V. Compère

Down-Regulation of GABAA Receptor via Promiscuity with the Vasoactive Peptide Urotensin II Receptor. Potential Involvement in Astrocyte Plasticity

GABAA receptor (GABAAR) expression level is inversely correlated with the proliferation rate of astrocytes after stroke or during malignancy of astrocytoma, leading to the hypothesis that GABAAR expression/activation may work as a cell proliferation repressor. A number of vasoactive peptides exhibit the potential to modulate astrocyte proliferation, and the question whether these mechanisms may imply alteration in GABAAR-mediated functions and/or plasma membrane densities is open. The peptide urotensin II (UII) activates a G protein-coupled receptor named UT, and mediates potent vasoconstriction or vasodilation in mammalian vasculature. We have previously demonstrated that UII activates a PLC/PIPs/Ca2+ transduction pathway, via both Gq and Gi/o proteins and stimulates astrocyte proliferation in culture. It was also shown that UT/Gq/IP3 coupling is regulated by the GABAAR in rat cultured astrocytes. Here we report that UT and GABAAR are co-expressed in cerebellar glial cells from rat brain slices, in human native astrocytes and in glioma cell line, and that UII inhibited the GABAergic activity in rat cultured astrocytes. In CHO cell line co-expressing human UT and combinations of GABAAR subunits, UII markedly depressed the GABA current (β3γ2>α2β3γ2>α2β1γ2). This effect, characterized by a fast short-term inhibition followed by drastic and irreversible run-down, is not relayed by G proteins. The run-down partially involves Ca2+ and phosphorylation processes, requires dynamin, and results from GABAAR internalization. Thus, activation of the vasoactive G protein-coupled receptor UT triggers functional inhibition and endocytosis of GABAAR in CHO and human astrocytes, via its receptor C-terminus. This UII-induced disappearance of the repressor activity of GABAAR, may play a key role in the initiation of astrocyte proliferation.

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

BACKGROUNDnThis 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).nnnMETHODSnFirst, 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).nnnRESULTSnThe 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).nnnCONCLUSIONnOur pilot study suggested that a senior-directed, peer-conducted educational training might improve the clinical reasoning of anaesthesia residents as measured by the SCT.

Evolution of stress in anaesthesia registrars with repeated simulated courses: An observational study

BACKGROUND AND OBJECTIVEnHigh-fidelity medical simulation is a source of stress for participants. The aim of this study was to assess if repeated simulated courses decrease perceived stress and/or physiological stress level and increase performance in anaesthesiology registrars.nnnMETHODnFourteen anaesthesiology specialty registrars participated individually in three successive sessions of crisis simulation in the operating room. Participants perceived stress levels were measured by self-assessment (simple numerical scale from 0 to 10 [0=no stress, 10=maximum stress]) and physiological stress was estimated via the maximal heart rate measured by a Holter system). Technical and non-technical performances were also assessed. Data are expressed as medians with interquartile ranges and extremes (median (IQR [Min-Max])).nnnRESULTSnBetween the first and third session, simulation repetition was associated with a decrease in perceived stress (9 (8-10 [5-10]) versus 7 (5-8 [2-9]) from session 1 to session 3 respectively, P=0.02), whereas physiological stress assessed by the maximum heart rate remained unchanged (130 beats per minute (116-141 [85-170]) and 123 beats per minute (115-136 [88-166]) between sessions 1 and 3 respectively). There was also a significant inverse correlation between perceived stress levels experienced by registrars during the session and non-technical performance (P=0.008).nnnCONCLUSIONnWe observed a reduction in perceived stress levels experienced by registrars while physiological stress was unchanged with repeating simulation sessions combining simulated practice and debriefing. Learning through simulation could improve perceived stress management in critical situations.

Residents in tutored practice exchange groups have better medical reasoning as measured by script concordance test: a controlled, nonrandomized study

STUDY OBJECTIVEnClinical reasoning by anesthesiology residents in emergency situations where optimal management is uncertain could be improved by setting up a tutored practice exchange group. This study attempted to evaluate the impact of a practice exchange group (PEG), tutored by a senior anesthesiologist, on anesthesiology residents in emergency situations. Changes in clinical reasoning were measured by script concordance tests (SCT).nnnDESIGNnWe conducted a controlled, non-randomized study.nnnSETTING AND PARTICIPANTSnParticipants are residents in anesthesiology in Rouen, Caen and Amiens University Hospitals.nnnINTERVENTIONSnTwo resident groups were made up without randomization. The first group was the control group and consisted of residents from Amiens University Hospital and Caen University Hospital. The second study group (PEG group) consisted of residents from Rouen University Hospital, who followed weekly PEG sessions. Two groups had the same learning objectives except the PEG.nnnMEASUREMENTSnIn both the control group and the study group, each residents clinical reasoning was assessed in the same formal manner by SCT. The primary outcome measurement of this study was to compare SCT results in the study group with PEG training (PEG group) with those without (control group).nnnMAIN RESULTSnPerformance in the SCT, expressed as degree of concordance with the expert panel (95% CI), was better in the PEG group (64% [62.1%-66%]) than in control group (60% [57.5%-62.8%])) (P= .004).nnnCONCLUSIONnOur study strongly suggests that an expert-directed, peer-conducted educational training program may improve the clinical reasoning of anesthesiology residents as measured by SCT.

Remote cerebellar hemorrhage as an early and potentially lethal complication of a discal lumbar herniation surgery.

Remote cerebellar hemorrhage (RCH) is an infrequent but serious complication after lumbar herniation surgery. Little is known about this complication but excessive cerebrospinal fluid (CSF) leakage is thought to be a leading cause of RCH. We describe the case of a patient suffering from a life-threatening RCH, which occurred a few hours after lumbar disc herniation surgery.

Effectiveness of a blended learning course and flipped classroom in first year anaesthesia training

BACKGROUNDnBlended learning, which combines internet-based platform and lecturing, is used in anaesthesiology and critical care teaching. However, the benefits of this method remain unclear.nnnMETHODSnWe conducted a prospective, multicentre, non-randomised work between 2007 and 2014 to study the effect of blended learning on the results of first year anaesthesia and critical care residents in comparison with traditional teaching. Blended learning was implemented in Rouen University Hospital in 2011 and residents affiliated to this university corresponded as the blended learning group. The primary outcome was the residents results as measured with multiple-choice questions between blended learning and control groups after beginning blended learning (post-interventional stage). The secondary outcomes included residents results between pre and post-interventional stages and homeworks time. Moreover, comparison between control and blended learning group before beginning blended learning (pre-interventional stage) was performed.nnnRESULTSnFrom 2007 to 2014, 308 residents were included. For the pre-interventional period, the mean score in the blended learning group (n=53) was 176 (CI 95% 163 to 188) whereas the mean score in the control group (n=106) was 167 (CI 95% 160 to 174) (no difference). For the post-interventional period, the mean score in blended learning group (n=54) was 232 on 300 (CI95% 227-237) whereas the mean score in the control group (n=95) is 215 (CI95% 209-220) (P<0.001). In the two groups, comparison between pre and post-interventional stages showed the increase of mean score, stronger for blended learning group (32% and 28% in blended learning and control group, P<0.05). The average time of homework in the blended learning group was 27h (CI 95% 18.2-35.8) and 10h in the control group (CI 95% 2-18) (P<0.05).nnnCONCLUSIONSnThis work suggests the positive effect of blended learning (associating internet-based learning and flipped classroom) on the anaesthesia and critical care residents knowledge by increasing their homeworks time.

Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: The IRIS Randomized Clinical Trial

Importance The use of cricoid pressure (Sellick maneuver) during rapid sequence induction (RSI) of anesthesia remains controversial in the absence of a large randomized trial. Objective To test the hypothesis that the incidence of pulmonary aspiration is not increased when cricoid pressure is not performed. Design, Setting, and Participants Randomized, double-blind, noninferiority trial conducted in 10 academic centers. Patients undergoing anesthesia with RSI were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge (last follow-up, February 8, 2017). Interventions Patients were assigned to a cricoid pressure (Sellick group) or a sham procedure group. Main Outcomes and Measures Primary end point was the incidence of pulmonary aspiration (at the glottis level during laryngoscopy or by tracheal aspiration after intubation). It was hypothesized that the sham procedure would not be inferior to the cricoid pressure. The secondary end points were related to pulmonary aspiration, difficult tracheal intubation, and traumatic complications owing to the tracheal intubation or cricoid pressure. Results Of 3472 patients randomized, mean (SD) age was 51 (19) years and 1777 (51%) were men. The primary end point, pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group. The upper limit of the 1-sided 95% CI of relative risk was 2.00, exceeding 1.50, failing to demonstrate noninferiority (Pu2009=u2009.14). The risk difference was −0.06% (2-sided 95% CI, −0.57 to 0.42) in the intent-to-treat population and −0.06% (2-sided 95% CI, −0.56 to 0.43) in the per protocol population. Secondary end points were not significantly different among the 2 groups (pneumonia, length of stay, and mortality), although the comparison of the Cormack and Lehane grade (Grades 3 and 4, 10% vs 5%; Pu2009<.001) and the longer intubation time (Intubation time >30 seconds, 47% vs 40%; Pu2009<.001) suggest an increased difficulty of tracheal intubation in the Sellick group. Conclusions and Relevance This large randomized clinical trial performed in patients undergoing anesthesia with RSI failed to demonstrate the noninferiority of the sham procedure in preventing pulmonary aspiration. Further studies are required in pregnant women and outside the operating room. Trial Registration ClinicalTrials.gov Identifier: NCT02080754

Operation and organisation of ambulatory surgery in France. Results of a nationwide survey; The OPERA study

Operation and organisation of ambulatory surgical activity in France remains largely undocumented. This nationwide observational prospective survey, carried out between December 2013 and December 2014, was undertaken to characterise the organisational processes of ambulatory surgery in France. Three hundred centres were randomly chosen from a list of 891 hospitals practicing ambulatory surgery, with stratification according to the type of facility (public general hospital, university hospital, private hospital) and region. An email was sent to the board of the randomly chosen facilities with an attached information letter explaining how the survey worked. Hospitals who did not reply to this email were contacted by phone. Among the 206 hospitals that answered the survey, 92 were private, 78 were public and 36 were university hospitals. Median accommodation capacities of ambulatory units were 8 beds, mostly distinct from conventional surgical ward. Patient pathways dedicated to ambulatory surgery appear as the current predominant practice. 77% of the French ambulatory units have a head nurse in charge of logistics and coordination. Several items still have to be improved, such as the adherence to modern fasting rules and the unnecessary use of stretcher to move the patient. Objective discharge score is used in 77% of ambulatory units. This survey highlights the implementation of some positive organisational parameters corresponding to common good practices recommendations. In contrast, several other recommendations are still insufficiently applied and may hamper the development of safe ambulatory surgery. This brings up new challenges for health regulatory boards, hospitals and ambulatory units managers.

The OPVI trial – perioperative hemodynamic optimization using the plethysmographic variability index in orthopedic surgery: study protocol for a multicenter randomized controlled trial

BackgroundHemodynamic optimization during surgery is of major importance to decrease postoperative morbidity and length of hospital stay. However, conventional cardiac output monitoring is rarely used at the bedside. Recently, the plethysmographic variability index (PVI) was described as a simplified alternative, using plug-and-play noninvasive technology, but its clinical utility remains to be established.Methods/designThe hemodynamic optimization using the PVI (OPVI) trial is a multicenter randomized controlled two-arm trial, randomizing 440 patients at intermediate risk of postoperative complications after orthopedic surgery. Hemodynamic optimization was conducted using either the PVI (PVI group) or conventional mean arterial pressure (control group). The anesthesiologist performed the randomization the day before surgery using an interactive web response system, available 24xa0hours a day, 7xa0days a week. The randomization sequence was generated using permutated blocks and stratified by center and type of surgery (knee or hip arthoplasty). Patients and surgeons, but not anesthesiology staff, were blinded to the allocation group. The primary outcome measure is the length of hospital stay following surgery. The attending surgeon, who was blinded to group assessment, determined hospital discharge. Secondary outcome measures are theoretical length of hospital stay, determined using a dedicated discharge-from-hospital checklist, postoperative arterial lactate level in the recovery room, postoperative troponin level, presence of serious postoperative cardiac complications, and postoperative acute kidney insufficiency.DiscussionThe OPVI trial is the first multicenter randomized controlled study to investigate whether perioperative hemodynamic optimization using PVI during orthopedic surgery could decrease the length of hospital stay and postoperative morbidity.Trial registrationClinicalTrials.gov NCT02207296.

Évaluation du raisonnement clinique des DESAR bénéficiant de groupes d’échange de pratiques : une étude contrôlée non randomisée

Introduction Le DESAR est confronte a des situations qu’il doit prendre en charge en urgence dans lesquelles persiste une part d’incertitude. Il doit ainsi faire intervenir son raisonnement clinique. Les groupes d’echange de pratique (GEP) sont une methode d’enseignement faisant intervenir la technique d’apprentissage par les pairsxa0: elle permettrait d’accroitre les qualites du raisonnement clinique. Dans notre etude, nous avons voulu evaluer l’impact de l’enseignement par des GEP, diriges par un anesthesiste senior, sur le raisonnement clinique des DESAR, mesure par des tests de concordance de script (TCS). Materiel et methodes Nous avons realise une etude prospective, controlee, non randomisee, multicentrique dans les CHU de Caen, Rouen et Amiens. Nous avons evalue, a l’aide des meme TCS, le raisonnement clinique des DESAR de deux groupes. Un premier groupe, le groupe GEP, etait compose des DESAR du CHU de Rouen beneficiant d’un enseignement a l’aide des GEP. Un deuxieme groupe, le groupe controle, etait compose par les DESAR des CHU de Caen et Amiens. Les deux groupes avaient les memes objectifs d’enseignement. Le critere principal de jugement etait la comparaison de la performance des deux groupes aux TCS, exprimee en degre de concordance avec un panel d’experts, evalue par une note sur 100 [intervalle de confiance a 95xa0%]. Le critere secondaire etait la difference de scores aux TCS entre les DESAR selon leur niveau d’experience et avec le panel d’experts. Les comparaisons entre les variables distribuees selon la loi normale ont ete effectuees en utilisant un test t unilateral parametrique. Les variables ne suivant pas la loi normale ont ete analysees en utilisant le test de Kruskall–Wallis pour les comparaisons multiples. Un calcul d’effectif a priori a ete effectue. Notre etude a recu un avis positif du comite d’ethique. Resultats Quarante-deux DESAR ont ete inclus dans chaque groupe. La performance aux TCS etait meilleure dans le groupe GEP (64xa0% [62,1–66xa0%]) que dans le groupe controle (60xa0% [57,5–62,8xa0%]) (pxa0=xa00,004). De plus, l’ensemble des DESAR, quel que soit leur niveau d’experience, avait significativement de moins bons resultats que le panel d’experts, a l’exception des DESAR de derniere annee beneficiant de l’enseignement par les GEP. Discussion Notre etude suggere que les groupes d’apprentissage par les pairs, diriges par un anesthesiste senior, pourrait ameliorer la qualite du raisonnement clinique des DESAR, mesure par des tests de concordance de script. La realisation d’une etude prospective, randomisee, permettrait de confirmer ces resultats.