Factors associated with initiation of medical advanced cardiac life support after out-of-hospital cardiac arrest.

BACKGROUND: Termination of resuscitation rule permits to stop futile resuscitative efforts by paramedics. In a different setting, the decision to withhold resuscitation by emergency physician could be based on different factors. We aimed to identify the factors associated with the initiation of a medical ACLS in out-of-hospital cardiac arrest patients. METHODS: We prospectively collected the characteristics of all out-of hospital cardiac arrest patients occurring in a French district between March 2010 and December 2013 and managed by the emergency medical system. We analyzed the factors associated with the initiation of medical ACLS. RESULTS: Medical ACLS was initiated in 69 % of the 2690 patients included in the register. ACLS patients were younger (69 years [55-80] vs. 84 years [77-90]) and more frequently men. A higher percentage of witnessed cardiac arrest and BLS were observed. Duration of no-flow was shorter in the ACLS patients, whereas BLS duration was longer. A higher proportion of shockable rhythm and application of AED were found in this group. Mains factors associated with the initiation of medical ACLS were a suspected cardiac cause (1.73 [1.30-2.30]) and use of an automated external defibrillator (1.59 [1.18-2.16]), whereas factors associated with no medical ACLS were higher age (0.93 [0.92-0.94]), absence of BLS (0.62 [0.52-0.73]), asystole (0.31 [0.18-0.51]) and location in nursing home (0.23 [0.11-0.51]). CONCLUSIONS: The medical decision to not initiate ACLS in out-of-hospital cardiac arrest patients seems to rely on a complex combination of validated criteria used for termination of resuscitation and factors resulting from an intuitive perception of the outcome.

[Modalities of care in anti HCV positive patients identified in General Medicine in the Alpes-Maritimes district]. / Analyse de la prise en charge en Médecine Générale de malades identifiés comme positifs pour le virus de l'hépatite C dans le département des Alpes-Maritimes.

UNLABELLED: Little is known about the management of HCV infected patients after screening in general medicine. On May 2000, 75 General Practitioners (GP) from South Eastern France were involved in an HCV screening campaign. Fifteen per cent of 6321 patients seen during this period presented at least one of the following risk factors: blood transfusion before 1991, drug abuse, imprisonment. Among the 238 HCV positive patients, 9 new cases were reported. AIM OF THE STUDY: To describe the management of these patients. RESULTS: One hundred and fifty-nine of these 238 cases were studied (100 males and 59 females). Mean age was 42 +/- 12 years. Mean delay between contamination and the discovery of HCV positive status was 8 +/- 6 years. Main routes of infection were: drug abuse (78%), transfusion before 1991 (15%), imprisonment (7%). The GP performed the entire follow up of cases in 34%. The following investigations were performed: ALT dosage in 98% (elevated: 59%, normal: 41%), qualitative HCV RNA detection in 77% (positive 78%, negative 22%), quantitative HCV RNA detection in 27%. A liver biopsy was performed in 62 patients (39%). Among the 159 patients 39 (19%) were treated with Interferon (with or without Ribavirin). Treatment and liver biopsy were not performed for the following reasons: patient refusal (26%), normal ALT values (26%), HIV co-infection (27%), elderly patients (3%), decompensated cirrhosis (5%), drug abuse or excessive alcohol intake (12%). CONCLUSION: The main reasons that adequate management in hepatitis C patients failed was fear of liver biopsy and/or Interferon therapy, and a population difficult that was difficult to treat (HIV coinfected, drug abuse or chronic alcoholism), A better collaboration between general practitioners and specialists could help improve the management of these patients.

[Screening and hepatitis C management survey in general medicine in the Alpes-Maritimes and east Var area]. / Enquête de pratique en Médecine Générale sur le dépistage et la prise en charge de l'hépatite C dans les Alpes-Maritimes et l'est du Var.

BACKGROUND: This study was performed to assess screening and management of hepatitis C by community-based practitioners in the Alpes Maritimes district in the South of France and to compare their practices with the recommendations issued by the consensus conferences in 1997 and 1999. This information was to be used to adapt continuing medical education to the needs of practitioners in the area. METHOD: Two hundred and nineteen general practitioners who were members of eighteen continuing medical education associations accepted to complete a questionnaire containing eighteen closed questions. It was issued late 1999 during one of the monthly meetings and completed by all the participating physicians. RESULTS: Only 32% of general practitioners knew the conclusions of one of the two French and European consensus conferences concerning hepatitis C. General practitioner practices were in accordance with recommendations for targeted screening in case of transfusion before 1991 (88%), intra-venous drug use (94%) and increased ALT (91%); however intra nasal drug use (35%) and imprisonment (46%) were underestimated risk factors. Frequency of screening was correlated to duration of practice (P<0.01), size of practice (P<0.02) and follow-up of hepatitis C infected patients, regardless of treatment (P<0.03). Upon discovery of a positive HCV status, 80% of general practitioners prescribed initial investigations but these included costly and needless procedures such as hepatic imaging (56%), RNA quantification (39%) and viral genotype (6%). On the other hand, 79% general practitioners recommended a liver biopsy for patients with elevated transaminase levels. When transaminase levels were normal, only 13% requested qualitative detection of viral RNA. Generally, general practitioners were confused concerning the indications for qualitative or quantitative viral RNA investigations. Few general practitioners followed treated HCV-infected patients and renewed interferon therapy prescriptions. Condom use was advised by 56% of GPs for couples in which one of the partners had a positive HCV status. CONCLUSIONS: This study demonstrates the weak impact of consensus conferences on hepatitis C management for general practitioners in the Alpes Maritimes. It provides an opportunity to identify the need for specific training which will be developed within the Côte d'Azur Hepatitis C Network.