Assessment of physicians' resilience level during the COVID-19 pandemic.

We aim to assess physicians' level of resilience and define factors that improve or decrease the resilience level during the COVID-19 pandemic. Physicians from hospitals located in areas with different COVID-19 caseload levels, were invited to participate in a national e-survey between April and May 2020. Study participants were mainly emergency physicians, and anaesthesiologists, infectious disease consultants, and intensive care. The survey assessed participant's characteristics, factors potentially associated with resilience, and resilience using the Connor-Davidson Resilience Scale (RISC-25), with higher scores indicative of greater resilience. Factors associated with the resilience score were assessed using a multivariable linear regression. Of 451 responding physicians involved in the care of COVID-19 patients, 442 were included (98%). Age was 36.1 ± 10.3 years and 51.8% were male; 63% worked in the emergency department (n = 282), 10.4% in anesthesiology (n = 46), 9.9% in infectious disease department (n = 44), 4.8% in intensive care unit (n = 21) or other specialties (n = 49). The median RISC-25 score was at 69 (IQR 62-75). Factors associated with higher RISC scores were anesthesia as a specialty, parenthood, no previous history of anxiety or depression and nor increased anxiety. To conclude, this study is the first to characterize levels of resilience among physicians involved in COVID-19 unit. Our data points to certain protective characteristics and some detrimental factors, such as anxiety or depression, that could be amenable to remediating or preventing strategies to promote resilience and support caregivers in a pandemic.

Impact of two-level filtering on emergency medical communication center triage during the COVID-19 pandemic: an uncontrolled before-after study.

BACKGROUND: Rapid access to emergency medical communication centers (EMCCs) is pivotal to address potentially life-threatening conditions. Maintaining public access to EMCCs without delay is crucial in case of disease outbreak despite the significant increased activity and the difficulties to mobilize extra staff resources. The aim of our study was to assess the impact of two-level filtering on EMCC performance during the COVID-19 outbreak. METHODS: A before-after monocentric prospective study was conducted at the EMCC at the Nantes University Hospital. Using telephone activity data, we compared EMCC performance during 2 periods. In period one (February 27th to March 11th 2020), call takers managed calls as usual, gathering basic information from the caller and giving first aid instructions to a bystander on scene if needed. During period two (March 12th to March 25th 2020), calls were answered by a first-line call taker to identify potentially serious conditions that required immediate dispatch. When a serious condition was excluded, the call was immediately transferred to a second-line call taker who managed the call as usual so the first-line call taker could be rapidly available for other incoming calls. The primary outcome was the quality of service at 20 s (QS20), corresponding to the rate of calls answered within 20 s. We described activity and outcome measures by hourly range. We compared EMCC performance during periods one and two using an interrupted time series analysis. RESULTS: We analyzed 45,451 incoming calls during the two study periods: 21,435 during period 1 and 24,016 during period 2. Between the two study periods, we observed a significant increase in the number of incoming calls per hour, the number of connected call takers and average call duration. A linear regression model, adjusted for these confounding variables, showed a significant increase in the QS20 slope (from - 0.4 to 1.4%, p = 0.01), highlighting the significant impact of two-level filtering on the quality of service. CONCLUSIONS: We found that rapid access to our EMCC was maintained during the COVID-19 pandemic via two-level filtering. This system helped reduce the time gap between call placement and first-line call-taker evaluation of a potentially life-threatening situation. We suggest implementing this system when an EMCC faces significantly increased activity with limited staff resources.

Impact of the COVID-19 lockdown period on adult musculoskeletal injuries and surgical management: a retrospective monocentric study.

The coronavirus disease 2019 (COVID-19) pandemic has led to the worldwide implementation of unprecedented public protection measures. On the 17th of March, the French government announced a lockdown of the population for 8 weeks. This monocentric study assessed the impact of this lockdown on the musculoskeletal injuries treated at the emergency department as well as the surgical indications. We carried out a retrospective study in the Emergency Department and the Surgery Department of Nantes University Hospital from 18 February to 11 May 2020. We collected data pertaining to the demographics, the mechanism, the type, the severity, and inter-hospital transfer for musculoskeletal injuries from our institution. We compared the 4-week pre-lockdown period and the 8-week lockdown period divided into two 4-week periods: early lockdown and late lockdown. There was a 52.1% decrease in musculoskeletal injuries among patients presenting to the Emergency Department between the pre-lockdown and the lockdown period (weekly incidence: 415.3 ± 44.2 vs. 198.5 ± 46.0, respectively, p < .001). The number of patients with surgical indications decreased by 33.4% (weekly incidence: 44.3 ± 3.8 vs. 28.5 ± 10.2, p = .048). The policy for inter-hospital transfers to private entities resulted in 64 transfers (29.4%) during the lockdown period. There was an increase in the incidence of surgical high severity trauma (Injury Severity Score > 16) between the pre-lockdown and the early lockdown period (2 (1.1%) vs. 7 (7.2%), respectively, p = .010) as well as between the pre-lockdown and the late lockdown period (2 (1.1%) vs. 10 (8.3%), respectively, p = .004). We observed a significant increase in the weekly emergency department patient admissions between the early and the late lockdown period (161.5 ± 22.9, 235.5 ± 27.7, respectively, p = .028). A pronounced decrease in the incidence of musculoskeletal injuries was observed secondary to the lockdown measures, with emergency department patient admissions being halved and surgical indications being reduced by a third. The increase in musculoskeletal injuries during the late confinement period and the higher incidence of severe trauma highlights the importance of maintaining a functional trauma center organization with an inter-hospital transfer policy in case of a COVID-19s wave lockdown.

Are third-generation cephalosporins associated with a better prognosis than amoxicillin-clavulanate in patients hospitalized in the medical ward for community-onset pneumonia?

OBJECTIVES: We aimed to assess whether treatment with ceftriaxone/cefotaxime is associated with lower in-hospital mortality than amoxicillin-clavulanate in pati0ents hospitalized in medical wards for community-onset pneumonia. METHODS: We conducted a retrospective and multicentre study of patients hospitalized in French medical wards for community-onset pneumonia between 2002 and 2015. Treatments with ceftriaxone/cefotaxime or amoxicillin-clavulanate were defined by their start in the emergency department for a duration of 5 days or more with no other ß-lactam. A logistic regression analysis was performed on the overall population, and a propensity score analysis was restricted to patients treated with either ceftriaxone/cefotaxime or amoxicillin-clavulanate. RESULTS: 1698 patients (median age, 80 y) were included, of which 716 and 198 were treated with amoxicillin-clavulanate and ceftriaxone/cefotaxime, respectively. In-hospital mortality was 10% (9-12%). In multivariate analysis, factors associated with in-hospital mortality were treatment with ceftriaxone/cefotaxime (aOR 2.9; (1.4-5.7)), pneumonia severity index class 4 or 5 (aOR 7.8 (4.3-15.7)), do-not-resuscitate order (aOR 8.7 (5.2-14.6)) and fluid therapy (aOR 6.3 (2.5-15.1)). The propensity score analysis was performed on 178 patients treated with ceftriaxone/cefotaxime matched with 178 patients treated with amoxicillin-clavulanate; no significant association between treatment with ceftriaxone/cefotaxime and in-hospital mortality was found (OR 1.5 (0.7-3.0)). CONCLUSION: In the largest study aiming to compare amoxicillin-clavulanate and ceftriaxone/cefotaxime in community-onset pneumonia, ceftriaxone/cefotaxime was not associated with lower in-hospital mortality than amoxicillin-clavulanate. Our results suggest that ceftriaxone/cefotaxime should not be preferred over amoxicillin-clavulanate for patients hospitalized in medical wards with community-onset pneumonia.

Prognostic performance of early absence of pupillary light reaction after recovery of out of hospital cardiac arrest.

INTRODUCTION: Loss of pupillary light reactivity (PLR) three days after a cardiorespiratory arrest is a prognostic factor. Its predictive value upon hospital admission remains unclear. Our objective was to determine the prognostic value of the absence of PLR upon hospital admission in patients with out-of-hospital cardiac arrest. METHODS: We prospectively included all out-of-hospital cardiac arrests occurring between July 2011 and July 2017 treated by a mobile medical team (MMT) based on data from a French cardiac arrest registry database. PLR was evaluated upon hospital admission and the outcome on day 30. The prognosis was classified as good for Cerebral Performance Category (CPC) 1 or 2, and poor for CPC 3-5 or in case of death. RESULTS: Data from 10151 patients was analysed. The sensitivity and specificity of the absence of PLR for a poor outcome were 72.2% (71.2-73.2) and 68.8% (66.7-70.1), respectively. We identified several variables modifying the sensitivity values and the false positive fraction of a factor, ranging from 0.49 (0.35-0.69) for the Glasgow Coma Scale to 2.17 (1.09-2.48) for pupillary asymmetry. Among those living with CPC 1 or 2 on day 30 (n = 1990; 19.6%), 621 (31.2% (29.2-33.3)) had no PLR upon hospital admission. In the multivariate analysis, loss of PLR was associated with a poor outcome (OR = 3.1 (2.7-3.5)). CONCLUSIONS: Loss of pupillary light reactivity upon hospital admission is predictive of a poor outcome after out-of-hospital cardiac arrest. However, it does not have sufficient accuracy to determine prognosis and decision making.

Systematic review: human gut dysbiosis induced by non-antibiotic prescription medications.

BACKGROUND: Global prescription drug use has been increasing continuously for decades. The gut microbiome, a key contributor to health status, can be altered by prescription drug use, as antibiotics have been repeatedly described to have both short-term and long-standing effects on the intestinal microbiome. AIM: To summarise current findings on non-antibiotic prescription-induced gut microbiome changes, focusing on the most frequently prescribed therapeutic drug categories. METHODS: We conducted a systematic review by first searching in online databases for indexed articles and abstracts in accordance with PRISMA guidelines. Studies assessing the intestinal microbiome alterations associated with proton pump inhibitors (PPIs), metformin, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, statins and antipsychotics were included. We only included studies using culture-independent molecular techniques. RESULTS: Proton pump inhibitors and antipsychotic medications are associated with a decrease in α diversity in the gut microbiome, whereas opioids were associated with an increase in α diversity. Metformin and NSAIDs were not associated with significant changes in α diversity. ß diversity was found to be significantly altered with all drugs, except for NSAIDs. PPI use was linked to a decrease in Clotridiales and increase in Actinomycetales, Micrococcaceae and Streptococcaceae, which are changes previously implicated in dysbiosis and increased susceptibility to Clostridium difficile infection. Consistent results showed that PPIs, metformin, NSAIDs, opioids and antipsychotics were either associated with increases in members of class Gammaproteobacteria (including Enterobacter, Escherichia, Klebsiella and Citrobacter), or members of family Enterococcaceae, which are often pathogens isolated from bloodstream infections in critically ill patients. We also found that antipsychotic treatment, usually associated with an increase in body mass index, was marked by a decreased ratio of Bacteroidetes:Firmicutes in the gut microbiome, resembling trends seen in obese patients. CONCLUSIONS: Non-antibiotic prescription drugs have a notable impact on the overall architecture of the intestinal microbiome. Further explorations should seek to define biomarkers of dysbiosis induced by specific drugs, and potentially tailor live biotherapeutics to counter this drug-induced dysbiosis. Many other frequently prescribed drugs should also be investigated to better understand the link between these drugs, the microbiome and health status.