Derivation and validation of a risk-stratification model for patients with probable or proven COVID-19 in EDs: the revised HOME-CoV score

BACKGROUND

The HOME-CoV (Hospitalisation or Outpatient ManagEment of patients with SARS-CoV-2 infection) score is a validated list of uniquely clinical criteria indicating which patients with probable or proven COVID-19 can be treated at home. The aim of this study was to optimise the score to improve its ability to discriminate between patients who do and do not need admission.

METHODS

A revised HOME-CoV score was derived using data from a previous prospective multicentre study which evaluated the original Home-CoV score. Patients with proven or probable COVID-19 attending 34 EDs in France, Monaco and Belgium between April and May 2020 were included. The population was split into a derivation and validation sample corresponding to the observational and interventional phases of the original study. The main outcome was non-invasive or invasive ventilation or all-cause death within 7 days following inclusion. Two threshold values were defined using a sensitivity of >0.9 and a specificity of >0.9 to identify low-risk and high-risk patients, respectively. The revised HOME-CoV score was then validated by retrospectively applying it to patients in the same EDs with proven or probable COVID-19 during the interventional phase. The revised HOME-CoV score was also tested against original HOME-CoV, qCSI, qSOFA, CRB65 and SMART-COP in this validation cohort.

RESULTS

There were 1696 patients in the derivation cohort, of whom 65 (3.8%) required non-invasive ventilation or mechanical ventilation or died within 7 days and 1304 patients in the validation cohort, of whom 22 (1.7%) had a progression of illness. The revised score included seven clinical criteria. The area under the curve (AUC) was 87.6 (95% CI 84.7 to 90.6). The cut-offs to define low-risk and high-risk patients were <2 and >3, respectively. In the validation cohort, the AUC was 85.8 (95% CI 80.6 to 91.0). A score of <2 qualified 73% of patients as low risk with a sensitivity of 0.77 (0.55-0.92) and a negative predictive value of 0.99 (0.99-1.00).

CONCLUSION

The revised HOME-CoV score, which does not require laboratory testing, may allow accurate risk stratification and safely qualify a significant proportion of patients with probable or proven COVID-19 for home treatment.

Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial

Rationale: Management of first episodes of primary spontaneous pneumothorax remains the subject of debate. Objectives: To determine whether first-line simple aspiration is noninferior to first-line chest tube drainage for lung expansion in patients with complete primary spontaneous pneumothorax. Methods: We conducted a prospective, open-label, randomized noninferiority trial. Adults aged 18-50 years with complete primary spontaneous pneumothorax (total separation of the lung from the chest wall), recruited at 31 French hospitals from 2009 to 2015, received simple aspiration (n = 200) or chest tube drainage (n = 202) as first-line treatment. The primary outcome was pulmonary expansion 24 hours after the procedure. Secondary outcomes were tolerance of treatment, occurrence of adverse events, and recurrence of pneumothorax within 1 year. Substantial discordance in the numerical inputs used for trial planning and the actual trial rates of the primary outcome resulted in a reevaluation of the trial analysis plan. Measurement and Main Results: Treatment failure occurred in 29% in the aspiration group and 18% in the chest tube drainage group (difference in failure rate, 0.113; 95% confidence interval [CI], 0.026-0.200). The aspiration group experienced less pain overall (mean difference, -1.4; 95% CI, -1.89, -0.91), less pain limiting breathing (frequency difference, -0.18; 95% CI, -0.27, -0.09), and less kinking of the device (frequency difference, -0.05; 95% CI, -0.09, -0.01). Recurrence of pneumothorax was 20% in this group versus 27% in the drainage group (frequency difference, -0.07; 95% CI, -0.16, +0.02). Conclusions: First-line management of complete primary spontaneous pneumothorax with simple aspiration had a higher failure rate than chest tube drainage but was better tolerated with fewer adverse events. Clinical trial registered with www.clinicaltrials.gov (NCT01008228).

Adaptation of ED design layout during the COVID-19 pandemic: a national cross-sectional survey

BACKGROUND

The aim was to describe the organisational changes in French EDs in response to the COVID-19 pandemic with regard to architectural constraints and compare with the recommendations of the various bodies concerning the structural adjustments to be made in this context.

METHODS

As part of this cross-sectional study, all heads of emergency services or their deputies were contacted to complete an electronic survey. This was a standardised online questionnaire consisting of four parts: characteristics of the responding centre, creation of the COVID-19 zone and activation of the hospital's emergency operations plan, flow and circulation of patients and, finally, staff management. Each centre was classified according to its workload related to COVID-19 and its size (university hospital centre, high-capacity hospital centre and low-capacity hospital centre). The main endpoint was the frequency of implementation of international guidelines for ED organisation.

RESULTS

Between 11 May and 20 June 2020, 57 French EDs completed the online questionnaire and were included in the analysis. Twenty-eight EDs were able to separate patient flows into two zones: high and low viral density (n=28/57, 49.1%). Of the centres included, 52.6% set up a specific triage area for patients with suspected COVID-19 (n=30/57). Whereas, in 15 of the EDs (26.3%), the architecture made it impossible to increase the surface area of the ED.

CONCLUSION

All EDs have adapted, but many of the changes recommended for the organisation of ED could not be implemented. ED architecture constrains adaptive capacities in the context of COVID-19.

Recognition and treatment of severe sepsis in the emergency department: retrospective study in two French teaching hospitals

BACKGROUND

Sepsis management in the Emergency Department remains a daily challenge. The Surviving Sepsis Campaign (SSC) has released three-hour bundle. The implementation of these bundles in European Emergency Departments remains poorly described. The main objective was to assess the compliance with the Severe Sepsis Campaign 3-h bundle (blood culture, lactate dosage, first dose of antibiotics and 30 ml/kg fluid challenge). Secondary objectives were the analysis of the delay of severe sepsis recognition and description of the population.

METHODS

In accordance with STROBE statement, we performed a retrospective study in two French University Hospital Emergency Departments from February to August 2015. Patients admitted during the study period were screened using the electronic files of the hospital databases. Patient's files were reviewed and included in the study if they met severe sepsis criteria. Demographics, comorbities, treatments were recorded. Delays from admission to severe sepsis diagnosis, fluid loading onset and antibiotics administration were calculated.

RESULTS

One hundred thirty patients were included (76 men, mean age 71 ± 14 years). Blood culture, lactate dosage, antibiotics and 30 ml/kg fluid loading were performed within 3 hours in % [95% confidence interval] 100% [96-100%], 62% [54-70%], 49% [41-58%] and 19% [13-27%], respectively. 25 patients out of 130 (19% [13-27%]) fulfilled each criteria of the 3-h bundle. The mean fluid loading volume was 18 ± 11 ml/kg. Mean delay between presentation and severe sepsis diagnosis was 200 ± 263 min, from diagnosis to fluid challenge and first antibiotic dose, 10 ± 27 min and 20 ± 55 min, respectively.

CONCLUSION

Compliance with SSC 3-h bundle and delay between admission and sepsis recognition have to be improved. If confirmed by other studies, an improvement program might be deployed.

[Quality of hospital emergency department discharge summaries to general practitioners]

INTRODUCTION

Improvement of the quality of exchanges between primary care and hospital medicine is a major challenge for continuity of care in France. The objective of this study was to evaluate the quality of communication of information to general practitioners concerning the management of patients attending a university hospital emergency department.

MATERIALS AND METHODS

This retrospective study was based on the medical charts of 602 patients consulting the Angers university hospital emergency department, using an evaluation grid of discharge summaries associated with a survey of general practitioners, by postal questionnaire, concerning the time to reception, the content and the mode of transmission of these discharge summaries.

RESULTS

Strong points were patient identification, the visit date, the presence of complementary imaging investigation results and the presence of a conclusion. Weak points and aspects requiring improvement were identification of the emergency physician, indicated in only 48% of discharge summaries, notification of the previous treatment absent in 93% of cases, the treatment received in the emergency department and on discharge was absent or incomplete in 78% and 92% of discharge summaries, respectively, follow-up advice was provided in 36% of cases and the information given to the patient was indicated in 16% of discharge summaries. The time to reception of discharge summaries was < or = 48 hours in 8.5% of cases and < or = one week in 99% of cases. General practitioners were satisfied with the content (90%) and the form (84%) of emergency department discharge summaries; however, they would like to receive better structured and more concise discharge summaries, preferably sent by secure e-mail for 62% of them.

CONCLUSION

Standardization of discharge summaries, adapted to the general practitioner's practice, given directly to the patient and sent by secure e-mail appear to be one of the main targets for improvement of the quality of management to be introduced in hospital emergency departments.

[Impact of the referral letter on triage decisions in adult patients admitted to the emergency department]

INTRODUCTION

We conducted a two-month prospective study (8,171 admissions) in the Angers university hospital emergency room to analyse the impact of the referral letter on the initial triage of patients admitted to the emergency room performed by the reception and triage nurse.

METHODS

We analysed the level of priority of the CIMU triage scale (nurse's classification of emergency room patients), the presenting complaint, and the need for an urgent procedure before and after reading the referral letter and examined the nurse's comments for explanations concerning any triage changes.

RESULTS

1,516 patients arriving with a referral letter (18.5% of admissions) were included and interpretable data were available for 756 of these cases. After reading the referral letter, nurses modified the CIMU triage level for 34 (4.5%) patients, the presenting complaint for 50 (6.6%) patients and eliminated the need for an urgent procedure for 70 (9.3%) patients. No significant difference was observed concerning the choice of the CIMU triage level (p = 0.908). However, changes in triage level were significantly more frequently towards a more urgent category (p = 0.005). Analysis of the nurse's comments showed that these results can be explained by the signs of severity indicated in the referral letter. Certain histories and/or diagnostic hypotheses appeared to lead nurses to eliminate the need for an urgent procedure.

CONCLUSION

In this study, the referring physician's letter had a limited impact on the choice of triage level defined by the nurse on admission to the emergency room except for patients in whom the referral letter mentioned signs of severity, not observed at reception, led the nurse to apply a more urgent triage level. It would be interesting to study the information contained in the referral letter, useful for triage of patients admitted to the emergency room, in order to improve the impact of the referral letter on the quality of triage.

Benefit of the Vittel criteria to determine the need for whole body scanning in a severe trauma patient

OBJECTIVE

To evaluate the use of the Vittel criteria in addition to a clinical examination to determine the need for a whole body scan (WBS) in a severe trauma patient.

MATERIALS AND METHODS

Between December 2008 and November 2009, 339 severe trauma patients with at least one Vittel criterion were prospectively evaluated with a WBS. The following data were collected: the Vittel criteria present, circumstances of the accident, traumatic injury on the WBS, and irradiation. The original intent to prescribe a computed tomography (CT) scan (whole body or a targeted region), based solely on clinical signs, was specified.

RESULTS

Injuries were diagnosed in 55.75% of the WBS (n=189). The most common Vittel criteria were "global assessment" (n=266), "thrown, run over" (n=116), and "ejected from vehicle" (n=94). The multivariate analysis used the following as independent criteria for predicting severe traumatic injury on the WBS: Glasgow score less than 13, penetrating trauma, and colloid resuscitation greater than 11. Based solely on clinical factors, 164 patients would not have had any scan or (only) a targeted scan. In that case, 15% of the severe injuries would have been missed.

CONCLUSION

Using the Vittel criteria to determine the need for a WBS in a severe trauma patient makes it possible to find serious injuries not suspected on the clinical examination, but at the cost of an increased number of normal scans.

Wireless ambulatory pH studies: manometric or endoscopic guidance?

Wireless pH studies are widely used to assess the presence and severity of gastroesophageal reflux disease. We hypothesized that sedation or air insufflation during a preceding endoscopy may systematically alter results. A retrospective review of ambulatory pH studies completed between January 2008 and April 2010 was performed. The pH capsule was placed 6 cm above the endoscopically determined location of the squamocolumnar junction or 5 cm above the manometrically localized upper border of the lower esophageal sphincter (LES). A total of 356 patients (65% women) underwent pH studies using the BRAVO system (GIVEN Imaging, Yoqneam, Israel). In 186 patients (E-P), the capsule was placed during endoscopy. In 170 patients (M-P), capsule placement was based on manometric determination of LES boundaries using pharyngeal anesthesia only. Endoscopic placement was successful in all cases, whereas two patients could not tolerate capsule insertion with topical anesthesia only. The mean recording time did not differ between the two groups (E-P: 2468 ± 38 min; M-P: 2415 ± 40 min). The number of patients with abnormal findings on day 1 but normal results for day 2 was similar with 15% for E-P compared with 11% for M-P. However, there was a significant difference in total acid exposure times between days 1 and 2 for endoscopically (day 1: 7.3 ± 1.2; day 2: 4.8 ± 0.5; P < 0.01), but not manometrically based placement (day 1: 7.7 ± 0.7; day 2: 7.2 ± 0.6). There was no difference in the number of symptoms between days or groups (E-P day 1:13.4 ± 1.3; E-P day 2: 16.0 ± 1.6; M-P day 1: 14.1 ± 2.1; M-P day 2: 15.7 ± 2.0). Similarly, the symptom sensitivity index did not differ significantly between days and groups (E-P: day 1: 4.1 ± 0.5; day 2: 5.9 ± 0.8; M-P: day 5.3 ± 0.8; day 2: 5.7 ± 0.8). The majority of patients tolerate insertion of a wireless pH monitoring capsule without sedation. Unsedated placement did not negatively affect total recording times. Although endoscopy resulted in higher acid exposure on day one it did not significantly increase the overall fraction of abnormal tests. If confirmed in prospective studies, the more consistent findings and a potential to lower cost favor manometrically guided capsule placement.

Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism

BACKGROUND

The revised Geneva score, a standardized clinical decision rule in the diagnosis of pulmonary embolism (PE), was recently developed. The Wells clinical decision is widely used but lacks full standardization, as it includes subjective clinician's judgement. We have compared the performance of the revised Geneva score with the Wells rule, and their usefulness for ruling out PE in combination with D-dimer measurement.

METHODS

In 300 consecutive patients, the clinical probability of PE was assessed prospectively by the Wells rule and retrospectively using the revised Geneva score. Patients comprised a random sample from a single center, participating in a large prospective multicenter diagnostic study. The predictive accuracy of both scores was compared by area under the curve (AUC) of receiver operating characteristic (ROC) curves.

RESULTS

The overall prevalence of PE was 16%. The prevalence of PE in the low-probability, intermediate-probability and high-probability categories as classified by the revised Geneva score was similar to that of the original derivation set. The performance of the revised Geneva score as measured by the AUC in a ROC analysis did not differ statistically from the Wells rule. After 3 months of follow-up, no patient classified into the low or intermediate clinical probability category by the revised Geneva score and a normal D-dimer result was subsequently diagnosed with acute venous thromboembolism.

CONCLUSIONS

This study suggests that the performance of the revised Geneva score is equivalent to that of the Wells rule. In addition, it seems safe to exclude PE in patients by the combination of a low or intermediate clinical probability by the revised Geneva score and a normal D-dimer level. Prospective clinical outcome studies are needed to confirm this latter finding.

Laboratory tests in the diagnosis of pulmonary embolism

The diagnosis of pulmonary embolism (PE) requires objective testing. However, all imaging techniques have their own limitations and costs and cannot be performed in every patient with suspected PE. After decades of unfruitful research, several laboratory tests have been evaluated for suspected PE, the most promising being the D-dimer test. As a general rule, the specificity of D-dimers is too low to confirm PE. Conversely, several (but not all) D-dimer assays have a high sensitivity for diagnosing PE. Outcome studies indicate that the Vidas D-dimer and SimpliRED D-dimer can be used safely to withdraw anticoagulation when the pretest probability of PE is low (SimpliRED) or when it is low or moderate (Vidas). These results may however not apply to other D-dimer assays and clinicians should know the characteristics of the test used in their hospital. Blood gas analysis does not have sufficient sensitivity and specificity to confirm or exclude PE, but it may be used to evaluate the clinical probability of PE before other testing is done. The diagnostic value of the alveolar dead space fraction in patients with suspected PE is currently investigated. Initial data suggest that it needs to be combined with a D-dimer test to safely exclude PE. Brain natriuretic peptide and cardiac troponin have limited usefulness for diagnosing PE, but both tests may identify patients with a poor prognosis, in whom more aggressive treatment may be warranted.

Efficacy of a nurse-led multidimensional preventive programme for older people at risk of functional decline. A randomized controlled trial

OBJECTIVE

To verify the efficacy of a multidimensional preventive programme on functional decline of older people.

DESIGN

Randomized controlled trial.

SETTING

Community of Sherbrooke City, Quebec, Canada.

SUBJECTS

A representative sample of individuals aged over 75 living at home and identified to be at risk of functional decline by postal questionnaire (n = 503).

INTERVENTION

Subjects randomized to the study group (n = 250) were assessed at home by a nurse on 12 dimensions (including medication, depressive mood, risk of falls, hearing). A report of the assessment was sent to the general practitioner with recommendations for interventions. A monthly telephone contact was carried out by the nurse for surveillance and to verify if the recommendations had been applied.

METHODS

The primary outcome--functional decline--was defined as either death, admission to an institution or increase of > or = 5 points on the disability score of the Functional Autonomy Measurement System (SMAF) scale during the reference year. Secondary outcomes were functional autonomy (on the SMAF), well-being (General Well-being Schedule), perceived social support (Social Provisions Scale) and use of health care services.

RESULTS

Of the 494 subjects who completed the study, 48 (19.6%) of 245 in the study group and 49 (19.7%) of 249 in the control group had functional decline (relative risk 1.00; 95% confidence interval 0.82-1.23). There were no differences between the groups in all secondary outcomes.

CONCLUSIONS

This study confirms the inefficacy of multidimensional programmes for preventing functional decline in the older population. More effort should be devoted to improving the efficacy of specific interventions for conditions causing functional decline.

A preventive program for community-dwelling elderly at risk of functional decline: a pilot study

A program has been designed to assess and survey community-dwelling elderly over 75, identified at risk of functional decline by a postal questionnaire. The objectives were to verify the acceptability and the feasability of the program and to explore its impact, mainly on the functional status. A randomized controlled study took place in an urban community where 99 participants were drawn from those having responded positively to two or more of the six questions asked in the postal questionnaire, previously studied in Sherbrooke, in 1992. The program consisted in a home visit by a nurse who administered a standardized assessment battery on risk factors identified specifically for functional decline. When problems were identified, experimental subjects were referred to their general practitioner or to other health professionals for diagnosis and interventions. The control subjects received the usual health services. Both process and outcome measures were utilized in the study. The process measures allowed to know whether the program was acceptable or not to subjects and if it was feasible when using the existing health care services. The outcome measures included the number of eliminated risk factors, the functional autonomy level, the general well-being, the perceived state of health and the social support. The results showed that the program was feasible to implement and acceptable by the subjects and by health professionals. After 6 months, study subjects did not loose autonomy whereas the control ones significantly declined (P<0.001). If preventive programs could be effective in reducing the loss of autonomy, the use and cost of health care services could also be reduced and the other health and wellfare problems could be also prevented.

[Analysis of the management of patients aged 75 and older in an admitting and emergency service of a large hospital]

A prospective survey carried out over two periods (35 days total) presented a typology of people aged 75 and older entering the admitting and emergency unit of a university hospital center, and underlined the specifics of the care they received. These patients represent 27.8% of patients received in the unit. The women (60.9%) live preferentially alone at home or in group establishment. The majority of admissions are the result of a referral from the patients' doctors. Tuesday remains the busiest day for admissions (19.7% of total admissions). 10.9% of patients arrive alone and without health records. The specialist is solicited for 41.3% of older people. Their autonomy level (measured with the AGGI R grid) is evaluated during the emergency visit. An analysis of pathological profiles shows a preponderance of acute problems with risk of degenerative problems (54.9%). Social problems (8.2% of patients) particularly affect the group with multiple pathologies. The choice of placement is more often in specialty services (61.3%) than geriatric services (18.7%). A return to ones previous home is more rarely re-envisaged. The placement obtained corresponds to the desired placement in 68% of cases. Lack of beds is the main cause in cases where the desired placement is not achieved. While the care of older people admitted for "specialised" reasons poses little problem many pathologies including "social" issues, and are admitted for "general" reasons) is a very different issue.

Severe lactic acidosis induced by nucleoside analogues in an HIV-infected man

Nucleoside analogues can induce myopathy or hepatitis by means of mitochondrial dysfunction. We report the case of a 31-year-old man infected with HIV who had a severe lactic acidosis without muscle or liver symptoms. He improved after hemodialysis and withdrawal of antiviral drugs. Muscle and liver evaluation allowed us to ascribe lactic acidosis to a mitochondriopathy induced by zidovudine and didanosine.

A weight-bearing, water-based exercise program for osteopenic women: its impact on bone, functional fitness, and well-being

OBJECTIVE

To evaluate the effects of a weight-bearing, water-based, exercise program designed for women with low bone mass.

DESIGN

A test-retest cross-sectional, prospective study.

SETTING

Community-dwelling women from a Canadian city.

PARTICIPANTS

Seventy-seven postmenopausal women, 50 to 70 years of age, with spinal or femoral bone density below the fracture threshold.

INTERVENTION

Subjects exercised in a pool with waist-high water for 60 minutes, 3 days a week, over a 12-month period. Forty minutes of each session were devoted to successive jumps and muscular exercises designed to promote bone accretion, strength, and endurance.

MAIN OUTCOME MEASURES

Spinal and femoral bone mineral density (BMD) measured by dual-energy X-ray absorptiometry, functional fitness (flexibility, coordination, agility, strength/endurance, and cardiorespiratory endurance) assessed with the American Alliance for Health, Physical Education, Recreation and Dance battery, and psychological states evaluated with Dupuy's General Well-Being Schedule.

RESULTS

Spinal BMD decreased significantly (p < .001), whereas there was no change in femoral neck BMD (p = .90). Four of the parameters chosen to assess functional fitness, namely, flexibility, agility, strength/endurance, and cardiorespiratory endurance, were affected positively by the exercise program (all p values < .001). Psychological well-being also improved significantly after participation in the exercise program (p < .001).

CONCLUSION

The intervention was successful in improving the functional fitness and psychological well-being of the participants, despite a lack of effect on the skeletal system. Future studies are needed to identify water exercises that are safe yet exert enough stress on the bones to initiate a bone response.

Short and longterm outcomes for patients with systemic rheumatic diseases admitted to intensive care units: a prognostic study of 181 patients

OBJECTIVE

To determine short and longterm outcomes and prognostic factors for patients with systemic rheumatic diseases admitted to intensive care units in 4 teaching hospitals.

METHODS

All adult intensive care unit admissions over a 12 year period for systemic rheumatic diseases were retrospectively assessed. One hundred and eighty-one patients with a mean age of 57 +/- 17 years were studied.

RESULTS

The death rate in intensive care units was 33% (59/181) and in-hospital mortality was 43% (77/181). One hundred and four patients were discharged alive from hospital; 40 died during followup (mean 105 +/- 7 mo). The estimated 5 year survival rate for the discharged patients was 69%. The 4 factors significantly associated with in-hospital mortality by multivariate analysis were simplified acute physiologic score (p = 10(-4)), poor prior health status (p = 10(-4)), corticosteroid administration (p = 0.005), and the reason for admission; mortality was higher in the group admitted to intensive care for infectious complication (55 versus 34% for others; p = 0.006). In contrast, in-hospital mortality was not influenced by age or by systemic rheumatic diseases. Using Cox's model, only age over 60 years was a prognostic factor significantly associated with an increase in longterm mortality (p = 10(-4)).

CONCLUSION

The short term outcome for patients with systemic rheumatic diseases in intensive care units was poor. The longterm prognosis after hospital discharge appeared fair, although the standardized mortality ratio was 5-fold that of a nonselected population. Short and longterm prognoses were similar for different systemic rheumatic disease groups.

Performance of the 'unaffected' upper extremity of elderly stroke patients

BACKGROUND AND PURPOSE

The main objective of this study was to compare the sensorimotor performance of the unaffected upper extremity (UE) of elderly stroke patients with that of healthy elderly people.

METHODS

The group of stroke patients was composed of 43 hemiplegic/paretic subjects who had had a cerebrovascular accident at least 6 months earlier. They were > or = 60 years old, were right-handed before the stroke, had visual perception within normal limits, and showed no major cognitive impairments. A group of 43 healthy subjects matched for dominance, age, and sex was used for comparison. The main parameters of the performance of the unaffected UE of the stroke subjects and of the same side of the healthy subjects were measured with valid, reliable instruments. Some variables potentially related to the unaffected UE were also measured: affected UE motor function, functional independence, length of time since the stroke, self-perceived health status, activity level, and hand anthropometry.

RESULTS

Statistical analyses showed significant deficits in the unaffected UE of hemiplegic/paretic subjects compared with normal subjects with regard to the following parameters: gross manual dexterity, fine manual dexterity, motor coordination, global performance, and kinesthesia (P < .01 to P < .0001). No significant clinical or statistical difference was found for grip strength (P < .81), static and moving two-point discrimination (P = .21 and P = .12), or touch/pressure threshold (P < .91).

CONCLUSIONS

Many factors (frequency of use of the unaffected hand, sensorimotor interaction tasks, severity of the deficits in corticifugal projections, and deficits in postural stabilization) could interact to provide the clinical picture obtained in the present study.

Gastric intramucosal pH: an indicator of weaning outcome from mechanical ventilation in COPD patients

The aim of this study was to determine whether gastric intramucosal pH (pHim) and/or gastric intramucosal carbon dioxide tension (PCO2,im) measured by tonometry can be used to predict the success of weaning in chronic obstructive pulmonary disease (COPD) patients. Twenty six consecutive COPD patients, undergoing mechanical ventilation for acute respiratory failure and satisfying the criteria of weaning from mechanical ventilation with nasogastric tonometer in place, were studied. Arterial blood gas values and PCO2,im were measured 24 h before (H-24), just before (H0), and after 20 min of a weaning trial on T-piece (H20min). Weaning failure was defined as the development of respiratory distress and/or arterial blood gas impairments during the first 2 h of spontaneous breathing on T-piece, or reintubation within 24 h after extubation. Between the weaning failure (n = 6) and weaning success (n = 20) groups, there were no differences in blood gas analysis readings at H-24 and H0 before the weaning period, age, Simplified Acute Physiology Score (SAPS) on admission, SAPS on the day of weaning trial, and duration of ventilation. Clinical status, tonometric and arterial gasometric data were similar at H-24 and H0 in all patients. During mechanical ventilation, pHim was < or = 7.30 in patients who failed weaning and > 7.30 in patients who were successfully weaned (p < 0.001; 100% sensitivity and specificity). The threshold value for PCO2,im of 8.0 kPa (60 mmHg) represents a clear demarcation with respect to outcome before the weaning trial. PCO2,im values during mechanical ventilation are significantly different (p < 0.001) between patients who were successfully weaned and those who were not (6.9 +/- 0.9 vs 9.9 +/- 1.1 kPa (51.9 +/- 6.7 vs 74.3 +/- 8.0 mmHg, respectively)). At H20min, pHim and PCO2,im were still statistically different between the weaning failure and the weaning success group. We conclude that measurement of gastric intramucosal pH (or gastric intramucosal carbon dioxide tension) represents a simple and accurate index to predict weaning outcome in chronic obstructive pulmonary disease patients before attempting weaning.

Impact of a 12-month exercise program on the physical and psychological health of osteopenic women

OBJECTIVE

To describe the effect of a supervised physical activity program on the physical and psychological health of osteopenic women.

DESIGN

A randomized controlled trial.

SETTING

Sherbrooke, Quebec, Canada.

PARTICIPANTS

A total of 124 community-living postmenopausal women, between 50 and 70 years of age, with low bone mass took part in the study.

INTERVENTION

Subjects allocated to the experimental group performed weight-bearing exercises (walking, stepping up and down from benches), aerobic dancing, and flexibility exercises for 60 minutes, three times a week, over a period of 12 months. All subjects were invited to attend bi-monthly educational seminars covering topics related to osteoporosis.

OUTCOME MEASURES

Spinal and femoral bone mineral density (BMD), functional fitness (flexibility, coordination, agility, strength/endurance, cardiorespiratory endurance), psychological well-being, back pain intensity, and self-perceived health.

RESULTS

Spinal BMD stabilized in the exercisers while decreasing significantly in the controls (P = .031). No change in femoral BMD was observed in either group (P = .597). Four of the five parameters chosen to evaluate functional fitness, namely flexibility, agility, strength, and endurance, were affected positively by the exercise program (all P < .01). Adjusting for prescores by means of an analysis of covariance revealed a significant difference between the groups in psychological well-being, which favored the exercisers (P = .012). After 12 months, back pain reported by exercisers was lower than that reported by controls (P = .008). Finally, self-perceived health increased in the exercise group, whereas no difference was observed in the control group (P = .790).

CONCLUSION

These results suggest that after 12 months, exercising can produce a significant increase above initial levels in the functional fitness, well-being, and self-perceived health of osteopenic women. Intensity of back pain can also be lowered by exercise. The exercise program succeeded in stabilizing spinal BMD but had no effect on femoral BMD.

[Prognosis of systemic diseases diagnosed in intensive care units]

OBJECTIVES

The aims of this study were to evaluate the prognosis of patients with systemic rheumatic disease diagnosed in medical intensive care unit (MICU) and to determine whether the outcome is different for patients with systemic rheumatic disease previously known hospitalized in MICU.

METHODS

Retrospective evaluation, over a ten-year period, of 88 cases of systemic rheumatic disease selected in two groups: group I: diagnosed in MICU, group II: previously known and treated.

RESULTS

Group I: 18 patients with necrotizing vasculitis (n = 6), extra-intestinal manifestations of inflammatory bowel disease (n = 4), systemic lupus erythematosus (n = 3), miscellaneous (n = 5). Group II: 70 patients with rheumatoid arthritis (n = 31), necrotizing vasculitis (n = 12), systemic lupus erythematosus (n = 12), polymyositis (n = 4), extra-intestinal manifestations of inflammatory bowel disease (n = 5), miscellaneous (n = 6). The main admission diagnoses were infectious diseases (p < 0.005) or iatrogenic complications in the group II (p < 0.01) and acute exacerbation of systemic rheumatic disease in the group I (p < 0.0001). Age; simplified acute physiologic score (SAPS); number of acute organ system failure; number of patients requiring mechanical ventilation, haemodialysis or right heart catheterization were not different between the two groups. The durations of mechanical ventilation and stay in the MICU were shorter in the group II (p < 0.005). MICU mortality rate was higher in the group II (p < 0.05), with a five years cumulative proportion of surviving statistically lower (p < 0.05). Mortality rate of the entire population (37.5%) was similar to that of a non-selected population with comparable SAPS. Multivariate analysis showed that SAPS, number of acute organ system failure and iatrogenic complications were the main prognostic factors (p = 0.05).

CONCLUSIONS

The prognosis was better for patients with systemic rheumatic disease diagnosed in MICU. Infectious diseases were the main cause of death, probably in relation with immunosuppressive treatments.

4-Methylpyrazole and hemodialysis in ethylene glycol poisoning

CASE REPORTS

Two patients severely intoxicated with ethylene glycol became anuric and were treated by hemodialysis and the antidote, 4-methylpyrazole. On admission, their plasma ethylene glycol concentrations were 0.42 and 3 g/L respectively and no alcohol was detected. The elimination of 4-methylpyrazole in the dialysate represented 45% of the total body elimination. Clearances of 4-methylpyrazole by hemodialysis were 80 mL/min and 52 mL/min respectively.

RESULTS

In such cases, the authors propose infusion of a 4-methylpyrazole loading dose of 10-20 mg/kg before dialysis and intravenous infusion of 1-1.5 mg/kg/h during the 8-12 hours of hemodialysis to compensate the loss in dialysate.

[The relation between unemployment and health : a prospective study : brief presentation and preliminary results of a study.]

In 1984, the authors undertook a major study on the multiple interrelations between unemployment and health. Tlie methodology in use is prospective, longitudinal, with a control group. Their presentation consists of a synthesis of work carried out so far followed by corresponding results. These results are in compliance with the four hypotheses developed through a priori reasoning. However, these results are not definitive. The analysis continues.