Withholding and withdrawal of life-sustaining therapy in 8569 trauma patients: A multicentre, analytical registry study.

BACKGROUND: This study aimed to determine the prevalence of withholding or withdrawal of life-sustaining therapy (WLST) decisions in trauma ICU patients, using a large registry. We hypothesised that this prevalence is similar to that of the general population admitted to an ICU. As secondary aims, it sought to describe the trauma patients for whom the decision was made for WLST and the factors associated with this decision. DESIGN: This observational study assessed data from 14 French centres listed in the TraumaBaseTM registry. All trauma patients hospitalised for more than 48 h were pro-spectively included. RESULTS: Data from 8569 trauma patients, obtained from January 2016 to December 2018, were included in this study. A WLST decision was made in 6% of all cases. In the WLST group, 67% of the patients were older men (age: 62 versus 36, P  < 0.001); more often they had a prior medical history and higher median severity scores than the patients in the no WLST decision group; SAPS II 58 (46 to 69) versus 21 (13 to 35) and ISS 26 (22 to 24) versus 12 (5 to 22), P  < 0.001. Neurological status was strongly associated with WLST decisions. The geographic area of the ICUs affected the rate of the WLST decisions. The ICU mortality was 11% (n = 907) of which 47% (n = 422) were preceded by WLST decisions. Fourteen percent of WLST orders were not associated to the death. CONCLUSION: Among 8569 patients, medical history, trauma severity criteria, notably neurological status and geographical areas were associated with WLST. These regional differences deserve to be investigated in future studies.

Judgments of relevance in preschoolers: a study of training and transfer of self-cueing strategies.

Introduction: When facing a task, children must analyze it precisely to fully identify what its goal is. This is particularly difficult for young children, who mainly rely on environmental cues to get there. Research suggests that training children to look for the most relevant perceptual cues is promising. Furthermore, as transferring skills to a new task is difficult, the question of whether young children are able to transfer such training remains open. The aim of this study was to test the extent to which two strategies of goal self-cueing-labeling and pointing-can help 4-year-old children to identify the relevant cues to clearly identify the goal of the task. The effects of explicit strategy training were tested in a near transfer task. Method: Ninety-nine typically developing 4 year olds took part in the study. They were divided into three groups: two were trained collectively in one of the two strategies and the third group as a control group with no strategy training. All children performed a cued card-sorting task four times: Pre-test, Collective training, Post-test, and Transfer with new cards. Results: Results confirmed the beneficial effect of strategy training on goal identification, particularly after training (Post-test). In the transfer phase, all three groups performed equally well. Discussion: This study contributes to our understanding of how young children seek information when they look for the most relevant cues for identifying the goal of a task, and the benefits they may derive in a transfer task. It seems that the use of visual cues and self-cueing strategies helps preschoolers to clearly identify the goal of a task. Results are discussed in the light of the self-regulated learning framework. Some possible classroom applications are suggested.

Impact of automatic tools for detecting new lesions on therapeutic strategies offered to patients with MS by neurologists.

BACKGROUND: Automatic tools for detecting new lesions in patients with MS between two MRI scans are now available to clinicians. They have been assessed from the radiologist's point of view, but their impact on the therapeutic strategies that neurologists offer their patients has not yet been documented. OBJECTIVES: To compare neurologist's decisions according to whether a lesion detection support system had been used and describe variability between neurologists on decision-making for the same clinical cases. METHODS: We submitted 28 clinical cases associated with pairs of MRI images and radiological reports (produced by the same radiologist without vs. with the help of a system to detect new lesions) to 10 neurologists who regularly follow patients with MS. They examined each clinical case twice (without vs. with support system) in two sessions several weeks apart, and their patient management decisions were recorded. RESULTS: There was considerable variability between neurologists on decision-making (both with and without support system). When the support system had been used, neurologists more often made changes to patient management (75 % vs. 68 % of cases, p = 0.01) and spent significantly less time analyzing the clinical cases (249 s vs. 216 s, p == 3.10-4). CONCLUSION: The use of a lesion detection support system has an impact not only on radiologists' reports, but also on neurologists' subsequent decision-making. This observation constitutes another strong argument for promoting the wider use of such systems in clinical routine. However, despite their use, there is still considerable variability in decision-making across neurologists, which should encourage us to refine the guidelines.

Goal choice in preschoolers is influenced by context, cognitive flexibility, and metacognition.

Introduction: Goal choice is one of the first, and most important, steps in self-regulated learning (SRL). It is particularly challenging for young children (before 5-6 years), who tend to rely on available environmental cues, which makes their goals fragile because of the instability and variability of the environment. Therefore, it can be assumed that the conditions under which a task is performed may influence a child's learning goal choice. Moreover, adapting to constraints involves control capacities provided by executive functions (EF) and metacognition. Methods: The main purpose of this study was to determine factors that influence the way preschoolers choose a learning goal during the first step of SRL. We tested whether adding constraints to perform a task may influence the choice of the procedure that a child aims to learn to perform this task. We also examined the role of cognitive flexibility and metacognition in goal selection in the face of these changes, and tested the influence of change over time, comparing participants' performance at two points in the school year. One hundred 4-year-olds were asked to perform a jigsaw puzzle task under two conditions: predictable vs. unpredictable environmental change. Individual levels of cognitive flexibility and metacognition were also measured. Results: The results show that only a predictable change, but not an unpredictable one, leaded children to change their learning goals. Furthermore, when participants were faced with an unpredictable change, metacognition and cognitive flexibility significantly predicted learning goal change. Results are discussed regarding the development of SRL, flexibility, and metacognition. Educational suggestions are proposed. Highlights - The choice of a learning goal by a preschooler is influenced by the conditions of task performance and environmental cues. Facing a predictable change is more disruptive to children before the age of 4.5, and more likely to cause them to change their goal.- A shift is observed, from age 4 and during the school year, from a perceptual to a conceptual level of processing.- Cognitive flexibility and metacognition also determine learning goal choice in preschoolers, but only in front of unpredictable changes.

False positive amphetamines and 3,4-methylenedioxymethamphetamine immunoassays in the presence of metoprolol-two cases reported in clinical toxicology.

Amphetamines, frequently used recreational drugs with high risk of toxicity, are commonly included in urine drug screens. This screening is based on enzyme immunoassay, which is a quick and easy-to-perform technique, but may lack specificity resulting from cross-reactivity with other compounds, causing false positive results. We present two cases of presumed false positive MULTIGENT® amphetamine/methamphetamine and MULTIGENT® ecstasy (Abbott®) immunoassays with the beta-blocker metoprolol. Both metoprolol-poisoned patients presented positive urine screening despite no history of drug abuse. No confirmation for amphetamine molecular structures was found with gas chromatography-mass spectrometry. The cross-reactivity was further investigated by doping urine samples with metoprolol and its two major phase-I metabolites. Metoprolol showed positive results for both amphetamine and MDMA tests at low concentrations (200 and 150 µg/mL, respectively). Metoprolol metabolites cross-reacted with the amphetamines immunoassay only, but at higher concentrations (i.e., 2000 µg/mL for α-hydroxymetoprolol and 750 µg/mL for O-demethylmetoprolol). In conclusion, false positive results in amphetamines and MDMA immunoassays are possible in the presence of metoprolol. Toxicologists should be aware of frequent analytical interferences with immunoassays and a detailed medication history should be taken into consideration for interpretation. In vitro investigation of suspected cross-reactivity should include not only the parent drug but also its related metabolites.