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.

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).

Management of decision of withholding and withdrawing life-sustaining treatments in French EDs.

BACKGROUND: Decisions of withholding or withdrawing life sustaining-treatments in emergency department are part of current practice but the decision-making process remains poorly described in the literature. STUDY OBJECTIVE: We conducted a study in two phases, the first comprising a retrospective chart review study of patients dying in the ED and the second comprising survey study of health care workers at 10 urban emergency departments in France. METHOD: In a first step, we analyzed medical records based on fifteen criteria of the decision-making process grouped into four categories: the collegiality, the traceability, the management and the communication as recommended by the international guidelines. In a second step, we conducted an auto-administrated survey to assess how the staff members (medical, paramedical) feel with the decision-making process. RESULTS: There were 273 deaths which occurred in the ED over the study period and we included 145 (53.1%) patients. The first-step analysis revealed that the traceability of the decision and the information given to patient or the relatives were the most reported points according to the recommendations. Three of the ten emergency departments had developed a written procedure. The collegial discussion and the traceability of the prognosis assessment were significantly increased in emergency department with a written procedure as well as management of pain, comfort care, and the communication with the patient or the relatives. In the second-step analysis, among the 735 staff members asked to take part in the survey, 287 (39.0%) answered. The medical and paramedical staff expressed difficult experience regarding the announcement and the communication with the patient and the relatives. CONCLUSION: The management of the decision to withhold or withdraw life-sustaining treatments must be improved in emergency departments according to the guidelines. A standard written procedure could be useful in clinical practice despite the lack of experienced difference between centers with and without procedures.

CDK2 is involved in the S-phase lengthening induced by glucocorticoids in normal human lymphocytes.

Involvement of CDK2 in glucocorticoid-mediated S-phase lengthening was analyzed in this work. Dexamethasone (DXM) treatment of PHA-stimulated lymphocytes induced a decrease in CDK2 mRNA expression without any change in mRNA stability. This glucocorticoid-induced decrease in CDK2 mRNA expression could be suppressed by cycloheximide treatment. These results support the hypothesis of an indirect effect of DXM at the transcriptional level. Furthermore, CDK2 protein expression also decreased while the rate of protein synthesis and stability remained unchanged, suggesting a second post-translational level of regulation with the preferential degradation of a CDK2 protein stock fraction. The analysis of co-precipitated proteins showed that glucocorticoids induced modifications of protein complex composition. We found i) a preservation of the linkage capability of CDK2 for cyclin E and A, ii) a relative increase in p27kip1 linkage, and iii) a decrease in p21waf1 complexed with CDK2. As a consequence of CDK2 decrease and modifications of protein complex composition, pRb and histone H1 kinase activity of CDK2 was profoundly decreased. All these results pinpoint the role of CDK2 in glucocorticoid-induced S-phase lengthening and the potential activator role of p21waf1 for CDK2 in human lymphocytes.