The latest reform of French medical studies has moved the National Ranking Examination before residency to the beginning of the sixth-year for undergraduate medical students, thus placing unprecedented workload during the preceding summer. The main objective was to determine whether study conditions and psychosocial factors were associated with student success in this model of intense workload. An online survey designed with six student-partners was sent at a French Medical School after the examination in 2023. The primary outcome was student success in achieving their main goal (Ranking, Knowledge, Well-being). A machine-learning model (eXtreme Gradient Boosting) was developed and explained using Artificial Intelligence. An AI-guided multivariate logistic regression was performed, Odd Ratios were calculated. Out of 123 responses, 75 (61%) of the students achieved their main goal. Motivation and socialization during the summer were the two most important variables for predicting student success. In guided multivariate logistic regression, summer motivation (Odd Ratio = 4.12, 95%CI[1.75-10.30]), summer loneliness (Odd Ratio = 0.35, 95%CI[0.14-0.86]), and student's main goal (Ranking, Odd Ratio = 2.94, 95%CI[1.15-7.79]) were associated with student success. Motivation and socialization during the summer preceding high-stakes examinations are strongly predictive of undergraduate medical students' success. This study highlights the importance of well-being during summer for student success.[Box: see text].
BACKGROUND: In critically ill patients, warnings about a risk of death and acute kidney injury (AKI) with hydroxyethyl starch (HES) solutions have been raised. However, HES solutions may yet have a role to play in major abdominal surgery. This meta-analysis and trial sequential analysis (TSA) aimed to investigate the effect of HES intravascular volume replacement on the risk of AKI, intraoperative blood transfusion, and postoperative intra-abdominal complications compared to crystalloid intravascular volume replacement. METHODS: In this meta-analysis and TSA, we searched for randomized controlled trials (RCTs) comparing intraoperative HES intravascular volume replacement to crystalloid intravascular volume replacement in adult patients undergoing major abdominal surgery. Primary outcome was 30-day AKI, defined as a binary outcome according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, combining stages 1, 2, and 3 into an AKI category versus no AKI category (stage 0). Secondary outcomes included rates of intraoperative blood transfusion and postoperative intra-abdominal complications. We used random effects models to calculate summary estimates. We used relative risk (RR) as summary measure for dichotomous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome ( P value <.05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes ( P value <.01 was considered statistically significant). RESULTS: Seven RCTs including 2398 patients were included. HES intravascular volume replacement was not associated with an increased risk of 30-day AKI (RR = 1.22, 95% CI, 0.94–1.59; P = .13), when compared to crystalloid intravascular volume replacement. According to TSA, this analysis was underpowered. HES intravascular volume replacement was associated with higher rates of blood transfusion (RR = 1.57 99% CI, 1.10–2.25; P = .001), and similar rates of postoperative intra-abdominal complications (RR = 0.76 99% CI, 0.57–1.02; P = .02). CONCLUSIONS: In this meta-analysis to focus on HES intravascular volume replacement in major abdominal surgery, HES intravascular volume replacement was not associated with a higher risk of 30-day AKI when compared to crystalloid intravascular volume replacement. However, CI and TSA do not exclude harmful effects of HES intravascular volume replacement on the renal function.
Long-term controlled mechanical ventilation (CMV) in intensive care unit (ICU) induces ventilatory-induced-diaphragm-dysfunction (VIDD). The transition from CMV to assisted mechanical ventilation is a challenge that requires clinicians to balance over-assistance and under-assistance. While the effects of over-assistance on the diaphragm are well known, we aimed to assess the impact of under-assistance on diaphragm function and structure in piglet model with pre-existing VIDD (after long-term CMV) or without VIDD (short-term CMV). Twenty-two Large-White female piglets were anesthetized, ventilated, and separated into two groups: a VIDD group (n=10) with long-term 72-hour CMV, and a no-VIDD group (n=12) with short-term 2-hour CMV. After sedation reduction at the end of CMV period, each piglet was switched to under-assisted ventilation for 2 hours. Diaphragm function (supramaximal diaphragm pressure-generating capacity assessed by negative tracheal pressure after transvenous phrenic nerve stimulation) and diaphragm structure (mini-invasive in vivo biopsies) were assessed before and after under-assisted ventilation. In VIDD group, supramaximal diaphragm pressure-generating capacity decreased by 22% from 69.9±12.7 to 54.9±19.7 cmH2O (p=0.04) after 72 hours of CMV evidencing VIDD, then dropped by a further 29% from 54.9±19.7 to 38.9±15.5 cmH2O (p<0.01) after 2 hours of under-assisted ventilation. Diaphragm pressure-generating capacity remains stable from 55.3±22.7 to 58.2±24 cmH2O (p=0.24) in no-VIDD group. Diaphragm structure showed sarcomeric injuries increase from 13±10% to 24±19% (p<0.01) and lipid droplets decrease from 14±8% to 11±6% (p=0.03) of the total micrograph area after 2 hours of under-assisted ventilation in the VIDD group. Sarcomeric injuries and lipid droplets accounted respectively for 17±16% and 2±3% of the total micrograph area after under-assisted ventilation in the no-VIDD group. In this porcine model, a short two-hour exposure of under-assisted ventilation induces impairment of diaphragm function with damage to the diaphragm structure in ICU condition with pre-existing VIDD.
Abstract Background In studies prior to lung-protective ventilation, liver cirrhosis in acute respiratory distress syndrome (ARDS) was associated with high mortality rates. Since patients with cirrhosis have been excluded from many trials on ARDS, their outcome when treated with lung-protective ventilation is unclear. The objectives were to assess whether cirrhosis is associated with mortality in ARDS and trends over time in mortality and severity. Methods We conducted a retrospective analysis of a prospective observational cohort conducted in a 20-bed tertiary ICU from October 2003 to December 2021. All consecutive adult critically ill patients with ARDS were included. ARDS was defined by the Berlin criteria. The primary outcome was 90 day mortality, assessed with Kaplan–Meier curves and multivariate Cox analysis. Time trends were assessed on 90 day mortality, Sequential Organ-Function Assessment score (SOFA) and non-hepatic SOFA. Ventilation settings were compared between patients with and without cirrhosis. Results Of the 7155 patients screened, 863 had a diagnosis of ARDS. Among these ARDS patients, 157(18%) had cirrhosis. The overall 90 day mortality was of 43% (378/863), 57% (90/157) in patients with cirrhosis and 41% (288/706) in patients without cirrhosis ( p < 0.001). On survival curves, cirrhosis was associated with 90 day mortality ( p < 0.001). Cirrhosis was independently associated with 90 day mortality in multivariate analysis (hazard ratio = 1.56, 95% confidence interval 1.20–2.02). There was no change in mortality over time in ARDS patients with and without cirrhosis. SOFA ( p = 0.04) and non-hepatic SOFA ( p = 0.02) increased over time in ARDS patients without cirrhosis, and remained stable in ARDS patients with cirrhosis. Tidal volume, positive end-expiratory pressure, plateau pressure and driving pressure were not different between ARDS patients with and without cirrhosis. Conclusions Although ARDS management improved over the last decades, the 90 day mortality remained high and stable over time for both ARDS patients with (57%) and without cirrhosis (41%). Nevertheless, the severity of patients without cirrhosis has increased over time, while the severity of patients with cirrhosis has remained stable. Graphical Abstract
Abstract Purpose Although noninvasive ventilation (NIV) may reduce reintubation in patients with acute hypoxemic respiratory failure following abdominal surgery, this strategy has not been specifically assessed in patients with obesity. Methods We conducted a post-hoc analysis of a multicenter randomized controlled trial comparing NIV delivered via facial mask (inspiratory pressure support level, 5-15cmH2O; positive end-expiratory pressure, 5-10cmH2O; fraction of inspired oxygen titrated to Spo2 ≥ 94%) to standard oxygen-therapy (up to 15 L/min to SpO2 ≥ 94%) among patients with obesity and acute hypoxemic respiratory failure within seven days after abdominal surgery. The primary outcome was reintubation within seven days. Secondary outcomes were invasive ventilation–free days at day 30, Intensive Care Unit (ICU)-acquired pneumonia and 30-day survival. Results Among 293 patients with hypoxemic respiratory failure following abdominal surgery, 76 (26%) patients had obesity and were included in the intention-to-treat analysis. Reintubation rate was significantly lower with NIV (13/42, 31%) than with standard oxygen-therapy (19/34, 56%) within seven days (absolute difference: -25%, 95%Confidence Interval(CI) -49% to -1%, p = 0.03). NIV was associated with significantly more invasive ventilation–free days compared with standard oxygen-therapy (27.1 ± 8.6 vs 22.7 ± 11.1 days; p = 0.02), while fewer patients developed ICU-acquired pneumonia (1/42, 2% vs 6/34, 18%; absolute difference, − 16%; 95%CI, − 31% to − 1%; p = 0.04). The 30-day survival was 98% in the NIV group (41/42) versus 85% in the standard oxygen-therapy (absolute difference, 13%; 95%CI, − 3–28%; p = 0.08). Conclusions Among patients with obesity and hypoxemic respiratory failure following abdominal surgery, use of NIV compared with standard oxygen-therapy reduced the risk of reintubation within seven days. Trial Registration clinicaltrials.gov Identifier: NCT01971892
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