'The Move', an innovative simulation-based medical education program using roleplay to teach neurological semiology: Students' and teachers' perceptions.

INTRODUCTION: Neurological disorders are frequently being managed by general practitioners. It is therefore critical that future physicians become comfortable with neurological examination and physical diagnosis. Graduating medical students often consider neurological examination as one of the clinical skills they are least comfortable with, and they even tend to be neurophobic. One way to improve the learning of neurological semiology is to design innovative learner-friendly educational methods, including simulation training. METHODS: The feasibility of mime-based roleplaying was tested by a simulation training program in neurological semiology called 'The Move'. The program was proposed to third-year medical students at Pierre and Marie Curie University in Paris during their neurology rotation. Students were trained to roleplay patients by miming various neurological syndromes (pyramidal, vestibular, cerebellar, parkinsonian) as well as distal axonopathy, chorea and tonic-clonic seizures. Using an anonymous self-administered questionnaire, the students' and teachers' emotional experience and views on the impact of the program were then investigated. RESULTS: A total of 223/365 students (61%) chose to participate in the study. Both students and teachers felt their participation was pleasant. Students stated that The Move increased their motivation to learn neurological semiology (78%), and improved both their understanding of the subject (77%) and their long-term memorization of the teaching content (86%). Although only a minority thought The Move was likely to improve their performance on their final medical examination (32%), a clear majority (77%) thought it would be useful for their future clinical practice. Both students (87%) and teachers (95%) thought The Move should be included in the medical curriculum. CONCLUSION: Mime-based roleplaying simulation may be a valuable tool for training medical students in neurological semiology, and may also help them to overcome neurophobia.

Access to Care in France for Elderly Immigrants from North Africa: Influence of Socio-cultural Factors (the MATC Survey).

France is faced with an ageing migrant population, and in the institutions for elderly, migrants represent only 4% and very few come from the Maghreb. Is it the result of a kind of discrimination or of other factors such as culture and traditions? In France migrants have access to aid and prevention of dependency plans. The reluctance to enter into institutions is maintained by the fear of cultural abuse and/or language barriers, and difficulties in financial and administrative matters. From the interviews of the MATC survey, we have pointed out the importance of culture and the tradition of filial piety. Nevertheless, solidarity in the family is decreasing but remains the basis of the care support to the elderly. The will to keep them in the family may limit both the diagnosis and the access to specific care. This attitude contributes to a kind of self-discrimination.

[Association between students' clinical performance and their success in the computerized national ranking tests: A single-center retrospective cohort study]. / Association entre les performances cliniques des étudiants et leur réussite aux Épreuves classantes nationales informatisées : une étude de cohorte rétrospective monocentrique.

INTRODUCTION: Before attending residency, 6th-year French medical students must validate a final examination including a practical clinical test in their faculty. However, the national ranking that determines their future specialty and region solely relies on a computerized knowledge test. Our goal was to investigate the association between the final faculty test and the national ranking test. METHODS: In our faculty, the final examination includes a computerized theoretical test (similar to the national one) and a practical test: a standardized evaluation of semiology skills at the bedside and a standardized assessment of relational skills with role plays. The agreements between the national test and faculty computerized and practical tests were analyzed by intraclass correlation coefficients (ICC). RESULTS: Data from 1806 students who underwent the three examinations from 2017 to 2021 were analyzed. There was a good agreement between the ranks in the faculty and national computerized tests: ICC 0.83 (95% CI 0.81-0.85). By contrast, the agreement between the ranks in the faculty practical test and the national computerized test was poor: ICC 0.13 (95% CI 0.08-0.17). Results were stable over the years. CONCLUSION: The agreement between the ranking of the current national test and the clinical skills assessed by a specific faculty test is poor. This could relate to a true independence or to different levels of motivation to perform well. Indeed, the result of the national test is the most important one as it determines their career. Incorporating a clinical assessment into the national ranking test will motivate students to acquire clinical skills and value those who perform well this practical dimension.

Are script concordance tests suitable for the assessment of undergraduate students? A multicenter comparative study.

INTRODUCTION: Script concordance tests (SCTs) have been developed to assess clinical reasoning in uncertain situations. Their reliability for the evaluation of undergraduate medical students has not been evaluated. METHODS: Twenty internal medicine SCT cases were implemented in undergraduate students of two programs. The results obtained on the SCTs were compared to those obtained by the same students on clinical-based classical multiple-choice questions (MCQs). RESULTS: A total of 551/883 students (62%) answered the SCTs. The mean aggregate score (based on a total 20 points) was 11.54 (3.29). The success rate and mean score for each question did not differ depending on the modal response but the discrimination rate did. The results obtained by the students on the SCT test correlated with their scores on the MCQ tests. Among students, 446/517 (86%) considered the SCTs to be more difficult than classical MCQs, although the mean score did not differ between the SCT and MCQ tests. CONCLUSION: The use of SCTs is a feasible option for the evaluation of undergraduate students. The SCT scores correlated with those obtained on classical MCQ tests.

Treating strangeness: Medicine and human dignity at the time of COVID-19.

The concomitance of a migratory wave and the hospital crisis once again raises the question of the care that the French healthcare system is able to provide to migrants. On the occasion of SFFEM's 19th annual day, we present a synthesis of the research work that has been communicated at that time. Firstly, we will discuss how doctors have been able to overcome strangeness to revive the notion of hospitality according to Levinas; secondly, we will discuss how the hospital is departing from its mission of institutional hospitality because of administrative injunctions; thirdly, we will discuss how ethnomedicine gives us keys to open up to other cultural norms; fourthly, we will see the inadequacy that exists between rights of access to medical care and their effectiveness; finally, the conclusion of Xavier Emmanuelli, founder of the social ambulance service, will remind us how much the values of the French Republic call us to the notion of care and openness to otherness.

Progressive clinical case-based multiple-choice questions: An innovative way to evaluate and rank undergraduate medical students.

INTRODUCTION: In France, at the end of the sixth year of medical studies, students take a national ranking examination including progressive clinical case-based multiple-choice questions (MCQs). We aimed to evaluate the ability of these MCQs for testing higher-order thinking more than knowledge recall, and to identify their characteristics associated with success and discrimination. METHODS: We analysed the 72 progressive clinical cases taken by the students in the years 2016-2019, through an online platform. RESULTS: A total of 72 progressive clinical cases (18 for each of the 4 studied years), corresponding to 1059 questions, were analysed. Most of the clinical cases (n=43, 60%) had 15 questions. Clinical questions represented 89% of all questions, whereas basic sciences questions accounted for 9%. The most frequent medical subspecialties were internal medicine (n=90, 8%) and infectious diseases (n=88, 8%). The most frequent question types concerned therapeutics (26%), exams (19%), diagnosis (14%), and semiology (13%). Level 2 questions ("understand and apply") accounted for 59% of all questions according to the Bloom's taxonomy. The level of Bloom's taxonomy significantly changed over time with a decreasing number of level 1 questions ("remember") (P=0.04). We also analysed the results of the students among 853 questions of training ECNi. Success and discrimination significantly decreased when the number of correct answers increased (P<0.0001 both). The success, discrimination, mean score, and mean number of discrepancies did not differ according to the diagnosis, exam, imaging, semiology, or therapeutic type of questions. CONCLUSION: Progressive clinical case-based MCQs represent an innovative way to evaluate undergraduate students.

[Respect of patient's dignity in the hospital]. / Le respect de la dignité à l'hôpital.

Every code of ethics of health professionals in France considers the respect of dignity as a fundamental duty. The French 2002 Law on patient rights says that the person has the right to respect of dignity and of private life. After a presentation of the articles of ethics codes regarding dignity, this paper presents recommendations to deliver medical care in situations where dignity might be endangered such as for patients hospitalized in psychiatric services without consent, or for medical examination of prisoners or medical care to vulnerable patients unable to express their will, especially in palliative care or at the end of life. Respect of dignity after death is illustrated by the reflection conducted by the Espace Ethique de l'AP-HP (Paris area hospitals) and in the Chart of the mortuary yard. A survey of the patients' letters of complaint received by the emergency service of the Toulouse University Hospital showed that, in five years, there were 188 letters and 18 pointed out infringements to the dignity of the person. The health professional team is now aware of this obligation, and in the accreditation of the hospitals, the respect of dignity is one of the indicators of the quality of medical care.

Diaphragm pacing restores olfaction in tetraplegia.

High cervical spinal cord injuries induce extreme handicap and tactile isolation. Tracheotomised tetraplegic patients are also bound to be olfaction deprived. By restoring negative pressure inspiration, diaphragm pacing (DP) should improve olfaction. We tested olfaction in 10 consecutive tetraplegics during positive pressure mechanical ventilation and DP, using the University of Pennsylvania Smell Identification Test (UPSIT). Quality of life was assessed using the Satisfaction with Life Scale (SWLS). Self-perceived benefits of DP were studied using an in-house questionnaire. Olfaction was very poor during positive pressure mechanical ventilation (UPSIT, mean+/-SD 17.1+/-6.4, anosmia or severe microsmia). It improved during DP (35.2+/-1.9, normosmia or mild microsmia; p<0.0001) and SWLS was 18.5+/-4.2. Nine patients stated that DP had improved their quality of life. This was driven by better mobility (ranked first), improved self-image and relationships with others (ranked second), improved olfaction and better feeling of security (both ranked third). Improved olfaction is among the benefits of DP and should be mentioned to patients considered for this therapy. Furthermore, attention to olfaction is warranted in tracheotomised ventilator-dependent patients, as a putative path towards improvement of quality of life.

[Comparing ethics committees from France and Quebec with respect to incapacity to consent to research]. / Comparaison des comités d'éthique de France et du Québec en regard de l'incapacité à consentir à la recherche.

BACKGROUND: French and Quebec legislation allow the inclusion of decisionally-incompetent subjects in research, provided certain conditions are met. In both jurisdictions, ethics committees are charged with ensuring that research protocols meet these conditions. We investigated committee members' knowledge and opinions regarding substitute consent for research purposes. METHODS: Two consecutive postal surveys were conducted among all members of ethics committees from France and Quebec. Knowledge and opinions about proxy consent were measured with clinical vignettes describing hypothetical situations involving incapable adults. For each vignette, respondents were asked to either identify the person legally authorized to consent or choose the substitute decision-maker whom they considered best suited to do so. RESULTS: Knowledge of the legislation governing substitute consent was poor in both samples, especially in situations involving an incompetent person who did not have a legal representative. Knowledge was worse among French ethics committee members (p<0.001). In hypothetical clinical studies that involved no risk to the subject's health, 59% of respondents favored consent from a close relative. As the risk increased, the proportion gradually decreased to 14.2%, while the proportion against soliciting the cognitively impaired older adult tended to increase (from 5.8 to 31.2%). These trends were observed in both samples. CONCLUSION: These findings underscore the need to better educate ethics committee members about legislation regarding prospective subjects who lack decisional capacity. Such efforts could improve both knowledge of and compliance with legal provisions that enable or restrict the participation of cognitively-impaired patients in research projects. Moreover, study findings provide some support for enlarging the category of persons who are authorized to consent to low-risk research on behalf of incapacitated adults who lack legal representation.

New developments for an electron impact (e,2e)(e,3e) spectrometer with multiangle collection and multicoincidence detection.

We describe new developments aimed to extend the capabilities and the sensitivity of the (e,2e)(e,3e) multicoincidence spectrometer at Orsay University [Duguet et al., Rev. Sci. Instrum. 69, 3524 (1998)]. The spectrometer has been improved by the addition of a third multiangle detection channel for the fast "scattered" electron. The present system is unique in that it is the only system which combines three toroidal analyzers all equipped with position sensitive detectors, thus allowing the triple coincidence detection of the three electrons present in the final state of an electron impact double ionization process. The setup allows measurement of the angular and energy distributions of the ejected electrons over almost the totality of the collision plane as well as that of the scattered electron over a large range of scattering angles in the forward direction. The resulting gain in sensitivity ( approximately 25) has rendered feasible a whole class of experiments which could not be otherwise envisaged. The setup is described with a special emphasis on the new toroidal analyzer, data acquisition hardware, and data analysis procedures. The performances are illustrated by selected results of (e,2e) and (e,3e) experiments on the rare gases.

Effect of simulated patient death on emergency worker's anxiety: a cluster randomized trial.

OBJECTIVE: Simulation-based teaching offers promising and diverse teaching possibilities. We aim to assess whether the death of the manikin increased anxiety amongst learner compared to similar simulation-based course where the manikin stays alive. METHODS: We conducted a cluster randomized study amongst multidisciplinary teams of emergency workers. Teams of physicians, nurses, and healthcare assistants were randomly assigned to participate in a simulation-based course where the simulated patient died (death group) or not (life group). We assessed anxiety at 1 month after the teaching using Spielberger STAI-state anxiety questionnaire. We compared reduction of anxiety when facing a life-threatening situation in both groups. RESULTS: We included 25 teams for a total of 129 participants. We analysed 63 participants in the death group and 57 in the life group. Baseline characteristics were similar in both groups, including baseline anxiety (STAI-state score 39.6 (7.8) in the death group vs 38.6 (7.1) in the life group). We report a significant reduction in both groups 1 month after the training: 6.6 (7.8) vs 6 (8.0), mean difference 0.5 (-2.4; 3.4). At 3 months, we report a significant greater reduction of anxiety in the death group (mean difference 4 [0.1; 7.9]). CONCLUSION: We observed in our sample that unexpected simulated patient death did not increase anxiety amongst multidisciplinary emergency workers.

[Newly formed French residents in pediatrics are not well prepared for conducting pediatric resuscitation after medical school]. / Le deuxième cycle des études médicales prépare-t-il les étudiants hospitaliers à leurs fonctions d'internes ? Exemple de l'arrêt cardiaque de l'enfant.

BACKGROUND: Medical schools aim to prepare medical students for their residency responsibilities. However, in France, there is no assessment of medical students' skills when they start their residency. GOAL: The objective of this study was to assess the quality of basic life support delivered by first-year residents in pediatrics during a simulated pediatric cardiopulmonary arrest. MATERIALS AND METHODS: First-year residents in pediatrics were assessed during a simulated pediatric cardiopulmonary arrest. Their performance score (based on adherence to international guidelines) and no-flow and no-blow fractions were recorded. RESULTS: Forty-two first-year residents were evaluated. Their median performance score was 4 out of 13. No-blow and no-flow fractions were 55 and 81 %, respectively. There was no correlation between their skills and their knowledge assessed during the national ranking exam at the end of the 6th year of medical school. CONCLUSION: At the beginning of their residency, pediatric residents are not able to properly provide basic life support. The introduction of simulation in French medical schools may be an effective way to improve their skills.

Expiratory flow limitation as a determinant of orthopnea in acute left heart failure.

OBJECTIVES: To assess the contribution of expiratory flow limitation (FL) in orthopnea during acute left heart failure (LHF). BACKGROUND: Orthopnea is typical of acute LHF, but its mechanisms are not completely understood. In other settings, such as chronic obstructive pulmonary disease, dyspnea correlates best with expiratory FL and can, therefore, be interpreted as, in part, the result of a hyperinflation-related increased load to the inspiratory muscles. As airway obstruction is common in acute LHF, postural FL could contribute to orthopnea. METHODS: Flow limitation was assessed during quiet breathing by applying a negative pressure at the mouth throughout tidal expiration (negative expiratory pressure [NEP]). Flow limitation was assumed when expiratory flow did not increase during NEP. Twelve patients with acute LHF aged 40-98 years were studied seated and supine and compared with 10 age-matched healthy subjects. RESULTS: Compared with controls, patients had rapid shallow breathing with slightly increased minute ventilation and mean inspiratory flow. Breathing pattern was not influenced by posture. Flow limitation was observed in four patients when seated and in nine patients when supine. In seven cases, FL was induced or aggravated by the supine position. This coincided with orthopnea in six cases. Only one out of the five patients without orthopnea had posture dependent FL. Control subjects did not exhibit FL in either position. CONCLUSIONS: Expiratory FL appears to be common in patients with acute LHF, particularly so when orthopnea is present. Its postural aggravation could contribute to LHF-related orthopnea.

[Removal of a tracheostomy in ventilator-dependent patients with neuromuscular disease]. / Sevrage de la trachéotomie chez des patients neuromusculaires dépendants d'une ventilation mécanique.

BACKGROUND: Ventilation via a tracheostomy is effective but very restricting in patients with neuromuscular disease. Return to non-invasive ventilation (NIV) is possible but this is not common practice, partly for want of standardised procedures ensuring a safe transition. METHODS: A procedure for transfer of ventilation via a tracheostomy to a mask has been developed based on the literature and local experience (feasibility of NIV, absence of laryngo-tracheal lesions, adequate leak compensation, effective cough). It has been tested in three patients with severe but stable neuromuscular disorders (chronic polyneuropathy in two cases and progressive spinal amyotrophy on one). RESULTS: The three patients were able to be extubated and established on domiciliary ventilation in 6,7 and 10 days, at the end of which all were discharged home. After 4 months in two cases and 6 months in the other no significant complications developed, the respiratory status under NIV was comparable to that previously under tracheostomy and the patients were satisfied with the change. CONCLUSION: The proposed algorithm seems to permit a rapid and safe transition from a tracheostomy to a mask. Large scale studies are needed to verify this concept and subsequently to identify within which group a similar approach may be correctly applied.

Assessment of the motor pathway to the diaphragm using cortical and cervical magnetic stimulation in the decision-making process of phrenic pacing.

BACKGROUND: Phrenic nerve pacing is a recognized substitute to positive pressure ventilation via tracheotomy in patients with high cervical cord lesions or central hypoventilation. Although its indications are infrequent, reliable strategies need to be used in the determinations of patients who may benefit from this treatment; contraindications should be carefully respected. STUDY OBJECTIVES: To determine whether modern and noninvasive means to study the motor pathway to the diaphragm, namely cortical magnetic stimulation (CxMS) and cervical magnetic stimulation (CMS), can contribute to the selection of patients who may benefit from phrenic pacing. DESIGN AND SETTING: Prospective study (18 months), on a consecutive basis, of patients referred for possible phrenic pacing to a 10-bed ICU associated with a respiratory neurophysiology laboratory. PATIENTS: Seven patients (high cervical cord injury, n = 5; central hypoventilation following neurosurgery, n = 1; idiopathic acquired central hypoventilation, n = 1). INTERVENTION, MEASUREMENTS, AND RESULTS: Electromyography of the diaphragm and transdiaphragmatic pressure were assessed in response to CxMS and CMS. In three cases, no interruption of the corticodiaphragmatic pathway was evidenced, the decision of pacing was postponed, and the patients eventually recovered a spontaneous breathing activity. In two cases, the diagnosis of irreversible peripheral phrenic dysfunction was reached and pacing was denied. In two cases, complete interruption of the corticodiaphragmatic pathway and integrity of peripheral conduction led to the decision of phrenic pacemaker implantation. CONCLUSION: CxMS and CMS can be used to refine the assessment of patients proposed for phrenic pacing. CxMS can possibly identify those in whom there is a possibility for eventual recovery, and therefore substantiate a decision to postpone the pacing.

Anterior magnetic phrenic nerve stimulation: laboratory and clinical evaluation.

OBJECTIVE: Anterior magnetic stimulation (aMS) of the phrenic nerves is a new method for the assessment of diaphragm contractility that might have particular applications for the clinical assessment of critically ill patients who are commonly supine. DESIGN: We compared aMS with existing techniques for measurement of diaphragm weakness and fatigue in 10 normal subjects, 27 ambulant patients with suspected diaphragm weakness and 10 critically ill patients. SETTING: Laboratory and intensive care unit of two university hospitals. RESULTS: Although aMS was not demonstrably supramaximal in normal subjects, the mean value of twitch transdiaphragmatic pressure (Tw Pdi) obtained at 100% of stimulator output, 23.7 cmH2O, did not differ significantly from that obtained with bilateral supramaximal electrical stimulation (ES), 24.9 cmH2O, or bilateral anterior magnetic phrenic nerve stimulation (BAMPS), 27.3 cmH2O. A fatiguing protocol produced a 20 % fall in aMS-Tw Pdi and a 19% fall in BAMPS-Tw Pdi; the fall in aMS-Tw Pdi correlated with the fall in BAMPS-Tw Pdi (r2 = 0.84, p = 0.03) indicating that aMS can detect diaphragm fatigue. In ambulant patients aMS agreed closely with existing measures of diaphragm strength. The maximal sniff Pdi correlated with both the aMS-Tw Pdi (r2 = 0.60, p < 0.0001) and the BAMPS-Tw Pdi (r2 = 0.65, p < 0.0001) and the aMS-Tw Pdi was a mean (SD) 2.2 (4.3) cmH2O less than BAMPS-Tw Pdi. In addition, aMS correctly identified diaphragm dysfunction in patients studied on the ICU. CONCLUSIONS: We conclude that aMS is of clinical value for the investigation of suspected diaphragm weakness.

Cervical magnetic stimulation as a method to discriminate between diaphragm and rib cage muscle fatigue.

Inspiratory muscle fatigue can probably determine hypercapnic respiratory failure. Diaphragm fatigue is detected by electrical phrenic stimulation (ELS), but there is no simple tool to assess rib cage muscle (RCM) fatigue. Cervical magnetic stimulation (CMS) costimulates the phrenic nerves and RCM. We reasoned that changes in transdiaphragmatic pressure twitch (Pdi,tw) with CMS and ELS should be different after selective diaphragm vs. RCM fatigue. Five volunteers performed inspiratory resistive tasks while voluntarily uncoupling diaphragm and RCM. Baseline Pdi,twELS and Pdi,twCMS were 28.57 +/- 1.68 and 32.83 +/- 2.92 cmH2O. After selective diaphragm loading, Pdi,twELS and Pdi,twCMS were reduced by 39 and 26%, with comparable decreases in gastric pressure twitch (Pga,tw). Esophageal pressure twitch (Pes,tw) was better preserved with CMS. Therefore Pes,tw/Pga,tw was lower with ELS than CMS (-1.24 +/- 0.16 vs. -1.73 +/- 0.11, P = 0.05). After selective RCM loading, there was no diaphragm fatigue, but Pes,twCMS was significantly reduced (-30%). These findings support the role of rib cage stiffening by CMS-related RCM contraction in the ELS-CMS differences and suggest that CMS can be used to assess RCM fatigue.

Comparison of magnetic and electrical phrenic nerve stimulation in assessment of phrenic nerve conduction time.

Cervical magnetic stimulation (CMS), a nonvolitional test of diaphragm function, is an easy means for measuring the latency of the diaphragm motor response to phrenic nerve stimulation, namely, phrenic nerve conduction time (PNCT). In this application, CMS has some practical advantages over electrical stimulation of the phrenic nerve in the neck (ES). Although normal ES-PNCTs have been consistently reported between 7 and 8 ms, data are less homogeneous for CMS-PNCTs, with some reports suggesting lower values. This study systematically compares ES- and CMS-PNCTs for the same subjects. Surface recordings of diaphragmatic electromyographic activity were obtained for seven healthy volunteers during ES and CMS of varying intensities. On average, ES-PNCTs amounted to 6.41 +/- 0.84 ms and were little influenced by stimulation intensity. With CMS, PNCTs were significantly lower (average difference 1.05 ms), showing a marked increase as CMS intensity lessened. ES and CMS values became comparable for a CMS intensity 65% of the maximal possible intensity of 2.5 Tesla. These findings may be the result of phrenic nerve depolarization occurring more distally than expected with CMS, which may have clinical implications regarding the diagnosis and follow-up of phrenic nerve lesions.

Effect of negative expiratory pressure on respiratory system flow resistance in awake snorers and nonsnorers.

In spontaneously breathing subjects, intrathoracic expiratory flow limitation can be detected by applying a negative expiratory pressure (NEP) at the mouth during tidal expiration. To assess whether NEP might increase upper airway resistance per se, the interrupter resistance of the respiratory system (Rint,rs) was computed with and without NEP by using the flow interruption technique in 12 awake healthy subjects, 6 nonsnorers (NS), and 6 nonapneic snorers (S). Expiratory flow (V) and Rint,rs were measured under control conditions with V increased voluntarily and during random application of brief (0.2-s) NEP pulses from -1 to -7 cmH(2)O, in both the seated and supine position. In NS, Rint,rs with spontaneous increase in V and with NEP was similar [3.10 +/- 0.19 and 3.30 +/- 0.18 cmH(2)O x l(-1) x s at spontaneous V of 1.0 +/- 0.01 l/s and at V of 1.1 +/- 0.07 l/s with NEP (-5 cmH(2)O), respectively]. In S, a marked increase in Rint,rs was found at all levels of NEP (P < 0.05). Rint,rs was 3.50 +/- 0.44 and 8.97 +/- 3.16 cmH(2)O x l(-1) x s at spontaneous V of 0.81 +/- 0.02 l/s and at V of 0.80 +/- 0.17 l/s with NEP (-5 cmH(2)O), respectively (P < 0.05). With NEP, Rint,rs was markedly higher in S than in NS both seated (F = 8.77; P < 0.01) and supine (F = 9.43; P < 0.01). In S, V increased much less with NEP than in NS and was sometimes lower than without NEP, especially in the supine position. This study indicates that during wakefulness nonapneic S have more collapsible upper airways than do NS, as reflected by the marked increase in Rint,rs with NEP. The latter leads occasionally to an actual decrease in V such as to invalidate the NEP method for detection of intrathoracic expiratory flow limitation.