Is there a role for the use of aviation assessment instruments in surgical training preparation? A feasibility study.

BACKGROUND: Selection for surgical residency programmes could potentially be improved through pretraining preparation, after assessment of surgical candidates' sensorimotor skills and personality traits. Existing aviation pilot selection instruments are available to test sensorimotor skills and personality traits. This study examined selected instruments to assess medical trainees' sensorimotor skills and personality traits. METHODS: Aviation's validated computer-based Computerized Pilot Aptitude and Screening System (COMPASS) and Checklist Professional Profile (CPP) were applied to 166 final year medical students during a surgical clerkship between 2013 and 2015. RESULTS: All trainees completed COMPASS and CPP within the prescribed 2 hours. Compared with an age-matched and gender-matched cohort of 165 pilot candidates, medical trainees scored significantly higher on eye-hand coordination (p<0.001), need for variation (p<0.001), empathy (p=0.006), helpfulness (p<0.001) and autonomy (p<0.001). Pilot candidates scored higher on eye-hand-foot coordination (p<0.001), spatial orientation (p<0.001), persuasiveness (p<0.001), stress tolerance (p<0.001), dominance (p<0.001), ambition (p<0.001) and resilience (p<0.001). CONCLUSIONS: Final year medical trainees from one medical school were able to complete aviation's sensorimotor skills and personality traits selection instruments within the set time frame. They scored differently from aviation trainees on selected skills and personality traits. The applicability and utility of aviation instruments to presurgical training preparation remains to be tested.

Mirtazapine in pregnancy and lactation: data from a case series.

Depression is a common disorder in pregnancy and associated with adverse effects for both mother and neonate. Pharmacological treatment and prevention options include mirtazapine. In a series of 56 cases, we investigated neonatal outcome after intrauterine exposure to mirtazapine and exposure through lactation in the first days postpartum.No increase in any neonatal complication was observed. None of the infants exposed to mirtazapine in the first trimester were born with a major malformation. Of the 54 infants exposed to mirtazapine in the third trimester, 14 were diagnosed with poor neonatal adaptation syndrome (PNAS). This incidence (25.9%) is similar to the incidence of PNAS after intrauterine exposure to other antidepressants. The incidence of PNAS after exposure to mirtazapine was significantly diminished in children who were partially or fully breastfed (18.6% versus 54.5%, P = 0.024).

Induction of labour with a Foley catheter or oral misoprostol at term: the PROBAAT-II study, a multicentre randomised controlled trial.

BACKGROUND: Induction of labour is a common obstetric procedure. At present, different methods are used for induction of labour in women with an unfavourable cervix. Recently, we showed that in term women with an unfavorable cervix the use of a Foley catheter in comparison with vaginal Prostaglandin E2 gel, results in a comparable vaginal delivery rate. A meta-analysis on the subject indicated lower rates of hyperstimulation, and probably as a sequel fewer cases of postpartum haemorrhage. Misoprostol (PgE1) is another type of prostaglandin frequently used for labour induction, recommended by the international federation of gynaecology and obstetrics (FIGO). Misoprostol can be administered by vaginal, rectal and oral route. There is evidence that oral administration results in less asphyxia and hyperstimulation than vaginal administration. At present, valid comparisons between oral misoprostol and Foley catheter are lacking. Therefore, we propose a randomised controlled trial comparing Foley catheter to oral misoprostol in order to assess safety and cost-effectiveness. METHODS/DESIGN: We plan a multicentre, randomised, controlled, open-label clinical trial among term pregnant women with a vital singleton in cephalic presentation, unfavorable cervix, intact membranes and an indication for induction of labour. After informed consent, women will be randomly allocated by a webbased randomisation system to transcervical Foley catheter or oral misoprostol (50 mcg every 4 hours). The primary outcome will be a composite of complications of uterine hyperstimulation, i.e. post partum haemorrhage and asphyxia. Secondary outcomes are mode of delivery, maternal and neonatal morbidity, costs and women's preference. Serious adverse events such as severe maternal or neonatal morbitity or mortality will be monitored and reported to an independent data safety monitory board. With a sample size of 1860 women we will be able to demonstrate a 5% non-inferiority of the Foley catheter as compared to misoprostol for the composite outcome. DISCUSSION: Worldwide, various methods are being used for labour induction. Results of the proposed trial will contribute to the answer which method of induction of labour is most safe, cost-effective, and patient friendly and will help to construct evidence based guidelines. TRIAL REGISTRATION: The Netherlands Trial Register NTR3466.

Criterion validity of a computer-assisted instrument of self-triage (ca-ISET) compared to the validity of regular triage in an ophthalmic emergency department.

OBJECTIVES: The computer-assisted version of a self-triage tool (ca-ISET) for an ophthalmic emergency department (ED) was developed to increase the validity of the triage procedure when trained ED staff is absent. METHODS: We tested whether sensitivity, specificity, Negative Predictive Value (NPV) and Positive Predictive Value (PPV) of the ca-ISET deviated from regular triage. Patients ≥18 years visiting the ED of the Rotterdam Eye Hospital in the Netherlands were invited to participate in this prospective study. This ED focuses on eye-related problems. Patient recruitment was carried out during working hours. The ca-ISET is a touch operated software application and the algorithm of the triage is based in the Manchester triage system. For all participants three triage scores were determined by (1) the participant using the ca-ISET; (2) triage by a regular, trained triage assistant and (3) triage by one physician who was specially trained in ophthalmic triage. The diagnosis of the physician was chosen as the reference standard to define criterion validity. The order of triage administration was alternated per patient. Only cases with triage scores from the two triage systems and the reference standard were included. The outcome variables, four triage colours, were transformed into a binary score: high urgent and low urgent. The difference between the ca-ISET and regular triage in terms of sensitivity, specificity, NPV and PPV was tested by Z-scores. RESULTS: Of 247 eligible patients, data was elicited from 189 patients (average age 54 years, range 18-89). The sensitivity of the ca-ISET (0.89, CI: 0.75-0.96) did not differ from the sensitivity of the regular triage (0.69, CI: 0.53-0.82, Z=1.74, p=0.08). The ca-ISET was less specific (0.78, CI: 0.71-0.84) than the regular triage (0.92, CI=0.86-0.95, Z=3.04, p=0.00). We found no significant difference between the ca-ISET and regular triage for PPV (Z=0.19, p=0.85) and NPV (Z=0.03, p=0.98). CONCLUSIONS: The sensitivity, PPV and NPV of the ca-ISET does not differ from the sensitivity of the regular triage, while the ca-ISET retained a reasonable level of specificity. Therefore the ca-ISET can be recommended as a tool for ophthalmic emergency departments, and could be used when trained ED staff is absent.

Adapted Finnegan scoring list for observation of anti-depressant exposed infants.

OBJECTIVE: The Finnegan scoring list (FSL) is widely used to screen for poor neonatal adaptation in infants exposed to anti-depressants in utero. However, the large number of FSL-items and differential weighing of each item is time consuming. The aim of this study was to shorten and simplify the FSL yet preserving its clinimetric properties. METHODS: This observational study examined infants exposed to an anti-depressant during pregnancy admitted for at least 72 h on a maternity ward. Trained nurses completed the FSL three times daily. Items for the adapted FSL were selected through forward analysis whereby the number of selected items was based on the area under the curve (AUC). Internal validity was assessed by cross-validation. RESULTS: 183 infants met the inclusion criteria. By forward analysis eight equally-weighed items resulted in an AUC of 0.91. In cross-validation, the mean AUC was 0.89 for 8 items. This adapted FSL had a sensitivity of 97.7% and specificity of 37.0% and a sensitivity of 41.9% and specificity of 86.2% regarding a cut-off of, respectively, 1 and 2. CONCLUSIONS: An adapted FSL with eight equally-weighed items has acceptable clinimetric properties and can serve as an easy to apply screening tool in infants exposed to anti-depressants during pregnancy.

[Withdrawal in newborns after exposure to psychotropic medications during pregnancy]. / Ontwenning bij de pasgeborene na blootstelling aan psychofarmaca tijdens de zwangerschap.

The use of psychotropic medications during pregnancy causes withdrawal symptoms in 20-30% of the newborns. The literature on withdrawal symptoms is not unanimous concerning their recognition and treatment. A search of PubMed and Embase revealed 198 articles in which potential withdrawal symptoms in newborns were described following exposure to psychotropic medications during pregnancy. Commonly occurring withdrawal symptoms are mostly mild, including restlessness and sleeping and feeding difficulties. Severe symptoms such as convulsions are rare. It can sometimes be difficult to differentiate between symptoms of intoxication and symptoms of withdrawal. The Finnegan scale is widely used to recognise withdrawal from psychotropic medication. An observation period of at least 48 h post-partum is advised. Recognition of withdrawal is important to prevent needless additional tests. In withdrawal symptoms supportive measures such as feeding on demand and swaddling are usually sufficient. If withdrawal symptoms are severe, phenobarbital is a therapeutic option.

[Pregnant women with psychiatric illness are able to stop smoking]. / Zwangere met psychiatrische stoornis kan stoppen met roken.

Smoking during pregnancy is associated with neonatal complications and health problems later in life. However, about 10% of the pregnant women in the Netherlands smoke and those with a psychiatric illness smoke even more frequently. Although giving up smoking may be more difficult for these women, it does not lead to an increase of psychiatric symptoms. We present two patients who smoked during pregnancy. A 28-year-old female started smoking again during her first pregnancy when her depression relapsed. We advised a higher dose of medication and with her midwife's support she gave up smoking. A 35-year-old female, suffering from posttraumatic stress disorder, had an increase of symptoms during her second pregnancy. She resumed smoking to feel more relaxed. Treatment with bupropion and an online support program helped her to give up smoking. We advise that every smoking pregnant woman with psychiatric problems be treated concurrently for the psychiatric illness and for smoking.

Health-related quality of life after induction of labor versus expectant monitoring in gestational hypertension or preeclampsia at term.

OBJECTIVE: Gestational hypertension (GH) and preeclampsia (PE) are major contributors to maternal and neonatal morbidity and mortality. In GH or PE, labor may be either induced or monitored expectantly. We studied maternal health-related quality of life (HR-QoL) after induction of labor versus expectant monitoring in GH or PE at term. We performed the HR-QoL study alongside a multicenter randomized controlled trial comparing induction of labor to expectant monitoring in women with GH or PE after 36 weeks. METHODS: We used written questionnaires, covering background characteristics, condition-specific issues, and validated measures: the Short-Form (SF-36), European Quality of Life (EuroQoL 6D3L), Hospital Anxiety and Depression Scale (HADS), and Symptom Checklist (SCL-90). Measurements were at the following time points: baseline, 6 weeks postpartum, and 6 months postpartum. A multivariate mixed model with repeated measures was defined to assess the effect of the treatments on the physical component score (PCS) and mental component score (MCS) of the SF-36. Analysis was by intention to treat. RESULTS: We analyzed the data of 491 randomized and 220 nonrandomized women. We did not find treatment effect on long-term HR-QoL (PCS: p = 0.09; MCS: p = 0.82). The PCS improved over time (p < 0.001) and was better in nonrandomized patients (p = 0.02). CONCLUSION: Despite a clinical benefit of induction of labor, long-term HR-QoL is equal after the induction of labor and expectant management in women with GH or PE beyond 36 weeks of gestation.

[Intrauterine exposure to SSRIs: no reason for routine hypoglycaemia screening]. / Intra-uteriene blootstelling aan SSRI's: geen reden voor routinematige controle op hypoglykemie.

OBJECTIVE: To investigate whether neonates who have been exposed to selective serotonin reuptake inhibitors (SSRIs) in utero have a higher risk of hypoglycaemia than unexposed neonates. DESIGN: Systematic review of cohort studies. METHODS: We searched in PubMed and Embase for available cohort studies in which neonates exposed to SSRIs in utero were compared to non-exposed neonates, with hypoglycaemia as an outcome parameter. The studies were evaluated with respect to methodological quality by applying the 'Guidelines for assessing quality in prognostic studies' (QUIPS). The results were noted qualitatively. RESULTS: We found 4 studies that were suitable for further analysis. The studies were similar in design but led to very variable results. Important confounders differed greatly between studies and were not corrected for. Therefore, with these studies no answer could be given to the research question. CONCLUSION: The literature does not contain enough evidence to conclude that neonates exposed to SSRIs during pregnancy have a higher risk of developing hypoglycaemia than non-exposed neonates. Only when a neonate shows clinical signs that can be attributed to both hypoglycaemia and withdrawal symptoms a single glucose check is indicated.