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Abstract: 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. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

Investigation of the feasibility and usefulness of pre-hospital transcranial Doppler (TCD) to guide early goal-directed therapy following severe traumatic brain injury (TBI). Prospective, observational study of 18 severe TBI patients during pre-hospital medical care. TCD was performed to estimate cerebral perfusion in the field and upon arrival at the Level 1 trauma centre. Specific therapy (mannitol, noradrenaline) aimed at improving cerebral perfusion was initiated if the initial TCD was abnormal (defined by a pulsatility index >1.4 and low diastolic velocity). Nine patients had a normal initial TCD and nine an abnormal one, without a significant difference between groups in terms of the Glasgow Coma Scale or the mean arterial pressure. Among patients with an abnormal TCD, four presented with an initial areactive bilateral mydriasis. Therapy normalized TCD in five patients, with reversal of the initial mydriasis in two cases. Among these five patients for whom TCD was corrected, only two died within the first 48 h. All four patients for whom the TCD could not be corrected during transport died within 48 h. Only patients with an initial abnormal TCD required emergent neurosurgery (3/9). Mortality at 48 h was significantly higher for patients with an initial abnormal TCD. Our preliminary study suggests that TCD could be used in pre-hospital care to detect patients whose cerebral perfusion may be impaired. [ABSTRACT FROM AUTHOR]

Summary: Prehospital management of ST-segment elevation myocardial infarction is a complex issue. Many components are involved, beginning with information of the public on the symptoms of heart attack, up to the choice of the final pathway and destination of the patients, with many intermediate steps including the regulation of emergency calls, the implementation of optimal diagnostic strategies, the choice of reperfusion therapy and of adjuvant medications. In recent years, optimization of these different components has led to improved patients’ outcomes in this still life-threatening condition. [ABSTRACT FROM AUTHOR]

Insertion of a central venous catheter (CVC) in an emergency situation is challenging and may be potentially associated with more complications. Because CVC positioning by ECG-guidance may help to decrease the frequency of a malpositioned catheter, we decided to prospectively evaluate the usefulness of positioning a CVC by ECG-guidance during prehospital emergency care. Prospective observational study during which all patients requiring CVC placement during prehospital care were included. We compared two periods of 1 year during which CVCs were inserted without and then with the help of ECG-guidance. Eighty successive patients were included. We observed a significant reduction of incorrectly positioned CVCs with ECG-guidance (13% vs. 38%, P < 0.05) and a decreased number of chest X-rays needed to verify the position of the CVC (40 vs. 54, P < 0.05). ECG-guidance is a safe and feasible technique which significantly improved the rate of CVCs correctly positioned during prehospital emergency care. [ABSTRACT FROM AUTHOR]

Objective. – To evaluate the effectiveness of prehospital medical care in head-injured patients.Patients and methods. – All head-injured patients admitted in Biceˆtre hospital from 1995 to 1999 were retrospectively studied. Glasgow Coma Scale (GCS) score, mean arterial pressure (MAP) and SpO2 measured on the field were compared to GCS, MAP and SpO2 on arrival in the hospital. All treatments given during transport and first data recorded in the hospital were noted. Each parameter was compared to outcome at 6 months. Then, significant parameters were compared with a multivariate analysis.Results. – Three hundred and four patients were included, 80% had a GCS ≤ 8 and 45% a GCS = 3. At 6 months, 43% of the patients had no or mild sequelae and 45% died. Prehospital time was 2 h 55 min ± 1 h 40 min. During transport, 75% of hypoxemic events were corrected, but GCS and MAP decreased significantly. None of the patients with non-reactive mydriasis received any osmotherapy and all patients with non-reactive mydriasis until hospital admission died (n = 55). After multivariate analysis, parameters significantly related to outcome were, on the field, MAP (p < 0.025) and at hospital SAPS II (p < 0,001), GCS (p < 0.001), non-reactive mydriasis (p < 0.025), hyperglycemia (p < 0.025) and low haemoglobinemia (p < 0.001).Conclusion. – Respect of guidelines is important to improve medical care. Prehospital management corrected hypoxemia but not hypotension. The lack of osmotherapy after mydriasis cannot be explained and is probably an error. Patient route must be simplified to decrease time delay from field to hospital. Improvement in prehospital care may decrease mortality in head-injured patients. [Copyright &y& Elsevier]

Abstract: Prior to transport, agreement must be reached among all the senior medical staff members involved in the transfer. Tight clinical surveillance is necessary during the transport. The aim of the pharmacological control of a severe hypertension is to allow a moderate reduction of the mean arterial blood pressure as well as dampening the large pressure variations. Boluses of calcium channel inhibitors, eventually combined with labetalol, are to be used as first line treatment. Systematic fluid expansion prior to admission is not recommended. However, it is indicated if obvious signs of hypovolaemia are present, such as a sudden drop in blood pressure, secondary to the initiating of an antihypertensive therapy. It is possible to use i.v. benzodiazepines for the treatment of eclampsia in the prehospital setting. If magnesium sulfate therapy has been initiated in a preeclamptic woman with neurological signs, it may be continued during her transport. [Copyright &y& Elsevier]

Abstract: 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 10years. 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. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]

Acute adult epiglottitis is a potentially life threatening infectious and respiratory emergency as it may result in airway obstruction. Endotracheal intubation, if needed, is a highly risky option in this situation and responsible for important morbidity and mortality rate. The option of a pharmaceutical anti-oedematous treatment, in order to avoid the risks involved in the endotracheal route has rarely been described. We here report the case of a 50-year-old man with a serious acute infectious epiglottitis who was treated at home by a Mobile Intensive Care Unit where a treatment of nebulized epinephrine and intravenous steroids was undoubtedly a successful option to the endotracheal route. So that, for adult patients and in the absence of any risk of an imminent respiratory arrest, this anti-oedematous treatment should be considered in order to avoid endotracheal route, an option which should be undertaken in case of complications. Nevertheless, this isolated case study concerning an adult is not transposable to children for which airway obstruction tolerance is lower. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

Résumé Introduction L’Agence française de sécurité sanitaire des produits de santé a publié des recommandations de bonnes pratiques (RBP) pour le traitement de la maladie thromboembolique veineuse (MTEV) en 2009. Quatre de ces recommandations s’appliquant à la prise en charge initiale de la maladie, l’objectif de notre étude est de déterminer si l’élaboration et la diffusion de ces quatre RBP ont eu un impact sur la pratique. Méthodes Étude rétrospective avant/après comparant 132 patients traités aux urgences des hospices civils de Lyon pour une thrombose veineuse profonde (TVP) et/ou une embolie pulmonaire (EP) en 2008–2009 (« avant ») et 153 patients traités en 2010–2011 (« après »). Résultats Dans la période « avant », 70 patients ont été traités pour une TVP et 62 patients pour une EP. Dans la période « après », 50 patients ont été traités pour une TVP et 103 patients pour une EP. Le taux de conformité n’était pas significativement différent pour les deux périodes pour chacune des RBP, hormis pour l’indication d’héparine de bas poids moléculaire (HBPM) ou du fondaparinux en l’absence d’insuffisance rénale sévère (21 % « avant » vs 45 % « après » ; p = 0,02) pour les patients avec une EP. La prise en charge pour les quatre recommandations était conforme pour 5,6 % des patients éligibles au cours de la période « avant » et pour 3,7 % des patients au cours de la période « après ». Conclusion Notre étude montre l’absence d’impact des RBP de manière globale. Les raisons paraissent multiples avec, en premier lieu, la simple diffusion et l’absence d’implémentation de ces guides de pratique. 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The article describes the case of a 32-year-old patient who underwent an operation for a subdural hematoma caused by a severe motorcycle crash. The patient presented with numerous facial edema after the intervention. The patient also underwent complete neurological assessment using a very precise examination.

Résumé Les techniques viscoélastiques sont utilisées depuis une dizaine d’année et comprennent le ROTEM ® et le TEG ® . Ces outils en utilisant les propriétés viscoélastiques du caillot vont permettre un diagnostic rapide des troubles de l’hémostase mais également une analyse globale de l’hémostase prenant en compte les phénomènes intercurrents tels que l’inflammation. L’utilisation de ces techniques dans des situations variées telles que la traumatologie, les hémorragies du post-partum ou digestive, la chirurgie cardiaque, vont réduire la consommation de produits sanguins labiles, diminuer le coût de la prise en charge et peut être améliorer le pronostic des patients. De plus, ces techniques permettant un diagnostic ciblé des troubles de l’hémostase, vont autoriser le développement de traitement ciblé avec des concentrés de facteurs de coagulation. 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

A response by Jean Stephane David, K. Tazarourte, J. P. Perfus, and D. Savary to a letter to the editor about their article "Is ECG-Guidance a Helpful Method to Correctly Position a Central Venous Catheter During Pre-Hospital Emergency Care?" in the previous issue of this journal is presented.

Abstract: Delayed neurological deficit occurs among 30% of patients after aneurysmal subarachnoid haemorrhage, mainly related to cerebral vasospasm. The early detection of cerebral ischemia remains problematic. Conventional cerebral monitoring (as intracranial pressure and cerebral perfusion pressure) appears to be insufficient, because cerebral ischemia may occur without elevated intracranial pressure. Global cerebral monitoring as venous jugular oxygen saturation are useful for regional monitoring. Local monitoring as oxygen tissue partial pressure (PtiO2) and microdialysis are sensible for brain ischemia detection, but may also ignore episodes occurring in non-monitored brain area. For the detection of most episodes of brain ischemia, several monitoring system should be use performing a multimodal intracerebral monitoring. Brain microdialysis and oxygen tissue partial pressure are promising monitoring system. [Copyright &y& Elsevier]

Abstract: Vasospasm is the leading cause of sequelae or deaths after aneurysmal subarachnoid haemorrhage. Vasospasm occurs 2–10 days after haemorrhage and that justifies close monitoring during this period. Because clinical signs appear often to late to reverse ischaemia, paraclinic tools have been developed. Arteriography is the historical gold standard for diagnosis but no clear validated rules exist to measure vessel sections. Diagnosis of vasospasm is, thus, relatively subjective and only reflects one moment of arteries status. Transcranial doppler is a non-invasive and easily repeatable method but sensibility and specificity for vasospasm diagnosis are low compared to arteriography. However, day-to-day changes of arterial blood cells velocities can help to determine vasospasm risk and/or indicate time for arteriography. CT-scanner, PET-scan or IRM can help to evaluate ratio between perfusion and metabolism. Nevertheless, as arteriography, it is only a one-time measurement without control of treatment effects. Waiting for improvement of diagnosis techniques, arteriography stays the gold standard. To choose the right moment for invasive methods, intensivists need to use clinical and transcranial doppler data and start treatment as early as possible to be efficacious. [Copyright &y& Elsevier]

Abstract: Increased natriuresis is a frequent situation after subarachnoid haemorrhage (SAH). It may be responsible for hyponatremia, which can be dangerous in case of severe hypo-osmolarity or hypovolemia. Inappropriate secretion of antidiuretic hormone or cerebral salt wasting syndrome (CSWS) have been incriminated for hyponatremia after SAH, but it remains difficult to distinguish between both syndromes. There are many explanations for increased natriuresis after SAH, depending on the level of blood pressure, the volemia, and the presence or not of natriuretic peptides. The cerebral insult and the treatments, which are done to fight against elevated intracranial pressure or vasospasm, can modify any of these parameters. So it appears that the word “cerebral” in CSWS is probably not a good term and it would be better to talk about appropriate or non-appropriate natriuretic response. Corticoïds or urea can be useful for controlling hypernatriuresis. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

Introduction L’Agence française de sécurité sanitaire des produits de santé (Afssaps) a publié en 2009 des recommandations de bonne pratique (RBP) pour la prévention et le traitement de la maladie thromboembolique veineuse en médecine, basées sur le niveau de preuve scientifique et l’accord d’experts. Très peu d’études ont évalué l’influence des guides de pratique thérapeutique sur la prise en charge thérapeutique de la MTEV [1–3] . Patients et méthodes Étude rétrospective « avant-après » de 132 patients pris en charge initiale (24 premières heures) dans les 3 services d’urgences des hospices civils de Lyon pour une embolie pulmonaire (EP) et/ou une thrombose veineuse profonde (TVP) en 2008 et 2009, en comparaison de 153 patients pris en charge en 2010 et 2011. Les dossiers ont été tirés au sort à partir des bases de données informatisées. La conformité aux recommandations AFSSAPS a été évaluée incluant : – la prise en charge ambulatoire ou hospitalière ; – le traitement anticoagulant initial (type d’héparine) ; – le recours aux anticoagulants injectables avant les tests diagnostiques en cas de forte probabilité clinique ; – le relais antivitamine K (AVK) à j1. Résultats Parmi les 132 patients de la période « avant », 70 ont été traités pour une TVP (53 % femmes, âge moyen 56,9 ans) et 62 pour une EP (53 % femmes, âge moyen 69,5 ans). Parmi les 153 patients de la période « après », 50 ont été traités pour une TVP (46 % femmes, âge moyen 66,2 ans) et 103 pour une EP (49 % femmes, âge moyen de 69 ans). Le taux de conformité aux RBP pour les patients éligibles n’était pas significativement différent entre les deux périodes pour chacune des recommandations (R) (pour la TVP : R1 : 97 % vs 94 %, R2 : 74 % vs 66 %, R3 : 36 % vs 46 %, R4 : 71 % vs 64 %, pour l’EP : R1 : 71 % vs 77 %, R3 : 18 % vs 38 % ; R4 : 47 % vs 54 %) hormis pour l’indication privilégiée des HBPM ou du fondaparinux en l’absence d’insuffisance rénale (38 %, 39 sur 103 en 2010–2011 vs. 18 %, 18 sur 62 en 2008–2009 ; p = 0,006) pour les patients traités pour une EP. En analyse multivariée, seul un âge supérieur à 65 ans (OR = 4,72 ; IC95 % : 1,59–16,19 avant 2009 et OR = 6,84, IC95 % : 2,67–20,08 après 2009 pour la recommandation 1) est associé à une meilleure compliance aux RBP et seule la prise en charge initiale par un interne (OR = 0,36 ; IC95 % : 0,12–0,99 pour la recommandation 4) est associée à une moins bonne compliance aux RBP. Concernant la prise en charge ambulatoire (< 24 heures) de l’EP, 31 % étaient éligibles dans la période « avant » et 24 % dans la période « après ». Aucun n’en a bénéficié dans notre étude. Conclusion Notre étude montre l’absence d’impact des RBP : seuls 12,7 % avaient une prise en charge adaptée selon ces recommandations avant 2009 et 20,1 % après. Les raisons paraissent multiples dont la simple diffusion et l’absence d’implémentation de ces guides de pratique thérapeutique. L’élaboration à un niveau national et non pas à un niveau interne peut également être incriminée. La comparaison avec d’autres études dans les autres pays montre que le taux de conformité aux recommandations nationales est souvent insatisfaisant : 54 % des patients bénéficient dans les 24 heures d’un anticoagulant per os en relais du traitement initial en Suisse [1] contre 66 % en Pennsylvanie [2] . En 2009 et 2010, les soins appropriés conformément aux recommandations australiennes ne concernent que 51 % des patients [3] . Ces constatations doivent servir de point de départ à l’élaboration de formations médicales collectives et de stratégies internes au sein des établissements qui traitent la MTEV. Ces mesures sont justifiées par la fréquence des MTEV et par l’inutilité et le surcoût qu’engendrent certaines de ses thérapeutiques. [ABSTRACT FROM AUTHOR]

Introduction La prise en charge en ambulatoire pure ou après une hospitalisation courte de certains patients atteint de MTEV, diagnostiqués dans les services d’urgence, est devenue une option possible, nécessitant une réorganisation de nos offres de consultation. Nous présentons notre expérience. Patients et méthodes À partir d’un document de travail élaboré par le réseau INNOVTE décrivant une filière « type » de prise en charge ambulatoire dédiée à la MTEV et prévoyant des consultations à j3, M1, M3 et/ou M6, nous avons en collaboration avec le service d’urgence et le service d’exploration vasculaire mise en place dans notre CHU une filière de consultation dédiée. Nous avons d’abord redéfini les protocoles de diagnostics et les critères de gravité (score sPESI et critères HESTIA), et élaboré un agenda informatique de prise de rendez-vous par les urgentistes, accessible 24 H sur 24. Une fiche d’information sur la MTEV est imprimée en même temps que le rendez-vous et donné au patient, avec les coordonnées le l’équipe MTEV. Des réunions d’ajustement des pratiques étaient régulièrement effectuées. Un dossier type a été intégré dans le dossier informatique de l’hôpital sous forme de fiche. Résultats De juin 2015 à janvier 2016 ont été élaboré les protocoles de prise en charge diagnostiques et thérapeutiques de l’EP et la TVP et obtenus les différentes autorisations, ainsi que la création de l’agenda, prévoyant 2 plages de consultation (RV) le lundi et 2 le jeudi. Cinquante-cinq médecins urgentistes ont été habilités à donner les rendez-vous. Les consultations étaient assurées par 4 médecins du service d’explorations vasculaires avec relais sur le plus long terme si besoin en médecine interne. La prise en charge des patients a pu être effective au 1 er février 2016. En 12 mois, 40 patients ont été inscrits à partir du service d’urgences médicale et du service d’urgence cardiologique. Quatre patients ne se sont pas présentés et ont été joint par téléphone. Les 36 patients effectifs (28 du service d’urgences médicales et 12 du service d’urgence cardiologique) se répartissent en 24 hommes et 12 femmes d’âge moyen 53,9 ans. Vingt-sept patients ont été vu des la première semaine (« j3 ») et 9 patients à 3 ou 4 semaines (« M1 »). Il s’agissait de 16 embolies pulmonaires (EP) dont 9 vues à j3, 8 thromboses veineuse profonde (TVP) proximales et 12 TVP distales. Aucun patient n’a été réhospitalisé au cours de son suivi. Trois patients ont consulté en semi-urgences pour une récidive de dyspnée, une hémorragie mineure et un vertige. Deux tiers des patients ont été prise en charge le week-end avec un RV dédié le lundi. La durée de la première consultation était de 45 minutes en moyenne. Le nombre de nouveaux patients a sensiblement augmenté en fin d’année (13 sur les 4 derniers mois) après une nouvelle présentation orale aux différents médecins impliqués. Sur les 36 patients, 33 ont été traité par anticoagulant oral direct. Sur la même période, 197 patients ont été prise en charge dans le service d’urgence médicale, dont 79 EP et 118 TVP. Discussion L’existence d’un document de travail national a facilité la mise en place de cette filière. Une des difficultés a été de faire connaître les procédures à l’ensemble des médecins et personnel impliqués (secrétaire, agent administratifs d’accueil…) et d’obtenir un dossier informatique transversal entre plusieurs unités fonctionnelles. L’augmentation du recrutement après nouvelle réunion d’information est le témoin de la nécessité de communiquer en permanence. Les patients ont été globalement satisfaits de la prise en charge, et l’absence de réhopistalisation confirme la bonne sélection des urgentistes. Les consultations sont longues du fait de nombreuses questions. Le dossier médical commun informatique devient un outil indispensable, facilitant la continuité des soins à partir du service d’urgence et rassure les patients. Le lien avec le médecin traitant mérite d’être amélioré, même si nous remettons au patient les fiches de consultation à l’issue de celle-ci. Notre expérience a depuis 6 mois été développé dans un deuxième pole hospitalier, dans le cadre d’une organisation transversale des praticiens impliqués dans la prise en charge hospitalière et ambulatoire de la MTEV au sein de notre CHU. Conclusion Le développement d’une filière dédiée à partir des urgences a permis un travail collaboratif utiles aux patients, selon les recommandations internationales et de façon sure. Notre objectif est de développer cette pratique aux autres services d’urgences et d’améliorer notre communication avec l’ensemble des partenaires de ville. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented related to a study to determine the relation between the number of foodservice retailer McDonald's Corp.'s restaurants across the world and the prevalence of obesity.