Are there socio-economic inequities in access to reperfusion therapy: The stroke 69 cohort.

BACKGROUND AND PURPOSE: Low socio-economic status of individuals has been reported to be associated with a higher incidence of stroke and influence the diagnosis after revascularization. However, whether it is associated with poorer acute stroke management is less clear. To determine whether social deprivation was associated with a poorer access to reperfusion therapy, either intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT) in a population-based cohort. METHODS: Over a 14-month period, all consecutive adult patients admitted to any emergency department or a comprehensive or primary stroke center (CSC/PSC) of the Rhône county with a confirmed ischemic stroke were included. The socioeconomic status of each patient was measured using the European Deprivation Index (EDI). The association between EDI and access to reperfusion therapy was assessed in univariate and multivariate logistic regression analyses. RESULTS: Among the 1226 consecutive IS patients, 316 (25%) were admitted directly in a PSC or CSC, 241 (19.7%) received a reperfusion therapy; 155 IVT alone, 20 EVT alone, and 66 both therapies. Median age was 79 years, 1030 patients had an EDI level of 1 to 4, and 196 an EDI of 5 (the most deprived group). The most deprived patients (EDI level 5) did not have a poorer access to reperfusion therapy compared to all other patients in univariate (OR 1.22, 95%CI [0.85; 1.77]) nor in multivariate analyses (adjOR 0.97, 95%CI [0.57; 1.66]). CONCLUSIONS: We did not find any significant association between socioeconomic deprivation and access to reperfusion therapy. This suggests that the implementation of EVT was not associated with increased access inequities.

Short and long-term impact of four sets of actions on acute ischemic stroke management in Rhône County, a population based before-and-after prospective study.

BACKGROUND: Optimizing access to recanalization therapies in acute ischemic stroke patients is crucial. Our aim was to measure the short and long term effectiveness, at the acute phase and 1 year after stroke, of four sets of actions implemented in the Rhône County. METHODS: The four multilevel actions were 1) increase in stroke units bed capacity and development of endovascular therapy; 2) improvement in knowledge and skills of healthcare providers involved in acute stroke management using a bottom-up approach; 3) development and implementation of new organizations (transportation routes, pre-notification, coordination by the emergency call center physician dispatcher); and 4) launch of regional public awareness campaigns in addition to national campaigns. A before-and-after study was conducted with two identical population-based cohort studies in 2006-7 and 2015-16 in all adult ischemic stroke patients admitted to any emergency department or stroke unit of the Rhône County. The primary outcome criterion was in-hospital management times, and the main secondary outcome criteria were access to reperfusion therapy (either intravenous thrombolysis or endovascular treatment) and pre-hospital management times in the short term, and 12-month prognosis measured by the modified Rankin Scale (mRS) in the long term. RESULTS: Between 2015-16 and 2006-7 periods ischemic stroke patients increased from 696 to 717, access to reperfusion therapy increased from 9 to 23% (p < 0.0001), calls to emergency call-center from 40 to 68% (p < 0.0001), first admission in stroke unit from 8 to 30% (p < 0.0001), and MRI within 24 h from 18 to 42% (p < 0.0001). Onset-to-reperfusion time significantly decreased from 3h16mn [2 h54-4 h05] to 2h35mn [2 h05-3 h19] (p < 0.0001), mainly related to a decrease in delay from admission to imaging. A significant decrease of disability was observed, as patients with mild disability (mRS [0-2]) at 12 months increased from 48 to 61% (p < 0.0001). Pre-hospital times, however, did not change significantly. CONCLUSIONS: We observed significant improvement in access to reperfusion therapy, mainly through a strong decrease of in-hospital management times, and in 12-month disability after the implementation of four sets of actions between 2006 and 2016 in the Rhône County. Reducing pre-hospital times remains a challenge.

French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury.

OBJECTIVES: To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury. DESIGN: A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS: The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology. RESULTS: The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS: There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.

Acute renal and splenic infarctions: a review.

BACKGROUND: Renal and splenic infarctions are close entities, with few data concerning their clinical, biological and radiological features. AIM: The aim of this study was to compare the clinical presentations, etiologies and outcomes of acute renal infarctions (RI) and splenic infarctions (SI). DESIGN: A retrospective multicentric cohort study included patients of the 6 university hospitals in Lyon with RI, SI, or associated RI-SI infarctions was conducted. METHODS: All consecutive cases diagnosed by CT imaging, between January 2013 and October 2016, were included. The exclusion criteria were causes of infarction that did not require additional investigations. RESULTS: A total of 161 patients were selected for analysis: 34 patients with RI, 104 patients with SI and 23 patients with both RI-SI. Mean ± SD age of patients was 63.2 ± 16.6 years; 59.6% were male. Only 5/161 (3.1%) were healthy prior to the event. The main symptoms were diffuse abdominal pain (26.4%), followed by nausea/vomiting (18.3%) and fever (16.4%).The causes of RI or SI varied significantly within the three groups. Hypercoagulable state was associated with SI, and embolic disease and arterial injury were associated with RI. Extensive (i.e.>2/3 of organ volume) (OR 6.22, 95%CI 2.0119.22) and bilateral infarctions (OR 15.05, 95%CI 1.79-126.78) were significantly associated with hemodynamic shocks. The survival at 1 month follow-up did not significantly differ between the three groups. CONCLUSION: Acute RI and SI are heterogenous entities in regards to their clinical presentation, etiology, associated venous or arterial thrombosis, but prognoses were not different at short term follow-up.

[Impact of the 2009 Afssaps guidelines on the management of venous thromboembolic disease in emergency department: Before/after study]. / Impact des recommandations Afssaps 2009 sur la prise en charge de la maladie thromboembolique veineuse aux urgences : étude avant/après.

INTRODUCTION: The French Agency for Health Safety of Products published recommendations of good practices (RGP) for the treatment of venous thromboembolic disease in 2009. Four of these recommendations apply to the initial management of the disease, with the objective of this study is to determine whether the development and diffusion of the four RGP has had an impact on the practice. METHODS: A retrospective before/after study comparing 132 patients treated in emergency department of the Civil Hospices of Lyon for pulmonary embolism (PE) and/or deep venous thrombosis (DVT) in 2008-2009 ("before") and 153 patients in 2010-2011 ("after"). RESULTS: In the "before" period, 70 patients were treated for DVT and 62 patients for PE. In the "after" period, 50 patients were treated for DVT and 103 patients for PE. The compliance rate was not significantly different for the two periods for each RGP except for the indication of low molecular weight Heparin (LMWH) or fondaparinux in the absence of severe renal failure (21% "before" vs. 45% "after"; P=0.02) for patients with PE. Management for the four recommendations was conform for 5.6% of eligible patients in the "before" period and for 3.7% for the "after" period. CONCLUSION: Our study shows that globally there is no impact of RGP. The reasons appear multiple with first, the mere dissemination and the absence of implementation of these guidelines.

Measurement of the potential geographic accessibility from call to definitive care for patient with acute stroke.

BACKGROUND: The World Health Organization refers to stroke, the second most frequent cause of death in the world, in terms of pandemic. Present treatments are only effective within precise time windows. Only 10% of thrombolysis patients are eligible. Late assessment of the patient resulting from admission and lack of knowledge of the symptoms is the main explanation of lack of eligibility. METHODS: The aim is the measurement of the time of access to treatment facilities for stroke victims, using ambulances (firemen ambulances or EMS ambulances) and private car. The method proposed analyses the potential geographic accessibility of stroke care infrastructure in different scenarios. The study allows better considering of the issues inherent to an area: difficult weather conditions, traffic congestion and failure to respect the distance limits of emergency transport. RESULTS: Depending on the scenario, access times vary considerably within the same commune. For example, between the first and the second scenario for cities in the north of Rhône county, there is a 10 min difference to the nearest Primary Stroke Center (PSC). For the first scenario, 90% of the population is 20 min away of the PSC and 96% for the second scenario. Likewise, depending on the modal vector (fire brigade or emergency medical service), overall accessibility from the emergency call to admission to a Comprehensive Stroke Center (CSC) can vary by as much as 15 min. CONCLUSIONS: The setting up of the various scenarios and modal comparison based on the calculation of overall accessibility makes this a new method for calculating potential access to care facilities. It is important to take into account the specific pathological features and the availability of care facilities for modelling. This method is innovative and recommendable for measuring accessibility in the field of health care. This study makes possible to highlight the patients' extension of care delays. Thus, this can impact the improvement of patient care and rethink the healthcare organization. Stroke is addressed here but it is applicable to other pathologies.

Prehospital parameters can help to predict coagulopathy and massive transfusion in trauma patients.

BACKGROUND: This study aimed to evaluate the accuracy of prehospital parameters, including vital signs and resuscitation (fluids, vasopressor), to predict trauma-induced coagulopathy (TIC, fibrinogen <1·5 g/l or PTratio > 1·5 or platelet count <100 × 109 /l), and a massive transfusion (MT, ≥10 RBC units within the first 24 h). METHODS: From a trauma registry (2011-2015), in which patients are prospectively included, we retrospectively retrieved the heart rate (HR), systolic blood pressure (SBP), volume of prehospital fluids and administration of noradrenaline. We calculated the shock index (SI: HR/SBP), the MGAP prehospital triage score and the Injury Severity Score (ISS). We also identified patients who had positive criteria from the Resuscitation Outcome Consortium (ROC, SBP < 70 mmHg or SBP 70-90 and HR > 107 pulse/min). For these parameters, we drew a ROC curve and defined a cut-off value to predict TIC or MT. The strength of association between prehospital parameters and TIC as well as MT was assessed using logistic regression, and cut-off values were determined using ROC curves. RESULTS: Among the 485 patients included in the study, TIC was observed in 112 patients (23%) and MT in 22 patients (5%). For the prediction of TIC, ISS had good accuracy (AUC: 0·844, 95% confidence interval, CI: 0·799-0·879), as did the volume of fluids (>1000 ml) given during prehospital care (AUC: 0·801, 95% CI: 0·752-0·842). For the prediction of MT, ISS had excellent accuracy (AUC: 0·932, 95% CI: 0·866-0·966), whereas good accuracy was found for SI (> 0·9; AUC: 0·859, 95% CI: 0·705-0·936), vasopressor administration (AUC: 0·828, 95% CI: 0·736-0·890) and fluids (>1000 ml; AUC: 0·811, 95% CI: 0·737-0·867). Vasopressor administration, ISS and SI were independent predictors of TIC and MT, whereas fluid volume and ROC criteria were independent predictor of TIC but not MT. No independent relationship was found between MGAP and TIC or MT. CONCLUSIONS: Prehospital parameters including the SI and resuscitation may help to better identify the severity of bleeding in trauma patients and the need for blood product administration at admission.

[Use of thrombelastography to guide posttraumatic hemostatic therapy: More coagulation factor concentrates and less allogenic blood transfusion?] / Intérêt de la thromboélastographie pour guider la correction de la coagulopathie post-traumatique : plus de MDS, moins de PSL ?

Viscoelastic technics are used for 10 years and include the ROTEM® and the TEG®. These devices that exploit the viscoelastic properties of the clotting blood, allow a rapid and global analysis of the haemostatic process taking into account all the process interfering with haemostasis such as inflammation. It has been shown that the use of these technics in clinical situations such as trauma, postpartum haemorrhage, gastrointestinal bleeding or cardiac surgery may reduce the need for blood product, the cost and perhaps may improve the outcome of the patients. Thanks to a rapid identification of the underlying coagulation deficit, these technics facilitate decision-making during acute care and help to guide the treatment, particularly with coagulation factor's concentrate.

[Storing succinylcholine in prehospital settings following the recommendations of the French National Agency for the safety of medicines]. / Conservation de la succinylcholine en préhospitalier après recommandations de l'Agence nationale de santé et du médicament.

OBJECTIVE: The French National Pharmaceuticals Agency (ANSM) has recommanded in July 2012 not to break the cold chain before using succinylcholine (Celocurine®). RESEARCH OBJECTIVE: to understand the pre-clinical evolution of the conservation modes of this curare. RESEARCH TYPE: Descriptive study before (year 2011) and after (year 2012). PATIENTS AND METHOD: Online survey to French Samu/Smur. DATA COLLECTED: SMUR location, conservation method at clinical base, in the mobile unit (UMH) and at the patient. Principal decision criteria: evolution of the conservation modes before and after the recommendation (qualitatives variables compared with a Fisher test). RESULTS: Out of 101 SAMU/SMUR, 62 answered. Conservation modes of succinylcholine vials were significantly different (P<0.001). Proper conservation was observed in 26 % of the cases before and 43 % after. Mobile units (UMH) equipped with a fridge increased from one out of two to 77 %. The lack of conservation modes passive or active on UMH went from 31 % to 3.4 % with isotherms bags with ice when a fridge was not available. The destruction of capsules at current temperature in a 24-hour period increased: 22 % before, 47 % after (P=0.04). CONCLUSION: After recommendations from ANSM, conservation modes and destruction of succinylcholine in a prehospital environment were significantly impacted.

Update on prehospital emergency care of severe trauma patients.

The prognosis of severe trauma patients is determined by the ability of a healthcare system to provide high intensity therapeutic treatment on the field and to transport patients as quickly as possible to the structure best suited to their condition. Direct admission to a specialized center ("trauma center") reduces the mortality of the most severe trauma at 30 days and one year. Triage in a non-specialized hospital is a major risk of loss of chance and should be avoided whenever possible. Medical dispatching plays a major role in determining patient care. The establishment of a hospital care network is an important issue that is not formalized enough in France. The initial triage of severe trauma patients must be improved to avoid taking patients to hospitals that are not equipped to take care of them. For this purpose, the MGAP score can predict severity and help decide where to transport the patient. However, it does not help predict the need for urgent resuscitation procedures. Hemodynamic management is central to the care of hemorrhagic shock and severe head trauma. Transport helicopter with a physician on board has an important role to allow direct admission to a specialized center in geographical areas that are difficult to access.

The concept of damage control: extending the paradigm in the prehospital setting.

OBJECTIVE: The purpose of this review is to present the progressive extension of the concept of damage control resuscitation, focusing on the prehospital phase. ARTICLE TYPE: Review of the literature in Medline database over the past 10 years. DATA SOURCE: Medline database looking for articles published in English or in French between April 2002 and March 2013. Keywords used were: damage control resuscitation, trauma damage control, prehospital trauma, damage control surgery. Original articles were firstly selected. Editorials and reviews were secondly studied. DATA SYNTHESIS: The importance of early management of life-threatening injuries and rapid transport to trauma centers has been widely promulgated. Technical progress appears for external methods of hemostasis, with the development of handy tourniquets and hemostatic dressings, making the crucial control of external bleeding more simple, rapid and effective. Hypothermia is independently associated with increased risk of mortality, and appeared accessible to improvement of prehospital care. The impact of excessive fluid resuscitation appears negative. The interest of hypertonic saline is denied. The place of vasopressor such as norepinephrine in the early resuscitation is still under debate. The early use of tranexamic acid is promoted. Specific transfusion strategies are developed in the prehospital setting. CONCLUSION: It is critical that both civilian and military practitioners involved in trauma continue to share experiences and constructive feedback. And it is mandatory now to perform well-designed prospective clinical trials in order to advance the topic.

The initial management of trauma patients is an especially relevant setting to evaluate professional practice patterns.

The initial management of trauma patients in a dedicated location is a crucial step in the treatment of these patients. The characteristics of this phase are such that they meet all the criteria for a professional practice patterns evaluation (PPPE or PPE): formalized protocols, clear-cut timeframes, specific roles of different stakeholders, and multidisciplinary medical and paramedical team. In addition, the expected result of the PPE approach, improved care, will have a direct impact on patient outcomes. This PPE modeled on an audit aims at evaluating the care process based on representative criteria. These criteria should include: the planned structure and organization; the protocols; the strategy and time frames for procedure implementation; the relationships between stakeholders; the results. For each criterion, differences between the expected characteristics and the observed reality are analyzed. The prospective (independent observer or video) and/or retrospective (records, register) collection of data during 20 consecutive encounters should be sufficient to identify dysfunctions and provide guidance on the changes that need to be implemented. The proposed data collection form includes 15 items representative of the five defined criteria. These items often describe departmental choice. The pursuit of quality is defined first in terms of medical and paramedical results, but also in administrative and financial terms. Following the analysis produced by a representative group of actors, a multidisciplinary discussion of the results should be followed by proposals for simple changes approved by everyone. After a few months of implementation, the impact of the proposed improvement measures will be assessed by a new survey. This approach, in addition to improving the quality of care, allows better team stress management and greater work enjoyment.

Predictive factors for 1-year outcome of a cohort of patients with severe traumatic brain injury (TBI): results from the PariS-TBI study.

OBJECTIVES: To assess outcome and predicting factors 1 year after a severe traumatic brain injury (TBI). METHODS: Multi-centre prospective inception cohort study of patients aged 15 or older with a severe TBI in the Parisian area, France. Data were collected prospectively starting the day of injury. One-year evaluation included the relatives-rating of the Dysexecutive Questionnaire (DEX-R), the Glasgow Outcome Scale-Extended (GOSE) and employment. Univariate and multivariate tests were computed. RESULTS: Among 257 survivors, 134 were included (mean age 36 years, 84% men). Good recovery concerned 19%, moderate disability 43% and severe disability 38%. Among patients employed pre-injury, 42% were working, 28% with no job change. DEX-R score was significantly associated with length of education only. Among initial severity measures, only the IMPACT prognostic score was significantly related to GOSE in univariate analyses, while measures relating to early evolution were more significant predictors. In multivariate analyses, independent predictors of GOSE were length of stay in intensive care (LOS), age and education. Independent predictors of employment were LOS and age. CONCLUSIONS: Age, education and injury severity are independent predictors of global disability and return to work 1 year after a severe TBI.

Refractory cardiac arrest in a rural area: mechanical chest compression during helicopter transport.

BACKGROUND: Out-of-hospital refractory cardiac arrest patients can be transported to a hospital for extracorporeal life support (ECLS), which can be either therapeutic or performed for organ donation. Early initiation is of vital importance and the main limitation when considering ECLS. This explains that all reported series of cardiac arrest patients referred for ECLS were urban ones. We report a series of rural out-of-hospital non-heart-beating patients transported by helicopter. METHODS: This observational study was performed in two rural districts in France. Data on patients with pre-hospital criteria for ECLS who were transported to the hospital by helicopter, maintained by mechanical chest compression, were recorded over a 2-year period. RESULTS: During the study period, 27 patients were referred for ECLS, of which 14 for therapeutic ECLS and 13 for organ preservation. The median transport distance was 37 km (25th and 75th percentiles: 31-58; range 25 to 94 km). Among the therapeutic ECLS patients, one survived to discharge from the hospital. Liver and kidneys were retrieved in another patient after brain death was ascertained. In the 13 patients referred for organ donation, four were excluded for medical reasons; 18 kidneys were retrieved in nine patients, of which six kidneys were successfully transplanted. CONCLUSION: In this preliminary study, we report the feasibility and the interest of helicopter transport of refractory cardiac arrest patients maintained by mechanical chest compression. Patients with refractory cardiac arrest occurring in rural areas, even at distance from a referral centre, can be candidates for ECLS.