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Importance: Clinical guidelines for the early management of acute heart failure in the emergency department (ED) setting are based on only moderate levels of evidence, with subsequent low adherence to these guidelines.Objective: To test the effect of an early guideline-recommended care bundle on short-term prognosis in older patients with acute heart failure in the ED.Design, Setting, and Participants: Stepped-wedge cluster randomized trial in 15 EDs in France of 503 patients 75 years and older with a diagnosis of acute heart failure in the ED from December 2018 to September 2019 and followed up for 30 days until October 2019.Interventions: A care bundle that included early intravenous nitrate boluses; management of precipitating factors, such as acute coronary syndrome, infection, or atrial fibrillation; and moderate dose of intravenous diuretics (n = 200). In the control group, patient care was left to the discretion of the treating emergency physician (n = 303). Each center was randomized to the order in which they switched to the "intervention period." After the initial 4-week control period for all centers, 1 center entered in the intervention period every 2 weeks.Main Outcomes and Measures: The primary end point was the number of days alive and out of hospital at 30 days. Secondary outcomes included 30-day all-cause mortality, 30-day cardiovascular mortality, unscheduled readmission, length of hospital stay, and kidney impairment.Results: Among 503 patients who were randomized (median age, 87 years; 298 [59%] women), 502 were analyzed. In the intervention group, patients received a median (interquartile range) of 27.0 (9-54) mg of intravenous nitrates in the first 4 hours vs 4.0 (2.0-6.0) mg in the control group (adjusted difference, 23.8 [95% CI, 13.5-34.1]). There was a significantly higher percentage of patients in the intervention group treated for their precipitating factors than in the control group (58.8% vs 31.9%; adjusted difference, 31.1% [95% CI, 14.3%-47.9%]). There was no statistically significant difference in the primary end point of the number of days alive and out of hospital at 30 days (median [interquartile range], 19 [0- 24] d in both groups; adjusted difference, -1.9 [95% CI, -6.6 to 2.8]; adjusted ratio, 0.88 [95% CI, 0.64-1.21]). At 30 days, there was no significant difference between the intervention and control groups in mortality (8.0% vs 9.7%; adjusted difference, 4.1% [95% CI, -17.2% to 25.3%]), cardiovascular mortality (5.0% vs 7.4%; adjusted difference, 2.1% [95% CI, -15.5% to 19.8%]), unscheduled readmission (14.3% vs 15.7%; adjusted difference, -1.3% [95% CI, -26.3% to 23.7%]), median length of hospital stay (8 d in both groups; adjusted difference, 2.5 [95% CI, -0.9 to 5.8]), and kidney impairment (1% in both groups).Conclusions and Relevance: Among older patients with acute heart failure, use of a guideline-based comprehensive care bundle in the ED compared with usual care did not result in a statistically significant difference in the number of days alive and out of the hospital at 30 days. Further research is needed to identify effective treatments for acute heart failure in older patients.Trial Registration: ClinicalTrials.gov Identifier: NCT03683212. [ABSTRACT FROM AUTHOR]

A reprint of the article "Feigned Amesia as a Defense Reaction," by George E. Price and William B. Terhune, which appeared in the Februrary 22, 1919 issue is presented. It discusses the tendency of many examiners to classify feigned as amnesia due to hysteria. It cites as an example the examination of soldiers under arrest at the office of the provost marshal of Paris, in which they feign amnesia as a defense reaction to escape punishment.

Offers an article originally published in the July 4, 1903 issue of the 'Journal of the American Medical Association. Dispensary abuse occurring in Paris, France; Effort to curtail the abuse.

The article attempts to determine the current complication rate during exercise performed in the course of cardiac rehabilitation. The study was conducted by the Functional Evaluation and Cardiac Rehabilitation Working Group of the French Society of Cardiology. The article shows that the frequency of major cardiovascular complications during supervised exercise training in France is quite low.

Background Posttraumatic stress disorder (PTSD) has been studied largely among adults and in the context of intentional, collective experiences such as war and terrorism. Far less is known about PTSD among adolescents and resulting from massive industrial accidents. Such an accident in Toulouse, France, 10 days after the World Trade Center disaster, provided an opportunity to examine its effects among adolescents already sensitized by media coverage of the World Trade Center disaster. Objectives (1) To assess the presence of symptoms consistent with PTSD (SCW-PTSD) among adolescents in Toulouse after a massive industrial accident, (2) to determine the “excess” of SCW-PTSD among those directly exposed vs those nondirectly exposed, and (3) to examine dosage effects for exposure and the cumulative effect on PTSD of accident-related experiences. Design, Setting, and Participants A survey containing questions on exposure and SCW-PTSD was administered to students aged 11 years, 13 years, 15 years, and 17 years who were enrolled in randomly selected, grade-stratified classrooms from schools for directly exposed students (n = 577) in Toulouse and nondirectly exposed students (n = 900) in the region. Main Outcome Measure The prevalence of SCW-PTSD among directly exposed and nondirectly exposed students. Results Nine months after the industrial accident, 44.6% of 11- and 13-year-old directly exposed students and 28.5% of 15- and 17-year-old directly exposed students still showed SCW-PTSD, compared with 22.1% of 11- and 13-year-old nondirectly exposed students and 4.4% of 15-year-old nondirectly exposed students. Among 11- and 13-year-olds, the likelihood of having SCW-PTSD was higher for girls who were enrolled in elementary schools, were personally injured, and had severe damage at home, as opposed to boys who were high-school students without severe damage at home or personal injury. Among the 15- and 17-year-olds, being a girl, 17 years old, and personally injured increased the likelihood of having SCW-PTSD, as opposed to 15-year-old boys who were not injured. The effects of injuries were cumulative: students injured personally and with an injured family member were more likely to have SCW-PTSD than those experiencing either personal or family injury but not both. Excess of SCW-PTSD attributable to direct exposure was 50.5% for 11-year-olds, 49.3% for 13-year-olds, and 73.5% for 15-year-olds. Conclusions A substantial proportion of Toulouse adolescents still had SCW-PTSD 9 months after the accident. Directly exposed students were far more likely to show SCW-PTSD than those nondirectly exposed, but both groups had SCW-PTSD at rates that were higher than expected. The symptoms were associated with demographic characteristics and direct experiences of trauma. Higher rates applied to students who were personally injured with injured family members and severe damage at home. Students with these characteristics predictive of SCW-PTSD should be given prompt attention to avoid long-lasting effects. [ABSTRACT FROM AUTHOR]

Describes the contribution of French surgeon and anatomist, Claude Couinaud, in the field of hepatobiliary surgery. Couinaud's historic segmental anatomic description of the liver; Education and career background of Couinaud; His concept of the segmental anatomy of the liver; Application of his concepts to liver surgery.

Forty-three state-run medical schools admit 30000 students per year but only 3500 receive their diploma after 6 years of studies. After passing a special examination, 480 of 2000 residents choose surgery and train during twelve 6-month rotations. Surgical research is organized through government agencies, individual units, or volunteer groups. In 1992, of 8268114 procedures, appendectomy represented 4.15%; hernia, 4.09%; varicose veins, 3.61%; and cholecystectomy, 1.82%. Appendectomy has decreased from 306500 per year in 1980 (34% of all gastrointestinal surgical procedures) to 159900 (15%) in 1996, whereas cholecystectomy has increased from 64700 to 95300. Emergency gastrointestinal procedures represented 15% of all surgical procedures in 1996, doubling in the last 4 years (essentially for labor and endoscopic procedures). Ambulatory procedures have increased 12-fold since 1980, essentially (75%) in private practice. About 27% of 160000 appendectomies and 77% of 95300 cholecystectomies were performed laparoscopically in 1997. One person of 4 in France has or has had cancer, mainly due to tobacco abuse. In 1993, 32000 surgical procedures were performed for gastrointestinal cancer. Of 532000 deaths (1992), about 150000 were due to cancer, 10000 to alcohol-related disease, and 22000 to trauma. Transplantation in France increased from 3180 procedures in 1993 to 2807 in 1996, essentially lungs and heart and lungs. Between 60% and 100% of health expenditures are reimbursed by the government, the remaining being covered by private insurances. Approximately 60% of 4500 French surgeons are in private practice; 25% also have part-time hospital employment. Almost 40% of surgeons work full-time in hospitals. [ABSTRACT FROM AUTHOR]

Focuses on a strike of French physicians against changes in the traditional health care system in that country. Reaction to an attempt by the French state to control physician's fees and limit the number of medical students; Details of the strike of residents in almost all of France's teaching hospitals; Health care financing in France; The system of physician training; The power of the state over health care; Political aspects of the dispute.

The article focuses on the adventure of three spelunkers Jean-Marie Chauvet, Eliette Brunel-Deschamps, and Christian Hillaire at Chauvet Cave in France. It mentions that drawings of a red mammoth elephant, red bear, and a panel of horses were found inside the cave. It says that the cave has been named after the lead explorer Chauvet and the chambers were named after Brunel-Deschamps and Hillaire.

The article discusses glass paperweights, focusing on the art and collection of a type of paperweight utilizing glasswork called "millefiori." The cover features a paperweight made in a glasshouse from Clichy, France, "Pièdouche Paperweight," designed in just such a style. Topics include small cross-sectional slices of glass cane, pressing colored molten glass to form rods, and a complex combination of shapes within shapes. Also discussed is the development of glass paperweights as a popular form in the middle of the 1800's.

Reports on attempts by physicians, mathematicians and philosophers in 18th century Europe to convince a skeptical public that smallpox inoculations were in their best interest. Fear among the public that inoculation would make them ill; Development by Daniel Bernoulli of France's Royal Academy of Science of mathematical formulas showing the benefits provided by universal inoculation; Book by Italian physician Angelo Gatti, which contended that individuals do not view medical risk through the lens of mathematical calculation; Role of the Parisian smallpox epidemic of 1762-1763 in the debate; Decision to inform the public, but allow individuals to make their own decisions on inoculation.

The article provides information on Snowscape With Cows at Montfoucault, one of the several paintings of French Impressionist and Neo-Impressionist painter Camille Pissaro. The painting, which is that of the property of Pissaro's friend Ludovic Piette, is said to demonstrate Pissaro's famous facility with landscape. The art work is also said to reflect Pissarro's metaphor for progress for work, for toil of the peasants and laborers and also serves as compositional devices and applications of the painter's use of color, hue and tone.

The article discusses the painting "Vuillard's Room at the Château des Clayes," circa 1932 by French painter Édouard Vuillard. The painting depicts a room in a mansion restored by the painter's friend Jos Hessel and his wife, Lucie located near Paris, France. It is noted that Vuillard intentionally used incongruities in the painting as he was familiar with the classical techniques of perspective and shading.

The article discusses artist Vincent van Gogh's stay at the asylum of Saint-Paul de Mausole located in Saint-Rémy-de-Provence, France. It cites his productiveness inside the asylum where he completed some of his best works including "Irises," and "The Starry Night." It notes how the asylum provided the support and rehabilitation that made Vincent productive.

The article recalls the story underlying artist Vincent van Gogh's painting "Courtyard of the Hospital at Arles." Vincent was hospitalized in Arles, France under the care of Doctor Félix Rey. He was diagnosed with larvate epilepsy with hallucinations aggravated by absinthe and alcohol abuse and received hydrotherapy. His "Courtyard of the Hospital at Arles" painting features an antique garden with a pond in the middle and flower beds with different flowers such as Christmas roses and ranunculus.

This section presents reprints of articles that appeared in the June 12, 1909 issue. One article reports that the National Model License League utilized a statement made by a physician concerning the link between whiskey consumption and death. Another reports that the birth rate in France was reported to increase in the first six months of 1908. The third notes that Professor Karl Pearson wrote in the May 6, 1909 issue of "Nature" to inquire about medical journals in England.

This article presents a reprint of a feature from the January 4, 1908 issue. The article announces the award of the Nobel Prize in Medicine to Alphonse Laveran who discovered the cause of malaria. The story of Laveran is told for its benefit in understanding how medical discoveries and made and received. Upon his discovery of the cause of the disease many in the medical community refused to accept his findings, especially the Italians who had a researcher who had come up with a different theory. A fellow French scientist confirmed Laveran's findings but it was a year before Italy would change its mind.

An article is reprinted which first appeared in the December 15, 1906 issue of the "Journal of the American Medical Association. " It is a biographical sketch of Theophraste Renaudot, 1584-1653. Renaudot, personal physician to Louis XIII, was the publisher of the "Gazette," the first newspaper in France, which he started in 1631, and also ran one of the first clinics for the sick poor. His unorthodox style won him the enmity of the Paris faculty of medicine, but the patronage of the King and Cardinal Richelieu enabled Renaudot to prosper despite the Parisian faculty's opposition. He was noted for promoting remedies which made use of antimony.

The article comments on "The Little Laundress," by Pierre Bonnard, the cover art of this issue. The painting is one of the lithographs that Bonnard did in the mid-1890s to capture various aspects of humble Parisian life. The article chronicles Bonnard's life and analyzes "The Little Laundress." Bonnard studied painting at the École des Beaux-Arts and the Académie Julian and lived in the Montmartre district of Paris with other artists. The artist walked around Paris with his camera capturing images that he would later transform into paintings.

Presents a reprint of an article appearing in the April 8, 1905 issue of JAMA, "A Queer Surgical Oversight". The topic of surgical instruments left in patients; A report from Paris about a woman who filed a lawsuit when eyeglasses were found in her abdomen; The number of procedures needed to remove the glasses; Uncertainty about who left them there and during which procedure.

Presents historical background to this issue's cover artwork, "Portrait Study" by Théodore Géricault. Painting which was created c.1818-1819; Other controversial works by the artist, most notably "The Raft of the Medusa"; His talent and the political environment of the time in his native France and elsewhere in Europe.

Profiles the late French impressionist artist Edgar Degas. Analysis of his painting 'Dancers,' and the classical composition of it; Impact of his poor eyesight on his paintings and his temperament; View that Degas' paintings of statuettes of dancers were his most appealing works.

Focuses on the French painter Jean-Baptiste-Simeon Chardin. His style; Biographical information; Some of his well-known works.

A talented young scientist, Thomas Harriot, wrote the first English account of the New World, "A Briefe and True Report of the New Found Land of Virginia," distinguished by its serious effort to describe and understand the American Indian. Harriot went on to make innovations in mathematics and was one of the first astronomers to use the telescope. His largely unappreciated contribution to the history of ophthalmology was the first formulation of the sine law of refraction of light, found in his unpublished papers long after his death in 1621. Willebrord Snell discovered the sine law in Holland in 1621 but also died without formally publishing it. Rene Descartes first published the sine law in 1637. The sine law of refraction became not only the prime law of all lens systems but ushered in a new world of physical laws.