Is E-FAST possible and useful on the battlefield? A feasibility study during medical courses in hostile environment (MEDICHOS): preliminary results.

INTRODUCTION: The extent of the French forces' territory in the Sahel band generates long medical evacuations. In case of many victims, to respect the golden hour rule, first-line sorting is essential. Through simulation situations, the aim of our study was to assess whether the use of ultrasound was useful to military doctors. METHODS: In combat-like exercise conditions, we provided trainees with a pocket-size ultrasound. Every patient for whom the trainees chose to perform ultrasound in role 1 was included. An extended focused assessment with sonography for trauma (E-FAST) was performed with six basic sonographic views. We evaluated whether these reference views were obtained or not. Once obtained by the trainees, pathological views corresponding to the scenario were shown to assess whether the trainees modified their therapeutic management strategy and their priorities. RESULTS: 168 patients were treated by 15 different trainee doctors. Of these 168 patients, ultrasound (E-FAST or point-of-care ultrasound) was performed on 44 (26%) of them. In 51% (n=20/39) of the situations, the practitioners considered that the realisation of ultrasound had a significant impact in terms of therapeutic and evacuation priorities. More specifically, it changed therapeutic decisions in 67% of time (n=26/39) and evacuation priorities in 72% of time (n=28/39). CONCLUSION: This original work showed that ultrasound on the battlefield was possible and useful. To confirm these results, ultrasound needs to be democratised and assessed in a real operational environment.

A dose ranging study of 2 different formulations of 15-valent pneumococcal conjugate vaccine (PCV15) in healthy infants.

BACKGROUND: Two new formulations of an investigational 15-valent pneumococcal conjugate vaccine (PCV15-A and PCV15-B) were developed using 2 different protein-polysaccharide conjugation processes and evaluated in separate phase I/II studies (NCT02037984 [V114-004] and NCT02531373 [V114-005]) to assess optimal concentrations of pneumococcal polysaccharide (PnPs) and Aluminum Phosphate Adjuvant. METHODS: Various lots of PCV15-A and PCV15-B containing different concentrations of PnPs and/or adjuvant were compared to PCV13 in young adults and infants. Adults received single dose and infants received 4 doses at 2, 4, 6, and 12-15 months of age. Adverse events (AEs) were collected after each dose. Serotype-specific immunoglobulin G (IgG) concentrations and opsonophagocytic activity (OPA) were measured prior and 30 days postvaccination in adults, at 1 month postdose 3 (PD3), pre-dose4, and postdose 4 (PD4) in infants. RESULTS: Safety profiles were comparable across vaccination groups. At PD3, serotype-specific IgG GMCs were generally lower for either PCV15 formulation than PCV13 for most shared serotypes. PCV15 consistently elicited higher antibody responses to the 2 serotypes unique to the vaccine (22F and 33F) and serotype 3 for which PCV13 was shown to be ineffective. Except for serotypes 6A and 6B, no dose-response effect was observed with increasing concentrations of PnPs and/or adjuvant. CONCLUSION: PCV15 is safe and induces IgG and OPA responses to all 15 serotypes in the vaccine. No significant differences in antibody responses were observed with increases in PnPs and/or Aluminum Phosphate Adjuvant.

[Ultrasound evaluation of the nasogastric tube position in prehospital]. / Contrôle échographique de la position de la sonde nasogastrique en préhospitalier.

OBJECTIVE: To assess the feasibility and actual performance of ultrasound control in verification of the correct positioning of a nasogastric tube in pre-hospital settings. STUDY TYPE: Prospective, observational, single-centre study. PATIENTS AND METHODS: Correct positioning of nasogastric tubes in patients intubated in a pre-hospital setting was verified by ultrasound and routinely compared with the results of two pre-hospital tests, namely a test involving insufflation of air through a syringe coupled with epigastric auscultation and a test involving aspiration of gastric fluid with a syringe. Routine x-ray control was carried out and compared with the pre-hospital results. RESULTS: Ninety-six patients were included. Mean age was 52 years (median: 53.5 years, SD: 23 years). In 83% of the patients (n=80), the nasogastric tube was located by ultrasound immediately during the insertion procedure. The mean times to ultrasound confirmation of correct positioning of the nasogastric tube were 7s (median: 2s; SD: 16s) and 19s for the syringe tests (median 19s, SD: 5s). Eight ultrasound control tests were negative. Location coupled with insufflation of air through a syringe allowed detection of the nasogastric tube in the stomach but without providing confirmation of the actual gastric position. The pre-hospital ultrasound results were confirmed by subsequent radiological controls at the hospital. CONCLUSION: The ultrasound test performed in our study to verify correct positioning of a nasogastric tube is feasible in a pre-hospital setting. This technique is rapid and non-irradiating and is more sensitive and specific than the syringe tests commonly used in pre-hospital settings, and it may be performed in place of the latter tests.

End-of-life issues in intensive care units: a national random survey of nurses' knowledge and beliefs.

OBJECTIVE: To investigate the knowledge, beliefs, and ethical concerns of nurses caring for patients dying in intensive care units. METHODS: A survey was mailed to 3000 members of the American Association of Critical-Care Nurses. The survey contained various scenarios depicting end-of-life actions for patients: pain management, withholding or withdrawing life support, assisted suicide, and voluntary and nonvoluntary euthanasia. RESULTS: Most of the respondents (N = 906) correctly identified the distinctions among the end-of-life actions depicted in the scenarios. Almost all (99%-100%) agreed with the actions of pain management and withholding or withdrawing life support. A total of 83% disagreed with assisted suicide, 95% disagreed with voluntary euthanasia, and 89% to 98% disagreed with nonvoluntary euthanasia. Most (78%) thought that dying patients frequently (31%) or sometimes (47%) received inadequate pain medicine, and almost all agreed with the double-effect principle. Communication between nurses and physicians was generally effective, but unit-level conferences that focused on grief counseling and debriefing staff rarely (38%) or never (49%) occurred. Among the respondents, 37% had been asked to assist in hastening a patient's death. Although 59% reported that they seldom acted against their consciences in caring for dying patients, 34% indicated that they sometimes had acted against their conscience, and 6% had done so to a great extent. CONCLUSIONS: Intensive care unit nurses strongly support good pain management for dying patients and withholding or withdrawing life-sustaining therapies to allow unavoidable death. The vast majority oppose assisted suicide and euthanasia. Wider professional and public dialogue on end-of-life care in intensive care units is warranted.

[Dyspnea after pneumonectomy due to atrial septum defect]. / Dyspnoe na pneumonectomie door een atriumseptumdefect.

A 55-year-old woman presented with complaints of recurrent dyspnoea one year after pneumonectomy carried out as treatment for a tumour of the left lung. During several months her symptoms progressed and eventually mechanical ventilation became necessary. On admission a patent foramen ovale was found with transoesophageal ultrasound but this was judged not to be the cause of her symptoms. The pulmonary angiogram showed a intracardiac shunt with no intrapulmonary shunts. After repeated transoesophageal ultrasound a second defect was found of a sinus venosus type. This large defect was proven to be clinically significant during catherisation of the heart, when occlusion with a balloon was performed. After surgical repair of these defects with an artificial patch, the patient recovered well. Since then she has been without complaints.

A sociocultural health model for late-in-life immigrants.

This study develops a sociocultural health and illness model for Iranian late-in-life immigrants in Sweden by analyzing ways in which they perceive, experience, and explain their health situations. Fifteen Iranian immigrants, ages 55 to 80, were interviewed; data were analyzed using the interpretive-phenomenology method. The interviews revealed the following concepts: Reflections on the meaning of health were interpreted as cultural understanding of health. Reflections expressing knowledge about preventing illness and maintaining health were interpreted as proposed strategies and beliefs. Reflections expressing how to prevent illness and maintain health were interpreted as practical strategies, which were based on understanding of cultures and were contingent on immigration. Health care providers might use the resulting model to assist patients and families in appropriating cures and symptom management to support patients' sense of well-being.

Health as continuity and balance in life.

Research on immigrant health emphasizes that the elderly are more vulnerable than other age groups in many immigrant populations. This study describes the meanings of health, illness, and disease for Iranian elderly immigrants in Sweden and their relationships with life disruptions. Analysis of interviews using an interpretive-phenomenological method illustrates that the participants, experience health as continuity and balance in life. Any disruption of this balance creates a sense of illness that is only partially related to the emergence of disease. Participants did not view health and disease as polarized. Rather, disease is just one component among many that may disrupt the experience of health. Health is perceived as a sense of well-being, can be achieved in spite of disease, and can be disrupted even in the absence of disease. This description of the meaning of health, disease, and illness contrasts with the Western biomedical perspective and is similar in its holism to various non-Western medical systems and complementary approaches. This knowledge can foster more culturally sensitive care.