Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

RATIONALE: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. OBJECTIVES: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables. MAIN RESULTS: 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients. CONCLUSIONS: In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Feasibility and impact of the implementation of a clinical scale-based sedation-analgesia protocol in severe burn patients undergoing mechanical ventilation. A before-after bi-center study

International audienceBackground: Severe burn patients undergo prolonged administration of sedatives and analgesics for burn care. There are currently no guidelines for the dose adaptation of sedation-analgesia in severe burn patients.Methods:We performed a before-after 2-center study to demonstrate the feasibility and efficacy of a sedation-analgesia scale-based protocol in severely burned patients receiving ≥24 h of invasive mechanical ventilation. Before the intervention, continuous infusion of hypnotic and morphine derivatives was continued. During the Intervention phase, general anesthesia was relayed from day 1 by RASS/BPS-titrated continuous infusion of hypnotic and morphine derivatives and with short half-life drugs adminstered for daily burn dressings. The primary outcome was the duration of invasive mechanical ventilation in the ICU.Results: Eighty-seven (46.2%) patients were included in the Control phase and 101 (53.7%) in the Intervention phase. The median burned cutaneous surface was 20% [11%–38%] and median ABSI was 7 [5–9]. The durations of hypnotic and opioid infusions were not statistically different between the 2 phases (8 days [2–24] vs. 6 days [2–17] (P = 0.3) and 17 days [4–32] vs. 8 days [3–23] (P = 0.06), respectively). The duration of mechanical ventilation was 14 days [3-29] in the Control phase and 7 days [2–24] in the Intervention phase (P = 0.7). When taking into account the competition between mortality and weaning from mechanical ventilation, we found no significant difference between the 2 phases (Gray test, P = 0.4). The time-series analysis showed no difference for the duration of mechanical ventilation in the Intervention phase (P = 0.6). Eighteen (20.7%) patients died in the Control phase, and 18 (18%) in the Intervention phase (P = 0.6).Conclusion: Scale-based lightening of continuous sedation-analgesia with repeated short general anesthesia for dressing is feasible in severe burn patients but failed to demonstrate a decrease in the duration of invasive mechanical ventilatio

Suivi citoyen des indicateurs des aléas d’érosion côtière et de submersion marine : création de l’application smartphone et tablette CoastAppli et expérimentation à Guissény (Finistère)

International audienceLes aléas côtiers (érosion, submersion, migration dunaire) et les dynamiques côtières sont souvent méconnus par le grand public. Or, dans un contexte de changement climatique et d’évolution de la législation (loi « Climat et résilience » en 2021) sur la gestion des aléas et des risques côtiers (risque(s) combinant aléa(s) et enjeu(x)), le suivi de l’évolution du littoral au travers d’indicateurs des aléas côtiers (position du trait de côte, niveau de la plage, niveau d’eau sur un repère lors d’une submersion, etc.) devrait être l’affaire de tous. Jusqu’à présent, aucune application citoyenne pour smartphone ou tablette ne permettait de suivre conjointement les indicateurs des aléas côtiers d’érosion et de submersion, alors que ces deux aléas sont souvent liés. Pour y remédier, dans le cadre d’un projet de recherche et de formation (2019-2022) regroupant des étudiants en géographie, en biologie et en informatique, nous avons créé l’application Android CoastAppli. CoastAppli, qui vise un public large (habitants, touristes, scolaires, gestionnaires du littoral, etc.) et a été expérimentée à Guissény (Finistère) entre janvier et octobre 2022 auprès de 86 personnes, permet de réaliser un suivi citoyen des indicateurs d’aléas côtiers. Grâce à l’implication des utilisateurs sur les quatre sites de cette commune, les résultats soulignent la fiabilité des données quantitatives (jusqu’à une erreur globale de ± 4 cm) et/ou qualitatives, ainsi que la haute fréquence d’acquisition (mensuelle). Par ailleurs, cela semble un bon moyen pour comprendre, discuter et réfléchir entre acteurs du territoire aux défis de gestion du littoral d’aujourd’hui et de demain

Suivi citoyen des indicateurs des aléas d’érosion côtière et de submersion marine : création de l’application smartphone et tablette CoastAppli et expérimentation à Guissény (Finistère)

International audienceLes aléas côtiers (érosion, submersion, migration dunaire) et les dynamiques côtières sont souvent méconnus par le grand public. Or, dans un contexte de changement climatique et d’évolution de la législation (loi « Climat et résilience » en 2021) sur la gestion des aléas et des risques côtiers (risque(s) combinant aléa(s) et enjeu(x)), le suivi de l’évolution du littoral au travers d’indicateurs des aléas côtiers (position du trait de côte, niveau de la plage, niveau d’eau sur un repère lors d’une submersion, etc.) devrait être l’affaire de tous. Jusqu’à présent, aucune application citoyenne pour smartphone ou tablette ne permettait de suivre conjointement les indicateurs des aléas côtiers d’érosion et de submersion, alors que ces deux aléas sont souvent liés. Pour y remédier, dans le cadre d’un projet de recherche et de formation (2019-2022) regroupant des étudiants en géographie, en biologie et en informatique, nous avons créé l’application Android CoastAppli. CoastAppli, qui vise un public large (habitants, touristes, scolaires, gestionnaires du littoral, etc.) et a été expérimentée à Guissény (Finistère) entre janvier et octobre 2022 auprès de 86 personnes, permet de réaliser un suivi citoyen des indicateurs d’aléas côtiers. Grâce à l’implication des utilisateurs sur les quatre sites de cette commune, les résultats soulignent la fiabilité des données quantitatives (jusqu’à une erreur globale de ± 4 cm) et/ou qualitatives, ainsi que la haute fréquence d’acquisition (mensuelle). Par ailleurs, cela semble un bon moyen pour comprendre, discuter et réfléchir entre acteurs du territoire aux défis de gestion du littoral d’aujourd’hui et de demain

Can CoastAppli (a citizen science smartphone app) improve monitoring and understanding of coastal hazards to support coastal management?

International audienceCoastal erosion and flooding remain unknown hazards and elected officials and coastal managers may have difficulty discussing these phenomena with the general public. However, a better knowledge of the evolution of these hazards, through citizen science, can help raise awareness of coastal dynamics among the general public and thus meet the current and future challenges of coastal management. During the OSIRISC project (2016-2020), funded by the Fondation de France, coastal managers wanted to set up a smartphone app to save time during their field surveys, while allowing citizens to perform some measurements. How to create a citizen science app on coastal hazards that is reliable and intelligible and that guarantees the sustainable support of participants (professionals and non professionals)? Within the framework of the observatory of coastal risks in Brittany (OSIRISC), protocols for measuring hazards 1) with common tools (benchmarks such as the size of one's finger, qualitative data with photographs) or cheap tools (tape measure, laser distance meter...), 2) applicable to all types of coasts (beach, cliff…) have been co-designed with the managers and integrated into the android app called CoastAppli. Co-funded by EUR ISblue (the interdisciplinary graduate school for the blue planet), Sea-Eu and Interreg AGEO projects, CoastAppli is currently being tested for 6 months (until April 2022) in the municipality of Guissény (Brittany, France) by grade school students, coastal managers and citizens. The feedback from this test will allow us to know: i) the reliability of the measurements; ii) whether the app meets the expectations of the coastal managers by saving time for data collection in the field; iii) the app ability to be understood and educative; iv) the sustainability of the commitment of the citizens. These results are essential to validate the application before a future deployment that is intended in Brittany, then in France and beyond

How did we take care of our older cancer patients during the first COVID-19 wave? The French experience

International audienceBACKGROUND: The management of older cancer patients has been highly challenging for clinicians in a health-care system operating at maximum capacity during the COVID-19 pandemic. PATIENTS AND METHODS: We analyzed data from 9 different institutions. The primary endpoint was to assess the prevalence of adapted patient care during the pandemic for elderly cancer patients. The secondary endpoint was to assess the incidence of hospitalization and mortality due to COVID-19. All patients were older than 65years of age. RESULTS: We analyzed data from 332 outpatients’ case files between 9th of March and 30th of April 2020. The median age was 75years (range: 65-101) and 53% were male. Because of the COVID-19 pandemic, more than half of the outpatients received modified patient care, defined as postponement or cancellation of surgery, irradiation scheme adapted, systemic treatment or the use of telemedicine. Among patients with localized cancer, 60% had a change in management strategy due to the pandemic. Changes in management strategy were made for 53% of patients at the metastatic stage. GCSF was used , in 83% of patients, increasing considerably in the context of the pandemic. Sixty-nine percent of physicians used telemedicine. In the final analysis, only one patient was hospitalized for COVID-19 infection. No deaths due to COVID-19 were reported in elderly cancer patients during this time period. CONCLUSION: Our study is the first to assess modification of patient care in elderly cancer outpatients during an epidemic. With this unprecedented crisis, our objective is to protect our patients from infection via protective barrier measures and social distancing, but also to guarantee the continuity of cancer care without overexposing this fragile population. Physicians were able to adapt their practice and used new forms of management, like telemedicine

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome Associated with COVID-19: An Emulated Target Trial Analysis

International audienc

Benefits and risks of noninvasive oxygenation strategy in COVID-19: a multicenter, prospective cohort study (COVID-ICU) in 137 hospitals

International audienceAbstract Rational To evaluate the respective impact of standard oxygen, high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) on oxygenation failure rate and mortality in COVID-19 patients admitted to intensive care units (ICUs). Methods Multicenter, prospective cohort study (COVID-ICU) in 137 hospitals in France, Belgium, and Switzerland. Demographic, clinical, respiratory support, oxygenation failure, and survival data were collected. Oxygenation failure was defined as either intubation or death in the ICU without intubation. Variables independently associated with oxygenation failure and Day-90 mortality were assessed using multivariate logistic regression. Results From February 25 to May 4, 2020, 4754 patients were admitted in ICU. Of these, 1491 patients were not intubated on the day of ICU admission and received standard oxygen therapy (51%), HFNC (38%), or NIV (11%) ( P < 0.001). Oxygenation failure occurred in 739 (50%) patients (678 intubation and 61 death). For standard oxygen, HFNC, and NIV, oxygenation failure rate was 49%, 48%, and 60% ( P < 0.001). By multivariate analysis, HFNC (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.36–0.99, P = 0.013) but not NIV (OR 1.57, 95% CI 0.78–3.21) was associated with a reduction in oxygenation failure). Overall 90-day mortality was 21%. By multivariable analysis, HFNC was not associated with a change in mortality (OR 0.90, 95% CI 0.61–1.33), while NIV was associated with increased mortality (OR 2.75, 95% CI 1.79–4.21, P < 0.001). Conclusion In patients with COVID-19, HFNC was associated with a reduction in oxygenation failure without improvement in 90-day mortality, whereas NIV was associated with a higher mortality in these patients. Randomized controlled trials are needed

Characteristics, management, and prognosis of elderly patients with COVID-19 admitted in the ICU during the first wave: insights from the COVID-ICU study

International audienceBackground: The COVID-19 pandemic is a heavy burden in terms of health care resources. Future decision-making policies require consistent data on the management and prognosis of the older patients (&gt; 70 years old) with COVID-19 admitted in the intensive care unit (ICU). Methods: Characteristics, management, and prognosis of critically ill old patients (&gt; 70 years) were extracted from the international prospective COVID-ICU database. A propensity score weighted-comparison evaluated the impact of intubation upon admission on Day-90 mortality. Results: The analysis included 1199 (28% of the COVID-ICU cohort) patients (median [interquartile] age 74 [72–78] years). Fifty-three percent, 31%, and 16% were 70–74, 75–79, and over 80 years old, respectively. The most frequent comorbidities were chronic hypertension (62%), diabetes (30%), and chronic respiratory disease (25%). Median Clinical Frailty Scale was 3 (2–3). Upon admission, the PaO2/FiO2 ratio was 154 (105–222). 740 (62%) patients were intubated on Day-1 and eventually 938 (78%) during their ICU stay. Overall Day-90 mortality was 46% and reached 67% among the 193 patients over 80 years old. Mortality was higher in older patients, diabetics, and those with a lower PaO2/FiO2 ratio upon admission, cardiovascular dysfunction, and a shorter time between first symptoms and ICU admission. In propensity analysis, early intubation at ICU admission was associated with a significantly higher Day-90 mortality (42% vs 28%; hazard ratio 1.68; 95% CI 1.24–2.27; p &lt; 0·001). Conclusion: Patients over 70 years old represented more than a quarter of the COVID-19 population admitted in the participating ICUs during the first wave. Day-90 mortality was 46%, with dismal outcomes reported for patients older than 80 years or those intubated upon ICU admission