Amniocentesis learning: Use of a home-made simulator.

BACKGROUND: Amniocentesis is the most performed invasive prenatal diagnostic procedure. Learning the procedure is difficult for the learner, the teacher and the patient because of the risks inherent to this technique and the anxiety generated by the procedure. The objective of this work was to evaluate a theoretical and practical amniocentesis training workshop using a simulator. METHODS: We were inspired by Pierre Jean's precepts for the planning of a medical training. We then carried out the pedagogical session with the gynecology residents of our Regional University Hospital, a type 3 maternity hospital in France. We evaluated the theoretical learning through a questionnaire before and after the training and then the practical session on a home-made simulator. The satisfaction of the participants was assessed by a questionnaire at the end of the session. RESULTS: Fifteen learners, from the first to the last semester of internship, participated in the training. The median score of the pre-training questionnaire ("pre-test" questionnaire) was 3.3 out of 10 (min = 1, max = 6) and that of the post-training questionnaire ("post-test" questionnaire) was 7.9 out of 10 (min = 6, max = 9). The post-training scores were significantly higher (p < 0.0007). The average score for the practical training was 30.5 out of 40 (24-36). 93 % of the learners were fully satisfied with the theoretical training and 100 % stated that they had improved their technical skills. CONCLUSION: The residents in our department expressed a need for training in this invasive procedure of antenatal diagnosis. The training proved to be beneficial following the evaluation of the learning but also following the feedback of the learners.

ACACIAS 1: The physiological and subjective impacts of high fidelity simulation of the breaking of bad news.

STUDY OBJECTIVE: Breaking bad news (BN) is difficult and necessitates targeted training. To be effective, training may call for High Fidelity Simulation (HFS). This prospective study was conducted to objectively assess the impact of HFS as a tool conducive to the development of clinical competence in situations involving the delivery of bad news. METHODS: This feasibility study was conducted from January to May 2021 and included students in medical oncology and digestive surgery. The subjective and objective impacts of HFS were evaluated by means of a self-administered questionnaire and a wristband, Affect-tag, which recorded several indicators: emotional power (EP), emotional density (DE) and cognitive load (CL) in students undergoing training. RESULTS: Forty-six (46) students with a median age of 25 years (21-34 years) were included. While the participants were effectively and emotionally involved in the HFS training, they were not completely overwhelmed by their emotions, a possible occurrence in this type of program. After two training programs, the students presented with lower EP (P<0.001) and higher DE (P=0.005), while their CL remained stable (P=0.751). The information given in the self-administered questionnaires and the evaluations by outside professionals (actor, nurse, psychologist…) highlighted improved skills. CONCLUSION: Taking into account the emotional parameters observed and the questionnaires collected, HFS can be considered as a suitable and effective tool in the breaking of bad news.

Psychometric properties of a self-assessment fear scale in children aged 4 to 12 years. Scary Scale.

BACKGROUND: Caregivers encounter difficulties differentiating fear and pain experienced by children and tend to interpret what children may feel, often resulting in inadequate pain management. While many pain self-assessment scales are available, there is no validated self-assessment fear scale for children. METHODS: The aim of this prospective study was to validate, in children aged 4 to 12 years, the psychometric properties of our scale. In a first part, in a school setting, five exercises were given to 484 children in order to validate the expression of fear, grade the intensity of the faces, the ability to discriminate the faces and the equality of the intervals. The scale's reproducibility was studied by assessing the children's fear in everyday situations at two different time points. In a second part, in a hospital setting, the aim was to test the scale's feasibility. Sixty children admitted to one emergency care department self-assessed their fear with the Scary Scale. FINDINGS: The expression of fear was validated by 57.64% (p < 0.0001) of the children in comparison with three other emotions (pain, surprise, sadness).The 7-9 year-olds validated the other properties (gradation, discrimination, equality, reproducibility). The 4-6 year-olds failed to validate the gradation exercise, but succeeded with the others. In the hospital, 95% of children self-assessed their fear using the scale. DISCUSSION: Our self-assessment fear scale was validated in children aged 7-12 years specifically and was readily feasible in the hospital. We recommend its use in that age group in every care situation triggering fear. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02675504.

[Qualitative study of parents' experience after their teen's suicide attempt]. / Étude qualitative de l'expérience des parents après la tentative de suicide de leur adolescent.

INTRODUCTION: Suicidal attempts are frequent during adolescence and concern the whole family, particularly parents whose role is crucial in provision of therapeutic support. Yet very few studies have been performed bearing on their lived experience. In this study, we will analyze the experience of parents after the suicidal attempt of their adolescent. PARTICIPANTS & METHODS: Qualitative study based on semi-structured interviews of 13 parents of teenagers followed in child and adolescent psychiatry for suicidal behavior. Interview included 5 to 6 open and conversational questions. We analyzed interviews, after transcription, using the Interpretative Phenomenological Analysis approach. RESULTS: The parents' wellness and behavior are directly affected by their child's mental status. When they are informed of the suicidal attempt, they feel very deep sadness, in a form of initial distress which is part of the grieving process regarding their image of idealized parents. They feel anger against the teenager, their anger is also directed against family members and close friends as well as against caregivers. Given the uncertainty, they doubt their own educative and empathetic competences, and lack confidence in their capacity for providing help. They express their need for help and support with regard to understanding their child's suicidal attempt, with regard to the emotional turmoil they experience and in reinforcing their competencies as carers. CONCLUSION: It appears that parents are extremely touched by their teenager suicidal attempt. They need a personal follow up, including familial medical care but also a personal space of support. Parents group, as well as psycho educative intervention, are also welcomed to give efficient method to lift their child.

Circumcision and Risk of Febrile Urinary Tract Infection in Boys with Posterior Urethral Valves: Result of the CIRCUP Randomized Trial.

BACKGROUND: Boys with posterior urethral valves (PUVs) have an increased risk of febrile urinary tract infections (fUTIs). Circumcision is believed to reduce the risk of fUTIs in boys, although there are no randomized trials demonstrating this. OBJECTIVE: To determine the effect of circumcision on the risk of fUTIs in boys with PUVs. DESIGN, SETTING, AND PARTICIPANTS: A clinical randomized trial that ran between August 2012 and July 2017 was conducted. The trial was multicentric, including 13 referral centers for pediatric urology. Male boys, aged 1-28 d, diagnosed with posterior urethral valves, confirmed by voiding cystogram, were included. The exclusion criteria included presence of a genital malformation contraindicating performing a circumcision. INTERVENTION: Participants were randomized to neonatal circumcision + antibiotic prophylaxis (CATB) or antibiotic prophylaxis alone (ATB), and followed for 2 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was a risk of presenting fUTIs in each group. An fUTI was defined as fever (>38.5 °C) with evidence of pyuria and culture-proven infection on urinalysis, obtained by urethral catheterization or suprapubic aspiration. A bivariate analysis of the primary outcome was performed using the Kaplan-Meier method. RESULTS AND LIMITATIONS: In total, 91 patients were included: 49 in group CATB and 42 in group ATB. The probability of presenting an fUTI was 20% in group ATB versus 3% in group CATB. The hazard ratio of presenting an fUTI within 2 yr in the ATB group compared with that in the CATB group was 10.3 (95% confidence interval: 1.3-82.5). Sixty-four children (70.3%) had a complete follow-up at 2 yr of age. CONCLUSIONS: Circumcision significantly decreases the risk of presenting an fUTI in boys with PUVs. PATIENT SUMMARY: In this report, we compared, in a multicentric trial, the number of febrile urinary tract infections (UTIs) in boys with posterior urethral valves who had either antibiotic prophylaxis alone or antibiotic prophylaxis and circumcision. We found that those who had a circumcision had a significantly lower risk of febrile UTIs.

Benefits of a 14-year surgical site infections active surveillance programme in a French teaching hospital.

BACKGROUND: Surgical site infections (SSIs) are the second most common healthcare-associated infection. Active SSI surveillance can help inform preventative measures and assess the impact of these measures. AIM: We aimed to describe the evolution in trends over 14 years of prospective active SSI surveillance and implementations of SSI prevention measures in a French Teaching Hospital. METHODS: We monitored and included in the study all surgical procedures performed from 2003 to 2016 in eight surgical units. The semi-automated surveillance method consisted of weekly collection of SSI declaration forms (pre-filled with patient and procedure administrative data and microbiology laboratory data), filled-in by surgeons and then monitored by the infection control practitioners. FINDINGS: A total of 181,746 procedures were included in our analysis and 3270 SSIs recorded (global SSI rate 1.8%). The SSI rate decreased significantly from 3.0% in 2003 to 1.1% in 2016. This decrease was mainly in superficial SSIs and high infectious risk procedures. Higher SSI rates were observed for procedures associated with the usual risk factors. During this 14-year period, several evolutions in surgical practices occurred that might have contributed to this decrease. CONCLUSIONS: With an overall decrease in SSI rate throughout the surveillance, our results revealed the benefits of an active and comprehensive hospital SSI surveillance programme for understanding the SSI rate trends, analysing local risk factors and assessing the effectiveness of prevention strategies. These findings also highlighted the importance of the collaboration between surgeons and infection control practitioners.

Transition effects from laparocscopic to robotic surgery skills in small cavities.

Conventional laparoscopic surgery (LS) is being challenged by the ever-increasing use of robotic surgery (RS) to perform reconstructive procedures. The purpose of this study was to assess the acquisition of skills in both techniques and the potential transfer of skills from one technique to the other when restricted spaces are involved. A preclinical randomized crossover study design was implemented. Twelve subjects performed two different reproducible drill procedures: "Thread the Ring" (TR) and "Transfer the Plot" (TP). To assess surgical proficiency in confined workspaces, these exercises were performed with LS and RS technology in a pediatric laparoscopic surgery (PLS) simulator. Each performance was recorded and evaluated by two reviewers using objective structured assessment of technical skills (OSATS). The times to complete the TP and the TR procedure were significantly shorter with RS compared to LS (64 s vs. 319 s; p < 0.0001 for both TP and TR). A significant transfer effect of skills between LS and RS was noted for the TP exercise (p = 0.006). The percentage improvement was greater overall with LS, meaning a higher number of trials were required to adequately master the procedure. This study demonstrated that RS performed significantly better compared to LS on pediatric simulation devices. A transfer effect was identified from LS to RS exclusively. The learning curves showed that progression was definitely longer with LS. These results, indicate that novice surgeons should be encouraged to persist with learning LS, and they support the use of a pediatric robotic simulation device.

Bertolotti's syndrome in children: From low-back pain to surgery. A case report.

Bertolotti's syndrome is a little-known and little-discussed pathology. We report the case of a 13-year-old child diagnosed with Bertolotti's syndrome after several years of functional complaints. Conventional radiography was used to diagnose the transverse mega-apophysis of L5, while sectional and functional imaging confirmed a lumbosacral-iliac impingement. In view of the transient efficacy of medical management, surgical resection of the transverse mega-apophysis was performed. The medium-term decline in symptoms was excellent and the patient resumed physical activities without limitation or pain.

Robotic-assisted laparoscopic surgery for pediatric tumors: a bicenter experience.

Mini-invasive surgery is more and more integrated in pediatric surgery. The robotic-assisted surgery brought new advantages from which the patient and the surgeon could benefit compared to laparoscopy. Its use in oncological surgery is still controversial. 12 robotic-assisted tumor resections with the da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA) were attempted in 11 children (mean age 7.65 years; age range 0.75-16.75 years; mean weight 30.3 kg; weight range 8.6-62 kg) in two centers. Mean total operative time was 145 min (range 72-263 min). 1 procedure (8.3%) was converted. The pathology included renal tumors (n = 2; one nephroblastoma, one metanephric adenoma), adrenal tumors (n = 9; three neuroblastomas, two pheochromocytomas, two adrenocortical adenomas, one cystic lymphangioma, one paraganglioma) and a pancreatic tumor (n = 1; one pancreatic cyst). 4 tumors (33.3%) were malignant. Every patient underwent a R0 resection. 1 child (8.3%) developed a post operative complication. Mean length of hospitalization was 3.0 days (range 2-5 days). Followup averaged 3.3 years with no recurrence. All children are alive. Robot-assisted MIS seems to be safe and feasible in pediatric tumors. The oncological surgical principles were respected in our series with low morbi/mortality and good long-term results. Robotic surgery and its technical advantages bring potential benefits for children with cancer. It has a role to play in pediatric oncological surgery but its place and indications still need to be better defined.

Highly-Exposed HIV-1 seronegative Female Commercial Sex Workers sustain in their genital mucosa increased frequencies of tolerogenic myeloid and regulatory T-cells.

We and others have shown that HIV-1 highly-exposed seronegative (HESN) female commercial sex workers (CSWs) maintain low genital inflammatory conditions to prevent HIV infection. HIV-1 interacts with toll-like receptors (TLR)-7/8 to induce interferon (IFN)-α, an important antiviral and immunomodulatory cytokine, which act together with interleukin (IL)-10, human leukocyte antigen (HLA)-G and immunoglobulin-like transcript (ILT)-4 to initiate a "tolerogenic/regulatory" anti-inflammatory loop. In view of further unravelling elements associated with natural immunity to HIV-1, we have characterised TLR-7, IFN-α, IL-10, HLA-G and ILT-4 expression profiles in the genital tract of female CSWs and HIV-1-uninfected non-CSWs from Benin. Endocervical myeloid HLA-DR+ cells from HESN CSWs expressed higher levels of IFN-α, TLR-7, IL-10 and HLA-G than those from both HIV-1-infected CSWs and HIV-1-uninfected non-CSWs. Further characterization of the endocervical myeloid HLA-DR+ cells in HESN CSWs revealed a population of "tolerogenic" CD103+ CD14+ CD11c+ myeloid cells expressing high levels of IFN-α and IL-10. Concomitantly, HESN CSWs had higher frequencies of endocervical regulatory CD4+ T-cells when compared to those from the two other groups of women. These novel findings provide strong evidence to support the implication of tolerogenic myeloid cells expressing high levels of antiviral molecules in shaping the genital mucosal immune response to prevent HIV infection.

[Pitfalls for renogram interpretation in pediatric urology]. / Biais d'interprétation de la scintigraphie rénale chez l'enfant.

Renograms are currently used for functional assessment by pediatric urologists. The aim of the present work was to focus on the potential pitfalls concerning renography. Potential confounding factors are described in reference to concrete cases. The main types of pitfalls concern venous or urinary catheters and background area definition. Protocols and renogram interpretation are critiqued in a bibliographic review. We propose a technical update and original data on the potential pitfalls in renography interpretation. Multidisciplinary discussion between nuclear medicine, pediatrics and pediatric surgery departments is required before drawing conclusions.

Long-term results with the laparoscopic transposition of renal lower pole crossing vessels.

BACKGROUND: For the treatment of ureterovascular pelviureteric junction obstruction (PUJO), transposition of lower pole crossing vessels (LPCV) has been described as an alternative to dismembered pyeloplasty. PURPOSE: To report on the long-term follow-up of children after laparoscopic transposition of LPCV. METHODS: A retrospective analysis of 70 children consecutively treated by laparoscopic transposition of LPCV. Candidate patients were selected on the basis of clinical history, renal ultrasound (US), and pre-operative mercaptoacetyltriglycine (MAG-3) scan. Selection criteria included: presence of LPCV with SFU Grade 1-2 hydronephrosis, impaired drainage on MAG-3 and intraoperative normal pelviureteric junction (PUJ) and ureter peristalsis. Thinned parenchyma, impaired renal function, or history of prenatal hydronephrosis were not considered as exclusion criteria. Children were clinically followed up with US and MAG-3 scan. Success was defined by symptom resolution with improvement in hydronephrosis. RESULTS: Seventy children, aged 8.3 years (range 2.75-16.0), were selected. Procedures were performed through transperitoneal laparoscopy (n = 42) or were robotic-assisted (n = 28). Operative time was 120 min and length of hospital stay was 2 days. The outcome was successful in 67/70 patients (96%), with a median follow-up of 52 months (range 13-114). There were three failures in children who eventually underwent dismembered pyeloplasty for a symptomatic, undiagnosed, intrinsic PUJ obstruction. Two of them had been postnatally followed for a resolving prenatally diagnosed hydronephrosis. Three children became free of symptoms, had improved hydronephrosis, but still showed impaired drainage on MAG-3 and are being closely followed up. DISCUSSION: Although this procedure proves to have long-term efficiency in selected indications, the main challenge is to intraoperatively ascertain the absence of associated intrinsic stenosis. Objective criteria remain difficult to establish, but intraoperative findings, including dependent, funnel-shaped, normal-looking PUJ with decreasing hydronephrosis after pelvis and LPCV mobilisation, and efficient peristalsis across the PUJ under intraoperative diuretic test, represent a low likelihood of associated intrinsic stenosis. Ipsilateral impaired renal function doesn't seem to be associated with an adverse outcome. In contrast, a prenatal history of mild or self-resolving hydronephrosis in a patient later presenting with intermittent dilatation, raises the suspicion of associated intrinsic PUJ obstruction, as it is associated with a higher risk of failure. CONCLUSION: With a long postoperative follow-up, the robotic-assisted or laparoscopic vascular hitch procedure has been successful in treating a selected group of children with obstructive LPCV, and represents a safe and reliable alternative to standard dismembered pyeloplasty in the absence of intrinsic PUJO suspected on prenatal US.

[Simulation training for urinary drainage improves skill retention]. / Simulation et rétention des acquisitions : application au drainage vésical.

INTRODUCTION: Urethral and suprapubic catheterizations are the two methods for urinary drainage. Systematic simulation training could improve the performance and reduce iatrogenic complications. The aim of the study was to evaluate the skills retention using simulation training. MATERIALS AND METHODS: It was an experimental study of the effect of urinary drainage simulation based skills on medical students in order to compare active and passive training methods. On the first session, randomization was proceeded. Then, the participant performed one of the two workshops (urethral or suprapubic catheterization) on a male mannequin. The maximal performance was 40 points on the assessment form. Both workshops were performed on the second (one month) and third sessions (six months). RESULTS: Eighteen participants were included. Main performance was 28.7/40 (23-34.2) at the first session. All the participants improved the performance on the second session with a significant difference (P<0.01) between passive 32.5 (26-36.5) and active participants 36.1/40 (34.5-39). On the third session, a similar difference was observed between passive and active participants (32.5 versus 30.4, P non significant). CONCLUSION: Simulation training seems to improve long-term skill retention of urinary drainage for inexperienced medical students. This preliminary study suggests to incorporate urinary drainage simulation training into all medical school curricula. LEVEL OF EVIDENCE: 4.

[Does prenatal diagnosis modify neonatal management and early outcome of children with esophageal atresia type III?]. / Le diagnostic anténatal modifie-t-il la prise en charge néonatale et le devenir à 1 an des enfants suivis pour atrésie de l'œsophage de type III ?

OBJECTIVE: Evaluate neonatal management and outcome of neonates with either a prenatal or a post-natal diagnosis of EA type III. STUDY DESIGN: Population-based study using data from the French National Register for EA from 2008 to 2010. We compared children with prenatal versus post-natal diagnosis in regards to prenatal, maternal and neonatal characteristics. We define a composite variable of morbidity (anastomotic esophageal leaks, recurrent fistula, stenosis) and mortality at 1 year. RESULTS: Four hundred and eight live births with EA type III were recorded with a prenatal diagnosis rate of 18.1%. Transfer after birth was lower in prenatal subset (32.4% versus 81.5%, P<0.001). Delay between birth and first intervention was not significantly different. Defect size (2cm vs 1.4cm, P<0.001), gastrostomy (21.6% versus 8.7%, P<0.001) and length in neonatal unit care were higher in prenatal subset (47.9 days versus 33.6 days, P<0.001). The composite variables were higher in prenatal diagnosis subset (38.7% vs 26.1%, P=0.044). CONCLUSION: Despite the excellent survival rate of EA, cases with antenatal detection have a higher morbidity related to the EA type (longer gap). Even if it does not modify neonatal management and 1-year outcome, prenatal diagnosis allows antenatal parental counseling and avoids post-natal transfer.

[Contribution of cardiac MRI in the initial evaluation and follow-up of myocarditis mimicking acute coronary syndrome: a series of 43 patients]. / Apport de l'IRM cardiaque dans l'évaluation initiale et le suivi des myocardites mimant un syndrome coronaire aigu : à propos d'une série de 43 patients.

AIMS: The diagnosis of acute myocarditis is complex, especially when the clinical presentation mimics an acute coronary syndrome. This condition may promote the progression to dilated cardiomyopathy and the occurrence of severe arrhythmias. A reassessment integrating a cardiac MRI at three months after the acute episode could help identify patients with a poor prognosis. PATIENTS AND RESULTS: This prospective series of 43 consecutive patients hospitalised for acute myocarditis included 36 men and seven women, with a mean age of 32 years, with no indication of heart failure. All patients presented elevated levels of troponin I. Echocardiography showed moderate left ventricular dysfunction in six cases and segmental wall motion abnormalities in 22 cases. After gadolinium injection, a subepicardial late enhancement was observed in 39 cases. Three months after the acute episode, all patients were asymptomatic. The echocardiography and laboratory tests were normal. In 23 cases, the MRI showed persistence of the late enhancement without segmental wall motion abnormality. After a mean follow-up of three years, one patient was lost to follow-up and only one suffered a heart failure revealing a dilated cardiomyopathy complicated by ventricular arrhythmias. CONCLUSION: On admission, the subepicardial localisation of late enhancement in the cardiac MRI is reliable criteria for the diagnosis of acute myocarditis, enabling to rule out an acute coronary syndrome. During follow-up, the persistence of late enhancement has no impact on prognosis. In this series, after a mean follow-up of three years, it was not associated with clinical or paraclinical abnormalities, except in one patient.

[Sociocultural and medical management of hypertension in sub-Saharan Africa]. / Prise en charge socioculturelle et médicale de l'hypertension artérielle en Afrique subsaharienne.

Hypertension has now become very prevalent in sub-Saharan Africa, in part due to the region's epidemiologic transition. Its long asymptomatic onset explains its late recognition and thus the high frequency of complications. Sociocultural conditions play an important role in the genesis of the disease in this region and in the difficulties encountered in its management. The breakdown of traditional ways of life, growing urbanization, and the switch to a western lifestyle and diet all have well-known deleterious effects on the cardiovascular system. High salt consumption, sedentarity, overweight and alcohol intake all promote these developments. The insufficient availability of medical care, poverty, and poor understanding of chronic diseases complicate the medical management of hypertension. In these regions, it is now a public health challenge that requires the training of healthcare workers and the involvement of the society as a whole, including political decisions, health education for school-children, and actions by social organizations and local officials and leaders. This communication must always respect traditional customs. Both curative measures and preventive actions are essential. Priority must be given to combatting excessive salt consumption, for the results of its reduction are known to be rapid and positive. Preventing or reducing overweight and obesity, sedentarity, and alcohol and tobacco consumption are effective steps against hypertension, but also atheromatous cardiovascular diseases and diabetes. Drug therapy must meet the three essential criteria: it must be effective, available, and inexpensive. Hypertension is not inevitable, but reflects changes in society. It appears to be transmitted in part by modern lifestyles, which can be modified.

[Exercise-induced left bundle branch block with chest pain related to antimalarial prophylaxis with chloroquine]. / Bloc de branche gauche douloureux d'effort associé à la chimioprophylaxie antipaludique par chloroquine.

Left bundle branch block (LBBB) during exercise can be associated with chest pain. Though this association is mostly correlated with an underlying coronary artery disease, painful LBBB has been described in patients with normal coronary arteries. We report a case of exercise-induced LBBB with typical angina pectoris related to antimalarial prophylaxis with chloroquine in a 66-year old woman with normal coronary arteries, which was reversed after treatment discontinuation. The effect of chloroquine on the electrophysiological properties of nodal cardiac tissue is responsible for this rate-dependent LBBB. Precautions for future antimalarial prophylaxis are also discussed.