Factors associated with delay in seeking healthcare for imported malaria: a retrospective study in a French hospital.

BACKGROUND: Delayed treatment is associated with a higher risk of severe malaria. In malaria-endemic areas, the main factors associated with delay in seeking healthcare are low educational level and traditional beliefs. In imported malaria, determinants of delay in seeking healthcare are currently unknown. METHODS: We studied all patients presenting with malaria, from 1 January 2017 to 14 February 2022, in the hospital of Melun, France. Demographic and medical data were recorded for all patients, and socio-professional data were recorded for a subgroup of hospitalized adults. Relative-risks and 95% confidence intervals were determined using univariate analysis by cross-tabulation. RESULTS: There were 234 patients included, all travelling from Africa. Among them, 218 (93%) were infected with P. falciparum, 77 (33%) had severe malaria, 26 (11%) were <18 years old and 81 were included during the SARS-CoV-2 pandemic. There were 135 hospitalized adults (58% of all patients). The median time to hospital admission (THA) , defined by the period from onset of symptoms to arrival at hospital, was 3 days (IQR = 2-5). A THA ≥3 days tended to be more frequent in travellers visiting friends and relatives (VFR; RR = 1.44, 95% CI = [1.0-2.05], P = 0.06), while it was less frequent in children and teenagers (RR = 0.58, 95% CI = [0.39-0.84], P = 0.01). Gender, African background, unemployment, living alone and absence of referring physician were not associated with delay in seeking healthcare. Consulting during the SARS-CoV-2 pandemic was neither associated with a longer THA nor with a higher rate of severe malaria. CONCLUSION: In contrast to an endemic area, socio-economic factors did not impact on delay in seeking healthcare in imported malaria. Prevention should focus on VFR subjects, who tend to consult later than other travellers.

COVID-19 among nursing home residents: results of an urgent pre-hospital intervention by a multidisciplinary task force

ABSTRACT The current coronavirus disease-2019 (COVID-19) pandemic caused 10,541 deaths among nursing home residents in France, by July 17th, 2020. This study reported the results of an urgent pre-hospital intervention in eight French nursing homes. A retrospective study was conducted from March 26th to May 7th, 2020, before and after the intervention of a task force which took action from April 9th to April 11th, 2020. The task force included nurses and specialists of the county general hospital. The intervention had four steps: i) daily notification of deaths; ii) audit by infectious diseases and hygiene specialists focused on nursing team reinforcing, tracking of suspected cases, patients' cohorting, review of preventive and protective measures, hydration, thromboembolism prevention; iii) intervention of an emergency team which urgently performed procedures suggested; iv) relay with a geriatric team. There were a total of 770 residents distributed in eight facilities with capacity varying from 53 to 145 residents. The number of deaths peaked at 139 in week 2 and the trough at 0 occurred in weeks 6−7. Comparison between periods (before vs after intervention) showed a significant decrease in number of new deaths (83/770; 11% vs 35/687; 5%, p = 0.0001) and new COVID-19 cases (348/770; 45% vs 123/422; 29%, p < 0.001). The urgent pre-hospital intervention by a multidisciplinary task force achieved mortality reduction during COVID-19 outbreak in nursing homes. Pre-hospital intervention is a valid alternative to hospitalization in case of hospital saturation.

COVID-19 among nursing home residents: results of an urgent pre-hospital intervention by a multidisciplinary task force.

The current coronavirus disease-2019 (COVID-19) pandemic caused 10,541 deaths among nursing home residents in France, by July 17th, 2020. This study reported the results of an urgent pre-hospital intervention in eight French nursing homes. A retrospective study was conducted from March 26th to May 7th, 2020, before and after the intervention of a task force which took action from April 9th to April 11th, 2020. The task force included nurses and specialists of the county general hospital. The intervention had four steps: i) daily notification of deaths; ii) audit by infectious diseases and hygiene specialists focused on nursing team reinforcing, tracking of suspected cases, patients' cohorting, review of preventive and protective measures, hydration, thromboembolism prevention; iii) intervention of an emergency team which urgently performed procedures suggested; iv) relay with a geriatric team. There were a total of 770 residents distributed in eight facilities with capacity varying from 53 to 145 residents. The number of deaths peaked at 139 in week 2 and the trough at 0 occurred in weeks 6-7. Comparison between periods (before vs after intervention) showed a significant decrease in number of new deaths (83/770; 11% vs 35/687; 5%, p = 0.0001) and new COVID-19 cases (348/770; 45% vs 123/422; 29%, p < 0.001). The urgent pre-hospital intervention by a multidisciplinary task force achieved mortality reduction during COVID-19 outbreak in nursing homes. Pre-hospital intervention is a valid alternative to hospitalization in case of hospital saturation.

[Emergency medicine and the elderly]. / Médecine d'urgence et personnes âgées.

Over the last twenty years or so, emergency departments have undergone significant changes. They have faced a continual increase in activity of around 2 to 5% per year. Numerous factors are to be taken into account with regard to elderly people, notably their fragility. This is why a full assessment is essential when the patient arrives. Whenever possible, a return home must be favoured.

Management of acute allergic reactions by dispatching physicians in a Medical Emergency Dispatch Centre.

BACKGROUND: Acute allergic reactions often occur in out-of-hospital settings, and some of these reactions may cause death in the short term. However, initial diagnosis, management and processing of acute allergic reactions by Medical Emergency Dispatch Centres are not documented. The aim of the present study was to describe acute allergic reactions and their management by a Medical Emergency Dispatch Centre. METHODS: A prospective study was conducted from 20 August 2006 to 5 November 2006 on incoming calls for acute allergic reactions to the Medical Emergency Dispatch Centre for the Hauts de Seine (Paris West suburb, France). The agreement between initial diagnosis (made by dispatching physician) and final diagnosis (made by the physician who later examined the patient), and between initial and final severity, were evaluated using Cohen's weighted κ coefficient. RESULTS: 210 calls were included. The diagnoses made by the dispatching physician were: in 58.1% of cases urticaria, in 23.8% angioedema, in 13.3% laryngeal oedema, and in 1.9% anaphylactic shock. The agreement between initial and final diagnoses was evaluated by a κ coefficient at 0.44 (95% CI 0.26 to 0.61) and the agreement between initial and final severity was evaluated using a κ coefficient at 0.37 (95% CI 0.24 to 0.50). CONCLUSIONS: Only moderate agreement is highlighted between the initial severity assessed by the dispatching physician and the final severity assessed by the physician later examining the patient. This demonstrates the need to develop a tool for assessing severity of acute allergic reactions for dispatching physicians in Medical Emergency Dispatch Centres.

Evaluation of the ventilator-user interface of 2 new advanced compact transport ventilators.

BACKGROUND: Mechanical ventilation during patient transport frequently utilizes compact portable pneumatic ventilators that have limited ventilator-settings options. New advanced transport ventilators should yield quality improvements, but their user-friendliness needs to be tested. OBJECTIVE: To evaluate the ventilator-user interface of 2 new transport ventilators. METHODS: This was a 2-center descriptive study in which the ventilator-user interfaces of the Oxylog 3000 and Elisée 250 were compared by 20 French senior emergency physicians who were initially unfamiliar with these ventilators. Each physician carried out 15 tasks with each ventilator and then assigned each ventilator a satisfaction score. RESULTS: With the Elisée 250 the task success rate was significantly higher (85.6% vs 66.6% with the Oxylog 3000, p < 0.0001), and the total number of errors was lower (46 vs 113). The main errors were related to inspiratory flow settings with the Oxylog 3000 (31 errors), inspiratory-expiratory ratio settings with the Elisée 250 (11 errors), ventilation mode choice with the Oxylog 3000 (17 errors), trigger sensitivity setting with the Elisée 250 (16 errors) and the Oxylog 3000 (11 errors), and alarm range setting with the Oxylog 3000 (10 errors). The mean satisfaction score was significantly better with the Elisée 250 (81% +/- 7, range 64-92%) than with the Oxylog 3000 (66% +/- 10, range 49-87%) (p < 0.0001). CONCLUSIONS: The Elisée 250 ventilator-user interface was easier to use than that of the Oxylog 3000. The applicability of these results to other types of users will require further studies, but the types of errors found in our study might help future users.

Management of severe acute pain in emergency settings: ketamine reduces morphine consumption.

OBJECTIVE: The aim of the study was to compare in emergency settings 2 analgesic regimens, morphine with ketamine (K group) or morphine with placebo (P group), for severe acute pain in trauma patients. METHODS: This was a prospective, multicenter, randomized, double-blind, clinical trial. Seventy-three trauma patients with a severe acute pain defined as a visual analog scale (VAS) score of at least 60/100 were enrolled. Patients in the K group received 0.2 mg x kg(-1) of intravenous ketamine over 10 minutes, and patients in the P group received isotonic sodium chloride solution. In both groups, patients were given an initial intravenous morphine injection of 0.1 mg x kg(-1), followed by 3 mg every 5 minutes. Efficient analgesia was defined as a VAS score not exceeding 30/100. The primary end points were morphine consumption and VAS at 30 minutes (T30). RESULTS: At T30, morphine consumption was significantly lower in the K group vs the P group, with 0.149 mg x kg(-1) (0.132-0.165) and 0.202 mg x kg(-1) (0.181-0.223), respectively (P < .001). The VAS score at T30 did not differ significantly between the 2 groups, with 34.1 (25.6-42.6) in the K group and 39.5 (32.4-46.6) in the P group (P = not significant). CONCLUSION: Ketamine was able to provide a morphine-sparing effect.

Paradoxical reaction to epinephrine induced by beta-blockers in an anaphylactic shock induced by penicillin.

Increased risk of severe and resistant anaphylactic shock is a rare and not widely known adverse effect of beta-blocker treatment. It is illustrated in a case of refractory anaphylactic shock occurring in a 47-year-old woman who received beta-blockers. Actually, beta-blockers increase the release of anaphylactic mediators, decrease the cardiovascular compensatory changes to the anaphylactic shock and promote paradoxical reflex vagotonic effects when using epinephrine.

Constant flow insufflation of oxygen as the sole mode of ventilation during out-of-hospital cardiac arrest.

BACKGROUND: Constant flow insufflation of oxygen (CFIO) through a Boussignac multichannel endotracheal tube has been reported to be an efficient ventilatory method during chest massage for cardiac arrest. METHODS: Patients resuscitated for out-of-hospital cardiac arrest were randomly assigned to standard endotracheal intubation and mechanical ventilation (MV; n =457) or use of CFIO at a flow rate of 15 l/min (n=487). Continuous chest compressions were similar in the two groups. Pulse oximetry level was recorded every 5[Symbol: see text]min. Outcome of initial resuscitation, hospital admission, complications, and discharge from the intensive care unit (ICU) were analyzed. The randomization scheme was changed during the study, but the in-depth analysis was performed only on the first cohort of 341 patients with CFIO and 355 with MV, because of randomization problems in the second part. RESULTS: No difference in outcome was noted regarding return to spontaneous circulation (CFIO 21%, MV 20%), hospital admission (CFIO 17%, MV 16%), or ICU discharge (CFIO 2.4%, MV 2.3%). The level of detectable pulse saturation and the proportion of patients with saturation above 70% were higher with CFIO. Ten patients with MV but only one with CFIO had rib fractures. CONCLUSIONS: CFIO is a simplified alternative to MV, with favorable effects regarding oxygenation and fewer complications, as observed in this group of patients with desperate prognosis.

Details of the initial management of cardiac arrest occurring in the workplace in a French urban area.

INTRODUCTION: Our goal was to evaluate the details and management of cardiac arrest (CA) occurring in the working environment. MATERIALS AND METHODS: We conducted a 10-year retrospective study based on the medical records of the Garches mobile intensive care unit. CA occurring in the workplace ("Inside W." group) was matched with two CA outside the workplace ("Outside W." group), with regard to sex, age and year of occurrence. The Chain of Survival and prognosis factors were analysed in a bi-multivariate analysis. RESULTS: From 1993 to 2002, 72 CA were included in the "Inside W." group, with 79% arising from suspected cardiac aetiology (there was a similar proportion in the "Outside W." group). Some variables in the cardiac aetiology patients were higher in the "Inside W." group compared to the "Outside W." group (P < 0.05): early external chest compression [(ECC), 37%, n = 20 versus 16%, n = 16)] and ventricular fibrillation as initial recorded rhythm (40%, n = 33 versus 16%, n = 16). The proportion of use of automated external defibrillator (AED) was similar in the two groups. The workplace was not associated with a better outcome, with 9% patients discharged alive compared to 4% n = 6, P > 0.05. Early ECC and defibrillation attempted with an AED were associated with patients discharged alive from the intensive care unit in a multivariate analysis (P < 0.05), but not the workplace and cardiac aetiology. CONCLUSION: Although our study did not support that concept that the workplace was a safer place, there was a better chain of survival for CA applied within workplace settings. Basic Life Support teaching and installation of AEDs could be helpful, though further cost-effectiveness studies are needed.

A randomized, double-blind study comparing morphine with fentanyl in prehospital analgesia.

STUDY OBJECTIVE: The aim of this study was to compare, by a randomized double-blind method, morphine (M) and fentanyl (F) in a prehospital setting. METHODS: Consecutive patients with severe, acute pain defined as a visual analog scale score (VASS) of 60/100 or higher were included. The M group received an initial intravenous M injection of 0.1 mg/kg then of 3 mg every 5 minutes. The F group received an initial intravenous F injection of 1 microg/kg then of 30 microg every 5 minutes. The goal of analgesia was a VASS of 30/100 or lower. The end point was the VASS measured 30 minutes after initial administration (VAS [T30]). RESULTS: There were 26 patients included in the M group and 28 in the F group. Initial VASS(T0) and VASS(T30), mean (95% CI), were 83 (78-88) and 40 (28-52) in the M group and 77 (72-82) and 35 (27-43) in the F group (P=NS). Sixty-two percent of patients in the M group described analgesia as excellent or good vs 76% of those in the F group who did (P=NS). There were no differences in the incidence of side effects in the 2 groups. CONCLUSION: This study demonstrates that M and F were comparable in treating severe, acute pain in a prehospital setting during the first 30 minutes in spontaneous breathing patients.

AMON: a wearable multiparameter medical monitoring and alert system.

This paper describes an advanced care and alert portable telemedical monitor (AMON), a wearable medical monitoring and alert system targeting high-risk cardiac/respiratory patients. The system includes continuous collection and evaluation of multiple vital signs, intelligent multiparameter medical emergency detection, and a cellular connection to a medical center. By integrating the whole system in an unobtrusive, wrist-worn enclosure and applying aggressive low-power design techniques, continuous long-term monitoring can be performed without interfering with the patients' everyday activities and without restricting their mobility. In the first two and a half years of this EU IST sponsored project, the AMON consortium has designed, implemented, and tested the described wrist-worn device, a communication link, and a comprehensive medical center software package. The performance of the system has been validated by a medical study with a set of 33 subjects. The paper describes the main concepts behind the AMON system and presents details of the individual subsystems and solutions as well as the results of the medical validation.

'Boussignac' continuous positive airway pressure system: practical use in a prehospital medical care unit.

Continuous positive airway pressure in acute cardiogenic pulmonary edema is rarely used by prehospital emergency care units, because of the particular technical drawbacks of existing equipment. The aim of this one year prospective descriptive open study without a control group was to assess the technical feasibility of using the Boussignac continuous positive airway pressure system (Vygon) in a prehospital medical care service. Statistical comparisons were performed using Student's t-test or a Wilcoxon T-test. There were 57 decisions to use continuous positive airway pressure. Seven records were excluded. Four patients were intubated on the scene and six within one hour after hospital admission. The respiratory rate and transcutaneous oxygen saturation improved significantly for all of the other patients (Student's t-test P < 0.001). The Boussignac continuous positive airway pressure system has many advantages, including flexibility and pressure monitoring, lower oxygen consumption, and ease of use. These should allow this technique to be used more widely by prehospital teams.