Fibrin monomers evaluation during hospitalization for COVID-19 is a predictive marker of in-hospital mortality

BackgroundCoagulopathy is one of the main triggers of severity and worsening of Coronavirus disease 2019 (COVID-19) particularly in critically ill patients. D-dimer has been widely used to detect COVID-19 coagulation disorders and has been correlated with outcomes such as disease severity and in-hospital mortality. Involvement of other fibrin degradation products, particularly fibrin monomers (FM), remains an ongoing question.MethodsWe performed a monocentric study of adult patients with COVID-19, who were admitted either in the medical ward (MW) or in the intensive care unit (ICU) and who had FM measurements performed on them during the first wave of COVID-19 outbreak. We analyzed the positivity of FM levels (FM > 7 µg/mL) to assess the ability of FM monitoring during the first days of hospitalization to predict COVID-19 outcomes.ResultsIn our cohort, 935 FM measurements were performed in 246 patients during their first 9 days of hospitalization. During patient follow-up, the FM levels were higher in patients admitted directly to the ICU than in those admitted to the MW. Moreover, we observed significantly increased levels of FM in patients when the data were stratified for in-hospital mortality. At hospital admission, only 27 (11%) patients displayed a positive value for FM; this subgroup did not differ from other patients in terms of severity (indicated by ICU referral at admission) or in-hospital mortality. When analyzing FM positivity in the first 9 days of hospitalization, we found that 37% of patients had positive FM at least once during hospitalization and these patients had increased in-hospital mortality (p = 0.001). Thus, we used non-adjusted Kaplan–Meier curves for in-hospital mortality according to FM positivity during hospitalization and we observed a statistically significant difference for in-hospital mortality (hazard ratio = 1.48, 95% CI: 1.25–1.76, p < 0.001). However, we compared the AUC of FM positivity associated with a ratio of D-dimer >70% and found that this combined receiver operating characteristic (ROC) curve was superior to the FM positivity ROC curve alone.ConclusionMonitoring of FM positivity in hospitalized patients with COVID-19 could be a reliable and helpful tool to predict the worsening condition and mortality of COVID-19

Level of care and outcomes in out-of-hospital cardiac arrest patients

Le pronostic de l’arrêt cardiaque extrahospitalier (ACEH), ne dépassant pas 8 % de survie globale en France. Ce taux de survie varie considérablement en fonction des régions mais aussi en fonction des établissements hospitaliers. La survie de ces patients repose sur les éléments de la prise en charge initiale et sur la qualité des soins prodigués pendant la phase post-arrêt cardiaque. Parallèlement, l’influence du niveau de ressources des prises en charge à la fois pré-hospitalières (Pompiers, SAMU) et intra-hospitalières (réanimations) sur le pronostic global, reste encore peu explorée. L’objectif de ce travail a été d’analyser l’influence du niveau de ressources des différentes étapes de la prise en charge, pré-hospitalière et intra-hospitalière, sur le pronostic des patients victimes d’un ACEH. Méthode : depuis Mai 2011, le registre du centre d’expertise de la mort subite collecte l’ensemble des cas d’ACEH survenant sur le territoire de Paris et sa petite couronne. Les caractéristiques socio-démographiques et, les critères d’Utstein sont prospectivement recueillis. Pour étudier la relation entre le niveau de ressources de la phase pré-hospitalière et hospitalière, et le pronostic (RACS et survie à la sortie de l’hôpital), nous avons utilisé principalement les méthodes de régression logistique et hiérarchique ajustées sur les facteurs pronostiques de l’ACEH. Les centres hospitaliers receveurs des ACEH ont été classés en trois catégories : centre A (grand volume d’activité et accès 24/7 à un plateau de coronarographie) ; centre B (volume d’activité intermédiaire et accès partiel à un plateau de coronarographie) et centre C (faible niveau d’activité et pas d’accès à un plateau de coronarographie). De même, la zone du Grand Paris a été divisé en 19 aires géographiques au sein desquelles le niveau de ressources pré-hospitalières (premiers secours et secours médicalisés) sont homogènes. Résultats : entre mai 2011 et décembre 2013, 1476 patients ont été admis vivants après un ACEH dans les 48 centres hospitaliers de la zone du Grand Paris. La survie globale à la sortie de réanimation a été de 30%. Les caractéristiques initiales des patients ont significativement varié selon les centres receveurs ; les centres du groupe A ont reçu ainsi des patients plus jeunes, avec une proportion plus importante de rythme initial choquable (p1.5 per neighborhood was significant (aOR= 1.30 (1.06-1.59) p=0.01). Conclusion: First, we observed wide disparities in crude in-hospital survival rate in the Greater Paris. After adjustment, the level of medical resources (ALS) was associated with prognosis. In addition, the type of receiving center no longer influenced either survival or neurological prognosis, which could result from a targeted EMS triage strategy. Our results suggest that a territorial adaptation in EMS resources and the implementation of a targeted triage strategy based on the patient's profile may be used in order to reduce disparities in prognosis of patients with OHCA

Organisation des stages de médecine adulte en pôle pédagogique (évaluation des avantages et inconvénients des pôles pédagogiques en termes de formation et de fonctionnement des services du point de vue des internes et des enseignants)

PARIS7-Xavier Bichat (751182101) / SudocSudocFranceF

Daily Monitoring of D-Dimer Allows Outcomes Prediction in COVID-19

International audienceNo abstract availabl

Evidence-based guidelines for thromboprophylaxis in patients with lower limb trauma requiring immobilization:an urgent, unmet need

Lower limb immobilization is a well-known risk factor for venous thromboembolism (VTE) accounting for up to 3% of all cases in previous registry data [1]. However, recommendations and practices strongly vary from one country to another and perhaps from one emergency physician to another [...]

Circulating Von Willebrand factor: a consistent biomarker predicting in-hospital mortality across different waves of the COVID-19 pandemic

International audienc

Pain Assessment Using Virtual Reality Facemask During Bone Marrow Aspiration: Prospective Study Including Propensity-Matched Analysis

BackgroundBone marrow aspiration (BMA) is a medical procedure necessary to the diagnosis and monitoring of patients with hematological or nonhematological disorders. This procedure is considered painful, and patients are generally anxious before and during BMA. ObjectiveThis study assesses the effect of immersive virtual reality on pain during BMA. MethodsThis observational prospective and monocentric study enrolled 105 consecutive patients who underwent sternal BMA with lidocaine anesthesia. The study was carried on during 2 periods. First, virtual reality facemask (VRF) was proposed to all patients in the absence of exclusion criteria. During the second period, BMA was performed without the VRF. For all patients, pain intensity after the procedure was assessed using a 10-point numerical pain rating scale (NPRS). All analyses were performed on propensity score–matched cohort (with or without VRF) to evaluate efficacy on NRPS levels. ResultsThe final matched cohort included 12 patients in the VRF group and 24 in the control group. No difference in anxiety level before BMA evaluated by the patient and by the operator was observed between groups (P=.71 and .42 respectively). No difference of NPRS was observed using VRF when compared to control group (median NPRS 3.8, IQR 2.0-6.3 vs 3.0, IQR 1.9-3.0, respectively; P=.09). ConclusionsOur study did not prove the efficacy of VRF to reduce pain during BMA

Endothelial Dysfunction as a Component of Severe Acute Respiratory Syndrome Coronavirus 2–Related Multisystem Inflammatory Syndrome in Children With Shock

NCT04420468. OBJECTIVES: Severe acute respiratory syndrome coronavirus 2–related multisystem inflammatory syndrome in children is frequently associated with shock; endothelial involvement may be one of the underlying mechanisms. We sought to describe endothelial dysfunction during multisystem inflammatory syndrome in children with shock and then assess the relationship between the degree of endothelial involvement and the severity of shock. DESIGN: Observational study. SETTING: A PICU in a tertiary hospital. PATIENTS: Patients aged under 18 (n = 28) with severe acute respiratory syndrome coronavirus 2–related multisystem inflammatory syndrome in children and shock, according to the Centers for Disease Control and Prevention criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Correlations between endothelial marker levels and shock severity were assessed using Spearman coefficient. The median (interquartile range) age was 9 years (7.5–11.2 yr). Sixteen children presented with cardiogenic and distributive shock, 10 presented with cardiogenic shock only, and two presented with distributive shock only. The median left ventricular ejection fraction, troponin level, and lactate level were, respectively, 40% (35–45%), 261 ng/mL (131–390 ng/mL), and 3.2 mmol/L (2–4.2 mmol/L). Twenty-five children received inotropes and/or vasopressors; the median Vasoactive and Inotropic Score was 8 (5–28). Plasma levels of angiopoietin-2 (6,426 pg/mL [2,814–11,836 pg/mL]), sE-selectin (130,405 pg/mL [92,987–192,499 pg/mL]), von Willebrand factor antigen (344% [288–378%]), and the angiopoietin-2/angiopoietin-1 ratio (1.111 [0.472–1.524]) were elevated and significantly correlated with the Vasoactive and Inotropic Score (r = 0.45, p = 0.016; r = 0.53, p = 0.04; r = 0.46, p = 0.013; and r = 0.46, p = 0.012, respectively). CONCLUSIONS: Endothelial dysfunction is associated with severe acute respiratory syndrome coronavirus 2–related multisystem inflammatory syndrome in children with shock and may constitute one of the underlying mechanisms

Impact of previous percutaneous transluminal coronary angioplasty and/or stenting revascularization on outcomes after surgical revascularization: insights from the imagine study

Aim To determine the impact of previous coronary artery revascularization by percutaneous transluminal coronary angioplasty and/or stenting (PCI) on outcome after subsequent coronary artery bypass grafting (CABG). Methods and results The ischaemia management with Accupril post-bypass Graft via Inhibition of the coNverting Enzyme (IMAGINE) trial, conducted between November 1999 and September 2004, tested whether early initiation of an angiotensin-converting enzyme inhibitor post-CABG, in stable patients with LVEF >= 40%, would reduce cardiovascular events. Of the 2489 patients included in the IMAGINE trial, undergoing their first operation, 430 had a history of PCI prior to surgery (PCI group), and 2059 were referred to surgery without previous PCI (non-PCI group). There was a significant increase in the primary IMAGINE endpoint in the PCI group, HR = 1.53 [1.17-1.98], P = 0.0016. Coronary revascularization, HR = 1.80 [1.13-2.87], P = 0.014, unstable angina requiring hospitalization, HR = 2.43 [1.52-3.89], P = 0.0002, were the two individual components that significantly increased in the PCI group, even when adjusted for baseline characteristics (age, sex, history of myocardial infarction or stroke, diabetes, treatment group, or off-pump surgery). Conclusion Patients with left ventricular ejection fraction >= 40% having a history of PCI prior to surgery had a worse outcome post-CABG than those with no prior PCI. Further studies are needed to investigate whether these results apply for drug eluting stents