Variance due to the examination conditions and factors associated with success in objective structured clinical examinations (OSCEs): first experiences at Paris-Saclay medical school.

BACKGROUND: We aimed to measure the variance due to examination conditions during the first sessions of objective structured clinical examinations (OSCEs) performed at a French medical school and identify factors associated with student success. METHODS: We conducted a retrospective, observational study using data from the first three OSCEs sessions performed at Paris-Saclay medical school in 2021 and 2022. For all sessions (each organized in 5 parallel circuits), we tested a circuit effect using a linear mixed-effects model adjusted for sex and the average academic level of students (according to written tests). Then, we studied the factors associated with student success at one station using a multivariate linear mixed-effects model, including the characteristics of students, assessors, and standardized patients. RESULTS: The study included three OSCEs sessions, with 122, 175, and 197 students and a mean (± SD) session score of 13.7(± 1.5)/20, 12.7(± 1.7)/20 and 12.7(± 1.9)/20, respectively. The percentage of variance due to the circuit was 6.5%, 18.2% (statistically significant), and 3.8%, respectively. For all sessions, the student's average level and station scenario were significantly associated with the score obtained in a station. Still, specific characteristics of assessors or standardized patients were only associated with the student's score in April 2021 (first session). CONCLUSION: The percentage of the variance of students' performance due to the examination conditions was significant in one out of three of the first OSCE sessions performed at Paris-Saclay medical school. This result seems more related to individual behaviors rather than specific characteristics of assessors or standardized patients, highlighting the need to continue training teaching teams. NATIONAL CLINICAL TRIAL NUMBER: Not applicable.

Effect of early low-dose hydrocortisone on survival without bronchopulmonary dysplasia in extremely preterm infants (PREMILOC): a double-blind, placebo-controlled, multicentre, randomised trial.

BACKGROUND: Bronchopulmonary dysplasia, a major complication of extreme prematurity, has few treatment options. Postnatal steroid use is controversial, but low-dose hydrocortisone might prevent the harmful effects of inflammation on the developing lung. In this study, we aimed to assess whether low-dose hydrocortisone improved survival without bronchopulmonary dysplasia in extremely preterm infants. METHODS: In this double-blind, placebo-controlled, randomised trial done at 21 French tertiary-care neonatal intensive care units (NICUs), we randomly assigned (1:1), via a secure study website, extremely preterm infants inborn (born in a maternity ward at the same site as the NICU) at less than 28 weeks of gestation to receive either intravenous low-dose hydrocortisone or placebo during the first 10 postnatal days. Infants randomly assigned to the hydrocortisone group received 1 mg/kg of hydrocortisone hemisuccinate per day divided into two doses per day for 7 days, followed by one dose of 0·5 mg/kg per day for 3 days. Randomisation was stratified by gestational age and all infants were enrolled by 24 h after birth. Study investigators, parents, and patients were masked to treatment allocation. The primary outcome was survival without bronchopulmonary dysplasia at 36 weeks of postmenstrual age. We used a sequential analytical design, based on intention to treat, to avoid prolonging the trial after either efficacy or futility had been established. This trial is registered with ClinicalTrial.gov, number NCT00623740. FINDINGS: 1072 neonates were screened between May 25, 2008, and Jan 31, 2014, of which 523 were randomly assigned (256 hydrocortisone, 267 placebo). 255 infants on hydrocortisone and 266 on placebo were included in analyses after parents withdrew consent for one child in each group. Of the 255 infants assigned to hydrocortisone, 153 (60%) survived without bronchopulmonary dysplasia, compared with 136 (51%) of 266 infants assigned to placebo (odds ratio [OR] adjusted for gestational age group and interim analyses 1·48, 95% CI 1·02-2·16, p=0·04). The number of patients needed to treat to gain one bronchopulmonary dysplasia-free survival was 12 (95% CI 6-200). Sepsis rate was not significantly different in the study population as a whole, but subgroup analyses showed a higher rate only in infants born at 24-25 weeks gestational age who were treated with hydrocortisone (30 [40%] of 83 vs 21 [23%] of 90 infants; sub-hazard ratio 1·87, 95% CI 1·09-3·21, p=0·02). Other potential adverse events, including notably gastrointestinal perforation, did not differ significantly between groups. INTERPRETATION: In extremely preterm infants, the rate of survival without bronchopulmonary dysplasia at 36 weeks of postmenstrual age was significantly increased by prophylactic low-dose hydrocortisone. This strategy, based on a physiological rationale, could lead to substantial improvements in the management of the most premature neonates. FUNDING: Assistance Publique-Hôpitaux de Paris.

Comparison of ultrasound and X-ray in determining the position of umbilical venous catheters.

OBJECTIVE: Thoraco-abdominal X-ray (TAX) is the most frequent used method to determine the route and tip position (TP) of umbilical venous catheters (UVCs). The aim of this study was to compare ability of TAX and ultrasonography (US) to determine UVC route and TP. PATIENTS AND METHODS: All neonates requiring UVC or admitted to our Paediatric and Neonatal Intensive Care with UVC were included in this prospective study. Catheter position was controlled by TAX and interpreted by the physician in charge of the patient. US examinations were performed by a paediatric radiologist blinded to TAX result. The UVC route (central or not central) and TP determined by each method were compared to the "actual UVC route and TP", as determined by senior paediatric radiologist and neonatologist referents joint interpretation of TAX and US results. RESULTS: Sixty-one UVCs were assessed in 60 neonates of mean gestational age of 34.7±4.2 weeks. To determine catheter route, sensitivity and specificity were respectively 96.4% and 93.9% for US and 92.8% and 78.8% for TAX. To determine catheter tip position, sensitivity and specificity were respectively 93.3% and 95.6% for US and 66.7% and 63.0% for TAX (p<0.001). Failure of TAX to define UVC tip position increased with birth weight (p<0.005). CONCLUSION: TAX and US are reliable in determining UVC route (central or not) but US examination is superior to TAX in determining UVC TP.

Apparent life-threatening events in presumably healthy newborns during early skin-to-skin contact.

The death or near death of a presumably healthy newborn in the delivery room is uncommon. We report here 6 cases of apparent life-threatening events (ALTEs) in the delivery room during the first 2 hours of life. In each case, the incident occurred in a healthy infant who was in a prone position on his or her mother's abdomen during early skin-to-skin contact. In most cases, the mother was primiparous, and in all cases the mother and infant were not observed during the initiation of skin-to-skin contact and breastfeeding. There are many benefits of early skin-to-skin contact and breastfeeding in the delivery room. However, in view of the risk of a rare but significant ALTE, we suggest that surveillance of newborns is needed. Although many ALTEs are apparently caused by obstruction, we suggest that a standardized investigational workup be performed after an ALTE.

Terlipressin as rescue therapy for refractory pulmonary hypertension in a neonate with a congenital diaphragmatic hernia.

We report the case of a 38-week gestational age neonate, with isolated congenital diaphragmatic hernia presenting with refractory persistent pulmonary hypertension, systemic hypotension, and hypoxemia, resistant to usual therapeutics. Arginine vasopressin is responsible for systemic vasoconstriction and decreases pulmonary hypertension. We theorized that terlipressin, its long-acting analogue, could have the same properties. We used terlipressin as rescue therapy after parental and local ethics committee acceptance. After a bolus of terlipressin 20 µg/kg and continuous infusion at a rate of 5 µg/kg per hour, blood oxygen saturation improved from 75% to 98%, oxygen requirements fell from fraction of inspired oxygen 100% to 40%, and mean arterial pressure rose from 28 to 46 mm Hg, allowing a decrease of vasopressor infusion. Terlipressin may be useful in the management of neonates with congenital diaphragmatic hernia and refractory pulmonary hypertension.

Sevoflurane for central catheter placement in neonatal intensive care: a randomized trial.

OBJECTIVE: To compare the efficacy and safety of sevoflurane deep sedation with glucose and nonnutritive sucking (GNNS) in reducing the duration of the procedure and in preventing pain-related effects during peripherally inserted central catheter (PICC) placement. BACKGROUND: PICC placement in neonatal intensive care is a delicate and stressful procedure that requires pain prevention. GNNS has been recommended in this situation but remain often inefficient. METHODS: We designed a randomized controlled study in a sixteen-bed pediatric and neonatal unit in a tertiary hospital. Fifty-nine neonates at >28 weeks of gestation with continuous positive airway pressure or invasive mechanical ventilation and requiring PICC placement were included. Patients were randomized to receive inhaled sevoflurane (IS) or glucose and non-nutritive sucking (GNNS). Procedural duration and conditions, hemodynamic and respiratory parameters, occurrence of movements and complications were compared (http://clinicaltrials.gov trial register no. NCT00420693). RESULTS: The two groups had similar demographics. There were no between-group differences in procedural duration (P = 0.84) despite greater immobility in IS group (P = 0.017). IS was also associated with fewer episodes of hypertension (P = 0.003), tachycardia (P < 0.001), and bradycardia (P = 0.02). Occurrences of hypotension were not different between the groups (P = 0.06). The GNNS group showed more desaturation during the 4 h after the procedure (P = 0.03). Complications during intensive care stay did not differ between groups. CONCLUSION: Inhaled sevoflurane does not make easier catheters placement but prevent pain-related symptoms. Because sevoflurane is responsible for hypotension, it requires careful monitoring and treatment adaptation.

Randomized controlled trial of sevoflurane for intubation in neonates.

BACKGROUND: Our aim was to determine whether sevoflurane can be used with safety and efficacy for anesthesia during intubation in term and preterm neonates in a prospective randomized-controlled nonblinded study in a tertiary neonatal intensive care unit. METHODS: Thirty-three neonates were randomly allocated to receive sevoflurane (inspired concentrations varying from 2% to 5%) or no medication (preoxygenation with 100% oxygen alone) before intubation. Minute by minute heart rate (HR), mean arterial blood pressure, SpO(2) and number of episodes of bradycardia (HR < 100 b.min(-1)) and desaturation (SpO(2) < 85% for >30 s) were noted from 5 min before to 10 min after intubation. Operator experience, ease and number of attempts were noted. RESULTS: No major adverse events were noted in the study group compared with the control group [hypotension (37.5% vs 37.5%, NS), number of desaturations [37.5% vs 44.5%, NS)]. Hypertension (25%, vs 56.3%P = 0.04) and incidence of bradycardias (8.3% vs 44.4%, P < 0.01) were greater in the control group. Intubation was easier in the study group: no movements: 95.5% vs 28% (P < 0.005); good glottis visualization: 73% vs 33% (P = 0.013). The failure rate was lower in the study group (25% vs 39%), but this difference was not statistically significant. CONCLUSION: Anesthesia for intubation with sevoflurane in neonates is well tolerated, even in the less mature. It facilitates the conditions for intubation and leads to fewer adverse events. Other studies are necessary to confirm these preliminary results.

Tunneled central venous catheter for neonates: A simple technique for prolonged indwelling central catheters in intensive care.

OBJECTIVE: To describe and evaluate a new technique to insert a 24-gauge Silastic catheter in a central vein with a subcutaneous tunneled catheter in newborns after peripherally inserted central catheter (PICC) insertion failure. DESIGN: Retrospective chart review. SETTING: Pediatric and neonatal intensive care unit. PATIENTS: Twenty-nine newborns in whom a new technique was used to insert a prolonged indwelling jugular, femoral, or subclavian Silastic tunneled central catheter. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: This new technique was used in 29 newborns between January 1, 2004, and December 31, 2005. The mean gestational age was 34 +/- 5 wks with a mean weight of 2440 +/- 1101 g. Thirty-four insertion attempts were carried out. Access sites were internal jugular (28 of 34), femoral (three of 34) or subclavian (three of 34) vein. In five cases, catheter insertion failed. Pneumothorax occurred two times, and no other serious complication were observed. CONCLUSIONS: This technique is an interesting alternative when PICC insertion is not possible.

Airway humidification with a heat and moisture exchanger in mechanically ventilated neonates : a preliminary evaluation.

OBJECTIVE: We set out to evaluate the efficacy of passive inspiratory gas conditioning in mechanically ventilated neonates and compared it with that of a heated humidifier (HH). DESIGN: Prospective, randomized, controlled study. SETTING: Neonatal and pediatric intensive care unit. PATIENTS: Fourteen mechanically ventilated neonates nursed in incubators. INTERVENTIONS: The HH was set to deliver a temperature of 37 degrees C and an absolute humidity of 40 mgH(2)O/l at the incubator entrance. Inspired temperature (T degrees ) and absolute humidity (AH) were measured by the psychometric method, transpulmonary pressure (Tpres) by means of a differential pressure transducer. Measurements were performed at 5, 10, and 15 min. MEASUREMENTS AND RESULTS: The values of T degrees were significantly higher using the HH (34.6+/-1.6 degrees C) than the heat and moisture exchanger (HME) (33.8+/2.3, p<0.001). The values of AH were significantly higher using the HH (36.6+/-2.5 mgH(2)O/l) than the HME (32.4+/-2.8 mgH(2)O/l, p<0.001). No significant changes were observed in transpulmonary pressure. A significant positive correlation was observed between incubator temperature and the temperature delivered by the HH (R(2)=0.61, p<0.001). CONCLUSIONS: The use of HMEs in neonates made it possible to achieve an absolute humidity of 28 mgH(2)O/l or more and a temperature of 30 degrees C or more. Higher values are obtained using a HH.

Erythropoietin as treatment for late hyporegenerative anemia in neonates with Rh hemolytic disease after in utero exchange transfusion.

We report the effects of recombinant human erythropoietin (rHuEPO) in the treatment of late hyporegenerative anemia in 2 neonates with Rh hemolytic disease who had received several in utero exchange transfusions. In both cases anemia occurred at 6 weeks of age and we started therapy at approximately 70 days of age. We used rHuEPO at 250 U/kg three times a week. We also used high-dose intravenous immunoglobulin therapy. One week after initiation of erythropoietin treatment, an increase in reticulocyte count and Hb level was noted in our 2 patients. They did not require further erythrocyte transfusions but they already had received two transfusions after birth. There were no side effects attributable to rHuEPO treatment.