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/)

Les cimetières paysagers

La conception paysagère des cimetières est un parti pris récent des responsables territoriaux qui répond d’une part, aux préoccupations environnementales exprimées par la population, et, d’autre part, au souci des communes d’améliorer l’intégration des cimetières dans le tissu urbain.Lanscaped conception of the cemeteries is a recent bias of the territorial persons in charge, which answers, on the one hand to environnemental worries expressed by the population, and on the other hand to the concern of districts to improve integration of cemeteries in the urban fabric

Les cimetières franciliens : des problèmes de gestion différents selon la taille des communes

En 1994, les cimetières occupent 1,6 ‰ de la surface de l’Île-de-France. Leur emprise au sol diminue du centre vers la périphérie, en fonction de la densité de population. Si cet espace public est soumis à une uniformité juridique, la marge de manœuvre des communes varie cependant en fonction de leur taille et de leur localisation.In 1994, cemeteries take up 1,6‰ of the surface of the «Ile-de-France» and their concentration decrease from the center to the periphery, according to the density of population. This public space is dominated by a juridical steadiness. However, the room to manœuvre of the districts changes according to their size and localization

Catalogue des sépultures

International audienc

Catalogue des sépultures

International audienc

La mort en Île-de-France

La mort est un sujet tabou dans notre société. Pourtant, c’est à sa manière d’envisager ou de représenter la mort qu’une société montre sa face cachée, ses angoisses profondes. Pour conjurer la crainte de ce franchissement, quoi de plus salutaire que d’écrire un livre à son sujet et de croiser des regards différents sur un phénomène souvent vécu de manière très, voire trop, personnelle. ...Les archéologues voient dans les sépultures et les nécropoles un témoignage précieux des mentalités du passé. ...Les aménageurs ont à résoudre les problèmes posés par les cimetières dans les grandes métropoles. ...Les juristes tentent de définir les droits et obligations des vivants face à la mort des autres et aux procédures qui s’ensuivent. ...Les artistes désacralisent les représentations habituelles en « truquant » la mort quand le cadavre devient travesti.Du moment que quelqu'un est né, a vécu, il en restera toujours quelque chose, même si on ne peut dire quoi ; nous ne pouvons plus faire désormais comme si ce quelqu'un était inexistant en général, ou n'avait jamais été. Jusqu'aux siècles des siècles, il faudra tenir compte de ce mystérieux « avoir-été ». Vladimir Jankélévitch, La mort, Flammarion, 1977 *** Quand on habite rue Belgrand ou rue des Pyrénées, On ne peut éviter d’apercevoir souvent Les deux énormes cheminées D’où chaque jour des corps s’échappent en fumées Que disperse le vent. Les âmes ont sans doute pris de l’avance ; étonnées, Elles regardent fuir ce nuage mouvant : La chair qui durant tant d’années Les tint dans sa chaleur délectable enfermées. Jacques RÉDA, Fumées, in La Course, Gallimard, 199

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

International audienc

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

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