Clinical decision-making training using the Script Concordance Test and simulation: A pilot study for pediatric residents.

BACKGROUND: Each year, new pediatric residents begin their shifts in the pediatric emergency room. While technical skills are often acquired during workshops, non-technical skills such as communication, professionalism, situational awareness, or decision-making are rarely tested. Simulation enables non-technical skills to be developed in situations frequently encountered in pediatric emergencies. Adopting an innovative approach, we combined two pedagogical methods: the Script Concordance Test (SCT) and simulation to improve clinical reasoning and non-technical skills of first-year pediatric residents in dealing with clinical situations involving febrile seizures. The aim of this work is to report the feasibility of such a combined training. METHODS: The first-year pediatric residents participated in a training session on how to manage a child attending the emergency department with a febrile seizure. At the beginning of the session, the trainees had to complete the SCT (seven clinical situations) and then participated in three simulation scenarios. Student satisfaction was assessed by means of a questionnaire at the end of the session. RESULTS: In this pilot study, 20 residents participated in the training. The SCT scores for the first-year pediatric residents were lower and more widely distributed than those of the experts with better concordance for diagnostic items compared to investigation or treatment items. All were satisfied with the teaching methods employed. Further sessions on additional topics relating to the management of pediatric emergency cases were requested. CONCLUSION: Although limited by the small size of our study, this combination of teaching methods was possible and seemed promising for the development of non-technical skills of pediatric residents. These methods are in line with the changes being made to the third cycle of medical studies in France and can be adapted to other situations and other specialties.

The "3R Team" in action! Implementation of a program of learning from excellence in a neonatal and pediatric intensive care unit in France.

BACKGROUND: The pursuit of improving quality of care and of patient safety is a crucial objective in intensive care units (ICUs). Classically, safety is characterized by analyzing adverse events. Neonatal and pediatric ICUs (NICUs/PICU) are highly technological units, with evidence of risk for elevated levels of emotional exhaustion and thus a significant level of staff turnover. We hypothesized that appreciative inquiry (AI), currently used in many organizations, could be introduced in our ICU. In the PICU and NICU, this new concept is termed "learning from excellence" (LFE). OBJECTIVE: To assess the impact of the implementation of an LFE program on well-being and on an educational program in the NICU/PICU of a tertiary care center in France. METHODS: We created a workgroup composed of caregivers called the "3R team" for "right resuscitations reviews," based on the concept of AI. Before and 1 year after implementation, we administered two validated surveys-the Maslach Burnout Inventory and the Siegrist survey-to the entire staff of the 22-bed unit. RESULTS: The questionnaire on satisfaction revealed a high percentage (93%) of satisfaction with the work of the 3R team and that scores of well-being and burnout were improved. The educational program was highly enhanced, especially simulation. Benevolence and happiness were increased. CONCLUSION: Implementation of an LFE program in a NICU and PICU is feasible, and tends to increase the well-being and self-confidence of all categories of caregivers. It promotes educational programs of dynamic learning, including simulation. The next important step will be to study the impact on staff turnover and on quality of care.

Sudden death by arrythmia in a 4-year-old boy.

Cardiac arrhythmia with sudden death is rare in children but mainly due to ventricular tachycardia. In case of pulseless ventricular tachycardia, prehospital treatment is crucial with immediate cardiopulmonary resuscitation and external electrical cardioversion. We report the case of pulseless ventricular tachycardia in a child with no past medical history. Sinus rhythm was obtained after 12min of cardiorespiratory resuscitation and three external electrical shocks. An exhaustive diagnostic approach allow us to find its origin. The clinical progression was marked by a severe encephalopathy. The authors discuss different etiologies and treatment of arrhythmia in children, reviewing the pediatric algorithm for shockable rhythm.

[Conservative management of tracheal injuries in children: Clinical case and literature review]. / Prise en charge conservatrice d'un traumatisme trachéal : cas clinique et revue de la littérature.

Tracheal injuries are a rare but potentially lethal entity, most particularly in pediatrics. While standardized management allows quick therapeutic decisions in adults, based on the results of the initial bronchoscopy, the use of diagnostic exams remains unclear during childhood. We describe the case of a 6-year-old patient with a posterior tracheal wall injury due to a car accident, which was managed without tracheal endoscopy. Based on our experience and on a literature review, we suggest clarifying the management of tracheal injury in children, defining the place of computerized tomodensitometry and endoscopy in the decision process.

Management of blunt tracheobronchial trauma in the pediatric age group.

INTRODUCTION: Tracheobronchial rupture (TBR) due to blunt chest trauma is a rare but life-threatening injury in the pediatric age group. The aim of this study was to propose a treatment strategy including bronchoscopy, surgery and extracorporeal membrane oxygenation (ECMO) to optimize the emergency management of these patients. METHODS: We reviewed a series of 27 patients with post-traumatic TBR treated since 1996 in our pediatric trauma center. RESULTS: Seven cases had persistent and large volume air leaks. Flexible bronchoscopy was performed in cases of persistent or large volume air leaks. It permitted accurate visualization of the rupture and its extent. It allowed for a clear-cut positioning of the endotracheal tube. Five were managed operatively. Four cases were considered to be life-threatening because of the combination of severe respiratory distress with hemodynamic instability. One of them had severe tracheal laceration and died. Another one had bilateral bronchi disconnection. Based on clinical and endoscopic findings, surgical repair was performed using extracorporeal membrane oxygenation as a ventilatory support. It provided quick relief from the injury, which was previously expected to result in a fatal issue. CONCLUSIONS: Prompt diagnosis and accurate management of surviving patients admitted to emergency rooms are necessary. Bronchoscopy remains a critical diagnosis step. Surgery is warranted for large tracheobronchial tears and ECMO could be beneficial as supportive therapy for selected cases.

[Gastric perforation caused by a lactobezoar in an infant: a case report]. / Lactobézoard du nourrisson compliqué de perforation gastrique.

Lactobezoar is a compact mass of undigested milk concretions and mucous secretions in the gastrointestinal tract. It is usually located in the stomach, resulting in various degrees of gastric outlet obstruction. Lactobezoar is the most common type of bezoar in infancy. We report the case of rare and complicated gastric outlet obstruction secondary to lactobezoar. A female infant, 35weeks and 4days' gestation, one of dichorionic, diamniotic twins (birth weight, 1.890kg), was referred to our center at 5days of life for shock and food intolerance. She was on discontinuous oral feedings with a maltodextrin-enriched infant formula. On examination on day 4, there was a tender mass palpable in the left hypochondrium and on day 5, there was abdominal distension with signs of hemodynamic instability and sepsis. Plain abdominal X-ray showed a pneumoperitoneum associated with a heterogeneous mass in a distended stomach, consistent with a bezoar. An emergency laparotomy revealed a gastric perforation secondary to a large lactobezoar, with necrosis of the greater curvature and anterior wall of the stomach. Surgical treatment consisted of extraction of the lactobezoar, partial gastrectomy (resection of necrotic areas), and gastrostomy. Pathological examination confirmed the necrosis of the gastric mucosa. The postoperative course was complicated by prolonged sepsis. The child was kept NPO for 21days. On day 21 postsurgery, an upper gastrointestinal contrast study showed a well-dimensioned stomach, with a good pyloric passage. Gastrostomy and oral feedings were then initiated with good outcome at 6months. Etiopathogenic factors of lactobezoar are prematurity, low birth weight, altered gastric secretions and disturbed gastric emptying, hypercaloric and predominantly casein-based formulas, and inadequate milk composition. Lactobezoar should be considered in infants with symptoms of gastrointestinal obstruction with evocative images. Conservative management with nil per os, parenteral nutrition, and regular saline gastric washes has a good prognosis with rapid resolution of symptoms. Surgical indications are rare, and early and appropriate diagnosis should help limit and reduce the morbidity of lactobezoar.

[Neonatal cellulitis caused by group B Streptococcus]. / Cellulite néonatale à streptocoque du groupe B.

Dermohypodermitis (cellulitis) in newborn infants and in infants aged up to 3 months is uncommon and often not typical. Because group B Streptococcus is known to induce rapid life-threatening complications, early diagnosis leading to emergency treatment is of utmost importance. We report on the case of a 14-day-old girl, initially admitted for viral bronchiolitis with suspected bacterial pulmonary infection, in the absence of any cutaneous injury. The disease actually was cellulitis of the face, caused by group B Streptococcus. The baby presented with a severe septic clinical condition. Early treatment with antibiotics (intravenous amoxicillin for 10 days) allowed a favorable course, with rapid control of the sepsis and regression of the submandibular tumefaction.

Genes involved in anaerobic metabolism of phenol in the bacterium Thauera aromatica.

Genes involved in the anaerobic metabolism of phenol in the denitrifying bacterium Thauera aromatica have been studied. The first two committed steps in this metabolism appear to be phosphorylation of phenol to phenylphosphate by an unknown phosphoryl donor ("phenylphosphate synthase") and subsequent carboxylation of phenylphosphate to 4-hydroxybenzoate under release of phosphate ("phenylphosphate carboxylase"). Both enzyme activities are strictly phenol induced. Two-dimensional gel electrophoresis allowed identification of several phenol-induced proteins. Based on N-terminal and internal amino acid sequences of such proteins, degenerate oligonucleotides were designed to identify the corresponding genes. A chromosomal DNA segment of about 14 kbp was sequenced which contained 10 genes transcribed in the same direction. These are organized in two adjacent gene clusters and include the genes coding for five identified phenol-induced proteins. Comparison with sequences in the databases revealed the following similarities: the gene products of two open reading frames (ORFs) are each similar to either the central part and N-terminal part of phosphoenolpyruvate synthases. We propose that these ORFs are components of the phenylphosphate synthase system. Three ORFs showed similarity to the ubiD gene product, 3-octaprenyl-4-hydroxybenzoate carboxy lyase; UbiD catalyzes the decarboxylation of a 4-hydroxybenzoate analogue in ubiquinone biosynthesis. Another ORF was similar to the ubiX gene product, an isoenzyme of UbiD. We propose that (some of) these four proteins are involved in the carboxylation of phenylphosphate. A 700-bp PCR product derived from one of these ORFs cross-hybridized with DNA from different Thauera and Azoarcus strains, even from those which have not been reported to grow with phenol. One ORF showed similarity to the mutT gene product, and three ORFs showed no strong similarities to sequences in the databases. Upstream of the first gene cluster, an ORF which is transcribed in the opposite direction codes for a protein highly similar to the DmpR regulatory protein of Pseudomonas putida. DmpR controls transcription of the genes of aerobic phenol metabolism, suggesting a similar regulation of anaerobic phenol metabolism by the putative regulator.

Three differentially expressed S-adenosylmethionine synthetases from Catharanthus roseus: molecular and functional characterization.

We describe the molecular and functional characterization of three closely related S-adenosyl-L-methionine synthetase (SAMS) isoenzymes from Catharanthus roseus (Madagascar periwinkle). The genes are differentially expressed in cell cultures during growth of the culture and after application of various stresses (elicitor, nutritional down-shift, increased NaCl). Seedlings revealed organ-specific expression and differential gene regulation after salt stress. A relationship analysis indicated that plant SAMS group in two main clusters distinguished by characteristic amino acid exchanges at specific positions, and this suggested differences in the enzyme properties or the regulation. SAMS1 and SAMS2 are of type I and SAMS3 is of type II. The properties of the isoenzymes were compared after heterologous expression of the individual enzymes, but no significant differences were detected in a) optima for temperature (37 to 45 degrees C) or pH (7 to 8.3); b) dependence on cations (divalent: Mg2+, Mn2+, Co2+; monovalent: K+, NH4+, Na+); c) K(m)s for ATP and L-methionine; d) inhibition by reaction products (S-adenosyl-L-methionine, PPi, Pi), by the reaction intermediate tripolyphosphate, and by the substrate analogues ethionine and cycloleucine; e) response to metabolites from the methyl cycle (L-homocysteine) or from related pathways (L-ornithine, putrescine, spermidine, spermine); f) native protein size (gel permeation chromatography). The results represent the first characterization of plant SAMS isoenzyme properties with individually expressed proteins. The possibility is discussed that the isoenzyme differences reflect specificities in the association with enzymes that use S-adenosyl-L-methionine.

Differential induction of enzymes involved in anaerobic metabolism of aromatic compounds in the denitrifying bacterium Thauera aromatica.

Differential induction of enzymes involved in anaerobic metabolism of aromatic substrates was studied in the denitrifying bacterium Thauera aromatica. This metabolism is divided into (1) peripheral reactions transforming the aromatic growth substrates to the common intermediate benzoyl-CoA, (2) the central benzoyl-CoA pathway comprising ring-reduction of benzoyl-CoA and subsequent beta-oxidation to 3-hydroxypimelyl-CoA, and (3) the pathway of beta-oxidation of 3-hydroxypimelyl-CoA to three acetyl-CoA and CO2. Regulation was studied by three methods. 1. Determination of protein patterns of cells grown on different substrates. This revealed several strongly substrate-induced polypeptides that were missing in cells grown on benzoate or other intermediates of the respective metabolic pathways. 2. Measurement of activities of known enzymes involved in this metabolism in cells grown on different substrates. The enzyme pattern found is consistent with the regulatory pattern deduced from simultaneous adaptation of cells to utilisation of other aromatic substrates. 3. Immunological detection of catabolic enzymes in cells grown on different substrates. Benzoate-CoA ligase and 4-hydroxybenzoate-CoA ligase were detected only in cells yielding the respective enzyme activity. However, presence of the subunits of benzoyl-CoA reductase and 4-hydroxybenzoyl-CoA reductase was also recorded in some cell batches lacking enzyme activity. This possibly indicates an additional level of regulation on protein level for these two reductases.