A method for calculating fall risk parameters from discrete stride time series regardless of sensor placement.

BACKGROUND: To complement traditional clinical fall risk assessments, research is oriented towards adding real-life gait-related fall risk parameters (FRP) using inertial sensors fixed to a specific body position. While fixing the sensor position can facilitate data processing, it can reduce user compliance. A newly proposed step detection method, Smartstep, has been proven to be robust against sensor position and real-life challenges. Moreover, FRP based on step variability calculated from stride times (Standard deviation (SD), Coefficient of Variance (Cov), fractal exponent, and sample entropy of stride duration) proved to be useful to prospectively predict the fall risk. RESEARCH QUESTIONS: To evaluate whether Smartstep is convenient for calculating FRP from different sensor placements. METHODS: 29 elderly performed a 6-minute walking test with IMU placed on the waist and the wrist. FRP were computed from step-time estimated from Smartstep and compared to those obtained from foot-mounted inertial sensors: precision and recall of the step detection, Root mean square error (RMSE) and Intraclass Correlation Coefficient (ICC) of stride durations, and limits of agreement of FRP. RESULTS: The step detection precision and recall were respectively 99.5% and 95.9% for the waist position, and 99.4% and 95.7% for the wrist position. The ICC and RMSE of stride duration were 0.91 and 54 ms respectively for both the waist and the hand position. The limits of agreement of Cov, SD, fractal exponent, and sample entropy of stride duration are respectively 2.15%, 25 ms, 0.3, 0.5 for the waist and 1.6%, 16 ms, 0.23, 0.4 for the hand. SIGNIFICANCE: Robust against the elderly's gait and different body locations, especially the wrist, this method can open doors toward ambulatory measurements of steps, and calculation of different discrete stride-related falling risk indicators.

The Association Between Age and Admission to an Inappropriate Ward: A Cross-Sectional Survey in France.

Half of elderly patient hospitalizations are preceded by an emergency department (ED) visit. Hospitalization in inappropriate wards (IWs), which is more frequent in case of ED overcrowding and high hospital occupancy, leads to increased morbidity. Elderly individuals are the most exposed to these negative health care outcomes. Based on a nationwide cross-sectional survey involving all EDs in France, the aim of this study was to explore whether age was associated with admission to an IW after visiting an ED. Among the 4384 patients admitted in a medical ward, 4065 were admitted in the same hospital where the ED was located, among which 17.7% were admitted to an IW. Older age was associated with an increased likelihood of being admitted to an IW (OR = 1.39; 95% CI = 1.02-1.90 for patients aged 85 years and older and OR = 1.40; 95% CI = 1.02-1.91 for patients aged 75-84 years, compared with those under 45 years). ED visits during peak periods and cardio-pulmonary presenting complaint were also associated with an increased likelihood of admission to an IW. Despite their higher vulnerability, elderly patients are more likely to be admitted to an IW than younger patients. This result reinforces the need for special attention to be given to the hospitalization of this fragile population.

Risk factors and mortality associated with undertriage after major trauma in a physician-led prehospital system: a retrospective multicentre cohort study.

PURPOSE: To assess the incidence of undertriage in major trauma, its determinant, and association with mortality. METHODS: A multicentre retrospective cohort study was conducted using data from a French regional trauma registry (2011-2017). All major trauma (Injury Severity Score ≥ 16) cases aged ≥ 18 years and managed by a physician-led mobile medical team were included. Those transported to a level-II/III trauma centre were considered as undertriaged. Multivariable logistic regression was used to identify factors associated with undertriage. RESULTS: A total of 7110 trauma patients were screened; 2591 had an ISS ≥ 16 and 320 (12.4%) of these were undertriaged. Older patients had higher risk for undertriage (51-65 years: OR = 1.60, 95% CI [1.11; 2.26], p = 0.01). Conversely, injury mechanism (fall from height: 0.62 [0.45; 0.86], p = 0.01; gunshot/stab injuries: 0.45 [0.22; 0.90], p = 0.02), on-scene time (> 60 min: 0.62 [0.40; 0.95], p = 0.03), prehospital endotracheal intubation (0.53 [0.39; 0.71], p < 0.001), and prehospital focussed assessment with sonography [FAST] (0.15 [0.08; 0.29], p < 0.001) were associated with a lower risk for undertriage. After adjusting for severity, undertriage was not associated with a higher risk of mortality (1.22 [0.80; 1.89], p = 0.36). CONCLUSIONS: In our physician-led prehospital EMS system, undertriage was higher than recommended. Advanced aged was identified as a risk factor highlighting the urgent need for tailored triage protocol in this population. Conversely, the potential benefit of prehospital FAST on triage performance should be furthered explored as it may reduce undertriage. Fall from height and penetrating trauma were associated with a lower risk for undertriage suggesting that healthcare providers should remain vigilant of the potential seriousness of trauma associated with low-energy mechanisms.

Assessment of atrial fibrillation in European emergency departments: insights from a prospective observational multicenter study.

BACKGROUND: The diagnosis and management of atrial fibrillation (AF) in emergency departments (EDs) have not been well described in France, with limited EU research. This study aimed to describe the diagnosis, management, and prognosis of AF patients in French EDs. METHODS: A prospective, observational 2-month study in adults diagnosed with AF was conducted at 32 French EDs. Data regarding patient characteristics, diagnosis, and treatment at EDs were collected, with 12-month follow-up. RESULTS: The study included a total of 1369 patients diagnosed with AF at an ED: 279 patients (20.4%) with idiopathic AF (no identified cause of the AF) and 1090 (79.6%) with secondary AF (with a principal diagnosis identified as the cause of AF). Patients were aged 84 years (median) and 51.3% were female. Significantly more idiopathic AF patients than secondary AF patients underwent CHA2DS2-VASc assessment (67.8% vs. 52.1%,) or echocardiography (21.2% vs. 8.3%), or received an oral anticoagulant and/or antiarrhythmic (62.0% vs. 12.9%). Idiopathic AF patients also had significantly higher rates of discharge to home (36.4% vs. 20.4%) and 3-month cardiologist follow-up (67.0% vs. 41.1%). At 12 months, 96% of patients with follow-up achieved sinus rhythm. The estimated Kaplan-Meier 12-month mortality rate was significantly lower with idiopathic AF than secondary AF (11.9% vs. 34.5%). CONCLUSIONS: Patients diagnosed with idiopathic or secondary AF at the ED presented heterogeneous characteristics and prognoses, with those with secondary AF having worse outcomes. Further studies are warranted to optimize patients' initial evaluation in EDs and provide appropriate follow-up.

Association between location of out-of-hospital cardiac arrest, on-scene socioeconomic status, and accessibility to public automated defibrillators in two large metropolitan areas in Canada and France.

AIM: To compare walking access times to automated external defibrillators (AEDs) between area-level quintiles of socioeconomic status (SES) in out-of-hospital cardiac arrest (OHCA) cases occurring in 2 major urban regions of Canada and France. METHODS: This was an international, multicenter, retrospective cohort study of adult, non-traumatic OHCA cases in the metropolitan Vancouver (Canada) and Rhône County (France) regions that occurred between 2014 and 2018. We calculated area-level SES for each case, using quintiles of country-specific scores (Q5 = most deprived). We identified AED locations from local registries. The primary outcome was the simulated walking time from the OHCA location to the closest AED (continuous and dichotomized by a 3-minute 1-way threshold). We fit multivariate models to analyze the association between OHCA-to-AED walking time and outcomes (Q5 vs others). RESULTS: A total of 6,187 and 3,239 cases were included from the Metro Vancouver and Rhône County areas, respectively. In Metro Vancouver Q5 areas (vs Q1-Q4), areas, AEDs were farther from (79 % over 400 m from case vs 67 %, p < 0.001) and required longer walking times to (97 % above 3 min vs 91 %, p < 0.001) cases. In Rhône Q5 areas, AEDs were closer than in other areas (43 % over 400 m from case vs 50 %, p = 0.01), yet similarly poorly accessible (85 % above 3 min vs 86 %, p = 0.79). In multivariate models, AED access time ≥ 3 min was associated with decreased odds of survival at hospital discharge in Metro Vancouver (odds ratio 0.41, 95 % CI [0.23-0.74], p = 0.003). CONCLUSIONS: Accessibility of public AEDs was globally poor in Metro Vancouver and Rhône, and even poorer in Metro Vancouver's socioeconomically deprived areas.

Prehospital Tranexamic Acid in Major Pediatric Trauma Within a Physician-Led Emergency Medical Services System: A Multicenter Retrospective Study.

OBJECTIVES: Describe prehospital tranexamic acid (TXA) use and appropriateness within a major trauma pediatric population, and identify the factors associated with its use. DESIGN: Multicenter, retrospective study, 2014-2020. SETTING: Data were extracted from a multicenter French trauma registry including nine trauma centers within a physician-led prehospital emergency medical services (EMS) system. PATIENTS: Patients less than 18 years old were included. Those who did not receive prehospital intervention by a mobile medical team and those with missing data on TXA administration were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nine-hundred thirty-four patients (median [interquartile range] age: 14 yr [9-16 yr]) were included, and 68.6% n = 639) were male. Most patients were involved in a road collision (70.2%, n = 656) and suffered a blunt trauma (96.5%; n = 900). Patients receiving TXA (36.6%; n = 342) were older (15 [13-17] vs 12 yr [6-16 yr]) compared with those who did not. Patient severity was higher in the TXA group (Injury Severity Score 14 [9-25] vs 6 [2-13]; p < 0.001). The median dosage was 16 mg/kg (13-19 mg/kg). TXA administration was found in 51.8% cases ( n = 256) among patients with criteria for appropriate use. Conversely, 32.4% of patients ( n = 11) with an isolated severe traumatic brain injury (TBI) also received TXA. Age (odds ratio [OR], 1.2; 95% CI, 1.1-1.2), A and B prehospital severity grade (OR, 7.1; 95% CI, 4.1-12.3 and OR, 4.5; 95% CI, 2.9-6.9 respectively), and year of inclusion (OR, 1.2; 95% CI, 1.1-1.3) were associated with prehospital TXA administration. CONCLUSIONS: In our physician-led prehospital EMS system, TXA is used in a third of severely injured children despite the lack of high-level of evidence. Only half of the population with greater than or equal to one criteria for appropriate TXA use received it. Conversely, TXA was administered in a third of isolated severe TBI. Further research is warranted to clarify TXA indications and to evaluate its impact on mortality and its safety profile to oversee its prescription.

PHAREO study: Perceived and observed accessibility to therapeutic drugs used for treating patients with inherited bleeding disorders.

WHAT IS KNOWN AND OBJECTIVE: The dispensing of clotting factor concentrates in hospital pharmacies imposes accessibility constraints on patients and their caregivers, thereby increasing the disease burden. Very few studies have addressed these issues so far in terms of individual perceptions and actual difficulties. The PHAREO study aims to report patient's perception of treatment accessibility and evaluate spatial accessibility. METHODS: The PHAREO study is an observational survey based on a questionnaire specifically designed for the study purpose in collaboration with patients' representatives in the second demographic and economic French region. RESULTS AND DISCUSSION: We collected 293 responses (participation rate of 64.1%) which show that 89.8% of respondents were either very or rather satisfied with regard to access to treatment. However, respondents reported difficulties in accessing the hospital pharmacy. The data also showed that 79.2% of respondents tended to over-estimate travel time which was reported above their acceptable threshold for 39.2% of them. The main determinants of dissatisfaction were parental burden (OR 2.5 [1.3; 4.8], p = 0.008) and waiting time at the hospital pharmacy (OR 1.5 [1.1;2.0], p = 0.016, per 10 min increase). WHAT IS NEW AND CONCLUSION: The PHAREO study provides subjective and objective data regarding satisfaction levels of persons with haemophilia and other coagulation deficiencies, with a high representativeness rate for patients on prophylaxis (87.5%). Both respondents and hospital pharmacists pled for an evolution of the current dispensing circuit to improve access to treatment and reduce the burden for patients. Currently, the community pharmacists are apart from the dispensing circuit. The authors propose improvements in the pathway of care for patients and their caregivers by including the community pharmacists alongside the hospital pharmacists in a centralized coordination scheme.

Temporal trends in reperfusion therapy for patients with acute ischemic stroke.

OBJECTIVES: To analyze the temporal trends in thrombolysis rates after implementation of a regional emergency network for acute ischemic stroke (AIS). METHODS: We conducted a retrospective study based on a prospective multicenter observational registry. The AIS benefited from reperfusion therapy included in 1 of the 5 primary stroke units or 1 comprehensive stroke center and 37 emergency departments were included using a standardized case report form. The population covers 3 million inhabitants. RESULTS: In total, 32,319 AIS was reported in the regional hospitalization database of which 2215 thrombolyzed AIS patients were included in the registry and enrolled in this study. The annual incidence rate of thrombolysis continuously and significantly increased from 2010 to 2018 (10.2% to 17.3%, P-trend = 0.0013). The follow-up of the onset-to-door and the door-to-needle delays over the study period showed stable rates, as did the all-cause mortality rate at 3-months (13.2%). CONCLUSION: Although access to stroke thrombolysis has increased linearly since 2010, the 3-month functional outcome has not evolved as favorably. Further efforts must focus on reducing hospital delays.

Rationale, development and implementation of the ReACanROC registry for out-of-hospital cardiac arrests in France and Canada.

France and Canada prehospital systems and care delivery in out-of-hospital cardiac arrests (OHCAs) show substantial differences. This article aims to describe the rationale, design, implementation and expected research implications of the international, population-based, France-Canada registry for OHCAs, namely ReACanROC, which is built from the merging of two nation-wide, population-based, Utstein-style prospectively implemented registries for OHCAs attended to by emergency medical services. Under the supervision of an international steering committee and research network, the ReACanROC dataset will be used to run in-depth analyses on the differences in organisational, practical and geographic predictors of survival after OHCA between France and Canada. ReACanROC is the first Europe-North America registry ever created to meet this goal. To date, it covers close to 80 million people over the two countries, and includes approximately 200 000 cases over a 10-year period.

Effect of adrenaline dose on neurological outcome in out-of-hospital cardiac arrest: a nationwide propensity score analysis.

BACKGROUND: Adrenaline is recommended during cardio-pulmonary resuscitation. The optimal dose remains debated, and the effect of lower than recommended dose is unknown. OBJECTIVE: To compare the outcome of patients treated with the recommended, lower or higher cumulative doses of adrenaline. DESIGN, SETTINGS, PARTICIPANTS: Patients were included from the French National Cardiac Arrest Registry and were grouped based on the received dose of adrenaline: recommended, higher and lower dose. OUTCOME MEASURES AND ANALYSIS: The primary endpoint was good neurologic outcome at 30 days post-OHCA, defined by a cerebral performance category (CPC) of less than 3. Secondary endpoints included return of spontaneous circulation and survival to hospital discharge. A multiple propensity score adjustment approach was performed. MAIN RESULTS: 27 309 patients included from July 1st 2011 to January 1st 2019 were analysed, mean age was 68 (57-78) years and 11.2% had ventricular fibrillation. 588 (2.2%) patients survived with a good CPC score. After adjustment, patients in the high dose group had a significant lower rate of good neurologic outcome (OR, 0.6; 95% CI, 0.5-0.7). There was no significant difference for the primary endpoint in the lower dose group (OR, 0.8; 95% CI, 0.7-1.1). There was a lower rate of survival to hospital discharge in the high-dose group vs. standard group (OR, 0.5; 95% CI, 0.5-0.6). CONCLUSION: The use of lower doses of adrenaline was not associated with a significant difference on survival good neurologic outcomes at D30. But a higher dose of adrenaline was associated with a lower rate of survival with good neurological outcomes and poorer survival at D30.

Prehospital predictors for return of spontaneous circulation in traumatic cardiac arrest.

BACKGROUND: Traumatic cardiac arrests (TCAs) are associated with high mortality and the majority of deaths occur at the prehospital scene. The aim of the present study was to assess, in a prehospital physician-led emergency medical system, the factors associated with sustained return of spontaneous circulation (ROSC) in TCA, including advanced life procedures. The secondary objectives were to assess factors associated with 30-day survival in TCA, evaluate neurological recovery in survivors, and describe the frequency of organ donation among patients experiencing a TCA. METHODS: We conducted a retrospective study of all TCA patients included in the French nationwide cardiac arrest registry from July 2011 to November 2020. Multivariable logistic regression analysis was used to identify factors independently associated with ROSC. RESULTS: A total of 120,045 out-of-hospital cardiac arrests were included in the registry, among which 4,922 TCA were eligible for analysis. Return of spontaneous circulation was sustained on-scene in 21.1% (n = 1,037) patients. Factors significantly associated with sustained ROSC were not-asystolic initial rhythms (pulseless electric activity (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.40-2.35; p < 0.001), shockable rhythm (OR, 1.83; 95% CI, 1.12-2.98; p = 0.016), spontaneous activity (OR, 3.66; 95% CI, 2.70-4.96; p < 0.001), and gasping at the mobile medical team (MMT) arrival (OR, 1.40; 95% CI, 1.02-1.94; p = 0.042). The MMT interventions significantly associated with ROSC were as follows: intravenous fluid resuscitation (OR, 3.19; 95% CI, 2.69-3.78; p < 0.001), packed red cells transfusion (OR, 2.54; 95% CI, 1.84-3.51; p < 0.001), and external hemorrhage control (OR, 1.74; 95% CI, 1.31-2.30; p < 0.001). Among patients who survived (n = 67), neurological outcome at Day 30 was favorable (cerebral performance categories 1-2) in 72.2% cases (n = 39/54) and 1.4% (n = 67/4,855) of deceased patients donated one or more organ. CONCLUSION: Sustained ROSC was frequently achieved in patients not in asystole at MMT arrival, and higher ROSC rates were achieved in patients benefiting from specific advanced life support interventions. Organ donation was somewhat possible in TCA patients undergoing on-scene resuscitation. LEVEL OF EVIDENCE: Prognostic and epidemiologic, Level III.

Discovering the underlying typology of emergency departments.

BACKGROUND: We hypothesized that monitoring the volume of activity and overall performance indicators is not sufficient to understand the underlying differences between emergency departments. We aimed to understand the underlying common characteristics of emergency departments and map their typology in order to propose adaptive solutions, that would take into account territorial specificities and manage existing resources. METHODS: We applied a multifactorial analysis based on input data at three levels; 1) the health care available in the area surrounding the emergency departments, 2) the level of medical technicality of the hospitals and 3) the profile of emergency department visits. RESULTS: We included 73 emergency departments in this study, representing 93.6% of the emergency departments in our region and seven groups were retained. The smallest group (n = 5) included both public and private structures with low volumes of activity. These medical structures were associated with the shortest length of stay and one of the lowest hospitalisation rates. The largest group (n = 21) included only public structures in peri-urban areas, which were associated with the highest rate of hospitalization in the region. The surrounding population was representative of the regional population, but the patients were older. CONCLUSIONS: This approach represents a systemic response to target the organisational needs and constraints, propose appropriate solutions and adjust the financial resources allocated to hospitals. Future policies to improve care delivery may benefit from stratifying solutions and performance objectives depending on these groups.

Estimating the Proportion of COVID-19 Contacts Among Households Based on Individuals With Myocardial Infarction History: Cross-sectional Telephone Survey.

BACKGROUND: Adults with cardiovascular diseases were disproportionately associated with an increased risk of a severe form of COVID-19 and all-cause mortality. OBJECTIVE: The aims of this study are to report the associated symptoms for COVID-19 cases, to estimate the proportion of contacts, and to describe the clinical signs and behaviors among individuals with and without myocardial infarction history among cases and contacts. METHODS: A 2-week cross-sectional telephone survey was conducted during the first lockdown period in France, from May 4 to 15, 2020. A total of 668 households participated, representing 703 individuals with pre-existing cardiovascular disease in the past 2 years and 849 individuals without myocardial infarction history. RESULTS: High rates of compliance with health measures were self-reported, regardless of age or risk factors. There were 4 confirmed COVID-19 cases that were registered from 4 different households. Based on deductive assumptions of the 1552 individuals, 9.73% (n=151) were identified as contacts, of whom 71.52% (108/151) were asymptomatic. Among individuals with a myocardial infarction history, 2 were COVID-19 cases, and the estimated proportion of contacts was 8.68% (61/703), of whom 68.85% (42/61) were asymptomatic. The cases and contacts presented different symptoms, with more respiratory signs in those with a myocardial infarction history. CONCLUSIONS: The telephone survey could be a relevant tool for reporting the number of contacts during a limited period and in a limited territory based on the presence of associated symptoms and COVID-19 cases in the households. This study advanced our knowledge to better prepare for future crises.

Effect of gender on out-of-hospital cardiac arrest survival: a registry-based study.

OBJECTIVE: The aim of the study was to compare outcomes after out-of-hospital cardiac arrest (OHCA) between comparable female and male OHCA cohorts in a large nationwide registry. METHODS: This was a national multicentre retrospective, case-control propensity score-matched study based on French National Cardiac Arrest Registry data from 1 July 2011 to 21 September 2017. Female and male survival rates at D30 were compared. RESULTS: At baseline 66 395 OHCA victims were included, of which 34.3% were women. At hospital admission, survival was 18.2% for female patients and 20.2% for male patients [odds ratio (OR), 1.138 (1.092-1.185)]; at 30 days, survival was 4.3 and 5.9%, respectively [OR, 1.290 (1.191-1.500)]. After matching (14 051 patients within each group), female patients received less advanced life support by mobile medical team (MMT), they also had a longer no-flow duration and shorter resuscitation effort by MMT than male patients. However, 15.3% of female patients vs. 9.1% of male patients were alive at hospital admission [OR, 0.557 (0.517-0.599)] and 3.2 vs. 2.6% at D30 [OR, 0.801 (0.697-0.921)], with no statistically significant difference in neurological outcome [OR, 0.966 (0.664-1.407)]. CONCLUSIONS: In this large nationwide matched OHCA study, female patients had a better chance of survival with no significant difference in neurological outcome. We also noticed that female patients received delayed care with a shorter resuscitation effort compared to men; these complex issues warrant further specific investigation. Encouraging bystanders to act as quickly as possible and medical teams to care for female patients in the same way as male patients should increase survival rates.

Comparison of the pathways of care and life courses between first-time ST-elevation myocardial infarction (STEMI) and STEMI with prior MI: findings from the OSCAR registry.

OBJECTIVES: We hypothesised that patients having experienced one coronary event in their life were susceptible to present differences in their pathways of care and within 1 year of their life courses. We aimed to compare pathways between first-time ST-elevation myocardial infarction (STEMI) and STEMI with prior myocardial infarction (MI). DESIGN: A retrospective observational study based on the Observatoire des Syndromes Coronariens Aigus du réseau RESCUe (OSCAR) registry collecting all suspected STEMI from 10 percutaneous coronary intervention centres in France. SETTING: All patients with STEMI from 2013 to 2017 were included (N=6306 with 5423 first-time STEMI and 883 STEMI with prior MI). We provided a matching analysis by propensity score based on cardiovascular risk factors. PARTICIPANTS: We defined first-time STEMI as STEMI occurring at the inclusion date, and STEMI with prior MI as STEMI with a history of MI prior to the inclusion date. RESULTS: Patients with first-time STEMI and patients with STEMI with prior MI were equally treated during hospitalisation and at discharge. At 12 months, patients with first-time STEMI had a lower adherence to BASIC treatment (ie, beta-blocker, antiplatelet therapy, statin and converting enzyme inhibitor) (48.11% vs 58.58%, p=0.0167), more frequently completed the cardiac rehabilitation programme (44.33% vs 31.72%, p=0.0029), more frequently changed their lifestyle behaviours; more frequently practiced daily physical activity (48.11% vs 35.82%, p=0.0043) and more frequently stopped smoking at admission (69.39% vs 55.00%, p=0.0524). The estimated mortality was higher for patients with STEMI with prior MI at 1 month (p=0.0100), 6 months (p=0.0500) and 1 year (p=0.0600). CONCLUSIONS: We provided an exhaustive overview of the real-life clinical practice conditions of STEMI management. The patients with STEMI with prior MI presented an optimised use of prehospital resources, which was probably due to their previous experience, and showed a better adherence to drug therapy compared with patients with first-time STEMI. TRIAL REGISTRATION NUMBER: Commission Nationale de l'Informatique et des Libertés (number 2 013 090 v0).

A Time-Dependent Propensity Score Matching Approach to Assess Epinephrine Use on Patients Survival Within Out-of-Hospital Cardiac Arrest Care.

BACKGROUND: Epinephrine effectiveness and safety are still questioned. It is well known that the effect of epinephrine varies depending on patients' rhythm and time to injection. OBJECTIVE: We aimed to assess the association between epinephrine use during out-of-hospital cardiac arrest (OHCA) care and patient 30-day (D30) survival. METHODS: Between 2011 and 2017, 27,008 OHCA patients were included from the French OHCA registry. We adjusted populations using a time-dependent propensity score matching. Analyses were stratified according to patient's first rhythm. After matching, 2837 pairs of patients with a shockable rhythm were created and 20,950 with a nonshockable rhythm. RESULTS: Whatever the patient's rhythm (shockable or nonshockable), epinephrine use was associated with less D30 survival (odds ratio [OR] 0.508; 95% confidence interval [CI] 0.440-0.586] and OR 0.645; 95% CI 0.549-0.759, respectively). In shockable rhythms, on all outcomes, epinephrine use was deleterious. In nonshockable rhythms, no difference was observed regarding return of spontaneous circulation and survival at hospital admission. However, epinephrine use was associated with worse neurological prognosis (OR 0.646; 95% CI 0.549-0.759). CONCLUSIONS: In shockable and nonshockable rhythms, epinephrine does not seem to have any benefit on D30 survival. These results underscore the need to perform further studies to define the optimal conditions for using epinephrine in patients with OHCA.

Nitrous oxide/oxygen plus acetaminophen versus morphine in ST elevation myocardial infarction: open-label, cluster-randomized, non-inferiority study.

BACKGROUND: Studies have shown disparate results on the consequences of morphine use in ST-segment elevation myocardial infarction (STEMI). No study has evaluated alternative treatments that could be at least non-inferior to morphine without its potentially damaging consequences for myocardial function and platelet reactivity. The aim of this study was to evaluate whether nitrous oxide/oxygen plus intravenous acetaminophen (NOO-A) is non-inferior to morphine to control chest pain in STEMI patients. METHODS: This multicenter, open-label, cluster-randomized, controlled, non-inferiority study compared NOO-A with morphine in 684 prehospital patients with ongoing suspected STEMI of < 12 h duration and a pain rating score ≥ 4. The primary endpoint was the proportion of patients achieving pain relief (numeric rating score ≤ 3) after 30 min. Secondary safety endpoints included serious adverse events and death at 30 days. RESULTS: The median baseline pain score was 7.0 in both groups. The primary endpoint occurred in 51.7% of the NOO-A group and 73.6% of the morphine group (absolute risk difference - 21.7%; 95% confidence interval - 29.6 to - 13.8). At 30 days, the rate of serious adverse events was 16.0 and 18.8% in the NOO-A and morphine groups respectively (p = NS). The rate of death was 1.8% (NOO-A group) and 3.8% (morphine group) (p = NS). CONCLUSION: Analgesia provided by NOO-A was inferior to morphine at 30 min in patients with acute STEMI in the prehospital setting. Rates of serious adverse events did not differ between groups. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02198378.

ReACanROC: Towards the creation of a France-Canada research network for out-of-hospital cardiac arrest.

AIMS: There are large differences between emergency medical systems, which may account for variability in outcomes. We seek to compare prehospital organizations, response modes, patient characteristics and outcomes after out-of-hospital cardiac arrest, between France and Canada, and discuss the need for the first European-North American prehospital research network on out-of-hospital cardiac arrest. METHODS: Preliminary comparative description of data drawn from two nation-wide, population-based, Utstein-style prospectively implemented registries for out-of-hospital cardiac arrest in France and Canada (France: RéAC, Canada: CanROC), covering approximately 80 million people, and soon to be participating in an international research network in 2020. RESULTS: Since creation, 103,722 cases were included in France and approximately 99,317 in Canada. Data used in this work were drawn from 2011 to 2016, and comprised around 33,688 adult, non-traumatic, treated cases in Canada, and 55,358 in France, leading to estimated incidence rates of 75.3/100,000 inhabitants in France and 83/100,000 in Canada. In both countries, out-of-hospital cardiac arrest predominantly occurred in male patients, in their late sixties, at home, of presumed cardiac aetiology. Bystander cardiopulmonary resuscitation was provided in half of the cases. First assessed cardiac rhythm was shockable in 16% (France) vs. 22% (Canada). Professional resuscitation was attempted in 82% (France) and 60% (Canada). Prehospital organizations and response modes differed in the constitution of responding teams (France: physician-led advanced life support, Canada: trained paramedics), in response time intervals (call to first professional responders' arrival at scene 6.5 min (interquartile range IQR [5.2-8.3]) (Canada) vs. 10 min [7-15] (France)), in on-scene interventions, type of referral at hospital (France: systematic bypass of emergency department, tertiary hospital first, Canada: occasional bypass, mainly closest hospital first), and in outcomes (overall survival at hospital discharge in France: 5% vs. Canada: 11%). CONCLUSION: Despite similarities in some out-of-hospital cardiac arrest Utstein variables, several differences exist between French and Canadian prehospital systems, and ultimately, between outcomes. The creation of the ReACanROC research network will facilitate the conduction of further analyses to better understand predictors of this variability.

Intraosseous Versus Peripheral Intravenous Access During Out-of-Hospital Cardiac Arrest: a Comparison of 30-Day Survival and Neurological Outcome in the French National Registry.

PURPOSE: To compare intraosseous access with peripheral venous access on adults out-of-hospital cardiac arrest (OHCA) patients' clinical outcomes. METHODS: A national retrospective multicentre study was conducted based on the French National Cardiac Arrest Registry. Comparison of patients (intraosseous vs. peripheral venous access) was conducted before and after a matching using a propensity score. The propensity score included confounding factors: age, time between the call (T0) to epinephrine (to take account of how quickly vascular access was achieved), the aetiology of OHCA, the shock and the patient initial rhythm at MMT arrival. RESULTS: A total of 1576 patients received intraosseous access, and 27,280 received peripheral intravenous access. Before matching, OHCA patients with intraosseous access were less likely to survive at all stages (return of spontaneous circulation (ROSC), 0-day survival and 30-day survival). No significant difference in neurological outcome was observed. After propensity score matching, no significant differences in 30-day survival rates (OR = 0.763 [0.473;1.231]) and neurological outcome (OR = 1.296 [0.973;1.726]) were observed. However, intraosseous patients still showed lower likelihood of short-term survival (ROSC and 0-day survival) even after propensity score matching was implemented. CONCLUSION: The populations we investigated were similar to those of other studies suggesting that intraosseous access is associated with reduced survival and poorer neurological outcome. Our findings suggest that intraosseous access is a comparably effective alternative to peripheral intravenous access for treating OHCA patients on matched populations.

Factors associated with inappropriate use of emergency departments: findings from a cross-sectional national study in France.

BACKGROUND: Inappropriate visits to emergency departments (EDs) could represent from 20% to 40% of all visits. Inappropriate use is a burden on healthcare costs and increases the risk of ED overcrowding. The aim of this study was to explore socioeconomic and geographical determinants of inappropriate ED use in France. METHOD: The French Emergency Survey was a nationwide cross-sectional survey conducted on June 11 2013, simultaneously in all EDs in France and covered characteristics of patients, EDs and counties. The survey included 48 711 patient questionnaires and 734 ED questionnaires. We focused on adult patients (≥15 years old). The appropriateness of the ED visit was assessed by three measures: caring physician appreciation of appropriateness (numeric scale), caring physician appreciation of whether or not the patient could have been managed by a general practitioner and ED resource utilisation. Descriptive statistics and multilevel logistic regression were used to examine determinants of inappropriate ED use, estimating adjusted ORs and 95% CIs. RESULTS: Among the 29 407 patients in our sample, depending on the measuring method, 13.5% to 27.4% ED visits were considered inappropriate. Regardless of the measure method used, likelihood of inappropriate use decreased with older age and distance from home to the ED >10 km. Not having a private supplementary health insurance, having universal supplementary health coverage and symptoms being several days old increased the likelihood of inappropriate use. Likelihood of inappropriate use was not associated with county medical density. CONCLUSION: Inappropriate ED use appeared associated with socioeconomic vulnerability (such as not having supplementary health coverage or having universal coverage) but not with geographical characteristics. It makes us question the appropriateness of the concept of inappropriate ED use as it does not consider the distress experienced by the patient, and segments of society seem to have few other choices to access healthcare than the ED.