Access to mechanical thrombectomy for cerebral ischaemia: A population-based study in the North-of-France.

BACKGROUND AND PURPOSE: Hospitals admitting acute strokes should offer access to mechanical thrombectomy (MT), but local organisations are still based on facilities available before MT was proven effective. MT rates and outcomes at population levels are needed to adapt organisations. We evaluated rates of MT and outcomes in inhabitants from the North-of-France (NoF) area. METHOD: We prospectively evaluated rates of MT and outcomes of patients at 3 months, good outcomes being defined as a modified Rankin scale (mRS) 0 to 2 or like the pre-stroke mRS. RESULTS: During the study period (2016-2017), 666 patients underwent MT (454, 68.1% associated with intravenous thrombolysis [IVT]). Besides, 1595 other patients received IVT alone. The rate of MT was 81 (95% confidence interval [CI] 72-90) per million inhabitants-year, ranging from 36 to 108 between districts. The rate of IVT was 249 (95% CI 234-264) per million inhabitants-year, ranging from 155 to 268. After 3 months, 279 (41.9%) patients who underwent MT had good outcomes, and 167 (25.1%) had died. Patients living outside the district of Lille where the only MT centre is, were less likely to have good outcomes at 3 months, after adjustment on age, sex, baseline severity, and delay. CONCLUSION: The rate of MT is one of the highest reported up to now, even in low-rate districts, but outcomes were significantly worse in patients living outside the district of Lille, and this is not only explained by the delay.

Empathy during consoling touch is modulated by mu-rhythm: An EEG study.

The aim of the present study was to examine the mechanisms of empathy for pain that contribute to consoling touch, a distress-alleviating contact behavior carried out by an observer in response to the suffering of a target. We tested romantic couples in a paradigm that involves consoling touch and examined the attenuation of the mu/alpha rhythm (8-13Hz) in the consoling partner. During the task, the toucher either held the consoled partner's right hand (human touch) or held onto the armrest of the chair (non-human touch), while the consoled partner experienced inflicted pain (pain condition) or did not experience any pain (no-pain condition). In accordance with our hypotheses, the results revealed an interaction between touch and pain at in mu/alpha rhythms in all central sites (C3, C4, Cz). Specifically, we found that the toucher's mu suppression was higher in the consoling touch condition, i.e., while touching the partner who is in pain, compared to the three control conditions. Additionally, we found that in the consoling touch condition, mu suppression at electrode C4 of the toucher correlated with a measure of situational empathy. Our findings suggest that electrophysiological and behavioral measures that have been associated with empathy for pain are modulated during consoling touch.

French lyophilized plasma versus fresh frozen plasma for the initial management of trauma-induced coagulopathy: a randomized open-label trial.

Essentials An immediate supply of plasma in case of trauma-induced coagulopathy is required. The Traucc trial compared French Lyophilised Plasma (FLyP) and Fresh Frozen Plasma (FFP). FLyP achieved higher fibrinogen concentrations compared with FFP. FLyP led to a more rapid coagulopathy improvement than FFP. SUMMARY: Background Guidelines recommend beginning hemostatic resuscitation immediately in trauma patients. We aimed to investigate if French lyophilized plasma (FLyP) was more effective than fresh frozen plasma (FFP) for the initial management of trauma-induced coagulopathy. Methods In an open-label, phase 3, randomized trial (NCT02750150), we enrolled adult trauma patients requiring an emergency pack of 4 plasma units within 6 h of injury. We randomly assigned patients to receive 4-FLyP units or 4-FFP units. The primary endpoint was fibrinogen concentration at 45 min after randomization. Secondary outcomes included time to transfusion, changes in hemostatic parameters at different time-points, blood product requirements and 30-day in-hospital mortality. Results Forty-eight patients were randomized (FLyP, n = 24; FFP, n = 24). FLyP reduced the time from randomization to transfusion of first plasma unit compared with FFP (median[IQR],14[5-30] vs. 77[64-90] min). FLyP achieved a higher fibrinogen concentration 45 min after randomization compared with FFP (baseline-adjusted mean difference, 0.29 g L-1 ; 95% confidence interval [CI], 0.08-0.49) and a greater improvement in prothrombin time ratio, factor V and factor II. The between-group differences in coagulation parameters remained significant at 6 h. FLyP reduced fibrinogen concentrate requirements. Thirty-day in-hospital mortality rate was 22% with FLyP and 29% with FFP. Conclusion FLyP led to a more rapid, pronounced and extended increase in fibrinogen concentrations and coagulopathy improvement compared with FFP in the initial management of trauma patients. FLyP represents an attractive option for trauma management, especially when facing logistical issues such as combat casualties or mass casualties related to terror attacks or disasters.

Are the results of intravenous thrombolysis trials reproduced in clinical practice? Comparison of observed and expected outcomes with the stroke-thrombolytic predictive instrument (STPI).

AIM: In patients with cerebral ischemia, intravenous (i.v.) recombinant tissue plasminogen activator (rt-PA) increases survival without handicap or dependency despite an increased risk of bleeding. This study evaluated whether the results of randomized controlled trials are reproduced in clinical practice. METHOD: Data from a registry of consecutive patients treated by rt-PA at Lille University Hospital were retrospectively analyzed for outcomes, using modified Rankin Scale (mRS) scores, at 3 months. The observed outcomes were then compared with the probability of good (mRS 0-1) and of catastrophic (mRS 5-6) outcomes, as predicted by the stroke-thrombolytic predictive instrument (STPI). RESULTS: Of the 1000 consecutive patients (469 male, median age 74 years, median baseline National Institutes of Health Stroke Scale 11, median onset-to-needle time 143min), 438 (43.8%) had a good outcome, 565 (56.5%) had an mRS score 0-2 or similar to their pre-stroke mRS, 155 (15.5%) died within 3 months and 74 (7.4%) developed symptomatic intracerebral hemorrhage according to ECASS-II (Second European-Australasian Acute Stroke Study) criteria. Of the 613 patients (61.3%) eligible for evaluation by the s-TPI, the observed rate of good outcomes was 41.3% (95% CI: 37.5-45.3%), while expected rates with and without rt-PA were 48.8% (95% CI: 44.8-52.7%) and 32.5% (95% CI: 28.8-36.2%), respectively; the observed rate of catastrophic outcomes was 17.0% (95% CI: 14.0-19.9%), while the expected rate was 19.2% (95% CI: 16.1-22.4%) with or without rt-PA. CONCLUSION: In clinical practice, the rate of good outcomes is slightly lower than expected, according to the s-TPI, except for the most severe cases, whereas the rate of catastrophic outcomes is roughly similar. However, the rate of good outcomes is higher than predicted without treatment. This finding suggests that rt-PA is effective for improving outcomes in clinical practice.

[Sources of information on suicide attempts in the Nord - Pas-de-Calais (France). Contributions and limitations]. / Les sources d'information sur les tentatives de suicide dans le Nord - Pas-de-Calais. Apports et limites.

BACKGROUND: There are very few permanent indicators of mental health in France; suicidal behavior is often only understood on the basis of deaths by suicide. METHOD: The epidemiological interest and methodological limits of four medico-administrative databases from which data on suicide attempts can be extracted have been the subject of a study in the Nord - Pas-de-Calais Region of France: telephone calls for emergency medical assistance after suicide attempt (2009 to 2011), admissions in emergency services with a diagnosis of suicide attempt (2012), medical-surgical hospital admissions as a result of suicide attempt (2009 to 2011), and psychiatric admissions with a diagnosis of suicide attempt (2011). RESULTS: Usable data were provided by one of two emergency medical assistance units, five of thirty emergency departments and all medical-surgical and psychiatric units; in data from the latter two sources, a unique anonymous identifier gave individual statistics, while the first two covered only suicide attempts. In 2011, the number of suicide attempt calls per 100,000 inhabitants was 304, whereas the number of hospitalisations with this diagnosis was 275; rates are highest in men between 20 and 49 years of age, and in women below 20 years of age and between 40 and 49. Sources are seen to be very homogeneous with regards to the average age at which suicide took place (between 37.8 and 38.5 years, depending on the source), and to the sex (55.0% to 57.6% of women). In 2011, the number of patients with a diagnosis of suicide attempt treated in psychiatry is 2.6 times lower than the number hospitalised for suicide attempt in medical-surgical units (3563 vs 9327). CONCLUSION: Permanent gathering of data, and the large volume of data recorded, should encourage the use of these databases in the definition and assessment of mental health policy: an increased contribution from emergency call centers and emergency services, and the coding of the suicidal nature of intoxications by a few clearly under-declaring units, must however be achieved in order to improve this source of information.

[Fever and jaundice... and if it was a leptospirosis. About a case of L. interrogans icterohaemorrhagiae in Northern France]. / Ictère fébrile et si c'était une leptospirose. À propos d'un cas de L. interrogans Icterohaemorrhagiae dans le Nord de la France.

Leptospirosis is an anthropozoonose, an animal disease transmissible to humans, caused by a spirochete of the genus Leptospira that lives mainly among rodents but also in wetlands. It occurs worldwide, particularly in Asia, Latin America and Africa. In Europe, the incidence is small (except in France and Great Britain, where its frequency has increased in recent years) but the frequency may be underestimated. Some areas overseas are particularly affected. In France, the potential epidemic of leptospirosis is subject to climatic variations, justifying a constant monitoring of the disease provided by the National Reference Centre (CNR) of leptospires. Transmission to humans primarily occurs through contact with environments contaminated by the urine of infected animals. The disease can affect the liver and kidneys (hepatonephritis) as cytolysis, cholestasis and renal failure associated with fever. A coagulopathy usually accompanies the clinical table. Its diagnosis is difficult because of the clinical polymorphism. Early diagnosis of leptospirosis allows effective medical care, improving patient outcomes. This is currently based on gene amplification (PCR) or serology positive by the microscopic agglutination test (MAT), which is the reference method. Its evolution is usually favorable with appropriate antibiotic treatment (aminopenicillin). However 5-10% of symptomatic patients have a severe multisystem defaillance. Nearly a century after the discovery of the causative agent, this zoonosis remains a public health problem, zoonosis priority in terms of virulence, its reporting is mandatory in our country. We report the case of a severe form of hepatonephritis due to water contaminated with Leptospira observed in Northern France.

Pre-hospital treatment of STEMI patients. A scientific statement of the Working Group Acute Cardiac Care of the European Society of Cardiology.

In ST-elevation myocardial infarction (STEMI) the pre-hospital phase is the most critical, as the administration of the most appropriate treatment in a timely manner is instrumental for mortality reduction. STEMI systems of care based on networks of medical institutions connected by an efficient emergency medical service are pivotal. The first steps are devoted to minimize the patient's delay in seeking care, rapidly dispatch a properly staffed and equipped ambulance to make the diagnosis on scene, deliver initial drug therapy and transport the patient to the most appropriate (not necessarily the closest) cardiac facility. Primary PCI is the treatment of choice, but thrombolysis followed by coronary angiography and possibly PCI is a valid alternative, according to patient's baseline risk, time from symptoms onset and primary PCI-related delay. Paramedics and nurses have an important role in pre-hospital STEMI care and their empowerment is essential to increase the effectiveness of the system. Strong cooperation between cardiologists and emergency medicine doctors is mandatory for optimal pre-hospital STEMI care. Scientific societies have an important role in guideline implementation as well as in developing quality indicators and performance measures; health care professionals must overcome existing barriers to optimal care together with political and administrative decision makers.

Construction of an adaptable and specific severity score for prehospital emergencies.

The aim of this study was to design a severity score specific to mobile emergency and resuscitation services (MERS). A prospective, multicentre cohort study including 17 868 patients was performed. The severity reference criterion was determined by multiple correspondence analysis. A multiple linear regression was used for the construction of the severity score. The score performances were analysed in terms of area under the receiver operating characteristics curves (AUC). Twelve variables were identified for the construction of the severity score. The multiple regression (r2 = 0.947; p<0.001) provided a severity score that took on values from 8 to 68. The score performs well in distinguishing the various patient outcomes in terms of AUC. This study develops the first adaptable and specific severity score of MERS activities.

[Mannequin-based simulation to evaluate difficult intubation training for emergency physicians]. / Intérêt de la simulation réaliste dans l'évaluation de l'enseignement de l'intubation difficile aux médecins urgentistes.

OBJECTIVES: The aim of this study was to evaluate for the interest of realistic mannequin-based simulations as a tool to assess the knowledge of emergency medicine physicians in the field of difficult tracheal intubation. STUDY DESIGN: Prospective. POPULATION: Emergency physicians. METHODS: Twenty-four emergency physicians were invited entering the study. The first step of the study consisted of an initial assessment of their knowledge in the field of difficult tracheal intubation. Then theoretical lectures on the tools and techniques of difficult tracheal intubation were given, followed by standard mannequin-based driven workshops. The second step was conducted six weeks later. Each physician's knowledge was re-evaluated and their ability to manage two difficult airway scenarios simulated on the AirMan simulator (Laerdal was assessed. RESULTS: Only one physician could not complete the program. Half of them worked at the University Hospital (UH) with half of them for less than three years. Lectures and standard mannequin-based driven workshops significantly improved physician's theoretical knowledge. Practical performance during difficult airway management scenarios was poor. CONCLUSION: We have demonstrated that theoretical lectures and standard mannequin-based driven workshops improved overall theoretical knowledge but did not translated to practical skill during of realistic mannequin-based simulations. Realistic mannequin-based simulations teaching programs in the field of difficult tracheal intubation should be considered.

[Pulmonary embolism and right diaphragmatic paralysis: "one train can hide another"]. / Embolie pulmonaire et paralysie diaphragmatique droite "un train peut en cacher un autre".

The authors report the case of an 84 year old woman admitted for a mild pulmonary embolism associated with severe hypoxaemia. The association of a right diaphragmatic paralysis with renewed patency of a foramenovale and creation of a right-to-left shunt is probably an underestimated cause of refractory hypoxaemia.

[Myocardial infarction with normal coronary arteries: role of transesophageal echocardiography]. / Infarctus du myocarde à artères coronaires saines: place de l'échographie cardiaque transcesophagienne.

We report the case of 74 years-old female patient hospitalized for a ST+ acute coronary syndrome with normal coronary angiography. The association of a patent foramen ovale, a deep venous thrombosis and a pulmonary embolism led us to conclude the diagnosis of paradoxical coronary embolism. This case allows us to remind different etiologies to be considered in case of myocardial infarction with normal coronary arteries, and the interest of transesophageal echocardiography for the diagnosis of its etiology.

Bypassing the emergency room reduces delays and mortality in ST elevation myocardial infarction: the USIC 2000 registry.

OBJECTIVE: To study the impact on outcomes of direct admission versus emergency room (ER) admission in patients with ST-segment elevation myocardial infarction (STEMI) DESIGN: Nationwide observational registry of STEMI patients SETTING: 369 intensive care units in France. INTERVENTIONS: Patients were categorised on the basis of the initial management pathway (direct transfer to the coronary care unit or catheterisation laboratory versus transfer via the ER). MAIN OUTCOME MEASURES: Delays between symptom onset, admission and reperfusion therapy. Mortality at five days and one year. RESULTS: Of 1204 patients enrolled, 66.9% were admitted direct and 33.1% via the ER. Bypassing the ER was associated with more frequent use of reperfusion (61.7% v 53.1%; p = 0.001) and shorter delays between symptom onset and admission (244 (interquartile range 158) v 292 (172) min; p < 0.001), thrombolysis (204 (150) v 258 (240) min; p < 0.01), hospital thrombolysis (228 (156) v 256 (227) min, p = 0.22), and primary percutaneous coronary intervention (294 (246) v 402 (312) min; p < 0.005). Five day mortality rates were lower in patients who bypassed the ER (4.9% v 8.6%; p = 0.01), regardless of the use and type of reperfusion therapy. After adjusting for the simplified Thrombolysis in Myocardial Infarction (TIMI) risk score, admission via the ER was an independent predictor of five day mortality (odds ratio 1.67, 95% confidence interval 1.01 to 2.75). CONCLUSIONS: In this observational analysis, bypassing the ER was associated with more frequent and earlier use of reperfusion therapy, and with an apparent survival benefit compared with admission via the ER.

Recruitment difficulties in a home telecare trial.

We analysed the difficulties encountered in recruiting predominantly older patients, suffering from an acute exacerbation of a chronic illness, to a randomized controlled trial of home telecare. Of 653 patients approached for study participation, after full assessment, 80% (519) met the trial eligibility criteria. Of these, 104 (20%) consented to study participation and 415 (80%) refused. A logistic regression model was constructed to examine independent effects of patient factors on probability of trial participation. Only two independent variables were associated with decreased likelihood of consent: increasing age (1 year older: odds ratio [OR] = 0.96); and being on inhaled steroid medication (OR = 0.60). The most common reason for refusal to participate, accounting for almost one-third of respondents, was a stated preference for a face-to-face nurse visiting service rather than a telecare service. Perhaps home telecare services should continue to be targeted at the more stable chronically ill population and not at those suffering from acute illness.

Compartmental distribution of hyperpolarization-activated cyclic-nucleotide-gated channel 2 and hyperpolarization-activated cyclic-nucleotide-gated channel 4 in thalamic reticular and thalamocortical relay neurons.

Hyperpolarization-activated cyclic-nucleotide-gated (HCN) channels conduct a monovalent cationic current, I(h), which contributes to the electrophysiological properties of neurons and regulates thalamic oscillations in circuits containing the glutamatergic ventrobasal complex (VB) and GABAergic reticular thalamic nucleus (RTN). Four distinct HCN channel isoforms (HCN1-4) have been identified, and mRNAs and proteins for HCN channels have been detected in the RTN and VB, with HCN2 and HCN4 being the predominant isoforms. RTN and VB neurons have distinct electrophysiological properties, and those differences may reflect variable compartmental distribution of HCN channels. Whole cell patch clamp recordings from thalamic neurons in brain slices obtained from C57/Bl6 mice demonstrate that I(h) is much smaller in RTN than in VB neurons although the time constants for I(h) current activation are very similar. To study the compartmental distribution of the underlying channels, we performed qualitative and quantitative examination of HCN2 and HCN4 expression using fluorescent immunohistochemistry and confocal microscopy. HCN2-immunoreactivity (IR) on the somata of RTN neurons was approximately 10-fold less than that seen in VB neurons while HCN4-IR was detected on the somata of RTN and VB neurons to an equal degree. HCN2-IR in RTN and VB did not overlap with synaptophysin-IR, but strongly colocalized with cortactin-IR, indicating that HCN2 was not present in axon terminals but was present in dendritic spines. Although HCN2-IR in spines was more pronounced in VB than in RTN, the ratio of spinous to somatic expression in RTN was dramatically higher than that in VB, strongly suggesting that HCN2-IR in RTN is principally located in sites distal to the soma. In contrast, HCN4-IR did not colocalize with either synaptophysin or cortactin. The colocalization of HCN2-IR with HCN4-IR was greater in VB than in RTN. The results suggest that the distinct compartmental distribution of HCN2 channels in RTN and VB neurons contributes to the profound differences in the I(h)-dependent properties of these cells.

Pseudomyxoma peritonei arising from colonic polyps.

AIMS: Pseudomyxoma peritonei may have as its primary site a mucinous gastrointestinal adenoma or carcinoma that gains access to the peritoneal cavity. This manuscript describes this disease arising from a benign or malignant colonic polyp. METHODS: From a database of over 1000 pseudomyxoma peritonei patients and colorectal carcinomatosis patients, three cases were identified in which the primary tumor site was a colonic polyp. The clinical history and course of these patients were studied. RESULTS: In a review of the clinical management of these patients, all three had an event whereby neoplastic cells from the surface of the colonic polyp could have gained access to the free peritoneal cavity. The patients developed the characteristic pseudomyxoma peritonei syndrome. All three patients were treated with cytoreductive surgery plus perioperative hyperthermic intraperitoneal chemotherapy. CONCLUSIONS: Colonic polyps can serve as a source of dysplastic cells whereby pseudomyxoma peritonei can result. Caution to prevent seeding to the free peritoneal cavity during surgery for colonic polyps should be observed. If pseudomyxoma peritonei develops, cytoreductive surgery and perioperative intraperitoneal chemotherapy should be considered for treatment.

[Management of acute coronary syndromes without ST elevation: the TOSCANE registry]. / Prise en charge des syndromes coronaires aigus sans sus-décalage du segment ST. Registre TOSCANE.

The problem of pre-hospital management of acute coronary syndromes without ST elevation has not been extensively studied. The practitioner is faced with three simultaneous problems: suspecting the diagnosis, how to confirm the diagnosis to introduce appropriate, rapid and effective treatment, and which prognostic criteria to use to install aggressive therapy in high risk groups (anti GP lIb/IIIa, clopidogrel, angioplasty). TOSCANE is the first multicentre French registry which analyses the impact of the emergency ambulance serve in the management of these patients. There are two objectives: to gather epidemiological data about pre-hospital and hospital management by the emergency physician and the cardiologist, and to identify at an early stage criteria of "high risk" (HR) which, according to the recommendations of the European Society of Cardiology, justify using the most aggressive therapies. From April to September 2003, 797 patients with suspected acute coronary syndromes were enrolled by 36 French centre. Of these patients, 780 were managed successfully by the emergency ambulance service and hospital cardiological department with or without a "Cath Lab", and included for analysis. The diagnosis of acute coronary syndrome without ST elevation was rarely certain in the pre-hospital period. The lack of formal paraclinical features confirming the diagnosis was often a handicap for the emergency physician. Although the European recommendations are well observed in the cardiology departments, their application and adaptability should be improved in the pre-hospital period. TOSCANE showed that all invasive strategies preceded by platelet anti-aggregant therapy in the prehospital period administered to high risk patients, significantly reduced the mortality and morbidity at one month.

Patient and provider perspectives on home telecare: preliminary results from a randomized controlled trial.

A randomized controlled trial of home telecare for the management of acute exacerbations of chronic obstructive pulmonary disease has been undertaken in the north-west of England. A videophone was used that communicates via the ordinary telephone network. The intervention period for each participant was two weeks. Participants in the telecare arm of the trial were asked to complete logbooks to record their experiences of each telecare encounter. A simple, self-completed, 10-item questionnaire was used that consisted of a Likert scale, ranging from 1 (totally disagree) to 5 (totally agree). Fourteen nurses completed 150 logbooks and 22 patients completed 145 logbooks. These results demonstrate significant differences in perception between patients and their health-care providers with regard to telecare encounters across all the domains addressed. Participating patients consistently demonstrated more positive views of the telecare encounters than their healthcare providers.

Management of prehospital thrombolytic therapy in ST-segment elevation acute coronary syndrome (<12 hours).

UNLABELLED: Acute myocardial infarction (AMI) is the prototype of a real emergency, and both efficacy and speed are necessary for effective management. The advent of thrombolysis therapy has transformed the care of these patients. In fact, the most frequent complication of AMI is sudden death which still occurs within the first hour after symptom onset. Thrombolytic therapy has been shown to reduce early and long term mortality about 20%. The mortality gain is dependent on the delay time of early reperfusion. A large number of studies have shown that this relationship is best described as exponential: in the first 1 to 2 hours after the onset of chest pain, the benefit of thrombolysis is greater. Reducing the time to thrombolysis must therefore be the main objective of prehospital treatment of AMI. In the last 10 years, a large number of strategies to reduce the time to reperfusion have been evaluated, including initiation of thrombolytic therapy prior to arrival to hospital. In France, prehospital emergency medicine is an integral part of the medical care system. The SAMU is a hospital department whose function is to centralize emergency medical calls and organise an appropriate response with the intention of ensuring the shortest delay between the initial call and the appropriate treatment. In the event of an emergency medical call concerning chest pain, the medical dispatcher of SAMU may decide to send a MICU (mobile intensive care unit). If a diagnosis of AMI is confirmed, clinical ECG criteria, prehospital thrombolysis is currently seen as the best treatment strategy. The SAMU experience has proven that prehospital thrombolysis is both safe and effective. During the last ten years to fifteen years the field of reperfusion during acute myocardial infarction was a real battlefield between the proponents of thrombolysis and those of primary percutaneous interventions. Nowadays there is a growing number of physicians who will consider that the best way forward is not to oppose these two effective methods but to find the most appropriate niche for each or even better to combine them to achieve reperfusion. In this respect, the concept of facilitated percutaneous intervention is a very attractive one which shows promising results. A large number of studies are now ongoing to demonstrate its efficacy and to help us to choosing the ideal combination of anti-thrombotic agents to be used. That is one of the main interests of the CAPTIM study. French trial comparing prehospital thrombolysis to primary angioplasty. There is no difference between the two strategies in term of primary end points. That could be the real life for acute myocardial infarction. We have to consider in this study the fact than 33% of the patients had a pre hospital thrombolysis followed by a fast angioplasty. The results are impressing: the 30 day mortality in the pre hospital thrombolysis arm is only 3.8%. But if the delay between pain to pre hospital thrombolysis is under 2 hours this 30 day mortality fall down to 2.2%. This is better RESULTS: Than il all the recent trials published comparing on site thrombolysis to primary angioplasty (DANAM II, C Port, PRAGUE II). These good results in the CAPTIM study when the delay pain to treatment is less than 2 hours include also the occurrence of cardiogenic shock in favour of pre hospital thrombolysis (1.3%). The good strategy in a next future could be the association of pre hospital thrombolysis and angioplasty. In a recent French register (USIC 2000) including all the patients arriving in CICU during a month and regarding the one month mortality this strategy seems to be the best (3.6%). The arrival of TNK-tPA is now changing the general management of prehospital AMI by reducing the time to treatment. This is clearly now the new standard of prehospital treatment. The reduction of UHF dose is recommended and the LWMH is considered as the next step as recently demonstrated in the ASSENT 3 and 3+ trials. Several recent registries have shown than we offer reperfusion to only half of the patients and even more important, when we do not offer it, this is unjustified in nearly half of the cases and these patients , forgotten for reperfusion have all a very poor prognosis. The other major problem is that patients are treated too late mainly because the call the emergency system too late. The are several ways to improve the time to treatment : information of the patients , shortening of the intra-hospital delays by better organisation and finally and perhaps more importantly , pre hospital triage and treatment. The efficacy and safety of the pre hospital strategy is now recognised worldwide. The best strategy for acute myocardial infarction should involve emergency physicians and cardiologist in a real local task-force to join and coordinate their efforts. That is the way to open more arteries earlier, that is to say save myocardium and more lives.

Time to treatment and the impact of a physician on prehospital management of acute ST elevation myocardial infarction: insights from the ASSENT-3 PLUS trial.

OBJECTIVES: To assess the impact of variation in prehospital care across distinct health care environments in ASSENT (assessment of the safety and efficacy of a new thrombolytic) -3 PLUS, a large (n = 1639) contemporary multicentred international trial of prehospital fibrinolysis. Specifically, the objectives were to assess predictors of time to treatment, whether components of time to treatment vary across countries, and the impact of physician presence before hospitalisation on time to treatment, adherence to protocol, and clinical events. METHODS: Patient characteristics associated with early treatment (< or = 2 hours), comparison of international variation in time to treatment, and components of delay were assessed. Trial specific patient data were linked with site specific survey responses. RESULTS: Younger age, slower heart rate, lower systolic blood pressure, and prior percutaneous coronary intervention were associated with early treatment. Country of origin accounted for the largest proportion of variation in time. Intercountry heterogeneity was shown in components of elapsed time to treatment. Physicians in the prehospital setting enrolled 63.8% of patients. The presence of a physician was associated with greater adherence to protocol mandated treatments and procedures but with delay in time to treatment (120 v 108 minutes, p < 0.001). CONCLUSION: Country of enrollment accounted for the largest proportion of variation in time to treatment and intercountry heterogeneity modulated components of delay. The effectiveness and safety of prehospital fibrinolysis was not influenced by the presence of a physician. These data, acquired in diverse health care environments, provide new understanding into the components of prehospital treatment delay and the opportunities to further reduce time to fibrinolysis for patients with ST elevation myocardial infarction.