Intensified screening for SARS-CoV-2 in 18 emergency departments in the Paris metropolitan area, France (DEPIST-COVID): A cluster-randomized, two-period, crossover trial.

BACKGROUND: Asymptomatic and paucisymptomatic infections account for a substantial portion of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmissions. The value of intensified screening strategies, especially in emergency departments (EDs), in reaching asymptomatic and paucisymptomatic patients and helping to improve detection and reduce transmission has not been documented. The objective of this study was to evaluate in EDs whether an intensified SARS-CoV-2 screening strategy combining nurse-driven screening for asymptomatic/paucisymptomatic patients with routine practice (intervention) could contribute to higher detection of SARS-CoV-2 infections compared to routine practice alone, including screening for symptomatic or hospitalized patients (control). METHODS AND FINDINGS: We conducted a cluster-randomized, two-period, crossover trial from February 2021 to May 2021 in 18 EDs in the Paris metropolitan area, France. All adults visiting the EDs were eligible. At the start of the first period, 18 EDs were randomized to the intervention or control strategy by balanced block randomization with stratification, with the alternative condition being applied in the second period. During the control period, routine screening for SARS-CoV-2 included screening for symptomatic or hospitalized patients. During the intervention period, in addition to routine screening practice, a questionnaire about risk exposure and symptoms and a SARS-CoV-2 screening test were offered by nurses to all remaining asymptomatic/paucisymptomatic patients. The primary outcome was the proportion of newly diagnosed SARS-CoV-2-positive patients among all adults visiting the 18 EDs. Primary analysis was by intention-to-treat. The primary outcome was analyzed using a generalized linear mixed model (Poisson distribution) with the center and center by period as random effects and the strategy (intervention versus control) and period (modeled as a weekly categorical variable) as fixed effects with additional adjustment for community incidence. During the intervention and control periods, 69,248 patients and 69,104 patients, respectively, were included for a total of 138,352 patients. Patients had a median age of 45.0 years [31.0, 63.0], and women represented 45.7% of the patients. During the intervention period, 6,332 asymptomatic/paucisymptomatic patients completed the questionnaire; 4,283 were screened for SARS-CoV-2 by nurses, leading to 224 new SARS-CoV-2 diagnoses. A total of 1,859 patients versus 2,084 patients were newly diagnosed during the intervention and control periods, respectively (adjusted analysis: 26.7/1,000 versus 26.2/1,000, adjusted relative risk: 1.02 (95% confidence interval (CI) [0.94, 1.11]; p = 0.634)). The main limitation of this study is that it was conducted in a rapidly evolving epidemiological context. CONCLUSIONS: The results of this study showed that intensified screening for SARS-CoV-2 in EDs was unlikely to identify a higher proportion of newly diagnosed patients. TRIAL REGISTRATION: Trial registration number: ClinicalTrials.gov NCT04756609.

Can transcutaneous carbon dioxide pressure be a surrogate of blood gas samples for spontaneously breathing emergency patients? The ERNESTO experience.

BACKGROUND: It is known that the arterial carbon dioxide pressure (PaCO2) is useful for emergency physicians to assess the severity of dyspnoeic spontaneously breathing patients. Transcutaneous carbon dioxide pressure (PtcCO2) measurements could be a non-invasive alternative to PaCO2 measurements obtained by blood gas samples, as suggested in previous studies. This study evaluates the reliability of a new device in the emergency department (ED). METHODS: We prospectively included patients presenting to the ED with respiratory distress who were breathing spontaneously or under non-invasive ventilation. We simultaneously performed arterial blood gas measurements and measurement of PtcCO2 using a sensor placed either on the forearm or the side of the chest and connected to the TCM4 CombiM device. The agreement between PaCO2 and PtcCO2 was assessed using the Bland-Altman method. RESULTS: Sixty-seven spontaneously breathing patients were prospectively included (mean age 70 years, 52% men) and 64 first measurements of PtcCO2 (out of 67) were analysed out of the 97 performed. Nineteen patients (28%) had pneumonia, 19 (28%) had acute heart failure and 19 (28%) had an exacerbation of chronic obstructive pulmonary disease. Mean PaCO2 was 49 mm Hg (range 22-103). The mean difference between PaCO2 and PtcCO2 was 9 mm Hg (range -47 to +54) with 95% limits of agreement of -21.8 mm Hg and 39.7 mm Hg. Only 36.3% of the measurement differences were within 5 mm Hg. CONCLUSIONS: Our results show that PtcCO2 measured by the TCM4 device could not replace PaCO2 obtained by arterial blood gas analysis.

Serum sodium abnormalities during nonexertional heatstroke: incidence and prognostic values.

BACKGROUND: Although heatstroke is often associated with dehydration, the clinical significance of serum sodium abnormalities in patients with heat-related illness during heat wave has been poorly documented. METHOD: We evaluated 1263 patients (age, 82±15 years; body temperature, 40.1°C+1.2°C) admitted to emergency departments during the August 2003 heat wave in Paris, having a core temperature greater than 38.5°C and measurement of serum sodium concentrations. Patients were classified according to our previously described risk score of death. RESULTS: Hyponatremia (<135 mmol/L) was reported in 409 (32%) and hypernatremia (>145 mmol/L) in 220 patients (17%). One-year survival was significantly decreased in patients with hypernatremia (45%; P=.004) but not in those with hyponatremia (58%; P=.86) as compared with patients with serum sodium concentration in the reference range (57%). Using Cox regression, only hypernatremia was an independent prognostic factor (hazard ratio, 1.35; 95% confidence interval, 1.09-1.36) when risk score was taken into account. Using logistic regression, 2 variables were independently associated with hyponatremia (heatstroke severity score and blood urea nitrogen-creatinine ratio<100). Conversely, 5 variables were independently associated with hypernatremia (living in an institution, dementia, serum creatinine>120 µmol/L, a blood urea nitrogen-creatinine ratio >100, and absence of long-term diuretic intake). CONCLUSIONS: Serum sodium abnormalities are frequently observed in patients with a nonexertional heatstroke during heat wave; however, only hypernatremia should be considered as an independent risk factor of death. Rapid measurement of serum sodium concentration is mandatory to appropriately guide electrolyte resuscitation.

Elevation of cardiac troponin I during non-exertional heat-related illnesses in the context of a heatwave.

INTRODUCTION: The prognostic value of cardiac troponin I (cTnI) in patients having a heat-related illness during a heat wave has been poorly documented. METHODS: In a post hoc analysis, we evaluated 514 patients admitted to emergency departments during the August 2003 heat wave in Paris, having a core temperature >38.5 degrees C and who had analysis of cTnI levels. cTnI was considered as normal, moderately elevated (abnormality threshold to 1.5 ngxmL-1), or severely elevated (>1.5 ngxmL-1). Patients were classified according to our previously described risk score (high, intermediate, and low-risk of death). RESULTS: Mean age was 84 +/- 12 years, mean body temperature 40.3 +/- 1.2 degrees C. cTnI was moderately elevated in 165 (32%) and severely elevated in 97 (19%) patients. One-year survival was significantly decreased in patients with moderate or severe increase in cTnI (24 and 46% vs 58%, all P < 0.05). Using logistic regression, four independent variables were associated with an elevated cTnI: previous coronary artery disease, Glasgow coma scale <12, serum creatinine >120 micromolxL-1, and heart rate >110 bpm. Using Cox regression, only severely elevated cTnI was an independent prognostic factor (hazard ratio 1.93, 95% confidence interval 1.35 to 2.77) when risk score was taken into account. One-year survival was decreased in patients with elevated cTnI only in high risk patients (17 vs 31%, P = 0.04). CONCLUSIONS: cTnI is frequently elevated in patients with non-exertional heat-related illnesses during a heat wave and is an independent risk factor only in high risk patients where severe increase (>1.5 ngxmL-1) indicates severe myocardial damage.

Non-interventional study evaluating exposure to inhaled, low-dose methoxyflurane experienced by hospital emergency department personnel in France.

OBJECTIVES: Low-dose methoxyflurane is a non-opioid, inhaled analgesic administered via the Penthrox inhaler and was recently licensed in Europe for emergency relief of moderate-to-severe trauma-associated pain in conscious adults. This non-interventional study investigated occupational exposure to methoxyflurane in the hospital emergency department (ED) personnel during routine clinical practice. SETTING AND PARTICIPANTS: The study was conducted in two hospital ED triage rooms in France over a 2-week and 3-week period, respectively. Low-dose methoxyflurane analgesia was self-administered by patients via the inhaler under the supervision of nursing staff, per routine clinical practice. An organic vapour personal badge sampler was attached to the uniform of the nurses working in the treatment rooms throughout an 8-hour shift (total of 140 shifts during the study period). Seven-day ambient air monitoring of each treatment room was also performed. Methoxyflurane levels adsorbed in each badge sampler were measured by a central laboratory. The primary objective was to evaluate methoxyflurane exposure experience by the hospital ED nurses during an 8-hour shift. RESULTS: In 138 badge samplers, the median (range) concentration of methoxyflurane present following 8-hour nursing shifts was 0.017 (0.008, 0.736) ppm. This level was almost 900-fold lower than the previously reported 8-hour-derived maximal exposure level of 15 ppm; methoxyflurane exposure approaching this threshold was not documented in any badges. There was no correlation between the number of applications of low-dose methoxyflurane administered during a shift (range 0-5) and the vapour exposure measured on the personal badge samplers. CONCLUSIONS: This study indicates that nurses working in hospital EDs experience very low levels of occupational exposure to methoxyflurane vapour during routine clinical practice. These real-world data can provide reassurance to healthcare providers supervising patients receiving low-dose methoxyflurane analgesia via a Penthrox inhaler; further studies may inform exposure in other hospital ED settings.

Effect of a Red Blood Cell Transfusion on Biological Markers Used to Determine the Cause of Anemia: A Prospective Study.

BACKGROUND: Blood test results required for the evaluation of anemia are considered difficult to interpret after red blood cell transfusion. However, this hypothesis is neither supported by a strong physiological rationale nor is it evidence based. METHODS: We conducted a prospective multicenter study to compare the values of key assays prior to and after a course of red blood cell transfusion in the emergency or internal medicine units in 4 university hospitals. The following parameters were measured prior to and within 48 to 72 hours after transfusion: complete blood count with reticulocyte count, direct Coombs' test, ferritin, transferrin saturation, soluble transferrin receptor, serum and erythrocyte folate, cobalamin, lactate dehydrogenase, bilirubin, haptoglobin, and C-reactive protein. We investigated the impact of transfusion on these parameters and assessed whether abnormal values prior to the transfusion became normal after transfusion (or conversely). RESULTS: There were 77 patients included in the study. Changes in mean values of mean corpuscular volume, soluble transferrin receptor, erythrocyte folate, cobalamin, haptoglobin, lactate dehydrogenase, C-reactive protein, and direct Coombs' test were not statistically significant. Changes in reticulocyte count, ferritin, transferrin saturation, serum folate, and total bilirubin concentrations were statistically significant, but they remained in the same diagnostic category (normal or abnormal) in 79% to 98% of the cases; 97% of patients with iron deficiency still had low ferritin or transferrin saturation after a transfusion. CONCLUSION: Blood tests performed after a one-time red blood cell transfusion can be used to establish the cause of anemia when they have not been performed before.

Prognostic factors in non-exertional heatstroke.

PURPOSE: To identify the prognostic factors associated with mortality in heat-related illness. METHODS: Multi-center observational cohort-study in 16 emergency departments (ED) belonging to the teaching hospital network of the Paris area. The cohort comprised all patients admitted to one of the EDs during the August 2003 heat wave in Paris and having a core temperature >38.5 degrees C. Baseline clinical and biological data in ED, patient's course and 1-year survival rate were recorded. Potential prognostic factors associated with death were assessed by Cox proportional-hazards analysis. RESULTS: A total of 1,456 patients were included. Mean age was 79 +/- 19 years. Critically ill conditions were noted in 391 patients (27%), but only 72 (5%) were admitted into an intensive care unit. The survival rate was 57% at 1 year as compared to an expected 90% (P < 0.001). Nine independent prognostic factors were identified: previous treatment with diuretics, living in an institution, age >80 years, cardiac disease, cancer, core temperature >40 degrees C, systolic arterial pressure <100 mmHg, Glasgow coma scale <12 and transportation to hospital by ambulance. We defined three risk groups: low, intermediate and high risk, with a 1-year survival rate of 85, 61 and 18%, respectively. CONCLUSIONS: We observed a low survival rate and developed a risk score based on easily obtained variables that may be useful to clinicians managing casualties from future heat waves.