus not a function of NO production by NOS II. We conclude that in the mouse, 3NT formation after specific allergen challenge is dependent on EPO activity, particularly in eosinophils themselves. In contrast, 3NT formation is not driven by upregulation of NOS II expression in this model and does not appear to depend on increases in the level of NO production.

To explore the possible role of eosinophils in NO-mediated tissue injury, we studied a murine model of allergic asthma. Male A/J mice were sensitized and challenged intranasally with ovalbumin (OVA). Following challenge, the number of eosinophils in bronchoalveolar lavage fluid (BALF) increased from 0.4% of total cells at baseline (0.02 x 10(4) cells/ml) to 60.2% at 48 h after the challenge (9.34 x 10(4) cells/ml). The rise in eosinophil count was accompanied by a 40.3% increase in total NO(2-) plus NO(3-) (NO(x)) in BALF. This in turn was accompanied by expression of inducible NO synthase (NOS II) in airway epithelial and inflammatory cells, as well as by evidence of staining for 3-nitrotyrosine (3NT) in peribronchial inflammatory cells and at the epithelial surface. Both NO(x) production and 3NT were significantly reduced by pretreatment of the challenged mice with the highly specific NOS II inhibitor N-3-aminomethyl-benzyl-acetamidine-dihydrochloride (1400W), as well as by the nonselective NOS inhibitor N(omega)-nitro-L-arginine methyl ester (L-NAME). L-NAME and 1400W also reduced the number of BALF eosinophils (37.2% and 61.5%, respectively, as compared with the control value), suggesting that NO production by NOS II contributes to eosinophil recruitment. To further examine the role of eosinophils, we pretreated additional mice with an anti-interleukin (IL)-5 antibody, which reduced BALF eosinophilia following OVA challenge by 90.1%. In concert with the decrease in eosinophils, the anti-IL-5 antibody reduced NO(x) in BALF almost to the baseline value, and decreased the number of 3NT-positive cells in the peribronchial region by 74.4%. Western blot analysis of protein extracted from whole lung confirmed the reduction in tyrosine nitration by anti-IL-5 antibody. These findings indicate that NO and eosinophilic inflammation are closely coupled, and suggest that eosinophils are an important source of tyrosine nitration.

Objective: Anterior magnetic stimulation (aMS) of the phrenic nerves is a new method for the assessment of diaphragm contractility that might have particular applications for the clinical assessment of critically ill patients who are commonly supine. Design: We compared aMS with existing techniques for measurement of diaphragm weakness and fatigue in 10 normal subjects, 27 ambulant patients with suspected diaphragm weakness and 10 critically ill patients. Setting: Laboratory and intensive care unit of two university hospitals. Results: Although aMS was not demonstrably supramaximal in normal subjects, the mean value of twitch transdiaphragmatic pressure (Tw Pdi) obtained at 100 % of stimulator output, 23.7 cmH2O, did not differ significantly from that obtained with bilateral supramaximal electrical stimulation (ES), 24.9 cmH2O, or bilateral anterior magnetic phrenic nerve stimulation (BAMPS), 27.3 cmH2O. A fatiguing protocol produced a 20 % fall in aMS-Tw Pdi and a 19 % fall in BAMPS-Tw Pdi; the fall in aMS-Tw Pdi correlated with the fall in BAMPS-Tw Pdi (r2 = 0.84, p = 0.03) indicating that aMS can detect diaphragm fatigue. In ambulant patients aMS agreed closely with existing measures of diaphragm strength. The maximal sniff Pdi correlated with both the aMS-Tw Pdi (r2 = 0.60, p < 0.0001) and the BAMPS-Tw Pdi (r2 = 0.65, p < 0.0001) and the aMS-Tw Pdi was a mean (SD) 2.2 (4.3) cmH2O less than BAMPS-Tw Pdi. In addition, aMS correctly identified diaphragm dysfunction in patients studied on the ICU. Conclusions: We conclude that aMS is of clinical value for the investigation of suspected diaphragm weakness.

Introduction L’objectif du deuxieme cycle des etudes medicales (DCEM) defini par le ministere de l’Enseignement superieur et de la recherche est « l’acquisition des competences generiques permettant aux etudiants d’exercer par la suite, en milieu hospitalier ou en milieu ambulatoire, les fonctions du troisieme cycle ». Cependant, si les connaissances sont appreciees par les epreuves classantes nationales, aucune etude ne s’est interessee aux competences des internes de pediatrie a l’aube de leur prise de fonction. Materiel et methodes L’ensemble des internes de pediatrie d’Ile-de-France nommes a l’issue des epreuves nationales classantes 2014 etaient invites a participer a cette etude. Chaque interne etait evalue sur un arret cardiorespiratoire de l’enfant simule a l’aide d’un mannequin haute-fidelite pediatrique. Le score de performance (respect de l’algorithme et technique de la reanimation, note sur 13), les temps a l’initiation de la ventilation et des compressions, et les fractions de temps sans ventilation et sans compression etaient recueillis. Resultats Quarante-deux des 79 (53 %) internes de pediatrie d’Ile-de-France ont ete evalues 10 a 15 jours avant leur prise de fonction. La mediane du score de performance etait de 4 (IQ1–3 : 3–6) sur 13. Les temps median necessaires a l’initiation de la ventilation et des compressions etaient respectivement de 105 et 149 secondes. Dix internes (24 %) n’ont jamais initie les compressions. Les fractions de temps sans ventilation et sans compression etaient respectivement de 55 % (IQ1–3 : 44–77) et 81 % (68–99). Il n’existait pas de correlation entre ces resultats et le classement des internes aux epreuves classantes nationales. Discussion La prise en charge de l’arret cardiorespiratoire de l’enfant n’est pas maitrisee par les internes de pediatrie a quelques jours de leur prise de fonction. Le niveau de performance des internes n’est pas correle a leurs rangs de classement a l’ECN. L’introduction de la simulation au cours du deuxieme cycle des etudes medicales devrait permettre l’acquisition de competences en plus des connaissances requises pour les epreuves classantes nationales.

Introduction La prise en charge de l’arret cardiorespiratoire (ACR) intra-hospitalier n’est pas maitrisee par les soignants. L’objectif etait d’etudier si l’intervention a distance d’un reanimateur appele a l’aide des Google Glass pouvait ameliorer la qualite de la reanimation cardiopulmonaire (RCP) en attendant l’arrivee de la reanimation. Materiel et methodes Etude randomisee controlee impliquant des internes de pediatrie confrontes a un scenario d’ACR de l’enfant sur simulateur haute-fidelite. Le groupe « Google Glass » pouvait decider a tout moment de se faire aider a distance par un reanimateur. Le groupe « temoin » initiait seul la RCP et pouvait appeler le reanimateur qui lui demandait de poursuivre la RCP. Le critere de jugement principal etait les fractions de temps sans ventilation et sans compression. Resultats Quarante-deux internes nouvellement nommes en pediatrie Ile-de-France en 2014 ont participe a l’etude. Tous les internes du groupe Google Glass ( n = 21) ont juge que la liaison avec le reanimateur les avait aides dans la prise en charge de l’enfant. Les fractions de temps sans ventilation et sans compression n’etaient pas differentes. La liaison par Google Glass permettait d’ameliorer l’efficacite de la ventilation ( p = 0,04), la technique ( p = 0,02) et le rythme des compressions ( p Discussion Notre projet montre la faisabilite d’une liaison audio-video par Google Glass lors d’un ACR de l’enfant et son interet pour optimiser la qualite de la RCP. Les enfants atteints d’un evenement rare et grave comme l’arret cardiorespiratoire devraient beneficier d’une expertise en urgence. S’il n’est pas possible que le reanimateur soit present physiquement des les premieres minutes du fait du caractere parfois imprevisible de l’ACR, il peut l’etre virtuellement grâce aux nouvelles technologies, pour un benefice reel pour les patients.

The application of negative expiratory pressure (NEP) at end expiration has been shown to cause reflex-mediated activation of the genioglossus muscle in awake humans. To test whether a reflex contraction of pharyngeal dilator muscles also occurs in response to NEP applied in early expiration, the effect on genioglossus muscle reflex activity of NEP pulses of 500 ms, given 0.2 s after the onset of expiration and during the end-expiratory pause, was assessed in 10 normal awake subjects at rest. The raw and integrated surface electromyogram of the genioglossus (EMGgg) was recorded with airflow and mouth pressure under control conditions and with NEP ranging from −3 to −10 cmH2O. Intraoral EMGgg was also recorded under the same experimental conditions in two subjects. The application of NEP at the end-expiratory pause elicited a consistent reflex response of EMGgg in seven subjects with a mean latency of 68 ± 5 ms. In contrast, when NEP was applied at the onset of expiration, EMGgg reflex activity was invariably observed in only one subject. No relationship was found between steady increase or abrupt fall in expiratory flow and the presence or the absence of a reflex activity of genioglossus during sudden application of NEP at the beginning of expiration. Our results show that a reflex activity of genioglossus is elicited much more commonly during application of NEP at the end rather than at the onset of expiration. These findings also suggest that when NEP is applied in early expiration to detect intrathoracic flow limitation the absence of upper airways narrowing does not imply the occurrence of a reflex-mediated activation of genioglossus and vice versa.

IMPORTANCE Despite advances in care, mortality and morbidity remain high in adults with acute bacterial meningitis, particularly when due to Streptococcus pneumoniae. Induced hypothermia is beneficial in other conditions with global cerebral hypoxia. OBJECTIVE To test the hypothesis that induced hypothermia improves outcome in patients with severe bacterial meningitis. DESIGN, SETTING, AND PATIENTS An open-label, multicenter, randomized clinical trial in 49 intensive care units in France, February 2009-November 2011. In total, 130 patients were assessed for eligibility and 98 comatose adults (Glasgow Coma Scale [GCS] score of

International audience; Rationale: Diaphragmatic insults occurring during intensive care unit (ICU) stays have become the focus of intense research. However, diaphragmatic abnormalities at the initial phase of critical illness remain poorly documented in humans. Objectives: To determine the incidence, risk factors, and prognostic impact of diaphragmatic impairment on ICU admission. Methods: Prospective, 6-month, observational cohort study in two ICUs. Mechanically ventilated patients were studied within 24 hours after intubation (Day 1) and 48 hours later (Day 3). Seventeen anesthetized intubated control anesthesia patients were also studied. The diaphragm was assessed by twitch tracheal pressure in response to bilateral anterior magnetic phrenic nerve stimulation (Ptr,stim). Measurements and Main Results: Eighty-five consecutive patients aged 62 (54-75) (median [interquartile range]) were evaluated (medical admission, 79%; Simplified Acute Physiology Score II, 54 [44-68]). On Day 1, Ptr, stim was 8.2 (5.9-12.3) cm H2O and 64% of patients had Ptr, stim less than 11 cm H2O. Independent predictors of low Ptr, stim were sepsis (linear regression coefficient, -3.74; standard error, 1.16; P = 0.002) and Simplified Acute Physiology Score II (linear regression coefficient, -0.07; standard error, 1.69; P = 0.03). Compared with nonsurvivors, ICU survivors had higher Ptr, stim (9.7 [6.3-13.8] vs. 7.3 [5.5-9.7] cm H2O; P = 0.004). This was also true for hospital survivors versus nonsurvivors (9.7 [6.3-13.5] vs. 7.8 [5.5-10.1] cm H2O; P = 0.004). Day 1 and Day 3 Ptr, stim were similar. Conclusions: A reduced capacity of the diaphragm to produce inspiratory pressure (diaphragm dysfunction) is frequent on ICU admission. It is associated with sepsis and disease severity, suggesting that it may represent another form of organ failure. It is associated with a poor prognosis.

Retrospective study of prospectively collected data to assess the reliability of cervical magnetic stimulation (CMS) to detect prolonged phrenic nerve (PN) conduction time at the bedside. Because PN injuries may cause diaphragm dysfunction, their diagnosis is relevant in intensive care units (ICU). This is achieved by studying latency and amplitude of diaphragm response to PN stimulation. Electrical stimulation (ES) is the gold standard, but it is difficult to perform in the ICU. CMS is an easy noninvasive tool to assess PN integrity, but co-activates muscles that could contaminate surface chest electromyographic recordings. In a first set of 56 ICU patients with suspected PN injury, presence and latency of compound motor action potentials elicited by CMS and ES were compared. With ES as the reference method, CMS was evaluated as a test designed to indicate presence or absence of PN injury. In eight additional patients, intramuscular diaphragm recordings were compared with surface diaphragm recordings and with the electromyograms of possible contamination sources. The sensitivity of CMS to diagnose abnormal PN conduction was 0.91, and specificity was 0.84, whereas positive and negative predictive values were 0.81 and 0.92, respectively. Passing–Bablok regression analysis suggested no differences between the two measures. The correlation between PN latency in response to CMS and ES was significant. The “diaphragm surface” and “needle” latencies were close, and were significantly different from those of possibly contaminating muscles. One hemidiaphragm showed likely signal contamination. CMS provides an easy reliable tool to detect prolonged PN conduction time in the ICU.