Hospital-based autonomous pre-clinical screening of COVID-19: An emergency triage using a vital signs recording system, Paris-Ile de France region.

Background: The COVID-19 pandemic has had a dramatic toll worldwide on the populations but also has been essentially supported by the existing public health system, particularly hospital-based emergency wards and intensive care units. In France, the first cases were identified on the 24th of January 2020. The first epidemic sprout emerged in the Eastern part of the country and spread in two weeks towards the center to the Paris-region where it peaked on the 14th of April 2020. In Paris and the region around it, the intensity of the epidemic has increased significantly to have a strong impact on all public and private hospital systems in a few weeks. During France's 2020 COVID-19 epidemic, a private hospital went into a major organizational change of its Emergency Department which mainly included the use of a Telemedicine Booth for vitals automatic recording during triage procedures.Purpose: The purpose of this study is to share a unique exerience centered on the use of a Telemedicine Booth as a screening process during an epidemic. Researche design: The present study is a case report describing the organizational scheme adopted by the hospital and discusses the data of 1844 patients that attended the facility over a month and the results of a questionaire survey adressed to the Emergency Department personnel.Study sample: The study population is the population that Data where collecte.Data collection and analysis: Quantitative activity indicators' data were collected with a specific triage register, patient management software and the Telemedicine Booth activity software and were analysed with basic statistics. Results and Conclusions: Among the 1844 patients, 766 were engaged in an automated triage process supported by a Telemedicine Booth. Patients' clinical characteristics are comparable to those found in international literature during the COVID-19 pandemic. The use of the Telemedicine Booth as a screening process facilitated patients' flow. It usefully participated in the patient rapid orientation, relieving the hospital emergency department, actively contributes in a safe and secure environment highly trusted by the hospital staff and health workers. To our knowledge, the Telemedicine Booth use as a screening process during an epidemic constitutes the first contribution to such an innovative approach.

Correction: A Teleconsultation Device, Consult Station, for Remote Primary Care: Multisite Prospective Cohort Study.

[This corrects the article DOI: 10.2196/33507.].

A Teleconsultation Device, Consult Station, for Remote Primary Care: Multisite Prospective Cohort Study.

BACKGROUND: Telemedicine technology is a growing field, especially in the context of the COVID-19 pandemic. Consult Station (Health for Development) is the first telemedicine device enabling completely remote medical consultations, including the concurrent collection of clinical parameters and videos. OBJECTIVE: Our aim was to collect data on the multisite urban and suburban implementation of the Consult Station for primary care and assess its contribution to health care pathways in areas with a low density of medical services. METHODS: In a proof-of-concept multisite prospective cohort study, 2134 consecutive patients had teleconsultations. Consultation characteristics were analyzed from both the patient and practitioner perspective. RESULTS: In this study, the main users of Consult Station were younger women consulting for low-severity seasonal infections. Interestingly, hypertension, diabetes, and preventive medical consultations were almost absent, while they accounted for almost 50% of consultations with a general practitioner (GP). We showed that for all regions where the Consult Station was implemented, the number of consultations increased as GP density decreased. The study of practitioner characteristics showed GPs from metropolitan areas are motivated to work with this device remotely, with a high level of technology acceptability. CONCLUSIONS: The multisite implementation of Consult Station booths is suitable for primary care and could also address the challenge of "medical deserts." In addition, further studies should be performed to evaluate the possible contribution of Consult Station booths to limiting work absenteeism.

Medical semiotics in the telemedicine era: The birth of telesemiotics.

BACKGROUND: Telemedicine and videoconferencing distance examination are new and growing swiftly. Distance alters the patient-physician diagnostic context interfering with the traditional methods used to collect and interpret medical signs, introducing new constraints and opportunities. This study is an early contribution to the exploration of the changes in medical semiotics introduced by telemedicine. OBJECTIVE: The main objective is to characterize the impact of telemedicine on medical semiotics and to analyze its consequences on distance medical examination. METHODS: On empirical bases, an inductive reasoning was built on the observation of telemedical practice and personal experience analysis and supported by the research of existing models and literature. RESULTS: The impossibility to touch the patient is the main constraint of telemedicine. While history taking and listening to the patient's symptoms depend on videoconferencing technology, for physical inspection, two main options exist: a helper-mediated physician-patient interaction and a direct physician-patient interaction without third-party intervention. In the latter case, the physician has to rely either on devices and-or on the patient becoming the physician's hands. This enhances the physician-patient partnership in the diagnostic process increasing the role of communication and means that the diagnostic tests usually performed by the physician need to be transformed to allow self-execution. Paradoxically, modern distance examination imposes a return to classical semiotics and puts the patient at the very core of the examination process through his/her active participation. The live use of connected medical devices and the direct access to computer facilities offer new opportunities for improved signs gathering and synchronous medical collaboration. CONCLUSION: We define telesemiotics, a special branch of medical semiotics mostly centered on self-performed physical examination, improved physician-patient communication and the use of computer facilities, that needs to become an integral part of medical training. It is hypothesized that the multiplication of empowered patients, actors of their own health, physically and intellectually participating in the diagnostic process, may lead to deep positive public health and societal repercussions.

Pharmacodynamics of unfractionated heparin during and after a hemodialysis session.

BACKGROUND: Anti-Xa activity is used as a clinical guide to anticoagulation with heparin, but heparin dosing regimens for hemodialysis were established before anti-Xa assays were developed; thus, the optimal regimen for heparin dosing was not determined. The aim is to confirm the interesting characteristics of unfractionated heparin pharmacokinetics for hemodialysis anticoagulation, provide insight into the hemorrhagic risk of hemodialysis patients, and determine the dose of unfractionated heparin and its adequate mode of administration. STUDY DESIGN: Cross-sectional study of the pharmacokinetics of unfractionated heparin performed during and after a 4-hour midweek hemodialysis session. SETTING & PARTICIPANTS: 35 long-term hemodialysis patients at the Sainte-Marguerite Unit of the Marseille University Hospital, Marseille, France. PREDICTOR: Hemodialysis anticoagulation with continuous unfractionated heparin infusion at a dose of 50 IU/kg/session (25 IU/kg/h during the first hour, 12.5 IU/kg during the second and third hours, and stop during the last hour). OUTCOME & MEASUREMENTS: Anti-Xa activity was monitored during the 10 hours after the beginning of the hemodialysis session. Levels of 0.3 to 0.7 IU/mL are considered sufficient for anticoagulation. Pharmacokinetics was determined by using a population approach (nonlinear mixed-effects modeling). The final model and corresponding parameter values (including interindividual and residual variability) were used to simulate 1,000 replicates. RESULTS: No case of clotting was recorded. A pharmacokinetic model with 1 compartment and first-order elimination best fitted the data. Terminal half-life was 54 minutes. Median anti-Xa activities were 0.55 IU/mL at peak, 0.25 IU/mL at end of the 4-hour session, and less than 0.1 IU/mL at 90 minutes after the session. We simulated a continuous infusion of the dose of 50 IU/kg for 1, 2, 3, and 4 hours. Peak values were 1.1, 0.8, 0.6, and 0.5 IU/mL, respectively. Values at the end of the session were 0.12, 0.18, 0.3, and 0.5 IU/mL, respectively. Values became less than 0.1 IU/mL at 15, 60, 105, and 120 minutes after the session, respectively. LIMITATIONS: Interindividual variability in unfractionated heparin pharmacokinetics. CONCLUSIONS: Unfractionated heparin administered by means of a 3-hour continuous infusion for hemodialysis anticoagulation provided an efficient and safe effect that quickly disappeared after the end of the session.

[Hemodialysis procedure in a patient treated with radioactive iodine]. / Procédure d'hémodialyse chez un patient traité par iode 131.

The treatment of a patient with 131I at activity over 740 mega Becquerel (MBq) must be performed in a nuclear medicine department. Isolation is stopped if the patient radiation level is less than 20 muSv/hour at one meter. As regards patients with chronic renal failure treated with hemodialysis (HD), the first HD session will eliminate the major part of the radioactivity. French regulations do not give definite recommendations for this session. However, it imposes to collect liquid and solid wastes contaminated by radioactivity. Thus, it seems necessary to collect dialysate and solid wastes and to stock them in a room dedicated to radiation decay. The risk for dialysis staff is to be contaminated by an accidental ingestion of a biologic fluid from the patient. The usual protection barriers used during the HD session are sufficient: mask, gloves, overgarments, cap. There is no risk linked to external exposure to radiations. The maximal theoretical dose received by the staff during the session is 65 muSv, while annual maximal dose for public exposed to radiations is 1000 muSv. Although the dosimetric follow-up of dialysis staff is not mandatory, the nuclear medicine department of Marseille University Hospital has decided to do it in an information perspective. The session is performed in the presence of a radiation safety technician who gives film badges and active dosimeters to the dialysis staff. He reports the dialysis staff to the nuclear safety agency (Autorité de sûreté nucléaire).

Cardiac troponins I and T in hemodialysis patients without acute coronary syndrome.

BACKGROUND: There is a reluctance to use cardiac troponins (cTn) for the monitoring of acute coronary syndrome (ACS) in hemodialysis (HD) patients because renal failure per se is thought to lead to increased cTn levels. The aim of this study was to analyse the proportion of patients with increased cTn levels in HD patients without ACS. METHODS: cTnI was measured with the AccuTnI(trade mark) from Beckman (cTnI-B) and Troponin I Stat(trade mark) from Dade Behring (cTnI-DB) assays; cTnT was measured with the third generation assay from Roche. The study included 105 HD patients. The clinical outcomes were determined after 2.5 years. RESULTS: Considering the receiver operator characteristic (ROC) cutoff, the proportion of patients with elevated cTnI-B, cTnI-DB and cTnT levels was respectively 2%, 3% and 27%. The proportion of patients with abnormal cTn values increased when a lower cutoff value was considered, based on the 99th percentile of a reference population with a coefficient of variation of less than 10% (99th percentile-10% CV cutoff). The proportion of patients with elevated values did not differ before and after the HD session. The 2.5 years mortality was associated with increased levels of cTnT but not with increased levels of cTnI. CONCLUSIONS: When the ROC cutoff is applied, cTnI assays are suitable for the monitoring of ACS in HD patients. cTnT could lead to false positive diagnosis of myocardial infarction, however it is predictive of long-term mortality. The 99th percentile-10% CV cutoff does not seem appropriate in HD patients.

The uremic solute p-cresol decreases leukocyte transendothelial migration in vitro.

Chronic renal failure (CRF) patients display an immunodeficiency state, and uremic solutes that accumulate during CRF may be involved in this immunodeficiency. In this study, we examined whether the uremic solute para-cresol (p-cresol), at concentrations similar to those found in patients, alters leukocyte transmigration in vitro. We found that p-cresol significantly inhibited monocyte THP-1 cell line and PBMCs transmigration across IL-1beta-stimulated human umbilical vein endothelial cell (HUVEC) in a static two-compartment model. This inhibitory effect of p-cresol persisted in the presence of a physiologic concentration of human serum albumin. In order to investigate the mechanism involved, expression of endothelial chemokines, fractalkine, monocyte chemoattractant protein 1 (MCP-1) and IL-8 and membrane expression of junctional adhesion molecule A (JAM-A or JAM-1) were studied. We found that p-cresol decreased mRNA expression of the chemokine fractalkine in IL-1beta-stimulated HUVEC, without modifying mRNA expression of MCP-1 and IL-8. In addition, p-cresol decreased IL-1beta-induced expression of membrane-bound and soluble forms of fractalkine and impaired the membrane expression of JAM-A. Taken together, these results suggest that p-cresol, by impairing leukocyte transendothelial migration, plays a role in the immune dysfunction of uremic patients.

Adsorption of the uremic toxin p-cresol onto hemodialysis membranes and microporous adsorbent zeolite silicalite.

Para-cresol CH3C6H4OH is a protein-bound solute which is not eliminated efficiently by hemodialysis systems. In this study, we present adsorption of p-cresol as a complementary process to hemodialysis. The kinetics and isotherms of adsorption onto cellulose-based membranes (cellulose diacetate and triacetate), synthetic membranes (polyamide, polysulfone, polyacrylonitrile and polymethylmethacrylate) and microporous zeolite silicalite (MFI), have been evaluated in static conditions. The results indicate that p-cresol has a low affinity to all membranes but polysulfone and polyamide and that the times to reach equilibrium conditions are slow. In contrast, equilibration time on silicalite is fast (2 min to eliminate 90%) while adsorption levels are high (maximum adsorption about 106 mg g(-1)). Adsorption onto microporous adsorbents could be a novel way to eliminate uremic toxins from blood.

The uremic solutes p-cresol and indoxyl sulfate inhibit endothelial proliferation and wound repair.

BACKGROUND: Cardiovascular diseases are the major causes of mortality in uremic patients, and the vascular endothelium is dysfunctional in uremia. We hypothesized that uremic retention solutes may be among the factors involved in this endothelial dysfunction. We therefore investigated the in vitro effect of a large panel of uremic retention solutes (guanidino compounds, polyamines, oxalate, myoinositol, urea, uric acid, creatinine, indoxyl sulfate, indole-3-acetic acid, p-cresol, hippuric acid, and homocysteine) on endothelial proliferation. In addition, we tested the effect of uremic solutes that altered proliferation on endothelial wound repair. METHODS: Human umbilical vein endothelial cells (HUVEC) were incubated with uremic retention solutes at concentrations in the range found in uremic patients. Protein-bound uremic solutes were also tested in the presence of 4% human albumin. Then, we determined the effect of each uremic solute on endothelial proliferation by a 5-bromo-2-deoxy-uridine (BrdU) labeling assay. In addition, confluent endothelial monolayers were injured, incubated with uremic solutes that altered endothelial proliferation, and the surface of the wound was measured at different intervals by image analysis. RESULTS: Endothelial proliferation was inhibited by two protein-bound uremic retention solutes: p-cresol and indoxyl-sulfate. Inhibition of endothelial proliferation by p-cresol was dose-dependent. Moreover, p-cresol and indoxyl sulfate decreased endothelial wound repair. The presence of albumin did not affect the inhibitory effect of these solutes on endothelial proliferation, but the decrease in endothelial wound repair was less marked in the presence of albumin. CONCLUSION: We demonstrated that both p-cresol and indoxyl sulfate decrease endothelial proliferation and wound repair. These solutes could play a role in endothelial dysfunction observed in uremic patients.

A rare example of a rearrangement involving four structural isomers: alpha-phosphinonitrile/C-phosphinoketenimine/1-aza-4- phosphabutadiene/1,2-dihydro-1,2-azaphosphete.

The stable compound [bis(dicyclohexylamino)phosphino](trimethylsilyl)-carbene (1) reacts with dimethyl cyanamide to afford the original 1,2-dihydro-1,2-azaphosphete 4a (51% yield). The surprising formation of this heterocycle involves the transient formation of a nitrile, a keteneimine, and a 1-aza-4 lambda 3-phosphabutadiene derivative. By using substituent effects and different synthetic routes, all of these structural isomers have been isolated.