Does the unexpected death of the manikin in a simulation maintain the participants' perceived self-efficacy? An observational prospective study with medical students.

BACKGROUND: The death of a simulated patient is controversial. Some educators feel that having a manikin die is prejudicial to learning; others feel it is a way of better preparing students for these situations. Perceived self-efficacy (PSE) reflects a person's perception of their ability to carry out a task. A high PSE is necessary to manage a task efficiently. In this study, we measured the impact of the death of a simulated patient on medical students' perceived self-efficacy concerning their ability to cope with a situation of cardiac arrest. METHODS: We carried out a single-centre, observational, prospective study. In group 1 (n = 27), pre-graduate medical students were warned of the possible death of the manikin; group 2 students were not warned (n = 29). The students' PSE was measured at the end of the simulated situation and after the debriefing. RESULTS: The PSE of the two groups was similar before the debriefing (p = 0.41). It had significantly progressed at the end of the debriefing (p < 0,001). No significant difference was noted between the 2 groups (p = 0.382). CONCLUSIONS: The simulated death of the manikin did not have a negative impact on the students' PSE, whether or not they had been warned of the possible occurrence of such an event. Our study helps defend the position which supports the inclusion of unexpected death of the manikin in a simulation setting.

[National exam for the validation of the second medicine cycle in France: What does this examination evaluates?]. / Épreuves classantes nationales (ECN) : qu'est-ce qu'elles évaluent ?

INTRODUCTION: Since 2004, the national exam for the validation of the second medicine cycle in France has been changed in its organization, its form and contents. The objective of this study is to analyze the records and the contents of this exam. MATERIAL AND METHOD: We analyzed according to a predetermined grid, each record in the annals of the national exam for the validation of the second medicine cycle in France since 2004. This represents 72 records with 525 questions in 8 years. The study focused on the knowledge and skills required by the student as well as the correlation between the advice given by the National College that organizes this exam and the authors of the files on the subjects themselves, to namely the form and content. RESULTS: The record files contain on average 214 words (range 59-514) with an average of three to four types of data for analysis, which requires a real work of synthesis. Eighty percent of cases require a diagnostic approach for students, underpinned by a genuine reason and paraclinical strategy. Three quarters of the questions are questions of paraclinical, diagnostic and treatment. More than a record of three requires the interpretation of laboratory results and a record of two requires the interpretation of imaging or other diagnostic tests varied. They meet in large part to the objectives followed by the National College that organizes the national exam for the validation of the second medicine cycle in France. CONCLUSION: The national exam for the validation of the second medicine cycle in France assesses students in their diagnostic approach and their ability to develop a coherent approach to manage the patient.

Gender stereotypes: an explanation to the underrepresentation of women in emergency medicine.

OBJECTIVES: Women are underrepresented in emergency medicine (EM) residency programs in comparison with many other specialties. The reasons for this are unclear. One hypothesis is that negative gender stereotypes about EM careers might exist among female medical students. In the field of education, negative gender stereotypes are known to lead to career avoidance, because they tend to decrease self-efficacy perception. The aims of this study were to assess the prevalence of negative gender stereotypes about EM practice among medical students and to measure the effects of these stereotypes on females' self-efficacy perception toward EM learning. METHODS: A survey was conducted of the 255 third-year medical students from three medical schools who attended a mandatory EM academic program in France. They completed an anonymous questionnaire exploring their gender stereotypes about EM practice and their self-efficacy perception toward EM learning. RESULTS: Gender stereotypes are common among medical students, especially in women. Self-efficacy perception is negatively correlated to female students' belief that EM careers are better suited for men (p < 0.05). CONCLUSIONS: Negative gender stereotypes among female medical students may lead to EM career avoidance, because of the decrease in their self-efficacy perception toward EM learning.

Development and validation of a questionnaire for quantitative assessment of perceived discomforts in critically ill patients.

PURPOSE: To develop and validate the IPREA (Inconforts des Patients de REAnimation) questionnaire for the assessment of discomfort perceived by patients related to their intensive care unit (ICU) stay. METHODS: This was a two step-study comprising a phase of item generation conducted in one ICU and a phase of psychometric evaluation during a multicenter prospective cohort study in 14 ICUs. Patients were unselected consecutive adult surviving ICU patients. On the day of ICU discharge, a nurse asked patients to rate the severity of 16 discomfort sources, from 0 to 100. Ten percent of patients were randomly chosen to be questioned again to assess the reproducibility. RESULTS: Of 1,380 eligible patients, 1,113 survived and 868 patients could be questioned. The highest scores were for sleep deprivation (35 ± 33), being restrained by tubing, wires, and cables (33 ± 30), pain (32 ± 30), and thirst (32 ± 34). No multidimensional structure was identified. The mean overall score of discomfort was 22 ± 14. Internal consistency was satisfactory using Cronbach's alpha coefficient (0.78). The test-retest reliability study found average measure intraclass correlations ranging from 0.70 to 0.92. The mean duration of the questionnaire administration was 10 ± 7 min. CONCLUSION: The psychometric properties and acceptability of the IPREA questionnaire make it a potential instrument for measuring discomfort perceived by unselected ICU patients.

Emotional electrodermal response in coma and other low-responsive patients.

Emotional processing in coma remains an open question. Skin conductance responses to emotional and neutral auditory stimuli were recorded in 13 low-responsive patients (12 of whom were in coma). A differential response between emotional and neutral stimuli was found, which significantly correlated with the Glasgow Coma Scale and the Cook and Palma score. These correlations indicate that emotional processing can occur in coma patients with relatively high clinical scores of reactivity.

Cortical information processing in coma.

OBJECTIVES: To evaluate cortical information processing (particularly, semantic processing) in acute nontraumatic coma by means of event-related brain potentials (ERPs). METHODS: The tests included measures of obligatory auditory processing (N100), automatic (Mismatch Negativity) and controlled (P300) detection of stimulus deviance, and semantic processing (ERP effects in word pairs and sentences). The tests were presented to 20 healthy participants and 42 coma patients with Glasgow Coma Scale <9. RESULTS: Responders (ie, patients whose ERP data indicate that their brain was able to process the corresponding stimuli) were found in each ERP test, and their distribution was statistically different from that expected by chance. Particularly, 7 responders were found in the word pair paradigm and 3 responders in the sentence paradigm. The P300 responsiveness highly correlated with other ERP responses, with Glasgow Coma Scale and with the future development of coma (ie, P300 on day 4 was related to the clinical state on day 20). CONCLUSIONS: Results suggest a wide range of cortical information processing in coma, including semantic processing. The question is discussed of whether, and to what extent, these processing operations are related to conscious awareness of stimuli.

Influence of drotrecogin alpha (activated) infusion on the variation of Bax/Bcl-2 and Bax/Bcl-xl ratios in circulating mononuclear cells: a cohort study in septic shock patients.

OBJECTIVE: Drotrecogin alpha (activated) (DAA), or recombinant human activated protein C, is a new treatment in sepsis-induced multiple organ failure, leading to significant reduction in the mortality rate, thanks to its anticoagulant properties. It has been suggested that DAA has anti-inflammatory and antiapoptotic effects in sepsis animal models. This study investigates the potential actions of DAA on circulating mononuclear cells apoptosis in human septic shock. DESIGN: Prospective, cohort study. SETTING: Two intensive care wards and two research laboratories in a university hospital. PATIENTS: Twenty-two septic shock patients with DAA treatment (DAA+), 19 septic shock patients without DAA treatment (DAA-), and 14 healthy controls were successively enrolled, but only 20 DAA+ and 16 DAA- patients fulfilled criteria for statistical analysis. INTERVENTIONS: Blood samples were collected at inclusion and 24 hrs later. MEASUREMENTS AND MAIN RESULTS: Circulating mononuclear cell apoptosis levels were assessed by flow cytometry with annexin V, and variations of the apoptotic rheostats (Bax/Bcl-2 and Bax/Bcl-xl ratios) were analyzed by real-time reverse transcription-polymerase chain reaction. Apoptosis was significantly increased in septic shock patients (DAA+, 12 +/- 6.4%; DAA-, 10.4 +/- 5%) vs. healthy patients (3.4 +/- 2.1%, p < .001). Twenty-four hours after DAA infusion, apoptosis was significantly lower in the DAA+ group compared with DAA- ones (respectively, 11.7 +/- 5.3% and 16.2 +/- 7.6%, p < .001). At inclusion, DAA+ and DAA- groups showed comparable Bax/Bcl-2 ratio (DAA+, 0.92 +/- 0.9; DAA-, 1.32 +/- 0.87) and Bax/Bcl-xl ratio (DAA+, 2 +/- 1.04; DAA-, 1.31 +/- 0.93). In contrast, 24 hrs later we observed a significant decrease in these ratios, indicating an antiapoptotic effect in the DAA+ group (Bax/Bcl-2, 0.39 +/- 0.27; Bax/Bcl-xl, 0.68 +/- 0.35) compared with the DAA- group (Bax/Bcl-2, 1.81 +/- 1.1; Bax/Bcl-xl, 1.22 +/- 0.92, p = .001 and p = .039, respectively). CONCLUSIONS: In vivo, in human septic shock, DAA has antiapoptotic effects on circulating mononuclear cells, assessed by a significant decrease of both the Bax/Bcl-2 and Bax/Bcl-xl ratios.

Haemodynamic management of severe sepsis: recommendations of the French Intensive Care Societies (SFAR/SRLF) Consensus Conference, 13 October 2005, Paris, France.

We present a consensus report from the SFAR/SLRF (Société Française d'Anesthésie et de Réanimation/Société de Réanimation de Langue Française) Consensus Conference, held on 13 October 2005 in Paris, France. The consensus report made recommendations on five topics relevant to the treatment of circulatory failure in sepsis and its underlying rationale. These topics are as follows: therapeutic goals of haemodynamic support in sepsis; goals of fluid resuscitation (including transfusion); role of inotropes and vasoactive drugs; role of other treatments; and treatment strategy. This report is reproduced from a translation of the original in Annales Francaises of Anesthésie and Réanimation.

Recovery from a variegate porphyria by a liver transplantation.

The porphyrias are a group of inherited or acquired enzymatic defects of heme biosynthesis. Each type of porphyria has a characteristic pattern of overproduction and accumulation of heme precursors based on the location of dysfunctional enzyme in the heme synthetic pathway. Variegate porphyria, one of the acute hepatic porphyrias, is characterized by a partial reduction in protoporphyrinogen oxidase, the seventh enzyme of the heme biosynthetic pathway. A case of liver transplantation is described with a recovery from a variegate porphyria. Acute porphyria is commonly worsened by a wide variety of medications. We describe a step-by-step perioperative management protocol.