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Summary Introduction One potential COVID-19 treatment, hydroxychloroquine has been the focus of much debate since its first publication by a French research team. To an unusual degree, this debate has extended outside of the medical community into the public sphere. Objective To know if this interest, which conceals the reality of scientific debate, occurred worldwide. Methods Methodological use of the Google-Trends was standardized. We researched the web queries for “hydroxychloroquine” and “chloroquine” and “amoxicillin” and “acetaminophen” as reference. Analysis was detailed by country. The relationship between these queries and the COVID-19 epidemic was supported by analysis of the main “related queries”. Google-Trends provided results on a relative value basis, on a scale from 0 to 100, with a value of 100 indicating the most researched criterion over the study period. Results Web queries for “amoxicillin” never exceeded the value of 1. Searches for “acetaminophen” peaked on March 13 with a value of 13. “Hydroxychloroquine” was the most frequently researched term. It reached its peak value of 99 on April 7. Queries for “chloroquine” peaked (value 100) on March 24. Searches for “hydroxychloroquine” came essentially from Asia and the United States, with France in 22nd position (value of 21). Searches for “chloroquine” came essentially from Africa, with France in 8th position (value of 55). The five main related searches were in both cases associated with the COVID-19 epidemic. Conclusion Interest in chloroquine is not specific to France. Results of ongoing studies have been and will be scrutinized attentively in all corners of the globe.

Resume Introduction Les complications metaboliques aigues, et tout particulierement l’hypoglycemie, constituent un motif frequent de recours aux systemes de soins d’urgence du patient diabetique insulino-traite. Ces complications peuvent etre prevenues ou traitees a domicile au prix d’une education adequate du patient diabetique et de son entourage. Objectif Etudier l’education des patients diabetiques insulino-traites et de leurs proches, en dehors de l’hopital. Methodes Nous avons conduit trois etudes successives aupres de patients diabetiques insulino-traites et de leurs proches. Ces patients etaient pris en charge en pre-hospitalier. Nous avons considere que le minimum pour les patients etait de savoir doser la glycemie capillaire, et pour leurs proches de connaitre les signes d’hypoglycemie et de savoir utiliser le glucagon. Resultats La premiere etude, monocentrique, a montre que 54% des proches des patients diabetiques, citaient spontanement la presence de sueurs comme signe d’hypoglycemie, 33% la survenue d’un malaise, et 25% de troubles de conscience ; 9% declaraient savoir utiliser le glucagon. Dans une seconde etude, nationale, multicentrique (561 patients diabetiques insulino-traites et 736 membres de leur entourage), 74% des patients et 59% des membres de leur entourage declaraient savoir realiser une glycemie capillaire. Les membres de l’entourage citaient spontanement deux (0-1) signes d’hypoglycemie ; 39% n’en citaient aucun ; 22% declaraient savoir utiliser le glucagon. Les principaux facteurs associes a l’education des patients (analyse multivariee) etaient le fait d’etre suivi par un diabetologue (odds ratio, OR = 3,20 [intervalles de confiance a 95%, IC 95% : 2,04-5,18]) ou une infirmiere (OR = 0,18 [IC 95% : 0,11-0,30]) ; et pour les proches, que le Francais soit la langue natale du patient ou de l’entourage (OR = 2,17 [IC 95% : 1,53-3,09] et OR = 2,55 [IC 95% : 1,51-4,31], respectivement). Enfin, le suivi d’un sous-groupe de 30 patients nous a permis de constater que ce n’etait pas l’ignorance de la gravite du diabete ou de l’hypoglycemie qui expliquait cette education insuffisante. En effet, 80% des patients consideraient que le diabete, et 100% que l’hypoglycemie, etaient graves ou tres graves. Discussion Les urgentistes souhaitaient attirer l’attention des medecins prenant en charge les patients diabetiques sur la necessaire education, du patient et de son entourage, en particulier vis-a-vis des urgences, dont l’hypoglycemie. Ce travail montre qu’une prise en charge par un diabetologue ameliore leur education, ce qui doit conduire a limiter le nombre et la gravite des complications urgentes.

To evaluate the prevalence of advance directives and their impact on the management of out-of-hospital cardiac arrest (OHCA) victims.We analyzed data extracted from the French national registry of adult OHCA patients (RéAC). The data concerned the emergency medical services (EMS) of a Paris suburb over the period 01/01/2013 to 30/11/2015. The primary endpoint was the prevalence of advance directives. Secondary endpoints were the characteristics of the population, of cardiac arrest, and of basic life support as well as outcomes in patients with or without advance directives.Advance directives were available for 148/1985 (7.5%) of OHCA patients. Advanced life support was given to 35 patients with directives and 941 patients without (24% vs. 51%, p0.0001) with no significant difference in the characteristics of the support provided. Spontaneous recovery of cardiac activity was observed in 5 patients with directives and in 217 patients without (14% vs. 23%, p=0.3). Among patients with advance directives, only one was admitted to hospital. He/she died within 24h of admission.Advance directives were accessed by EMS for 7.5% OHCA patients. Despite their availability, advanced life support was provided to 24% of patients.

INTRODUCTION Out-of-hospital cardiac arrest (OHCA) is a major public health challenge. Use of automated external defibrillators (AED) by laypersons improves survival of patient's victim of OHCA. The aim of our study was to compare onsite AED vs. dispatched AED management of cardiac arrest occurring in international airports. METHODS We conducted a retrospective, observational, comparative, study on data collected from three international airports: Paris-Charles-de-Gaulle (CDG), Chicago and Madrid-Barajas. We included patients with OHCA occurring inside the airport between 2009 and 2013. Group public access (PUB) included airports where AED were available to laypersons and group dispatched (SEC) was represented by Paris-CDG airport where AED was provided by paramedic teams. The primary endpoint was successful resuscitation defined as survival at time of hospital admission. RESULTS We included 150 consecutive patients victim of OHCA in the three airports. The time between collapse and AED setting was significantly shorter in the PUB vs. SEC group (4±3minutes vs. 11±11, P=0.0006). The total duration of resuscitation was shorter in the PUB group (10±10minutes vs. 36±25minutes, P

In medicina d’urgenza, il dolore acuto e una realta che riguarda la maggior parte dei pazienti. E accertato che la sua gestione sia una situazione d’urgenza a causa dei suoi effetti potenzialmente nocivi. Questa gestione deve essere individualizzata, vale a dire adattata al dolore, al paziente e alla patologia causale. La valutazione del dolore e la misurazione della sua intensita sono fondamentali per una buona gestione, ma queste devono essere adattate ad ogni paziente. La gestione del dolore si basa sulla multimodalita, utilizzando mezzi farmacologici e non farmacologici e, soprattutto, una collaborazione e un atteggiamento empatico del caregiver. La morfina e un analgesico importante il cui uso potrebbe essere piu esteso attraverso specifiche procedure e la corretta formazione dei caregiver. Inoltre, devono essere anticipati i dolori provocati da procedure e interventi. Alcune procedure richiedono una vera e propria sedazione, che deve essere perfettamente padroneggiata dalle equipe di operatori sanitari per limitare il rischio di effetti collaterali.

Resume Introduction Plus de 60 000 pacemakers sont implantes chaque annee en France. Ce nombre est en augmentation reguliere depuis une decennie. Divers incidents peuvent conduire les patients porteurs de pacemaker ou leurs proches a contacter les services d’urgence. A la suite de l’appel au Samu-Centre 15 d’une patiente de 90 ans, asymptomatique, mais dont le pacemaker faisait « tic-tac », nous avons evalue la connaissance des medecins participant a la permanence de soins Samu-Centre 15 sur l’existence d’alarmes sonores de pacemakers. Methodes Quarante-deux medecins, urgentistes et generalistes, participant regulierement a la regulation medicale et a la permanence de soins du Samu-Centre 15 de Seine-Seine-Denis ont ete interroges. Nous leur avons demande comment un patient porteur d’un pacemaker pouvait etre informe d’un dysfonctionnement de celui-ci sans etre symptomatique. Resultats Aucun medecin interroge n’a evoque une alarme sonore. Tous ont confirme en ignorer l’existence. Un medecin avait deja ete sollicite pour un motif analogue et avait oriente le patient vers le service des urgences sans savoir qu’il s’agissait d’une alarme. Conclusion Patients et medecins semblent insuffisamment informes de l’existence d’une alarme sonore dans les pacemakers. Un effort doit etre fait pour que l’existence d’une telle alarme et la conduite a tenir lors de son declenchement soit connues des patients et des medecins amenes a les prendre en charge.

Introduction: Hanging-induced Out-of-Hospital cardiac arrest (OHCA) is poorly studied and a better understanding of these specific OHCA could be helpful to improve patients’ outcome. The main objective of our study was to describe characteristics and outcomes in patients who had OHCA from hanging injuries. Methods: From May 2011 to December 2017 we analyzed a prospectively collected Utstein database for all OHCA adults. All cases due to hanging were included. Utstein style variables were compared for 2 groups of patients: those with a Return of Spontaneous Circulation (ROSC) and those without (non-ROSC). Continuous data are described as means (extremes). Results: Among 25 055 OHCA, 500 patients were included. They were 49 (18-100) years old. Seventy-three (14.6%) hanging were witnessed and 58 (11.6%) benefited from a bystander cardiopulmonary resuscitation before Emergency Medical Service (EMS) arrival. No-flow duration was 29.1 (4-180) minutes. Advance life support was initiated by EMS in 299 (59.8%) cases. Low-flow duration was 23.8 (2-79) minutes. Nine patients (1.8%) had a shockable initial rhythm. We observed 83 (16.6%) ROSC. Four (0.8%) patients were discharged alive from hospital. They were all CPC 1. Table 1 compares characteristics with significant differences between ROSC and non-ROSC groups. Conclusion: As expected, younger age, short no-flow and low-flow durations and shockable rhythm on EMS arrival were significantly associated with ROSC. Overall prognosis is dramatically poor when OHCA is due to hanging (

International audience; INTRODUCTION:Obesity and overweight strongly contribute to increasing cardiovascular morbidity and mortality, and are becoming a worldwide health issue. The prevalence of obesity has increased dramatically in Latin America. Child obesity is a major issue. Fast food is strongly suspected of contributing to this epidemic of obesity, although there is a lack of evidence.METHODS:We studied the correlation between the number of McDonald restaurants and overweight and obesity prevalence by region stratified by gender and age. Data on prevalences were obtained within national studies conducted by the Brazilian Ministry of Health. Three age sub-groups were analyzed: 5 to 9-year-olds, 10 to 19-year-olds and over 19-year-olds.RESULTS:There was a very strong positive correlation between overweight rates and the number of McDonald restaurants for both males and females between 5 and 9 years old (R2 respectively = 0.92 and 0.84) and a strong positive correlation for females between 10 and 19 years old (R2 = 0.68). There was a very strong positive correlation between obesity rates and the number of McDonald restaurants for males between 5 and 9 years old (R2 = 0.95). This positive correlation was strong for both males and females between 10 and 19 years old (R2 respectively = 0.77 and 0.63). Other correlations were not significant.CONCLUSION:A strong correlation between the prevalence of overweight and obesity and the number of McDonald restaurants was found for Brazilian children and was most important within the group of youngest children. These results should be taken into consideration by education and prevention campaigns.

Resume Introduction Les directives academiques incitent les etablissements scolaires (ES) a appeler d’emblee le SAMU pour tout enfant malade ou accidente. Le nombre de ces appels nous a semble en augmentation. L’objectif etait d’etudier l’evolution des appels emanant des etablissements scolaires et de les caracteriser. Methodes Les appels emanant d’ES sont systematiquement identifies a la prise d’appel au SAMU 93. Tous les appels pour des patients de moins de vingt ans ont ete analyses, du 03/01/2011 au 27/01/2016. Date, âge, sexe du patient, motif de recours, decision medicale, orientation et devenir du patient (en cas d’envoi d’une equipe SMUR) etaient releves. Resultats Au total, 12 379 (1,5 %) dossiers de regulation medicale emanaient d’ES, dont 10 656 pour des patients de moins de 20 ans qui ont ete analyses : 5703 (54 %) garcons et 4881 (46 %) filles, d’âge median 12 (8–15) ans. Le nombre d’appels a significativement augmente avec le temps : medianes (IQ) de 155 (115–220) versus 208 (172–236) respectivement pour le premier et le dernier trimestre de la periode etudiee soit une augmentation de 34 % en cinq ans. Le motif de l’appel etait traumatologique pour 5397 (51 %) des appels. Les decisions prises en regulation etaient l’envoi d’un premier secours (n = 3486 ; 34 %), d’une ambulance (n = 3634 ; 36 %) cas et un conseil medical telephonique (n = 1987 ; 20 %) ; un SMUR a ete envoye 471 (5 %) fois et le transport a ete medicalise 129 (1 %) fois. Finalement, 11 patients ont ete admis en reanimation soit une admission pour 969 appels. Conclusion Les appels emanant d’ES augmentaient. L’envoi d’un SMUR etait rare et la medicalisation exceptionnelle. La strategie de gestion de ces nombreux appels reste a codifier.

International audience; Objective: Hereditary angiœdema (HAE) is a rare autosomal dominant disease characterized by recurrent, unpredictable, potentially life-threatening swelling. Objective is to assess the management of the acute HAE attacks in the real life setting through a call center in France.Methods: A pre-specified ancillary study of SOS-HAE, a cluster-randomized prospective multicenter trial, was conducted. HAE patients were recruited from 8 participating reference centers. The outcome of interest was the rate of hospitalization.Results: onerhundred patients were included. The median (quartile) age was 38 (29-53) years, and 66 (66%) were female. Eighty (80%) patients had HAE type I, 8 (8%) had HAE type II and 12 (12%) patients had FXII-HAE. Fifty-one (51%) patients had experienced at least one time the call center during the follow-up. Nine over 166 (5%) attacks for 9 different patients resulted in hospital admission to the hospital (in the short-stay unit, ie

BACKGROUND Out-of-hospital cardiac arrest (OHCA) is an important public health problem. The French organization, combining OHCA basic life support (BLS) and advanced life support (ALS), has been recently questioned. The study was conducted to evaluate the association between early ALS (E-ALS) arrival and good neurological outcome at 1 month in nontraumatic OHCA patients. MATERIALS AND METHODS Retrospective cohort study using data from ReAC, multicentre OHCA database since June 2011. Adult patients with nontraumatic cardiac arrest were identified, and firefighters' (BLS) arrival time was recorded. The main analysis was performed after multiple imputation, using propensity score matching with a variable ratio. Sensitivity analyses were also performed. The exposure was early ALS (E-ALS), start of ALS before. or simultaneously with BLS. The primary outcome was the cerebral performance category (CPC) at day 30 after the cardiac arrest (1-2 vs 3-5), while cumulative incidence of return of spontaneous circulation (ROSC) defined secondary outcomes. RESULTS Between January 2013 and January 2016, a total of 30 672 adult nontraumatic OHCA with resuscitation were identified, from whom 20 804 were included, 2711 in the E-ALS group and 18 093 in the control group. Based on the matched sample, patients in the E-ALS group had a significantly lower rate of good neurological outcome than those in the control group (OR, 0.95; 95% CI, 0.93-0.96). Sensitivity analyses were mostly consistent with this result. Cumulative incidence of ROSC was higher in delayed ALS (D-ALS) group. CONCLUSIONS This study showed that patients in the E-ALS group were less likely to have a good neurological outcome. One explanation of this unexpected result could be the total duration of resuscitation performed, which may be interrupted prematurely in cases of E-ALS.

Resume Introduction La conference des Nations Unies pour les changements climatiques (COP21) a reuni en France des delegations venues du monde entier, avec chaque jour 20 000 delegues de 195 pays dont 150 chefs d’etat lors des 48 premieres heures. Un dispositif medical specifique a ete organise dans un contexte particulier « post-attentats » et avec des contraintes fortes dues a la creation d’une zone sous l’unique autorite de l’ONU (zone bleue). Objectif Dresser le bilan des moyens medicaux engages et des soins dispenses. Methodes Dispositif medical gere par le Samu 93 en collaboration avec le Samu zonal et l’Agence regionale de sante (ARS) pour tout le site dont la zone bleue. Criteres de jugement : effectifs engages, nombre de consultations, d’evacuations dont evacuations medicalisees. Resultats En « zone France » (poste de commandement operationnel) : un medecin regulateur et un assistant pendant 20 jours. En « zone bleue » : 20 secouristes, une equipe medicale (Smur) H24 et deux medecins urgentistes (consultations) 12/24 heures pendant 16 jours. Au total, 47 medecins, 25 infirmiers, 25 ambulanciers Smur, 20 assistants ont participe au dispositif medical. Ceci correspondait a trois equivalents temps plein (ETP) medical d’urgentiste pendant 16 jours. Consultations realisees : 1238 soit 97/j resultant en 34 (3 %) evacuations dont sept medicalisees. Les patients etaient 706 (57 %) hommes et 495 (43 %) femmes, d’âge moyen 43 ± 1 an. La traumatologie predominait (20 %). Conclusion Les moyens medicaux engages etaient consequents pendant 16 jours. L’activite medicale etait soutenue, mais une evacuation medicalisee rarement requise.

In out-of-hospital cardiac arrest (OHCA), geographic disparities in outcomes may reflect baseline variations in patients' characteristics but may also result from differences in the number of ambulances providing basic life support (BLS) and advanced life support (ALS). We aimed at assessing the association between allocated ambulance resources and outcomes in OHCA patients in a large urban community.From May 2011 to January 2016, we analyzed a prospectively collected Utstein database for all OHCA adults. Cases were geocoded according to 19 neighborhoods and the number of BLS (firefighters performing cardiopulmonary resuscitation and applying automated external defibrillator) and ALS ambulances (medicalized team providing advanced care such as drugs and endotracheal intubation) was collected. We assessed the respective associations of Utstein parameters, socioeconomic characteristics, and ambulance resources of these neighborhoods using a mixed-effect model with successful return of spontaneous circulation as the primary end point and survival at hospital discharge as a secondary end point.During the study period, 8754 nontraumatic OHCA occurred in the Greater Paris area. Overall return of spontaneous circulation rate was 3675 of 8754 (41.9%) and survival rate at hospital discharge was 788 of 8754 (9%), ranging from 33% to 51.1% and from 4.4% to 14.5% respectively, according to neighborhoods ( P0.001). Patient and socio-demographic characteristics significantly differed between neighborhoods ( P for trend0.001). After adjustment, a higher density of ambulances was associated with successful return of spontaneous circulation (respectively adjusted odds-ratio [aOR], 1.31 [1.14-1.51]; P0.001 for ALS ambulances1.5 per neighborhood and aOR, 1.21 [1.04-1.41]; P=0.01 for BLS ambulances4 per neighborhood). Regarding survival at discharge, only the number of ALS ambulances1.5 per neighborhood was significant (aOR, 1.30 [1.06-1.59] P=0.01).In this large urban population-based study of out-of-hospital cardiac arrests patients, we observed that allocated resources of emergency medical service are associated with outcome, suggesting that improving healthcare organization may attenuate disparities in prognosis.

Notre objectif etait d’optimiser la prise en charge des AE bradykiniques en urgence pour aboutir a une diminution de la morbi-mortalite mais aussi de l’impact socio-economique accompagnant cette pathologie. Notre travail a permis de montrer que l’atteinte des voies aeriennes superieures au cours des crises aigues d’AE bradykiniques etait associee a une hospitalisation en reanimation. L’oedeme larynge et la macroglossie etaient plus frequents chez les patients presentant un AE secondaire aux IEC que dans les formes hereditaires ou les crises douloureuses abdominales sont plus frequentes. L’auto-administration a domicile d’icatibant pourrait eviter l’hospitalisation des patients presentant une crises aigue d’AEH. Nous avons montre que l’atteinte laryngee et le caractere progressif de l’oedeme etaient des facteurs de risque d’hospitalisation lors des crises d’AE secondaire aux IEC. Enfin, notre travail pourrait permettre de proposer une nouvelle strategie de prise en charge des patients atteints d’AEH avec le recours a un centre d’appels unique lors de leurs crises aigues. L’ensemble des facteurs identifies dans ce travail doit etre pris en compte pour ameliorer les pratiques des urgentistes lors de la prise en charge en urgence des patients atteints d’AE bradykinique.

Background Intubation and extubation of ventilated patients are not risk-free procedures in the intensive care unit (ICU) and can be associated with morbidity and mortality. Intubation in the ICU is frequently required in emergency situations for patients with an unstable cardiovascular or respiratory system. Under these circumstances, it is a high-risk procedure with life-threatening complications (20–50%). Moreover, technical problems can also give rise to complications and several new techniques, such as videolaryngoscopy, have been developed recently. Another risk period is extubation, which fails in approximately 10% of cases and is associated with a poor prognosis. A better understanding of the cause of failure is essential to improve success procedure. Results and conclusion In constructing these guidelines, the SFAR/SRLF experts have made use of new data on intubation and extubation in the ICU from the last decade to update existing procedures, incorporate more recent advances and propose algorithms.

Out-of-hospital cardiac arrest (OHCA) is considered an important public health issue but its incidence has not been examined in France. The aim of this study is to define the incidence of OHCA in France and to compare this to other neighbouring countries. Data were extracted from the French OHCA registry. Only exhaustive centres during the period from January 1, 2013, to September 30, 2014 were included. All patients were included, regardless of their age and cause of OHCA. The participating centres covered about 10% of the French population. The study involved 6918 OHCA. The median age was 68 years, with 63% of males. Paediatric population (< 15 years) represented 1.8%. The global incidence of OHCA was 61.5 per 100,000 inhabitants per year in the total population corresponding to approximately 46,000 OHCA per year. In the adult population, we found an incidence of 75.3 cases per 100,000 inhabitants per year. In adults, the incidences were 100.3 and 52.7 in males and females, respectively. Most (75%) OHCA occurred at home and were due to medical causes (88%). Half of medical OHCA had cardiovascular causes. Survival rates at 30 days was 4.9% [4.4; 5.4] and increased to 10.4% [9.1; 11.7] when resuscitation was immediately performed by bystander at patient's collapse. The incidence and survival at 30 days of OHCA in France appeared similar to that reported in other European countries. Compared to other causes of deaths in France, OHCA is one of the most frequent causes, regardless of the initial pathology.

International audience; STUDY OBJECTIVE: Hereditary angioedema is a rare disease associated with unpredictable, recurrent attacks of potentially life-threatening edema. Management of severe attacks is currently suboptimal because emergency medical teams are often unaware of new specific treatments. The objective of this trial is to test whether a dedicated national telephone care-management strategy would reduce resource use during severe hereditary angioedema attacks.METHODS: We conducted a cluster-randomized multicenter prospective trial of patients with a documented diagnosis of hereditary angioedema (type I, II or FXII hereditary angioedema). Participants were enrolled between March 2013 and June 2014 at 8 participating reference centers. The randomized units were the reference centers (clusters). Patients in the intervention arm were given a national free telephone number to call in the event of a severe attack. Emergency physicians in the SOS-hereditary angiœdema (SOS-HAE) call center were trained to advise or prescribe specific treatments. The primary outcome was number of admissions for angioedema attacks. Economic evaluation was also performed.RESULTS: We included 100 patients in the SOS-HAE group and 100 in the control group. During the 2 years, there were 2,368 hereditary angioedema attacks among 169 patients (85%). Mean number of hospital admissions per patient in the 2-year period was significantly greater in the usual-practice group (mean 0.16 [range 0 to 2] versus 0.03 [range 0 to 1]); patient risk difference was significant: -0.13 (95% confidence interval -0.22 to -0.04; P=.02). Probabilistic sensitivity graphic analysis indicated a trend toward increased quality-adjusted life-years in the SOS-HAE group.CONCLUSION: A national dedicated call center for management of severe hereditary angioedema attacks is associated with a decrease in hospital admissions and may be cost-effective if facilities and staff are available to deliver the intervention alongside existing services.

Introduction : La recherche medicale obeit a un cadre reglementaire dont fait partie la soumission au Comite de protection des personnes (CPP). Cela a recemment conduit la Societe francaise de medecine d’urgence (SFMU) a rechercher cette information lors de la soumission d’un resume de communication pour le congres annuel de la SFMU : « Urgences ». L’objectif etait d’evaluer la reponse des auteurs de resumes soumis a la SFMU a la question sur le CPP. Methodes : L’ensemble des resumes soumis a Urgences 2014 a ete lu par un investigateur en aveugle des objectifs de l’etude. En cas de doute, le resume etait relu par deux autres investigateurs. Les informations recueillies etaient les caracteristiques de l’etude (retrospective ou prospective, randomisee, interventionnelle, multicentrique) et la soumission a l’avis du CPP (oui, non ou non applicable). Le critere de jugement etait la reponse adaptee a la demande au CPP, consideree indispensable pour les etudes interventionnelles avec ou sans randomisation, conseillee pour toutes les etudes prospectives et possible dans les autres cas. Resultats : Six cent quatre-vingt-quinze soumissions ont ete revues, dont 159 (23 %) resumaient une etude multicentrique. L’avis du CPP etait obtenu pour 105 (15 %) resumes et considere comme « non applicable » pour 528 (76 %). Les auteurs consideraient l’avis du CPP comme « non applicable » pour 13 (59 %) etudes randomisees, 120 (68 %) etudes interventionnelles et dans 277 (72 %) etudes prospectives. Conclusion : L’avis du CPP etait rarement demande, meme pour des etudes randomisees. Cette sous-declaration est a haut risque juridique pour les structures de recherche. Un rappel du cadre reglementaire et une surveillance accrue par la SFMU semblent necessaires.

Introduction Proposition of assistance and alarm for elderly and dependent people are increasing. Calls from these companies have become numerous in emergencydispatching center (SAMU). The purpose of this study was to characterize these calls.

Background Acute attacks of hereditary angioedema are characterized by recurrent localized edema. These attacks can be life threatening and are associated with substantial morbidity and mortality. Objective To determine factors associated with hospital admission of patients with an acute attack of hereditary angioedema presenting at the emergency department. Methods This was a multicenter prospective observational study of consecutive patients (January 2011 through December 2013) experiencing an acute hereditary angioedema attack and presenting at the emergency department at 1 of 4 French reference centers for bradykinin-mediated angioedema. Attacks requiring hospital admission were compared with those not requiring admission. Results Of 57 attacks in 29 patients, 17 (30%) led to hospital admission. In multivariate analysis, laryngeal and facial involvements were associated with hospital admission (odds ratio 18.6, 95% confidence interval 3.9–88; odds ratio 7.7, 95% confidence interval 1.4–43.4, respectively). Self-injection of icatibant at home was associated with non-admission (odds ratio 0.06, 95% confidence interval 0.01–0.61). The course was favorable in all 57 cases. No upper airway management was required. Conclusion Most patients attended the emergency department because they were running out of medication and did not know that emergency treatment could be self-administered. Risk factors associated with hospital admission were laryngeal and facial involvement, whereas self-injection of icatibant was associated with a return home.

En France, la regulation medicale est une etape fondamentale dans la gestion des urgences prehospitalieres. Il existe tres peu de donnees concernant son enseignement durant le cursus universitaire. L’objectif de ce travail etait de realiser un etat des lieux de l’enseignement a la regulation medicale au cours du Diplome d’Etudes Specialisees Complementaires de Medecine d’Urgence d’Ile-de-France (DESC-MU IDF) a la recherche d’eventuelles carences et de pistes d’amelioration pour cette formation. Il s’agit d’une etude observationnelle, prospective, declarative, realisee entre mars et avril 2014, a partir d’un questionnaire s’adressant aux medecins titulaires du DESC-MU IDF des promotions 2012 et 2013. Les questionnaires ont ete envoyes a 177 medecins. Sur les soixante-sept medecins participants (38 %), neuf (13 % [IC95 %:7–24]) ont recu une formation theorique et pratique a la regulation medicale. Soixante-douze pour cent estiment avoir ressenti des carences de formation au cours de leurs premieres regulations en tant que medecin senior. Plus de neuf medecins sur dix recommandent une formation theorique et pratique de la regulation medicale. Ce travail met en evidence les carences existantes dans la formation a la regulation medicale au cours de la formation du DESC-MU IDF. Ces resultats doivent faire discuter l’enseignement au niveau de chaque site de stage ainsi qu’au niveau regional, tant sur le plan theorique que pratique.

Background The optimal therapeutic strategy for patients with high-risk acute coronary syndrome without ST-segment elevation (NSTE-ACS) remains unclear. Objective Our aim was to compare the effectiveness of an early invasive strategy and a delayed invasive strategy in the management of high-risk NSTE-ACS patients. Methods This randomized clinical trial in a primarily pre-hospital setting enrolled patients with chest pain, electrocardiographic criteria for an NSTE-ACS, and at least one criterion of severity (ESC criterion or TIMI score >5). Patients were randomized to either an early invasive strategy (tirofiban infusion and coronary angiography within 6h) or delayed invasive strategy (as per guidelines and physician discretion; coronary angiography within 6h was not advised). The primary endpoint was the cumulative incidence of deaths, myocardial infarctions, or urgent revascularizations at 30days of follow-up. Secondary endpoints were failure of delayed management, length of hospital stay and long-term mortality. Results Between January 2007 and February 2010, 170 patients were enrolled. The cumulative incidence of adverse outcomes was significantly lower for early invasive than delayed management (2% [95% CI 0–9] vs. 24% [95% CI 16–35], p −4 ). Delayed management failed in 24% of cases. The length of hospital stay was significantly shorter in patients undergoing angioplasty or treated with tirofiban within 6h (p=0.0003). Long-term mortality was 16% in both arms after a median follow-up of 4.1years. Conclusion An early invasive strategy reduced major adverse cardiac events in patients with high-risk NSTE-ACS. Early angiography or tirofiban (GP IIb/IIIa inhibitor) infusion proved necessary in a quarter of patients assigned to delayed management.

Objective To evaluate the long-term prognostic effect of resting heart rate (HR) at index myocardial infarction (MI) and during the first year after MI among 1-year survivors. Patients and Methods The community-based cohort consisted of 1571 patients hospitalized with an incident MI from January 1, 1983, through December 31, 2007, in Olmsted County, Minnesota, who were in sinus rhythm at index MI and had HR measurements on electrocardiography at index and during the first year after MI. Outcomes were all-cause and cardiovascular deaths. Results During a median follow-up of 7.0 years, 627 deaths and 311 cardiovascular deaths occurred. Using patients with HRs of 60/min or less as the referent, this study found that long-term all-cause mortality risk increased progressively with increasing HR at index (hazard ratio, 1.62; 95% CI, 1.25-2.09) and even more with increasing HR during the first year after MI (hazard ratio, 2.16; 95% CI, 1.64-2.84) for patients with HRs greater than 90/min, adjusting for clinical characteristics and β-blocker use. Similar results were observed for cardiovascular mortality (adjusted hazard ratio, 1.66; 95% CI, 1.14-2.42; and adjusted hazard ratio, 1.93; 95% CI, 1.27-2.94; for HR at index and within 1 year after MI, respectively). Conclusion These data from a large MI community cohort indicate that HR is a strong predictor of long-term all-cause and cardiovascular mortality not only at initial presentation of MI but also during the first year of follow-up.

RATIONALE, AIMS AND OBJECTIVES Care quality is a primary concern in health field. In France, the care practice report card (CPRC) is compulsory for practitioners. It is the first step towards the culture of excellence. In this context, practitioners have to assess and improve their practices. Competent authorities define registries as reliable sources for CPRC. The first aim of this work is to describe how we designed and built a universally transposable CPRC model based on an Utstein-style cardiac arrest registry. The second aim is to measure the adherence of practitioners to this approach and to show how such a tool can be used in real situation. METHODS Our report card is adapted from in-hospital CA care quality and safety indicators. We built a 2-section grid. The first part described the quality and completeness of the analysed data. The second part distinguished medical and traumatic CA and assesses care practices. We analysed the practitioners' adherence thanks to a satisfaction survey. Finally, we presented a CPRC case study. RESULTS This tool was tested in 92 centres gathering 8433 patients. The satisfaction survey showed that this CPRC was well accepted by emergency professionals. We presented an implementation example of this tool in a centre in real-life situation. CONCLUSIONS We designed and implemented a fully automated CPRC tool routinely usable for Utstein-style CA registries. This CPRC is easily transferable in all other Utstein CA registries. The debriefing report source codes are freely distributed upon request. This tool enables the care assessment and improvement.

International audience

The atmospheric pollution is a growing public health problem. The highly urbanized regions such as Paris area seem particularly exposed. However, the overall health impact is poorly documented.To investigate the influence of air quality degradation on the demand for primary care.Site: medical dispatching center SAMU 93-Center 15. Related population: 1.6 million inhabitants.daily number of medical regulation records (DRM) and daily air quality index (AQI) using the AirparifThe analysis covered 1134 consecutive days and a total of 639,576 DRM. Average daily DRM number: 564 (507-643). IQA≥4 for 56 (5%) days and≥5 for 4 (0.4%) days. The number of DRM was very closely correlated with the IQA (RDegradation of air quality was significantly correlated with demand for primary care. The environmental alert is also a health alert. The impact was major (DRM +30%) considering all pathologies, all the pollutants on a departmental scale.

Background Hypothermia is common in trauma victims and is associated with increased mortality, however its causes are little known. The objective of this study was to identify the risk factors associated with hypothermia in prehospital management of trauma victims. Methods This was an ancillary analysis of data recorded in the HypoTraum study, a prospective multicenter study conducted by the emergency medical services (EMS) of 8 hospitals in France. Inclusion criteria were: trauma victim, age over 18 years, and victim receiving prehospital care from an EMS team and transported to hospital by the EMS team in a medically equipped mobile intensive care unit. The following data were recorded: victim demographics, circumstances of the trauma, environmental factors, patient presentation, clinical data and time from accident to EMS arrival. Independent risk factors for hypothermia were analyzed in a multivariate logistic regression model. Results A total of 461 trauma patients were included in the study. Road traffic accidents (N = 261; 57%) and falls (N = 65; 14%) were the main causes of trauma. Hypothermia (

To determine the contributing factors in the successful diabetes education of patients and their entourage. Prospective observational study conducted in a pre-hospital setting by 17 emergency services across France (September 2009–January 2011) included all insulin-treated patients (≥18 years) provided that at least one family member was present on scene. Data were collected from patients and their entourage: (1) personal details including language proficiency and educational attainment, (2) treatments, (3) diabetes-related data (log sheets, glucose meter, glucagon, glycated hemoglobin, prior hypoglycemic episodes); (4) care by diabetologist, general practitioner and/or visiting nurse. The main end points were ability to measure capillary blood sugar (patient) and awareness of hypoglycemia symptoms and ability to administer glucagon (entourage). Overall, 561 patients and 736 family members were included; 343 patients (61%) were experiencing a hypoglycemic episode (

As post-cardiac arrest care may influence patients' outcome, characteristics of receiving hospitals should be integrated in the evaluation of survival. We aimed at assessing the influence of care level center on patients' survival at hospital discharge using a regional registry of out-of-hospital cardiac arrest patients (OHCA).We retrospectively analysed a Utstein and in-hospital data prospectively collected for all non-traumatic OHCA patients, in whom a successful return of spontaneous circulation (ROSC) had been obtained, from a large metropolitan area (Great Paris). Receiving hospitals were categorized in 3 groups as follows: A centers (High-case volume with cath-lab 24/7), B centers (Intermediate-case volume with cath-lab partly available) and C centers (Low-case volume and no cath-lab) We compared patients' characteristics and outcome in the 3 groups and performed a multivariate logistic regression using survival to discharge as primary endpoint.Between May 2011 and December 2013, 1476 patients were admitted in 48 hospitals (group A: n=917; group B: n=428; group C: n=91). Overall survival rate at discharge was 433/1436 (30%). Patients' baseline characteristics significantly differed, as hospitals from group A received younger patients with a higher rate of shockable cardiac rhythms (p0.001). Unadjusted survival rate differed significantly among the 3 groups of hospitals (respectively 34%, 25% and 15.4% for A-C, p0.01). In multivariate analysis, the category of receiving hospital was no longer associated with survival, even in the subgroup of witnessed arrest and shockable patients.In this population-based study, characteristics of receiving hospitals are not associated with survival rate at discharge. This might be partially explained by the prehospital triage organization used in France.

Resume La relation entre accidents thromboemboliques et voyages aeriens est clairement etablie. L’incidence des evenements est rare (quelques en cas par millions de voyageurs). Le risque augmente significativement pour les vols de plus de 5000 km. Le role de la classe du voyage, de l’hypoxie, de l’hypobarie et des facteurs de risque thromboemboliques du voyageur ne sont pas connus. Diverses mesures de prophylaxie, parfois contradictoires en l’absence d’etude validee, ont ete proposees. La strategie prophylactique est determinee sur la combinaison de deux categories de risque : le voyage (sa duree) et le patient (et son risque thromboembolique propre). Les mesures prophylactiques comportementales et le port de chaussettes de contention sont volontiers recommandes. Le recours a une prophylaxie pharmacologique doit demeurer exceptionnel et etre discute au cas par cas.

Background: Combination drug therapy is often used to achieve optimal analgesia in surgery. Paracetamol can be used as one component of an analgesic regime following hepatic resection. Objective: This study was designed to investigate paracetamol and its metabolites by proton NMR spectroscopy in patient urine and to assess whether N-acetyl-p-benzoquinone imine (NAPQI, a hepatotoxic metabolite) formation is increased after liver resection. Method: We studied the excretion of acetaminophen and its metabolites by 5 patients who were operated on for partial liver resection by proton NMR spectroscopy. As an intravenous infusion 1 g of paracetamol was given over 15 min every 6 h during 48 h. The first injection was given in the operating theatre after liver resection was completed. Urine samples were collected before injection (T1) and 24 and 48 h after the first injection (T2 and T3); the samples were frozen and kept at -20°C up to the analysis by NMR spectroscopy. Results: Metabolites of the paracetamol were detected for all patients. Among the discerned metabolites, 4 were identified as metabolites of paracetamol: paracetamol glucuronide, paracetamol sulfate, N-acetyl-L-cysteinyl paracetamol (metabolite of NAPQI) and paracetamol. Their ratios, respectively, were: 46-82.9, 12.6-30.0, 0.5-5.5 and 1.43-3.54%. Conclusion: This study showed that there was no increase in the formation of toxic metabolite (NAPQI) after treatment with paracetamol in these few cases of liver resections. A larger study is necessary to confirm these results.

OBJECTIVE We aimed to evaluate the impact of the same-day GPs' strike and terrorist attacks on a call centre's activity. METHODS We compared the number of calls received, the number of patient's medical files (PMFs) created and the number of mobile ICU (MICU) dispatched per hour on Friday, 13 November, to the repository established on the five previous Fridays. As previously published, the variation criterion was set to an activity variation above 20% for more than 2 h. RESULTS On Friday, 13 November, 1745 calls were received compared with 1455 calls, on average, for the five previous Fridays. The number of calls received increased after the terrorist attacks (≤90%) and remained above the threshold for 3 h. The number of PMFs exceeded the threshold from 10:00 a.m. to 05:00 p.m., but was not affected by the attacks. The number of MICUs dispatched exceeded the threshold (>500%) in the first hour after the attacks. CONCLUSION The GPs' strike and the terrorist attacks did not impact our call centre's activity in the same manner. The strike increased the number of PMFs without increasing the number of calls received. The attacks increased the number of calls received and MICU dispatched without increasing the number of PMFs. Many markers are at the disposal of call centres to evaluate the impact of healthcare events.

IntroductionThis study protocol describes a trial designed to investigate whether antihistamine alone in patients with acute urticaria does not increase the 7-day Urticaria Activity Score (UAS7) in comparison with an association of antihistamine and glucocorticoids and reduces short-term relapses and chronic-induced urticaria.Methods and analysisThis is a prospective, double-blind, parallel-group, multicentre non-inferiority randomised controlled trial. Two-hundred and forty patients with acute urticaria admitted to emergency department will be randomised in a 1:1 ratio to receive levocetirizine or an association of levocetirizine and prednisone. Randomisation will be stratified by centre. The primary outcome will be the UAS7 at day 7. The secondary outcomes will encompass recurrence of hives and/or itch at day 7; occurrence of spontaneous hives or itch for >6 weeks; patients with angioedema at day 7, and 2, 6, 12 and 24 weeks; new emergency visits for acute urticaria recurrences at days 7 and 14, and 3 months; Dermatology Life Quality Index at days 7 and 14, and 3 and 6 months; and Chronic Urticaria Quality of Life Questionnaire at 6 weeks.Ethics and disseminationThe protocol has been approved by the Comité de Protection des PersonnesSud-Méditerranée II and will be carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. A steering committee will oversee the progress of the study. Findings will be disseminated through national and international scientific conferences and publication in peer-reviewed journals.Trial registration numberNCT03545464

Introduction Bien qu’une corticotherapie, qui peut reduire la duree et l’activite de la maladie, soit incluse dans le consensus de traitement des patients avec une urticaire aigue, le benefice d’une corticotherapie dans l’urticaire aigue est controverse dans differentes etudes. L’objectif de notre etude etait de determiner les facteurs associes aux rechutes chez les patients avec une urticaire aigue. Patients et methodes Etude retrospective observationnelle incluant tous les patients adultes avec une urticaire aigue entre janvier 2015 et juin 2017. Le critere de jugement principal etait la rechute a 7 jours et le critere de jugement secondaire etait la rechute a 6 semaines. L’urticaire etait spontanee ou induite. Les plaques d’urticaire pouvaient etre associees a un angiœdeme. Les criteres d’exclusion etaient un diagnostic isole d’angiœdeme sans plaques d’urticaire, une anaphylaxie, un angiœdeme bradykinique, l’administration de corticoides dans les 5 jours precedents l’inclusion, l’administration d’antihistaminiques dans les 5 jours precedents l’inclusion, l’utilisation de traitement pour urticaire (omalizumab, montelukast et ciclosporine) et les autres maladies dermatologiques (dermatite atopique, eczema, pemphigoid bulleuse et exantheme). L’urticaire aigue etait definie par la survenue de plaques, d’angiœdeme ou les 2 pour une duree de moins de 6 semaines. L’urticaire chronique etait definie par une duree de plus de 6 semaines. Resultats Un total de 184 patients avec un premier episode d’urticaire aigue etait inclus. Une majorite des patients etait des femmes (66 %) d’âge moyen de 42 ± 16 ans. Un traitement corticoide pour urticaire aigue etait utilise chez 102 (55 %) patients. Un traitement corticoide etait utilise chez 87 des 102 patients qui presentait un angiœdeme (85 %) et chez 12 des 102 qui presentait un oedeme larynge (12 %). Un traitement antihistaminique etait administre chez 167 (91 %) cas sans difference entre les 2 groupes avec ou sans corticoides. Quatre-vingt-cinq (46 %) patients rechutaient dans les 7 jours tandis que 168 (91 %) patients rechutaient apres 6 semaines. En analyse univariee, le taux d’administration de corticoides etait significativement plus eleve dans les rechutes 6 semaines apparaissait. En analyse multivariee, le facteur independamment associe aux rechutes Discussion Dans notre etude de 184 patients avec urticaire aigue, l’utilisation de corticoides etait significativement associee aux rechutes Conclusion La prevalence de l’administration d’une corticotherapie chez les patients avec urticaire aigue est elevee. Cette prevalence est plus elevee chez les patients quand l’angiœdeme etait associe a l’urticaire aigue. Dans notre etude, l’administration de corticoides etait un facteur de risque independant associe aux rechutes

La Presse Medicale - In Press.Proof corrected by the author Available online since samedi 3 janvier 2015

L’attitude de l’equipe soignante vis-a-vis des proches lors d’une reanimation cardiopulmonaire (RCP) reste tres debattue. Les resultats recents de l’essai clinique « PRESENCE » montrent un effet benefique de la proposition a la famille d’assister a la reanimation en termes de stress posttraumatique et de symptomes d’anxiete et de depression. De plus, la presence de la famille ne semble pas avoir d’influence sur la qualite de la reanimation, le stress de l’equipe soignante, ni le nombre de plaintes. Cette etude augmente le niveau de preuve des recommandations internationales sur la prise en charge de l’arret cardiaque qui, depuis 2005, preconisaient d’autoriser la presence des proches lors d’une RCP. Cette strategie doit etre encadree par une procedure bien definie, un soignant accompagnant les proches et une formation prealable des equipes soignantes. Les etudes futures devraient viser a ameliorer notre comprehension des raisons pour lesquelles la presence des membres de la famille pendant la RCP peut reduire leur souffrance et dans quels systemes de sante une telle approche pourrait etre mise en pratique d’une maniere sure et rentable.