[A randomized study of subconjonctival bevacizumab (Avastin®) injection for corneal neovascularization]

PURPOSE

The goal of this phase III, comparative, multicentric, randomized, double-blinded clinical trial was to investigate the superiority of subconjunctival bevacizumab injections versus placebo in the treatment of corneal neovascularization.

PATIENTS AND METHODS

We included 38 eyes (38 patients) with corneal neovascularization. Twenty patients received bevacizumab and 18 placebos. Patients received 3 monthly injections of either 5mg (0.2mL) bevacizumab or placebo. The main criteria of success was reduction of the surface area of corneal neovascularization after 3months (M3) versus baseline, as measured using semi-automatic analysis of color photographs.

RESULTS

The percentage of neovascularized corneal surface decreased by -8.6%±32.8 with bevacizumab, versus -2.6%±20.8 with placebo (p=0.5284). Four patients were determined to be responders (reduction of more than 30%), 3 in the bevacizumab group and 1 in the placebo group, all with neovascularization of less than 1year duration. When restricting the analysis to neovascularization of less than 1 year duration, the difference approached the threshold for significance (-31.8%±42.4 in the bevacizumab group and -0.9%±23.1 in the placebo group) (p=0.0637), as well as the number of responders (3/6 in the bevacizumab group versus 1/10 in the placebo group) (p=0.1181). No serious adverse event was reported.

CONCLUSION

This study shows the efficacy of subconjunctival bevacizumab injection in the reduction of neovascularized corneal surface area versus placebo, but only when the neovascularization has been present less than 1year. Nevertheless, the study did not attain the statistical power to pass the threshold of significance.

Targeted prophylactic anticoagulation based on the TRiP(cast) score in patients with lower limb immobilisation: a multicentre, stepped wedge, randomised implementation trial

BACKGROUND

Prophylactic anticoagulation in emergency department patients with lower limb trauma requiring immobilisation is controversial. The Thrombosis Risk Prediction for Patients with Cast Immobilisation-TRiP(cast)-score could identify a large subgroup of patients at low risk of venous thromboembolism for whom prophylactic anticoagulation can be safely withheld. We aimed to prospectively assess the safety of withholding anticoagulation for patients with lower limb trauma at low risk of venous thromboembolism, defined by a TRiP(cast) score of less than 7.

METHODS

CASTING was a stepped-wedge, multicentre, cluster-randomised trial with blinded outcome assessment. 15 emergency departments in France and Belgium were selected and randomly assigned staggered start dates for switching from the control phase (ie, anticoagulation prescription according to the physician's usual practice) to the intervention phase (ie, targeted anticoagulation according to TRiP(cast) score: no prescription if score <7 and anticoagulation if score was ≥7). Patients were included if they presented to a participating emergency department with lower limb trauma requiring immobilisation for at least 7 days and were aged 18 years or older. The primary outcome was the 3-month cumulative rate of symptomatic venous thromboembolism during the intervention phase in patients with a TRiP(cast) score of less than 7. The targeted strategy was considered safe if this rate was less than 1% with an upper 95% CI of less than 2%. The primary analysis was performed in the intention-to-treat population. This study is registered at ClinicalTrials.gov (NCT04064489).

FINDINGS

Between June 16, 2020, and Sept 15, 2021, 15 clusters and 2120 patients were included. Of the 1505 patients analysed in the intervention phase, 1159 (77·0%) had a TRiP(cast) score of less than 7 and did not receive anticoagulant treatment. The symptomatic venous thromboembolism rate was 0·7% (95% CI 0·3-1·4, n=8/1159). There was no difference between the control and the intervention phases in the cumulative rate of symptomatic venous thromboembolism or in bleeding rates.

INTERPRETATION

Patients with a TRiP(cast) score of less than 7 who are not receiving anticoagulation have a very low risk of venous thromboembolism. A large proportion of patients with lower limb trauma and immobilisation could safely avoid thromboprophylaxis.

FUNDING

French Ministry of Health.

Guideline adherence in the management of acute pulmonary oedema: Study protocol for a French survey involving cardiologists, emergency physicians and intensivists

BACKGROUND

Because of their high morbidity and mortality, patients with acute pulmonary oedema (APE) require early recognition of symptoms, identification of precipitating factors and admission to specialized care units (cardiac critical care or intensive care). APE is at the crossroads of different specialties (cardiology, emergency medicine and intensive care medicine). Although multidisciplinary expertise and management may be a strength, it can also be a source of confusion, with unexpected heterogeneity in patient care. We hypothesized that the management of severe APE may be heterogeneous between specialties and, in some situations, may differ from international recommendations.

AIM

We designed a survey to compare management of different APE phenotypes according to the physicians' medical specialty, and to compare the results with what experts would do and European guidelines.

METHODS

Four clinical cases of typical APE with questions pertaining to the latest guidelines were designed by a Scientific Committee designated by the French Scientific Societies for Cardiology, Emergency Medicine and Intensive Care Medicine. We focused on oxygenation and ventilation strategies, management of precipitating factors, including timing of coronary revascularization, use of diuretics and management of diuretic resistance, and discharge coverage. From 20 June 2022 until 09 September 2022, the four cases of APE (two during hypertensive crises, two during acute coronary syndromes) were proposed to French physicians involved in APE care, and to experts, using an open online survey. To avoid any diagnostic ambiguity, the diagnosis of APE was given at the beginning of each clinical case.

RESULTS

The intention is to present the results at national and international conferences and publish them in a peer-reviewed journal.

CONCLUSIONS

The results of this survey are intended to pave the way for the generation of novel hypotheses for future clinical trials in case of equipoise between subsets of therapeutic procedures in APE.

Central anticholinergic syndrome secondary to atropine eye drops: A case study

Atropine eye drops are frequently used in the treatment of keratitis and during ophthalmic surgery. We described a rare complication of central anticholinergic syndrome secondary to atropine eye drops.

[Colchicum poisoning by confusion with wild garlic (Allium ursinum)]

INTRODUCTION

Colchicine poisoning is a life-threatening intoxication.

CASE REPORT

We report a case of food poisosing with Colchicum autumnale by confusion with wild garlic. The clinical presentation is the same as that of colchicine drug intoxication. The evolution can be fatal in case of massive ingestion. The proximity of the place of growth and their similar appearance in spring make Colchicum and wild garlic plants that can easily be confused.

CONCLUSION

Physicians have to be vigilant in case of dysenteric syndrome and biological disturbances in spring and look for the consumption of perennial plant preceding symptoms.

Factors associated with delayed revascularization in patients with ischemic stroke: a prospective study in one French region

BACKGROUND AND IMPORTANCE

Optimizing the care pathway of stroke is crucial for the revascularization of ischemic stroke.

OBJECTIVES

to identify factors associated with (1) a time interval over 4 h between the symptom onset and cerebral imaging in suspected stroke patients and (2) the absence of revascularization in patients with ischemic stroke.

DESIGN, SETTINGS AND PARTICIPANTS

Patients over 18 years old with a suspected stroke admitted in 22 emergency rooms or stroke units in one French region between 1 March 2019 and 30 April 2019 were prospectively included by filling a dedicated form.

OUTCOME MEASURES AND ANALYSIS

Factors associated with the previously mentioned outcome measures were identified using logistic regression models.

MAIN RESULTS

In total 991 patients were included; 537 patients (64% of 845 with available time intervals) were admitted more than 4 h after symptom onset. Three predictors were identified: not calling emergency medical services (EMS) [odds-ratio (OR) 5.2; 95% confidence interval (3.4-8.1)], a preexisting autonomy loss [2.0 (1.3-2.9)] and atypical clinical presentation [2.0 (1.3-3.1)]. A total of 385 patients had an ischemic stroke of whom 93 underwent a revascularization procedure (24%). The same three predictors were associated with the absence of revascularization procedure, added to an initial admission in a hospital without stroke unit [3.1 (1.1-8.6)].

CONCLUSION

This study shows that efforts to organize the care chain for stroke need to be intensified in the region to reduce treatment time intervals, which could include information campaigns focused on the impact of EMS call and the clinical presentation recognition.

Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial

IMPORTANCE

Uncontrolled studies suggest that pulmonary embolism (PE) can be safely ruled out using the YEARS rule, a diagnostic strategy that uses varying D-dimer thresholds.

OBJECTIVE

To prospectively validate the safety of a strategy that combines the YEARS rule with the pulmonary embolism rule-out criteria (PERC) rule and an age-adjusted D-dimer threshold.

DESIGN, SETTINGS, AND PARTICIPANTS

A cluster-randomized, crossover, noninferiority trial in 18 emergency departments (EDs) in France and Spain. Patients (N = 1414) who had a low clinical risk of PE not excluded by the PERC rule or a subjective clinical intermediate risk of PE were included from October 2019 to June 2020, and followed up until October 2020.

INTERVENTIONS

Each center was randomized for the sequence of intervention periods. In the intervention period (726 patients), PE was excluded without chest imaging in patients with no YEARS criteria and a D-dimer level less than 1000 ng/mL and in patients with 1 or more YEARS criteria and a D-dimer level less than the age-adjusted threshold (500 ng/mL if age <50 years or age in years × 10 in patients ≥50 years). In the control period (688 patients), PE was excluded without chest imaging if the D-dimer level was less than the age-adjusted threshold.

MAIN OUTCOMES AND MEASURES

The primary end point was venous thromboembolism (VTE) at 3 months. The noninferiority margin was set at 1.35%. There were 8 secondary end points, including chest imaging, ED length of stay, hospital admission, nonindicated anticoagulation treatment, all-cause death, and all-cause readmission at 3 months.

RESULTS

Of the 1414 included patients (mean age, 55 years; 58% female), 1217 (86%) were analyzed in the per-protocol analysis. PE was diagnosed in the ED in 100 patients (7.1%). At 3 months, VTE was diagnosed in 1 patient in the intervention group (0.15% [95% CI, 0.0% to 0.86%]) vs 5 patients in the control group (0.80% [95% CI, 0.26% to 1.86%]) (adjusted difference, -0.64% [1-sided 97.5% CI, -∞ to 0.21%], within the noninferiority margin). Of the 6 analyzed secondary end points, only 2 showed a statistically significant difference in the intervention group compared with the control group: chest imaging (30.4% vs 40.0%; adjusted difference, -8.7% [95% CI, -13.8% to -3.5%]) and ED median length of stay (6 hours [IQR, 4 to 8 hours] vs 6 hours [IQR, 5 to 9 hours]; adjusted difference, -1.6 hours [95% CI, -2.3 to -0.9]).

CONCLUSIONS AND RELEVANCE

Among ED patients with suspected PE, the use of the YEARS rule combined with the age-adjusted D-dimer threshold in PERC-positive patients, compared with a conventional diagnostic strategy, did not result in an inferior rate of thromboembolic events.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04032769.

[Epidemiology of patients presenting to the emergency room for dyspnea in Belgium]

Studies about patients' profile presenting to the emergency department for dyspnea are scarce in Europe, and even more in Belgium. We analyze here a cohort of patients with acute dyspnea in three Belgian centers, as to the epidemiology of this dyspnea, the tests carried out, the diagnoses retained, the treatments administered, the hospitalization and survival rates. The secondary objective is to compare this Belgian cohort with a European population resulting from a large multicenter study. The analysis of 131 patients showed that acute dyspnea in the emergency department corresponds to four main diagnoses (exacerbation of chronic obstructive pulmonary disease, infections of the lower respiratory tract, acute cardiac decompensation and asthma). The age of patients is over 80 years in a quarter of them, the hospitalization rate is 57 % and the mortality is 5 %. Our analysis also reveals that the check of vital parameters may be insufficiently realized, as may the use of non-invasive ventilation. Etiological diagnoses made in the emergency department are confirmed at the end of hospitalization in 75 % of cases. The Belgian population is younger than the European population (62 against 69 years), presents fewer infection of the lower respiratory tract (20 % against 31 %), and is comparable to the European population for the other parameters studied. The article ends with 10 key messages that will enlighten clinicians about the reality of acute dyspnea in emergency rooms in Belgium.

Cancer Patients' Prehospital Emergency Care: Post Hoc Analysis from the French Prospective Multicenter Study EPICANCER

Background: Very little data are available concerning the prehospital emergency care of cancer patients. The objective of this study is to report the trajectories and outcomes of cancer patients attended by prehospital emergency services. Methods: This was an ancillary study from a three-day cross-sectional prospective multicenter study in France. Adult patients with cancer were included if they called the emergency medical dispatch center Service d’Aide Médicale Urgente (SAMU). The study was registered on ClinicalTrials.gov (NCT03393260, accessed on 8th January 2018). Results: During the study period, 1081 cancer patients called the SAMU. The three most frequent reasons were dyspnea (20.2%), neurological disorder (15.4%), and fatigue (13.1%). Among those patients, 949 (87.8%) were directed to the hospital, among which 802 (90.8%) were directed to an emergency department (ED) and 44 (5%) were transported directly to an intensive care unit (ICU). A mobile intensive care unit (MICU) was dispatched 213 (31.6%) times. The decision to dispatch an MICU seemed generally based on the patient’s reason for seeking emergency care and the presence of severity signs rather than on the malignancy or the patient general health status. Among the patients who were directed to the ED, 98 (16.1%) were deceased on day 30. Mortality was 15.4% for those patients directed to the ED but who were not admitted to the ICU in the next 7 days, 28.2% for those who were admitted to ICU in the next 7 days, and 56.1% for those patients transported by the MICU directly to the ICU. Conclusion: Cancer patients attending prehospital emergency care were most often directed to EDs. Patients who were directly transported to the ICU had a high mortality rate, raising the question of improving triage policies.

Recognition of child maltreatment in emergency departments in Europe: Should we do better?

OBJECTIVES

To evaluate the different policies to recognize child maltreatment in emergency departments (EDs) in Europe in order to define areas of improvement.

METHODS

A survey was conducted on the recognition of child maltreatment in EDs in European countries with a focus on screening methods, parental risk factors, training and hospital policies. The survey was distributed through different key members from the EUSEM, REPEM and the EuSEN. A summary score based on the NICE guideline (4 questions on child characteristics, 4 questions on parental characteristics and 5 questions on hospital policy) was calculated.

RESULTS

We analysed 185 completed surveys, representing 148 hospitals from 29 European countries. Of the respondents, 28.6% used a screening tool, and 31.8% had guidelines on parental risk factors. A total of 42.2% did not follow training based on child characteristics, and 57.6% did not follow training on parental characteristics. A total of 71.9% indicated that there was a need for training. 50.8% of the respondents reported a standardized policy for the detection of child maltreatment. Translating the survey results to NICE summary scores of the EDs in Europe, we found that 25.6% (34/133) met most, 22.6% (30/133) met some and 51.9% (69/133) met few of the NICE guideline recommendations. More specifically, with respect to hospital policies, 33.8% (45/133) met most, 15.0% (20/133) met some and 51.1% (68/133) met few of the NICE guideline recommendations.

CONCLUSION

There is high variability regarding policies for child maltreatment detection and only a quarter of the EDs met most of the NICE guideline recommendations for child maltreatment. There is a need for the use of screening tools, training of ED staff and implementation of local hospital policies.

Assessment of atrial fibrillation in emergency department

Introduction

Atrial Fibrillation (AF) is the most common arrythmia, especially in older adults. AF represents 1% of emergency department (ED) visits a third of which are de novo or recurrent. While the diagnosis is given quickly by reading the electrocardiogram (ECG), its management both remains complex. European guidelines have been published in 2016.

Purpose

Our study aimed to investigate guidelines implementation in French ED.

Methods

Prospective national multicenter study (clinical trials NCT 03836339) and core interpretation of ECG. Consecutive patients admitted in 32 French ED for AF confirmed by ECG were prospectively included. Clinical characteristics at admission were recorded by the physician. The 3-months telephone follow-up was ensured by one operator.

Results

From 1/10/2018 to 30/11/2018, 1369 patients with AF were included, of whom 295 (21.55%) had a de novo AF. Patients were 80 [65; 87] years old, 51.17% of men, 71.53% self-ruling, 91.53% living at home, 65.42% transported by firemen or by ambulances and 4,07% by a mobile intensive care unit. Twenty-six (8.84%) patients had a history of stroke or transient ischemic stroke and none of them on anticoagulants. CHA2DS2-VASC score was performed in 66.78% of patients and was 0 in 14 (7.11%) patients. HAS-BLED score = 2 [1; 3]. At admission 50.17% of patients received anticoagulants, of whom 49.32% a non-vitamin K antagonist oral anticoagulant, 0.68% Vitamin K antagonists, 50.68% UFH or LMWH. Beta-blockers were administered in 102 (24.01%) patients and amiodarone in 38 (12.89%). Cardiac echography has been performed in 20.34% of patients. Atrial fibrillation was the primary diagnosis in 42.71% of patients. It has been associated to a pneumopathy in 25.17% of patients, a pulmonary embolism in 4.76% and acute alcoholism in 1.36% of them. Precipitating factor was often undetermined. The discharge to the home concerned 18.64% of patients, 26.78% of patients were hospitalized in ED hospitalization unit, 23.05% in cardiology or intensive care unit. At 3 months, 49% of patients were on anticoagulants, of whom 90% on non-vitamin K antagonist oral anticoagulants, 95% of them didn't report any bleeding event and 41.77% of them were able to have a cardiology consultation within three months. Three-months mortality was about 22.09%, and rehospitalization rate about 22.89%.

Conclusion

It seems to be a reticence to initiate anticoagulation of patients admitted to ED with a de novo AF. It could be explained by both the advanced age of the patients and the lack of an organized access to a systematic cardiology consultation at discharge. Patients with chronic AF are subject to high mortality at 3 months and a significant risk of readmission. The application of the guidelines could be optimized by a better training program and the implementation of a dedicated pathway of care.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Bayer

Follow-up of adults with noncritical COVID-19 two months after symptom onset

Objectives

To describe the clinical evolution and predictors of symptom persistence during 2 months' follow-up in adults with noncritical coronavirus disease 2019 (COVID-19).

Methods

We performed descriptive clinical follow-up (day (D) 7, D30 and D60) of 150 patients with noncritical COVID-19 confirmed by real-time reverse transcriptase PCR at Tours University Hospital from 17 March to 3 June 2020, including demographic, clinical and laboratory data collected from the electronic medical records and by phone call. Persisting symptoms were defined by the presence at D30 or D60 of at least one of the following: weight loss ≥5%, severe dyspnoea or asthenia, chest pain, palpitations, anosmia/ageusia, headache, cutaneous signs, arthralgia, myalgia, digestive disorders, fever or sick leave.

Results

At D30, 68% (103/150) of patients had at least one symptom; and at D60, 66% (86/130) had symptoms, mainly anosmia/ageusia: 59% (89/150) at symptom onset, 28% (40/150) at D30 and 23% (29/130) at D60. Dyspnoea concerned 36.7% (55/150) patients at D30 and 30% (39/130) at D60. Half of the patients (74/150) at D30 and 40% (52/130) at D60 reported asthenia. Persistent symptoms at D60 were significantly associated with age 40 to 60 years old, hospital admission and abnormal auscultation at symptom onset. At D30, severe COVID-19 and/or dyspnoea at symptom onset were additional factors associated with persistent symptoms.

Conclusions

Up to 2 months after symptom onset, two thirds of adults with noncritical COVID-19 had complaints, mainly anosmia/ageusia, dyspnoea or asthenia. A prolonged medical follow-up of patients with COVID-19 seems essential, whatever the initial clinical presentation.

Emergency department outcome of elderly patients assisted by professional home services, the EPIGER study

BACKGROUND

For the elderly population living at home, the implementation of professional services tends to mitigate the effect of loss of autonomy and increases their quality of life. While helping in avoiding social isolation, home services could also be associated to different healthcare pathways. For elderly patients, Emergency Departments (EDs) are the main entrance to hospital where previous loss of autonomy is associated to worst hospital outcomes. Part of elderly patients visiting EDs are still admitted to hospital for having difficulties coping at home without presenting any acute medical issue. There is a lack of data concerning elderly patients visiting EDs assisted by home services. Our aim was to compare among elderly patients visiting ED those assisted by professional home services to those who do not in terms of emergency resources' use and patients' outcome.

METHODS

A multicenter, prospective cohort study was performed in 124 French EDs during a 24-h period on March 2016.Consecutive patients living at home aged ≥80 years were included. The primary objective was to assess the risk of mortality for patients assisted by professional home services vs. those who were not. Secondary objectives included admission rate and specific admission rate for "having difficulties coping at home". The primary endpoint was in-hospital mortality. Cox proportional-hazards regression model was used to test the association between professional home services and the primary endpoint. Multi variables logistic regressions were performed to assess secondary endpoints.

RESULTS

One thousand one hundred sixty-eight patients were included, median age 86(83-89) years old,32% were assisted by professional home services. The overall in-hospital mortality rate was 7%. Assisted patients had more investigations performed. Home services were not associated with increased in-hospital mortality (HR = 1.34;95%CI [0.68-2.67]), nor with the admission rate (OR = 0.92;95%CI [0.65-1.30]). Assisted patients had a lower risk of being admitted for "having difficulties coping at home" (OR = 0.59;95%CI [0.38-0.92]).

CONCLUSION

Professional home services which assist one-third of elderly patients visiting EDs, were not associated to lower in-hospital mortality or to an increased admission rate. Assisted patients were associated to a lower risk of being admitted for «having difficulties coping at home».Professional home services could result in avoiding some admissions and their corollary complications.

TRIAL REGISTRATION

Clinicaltrial.gov - NCT02900391 , 09/14/2016, retrospectively registered.

Predicting a diagnosis of acute coronary syndrome during telephone evaluation by an emergency dispatcher: the SCARE predictive scale

OBJECTIVES

Correctly identifying patients with acute coronary syndrome (ACS) on first contact is essential, yet emergency dispatchers currently lack a risk scale that can help predict an ACS diagnosis. Our main aim was to develop and validate such a risk scale.

MATERIAL AND METHODS

Prospective, observational single-center study in 2016 (January 1 to December 31). We included patients who called our emergency dispatch center to report nontraumatic chest pain. Included patients were randomly assigned to a development or a validation sample. The predictive SCARE scale was built with logistic regression analysis. Discrimination and calibration were analyzed by calculating the area under the receiver operating characteristic curve; calibration was assessed with the Hosmer-Lemeshow test.

RESULTS

The development sample included 902 patients. The regression model identified 7 variables associated with a final diagnosis of ACS: male sex, age, smoking, typical pain characteristics, first episode of chest pain, diaphoresis, and physician intuition (the teledispatcher's suspicion). When we applied the scale in the validation sample of 465 patients the area under the curve was 0.81 (95% CI, 0.76-0.87). The Hosmer-Lemeshow statistic was 5.18 (P=.74).

CONCLUSION

The SCARE scale had good discrimination and calibration properties. The scale should be further validated in an external sample from a multicenter study before it is implemented by emergency dispatch centers.

Trends and prediction of antimicrobial susceptibility in urinary bacteria isolated in European emergency departments: the EuroUTI 2010-2016 Study

Objectives

To assess recent trends in susceptibility to antibiotics among urinary isolates isolated in European emergency departments (EDs) and to identify isolates with a high (90% or more) predicted probability of susceptibility to fluoroquinolones or third-generation cephalosporins (3GCs).

Methods

In this cross-sectional study, we included urine cultures obtained from adult patients between 2010 and 2016 in 24 European EDs. Temporal trends were assessed using time-series analysis and multivariate logistic models. Multivariate logistic models were also used to predict susceptibility to fluoroquinolones or 3GCs from patient age and sex, year, month and ED.

Results

We included 88242 isolates. Time-series analysis found a significant increase in susceptibility to fluoroquinolones and no significant trend for susceptibility to 3GCs. Adjusting for patient age and sex, ED and organism, multivariate models showed that susceptibility to 3GCs decreased from 2014 to 2016, while susceptibility to fluoroquinolones increased in 2015 and 2016. Among isolates from 2016, multivariate models predicted high probability of susceptibility to fluoroquinolones in 11% of isolates (positive predictive value 91%) and a high probability of susceptibility to 3GCs in 35% of isolates (positive predictive value 94%).

Conclusions

Susceptibility of ED urinary isolates to fluoroquinolones increased from 2014, while susceptibility to 3GCs decreased from 2015. Predictive models identified isolates with a high probability of susceptibility to fluoroquinolones or 3GCs. The ability of such models to guide the empirical treatment of pyelonephritis in the ED remains to be determined.

Agents with vasodilator properties in acute heart failure

Millions of patients worldwide are admitted for acute heart failure (AHF) each year and physicians caring for these patients are confronted with the short-term challenges of reducing symptoms while preventing end organ dysfunction without causing additional harm, and the intermediate-term challenges of improving clinical outcomes such as hospital readmission and survival. There are limited data demonstrating the efficacy of any currently available therapies for AHF to meet these goals. After diuretics, vasodilators are the most common intravenous therapy for AHF, but neither nitrates, nitroprusside, nor nesiritide have robust evidence supporting their ability to provide meaningful effects on clinical outcomes, except perhaps early symptom improvement. Recently, a number of novel agents with vasodilating properties have been developed for the treatment of AHF. These agents include serelaxin, natriuretic peptides (ularitide, cenderitide), β-arrestin-biased angiotensin II type 1 receptor ligands (TRV120027), nitroxyl donors (CXL-1020, CXL-1427), soluble guanylate cyclase modulators (cinaciguat, vericiguat), short-acting calcium channel blockers (clevidipine), and potassium channel activators (nicorandil). These development programmes range from the stage of early dose-finding studies (e.g. TRV120027, CXL-1427) to large, multicentre mortality trials (e.g. serelaxin, ularitide). There is an urgent need for agents with vasodilating properties that will improve both in-hospital and post-discharge clinical outcomes, and these novel approaches may provide opportunities to address this need.

Trends in death attributed to myocardial infarction, heart failure and pulmonary embolism in Europe and Canada over the last decade

BACKGROUND

Worldwide, cardiovascular diseases and cancer account for ∼40% of deaths. Certain reports have shown a progressive decrease in mortality. Our main objective was to assess mortality trends related to myocardial infarction (MI), heart failure (HF) and pulmonary embolism (PE).

METHODS

MI, HF and PE were studied as cause of death based on the analysis of death certificates in Canada (C), England and Wales (E), France (F) and Sweden (S). We also used a multiple cause approach. Age-standardized death rates (SDR) were calculated.

RESULTS

The SDR for MI, HF or PE as the underlying cause of death, all decreased during the last decade. The decrease in SDR secondary to MI exceeded that for HF or PE. Concerning multiple cause of death, a greater decrease was also found for MI, compared with HF or PE.

CONCLUSIONS

We confirm the beneficial trends in SDR with MI, HF or PE both as underlying or multiple causes in the studied countries. For HF and PE, multiple cause approach seems more accurate to describe the burden of these two pathologies. Our study also suggests that more efforts should be dedicated to HF and PE in order to achieve similar trends than in MI.

[Improving vital organs perfusion by the respiratory pump: physiology and clinical use]

OBJECTIVE

In this article, we review the effects of the respiratory pump to improve vital organ perfusion by the use of an inspiratory threshold device.

DATA SOURCES

Medline and MeSH database.

STUDY SELECTION

All papers with a level of proof of I to III have been used.

DATA EXTRACTION

The analysis of the papers has focused on the physiological modifications induced by intrathoracic pressure regulation.

DATA SYNTHESIS

Primary function of breathing is to provide gas exchange. Studies of the mechanisms involved in animals and humans provide the physiological underpinnings for "the other side of breathing": to increase circulation to the heart and brain. We describe studies that focus on the fundamental relationship between the generation of negative intrathoracic pressure during inspiration through a low-level of resistance created by an impedance threshold device and the physiologic effects of a respiratory pump. A decrease in intrathoracic pressure during inspiration through a fixed resistance resulting in an intrathoracic pressure of -7 cmH2O has multiple physiological benefits including: enhanced venous return, cardiac stroke volume and aortic blood pressure; lower intracranial pressure; resetting of the cardiac baroreflex; elevated cerebral blood flow oscillations and increased tissue blood flow/pressure gradient.

CONCLUSION

The clinical and animal studies support the use of the intrathoracic pump to treat different clinical conditions: hemorrhagic shock, orthostatic hypotension, septic shock, and cardiac arrest.

[Faisability of foetal monitoring in prehospital care]

The use of mobile monitoring system for foetal cardiotachometry has never been evaluated in the prehospital care. The aim of the survey was to evaluate the faisability of this device. Twenty-five patients were enrolled, mostly within the context of interhospital transfer because of threatening premature delivery (n = 20). Foetal monitoring was effective for 64 % of the patients during initial physical examination and for 52 % during transport by ambulance. Prehospital treatment was improved in one case of eclampsia after on-scene fetal monitoring. Cardiotocography can be easily performed in the prehospital setting.