Impact de la Covid-19 sur les arrêts cardiaques extrahospitaliers en phase de suractivité épidémique : données du registre RéAC

Introduction : Notre objectif était d’analyser la survie des patients victimes d’un arrêt cardiaque extrahospitalier (ACEH) durant la pandémie Covid-19 et de comparer les données en fonction du centre de traitement de l’appel choisi, le 15 ou le 18.

Méthode : Nous avons extrait les données exhaustives du Registre des arrêts cardiaques (RéAC), entre le 1er mars et le 30 avril 2020. Nous avons effectué trois comparaisons de la survie à 30 jours (J30) de cohortes de patients : 1) Covid vs non-Covid ; 2) appels arrivés au service d’aide médicale urgente (Samu) (15) vs aux sapeurs-pompiers (SP) (18) et 3) appels arrivés au 15 vs 18 pour les patients Covid.

Résultats : Sur un total de 870 ACEH, 184 étaient atteints de la Covid. Nous avons observé 487 (56 %) appels arrivés au 15 et 383 (44 %) au 18. La survie à J30 était de 3 %. Les ACEH Covid avaient une survie à J30 plus faible que les non-Covid (0 vs 4 %, p < 0,001). Le délai d’arrivée de SP était plus long lors d’un appel au 15. En revanche, aucune différence de survie n’est observée entre les appels arrivés au 15 ou au 18.

Conclusion : La survie consécutive à un ACEH durant la pandémie est extrêmement faible. Cependant, quel que soit le numéro composé (15 ou 18), la survie n’est pas différente, même si le délai d’arrivée des prompts secours est plus court lors d’un appel au 18.

P4169The crucial role of the bystander in out-of-hospital cardiac arrest resuscitation

Background

Out-of-hospital cardiac arrest (OHCA) is a major public health concern in France, given that there are 61.5 cases per 100,000 inhabitants a year. The impact of bystander action, performed before the arrival of emergency medical services (EMS), on survival has never been studied in France.

Purpose

Determine whether bystander cardiopulmonary resuscitation (CPR), performed before the arrival of EMS, was correlated with an increased 30-day survival rate after an OHCA.

Methods

24,885 out-of-hospital cardiac arrests witnessed in France from 1 January 2012 to 1 May 2018 were analysed to determine whether CPR, performed before the arrival of EMS, was correlated with survival. Data from the Electronic Registry of Cardiac Arrests was used. The association between the effect of CPR performed before the arrival of EMS and 30-day survival rate was studied, using propensity analysis (which included variables such as age and sex of the patient, location, cause, and year of cardiac arrest, initial cardiac rhythm, EMS response time and no-flow time).

Results

CPR was performed before the arrival of EMS in 14,904 cases (59.9%) and was not performed in 9,981 cases (40.1%). The 30-day survival rate was 10.2% when CRP was performed by bystanders versus 3.9% when CRP was not performed before the EMS arrival (p<0.001). CPR performed by bystanders was associated with an increased 30-day survival rate (odds ratio 1.269; 1.207 to 1.334).

The effect of bystander CPR on survival

Conclusion

Bystander CPR performed before the arrival of EMS was associated with an increased 30-day survival rate after an out-of-hospital cardiac arrest in France.

Compliance to oral nutritional supplementation decreases the risk of hospitalisation in malnourished older adults without extra health care cost: Prospective observational cohort study

BACKGROUND & AIMS

Malnutrition affects 5-10% of elderly people living in the community. A few studies suggest that nutritional intervention may reduce health care costs. The present study included malnourished elderly patients living at home. It aimed to compare health care costs between patients that were prescribed ONS by their general practitioner and those who were not, and to assess the effect of ONS prescription on the risk of hospitalisation.

METHODS

This prospective multicentre observational study included malnourished patients ≥70 years old who lived at home. Patients were defined as malnourished if they presented with one or more of the following criteria: weight loss ≥5% in 1 month, weight loss ≥10% in 6 months, BMI <21 kg/m², albuminemia <35 g/L or Short-Form MNA ≤ 7. Their general practitioners prescribed an ONS, or not, according to their usual practice. Health care costs were recorded during a 6-month period. Other collected data were diseases, disability, self-perception of current health status, quality of life (QoL), nutritional status, appetite and compliance to ONS. A propensity score method was used to compare costs and risk of hospitalisation to adjust for potential confounding factors and control for selection bias.

RESULTS

We analysed 191 patients. At baseline, the 133 patients (70%) who were prescribed ONS were more disabled (p < 0.001) and had poorer perception of their health (p = 0.02), lower QoL (p = 0.04) and lower appetite (p < 0.001) than the 58 patients (30%) who were not prescribed ONS. At 6 months, appetite had improved more in the ONS prescription group (p = 0.001). Weight change was not different between groups. Patients prescribed ONS were more frequently hospitalised (OR 2.518, 95% CI: [1.088; 5.829] hosp; p = 0.03). Analyses of adjusted populations revealed no differences in health care costs between groups. In the ONS prescription group, we identified that health care costs were lower (p = 0.042) in patients with an energy intake from ONS ≥ 500 kcal/d (1389 ± 264 €) vs. < 500 kcal/d (3502 ± 839 €). The risk of hospitalisation was reduced 3 and 5 times when the intake from ONS was ≥30 g of protein/day or ≥500 kcal/d, respectively.

CONCLUSIONS

ONS prescription in malnourished elderly patients generated no extra heath care cost. High energy and protein intake from ONS was associated with a reduced risk of hospitalisation and health care costs.

Prognostic performance of early absence of pupillary light reaction after recovery of out of hospital cardiac arrest

INTRODUCTION

Loss of pupillary light reactivity (PLR) three days after a cardiorespiratory arrest is a prognostic factor. Its predictive value upon hospital admission remains unclear. Our objective was to determine the prognostic value of the absence of PLR upon hospital admission in patients with out-of-hospital cardiac arrest.

METHODS

We prospectively included all out-of-hospital cardiac arrests occurring between July 2011 and July 2017 treated by a mobile medical team (MMT) based on data from a French cardiac arrest registry database. PLR was evaluated upon hospital admission and the outcome on day 30. The prognosis was classified as good for Cerebral Performance Category (CPC) 1 or 2, and poor for CPC 3-5 or in case of death.

RESULTS

Data from 10151 patients was analysed. The sensitivity and specificity of the absence of PLR for a poor outcome were 72.2% (71.2-73.2) and 68.8% (66.7-70.1), respectively. We identified several variables modifying the sensitivity values and the false positive fraction of a factor, ranging from 0.49 (0.35-0.69) for the Glasgow Coma Scale to 2.17 (1.09-2.48) for pupillary asymmetry. Among those living with CPC 1 or 2 on day 30 (n = 1990; 19.6%), 621 (31.2% (29.2-33.3)) had no PLR upon hospital admission. In the multivariate analysis, loss of PLR was associated with a poor outcome (OR = 3.1 (2.7-3.5)).

CONCLUSIONS

Loss of pupillary light reactivity upon hospital admission is predictive of a poor outcome after out-of-hospital cardiac arrest. However, it does not have sufficient accuracy to determine prognosis and decision making.

Body mass index and childhood obesity classification systems: A comparison of the French, International Obesity Task Force (IOTF) and World Health Organization (WHO) references

AIM

This study aims to compare three body mass index (BMI)-based classification systems of childhood obesity: the French, the International Obesity Task Force (IOTF) and the World Health Organization (WHO) references.

METHODS

The study involved 1382 schoolchildren, recruited from the Lille Academic District in France in May 2009 aged 8.4±1.7 years (4.0-12.0 years). Their mean height and body mass were 131.5±10.9cm and 30.7±9.2kg, respectively, resulting in a BMI of 17.4±3.2kg/m(2). The weight status was defined according to the three systems considered in this study. The agreement between these references was tested using the Cohen's kappa coefficient.

RESULTS

The prevalence of overweight was higher with the WHO references (20.0%) in comparison with the French references (13.8%; P<0.0001) and the IOTF (16.2%; P≤0.01). A similar result was found with obesity (WHO: 11.6% vs. IOTF: 6.7%; or French references: 6.7%; P<0.0001). Agreement between the three references ranged from "moderate" to "perfect" (0.43≤κ≤1.00; P<0.0001). Kappa coefficients were higher when the three references were used to classify children as obese (0.63≤κ≤1.00; P<0.0001) as compared to classification in the overweight (obesity excluded) category (0.43≤κ≤0.94; P<0.0001). When sex and age categories (4-6 years vs. 7-12 years) were considered to define the overweight status, the lowest kappa coefficient was found between the French and WHO references in boys aged 7-12 years (κ=0.28; P<0.0001), and the highest one in girls aged 7-12 years between the French references and IOTF (κ=0.97; P<0.0001). As for obesity, agreement between the three references ranged from 0.60 to 1.00 (P<0.0001), with the lowest values obtained in the comparison of the WHO references against French references or IOTF among boys aged 7-12 years (κ=0.60; P<0.0001).

CONCLUSION

Overall, the WHO references yield an overestimation in overweight and/or obesity within this sample of schoolchildren as compared to the French references and the IOTF. The magnitude of agreement coefficients between the three references depends on of both sex and age categories. The French references seem to be in rather close agreement with the IOTF in defining overweight, especially in 7-12-year-old children.

Does biological maturity actually confound gender-related differences in physical activity in preadolescence?

AIM

To examine: (i) if maturity-related gender differences in moderate-to-vigorous physical activity (MVPA) depend on how maturity status is defined and measured; and (ii) the influence of maturity level on compliance with PA recommendations.

METHODS

The study involved 253 children (139 boys) aged 9.9 ± 0.9 years, with mean stature and weight of 1.39 ± 0.08 m and 35.8 ± 8.8 kg respectively. Their PA was evaluated using an Actigraph accelerometer (Model 7164). Maturity was assessed using the estimated age at peak height velocity (APHV) and a standardized APHV by gender (i.e. centred APHV).

RESULTS

Boys engaged in significantly more MVPA than girls (P < 0.0001). There was a significant correlation between the centred APHV and MVPA in boys (r = 0.20; P = 0.016), but not in girls (r = 0.13; P = 0.155). An ancova controlling for the estimated APHV showed no significant interactions between gender and APHV, and the main effect of gender on MVPA was negated. Conversely, there was a significant main effect of APHV on MVPA (F 1,249 = 6.12; P = 0.014; η p (2) = 0.024). Only 9.1% of children met the PA recommendations, including 14.4% of boys and 2.6% of girls (P < 0.01). This observation also applies in both pre-APHV (12.7% of boys vs. 2.4% of girls, P < 0.001) and post-APHV children (23.8% of boys vs. 3.4% of girls, P < 0.0001). No differences in PA guidelines were observed between pre-APHV and post-APHV children.

CONCLUSIONS

Among prepubescent children, the influence of biological maturity on gender differences in PA may be a function of how maturity status is determined. The most physically active prepubescent children were those who were on time according to APHV.

[Cardiac arrest in France: Why a national register?]

Cardiac arrest is a public health issue for which international guidelines are updated every five years (last bringing up to date on 2010 october). The lake of epidemiologic data on cardiac arrest justifies the building of a national register. French SAMU experienced registers especially in the field of acute coronary syndrom. Our national register "RéAC"is planned to deploy the present year for out-of-hospital cardiac arrest with the help of our scientific societies and the Department of Health. It is integrated in a program of evaluation and improvement of professional practices for physicians and prehospital teams who will be involved in its exhaustive use.

High-Pressure, High-Temperature Synthesis of Superhard Boron Suboxide

A multianvil device was used to investigate the formation of BxO phases produced in the 2 to 10 GPa pressure range with temperatures between 1000 and 1800 °C.Amorphous and crystalline B and BP were oxidized using B2O3 and CrO3. Using powder X-ray diffraction and parallel electron energy-loss spectroscopy (PEELS), we were unable to detect graphitic or diamondstructured B2O, reported in previous studies. The refractory boride B6O, which has the α-rhombohedral boron structure, is the dominant suboxide in the P and T range of our investigation. PEELS with a transmission electron microscope was used to characterize the boron oxides.

An architecture for online comparison and validation of processing methods and computerized guidelines in intensive care units

Clinical decision support systems are a combination of software techniques to help the clinicians in their medical decision making process via functionalities ranging from basic signal analysis to therapeutic planning and computerized guidelines. The algorithms providing all these functionalities must be very carefully validated on real patient data and must be confronted to everyday clinical practice. One of the main problems when developing these techniques is the difficulty to obtain high-quality complete patient records, comprising data coming both from the biomedical equipment (high-frequency signals), and from numerous other sources (therapeutics, imagery, clinical actions, etc.). In this paper, we present an infrastructure for developing and testing such software algorithms. It is based on a bedside workstation where testing different algorithms simultaneously on real-time data is possible in the ward. It is completed by a collaborative portal enabling different teams to test their software algorithms on the same patient records, making comparisons and cross-validations more easily.

Patient survival and health care utilization in Medicare beneficiaries diagnosed with cancer of unknown primary

6064

Background: For patients presenting with cancer of unknown primary (CUP), identifying the site of origin can improve survival and treatment outcomes. We analyzed outcomes in patients who present with an initial diagnosis of malignant neoplasm without specification of site (ICD-9 199.0 and 199.1). Methods: Based on a 5% Medicare beneficiary sample from 2002 through 2004, we conducted a retrospective claims data analysis identifying patients who were cancer free in 2002 and who subsequently had a claim with a CUP diagnosis (ICD-9 199.0 or 199.1) in 2003. We evaluated survival and Medicare charges by procedure and diagnosis code for four consecutive quarters following CUP diagnosis. We assigned patients to one of two groups. The “differential” group consisted of CUP patients having a subsequent claim with a differential diagnosis code (ICD-9 140–229, excluding 199.0 and 199.1). The “unknown” group consisted of CUP patients with no later change in diagnosis. We applied chi-square and t-tests to examine differences in survival, resource utilization, and Medicare charges between groups. We developed Cox survival and linear regression models for multivariate analyses. Results: Of the 388 patients, 277 (71%) did not have a claim with a differential diagnosis during the follow-up period. Both groups were similar in race (80% white) gender (60% female) and age (range 70–79). The one-year mortality of the unknown group was 32.9% compared to 19.8% in the differential group (p=0.01). First quarter charges were higher for the unknown group: $2,549 vs. $1,683 (p < 0.001). Total allowed charges were higher for the differential group over the one-year follow up period: $7,493 vs. $5,540 (p < 0.05), even when adjusted for survival. Conclusions: Following a diagnosis of CUP, patients who obtain a differential diagnosis live longer and incur higher charges over time as a result of ongoing management and intervention. Improved diagnostic tests may affect patient survival and how Medicare resources are applied.

No significant financial relationships to disclose.

Assessing excess nurse work load generated by multiresistant nosocomial bacteria in intensive care

OBJECTIVE

To compare three methods for assessing the excess nurse work load related to recommended procedures for managing nosocomial infections (NI) due to multiresistant bacteria (MRB): two activity scores, the Omega score and the Projet de Recherche en Nursing (PRN) system, and a specific evaluation based on functional analysis of nursing procedures.

SETTING

10 beds in a medical intensive care unit (MICU).

PATIENTS

Patients admitted from November 15, 1995, to June 15, 1996, were included and divided in two groups based on presence of MRB colonization or infection (MRB+ and MRB-groups).

METHODS

Data were collected regarding length of stay (LOS) in days; Omega score for the entire stay; PRN score for the entire stay and per day; and time required to perform correctly four nursing procedures related to MRB NI, as evaluated specifically by the nursing staff, using a detailed functional analysis document that described all elementary nursing tasks in chronological order and all material needed to carry out those tasks.

RESULTS

The LOS and total Omega and PRN scores were higher in the MRB+ group than in the MRB- group: LOS, 23 +/- 20.6 versus 12 +/- 15.3 days, (P<.001); Omega score, 164 +/- 103.4 versus 123 +/- 93.7 points (P<.001); PRN score, 3,606 +/- 3,187 versus 1,854 +/- 2,356 points (P<.001), respectively. The daily PRN score was also higher in MRB+ group (PRN, 160 +/- 25 vs 146 +/- 34 points in the MRB- group; P<.028). Four nursing procedures made necessary by MRB acquisition were identified: isolation precautions, with two levels according to whether the risk of contamination was mild-moderate or high; bathing the patient with antiseptic solution; bedpan management; and microbiological screening. The functional analysis indicated that the time needed to carry out these four procedures correctly was 245 minutes per patient per day, as compared to 85 minutes according to the PRN system.

CONCLUSIONS

Our data confirm that MRB NIs are responsible for an increase in nurse work load, as estimated by LOS, Omega, and PRN scores. However, the daily excess nurse work load related directly to recommended procedures for managing MRB NIs in MICUs is underestimated by these activity scores, as compared to a specific functional analysis of nursing tasks. This may be of importance in evaluating potential links between nurse work load and MRB NIs and in determining the number of nurse hours needed to comply with infection control recommendations.

Efficiency of the OVATEC unit for estrus detection and calf sex control in beef cows

Seventy five spring calving Gelbvieh and Angus cows were utilized over a three year period to evaluate the usefulness of the OVATEC intravaginal probe for indicating the onset of estrus and providing the possibility to influence the sex of the offspring by choosing a breeding time in relation to critical changes in cervical mucus conductivity. Cows were randomly assigned by breed each year into one of four treatments: (1) probed and inseminated when impedance values declined, creating conditions expected to favor X-bearing sperm and with it an increase in the conception of females (PF); (2) probed and inseminated when impedance values were rebounding, expected to favor Y-bearing sperms and with it an increase in the conception of males (PB); (3) standing estrus (AI); or (4) natural service by bull (NS). Cows grazed or were fed hay from tall fescue-legume pastures. Lutalyse was used to synchronize estrus in a two injection scheme. Vaginal probe readings were taken at first injection, second injection and every 12 h thereafter for 6 days. Visual observations for estrus were obtained for PF, PB and AI every 12 h postsecond injection. Rectal palpations of ovaries were obtained at standing heat in all but NS treatments. In cycling cows, probe readings increased prediction of estrus onset (P < 0.10) compared to visual observations and were similar (P > 0.95) to rectal palpations in all probed cows. PF cows delivered heifer calves at greater rates (P < 0.025) than all other treatments whereas PB cows delivered bulls at greater rates (P < 0.05) than all other treatments. Heifer to bull ratios were not different (P > 0.95) for AI or NS treatments. The results of this study indicate that the potential exists for increasing female offspring conceptions utilizing cervical mucus conductivity as a gauge for insemination times.

Relationship of running to musculoskeletal pain with age. A six-year longitudinal study

OBJECTIVE

To determine, by longitudinal study, whether long-distance running, maintained for many years, is associated with increased musculoskeletal pain with age.

METHODS

A 6-year prospective longitudinal study of 410 runners' club members and 289 community controls, age 53-75 years at study initiation, was conducted. Subjects were also categorized as ever-runners (n = 488) and never-runners (n = 211). The primary dependent variable was pain score as indicated on a horizontal double-anchored analog scale; data for this variable were available beginning in 1987. Statistical adjustment for age, education level, smoking, alcohol consumption, history of arthritis, and presence of other major medical conditions was done by analysis of covariance. Further analyses of previously reported associations of regular vigorous physical activity with decreased disability and mortality after 9 years were performed.

RESULTS

The degree of musculoskeletal pain was slightly lower in the exercise group compared with controls, and the difference was statistically significant for women but not for men. Average adjusted pain scores for men were 18.3 (SEM 0.8) in runners' club members, 20.2 (1.2) in controls, 18.6 (0.8) in ever-runners, and 20.3 (1.6) in never-runners. For women, these scores were 17.5 (1.8) in runners' club members versus 22.8 (1.4) in controls (P < 0.05), and 17.2 in ever runners versus 23.7 (1.5) in never-runners (P < 0.002). Disability had continued to develop in runners' club members at a rate only one-third that in the controls after 9 years of observation. Mortality over 9 years consisted of 51 deaths, of which 41 were in the control group and only 10 were among runners' club members.

CONCLUSION

Vigorous running activity over many years is not associated with an increase in musculoskeletal pain with age, and there may be a moderate decrease in pain, particularly in women. Vigorous physical activity is associated with greatly decreased levels of disability and with decreased mortality rates.

The CARDIA dietary history: development, implementation, and evaluation

To meet the objectives for dietary assessment in the Coronary Artery Risk Development in Young Adults (CARDIA) prospective study, we developed a dietary history to provide accurate and reliable quantitative data on habitual individual nutrient intakes at baseline. The CARDIA dietary history was an interviewer-administered method that included a short questionnaire regarding general dietary practices followed by a comprehensive food frequency questionnaire about typical intake of foods using the previous month as a reference for recall. For each broad category of foods, participants were questioned in detail about specific foods only if they indicated that they consumed foods from that category. Follow-up questions for selected foods concerned serving size, frequency of consumption, and common additions to these foods. Provision was made for reporting foods not found in the food frequency list. The interview took approximately 45 minutes. Cue cards prompted responses and plastic food models assisted in estimating usual amounts consumed. A precoded format standardized coding for reported items and established the detail needed for recall during the interview. Baseline nutrient analyses from the CARDIA dietary history provided estimates that agreed reasonably well with expected caloric intake for body mass index according to the age- and sex-specific Recommended Dietary Allowances, but were higher than those reported from 24-hour recalls for comparable age, sex, and race groups in the second National Health and Nutrition Examination Survey. The CARDIA dietary history is a comprehensive assessment tool that can provide a dietitian with detailed information regarding habitual eating patterns and nutrient intakes among adults.

Viscoelasticity and red blood cell aggregation in patients with coronary heart disease

Viscoelastic parameters were evaluated in 169 consecutive male patients with clinical signs of coronary heart disease. The patients were classified according to the extent of coronary artery stenosis. Levels of blood viscosity, erythrocyte aggregation, and plasma viscosity were elevated in patients with extensive coronary vessel disease. However, the differences between the several groups were not statistically significant. The increase of hemorheologic parameters was mainly due to high hematocrit, fibrinogen, and cholesterol concentrations. There was a significant correlation between plasma fibrinogen values and plasma viscosity levels. Blood viscosity and erythrocyte aggregation can be described by multiple linear regression as a function of the sum of log hematocrit, fibrinogen, cholesterol, and alpha 2-macroglobulin.

Regression analysis of data with correlated errors: an example from the NHLBI twin study

Epidemiologic studies often involve genetically related individuals, spouses, or repeat observations on the same individual. When regression analysis is required in such studies, significant correlation of the residuals may affect the estimates of the standard errors of the regression coefficients. Ordinary least squares may not provide the best (minimum variance) estimates of the regression coefficients. Generalized least squares (weighted least squares) is more appropriate when the covariance matrix of the errors is known or can be estimated with some degree of confidence. Data from a twin study of pulmonary function were analyzed by three different regression techniques and comparisons of the coefficients and standard errors are made to illustrate the potential effects of correlated errors.

[Clinical experiences with a 6% hydroxyethyl starch 40000 solution; metabolic parameters and tolerance]

A 6% hycroxyethyl starch solution with a mean molecular weight of 40 000 and a degree of substitution of 0.5--0.55 was tested under controlled conditions at 79 clinics in West Germany. The following parameters were evaluated: tolerance, circulation effectiveness, influence on serum electrolytes, hemoglobin and hematocrit. A total of 779 patients received either 6% HES 40 000 alone, 6% HES 40 000 and electrolyte solution or 6% HES 40 000 solution and other volume effective plasma substitutes for treatment of hypovolemia. The results show that stable circulation can be achieved in 4 to 6 hours during narcosis as well as in the subsequent phase with a sufficient supply of fluid through 6% HES 40 000 solution. One case of flush and a slight chill were reported as side effects related to the hydroxyethyl starch.