Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Vers une gouvernance inframunicipale de la transition écologique ? Le cas de l’Arrondissement de Rosemont–La Petite-Patrie à Montréal

Bien que la notion de transition écologique continue aujourd’hui à faire l’objet d’un processus de définition qui est loin d’être univoque, elle devient un enjeu de gouvernance municipale de plus en plus urgent. Dans les nombreuses situations où cette gouvernance est organisée de manière multiscalaire entre différents ordres de gouvernement ayant un certain nombre de compétences partagées, le problème de l’inexistence d’une définition stabilisée et opérationnelle de la transition se double du défi de l’identification et de la mise en oeuvre des actions à entreprendre. Cet article présente les résultats d’une recherche partenariale effectuée avec l’Arrondissement de Rosemont–La Petite-Patrie à Montréal autour de deux questions principales, à savoir « qu’est-ce que la transition écologique à l’échelle inframunicipale ? » et « comment la mettre en oeuvre ? ». L’analyse des documents et des interventions de ce partenaire a, entre autres, mené à la création de deux typologies : l’une sur les thématiques abordées et l’autre sur les types d’instruments utilisés. Les résultats ainsi obtenus permettent d’identifier trois défis pouvant être associés à cette gouvernance inframunicipale de la transition écologique, soit de concilier l’approche par les milieux de vie et la transition juste, de trouver des leviers pour les enjeux à responsabilité distribuée et de miser davantage sur les instruments réglementaires et incitatifs.While the concept of an ecological transition is still being defined through an ambiguous process, it also becomes an increasingly urgent municipal governance issue. In places where this governance is multiscalar and the responsibilities are shared among a number of jurisdictions, the absence of a stable and operational definition of a transition adds to the challenge of defining and implementing effective interventions. This paper presents the results of a partnership research with the borough of Rosemont–La Petite-Patrie, in Montreal, that aimed at tackling two questions : “what is an ecological transition at an inframunicipal level ?” and “how can it be implemented ?” The analysis of our partner’s documents and interventions led to the creation of two typologies. The first typology classifies the topics with the concept of ecological transition, while the second identifies the policy instruments used to act on these topics. The results led us to identify three challenges related to the inframunicipal governance of ecological transition : conciliating the living environment-focused approach of the borough and the principles of a just transition, finding new levers for shared responsibility issues, and applying incitative tools and planning regulations (discretionary and/or regulatory) more thoroughly

Telenephrology and on-site nephrology: Comparable adequate dialysis care to patients living in remote Pacific Islands

Introduction End-stage renal disease is a major public health concern in New Caledonia and in Wallis and Futuna (prevalence value: 2542 per million population in 2017). Spread over the territory, 594 dialysis patients are followed up by nephrologists and partially by telemedicine due to the distance. The aim of our this study was to evaluate the quality of care provided by telemedicine for chronic dialysis patients on Wallis Island, a dialysis unit remote from Noumea (2100 km). Methods We compared two populations of haemodialysis patients, one based in Poindimie in New Caledonia and followed by monthly physical consultation, the other based on Wallis Island and followed by monthly teleconsultation and quarterly on-site consultation. Results From January 2012–December 2017, dialysis adequacy and survival data were recorded for 84 patients: 44 in Poindimie, 40 on Wallis Island. Dialysis adequacy (i.e. clinical, biological parameters) as well as occurrence of vascular access complications were no different regardless of the means of follow-up. During the study, 23 deaths occurred (11 in Poindimie, 12 on Wallis Island; p = 0.464). We did not find any difference in survival at one and six years ( p = 0.46) between the two dialysis units. Evaluation for transplantation was lower for Wallisian patients ( p = 0.042), without impact on the number of patients being transplanted ( p = 0.678). Conclusion Telemedicine is a valuable opportunity for the follow-up of remote chronic haemodialysis patients, allowing them to be treated close to home while ensuring optimal quality of care </jats:sec

Dictionnaire critique de la RSE

Tout le monde parle de la RSE mais qui sait vraiment à quoi renvoie ce phénomène ? Si chacun s'accorde sur le fait qu'il bouleverse le mode traditionnel de négociation sociale et de médiation publique, il n'existe en revanche aucune forme de consensus clair quant à ses contours et limites. Avancée pour les uns, recul pour les autres, phénomène intriguant pour tous, la RSE interpelle, mobilise, divise… sans que l'on dispose d’un minimum de référent commun concernant le sens, la nature, l’extension, le potentiel, le contenu de la « Responsabilité Sociale de l’Entreprise ». C’est ce vide que ce premier dictionnaire, critique, réflexif, pluridisciplinaire, vient combler. Ouvrage collectif constitué de contributions des spécialistes reconnus de cette question dans le champ des sciences sociales, il se présente comme un outil de référence pour les praticiens et les analystes de ce phénomène qui change la donne en matière de régulation sociale. Avec cet outil, la discussion peut commencer sur des bases communes

Correction to: National dose reference levels in computed tomography–guided interventional procedures—a proposal

International audienceAbstract Computed tomography imaging plays a major role in the preoperative assessment of tumor burden by providing an accurate mapping of the distribution of peritoneal metastases (PM). Spectral Photon Counting Computed Tomography (SPCCT) is an innovative imaging modality that could overcome the current limitations of conventional CT, offering not only better spatial resolution but also better contrast resolution by allowing the discrimination of multiple contrast agents. Based on this capability, we tested the feasibility of SPCCT in the detection of PM at different time of tumor growth in 16 rats inoculated with CC531 cells using dual-contrast injection protocols in two compartments (i.e. intravenous iodine and intraperitoneal gadolinium or the reverse protocol), compared to surgery. For all peritoneal regions and for both protocols, sensitivity was 69%, specificity was 100% and accuracy was 80%, and the correlation with surgical exploration was strong ( p = 0.97; p = 0.0001). No significant difference was found in terms of diagnostic performance, quality of peritoneal opacification or diagnostic quality between the 2 injection protocols. We also showed poor vascularization of peritoneal metastases by measuring low concentrations of contrast agent in the largest lesions using SPCCT, which was confirmed by immunohistochemical analyses. In conclusion, SPCCT using dual-contrast agent injection protocols in 2 compartments is a promising imaging modality to assess the extent of PM in a rat model

Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone

International audienc