How effective is the BNT162b2 mRNA vaccine against SARS-CoV-2 transmission and infection? A national programme analysis in Monaco, July 2021 to September 2022.

BACKGROUND: We quantified SARS-CoV-2 dynamics in different community settings and the direct and indirect effect of the BNT162b2 mRNA vaccine in Monaco for different variants of concern (VOC). METHODS: Between July 2021 and September 2022, we prospectively investigated 20,443 contacts from 6320 index cases using data from the Monaco COVID-19 Public Health Programme. We calculated secondary attack rates (SARs) in households (n = 13,877), schools (n = 2508) and occupational (n = 6499) settings. We used binomial regression with a complementary log-log link function to measure adjusted hazard ratios (aHR) and vaccine effectiveness (aVE) for index cases to infect contacts and contacts to be infected in households. RESULTS: In households, the SAR was 55% (95% CI 54-57) and 50% (48-51) among unvaccinated and vaccinated contacts, respectively. The SAR was 32% (28-36) and 12% (10-13) in workplaces, and 7% (6-9) and 6% (3-10) in schools, among unvaccinated and vaccinated contacts respectively. In household, the aHR was lower in contacts than in index cases (aHR 0.68 [0.55-0.83] and 0.93 [0.74-1.1] for delta; aHR 0.73 [0.66-0.81] and 0.89 [0.80-0.99] for omicron BA.1&2, respectively). Vaccination had no significant effect on either direct or indirect aVE for omicron BA.4&5. The direct aVE in contacts was 32% (17, 45) and 27% (19, 34), and for index cases the indirect aVE was 7% (- 17, 26) and 11% (1, 20) for delta and omicron BA.1&2, respectively. The greatest aVE was in contacts with a previous SARS-CoV-2 infection and a single vaccine dose during the omicron BA.1&2 period (45% [27, 59]), while the lowest were found in contacts with either three vaccine doses (aVE - 24% [- 63, 6]) or one single dose and a previous SARS-CoV-2 infection (aVE - 36% [- 198, 38]) during the omicron BA.4&5 period. CONCLUSIONS: Protection conferred by the BNT162b2 mRNA vaccine against transmission and infection was low for delta and omicron BA.1&2, regardless of the number of vaccine doses and previous SARS-CoV-2 infection. There was no significant vaccine effect for omicron BA.4&5. Health authorities carrying out vaccination campaigns should bear in mind that the current generation of COVID-19 vaccines may not represent an effective tool in protecting individuals from either transmitting or acquiring SARS-CoV-2 infection.

The Impact of Severe Acute Respiratory Syndrome Coronavirus 2 Vaccination and Infection on Neutralizing Antibodies: A Nation-wide Cross-sectional Analysis.

BACKGROUND: Neutralising antibodies (nAbs) play a critical role in the protection against severe COVID-19. In the era of vaccine boosters and repeated SARS-CoV-2 outbreaks, identifying individuals at risk represents a public health priority. METHODS: Relying on the Monaco COVID Public Health Programme, we evaluated nAbs from July 2021-June 2022 in 8,080 SARS-CoV-2 vaccinated and/or infected children and adults, at their inclusion visit. We stratified by infection status and investigated variables associated with nAbs using a generalised additive model. RESULTS: Infected and vaccinated participants had high and consistent nAbs (>800 IU/mL), which remained stable over time since injection, regardless of the number of vaccine doses, body mass index, sex, or age. By contrast, uninfected participants showed larger variability (two doses [V2] median 157.6; interquartile range [IQR] 43.3-439.1 IU/mL) versus three doses [V3] median 882.5; [829.5-914.8] IU/mL). NAbs decreased by 20% per month after V2 (adjusted ratio 0.80; 95%CI [0.79-0.82]), but remained stable after V3 (adjusted ratio 0.98; 95%CI [0.92-1.05]). CONCLUSIONS: Hybrid immunity provided stable, high and consistent nAbs over time. The benefit of boosters was marked to restore decaying nAbs in uninfected participants. NAbs could identify individuals at risk of severe COVID-19 and provide more targeted vaccine boosters' campaigns.

Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited.

BACKGROUND: The clamshell incision (CI) offers a better exposure than the left anterolateral thoracotomy (LAT) as a resuscitative thoracotomy. Most surgeons will have to manage a heart wound only once or twice in their career. The patient's survival depends on how fast the surgeon can control the heart wound; however, it is unclear which of the two incisions allows for faster control in the hands of inexperienced surgeons. The aim of this study was to compare the time needed to access and control a standardized stab wound to the right ventricle, by inexperienced surgical trainees, by LAT or CI; we hypothesized that the CI does not take longer than the LAT. METHODS: Sixteen residents were shown a video on how to perform both procedures. They were randomly assigned to control a standardized stab wound of the right ventricle on perfused human cadavers by LAT (n = 8) or CI (n = 8). Access time (skin to maximal exposure), control time (maximal exposure until control of the heart wound) and total time (the sum of access and control times) were recorded. RESULTS: Total time was 6.62 min [3.20-8.14] (median [interquartile range]) for LAT and 4.63 min [3.17-6.73] for CI (p = 0.46). Access time was 2.39 min [1.21-2.76] for LAT and 2.33 min [1.58-4.86] for CI (p = 0.34). Control time was 4.16 min [2.32-5.49] for LAT and 1.85 min [1.38-2.23] for CI (p = 0.018). CONCLUSIONS: The time needed from skin incision until cardiac wound control via CI was not longer than via LAT and the easier control of the cardiac wound when using CI was confirmed.

Benchmarking of trauma care worldwide: the potential value of an International Trauma Data Bank (ITDB).

BACKGROUND: National trauma registries have helped improve patient outcomes across the world. Recently, the idea of an International Trauma Data Bank (ITDB) has been suggested to establish global comparative assessments of trauma outcomes. The objective of this study was to determine whether global trauma data could be combined to perform international outcomes benchmarking. METHODS: We used observed/expected (O/E) mortality ratios to compare two trauma centers [European high-income country (HIC) and Asian lower-middle income country (LMIC)] with centers in the North American National Trauma Data Bank (NTDB). Patients (≥16 years) with blunt/penetrating injuries were included. Multivariable logistic regression, adjusting for known predictors of trauma mortality, was performed. Estimates were used to predict the expected deaths at each center and to calculate O/E mortality ratios for benchmarking. RESULTS: A total of 375,433 patients from 301 centers were included from the NTDB (2002-2010). The LMIC trauma center had 806 patients (2002-2010), whereas the HIC reported 1,003 patients (2002-2004). The most important known predictors of trauma mortality were adequately recorded in all datasets. Mortality benchmarking revealed that the HIC center performed similarly to the NTDB centers [O/E = 1.11 (95% confidence interval (CI) 0.92-1.35)], whereas the LMIC center showed significantly worse survival [O/E = 1.52 (1.23-1.88)]. Subset analyses of patients with blunt or penetrating injury showed similar results. CONCLUSIONS: Using only a few key covariates, aggregated global trauma data can be used to adequately perform international trauma center benchmarking. The creation of the ITDB is feasible and recommended as it may be a pivotal step towards improving global trauma outcomes.

Comparative effectiveness of inhospital trauma resuscitation at a French trauma center and matched patients treated in the United States.

OBJECTIVE: The objective of this paper is to compare mortality outcomes between patients treated at a trauma center in France and matched patients in the United States. BACKGROUND: Although trauma systems in France and the United States differ significantly in prehospital and inhospital management, previous comparisons have been challenged by the lack of comparable data. METHODS: Coarsened exact matching identified matching patients between a single center trauma database from Lyon, France, and the National Trauma Data Bank (NTDB) of the United States. Moderate to severely injured [injury severity score (ISS) > 8] adult patients (age ≥ 16) presenting alive to level 1 trauma centers from 2002 to 2005 with blunt or penetrating injuries were included. After matching patients, multivariate regression analyses were performed to determine difference in mortality between patients in Lyon and the NTDB. RESULTS: A total of 1043 significantly injured patients were presented to the Lyon center. Matching eligible patients with complete records were sought from 219,985 patients in the NTDB. The unadjusted odds of mortality at the Lyon center was 2.5 times higher than that of the NTDB [95% confidence interval (CI) = 2.18-2.98]. However, the Lyon center received patients with higher ISS, lower Glasgow Coma Score (GCS), and lower systolic blood pressure (SBP) (all P < 0.001). After 1:1 matching, 858 patient pairs were produced, and the odds of mortality became equivalent [odds ratio (OR) = 1.3, 95% CI = 0.91-1.73]. Similar results were found in multiple subset analyses. CONCLUSIONS: Trauma patients admitted to a single French trauma center had an equal chance of survival compared with similarly injured patients treated at US trauma centers.

Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study.

BACKGROUND: Emergency thoracotomy (ET) is a procedure that provides rapid access to intrathoracic structures for thoracic trauma patients arriving at the hospital in extremis. This study assesses the accessibility of intrathoracic structures provided by six different ET incisions. We hypothesize that the bilateral anterior thoracotomy ("clamshell" incision) provides the most rapid and definitive accessibility to intrathoracic structures. METHODS: Six ET incision types (left anterolateral thoracotomy, right anterolateral thoracotomy, left 2nd intercostal space incision, left 3rd intercostal space incision, median sternotomy, and bilateral anterior thoracotomy) were performed multiple times on eight cadavers. The critical intrathoracic structures were assessed for rapid accessibility and control, and they were characterized as "readily accessible," "accessible," and "inaccessible" on anatomic accessibility maps. RESULTS: Median sternotomy provided better access to intrathoracic structures than left and right anterior thoracotomies. Definitive control of the origin of the left subclavian artery was difficult with left 2nd or 3rd intercostal space incisions. Bilateral anterior thoracotomy, the clamshell incision, was easy to perform and gave superior access to all intrathoracic structures. CONCLUSIONS: In severe thoracic trauma, specific injuries are unknown, even if they can be anticipated. The best incision is therefore one that provides the most rapid and definitive access to all thoracic structures for assessment and control. While the right and left anterolateral incisions may be successfully employed by surgeons with extensive experience in ET, the clamshell incision remains the superior incision choice.

Distinctive serotypes of SARS-related coronaviruses defined by convalescent sera from unvaccinated individuals.

Multiple Omicron sub-lineages have emerged, with Omicron XBB and XBB.1.5 subvariants becoming the dominant variants globally at the time of this study. The key feature of new variants is their ability to escape humoral immunity despite the fact that there are limited genetic changes from their preceding variants. This raises the question of whether Omicron should be regarded as a separate serotype from viruses serologically clustered with the ancestral severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Here, we present cross-neutralization data based on a pseudovirus neutralization test using convalescent sera from naïve individuals who had recovered from primary infection by SARS-CoV-1 and SARS-CoV-2 strains/variants including the ancestral virus and variants Beta, Delta, Omicron BA.1, Omicron BA.2 and Omicron BA.5. The results revealed no significant cross-neutralization in any of the three-way testing for SARS-CoV-1, ancestral SARS-CoV-2 and SARS-CoV-2 Omicron subvariants. The data argue for the assignment of three distinct serotypes for the currently known human-infecting SARS-related coronaviruses.

The flap by flap dissection in terminal ballistic applied to less lethal weapons.

Medical examiners often have to solve questions such as firing distance and bullet trajectory for lethal weapons. Knowledge in the field of terminal ballistics has increased during the last 30 years and layer by layer dissection reveals superficial wounds that can be linked with the permanent cavity. At the end of the 1990s, terminal ballistics also focused on less lethal weapons and their wounds. Here, 2 different less lethal weapons with single bullets were tested on nonembalmed and undressed cadavers (N = 26) at different ranges and speeds. We have developed a technique for dissection which we call flap by flap dissection that reveals the advantage of the bullet-skin-bone entity, the absence of wounds linking its components and range of less lethal weapons.

Intrathoracic pressure impulse predicts pulmonary contusion volume in ballistic blunt thoracic trauma.

BACKGROUND: Blunt thoracic trauma including behind armour blunt trauma or impact from a less lethal kinetic weapon (LLKW) projectile may cause injuries, including pulmonary contusions that can result in potentially lethal secondary complications. These lung injuries may be caused by intrathoracic pressure waves. The aim of this study was to observe dynamic changes in intrathoracic hydrostatic pressure during ballistic blunt thoracic trauma and to find correlations between these hydrostatic pressure parameters (especially the impulse parameter) and physical damages. METHODS: Thirty anesthetized pigs sustained a blunt thoracic trauma. In group 1 (n = 20), pigs were protected by a National Institute of Justice class III or IV bulletproof vest and shot with 7.62 NATO bullets. In group 2 (n = 10), pigs were shot by an LLKW. Intrathoracic pressure was recorded with an intraesophageal pressure sensor and three parameters were determined: intrathoracic maximum pressure, intrathoracic maximum pressure impulse (PI(max)), and the Pd.P/dt(max), derived from Viano's viscous criterion. Relative right lower lung lobe contusion volume was also measured. RESULTS: Different thoracic loading conditions were obtained. PI(max) best correlated with relative pulmonary contusion volume (R² = 0.64 and p < 0.0001). This result was homogenous for all experiments and was not related to the type of chest impact (LLKW-induced trauma or behind armour blunt trauma). CONCLUSIONS: The PI(max) is a good predictor of pulmonary contusion volume after ballistic blunt thoracic trauma. It is a useful criterion when the kinetic energy record or thoracic wall displacement data are unavailable, and the recording and calculation of this physical value are quite simple on animals.

First clinical study of a new virus-inhibiting surgical glove.

QUESTION UNDER STUDY: Prospective clinical study to evaluate the tolerance, ergonomics and glove barrier value (mechanical resistance to breach) of a new surgical glove sandwiching droplets of a disinfecting agent between two layers of a synthetic elastomer (G-VIR) able to inactivate viruses when breached. METHODS: 100 surgical procedures were performed by six surgeons wearing G-VIR on 100 patients included after informed consent. Procedures were classified into laparoscopic (n = 28) or open surgery (n = 72); open surgery being subdivided either into superficial (n = 33) and deep (n = 39) or into hernia (n = 32) and non hernia (n = 40). The ergonomics and tolerance of the glove were evaluated by the surgeons using a questionnaire. Patients were clinically evaluated daily during hospitalization and once between the 4th to 6th postoperative week. All used gloves underwent a water leak test to detect any breach. RESULTS: 834 G-VIR gloves were used, 456 by the first surgeon and 378 by the assistant surgeon, resulting in 195 exposures, lasting 288 operator-hours (OH). No adverse effect on patients and/or surgeons linked to G-VIR could be observed. Ergonomics of G-VIR has been evaluated as equivalent as standard double gloving, excepted for donning which was more difficult (P <0.05). The breach rate per glove (BRpG) amounted to 1.8%. According to breach rate per operator-hour (BRpOH), surgical procedures could be categorized in low (laparoscopy), middle (non hernia and hernia superficial) and high (hernia deep) risk procedures. CONCLUSIONS: G-VIR gloving offers an excellent mechanical protection, is suitable for daily surgical practice and maybe recommended in high risk surgical procedures.

Fixed-Distance Model for Balloon Placement During Fluoroscopy-Free Resuscitative Endovascular Balloon Occlusion of the Aorta in a Civilian Population.

Importance: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an innovative procedure in the treatment of noncompressible truncal hemorrhage. However, readily available fluoroscopy remains a limiting factor in its widespread implementation. Several methods have been proposed to perform REBOA without fluoroscopic guidance, and these methods were adapted predominantly from the military theater. Objective: To develop a method for performing REBOA in a civilian population using a standardized distance from a set point of entry. Design, Setting, and Participants: A retrospective study of whole-body computed tomographic (CT) scans from a cohort of 280 consecutive civilian trauma patients from University Hospitals of Lyon, France, was used to calculate the endovascular distances from both femoral arteries at the level of the upper border of the symphysis pubis to aortic zone I (descending thoracic aorta) and zone III (infrarenal aorta). These whole-body CT scans were performed between 2013 and 2015. Data were analyzed from July 16 to December 7, 2015. Main Outcomes and Measures: Two segments (1 per zone) common to all CT scans were isolated, and their location, length, prevalence in the cohort, and predicted prevalence in the general population were calculated by inverting 99% certainty tolerance limits. Results: Among the 280 trauma patients (140 men and 140 women) in this study, the mean (SD) height was 170.7 (8.7) cm, and the mean (SD) age was 38.8 (16.5) years. The common segment in zone I (414-474 mm) existed in all CT scans. The common segment in zone III (236-256 mm) existed in 99.6% and 97.9% of CT scans from the right and left femoral arteries, respectively. These segments are expected to exist in 98.7% (zone I) and 94.9% (zone III) of the general population. Conclusions and Relevance: Target distances for blind placement of REBOA exist with more than 94% prevalence in a civilian population. These findings support the expanded use of REBOA in emergency department and prehospital settings. Validation for safety and efficacy on cadaveric and clinical models is necessary.

A new ultrasonic process for a renewal of aortic valve decalcification.

BACKGROUND: Aortic valve decalcification by ultrasound was given up. We evaluated a new ultrasound microhandpiece (Dissectron Penstyle) to rehabilitate this alternative treatment. METHODS: We used under magnifying lenses the ultrasound microhandpiece to decalcify 30 explanted aortic valves. In the cases with embedded calcifications the thin top of the probe could be introduced into the thickness of the leaflet preserving covering layers. RESULTS: The leaflets were totally decalcified and flexible, and surrounding structures were preserved as assessed by histological examination. CONCLUSION: This new approach of ultrasonic aortic valve decalcification gives good in vitro results which allow to consider a clinical evaluation of this procedure.

Kendrick's extrication device and unstable pelvic fractures: Should a trochanteric belt be added? A cadaveric study.

INTRODUCTION: Pre-hospital pelvic stabilisation is advised to prevent exsanguination in patients with unstable pelvic fractures (UPFs). Kendrick's extrication device (KED) is commonly used to extricate patients from cars or crevasses. However the KED has not been tested for potential adverse effects in patients with pelvic fractures. The aim of this study was to examine the effect of the KED on pubic symphysis diastasis (SyD) with and without the use of a trochanteric belt (TB) during the extraction process following a MVC. MATERIALS AND METHODS: Left-sided "open-book" UPFs were created in 18 human cadavers that were placed in seven different positions simulating pre-extraction and extraction positions using the KED with and without a TB in two different positions (through and over the thigh straps). The SyD was measured using anteroposterior radiographs. The effects of the KED with and without TB, on the SyD, were evaluated. RESULTS: The KED alone resulted in a non-significant increase of the SyD compared to baseline, whereas the addition of a TB to the KED resulted in a significant reduction of the SyD (p<0.001). The TB through the straps provided a significantly better reduction than the TB over the straps in the extracted position (p<0.05). CONCLUSION: Our study demonstrated that a TB in combination with the KED on UPFs is an effective way to achieve early reduction. The addition of the TB in combination with the KED could be considered for Pre-Hospital Trauma Life Support (PHTLS) training protocols.

Effect of continuous oxygen insufflation on induced-gastric air volume during cardiopulmonary resuscitation in a cadaveric model.

BACKGROUND: The main objective of this study was to compare the volume of gas insufflated in the stomach with continuous external chest compressions plus continuous oxygen insufflation (C-CPR) versus standard-CPR (S-CPR) which alternates external chest compressions and synchronized positive insufflations through a bag-valve-mask with a 30/2 ratio. The secondary objective was to compare upper airway pressures (intratracheal and intramask) generated during continuous oxygen insufflation. MATERIAL AND METHODS: Open, prospective, randomized, cross over, comparative, non-inferiority study. CPR was performed for six minutes periods, on seven fresh human corpses, with C-CPR or S-CPR in a random order. Before each CPR period, the stomach was completely emptied through the gastrostomy tube, and then 200 mL of air was injected in the stomach to be sure it was not collapsed. The gastric volume was measured at the end of each intervention. Intratracheal and intramask pressures were recorded continuously during C-CPR. Results were provided as mean ± standard deviation. Statistical analyses were done with a paired student t test. RESULTS: Induced-gastric inflation was lower with C-CPR (221 ± 130 mL) than with S-CPR (5401 ± 2208 mL, p = 0.001). Throughout C-CPR, no difference was found between the intratracheal and intramask pressures (4.4 ± 1.2; 4.0 ± 0.8 cmH2O, respectively, p = 0.45). CONCLUSION: This human cadaver study demonstrates that continuous oxygen insufflation induced less gastric inflation than intermittent insufflation during CPR.

[Does scrotal blunt trauma require surgical treatment?]. / Faut-il opérer les traumatismes fermés des bourses?

Blunt trauma to the scrotum is increasingly frequent and is mainly due to motor vehicle accidents, especially with direct trauma from a motorbike petrol tank or falling astride a bicycle frame. The surgical exploration of these cases of trauma remains a controversial issue. However, according to the authors, the presence of haematocele on clinical examination justifies systematic early surgical exploration, which shortens the patient's length of hospital stay allowing more rapid return to work. Ultrasound is only really indicated in the case of scrotal trauma without haematocele, looking for rupture of the tunica albuginea or intratesticular haematoma.

[A case of late pancreatic metastasis from renal cell carcinoma]. / Un cas de métastase pancréatique tardive d'un carcinome à cellules claires rénal.

The authors report the case of a 58-year-old man who developed four pancreatic metastases ten years after radical nephrectomy for pT3NO renal cell carcinoma. Total pancreatectomy was performed and, three years later, the patient was in good general health, free from any tumour recurrence. Pancreatic metastases from renal cell carcinoma are rare and generally occur late. They are usually discovered on computed tomography performed for surveillance of the renal cancer. Treatment is surgical and usually consists of cephalic duodenopancreatectomy, splenopancreatectomy or total pancreatectomy. The prognosis is better than that of primary pancreatic cancer, as the estimated median survival is 30 months after treatment.