Delayed versus Immediate Cord Clamping in Preterm Infants.

BACKGROUND: The preferred timing of umbilical-cord clamping in preterm infants is unclear. METHODS: We randomly assigned fetuses from women who were expected to deliver before 30 weeks of gestation to either immediate clamping of the umbilical cord (≤10 seconds after delivery) or delayed clamping (≥60 seconds after delivery). The primary composite outcome was death or major morbidity (defined as severe brain injury on postnatal ultrasonography, severe retinopathy of prematurity, necrotizing enterocolitis, or late-onset sepsis) by 36 weeks of postmenstrual age. Analyses were performed on an intention-to-treat basis, accounting for multiple births. RESULTS: Of 1634 fetuses that underwent randomization, 1566 were born alive before 30 weeks of gestation; of these, 782 were assigned to immediate cord clamping and 784 to delayed cord clamping. The median time between delivery and cord clamping was 5 seconds and 60 seconds in the respective groups. Complete data on the primary outcome were available for 1497 infants (95.6%). There was no significant difference in the incidence of the primary outcome between infants assigned to delayed clamping (37.0%) and those assigned to immediate clamping (37.2%) (relative risk, 1.00; 95% confidence interval, 0.88 to 1.13; P=0.96). The mortality was 6.4% in the delayed-clamping group and 9.0% in the immediate-clamping group (P=0.03 in unadjusted analyses; P=0.39 after post hoc adjustment for multiple secondary outcomes). There were no significant differences between the two groups in the incidences of chronic lung disease or other major morbidities. CONCLUSIONS: Among preterm infants, delayed cord clamping did not result in a lower incidence of the combined outcome of death or major morbidity at 36 weeks of gestation than immediate cord clamping. (Funded by the Australian National Health and Medical Research Council [NHMRC] and the NHMRC Clinical Trials Centre; APTS Australian and New Zealand Clinical Trials Registry number, ACTRN12610000633088 .).

Evaluating Clinical Reasoning in Undergraduate Medical Education: The Value of a Virtual Oral Assessment.

BACKGROUND: Oral assessments are essential components of board certification in numerous fields, as they provide insight into problem-solving capacity and clinical reasoning. The development of clinical reasoning often begins in undergraduate medical education and remains a challenge to assess. OBJECTIVE: We developed a pilot oral assessment to evaluate medical student oral presentations and systematically assess clinical reasoning. This was incorporated into a previously existing cumulative assessment at the conclusion of the third year of medical school, with the intent to demonstrate feasibility and future reliability of this exam format. METHODS: This pilot oral assessment was developed using content taught during third year clerkships. A modified Assessment of Reasoning Tool (ART) was used as the evaluation metric. It was conducted virtually to include faculty members from multiple disciplines and accommodate schedules and space limitations. RESULTS: A total of 152 third year medical students completed the exam, with a total of 15 faculty examiners. 89% of medical students scored as complete in hypothesis directed history, 93% in problem representation, 86% in prioritized differential diagnoses, and 67% in effectively directing management. Most examiners felt an oral assessment is effective to determine a medical student's clinical reasoning ability. CONCLUSIONS: Virtual oral assessments of clinical reasoning can be incorporated in undergraduate medical education to identify students struggling with components of clinical reasoning, while also allowing maximum flexibility for the clinician educator workforce as examiners. Longitudinal use of these exams would be valuable to track the development of clinical reasoning across the medical school curriculum.

Implementation of a novel daily performance improvement checklist (PIC) improves alcohol screening and intervention compliance in trauma.

Introduction: Screening, brief intervention, and referral to treatment (SBIRT) has demonstrated up to 50% reduction in alcohol-related traumatic injury and is mandated by the American College of Surgeons for trauma center accreditation. While SBIRT effectiveness has been previously investigated, optimal implementation in the trauma setting has not. We sought to improve SBIRT compliance through integration of screening into a performance improvement checklist (PIC) deployed during morning report. We hypothesized that PIC would establish a self-sustaining model for improved alcohol screening/intervention. Methods: This was a retrospective study comparing trauma patients pre-PIC (January-May 2022) to post-PIC (January-May 2023) after PIC implementation in January 2023. The primary outcome was SBIRT performance. The PIC prompted alcohol intervention specialist consultation if blood alcohol content >80 mg/dL, <21 years old, or Alcohol Use Disorders Identification Test ≥8. Significance was determined if p<0.05. Results: There were 705 pre-PIC and 840 post-PIC patients. Pre-PIC unscreened patients were more often uninsured (13% vs. 25%, p<0.01) and black (8% vs. 14%, p=0.02) compared with screened pre-PIC patients. There were no significant differences among screened versus unscreened patients after PIC with respect to age, sex, race, or ethnicity (p>0.05). Overall, screening improved pre-PIC to post-PIC (52% vs. 88%, p<0.01) and the percentage of patients who screened positively also increased after PIC (8% vs. 23%, p<0.01). Brief intervention was unchanged (83% vs. 81%, p=1). Conclusion: The PIC is a novel tool that demonstrated improved alcohol screening and referral. It improved compliance with SBIRT and reduced implicit bias in the population screened. Utilization of a PIC is easily translatable to other centers and could become a national standard to advance performance improvement. Level of evidence: IV.

Triphasic response of pituitary stalk injury following TBI: a relevant yet uncommonly recognised endocrine phenomenon.

The triphasic response of pituitary stalk injury has previously been described in a minority of patients following intracranial surgery, however, this phenomenon can also occur after traumatic brain injury. We present the case of a 20-year-old male who experienced the triphasic response of pituitary stalk injury (central diabetes insipidus, syndrome of inappropriate antidiuretic hormone and central diabetes insipidus again) after striking his head on a concrete curb. His history and presentation highlight the importance of recognising the distinctive symptoms of each individual stage of pituitary stalk injury, and using the appropriate diagnostic tools and therapies to guide further management.