Antenatal magnesium sulphate administration for fetal neuroprotection: a French national survey.

BACKGROUND: Magnesium sulphate (MgSO4) is the only treatment approved for fetal neuroprotection. No information on its use is available in the absence of a national registry of neonatal practices. The objective of our study was to evaluate the use of MgSO4 for fetal neuroprotection in French tertiary maternity hospitals (FTMH). METHODS: Online and phone survey of all FTMH between August 2014 and May 2015. A participation was expected from one senior obstetrician, one senior anaesthetist and one senior neonatologist from each FTMH. Information was obtained from 63/63 (100%) FTMH and 138/189 (73%) physicians. Use of MgSO4 for fetal neuroprotection, regimen and injection protocols, reasons for non-use were the main outcome measures. RESULTS: 60.3% of FTMH used MgSO4 for fetal neuroprotection. No significant difference was observed between university and non-university hospitals or according to the annual number of births. Protocols differed especially in terms of the maximum gestational age (3% <28 WG, 71% <33 WG, 18% <34 WG and 8% < 35 WG). Eighty seven percent of centers using MgSO4 prescribed retreatment when necessary, but according to non-consensual modalities in terms of number of treatments or between-treatment intervals. Injections and monitoring were mostly performed in the delivery room (97%) but also in the recovery room in one half of hospitals. Lack of experience (52%), absence of a written protocol (49%) and national guidelines (46%) were the reasons most commonly reported to explain non-use of MgSO4 as a neuroprotective agent. CONCLUSIONS: Sixty percent of FTMH used MgSO4 for fetal neuroprotection, but according to heterogeneous regimens. National guidelines could allow standardization of practices and better MgSO4 coverage.

Laparoscopic management of diaphragmatic endometriosis by three different approaches.

OBJECTIVE: To report our three surgical approaches in the management of diaphragmatic endometriosis. DESIGN: Video article presenting laparoscopic surgical techniques, with and without robotic assistance. SETTING: University hospital. PATIENT(S): Nulliparas with deep endometriosis associated with multiple endometriosis lesions of the diaphragm. INTERVENTION(S): Laparoscopic approach in women who present with small black-pigmented diaphragmatic lesions, with or without infiltration of the diaphragm, which are ablated using plasma energy. Robotic-assisted laparoscopic route in larger deep infiltrating implants, which are resected. To avoid phrenic nerve injury, robotic-assisted thoracoscopy is preferred in large lesions involving the central tendon of the diaphragm. MAIN OUTCOME MEASURE(S): The steps of each technique are emphasized. Surgical technique reports in anonymous patients are exempted from ethical approval by the Institutional Review Board. RESULT(S): Seven patients have been managed by these procedures from July 2015 to March 2016. Patients' functional outcomes were uneventful, with no phrenic nerve palsy or residual chest and right shoulder pain. CONCLUSION(S): By combining resection and ablation techniques, the laparoscopy and thoracoscopy route, conventional and robotic-assisted minimally invasive approach, we offer a surgical strategy that is as conservative as possible, with an aim to limit postoperative adhesions between the liver and the diaphragm, and avoid diaphragmatic paralysis.

Residents in tutored practice exchange groups have better medical reasoning as measured by the script concordance test: A pilot study.

BACKGROUND: This pilot study attempted to evaluate the impact of a practice exchange group (PEG) tutored by a senior anaesthesiologist on clinical reasoning performance of anaesthesiology residents for uncertain situations. Changes in clinical reasoning were measured by script concordance tests (SCT). METHODS: First, a curriculum, with educational objectives and assessment tools, was proposed to all residents at the beginning of their 6-month training. The first group (control) consisted of residents undergoing a 6-month rotation without PEG training. The second group (PEG group) consisted of the residents starting a new rotation 6 months later, who followed a weekly PEG session. In both groups, clinical reasoning was assessed in the same manner, with SCTs, multiple-choice questions (MCQs) and questions with short answers. The primary outcome measurement of this study was the SCT results in the group with PEG training (PEG group) in comparison with those without (control group). RESULTS: The performance in the SCT, expressed as the degree of concordance with the panel [95% confidence interval or CI], was better in the PEG group including 19 residents (72 [68 to 76] %) as compared to the control group including 17 residents (60 [57 to 63] % P<0.001). Performances (mean [95% CI]) in MCQs and short answers were better in the PEG group (64 [57 to 71] and 74 [68 to 72] %, respectively) when compared with the control group (32 [28 to 36]% [P<0.001] and 60 [52 to 68] % [P<0.01], respectively). CONCLUSION: Our pilot study suggested that a senior-directed, peer-conducted educational training might improve the clinical reasoning of anaesthesia residents as measured by the SCT.

School-age outcomes following a randomized controlled trial of magnesium sulfate for neuroprotection of preterm infants.

In a French randomized trial, children at school-age demonstrated no evidence of harm from fetal exposure to MgSO4 before very preterm birth. Motor dysfunction/death, qualitative behavioral disorders, cognitive difficulties, school grade repetition, and education services were decreased in the children exposed to MgSO4, although the differences were not significant.