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Objective: Assessment of suicidal risk is one of the most challenging tasks faced by health professionals, notably in emergency care. We compared telephone suicide risk assessment at prehospital Emergency Medical Services Dispatch Center (EMS-DC), with subsequent face-to-face evaluation at Psychiatric Emergency Service (PES), using French national Risk-Urgency-Danger standards (RUD)., Method: Data were collected for all suicidal adult patients ( N  = 80) who were addressed by EMS-DC to PES between December 2018 and August 2019 and benefited from RUD assessment at both services. Suicidal risk was given a score of 1, 2, 3 or 4, in order of severity., Results: Mean of the differences between the RUD score at EMS-DC and PES was -0.825 (SD = 1.19), and was found to be significant ( p  < 0.01). The average time between RUD assessments was 420 min (SD = 448) and was negatively correlated with the difference in the RUD score ( r  = -0.295, p  = 0.008). Associated suicide attempt increased the odds of a decrease in the RUD score (OR = 2.989; 95% CI = 1.141-8.069; p  < 0.05)., Conclusions: Telephone evaluation of suicidal risk using RUD at EMS-DC yielded moderately higher scores than those obtained by a subsequent face-to face evaluation at PES, with this difference partially explained by the time between assessments, and by clinical and contextual factors.

Background: The use of myocardial reperfusion-mainly via angioplasty-has increased in our region to over 95%. We wondered whether old and very old patients have benefited from this development., Methods: Setting: Greater Paris Area (Ile-de-France)., Data: Regional registry, prospective, including since 2003, data from 39 mobile intensive care units performing prehospital treatment of patients with ST segment elevation myocardial infarction (STEMI) (<24 h)., Parameters: Demographic, decision to perform reperfusion and outcome (in-hospital mortality)., Primary Endpoint: Reperfusion decision rate by decade over age 70., Secondary Endpoint: Outcome., Results: We analysed the prehospital management of 27,294 patients. There were 21,311 (78%) men and 5,919 (22%) women with a median age of 61 (52-73 years). Among these patients, 8,138 (30%) were > 70 years, 3,784 (14%) > 80 years and 672 (2%) > 90 years.The reperfusion decision rate was 94%. It decreased significantly with age: 93, 90 and 76% in patients in their seventh, eighth and ninth decade, respectively. The reperfusion decision rate increased significantly over time. It increased in all age groups, especially the higher ones. Mortality was 6%. It increased significantly with age: 8, 16 and 25% in patients in their seventh, eighth and ninth decade, respectively. It significantly decreased over time in all age groups. The odds ratio of the impact of reperfusion decision on mortality reached 0.42 (0.26-0.68) in patients over 90 years., Conclusion: the increase in the reperfusion decision rate was the greatest in the oldest patients. It reduced mortality even in patients over 90 years of age., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The e-MUST registry has continuously and comprehensively documented ST-segment elevation myocardial infarctions (STEMIs) managed in the prehospital setting by the 39 Mobile Emergency and Resuscitation Services (SMUR) of the 8 Emergency Medical Assistance System (SAMU) and subsequently managed in the 36 interventional cardiology services in Île-de-France since 2000. This encompasses a population of over 12 million residents. To date, nearly 44,000 patients have been enrolled. The analysis of these findings reflects the real-world management of these patients and the evolution of their care. The results are shared annually with the investigators' teams and have led to around twenty publications. The latest acquired results have demonstrated, in a series of over 630 patients aged over 90, that nonagenarians particularly benefit from prehospital coronary reperfusion decisions, resulting in a nearly 60% reduction in mortality., (Copyright © 2023. Published by Elsevier Masson SAS.)

Background: ST-segment-elevation myocardial infarction (STEMI) guidelines recommend pharmaco-invasive treatment if timely primary percutaneous coronary intervention (PCI) is unavailable. Full-dose tenecteplase is associated with an increased risk of intracranial hemorrhage in older patients. Whether pharmaco-invasive treatment with half-dose tenecteplase is effective and safe in older patients with STEMI is unknown., Methods: STREAM-2 (Strategic Reperfusion in Elderly Patients Early After Myocardial Infarction) was an investigator-initiated, open-label, randomized, multicenter study. Patients ≥60 years of age with ≥2 mm ST-segment elevation in 2 contiguous leads, unable to undergo primary PCI within 1 hour, were randomly assigned (2:1) to half-dose tenecteplase followed by coronary angiography and PCI (if indicated) 6 to 24 hours after randomization, or to primary PCI. Efficacy end points of primary interest were ST resolution and the 30-day composite of death, shock, heart failure, or reinfarction. Safety assessments included stroke and nonintracranial bleeding., Results: Patients were assigned to pharmaco-invasive treatment (n=401) or primary PCI (n=203). Median times from randomization to tenecteplase or sheath insertion were 10 and 81 minutes, respectively. After last angiography, 85.2% of patients undergoing pharmaco-invasive treatment and 78.4% of patients undergoing primary PCI had ≥50% resolution of ST-segment elevation; their residual median sums of ST deviations were 4.5 versus 5.5 mm, respectively. Thrombolysis In Myocardial Infarction flow grade 3 at last angiography was ≈87% in both groups. The composite clinical end point occurred in 12.8% (51/400) of patients undergoing pharmaco-invasive treatment and 13.3% (27/203) of patients undergoing primary PCI (relative risk, 0.96 [95% CI, 0.62-1.48]). Six intracranial hemorrhages occurred in the pharmaco-invasive arm (1.5%): 3 were protocol violations (excess anticoagulation in 2 and uncontrolled hypertension in 1). No intracranial bleeding occurred in the primary PCI arm. The incidence of major nonintracranial bleeding was low in both groups (<1.5%)., Conclusions: Halving the dose of tenecteplase in a pharmaco-invasive strategy in this early-presenting, older STEMI population was associated with electrocardiographic changes that were at least comparable to those after primary PCI. Similar clinical efficacy and angiographic end points occurred in both treatment groups. The risk of intracranial hemorrhage was higher with half-dose tenecteplase than with primary PCI. If timely PCI is unavailable, this pharmaco-invasive strategy is a reasonable alternative, provided that contraindications to fibrinolysis are observed and excess anticoagulation is avoided., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT02777580., Competing Interests: Disclosures Dr Van de Werf reports institutional grants from Boehringer Ingelheim. Dr Ristić reports grants from Boehringer-Ingelheim and Novartis and travel fees from Astra Zeneca and Pfizer. Dr Arias-Mendoza reports grants from Merck and Novo Nordisk and personal fees from Novartis, Roche, Bayer, Boehringer Ingelheim, and Asofarma. Dr Saraiva received personal fees from Boehringer Ingelheim, Astra Zeneca, Novo Nordisk, Lily, Janssen, Daichii Sankyo, Bayer, Novartis, Nova Quimica Brazil, and Albert Einstein ARO Brazil. Dr Musić reports a grant from Boehringer Ingelheim and travel fees from Astra Zeneca and Pfizer. Dr Westerhout reports consulting fees from Bayer Canada. Dr Pagès is a senior medical advisor of Boehringer Ingelheim. Dr Danays reports consulting fees from Boehringer Ingelheim. Dr Bainey reports personal fees from Bayer, Astra Zeneca, Boehringer Ingelheim, and HLS Therapeutics. Dr Sinnaeve reports consulting fees to his institution (KU Leuven). Dr Welsh reports personal fees and travel fees from Boehringer Ingelheim. Dr Armstrong reports institutional and personal grants from Merck, Bayer, CLS Limited, Eli Lilly, and Boehringer Ingelheim and personal fees from Merck, Boehringer Ingelheim, Bayer, and Novo Nordisk. All other authors report no competing interests.

During winter 2020-2021, France and other European countries were severely affected by highly pathogenic avian influenza H5 viruses of the Gs/GD/96 lineage, clade 2.3.4.4b. In total, 519 cases occurred, mainly in domestic waterfowl farms in Southwestern France. Analysis of viral genomic sequences indicated that 3 subtypes of HPAI H5 viruses were detected (H5N1, H5N3, H5N8), but most French viruses belonged to the H5N8 subtype genotype A, as Europe. Phylogenetic analyses of HPAI H5N8 viruses revealed that the French sequences were distributed in 9 genogroups, suggesting 9 independent introductions of H5N8 from wild birds, in addition to the 2 introductions of H5N1 and H5N3., (© 2022 The Authors. Transboundary and Emerging Diseases published by Wiley-VCH GmbH.)

Background and Purpose: Ischemic stroke is one of the most common causes of morbidity and mortality and has numerous clinical mimics. Previous studies have suggested a potential role of the tryptophan-serotonin (5-HT)-kynurenine (TSK) axis in ischemic stroke. Studies assessing this axis in the hyperacute phase of ischemic stroke (<4.5 h) are lacking. This prospective study thus evaluates the TSK axis in transient ischemic attack (TIA) and hyperacute ischemic stroke (AIS) patients. Methods: This study included 28 patients (24 AIS and 4 TIA) and 29 controls. The blood and urine samples of patient were collected within 4.5 h of symptoms onset (day 0, D0), then at 24 h and 3 months. Control blood and urine samples were collected once (D0). The TSK axis markers measured were platelet serotonin transporter (SERT) and 5-HT 2A receptor (5-HT 2A R) densities and platelet, plasma, and urinary 5-HT, plasma and urinary 5-hydroxyindole acetic acid (5-HIAA), and plasma kynurenine and tryptophan (TRP) levels. Results: At D0, patients exhibited a lower ( p = 10 -5 ) platelet SERT density, higher ( p < 10 -6 ) platelet 5-HT 2A R density, higher ( p = 10 -5 ) plasma kynurenine/tryptophan (K/T) ratio, and higher urinary 5-HT ( p = 0.011) and 5-HIAA ( p = 0.003) levels than controls. Conclusions: We observed, for the first time, a hyperacute dysregulation of the serotonergic axis, and hyperacute and long-lasting activation of the tryptophan-kynurenine pathway in brain ischemia., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Saccaro, Pico, Chadenat, Richard, Launay, Bastenaire, Jullien, Lambert, Feuga, Macquet, Callebert, Lambert and Spreux-Varoquaux.)

Managing a patient with chest pain suspected to be a ST segment elevation myocardial infarction is a race against time. This management is based on a chain, like what is presented for cardiac arrest. Three phases follow one another, with potential loss of time successively attributable to the patient, the emergency physician and then the cardiologist. It would be tempting to consider that the main culprit in the event of delayed treatment is the patient. This review is the opportunity to show that it is not the case. The emergency physician, the cardiologist and their interconnection are the main providers of delay and, as such, the main enemies of myocardial reperfusion., (Copyright © 2021. Published by Elsevier Masson SAS.)

Background: The time lapse between onset of symptoms and a call to an emergency dispatch center (pain-to-call time) is a critical prognostic factor in patients with chest pain. It is therefore important to identify factors related to delays in calling for help., Objectives: To analyze whether age, gender, or time of day influence the pain-to-call delay in patients with acute STsegment elevation myocardial infarction (STEMI)., Material and Methods: Data were extracted from a prospective registry of STEMI cases managed by 39 mobile intensive care ambulance teams before hospital arrival within 24 hours of onset in our region, the greater metropolitan area of Paris, France. We analyzed the relation between pain-to-call time and the following factors: age, gender, and the time of day when symptoms appeared. We also assessed the influence of pain-to-call time on the rate of prehospital decisions to implement reperfusion therapy., Results: A total of 24 662 consecutive patients were included; 19 291 (78%) were men and 4371 (22%) were women. The median age was 61 (interquartile range, 52-73) years (men, 59 [51-69] years; women, 73 [59-83] years; P .0001). The median pain-to-call time was 60 (24-164) minutes (men, 55 [23-150] minutes; women, 79 [31-220] minutes; P .0001). The delay varied by time of day from a median of 40 (17-101) minutes in men between 5 pm and 6 pm to 149 (43-377) minutes in women between 2 am and 3 am. The delay was longer in women regardless of time of day and increased significantly with age in both men and women (P .001). A longer pain-to-call time was significantly associated with a lower rate of implementation of myocardial reperfusion (P .001)., Conclusion: Pain-to-call delays were longer in women and older patients, especially at night. These age and gender differences identify groups that would benefit most from health education interventions.

Between May 2018 and 2019, a syndromic bovine mortality surveillance system (OMAR) was tested in 10 volunteer French départements (French intermediate-level administrative unit) to assess its performance in real conditions, as well as the human and financial resources needed to ensure normal functioning. The system is based on the automated weekly analysis of the number of cattle deaths reported by renderers in the Fallen Stock Data Interchange Database established in January 2011. In our system, every Thursday, the number of deaths is grouped by ISO week and small surveillance areas and then analyzed using traditional time-series analysis steps (cleaning, prediction, signal detection). For each of the five detection algorithms implemented (i.e., the exponentially weighted moving average chart, cumulative sum chart, Shewhart chart, Holt-Winters, and historical limits algorithms), seven detection limits are applied, giving a signal score from 1 (low excess mortality) to 7 (high excess mortality). The severity of excess mortality (alarm) is then classified into four categories, from very low to very high, by combining the signal scores, the relative excess mortality, and the persistence of the signal(s) over the previous 4 weeks. Detailed and interactive weekly reports and a short online questionnaire help pilot départements and the OMAR central coordination cell assess the performance of the system. During the 1-year test, the system showed highly variable sensitivity among départements . This variability was partly due not only to the demographic distribution of cattle (very few signals in low-density areas) but also to the renderer's delay in reporting to the Fallen Stock Data Interchange Database (on average, only 40% of the number of real deaths had been transmitted within week, with huge variations among départements ). As a result, in the pilot départements , very few alarms required on-farm investigation and excess mortality often involved a small number of farms already known to have health or welfare problems. Despite its perfectibility, the system nevertheless proved useful in the daily work of animal health professionals for collective and individual surveillance. The test is still ongoing for a second year in nine départements to evaluate the effectiveness of the improvements agreed upon at the final meeting., (Copyright © 2020 Sala, Vinard, Pandolfi, Lambert, Calavas, Dupuy, Garin and Touratier.)

Background: Our purpose was to describe the care pathway of patients hospitalized for acute heart failure (AHF) and investigate whether a management involving a cardiology department had an impact on in-hospital mortality., Methods: Between June 2014 and October 2018, we included patients hospitalized for AHF in 24 French hospitals. Characteristics of the episode, patient's care pathway and outcomes were recorded on a specific assessment tool. The primary outcome was the association between patient care pathway and in-hospital mortality. The independent association between admission to a cardiology ward and in-hospital mortality was assessed through a multivariate regression model and propensity score matching., Results: A total of 3677 patients, mean age of 78, were included. The in-hospital mortality rate was 8% (n = 287) and was associated on multivariate regression with advanced age, presence of sepsis, of cardiogenic shock, high New York Heart Association (NYHA) score and increased plasma creatinine level on admission. High blood pressure and admission to a cardiology department appeared as protective factors. After propensity score matching, hospitalization in a cardiology department remained a protective factor of in-hospital mortality (OR = 0.61 [0.44-0.84], p = 0.002)., Conclusion: A hospital course of care involving a cardiology department was associated with an increase in hospital survival in AHF patients. These finding may highlight the importance of collaboration between cardiologists and other in-hospitals specialties, such as emergency physicians, in order to find the best in-hospital pathway for patients with AHF.Clinical Trial NCT03903198., (© 2019 The Authors. Published by Elsevier B.V.)

Objective: Mortality in patients with ST-segment elevation myocardial infarction (STEMI) has been associated with the volume of activity of percutaneous coronary intervention (PCI) facilities. This observational study investigated whether the coronary reperfusion-decision rate is associated with the volume of activity in a prehospital emergency setting., Methods: Prospectively collected data for the period 2003-2013 were extracted from a regional registry of all STEMI patients handled by eight dispatch centers (SAMUs) in and around Paris [41 mobile ICU (MICUs)]. A possible association between volume of activity (number of STEMIs) and coronary reperfusion-decision rate, and subsidiarily between volume of activity and choice of technique (fibrinolysis vs. primary PCI), were investigated. Explanatory factors (patient age, sex, delay between pain onset and first medical contact, and access to a PCI facility) were analyzed in a multivariate analysis., Results: Overall, 18 162 patients; male/female 3.5/1; median age 62 (52-72) years were included in the analysis. The median number of STEMIs per MICU was 339 (IQ 220-508) and that of reperfusion-decisions was 94% (91-95). There was no association between the decision rate and the number of STEMIs (P = 0.1). However, the decision rate was associated with age, sex, delay, and access to a PCI facility (P < 0.0001) in a highly significant way. Fibrinolysis was a more frequent option for low-volume (remoter PCI facilities) than high-volume MICUs (30 vs. 16%)., Conclusion: The decision of coronary reperfusion in a prehospital emergency setting depended on patient characteristics, delay between pain onset and first medical contact, and access to a PCI facility, but not on volume of activity. Promoting fibrinolysis use in underserved areas might help increase the reperfusion-decision rate.

Objective: The objective this study was to investigate the relative contributions of gender, common mental health symptoms, and experiences of interpersonal violence to the presence of sleep disturbances in Youth in Care under Child Welfare Society admitted to residential facilities., Methods: A sample of 315 teenagers (14-18 years old) completed a self-reported questionnaire upon admission, followed by a medical consultation with a nurse and a physician. Information regarding experiences of interpersonal violence, mental health symptoms, and sleep disturbances was collected using a standardized questionnaire., Results: Anxiety, ADHD symptoms, and sexual abuse were associated with sleep disturbances, F(10, 264) = 5.95, p < 0.001. Results from hierarchical regression analyses revealed that experiences of interpersonal violence, more specifically sexual abuse, were associated with sleep disturbances over and beyond gender and the presence of mental health symptoms., Conclusions: These results highlight practical implications for health professionals in terms of assessment and intervention for vulnerable youth exposed to interpersonal violence. Implications for research and practice are discussed., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Recent-onset atrial fibrillation (RAF) is the most frequent supraventricular dysrhythmia in emergency medicine. Severely compromised patients require acute treatment with injectable drugs OBJECTIVE: The main purpose of this external validity study was to compare the short-term efficacy of esmolol with that of amiodarone to treat severe RAF in an emergency setting., Methods: This retrospective survey was conducted in mobile intensive care units by analyzing patient records between 2002 and 2013. We included RAF with (one or more) severity factors including: clinical shock, angina pectoris, ST shift, and very rapid ventricular rate. A blind matching procedure was used to constitute esmolol group (n = 100) and amiodarone group (n = 200), with similar profiles for age, gender, initial blood pressure, heart rate, severity factors, and treatment delay. The main outcome measure was the percentage of patients with a ventricular rate control defined as heart frequency ≤ 100 beats/min. More stringent (rhythm control) and more humble indicators (20% heart rate reduction) were analyzed at from 10 to 120 min after treatment initiation., Results: Patient characteristics were comparable for both groups: age 66 ± 16 years, male 71%, treatment delay < 1 h 36%, 1-2 h 29%, > 2 h 35%, chest pain 61%, ST shift 62%, ventricular rate 154 ± 26 beats/min, and blood pressure 126/73 mm Hg. The superiority of esmolol was significant at 40 min (64% rate control with esmolol vs. 25% with amiodarone) and for all indicators from 10 to 120 min after treatment onset., Conclusion: In "real life emergency medicine," esmolol is better than amiodarone in the treatment of RAF., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Mortality of ST-segment-elevation myocardial infarction (STEMI) decreased drastically, mainly through reduction in inhospital mortality. Prehospital sudden cardiac arrest (SCA) became one of the most feared complications. We assessed the incidence, outcome, and prognosis' predictors of prehospital SCA occurring after emergency medical services (EMS) arrival., Methods and Results: Data were taken between 2006 and 2014 from the e-MUST study (Evaluation en Médecine d'Urgence des Strategies Thérapeutiques des infarctus du myocarde) that enrolls all STEMI managed by EMS in the Greater Paris Area, including those dead before hospital admission. Among 13 253 STEMI patients analyzed, 749 (5.6%) presented EMS-witnessed prehospital SCA. Younger age, absence of cardiovascular risk factors, symptoms of heart failure, extensive STEMI, and short pain onset-to-call and call-to-EMS arrival delays were independently associated with increased SCA risk. Mortality rate at hospital discharge was 4.0% in the nonSCA group versus 37.7% in the SCA group ( P<0.001); 26.8% of deaths occurred before hospital admission. Factors associated with increased mortality after SCA were age, heart failure, and extensive STEMI, while male sex and cardiovascular risk factors were associated with decreased mortality. Among patients admitted alive, PCI was the most important mortality-reduction predictor (odds ratio, 0.40; 95% CI, 0.25-0.63; P<0.0001)., Conclusions: More than 1 of 20 STEMI presents prehospital SCA after EMS arrival. SCA occurrence is associated with a 10-fold higher mortality at hospital discharge compared with STEMI without SCA. PCI is the strongest survival predictor, leading to a twice-lower mortality. This highlights the persistently dramatic impact of SCA on STEMI and the major importance of PCI in this setting.

Introduction: Recent studies reported a decrease in the incidence of acute myocardial infarction. This favorable evolution does not extend to young women. The interaction between gender, risk factors and myocardial infarction incidence remains controversial., Objective: To compare the evolution of the age pyramid of patients with ST-elevation myocardial infarction (STEMI) according to gender., Methods: Data from patients with STEMI managed in pre-hospital settings prospectively collected in the greater Paris area. Evolution of patient demographics and risk factors was investigated., Results: 28,249 patients with STEMI were included in the registry between 2002 and 2014, 21,883 (77%) males and 6,366 (23%) females. The sex ratio did not significantly vary over the study period ( p = 0.4). Median patient age was 60.1 years (51.1⁻73.0) and was significantly different between males and females, respectively 57.9 (50.0⁻68.3) vs. 72.9 years (58.3⁻82.2) ( p = 0.0004). The median age of males significantly ( p = 0.0044) increased from 57.6 (50.1⁻70.0) in 2002 to 58.1 years (50.5⁻67.8) in 2014. The median age of females significantly ( p = 0.0006) decreased from 73.7 (57.9⁻81.8) to 69.6 years (57.0⁻82.4). The median gap between the age of men and women significantly ( p = 0.0002) decreased, from 16.1 to 11.5 years. Prevalence of risk factors was unchanged or decreased except for hypertension which significantly increased in males. The rate of STEMI without reported risk factors increased in both males and females., Conclusion: The age of STEMI onset significantly decreased in females, whereas it significantly increased in males. The prevalence of risk factors decreased in males, whereas no significant variation was found in females.

Background: The frequency of complex percutaneous coronary interventions (PCIs) has increased in the last few years, with a growing concern on the radiation dose received by the patients. Multicenter data from large unselected populations on patients' radiation doses during coronary angiography (CA) and PCI and temporal trends are lacking. This study sought to evaluate the temporal trends in patients' exposure to radiation from CA and PCI., Methods and Results: Data were taken from the CARDIO-ARSIF registry that prospectively collects data on all CAs and PCIs performed in the 36 catheterization laboratories in the Greater Paris Area, the most populated regions in France with about 12 million inhabitants. Kerma area product and Fluoroscopy time from 152 684 consecutive CAs and 103 177 PCIs performed between 2009 and 2013 were analyzed. A continuous trend for a decrease in median [interquartile range] Kerma area product was observed, from 33 [19-55] Gy cm 2 in 2009 to 27 [16-44] Gy cm 2 in 2013 for CA ( P <0.0001), and from 73 [41-125] to 55 [31-91] Gy cm 2 for PCI ( P <0.0001). Time-course differences in Kerma area product remained highly significant after adjustment on Fluoroscopy time, PCI procedure complexity, change of x-ray equipment, and other patient- and procedure-related covariates., Conclusions: In a large patient population, a steady temporal decrease in patient radiation exposure during CA and PCI was noted between 2009 and 2013. Kerma area product reduction was consistent in all types of procedure and was independent of patient-related factors and PCI procedure complexity., (© 2017 American Heart Association, Inc.)

Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Aims: To determine the contributing factors in the successful diabetes education of patients and their entourage., Methods: Prospective observational study conducted in a pre-hospital setting by 17 emergency services across France (September 2009-January 2011) included all insulin-treated patients (≥18 years) provided that at least one family member was present on scene. Data were collected from patients and their entourage: (1) personal details including language proficiency and educational attainment, (2) treatments, (3) diabetes-related data (log sheets, glucose meter, glucagon, glycated hemoglobin, prior hypoglycemic episodes); (4) care by diabetologist, general practitioner and/or visiting nurse. The main end points were ability to measure capillary blood sugar (patient) and awareness of hypoglycemia symptoms and ability to administer glucagon (entourage)., Results: Overall, 561 patients and 736 family members were included; 343 patients (61%) were experiencing a hypoglycemic episode (<2.5 mmol/L). A total of 141 (75%) patients and 343 (50%) family members could measure capillary blood sugar. They could name a median of 2 [0-3‰] hypoglycemia symptoms although 217 (39%) patients and 262 (39%) family members could name no symptom. Few patients (33%) had glucagon available. In multivariate analyses, the main factor associated with better patient education was care by a diabetologist. Lack of an educational qualification and visits by a nurse were associated with poor patient education, and French mother tongue and care by a diabetologist with better education of the entourage., Conclusions: In France, diabetic patients and their entourage are inadequately educated. Their education benefits most from care by a diabetologist.

Background: In-hospital mortality of ST-segment-elevation myocardial infarction (STEMI) has decreased drastically. In contrast, prehospital mortality from sudden cardiac arrest (SCA) remains high and difficult to reduce. Identification of the patients with STEMI at higher risk for prehospital SCA could facilitate rapid triage and intervention in the field., Methods: Using a prospective, population-based study evaluating all patients with STEMI managed by emergency medical services in the greater Paris area (11.7 million inhabitants) between 2006 and 2010, we identified characteristics associated with an increased risk of prehospital SCA and used these variables to build an SCA prediction score, which we validated internally and externally., Results: In the overall STEMI population (n=8112; median age, 60 years; 78% male), SCA occurred in 452 patients (5.6%). In multivariate analysis, younger age, absence of obesity, absence of diabetes mellitus, shortness of breath, and a short delay between pain onset and call to emergency medical services were the main predictors of SCA. A score built from these variables predicted SCA, with the risk increasing 2-fold in patients with a score between 10 and 19, 4-fold in those with a score between 20 and 29, and >18-fold in patients with a score ≥30 compared with those with scores <10. The SCA rate was 28.9% in patients with a score ≥30 compared with 1.6% in patients with a score ≤9 (P for trend <0.001). The area under the curve values were 0.7033 in the internal validation sample and 0.6031 in the external validation sample. Sensitivity and specificity varied between 96.9% and 10.5% for scores ≥10 and between 18.0% and 97.6% for scores ≥30, with scores between 20 and 29 achieving the best sensitivity and specificity (65.4% and 62.6%, respectively)., Conclusions: At the early phase of STEMI, the risk of prehospital SCA can be determined through a simple score of 5 routinely assessed predictors. This score might help optimize the dispatching and management of patients with STEMI by emergency medical services., (© 2016 American Heart Association, Inc.)

Rationale Remote ischemic per-conditioning-causing transient limb ischemia to induce ischemic tolerance in other organs-reduces final infarct size in animal stroke models. Aim To evaluate whether remote ischemic per-conditioning during acute ischemic stroke (<6 h) reduces brain infarct size at 24 h. Methods and design This study is being performed in five French hospitals using a prospective randomized open blinded end-point design. Adults with magnetic resonance imaging confirmed ischemic stroke within 6 h of symptom onset and clinical deficit of 5-25 according to National Institutes of Health Stroke Scale will be randomized 1:1 to remote ischemic per-conditioning or control (stratified by center and intravenous fibrinolysis use). Remote ischemic per-conditioning will consist of four cycles of electronic tourniquet inflation (5 min) and deflation (5 min) to a thigh within 6 h of symptom onset. Magnetic resonance imaging is repeated 24 h after stroke onset. Sample size estimates For a difference of 15 cm 3 in brain infarct growth between groups, 200 patients will be included for 5% significance and 80% power. Study outcomes The primary outcome will be the difference in brain infarct growth from baseline to 24 h in the intervention versus control groups (by diffusion-weighted image magnetic resonance imaging). Secondary outcomes include: National Institutes of Health Stroke Scale score absolute difference between baseline and 24 h, three-month modified Rankin score and daily living activities, mortality, and tolerance and side effects of remote ischemic per-conditioning. Discussion The only remote ischemic per-conditioning trial in humans with stroke did not show remote ischemic per-conditioning to be effective. REmote iSchemic Conditioning in acUtE BRAin INfarction, which has important design differences, should provide more information on the use of this intervention in patients with acute ischemic stroke.

Aims: The mortality rate in patients with STEMI is higher in women than in men. This higher mortality rate is partly accounted for by certain known characteristics inherent in the female population (age, diabetes). Using data from the e-MUST registry on STEMI patients in the Greater Paris area, we assessed the differences between men and women treated with reperfusion strategies., Methods and Results: Patients presenting within 24 hours of pain onset between 2006 and 2010 were included in the study. The male and female subpopulations were compared according to their baseline characteristics, their management delays and their early outcomes. Five thousand eight hundred and forty males (78.9%) and 1,557 females (21.1%) were included in the study. In-hospital mortality was significantly higher in women than in men, 143 (9.4%) vs. 254 (4.4%), p<0.0001, with a longer time to treatment initiation, symptoms to call (2.7±3.6 vs. 2.2±3.4 hours, p<0.0001), symptoms to first medical contact (FMC) (3.1±3.7 vs. 2.6±3.4 hours, p<0.0001), and call to FMC (25.6±23.5 vs. 23.6±18.3 min, p=0.02). After adjustment for clinical factors, severity criteria, myocardial infarction (MI) location and delays, mortality remained higher in women than in men with an odds ratio of 1.40 [1.06-1.84], p=0.017., Conclusions: We demonstrated longer pre-hospital delays and higher in-hospital mortality in women. The increase in the time to treatment alone does not completely explain the persistent increase in mortality. Further studies, public awareness programmes and physician education are necessary to reduce delays and improve the prognosis of STEMI in women.

Background: Few data are available on primary percutaneous coronary intervention (pPCI) in nonagenarians. In a large prospective registry on pPCI for STEMI we compared the demographics, procedural and in-hospital outcomes between nonagenarians (age ≥ 90 years) and patients aged < 90 years., Methods and Results: We included 26,157 consecutive patients with pPCI in the Greater Paris Area region between 2003 and 2011. Of these, 418 (1.6%) were ≥ 90 years old. Nonagenarians (versus patients < 90 years) were more likely to be female (62.3% versus 22.5%, p < 0.0001), nonsmokers (81.6% versus 36.7%, p < 0.0001), in cardiogenic shock (Killip IV) upon admission (10.5% versus 4.8%, p < 0.001), and had significant co-morbidities. Over two-thirds of patients underwent procedures via the radial artery (61% versus 72.1%, p = 0.007). Both groups had high and similar angiographic success rates (98.1% versus 98.7%, p = 0.33). Drug-eluting stents were used less often in nonagenarians (4.4% versus 16.7%, p < 0.0001). Hospital mortality was significantly much higher in patients over 90 years old (24.9% versus 5.1%, p < 0.001) in univariate analysis. After adjustment for sex, cardiogenic shock, diabetes, triple vessel disease, drug-eluting stent use and glycoprotein IIb/IIIa inhibitors use, mortality remains higher in nonagenarian patients (OR: 4.31; 95% CI: 3.26-5.71, p < 0.0001)., Conclusions: In a real-world setting, we found important demographic differences in nonagenarian compared to younger patients. Despite achieving a high rate of reperfusion with pPCI using mainly radial access, similar to that achieved in younger patients, hospital mortality was higher in nonagenarians., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Introduction: ST-segment-elevation acute myocardial infarction (STEMI) is a therapeutic emergency. Early reperfusion is the key to successful reperfusion. Guidelines recommend organizing regional networks. In France, this starts with a call to a medical dispatch center, the SAMU-centre 15. The aim of this study was to evaluate regional STEMI management using data collected from 2002 to 2010., Methods: Observational, prospective, multicenter survey. STEMI patient with chest pain lasting for less than 24hours managed by 40 mobile emergency and resuscitation service (SMUR) and 8 emergency medical system (SAMU) from the Greater Paris Area (Île-de-France) were analyzed. Demographic data, cardiovascular risk factors, infarction location, decision of reperfusion and delays were collected. The rate of coronary reperfusion was chosen as the primary endpoint., Results: Eleven thousand five hundred and eighty-eight patients enrolled from 2002 to 2010 were analyzed. Median age was 59.9 (51.0 to 72.9) years; 9080 (78.5%) were men. The number of patients included decreased from 1376 in 2002 to 1119 in 2010. Reperfusion was achieved by fibrinolysis in 2644 (23%) cases and primary angioplasty in 7999 (69%) cases. The rate of decision of coronary reperfusion significantly increased from 86.7% in 2002 to 94.8% in 2010 (P<0.0001). Interaction between the increasing decision of reperfusion and all factors studied (demographics, cardiovascular risk factors, infarct location and delays) was significant only for family history of coronary artery disease (P=0.03). In-hospital mortality was 2.8% (321 cases)., Conclusion: The number of patients with STEMI managed by the SAMU declined slightly over the past decade. The rate of decision of reperfusion progressively increased up to 95%. Entrance into the network by the SAMU-centre 15 is a guarantee of a wide and early access to the coronary reperfusion., (Copyright © 2015. Published by Elsevier Masson SAS.)

Background: Elderly patients with ST-segment elevation myocardial infarction (STEMI) have worse outcomes and a greater risk of intracranial bleeding than nonelderly patients. Baseline characteristics, clinical outcomes, and the relationship of the tenecteplase (TNK) dose reduction to the efficacy, safety, and electrocardiographic indicators of reperfusion efficacy were evaluated in STEMI patients ≥75 years., Methods: The STREAM trial evaluated early presenting STEMI patients who could not undergo primary percutaneous coronary intervention within 1 hour of first medical contact. Because of excess intracranial hemorrhage (ICH) in patients ≥75 years, the dose of TNK was reduced by 50%., Results: Before dose amendment, there were 3 (7.1%) of 42 elderly patients with ICH; 2 of these were fatal, whereas no ICH occurred in the 93 elderly patients who received half-dose TNK postamendment. The median extent of ST-segment elevation resolution (≥50%) and proportion of patients with ≥2 mm in the electrocardiogram lead with greatest ST-segment elevation was comparable in elderly patients preamendment and postamendment (63.2% vs 56.0% and 43.6% vs 40.0%, respectively). Patients requiring rescue coronary intervention after TNK was also similar (42.9% vs 44.1%). The primary composite end point (30-day all-cause death, cardiogenic shock, congestive heart failure, and reinfarction) was 31.0% before versus 24.7% postamendment., Conclusions: Our data, from a modest-sized population of elderly STEMI patients, indicate that half-dose TNK reduces the likelihood of ICH without compromising reperfusion efficacy. These observations are hypothesis generating and warrant further confirmation in randomized clinical trials in the elderly., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Environmental parameters have been reported to be triggers of acute myocardial infarction (MI). However, the individual role of each parameter is unknown. We quantified the respective association of climate parameters, influenza epidemics and air pollutants with the onset of ST elevation MI (STEMI) in Paris and the surrounding small ring., Methods: Data from the CARDIO-ARSIF registry (Paris and small ring STEMI population), Météo France (Climate), GROG (Influenza epidemic) and AIRPARIF (Air Pollution) were analyzed. The association between short-term exposure (1 day lag time) to environmental parameters and STEMI occurrence was quantified by time series modeling of daily STEMI count data, using Poisson regression with generalized additive models., Results: Between 2003 and 2008, 11,987 <24H STEMI confirmed by angiography were adjudicated. There was a 5.0% excess relative risk (ERR) of STEMI per 10°C decrease in maximal temperature (95% CI 2.1% to 7.8%: p=0.001) and an 8.9% ERR (95% CI 3.2% to 14.9%: p=0.002) during an influenza epidemic after adjustment on week-days and holidays. Associations were consistent when short-term exposure varied from 2 to 7 days. Associations between lower temperatures and STEMI were stronger in magnitude when influenza epidemic was present. Short-term exposure to climatic parameters or pollutants was not associated with STEMI., Conclusions: The present population based registry of STEMI suggests that short-term exposure to lower temperature and influenza epidemic is associated with a significant excess relative risk of STEMI. Subjects at risk for MI may benefit from specific protections against cold temperature and influenza infection., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: We evaluated the prespecified endpoint, aborted myocardial infarction (AbMI), according to the use of a pharmacoinvasive (PI) strategy versus primary percutaneous coronary intervention (PCI) in 1754 patients randomised within 3 h of symptom onset in the STrategic Reperfusion Early After Myocardial infarction (STREAM) trial., Methods: Based on sequential ECG's and biomarkers, AbMI was defined as ST-elevation resolution ≥50% (90 min posttenecteplase (TNK) in the PI arm or 30 min postprimary PCI) with minimal biomarker rise., Results: In the PI arm 11.1% (n=99) had AbMI versus 6.9% (n=59) in primary PCI arm (p<0.01). In a multivariable model, AbMI patients overall had less baseline ΣST-deviation, fewer baseline Q-waves and shorter total ischaemic times. PI AbMI patients had faster time to TNK (90 vs 100 min, p=0.015): total ischaemic time was 100 min longer in primary PCI AbMI patients and no difference in ischaemic time existed between AbMI and non-AbMI patients within this group. Although no significant interaction between treatment and AbMI on the composite endpoint of death/shock/congestive heart failure/recurrent MI occurred (p=0.292), PI AbMI patients had a lower incidence in this endpoint than non-AbMI patients (5.1 vs 12%, p=0.038); this was not evident in primary PCI patients. Forty-five patients (ie, 2.5%) had masquerading MI with minimal biomarker elevation and no evolution in baseline ST-elevation., Conclusions: A PI strategy of early fibrinolysis more frequently aborts MI than primary PCI. Such PI patients had more favourable outcomes as compared with non-AbMIs. Diligent review of ECG evolution in STEMI distinguishes AbMI from infarct masquerade. ClinicalTrials.gov ID: NCT00623623., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: In the Strategic Reperfusion Early After Myocardial Infarction (STREAM) trial, a pharmaco-invasive (PI) strategy was compared with primary percutaneous coronary intervention (pPCI) in ST-segment-elevation myocardial infarction patients presenting within 3 hours after symptom onset but unable to undergo pPCI within 1 hour. At 30 days, the PI approach was associated with a nominally but nonstatistically significant lower incidence of the composite primary end point of death, shock, congestive heart failure, and reinfarction when compared with pPCI. The aim of the present study was to determine the effect of these strategies on 1-year mortality., Methods and Results: Vital status at 1 year was available in 936 of 944 (99.2%) and 941 of 948 (99.3%) patients in the PI and pPCI arm, respectively. At 1 year, all-cause mortality rates (6.7% versus 5.9%) were similar for PI and pPCI-treated patients (P=0.49; risk ratio, 1.13; 95% confidence interval, 0.79-1.62). Cardiac mortality rates were similar as well (4.0% versus 4.1%, P=0.93; risk ratio, 0.98; 95% confidence interval, 0.62-1.54). Overall, only 34 patients died between day 30 and 1 year, 20 in the PI arm and 14 in the pPCI arm, of whom 20 died of noncardiac reasons (13 in the PI and 7 in the pPCI arm). There was no significant difference in 1-year all-cause mortality between the 2 groups among the prespecified key subgroups., Conclusions: At 1 year, mortality rates in the PI and pPCI arms were similar in ST-segment-elevation myocardial infarction patients presenting within 3 hours after symptom onset and unable to undergo pPCI within 1 hour., Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT00623623., (© 2014 American Heart Association, Inc.)

Background: ESC guidelines recommend a shorter (90 min) delay for the use of primary percutaneous intervention (pPCI) in patients presenting within the first 2h of pain onset. Using registry data on STEMI patients in the Greater Paris Area, we assessed changes between 2003 and 2008 in the rates of pPCI, pre-hospital fibrinolytic therapy (PHF) and time delays in patients presenting within 2h of STEMI pain onset., Methods: The Greater Paris Area was divided in 3 regions: Paris, the small and large rings. Patients were divided in three groups according to their reperfusion strategy: a) PHF, b) timely pPCI (FMC to balloon inflation time < 90 min), and c) late pPCI (FMC to balloon inflation time > 90 min)., Results: Among the 5592 patients included, 1695 (39%) had PHF, 1266 (29%) had timely pPCI, and 1415 (32%) had late pPCI. Over the 6 years, there was a sharp increase in timely pPCI in all regions, balanced by a decrease in PHF. The rate of late pPCI remained globally stable, with a decrease in Paris, stabilization in the small ring, and an increase in the large ring, where the density of catheterization laboratories was the lowest. By multivariate analysis, using on-time pPCI as a reference group, mortality was higher in the PHF and late pPCI groups., Conclusions: In areas with a low density of pPCI centers, efforts should be made to improve the timeliness of pPCI. Otherwise, PHF followed by an immediate transfer to a pPCI capable hospital may be considered., (© 2013.)

Background: It is not known whether prehospital fibrinolysis, coupled with timely coronary angiography, provides a clinical outcome similar to that with primary percutaneous coronary intervention (PCI) early after acute ST-segment elevation myocardial infarction (STEMI)., Methods: Among 1892 patients with STEMI who presented within 3 hours after symptom onset and who were unable to undergo primary PCI within 1 hour, patients were randomly assigned to undergo either primary PCI or fibrinolytic therapy with bolus tenecteplase (amended to half dose in patients ≥75 years of age), clopidogrel, and enoxaparin before transport to a PCI-capable hospital. Emergency coronary angiography was performed if fibrinolysis failed; otherwise, angiography was performed 6 to 24 hours after randomization. The primary end point was a composite of death, shock, congestive heart failure, or reinfarction up to 30 days., Results: The primary end point occurred in 116 of 939 patients (12.4%) in the fibrinolysis group and in 135 of 943 patients (14.3%) in the primary PCI group (relative risk in the fibrinolysis group, 0.86; 95% confidence interval, 0.68 to 1.09; P=0.21). Emergency angiography was required in 36.3% of patients in the fibrinolysis group, whereas the remainder of patients underwent angiography at a median of 17 hours after randomization. More intracranial hemorrhages occurred in the fibrinolysis group than in the primary PCI group (1.0% vs. 0.2%, P=0.04; after protocol amendment, 0.5% vs. 0.3%, P=0.45). The rates of nonintracranial bleeding were similar in the two groups., Conclusions: Prehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within 1 hour after the first medical contact. However, fibrinolysis was associated with a slightly increased risk of intracranial bleeding. (Funded by Boehringer Ingelheim; ClinicalTrials.gov number, NCT00623623.).

Smoke inhalation is a common cause of cyanide poisoning during fires, resulting in injury and even death. In many cases of smoke inhalation, cyanide has increasingly been recognized as a significant toxicant. The diagnosis of cyanide poisoning remains very difficult, and failure to recognize it may result in inadequate or inappropriate treatment. Findings suggesting cyanide toxicity include the following: (a) a history of enclosed-space fire; (b) any alteration in the level of consciousness; (c) any cardiovascular changes (particularly inexplicable hypotension); and (d) elevated plasma lactate. The feasibility and safety of empiric treatment with hydroxocobalamin for fire smoke victims have been reported in the literature. On the basis of a literature review and a panel discussion, a group of European experts has proposed emergency management protocols for cyanide toxicity in fire smoke victims.

Background: Primary care improvement is the cornerstone of current reforms. Mental disorders (MDs) are a leading cause of morbidity worldwide and widespread in industrialised countries. MDs are treated mainly in primary care by general practitioners (GPs), even though the latter ability to detect, diagnose, and treat patients with MDs is often considered unsatisfactory. This article examines GPs' management of MDs in an effort to acquire more information regarding means by which GPs deal with MD cases, impact of such cases on their practices, factors that enable or hinder MD management, and patient-management strategies., Methods: This study employs a mixed-method approach with emphasis on qualitative investigation. Based on a previous survey of 398 GPs in Quebec, Canada, 60 GPs representing a variety of practice settings were selected for further study. A 10-minute-long questionnaire comprising 27 items was administered, and 70-minute-long interviews were conducted. Quantitative (SPSS) and qualitative (NVivo) analyses were performed., Results: At least 20% of GP visits were MD-related. GPs were comfortable managing common MDs, but not serious MDs. GPs' based their treatment of MDs on pharmacotherapy, support therapy, and psycho-education. They used clinical intuition with few clinical tools, and closely followed their patients with MDs. Practice features (salary or hourly fees payment; psycho-social teams on-site; strong informal networks), and GPs' individual characteristics (continuing medical education; exposure and interest in MDs; traits like empathy) favoured MD management. Collaboration with psychologists and psychiatrists was considered key to good MD management. Limited access to specialists, system fragmentation, and underdeveloped group practice and shared-care models were impediments. MD management was seen as burdensome because it required more time, flexibility, and emotional investment. Strategies exist to reduce the burden (one-problem-per-visit rule; longer time slots). GPs found MD practice rewarding as patients were seen as grateful and more complying with medical recommendations compared to other patients, generally leading to positive outcomes., Conclusions: To improve MD management, this study highlights the importance of extending multidisciplinary GP practice settings with salary or hourly fee payment; access to psychotherapeutic and psychiatric expertise; and case-discussion training involving local networks of GPs and MD specialists that encourage both knowledge transfer and shared care.

When epidemic cholera appeared in Haiti in October 2010, the medical community there had virtually no experience with the disease and needed rapid training as the epidemic spread throughout the country. We developed a set of training materials specific to Haiti and launched a cascading training effort. Through a training-of-trainers course in November 14-15, 2010, and department-level training conducted in French and Creole over the following 3 weeks, 521 persons were trained and equipped to further train staff at the institutions where they worked. After the training, the hospitalized cholera patients' case-fatality rate dropped from 4% to <2% by mid-December and was <1% by January 2011. Continuing in-service training, monitoring and evaluation, and integration of cholera management into regular clinical training will help sustain this success.

Aims: To discriminate early ST-segment elevation myocardial infarction (STEMI) presenters at a high probability of successful pre-hospital thrombolysis (PHT) using a simple nomogram based on independent predictors of complete ST resolution., Methods and Results: OPTIMAL was an observational, prospective study undertaken at 79 medical centres in France in patients with STEMI undergoing pre-hospital thrombolysis (PHT) within six hours of symptom onset and coronary angiography within six hours of thrombolysis. The baseline and pre-coronary angiography ECGs of 800 patients were analysed. The main outcome measure was ST segment resolution ≥ 70%. ST resolution was associated with a significant reduction in mortality (1.8% vs. 4.3%; p=0.05). After multivariable logistic regression analysis, five independent predictors of successful myocardial reperfusion were identified: ≤ 1 h between pain onset and thrombolysis (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.18-2.62); body mass index (BMI) <30 kg/m2 (OR 1.74, CI 1.12-2.72); current/previous smoking (OR 1.71, CI 1.21-2.43); non-anterior infarct territory (OR 1.75, CI 1.27-2.41); and maximum amplitude of ST elevation <3 mm (OR 1.83, CI 1.32-2.54). The C-statistic of the model was 0.71 (95% CI 0.67-0.74). Using these five independent factors, a simple nomogram was developed to assess the probability of ST resolution after PHT. This nomogram allows discrimination of probabilities ranging from 13 to 72%., Conclusions: This simple nomogram can predict the probability of successful myocardial reperfusion after thrombolysis. This may be useful in the triage of STEMI presenters.

Aims: To determine if female gender is an independent predictor of in-hospital mortality after percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI). A higher early mortality rate after STEMI has been reported in women before the widespread use of PCI in STEMI. PCI improves the prognosis of STEMI, however, the effect of PCI in women in this setting is controversial. In a large regional prospective registry, we examined the in-hospital mortality after PCI for STEMI., Methods and Results: The greater Paris area comprises 11 million inhabitants. Data from all PCIs performed in 41 centres is entered in a mandatory registry. In-hospital mortality is recorded in another hospital-based database. From 2003 to 2007, 16,760 patients were treated by PCI for STEMI <24 hours; 21.9% were women. Female patients were significantly older than men, 69.7 ± 14.3 years versus 59.3 ± 13.0 years (p<0.0001). The rate of diabetes mellitus and cardiogenic shock were significantly higher in women versus men, respectively 19.0% versus 15.6%, p<0.0001 and 6.7% versus 4.0%, p<0.0001. The success rate of PCI was significantly lower in women: 94.7% versus 95.9%, p=0.002. In-hospital mortality was significantly higher in women 9.8 % versus 4.3%, p<0.0001 and the impact of gender on mortality was significant only after the age of 75. By multivariate analysis, female gender is associated with higher in-hospital mortality., Conclusions: After PCI for STEMI, female gender is still an independent predictor of in-hospital mortality.

Objectives: Few outcome data are available about convulsive status epilepticus managed in the intensive care unit. We studied 90-day functional outcomes and their determinants in patients with convulsive status epilepticus., Design: Two hundred forty-eight convulsive status epilepticus patients admitted to 18 intensive care units in 2005-2007 were included in a prospective observational cohort study. The main outcome measure was a Glasgow Outcome Scale score of 5 (good recovery) on day 90., Main Results: Convulsive status epilepticus occurred out of hospital in 177 (67%) patients, and all but 15 patients were still seizing at medical team arrival. The median time from convulsive status epilepticus onset to anticonvulsant drug initiation was 40 mins (interquartile range, 5-80). Total seizure duration was 85 mins (interquartile range, 46.5-180). Convulsive status epilepticus was refractory in 49 (20%) patients. The most common causes of convulsive status epilepticus were anticonvulsive agent withdrawal (36.4%) in patients with previous epilepsy and stroke (27.7%) in inaugural convulsive status epilepticus. Mechanical ventilation was needed in 210 (85%) patients. On day 90, 42 (18.8%) patients were dead, 87 (38.8%) had marked functional impairments (Glasgow Outcome Scale score, 2-4), and 95 (42.4%) had a good recovery (Glasgow Outcome Scale score, 5). Factors showing independent positive associations with poor outcome (Glasgow Outcome Scale score, <5) were older age (odds ratio, 1.04/year; 95% confidence interval, 1.02-1.05; p=.0005), cerebral insult (odds ratio, 2.70; 95% confidence interval, 1.37-5.26; p=.007), longer seizure duration (odds ratio, 1.72/120 min; 95% confidence interval, 1.05-2.86; p=.03), on-scene focal neurologic signs (odds ratio, 2.08; 95% confidence interval, 1.03-4.16; p=.04), and refractory convulsive status epilepticus (odds ratio, 2.70; 95% confidence interval, 1.02-7.14; p=.045)., Conclusions: Ninety days after intensive care unit admission for convulsive status epilepticus, half the survivors had severe functional impairments. Longer seizure duration, cerebral insult, and refractory convulsive status epilepticus were strongly associated with poor outcomes, suggesting a role for early neuroprotective strategies.

Background: Fibrinolytic therapy for acute ST-elevation myocardial infarction (STEMI) is frequently limited by delays in administration and by incomplete reperfusion or reocclusion of the infarct-related artery. Intensified prehospital management of STEMI may shorten time to treatment and improve outcomes., Methods: We carried out a prospective substudy in 11 ambulance systems in 216 of the 3,491 patients with STEMI who were enrolled in the CLARITY-TIMI 28 trial. They were randomized in the ambulance to clopidogrel (n = 109) or placebo (n = 107) along with fibrinolysis, aspirin, and heparin. The primary endpoint was the composite of an occluded infarct-related artery (TIMI flow grade 0 or 1), or death or recurrent myocardial infarction before angiography., Results: All patients received a fibrin-specific lytic and the baseline characteristics in both groups were comparable. The incidence of the primary endpoint was 16.5% in the clopidogrel-treated and 27.1% in the placebo patients (adj OR 0.62, 95% CI 0.31-1.21, p = 0.16), an effect that was consistent with the effects seen in the in-hospital patients in the main CLARITY-TIMI 28 trial. Prehospital clopidogrel therapy reduced the incidence of an occluded infarct-related artery on the predischarge angiogram (11.8% vs. 22.3%, adj OR 0.52, 95% CI 0.24-1.13, p = 0.10). The 30-day incidence of cardiovascular death, recurrent MI or recurrent myocardial ischemia requiring urgent revascularization was 12.8% vs. 14.0% (adj OR 1.07, 95% CI 0.48-2.39, p = 0.87). Early TIMI major bleeding occurred in no clopidogrel patients compared with two placebo patients (1.9%)., Conclusions: Addition of clopidogrel to medical reperfusion of STEMI with fibrinolysis, heparin, and aspirin before reaching the hospital is feasible in medically equipped ambulances without an apparent increase in bleeding. Furthermore, prehospital clopidogrel tended to show better early coronary patency compared to placebo, a result consistent with that observed in patients randomized in-hospital in the CLARITY-TIMI 28 trial.

Methods: A regional survey was performed between June and September 2002, to evaluate knowledge and attitudes of emergency physicians regarding adverse drug reaction (ADR) reporting in a French district. 100 questionnaires completed by physicians working in emergency departments and/or mobile intensive care units were analysed., Results: The frequency of ADRs encountered by emergency practitioners was estimated at > or = 0.73 per year and per physician. The ADR notification rate in emergency medicine was estimated at < or = 6%. A minority of physicians were responsible for the majority of ADR reporting. Sixty-four percent of emergency physicians underestimated the conditions required for ADR notification: 28% thought that certain causality was an absolute necessary condition for notification, while 37% considered that notification was required only for ADRs that were both severe and unexpected., Conclusion: Interventions focused on advertising ADR reporting procedures could help to improve the notification rate in emergency medicine.