Association Between Reported Long Working Hours and History of Stroke in the CONSTANCES Cohort.

Background and Purpose- Long working hours (LWHs) are a potential risk factor for stroke. The aim of this study was to investigate this association in a large general population cohort. Methods- We used the French population-based cohort, CONSTANCES (Cohorte des Consultants des Centres d'Examens de Santé), to retrieve information on age, sex, smoking, and working hours from the baseline, self-administered questionnaire. Other cardiovascular risk factors and previous occurrence of stroke were taken from a parallel medical interview. We defined LWH as working time >10 hours daily for at least 50 days per year. Participants with primarily part-time jobs were excluded as were those with stroke before LWH exposure. We used logistic models to estimate the association between LWH and stroke, stratified by age, sex, and occupation. In additional modeling, we excluded subjects whose stroke occurred within 5 years of the first reported work exposure. Results- Among the 143 592 participants in the analyses, there were 1224 (0.9%) strokes, 42 542 (29.6%) reported LWH, and 14 481 (10.1%) reported LWH for 10 years or more. LWH was associated with an increased risk of stroke: adjusted odds ratio of 1.29 (95% CI, 1.11-1.49). Being exposed to LWH for 10 years or more was more strongly associated with stroke, adjusted odds ratio of 1.45 (95% CI, 1.21-1.74). The association showed no differences between men and women but was stronger in white-collar workers under 50 years of age. Conclusions- This large analysis reveals a significant association between stroke and exposure to LWH for 10 years or more. The findings are relevant for individual and global prevention.

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.

The pathophysiology of "happy" hypoglycemia.

BACKGROUND: Hypoglycemia usually includes various neurological symptoms, which are the consequence of neuroglycopenia. When it is severe, it is associated with altered mental status, even coma. CASE PRESENTATION: We report the case of a patient with severe hypoglycemia, completely asymptomatic, due to the increase of lactate production in response to tissue hypoperfusion following a hemorrhagic shock. This illustrates that lactate can substitute glucose as an energy substrate for the brain. It is also a reminder that this metabolite, despite its bad reputation maintained by its role as a marker of severity in critical care patients, has a fundamental role in our metabolism. CONCLUSIONS: Following the example of the "happy hypoxemia" recently reported in the literature describing asymptomatic hypoxemia in COVID-19 patients, we describe a case of "happy hypoglycemia."

Collective Critical Care Ambulance: an innovative transportation of critical care patients by bus in COVID-19 pandemic response.

BACKGROUND: During the COVID-19 pandemic, as the number of available Intensive Care beds in France did not meet the needs, it appeared necessary to transfer a large number of patients from the most affected areas to the less ones. Mass transportation resources were deemed necessary. To achieve that goal, the concept of a Collective Critical Care Ambulance (CCCA) was proposed in the form of a long-distance bus re-designed and equipped to accommodate up to six intensive care patients and allow Advanced Life Support (ALS) techniques to be performed while en route. METHODS: The expected benefit of the CCCA, when compared to ALS ambulances accommodating a single patient, was to reduce the resources requirements, in particular by a lower personnel headcount for several patients being transferred to the same destination. A foreseen prospect, comparing to other collective transportation vectors such as airplanes, was the door-to-door capability, minimalizing patients' handovers for safety concerns and time efficiency. With the project of a short-distance transfer of several Intensive Care Unit (ICU) patients together, the opportunity came to test the CCCA under real-life conditions and evaluate safely its technical feasibility and impact in time and resources saving, before it could be proposed for longer distances. RESULTS: Four COVID-19 patients were transported over 37 km. All patients were intubated and under controlled ventilation. One of them was under Norepinephrine support. Mean loading time was 1 min 39 s. Transportation time was 29 min. At destination, the mean unloading time was 1 min 15 s. No serious adverse effect, in particular regarding hemodynamic instability or ventilation disorder, has been observed. No harmful incident has occurred. CONCLUSIONS: It was a very instructive test. Collective medical evacuation by bus for critically ill patients under controlled ventilation is suitable and easy to implement. Design, ALS equipment, power autonomy, safety and resources saving, open the way for carrying up to 6 ICU-patients over a long distance. The CCCA could bring a real added-value in an epidemic context and could also be helpful in many other events generating multiple victims such as an armed conflict, a terrorist attack or a natural disaster.

Personal protective equipment and doffing procedures in out-of-hospital practice: assessment with a contamination simulation.

BACKGROUND: The use of personal protective equipment (PPE) by emergency medical services (EMS) providers requires specific attention, as it takes place in out-of-hospital unsecured settings. The aim of this study was to evaluate which PPE gown was less contaminating during doffing procedures in an EMS setting. Six well-trained healthcare worker (HCW) subjects tested 4 different gowns: (1) surgical gowns (SG), (2) full body coveralls (FBC), (3) self-made alternative PPEs (SMP), and (4) non-surgical isolation gowns (NSIG). An invisible tracer was sprayed on the gown after donning each subject. After doffing, each HCW was photographed under UV lights to show areas of fluorescent "contamination" on their clothes. The number, size, and intensity level of contaminated areas were noted, as well as observational deviation from the procedure and doffing time. In addition, the subjects were asked to take a questionnaire about their perception of the level of comfort, ease of doffing, and overall safety for each gown. RESULTS: Despite a well-trained team of HCW subjects, contamination while doffing was observed with every type of PPE gown, and with each HCW subject. All body areas were contaminated at least once, except the face. Contamination was more frequent while doffing FBCs. On the other hand, the removal of SG was found to be the least contaminating. The mean doffing time was significantly shorter with SG 1:29 and longer with FBC 2:26 (p=0.005). CONCLUSION: Results of this study converge towards the selection of surgical gowns over other types of PPE gowns, which met both contamination criteria as well as staff appreciation in this context. Specific attention should be paid to the legs and abdomino-pelvic areas. Additional protection such as protective trousers or aprons could be added.

Cumulative Exposure to Long Working Hours and Occurrence of Ischemic Heart Disease: Evidence From the CONSTANCES Cohort at Inception.

Background Long-working hours (LWH) are a probable risk factor for ischemic heart diseases (IHD); however, no previous study has considered duration of exposure to LWH when addressing this topic. We aimed to determine the association between cumulative exposure to LWH and IHD while accounting for relevant confounders. Methods and Results In this retrospective study, we included all baseline participants from the French population-based cohort CONSTANCES. Part-time employees and those who reported a cardiac event in the 5 years before LWH exposure were excluded. From self-administered questionnaires and clinical examinations, we obtained participants' age, sex, body mass index, occupational status, smoking habits, high blood pressure, diabetes mellitus, familial history of cardiovascular disease, dyslipidemia, exposure to LWH, and its duration. We defined LWH as working for >10 hours daily for at least 50 days per year. The main outcome was reported history of IHD, ie, myocardial infarction or angina pectoris, during a clinical examination. Of 137 854 included participants, 69 774 were men. There were 1875 cases (1.36%) of IHD, and exposure to LWH was reported by 42 462 subjects (30.8%) among whom 14 474 (10.50%) reported exposure for at least 10 years. Overall, exposure to LWH for ≥10 years was associated with an increased risk of IHD, adjusted odds ratio (aOR) 1.24 (1.08-1.43), P=0.0021. In stratified analyses, this effect was not observed in women, but was significant amongst men, aOR 1.28 (1.11-1.48), P=0.0008. Conclusions This large population-based study supports an association between cumulative exposure to LWH and IHD in men. Future research should consider relevant strategies for reducing LWH exposure and duration.

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.

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.

Occupational Practitioner's Role in the Management of a Crisis: Lessons Learned from the Paris November 2015 Terrorist Attack.

In massive catastrophic events, occupational health practitioners are more and more frequently involved in the management of such situations. We aim to describe the multiple aspects of the role that occupational health practitioners might play, by focusing on the recent example of the Paris terrorist attack of November 2015. During and after the Paris attack, occupational practitioners, in collaboration with emergency and security professionals, were involved in psychological care, assembling information, follow-up, return-to-work, and improving in-company safety plans. Based on this experience and other industrial disasters, we distinguish three phases: the critical phase, the post-critical phase, and the anticipation phase. In the critical phase, the occupational practitioner cares for patients before the emergency professionals take charge, initiates the psychological management, and may also play an organizational role for company health aspects. In the post-critical phase, he or she would be involved in monitoring those affected by the events and participate in preventing, to the extent possible, posttraumatic stress disorder, helping victims in the return-to-work process, and improving procedures and organizing drills. In addition to their usual work of primary prevention, occupational practitioners should endeavor to improve preparedness in the anticipation phase, by taking part in contingency planning, training in first aid, and defining immediately applicable protocols. In conclusion, recent events have highlighted the essential role of occupational health services in anticipation of a crisis, management during the crisis, and follow-up.

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.

Difficulties encountered by physicians in interpreting focused echocardiography using a pocket ultrasound machine in prehospital emergencies.

OBJECTIVE: Pocket ultrasound devices (PUDs) increase the scope of transthoracic echocardiography. We assessed the ability of emergency physicians (EPs) to obtain and interpret views using PUDs in prehospital emergencies. MATERIALS AND METHODS: Nine EPs underwent a 2-day training program focused on acquisition of four views and on evaluation of left ventricular function, right ventricular size, the inferior vena cava, and detection of pericardial effusion. Then, EPs used a PUD to perform transthoracic echocardiography in patients with shock or acute respiratory failure. The quality and interpretation of views were graded by an expert as not obtained/inadequate, adequate, or optimal. Agreement between the expert and the physicians was evaluated using Cohen's κ test. RESULTS: One hundred consecutive exams were evaluated in patients with shock or acute respiratory failure. Parasternal long-axis and short-axis views, and a subcostal view were not obtained or inadequate in 56, 54, and 54 patients, respectively. An apical four-chamber view was not obtained or inadequate in 33 patients. One, two, or three views were graded as adequate or optimal in 86, 65, and 35 patients. Agreement between physicians and experts for left ventricular systolic function, right ventricular size, and pericardial effusion was weak [κ 0.37 (0.17; 0.59), 0.27 (0.023; 0.53), and 0.33 (-0.008; 0.67)]. Agreement for inferior vena cava evaluation was very weak [0.13 (-0.17; 0.43)]. CONCLUSION: After a very short training program, echocardiography using a PUD in prehospital emergencies was feasible in half of patients. Acquisition of technical skills is reasonable, but accurate evaluation of cardiac function may require more extensive training.

Cardiac arrest in the workplace and its outcome: a systematic review and meta-analysis.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) in the workplace appears to be managed more effectively than OHCA occurring in other places. A systematic review and meta-analysis of the available epidemiological data was performed, comparing the rate of survival for OHCA in the workplace, versus survival in other locations. METHODS: Four databases (Pub-Med, Scopus, Web of science, "Base de Données de Santé Publique", BDSP, i.e. the French Public Health Database) were searched from 01/2000 to 03/2015, using the key words: ("Cardiac arrest") and ("occupational" OR "workplace" OR "public location"). A two stage process with two independent readers was used to select relevant papers. Numbers of subjects who suffered from OHCA in the workplace versus other locations were extracted when possible, as well as their respective outcomes (admitted alive to the hospital, discharged alive, good neurological outcome). Metarisks were calculated using the generic variance approach (meta-odds ratios metaOR). RESULTS: After full-text reading, 17 papers were included, from 9 countries, mostly published after 2005, and coming mostly from prospective registers. "Workplace" was defined differently in different studies, mostly in terms of industrial sites and offices. The workplace was an exceptional location for occurrences of OHCA (from 0.3% to 4.7% of all OHCA, from 1.3 to 23.8 events per million people per year), based on 2077 OHCA. In the quantitative analyses (survival available, 10 studies), MetaOR were found to be relatively consistent and high (from 1.9 (1.5-2.3) to 5.9(2.7-13.0)). When OHCA occurring at workplaces were compared to other public sites, no significant differences were found. CONCLUSION: There is sufficient evidence to support the view that there will be better outcomes for OHCA cases that occur in the workplace than for those occurring elsewhere. Requirements for occupational health and safety should include prevention of such major (albeit rare) events.

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.