[Uroflowmetry: A follow-up tool for neurogenic bladder patients treated by transcutaneous tibial posterior stimulation?] / Débitmétrie : outil de suivi chez les patients avec vessie neurologique traités par neurostimulation tibiale postérieure ?

OBJECTIVE: Neurogenic bladders can suffer from overactivity, underactivity or dyssynergia depending on the level of the initial lesion. These symptoms can lead to severe alterations of the upper urinary tract. One of the first-line treatments is the transcutaneous tibial posterior stimulation (TTNS), which was demonstrated to be efficient on urodynamics. But it is an invasive, expensive and sometimes not patient-accepted examination, contrary to the uroflowmetry. The aim of this study is to assess the feasibility of a follow-up with a uroflowmetry when treated by TTNS and show that the maximum flow rate increased after treatment, displaying a better detrusor contraction. METHODS: In total, 38 patients with neurogenic bladder undergoing a 12-weeks TTNS treatment and with 2 uroflowmetries interpretable before and after treatment were included. The maximum flow rate (Qmax), the urinated volume and the post-void residual (PVR) were retrieved from the uroflowmetry, and the USP-score and the urinary discomfort were asked at each appointment. RESULTS: Qmax is increased from 17,53ml/s to 18,26ml/s, as well as the PVR (from 76,97ml to 79,16ml). Urinated volume is decreased from 241,4ml to 193,66ml. Patients feel enhanced after TTNS according to the decrease in the USP-score and the urinary discomfort scale. CONCLUSION: The increase of the cystomanometric capacity and the delay of the detrusor overactivity due to TTNS explains the reduction of the urinated volume and the increase of PVR. Increased Qmax might show a better voluntary bladder contraction, with a restraint due to the lack of abdominal pressure measurement during voiding.

High-dose tranexamic acid reduces blood loss in postpartum haemorrhage.

INTRODUCTION: Our purpose in conducting this study was to determine whether administration of high-dose tranexamic acid (TA) at the time of diagnosis of postpartum haemorrhage (PPH) could reduce blood loss. METHODS: This was a randomised, controlled, multicentred, open-label trial. Women with PPH >800 mL following vaginal delivery were randomly assigned to receive TA (loading dose 4 g over 1 hour, then infusion of 1 g/hour over 6 hours) or not. In both groups, packed red blood cells (PRBCs) and colloids could be used according to French guidelines. The use of additional procoagulant treatments was permitted only in cases involving intractable bleeding. The primary objective was to assess the efficacy of TA in the reduction of blood loss in women with PPH, and the secondary objectives were the effect of TA on PPH duration, anaemia, transfusion and the need for invasive procedures. RESULTS: A total of 144 women fully completed the protocol (72 in each group). Blood loss between enrolment and 6 hours later was significantly lower in the TA group than in the control group (median, 173 mL; first to third quartiles, 59 to 377) than in controls (221 mL; first to third quartiles 105 to 564) (P = 0.041). In the TA group, bleeding duration was shorter and progression to severe PPH and PRBC transfusion was less frequent than in controls (P < 0.03). Invasive procedures were performed in four women in the TA group and in seven controls (P = NS). PPH stopped after only uterotonics and PRBC transfusion in 93% of women in the TA group versus 79% of controls (P = 0.016). Mild, transient adverse manifestations occurred more often in the TA group than in the control group (P = 0.03). CONCLUSIONS: This study is the first to demonstrate that high-dose TA can reduce blood loss and maternal morbidity in women with PPH. Although the study was not adequately powered to address safety issues, the observed side effects were mild and transient. A larger international study is needed to investigate whether TA can decrease the need for invasive procedures and reduce maternal morbidity in women with PPH. TRIAL REGISTRATION: Controlled Trials ISRCTN09968140.

Monitoring medical students' professional attributes: development of an instrument and process.

PURPOSE: To describe and evaluate the implementation of an instrument and process to assess and monitor professional attributes in medical students. METHOD: The instrument was developed following a survey of professional attributes of concern displayed by medical students. This was followed by development and validation, amongst medical faculty staff and students, of the instrument and its supporting process. Evaluation was by recording participation rates by staff and by determining the consistency of the instrument across dimensions and across clerkships. Implementation in practice is described by using a case study based on one school's first year of use amongst all the students. RESULTS: In its first year of use 7,418 forms were distributed to 376 students and 6,621 forms were returned (89%). The instrument's reliability was greatest where staff were diligent in ensuring thorough implementation. The process was able to detect students of concern and provide effective remediation and ongoing monitoring. CONCLUSION: The process that has been developed is sensitive, robust and is able to detect, monitor and remedy attributes traditionally regarded as difficult to define and defend. The strengths of the process lie in (1) clear definitions of acceptable and unacceptable behaviors, (2) reliance on observations by more than one person and over more than a single time period, (3) the ability to provide a longitudinal view of student's progress.

Was a breach of examination security unfair in an objective structured clinical examination? A critical incident.

One-third of a class of students was inadvertently given the names of stations immediately prior to an OSCE and two-thirds of the class were not. This provided an opportunity to explore student perceptions of fairness and to explore any effect of this cueing. The subjects were medical students undertaking an end of fifth year multidisciplinary OSCE. OSCE score data from the 20 students who had received the information were compared with those of the 40 students who did not. We also compared their performance on other assessments to determine whether the two groups were comparable. The overall OSCE mark was not significantly different between the two groups. There were significant differences between groups on four stations but this was not in a consistent direction that advantaged one group. There were no significant differences between the two groups in their performance on the other examinations. This inadvertent security breach had no systematic effect on student OSCE station scores. This incident provided a valuable opportunity to admit error, approach it rationally and restore any resulting breach of trust.

Patients' global ratings of student competence. Unreliable contamination or gold standard?

PURPOSE: To determine whether global ratings by patients are valid and reliable enough to be used within a major summative assessment of medical students' clinical skills. METHOD: In 11 stations of an 18-station objective structured clinical examination (OSCE), where a student was asked to educate or take a history from a patient, the patient was asked, 'How likely would you be to come back and discuss your concerns with this student again?' These 11 opinions were aggregated into a single patient opinion mark and correlated with other measures of student competence. The patients were not experienced in student assessment. RESULTS: A total of 204 students undertook the OSCE. Reliability of patient opinion across all 11 stations revealed a Cronbach alpha of 0.65. The correlation coefficient between the patient ratings and the total OSCE score was good (r = 0.74; P < 0.001) and was better than the correlation between any single OSCE station and the total OSCE score. It was also better than the correlation between the aggregated patient opinion and tests of student knowledge (r = 0.47). CONCLUSION: It is known that patients can reliably complete checklists of clinical skills and that doctors can reliably provide global ratings of students. We have now shown that, by controlling the context, asking the right question and aggregating several opinions, untrained patients can provide a reliable and valid global opinion that contributes to the assessment of a student's clinical skills.