Introduction
: La simulation apparaît aujourd’hui comme un outil indispensable dans l’apprentissage de compétences médicales techniques et non techniques, tout en respectant le principe éthique ...suivant : «
Jamais la première fois sur le patient
». Actuellement, l’intégration de la simulation dans les programmes de formation des internes de médecine d’urgence est disparate : son cadre demeure à définir devant l’ouverture récente du diplôme d’études spécialisée (DES) de médecine d’urgence à l’automne 2017.
Objectif de l’étude
: Cette étude a évalué l’utilisation de la simulation en France dans l’enseignement actuel de la médecine d’urgence, afin d’initier une réflexion sur la place que pourrait avoir ce type d’enseignement pour le DES.
Méthode
: Il s’agissait d’une étude observationnelle multicentrique. Un questionnaire a été envoyé par e-mail à l’ensemble des responsables universitaires de France impliqués dans l’enseignement de la médecine d’urgence. Les données ont été colligées dans Excel (Microsoft). Elles étaient à la fois quantitatives et qualitatives et concernaient le cadre, la structuration et le contenu de la formation par la simulation.
Résultats
: Vingt-cinq facultés de médecine sur 29 ont répondu au questionnaire. Parmi elles, 23 utilisaient la simulation (soit 92 %), dont 22 la simulation haute fidélité et 21 la simulation procédurale. Arrêt cardiorespiratoire (22), état de choc (21), douleur thoracique et tachycardies (20), traumatisé crânien et traumatisé grave (17) étaient les thématiques majoritairement abordées. Les gestes techniques les plus enseignés étaient : intubation (22), intubation difficile (21), ventilation assistée-contrôlée et voie intraosseuse (18). En médiane, la formation comptait entre deux et trois jours de simulation par année de formation. Par ailleurs, dans 12 centres (soit 52 %), les formateurs avaient un temps professionnel dédié, et 15 centres (soit 65 %) bénéficiaient de personnel salarié. Enfin, seulement 12 centres (52 %) estimaient « plutôt » respecter l’adage «
Jamais la première fois sur le patient
».
Discussion
: L’utilisation de la simulation dans l’enseignement de la médecine d’urgence est inégale. Les responsables pédagogiques interrogés semblent tomber d’accord quant aux principales thématiques et techniques à aborder. Le développement de la simulation semble souhaité de tous, mais demeure complexe en raison notamment de l’investissement humain et matériel que cela représente. Ces réponses pourraient fournir un axe de réflexion afin d’établir un programme de simulation commun à l’ensemble des facultés.
Background
: Simulation appears to be now an essential tool for the training of both technical and nontechnical medical skills. It allows to respect the ethical statement: “Never the first time on a real patient”. Currently, integration of simulation in training programs is not harmonized between French medicine faculties. The corresponding framework remains to be defined in anticipation of the creation of the diploma of Emergency Medical Specialty (DES) planned for fall 2017.
Objective
: This investigation addressed the use of simulation in French initial formation in emergency medicine. It was intended as a first step toward establishing a simulationbased training program.
Method
: This observational study was multicentric. A questionnaire was sent by e-mail to all coordinators of Emergency Medicine initial formation in France. Data were compiled with Excel software (Microsoft Inc.). They included both quantitative and qualitative items that concerned the general context, the structure, and the content of the simulation-based training.
Results
: Twenty-five out of 29 universities answered the questionnaire. Among those, 23 (92%) used simulation, 22 of them used high-fidelity simulation, and 21 used procedural simulation. The most involved application fields were: cardiac arrest (22), shock state (21), chest pain, tachycardia (20), severe trauma and traumatic brain injury (17). The most practiced technical procedures were: intubation (22), difficult intubation (21), mechanical ventilation and intraosseous access (18). Median time was 2–3 days of simulation by year. In 12 centers (52%), the training staff had dedicated time duty and 15 centers (65%) benefited from remunerated staff. Finally, only 12 centers (52%) felt they essentially complied with the statement “Never the first time on a real patient”.
Discussion
: Simulation use in French emergency physician’s initial training is heterogeneous. The main limitation of our study was the absence of response from 4 faculties. Generally, responding coordinators agreed on the main situations and techniques to be taught. As in other countries, promotion of simulation seems to be consensual. However, effective deployment remains difficult due to material investment, formation and availability of staff. This study could provide a basis for the establishment of a national simulation-based training program.
Summary
Background
Dermatoscopy increases both the sensitivity and specificity of melanoma diagnosis. Reflectance confocal microscopy (RCM) is a noninvasive technique that complements dermatoscopy in ...the evaluation of equivocal lesions at cellular resolution.
Objectives
To determine prospectively the potential impact of confocal microscopy when implemented in a routine melanoma diagnosis workflow.
Methods
Patients referred to a single melanoma clinic were consecutively enrolled. At dermatoscopy, patients were referred to one of the following pathways: (i) no further examination or (ii) RCM examination. On examination atypical lesion(s) were referred for either (a) RCM documentation (lesions with consistent suspicious clinical/dermatoscopic criteria, already qualified and scheduled for surgical excision) or (b) RCM consultation for equivocal lesions, where RCM diagnosis would determine lesion definite outcome (excision or digital follow‐up).
Results
Reflectance confocal microscopy examination was performed for 41% of 1005 patients enrolled. In two‐thirds of these cases RCM influenced the lesion outcome. The systematic application of RCM for equivocal lesions saved over 50% of benign lesions from unnecessary excision. The number needed to excise a melanoma was 6·8 with RCM examination, compared with a hypothetical 14·6 without RCM evaluation.
Conclusions
Reflectance confocal microscopy as a second‐level examination to dermatoscopy proved to be highly accurate in diagnosis and reduced the number of unnecessary excisions. Improved accuracy, considering that RCM enabled the detection of the six melanomas (2%) in the group of 308 lesions eligible for follow‐up, also minimizes the risk of referring a melanoma to digital dermatoscopy monitoring, and potentially losing the patient to follow‐up.
What's already known about this topic?
Reflectance confocal microscopy is an add‐on tool to dermatoscopy that can increase specificity and improve diagnostic accuracy.
What does this study add?
We demonstrated that the systematic use of confocal microscopy can reduce the number of benign lesions excised to rule out a melanoma and minimize the risk to refer a melanoma to digital dermatoscopy monitoring.
Capacity degradation by phase changes and oxygen evolution has been the largest obstacle for the ultimate commercialization of high‐capacity LiNiO2‐based cathode materials. The ultimate thermodynamic ...and kinetic reasons of these limitations are not yet systematically studied, and the fundamental mechanisms are still poorly understood. In this work, both phenomena are studied by density functional theory simulations and validation experiments. It is found that during delithiation of LiNiO2, decreased oxygen reduction induces a strong thermodynamic driving force for oxygen evolution in bulk. However, oxygen evolution is kinetically prohibited in the bulk phase due to a large oxygen migration kinetic barrier (2.4 eV). In contrast, surface regions provide a larger space for oxygen migration leading to facile oxygen evolution. These theoretical results are validated by experimental studies, and the kinetic stability of bulk LiNiO2 is clearly confirmed. Based on these findings, a rational design strategy for protective surface coating is proposed.
Thermodynamic and kinetic reasons for structural instability of LiNiO2‐based cathode materials are studied by combined first‐principle calculation and experiments. Deep battery charging decreases oxygen reduction and induces strong thermodynamic driving force for oxygen evolution from surface and grain boundary. In contrast, oxygen evolution is kinetically prohibited in bulk phase, implying a promising direction for stabilizing these materials.
Transcription poses a threat to genomic stability through the formation of R-loops that can obstruct progression of replication forks. R-loops are three-stranded nucleic acid structures formed by an ...RNA-DNA hybrid with a displaced non-template DNA strand. We developed RNA-DNA Proximity Proteomics to map the R-loop proximal proteome of human cells using quantitative mass spectrometry. We implicate different cellular proteins in R-loop regulation and identify a role of the tumor suppressor DDX41 in opposing R-loop and double strand DNA break accumulation in promoters. DDX41 is enriched in promoter regions in vivo, and can unwind RNA-DNA hybrids in vitro. R-loop accumulation upon loss of DDX41 is accompanied with replication stress, an increase in the formation of double strand DNA breaks and transcriptome changes associated with the inflammatory response. Germline loss-of-function mutations in DDX41 lead to predisposition to acute myeloid leukemia in adulthood. We propose that R-loop accumulation and genomic instability-associated inflammatory response may contribute to the development of familial AML with mutated DDX41.
Whether machine-learning algorithms can diagnose all pigmented skin lesions as accurately as human experts is unclear. The aim of this study was to compare the diagnostic accuracy of state-of-the-art ...machine-learning algorithms with human readers for all clinically relevant types of benign and malignant pigmented skin lesions.
For this open, web-based, international, diagnostic study, human readers were asked to diagnose dermatoscopic images selected randomly in 30-image batches from a test set of 1511 images. The diagnoses from human readers were compared with those of 139 algorithms created by 77 machine-learning labs, who participated in the International Skin Imaging Collaboration 2018 challenge and received a training set of 10 015 images in advance. The ground truth of each lesion fell into one of seven predefined disease categories: intraepithelial carcinoma including actinic keratoses and Bowen's disease; basal cell carcinoma; benign keratinocytic lesions including solar lentigo, seborrheic keratosis and lichen planus-like keratosis; dermatofibroma; melanoma; melanocytic nevus; and vascular lesions. The two main outcomes were the differences in the number of correct specific diagnoses per batch between all human readers and the top three algorithms, and between human experts and the top three algorithms.
Between Aug 4, 2018, and Sept 30, 2018, 511 human readers from 63 countries had at least one attempt in the reader study. 283 (55·4%) of 511 human readers were board-certified dermatologists, 118 (23·1%) were dermatology residents, and 83 (16·2%) were general practitioners. When comparing all human readers with all machine-learning algorithms, the algorithms achieved a mean of 2·01 (95% CI 1·97 to 2·04; p<0·0001) more correct diagnoses (17·91 SD 3·42 vs 19·92 4·27). 27 human experts with more than 10 years of experience achieved a mean of 18·78 (SD 3·15) correct answers, compared with 25·43 (1·95) correct answers for the top three machine algorithms (mean difference 6·65, 95% CI 6·06–7·25; p<0·0001). The difference between human experts and the top three algorithms was significantly lower for images in the test set that were collected from sources not included in the training set (human underperformance of 11·4%, 95% CI 9·9–12·9 vs 3·6%, 0·8–6·3; p<0·0001).
State-of-the-art machine-learning classifiers outperformed human experts in the diagnosis of pigmented skin lesions and should have a more important role in clinical practice. However, a possible limitation of these algorithms is their decreased performance for out-of-distribution images, which should be addressed in future research.
None.
Anion doping is one of the most widely adopted strategies to improve the electrochemical performance of cathode materials for Li-ion batteries. However, undesirable side effects are often observed ...together with enhanced electrochemical properties, leading to an unsatisfactory overall performance. In order to develop an anion doping strategy which enhances the positive effects and suppresses undesirable side effects, the understanding of their origin at the atomic scale is a crucial step. In this work, using density functional theory (DFT), we report a systematic study on the effects of three common anion dopants (F, S, Cl) on a wide range of properties of a model cathode material, LiNiO2, including redox potential, ionic conductivity, Li/Ni exchange, lattice distortion, and Ni migration upon delithiation. The results show that the dopants improve certain properties but worsen others, revealing some distance-dependent features. Overall, our work shows conflicting roles of anion doping on the battery voltage, rate performance, and structural stability of the cathode material. By identifying the origins of the different roles, we propose a rational anion doping strategy for the optimization of the overall electrochemical performance of the cathode material. These results for LiNiO2 can also promote anion doping studies and improved materials design in other Ni-rich layered oxide cathode materials.
Histological regression in primary cutaneous melanoma occurs in 10–35% of cases. Although a large body of literature exists to suggest that histological regression serves very little purpose in ...predicting biologic behaviour with melanoma, recognizing the presence of regression at clinical and histological ground may still retain some value in grading melanoma aggressiveness. In the current review, a comprehensive overview of the main aspects of regression will be provided. Histologically, many classifications have been reported so far, but all of them only agreed on the presence of an infiltrate of lymphocytes admixed with pigment‐laden macrophages underlying an atrophic epidermis with flattened rete ridges. Upon dermoscopy, regression is also named Blue White Scar‐like areas and could be variably admixed with granularity or peppering. Almost fully regressed lesions represent a main diagnostic issue in dermoscopy, and thus, confocal microscopy can be of help to identify whether the tumour is melanocytic or not. The clinical utility of regression as a prognostic factor has been challenged recently. Nowadays, evidences showed that it is less likely associated to SLN metastases.
Abstract
In an electronic device based on two dimensional (2D) transitional metal dichalcogenides (TMDs), finding a low resistance metal contact is critical in order to achieve the desired ...performance. However, due to the unusual Fermi level pinning in metal/2D TMD interface, the performance is limited. Here, we investigate the electronic properties of TMDs and transition metal oxide (TMO) interfaces (MoS
2
/MoO
3
) using density functional theory (DFT). Our results demonstrate that, due to the large work function of MoO
3
and the relative band alignment with MoS
2
, together with small energy gap, the MoS
2
/MoO
3
interface is a good candidate for a tunnel field effect (TFET)-type device. Moreover, if the interface is not stoichiometric because of the presence of oxygen vacancies in MoO
3
, the heterostructure is more suitable for
p
-type (hole) contacts, exhibiting an Ohmic electrical behavior as experimentally demonstrated for different TMO/TMD interfaces. Our results reveal that the defect state induced by an oxygen vacancy in the MoO
3
aligns with the valance band of MoS
2
, showing an insignificant impact on the band gap of the TMD. This result highlights the role of oxygen vacancies in oxides on facilitating appropriate contacts at the MoS
2
and MoO
x
(x < 3) interface, which consistently explains the available experimental observations.
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