A Scalable Framework for Telehealth: The Mayo Clinic Center for Connected Care Response to the COVID-19 Pandemic.

Background: The Mayo Clinic Center for Connected Care has an established organizational framework for telehealth care delivery. It provides patients, consumers, care teams, and referring providers access to clinical knowledge through technologies and integrated practice models. Central to the framework are teams that support product management and operational functions. They work together across the asynchronous, synchronous video telemedicine, remote patient monitoring (RPM), and mobile core service lines. Methods: The organizational framework of the Center for Connected Care and Mayo Clinic telehealth response to the COVID-19 pandemic is described. Barriers to telehealth delivery that were addressed by the public health emergency are also reported. This report was deemed exempt from full review by the Mayo Clinic IRB. Results: After declaration of the COVID-19 pandemic, there was rapid growth in established telehealth offerings, including patient online services account creation, secure messaging, inpatient eConsults, express care online utilization, and video visits to home. Census for the RPM program for patients with chronic conditions remained stable; however, its framework was rapidly adapted to develop and implement a COVID-19 RPM service. In addition to this, other new telehealth and virtual care services were created to support the unique needs of patients with COVID-19 symptoms or disease and the health care workforce, including a digital COVID-19 self-assessment tool and video telemedicine solutions for ambulances, emergency departments, intensive care units, and designated medical-surgical units. Conclusion: Rapid growth, adoption, and sustainability of telehealth services through the COVID-19 pandemic were made possible by a scalable framework for telehealth and alignment of regulatory and reimbursement models.

Mobile Point-of-Care Medical Photography: Legal Considerations for Health Care Providers.

Medical photographs have been used for decades to document clinical findings. The ease with which medical photographs can be captured and integrated into the electronic health record (EHR) has increased as digital cameras obviated the need for the film development process. Today, cameras integrated into smartphones allow for high-resolution images to be instantly uploaded and integrated into the EHR. With major EHR vendors offering mobile smartphone applications for the conduct of point-of-care medical photography, health care providers and institutions need to be aware of legal questions that arise in the conduct of medical photography. Namely, (1) what are the requirements for consent when taking medical photographs, and how may photographs be used after consent is obtained, (2) are medical photographs admissible as evidence in court, and (3) how should a provider respond to a request by a patient or parent requesting that a photograph be deleted from the medical record? Herein, we review relevant laws and legal cases in the context of accepted standards of medical practice pertaining to point-of-care medical photography. This review is intended to aid health care providers and institutions seeking to develop or revise policies regarding using a mobile application at their clinical practice.

Medical Videography Using a Mobile App: Retrospective Analysis.

BACKGROUND: As mobile devices and apps grow in popularity, they are increasingly being used by health care providers to aid clinical care. At our institution, we developed and implemented a point-of-care clinical photography app that also permitted the capture of video recordings; however, the clinical findings it was used to capture and the outcomes that resulted following video recording were unclear. OBJECTIVE: The study aimed to assess the use of a mobile clinical video recording app at our institution and its impact on clinical care. METHODS: A single reviewer retrospectively reviewed video recordings captured between April 2016 and July 2017, associated metadata, and patient records. RESULTS: We identified 362 video recordings that were eligible for inclusion. Most video recordings (54.1%; 190/351) were captured by attending physicians. Specialties recording a high number of video recordings included orthopedic surgery (33.7%; 122/362), neurology (21.3%; 77/362), and ophthalmology (15.2%; 55/362). Consent was clearly documented in the medical record in less than one-third (31.8%; 115/362) of the records. People other than the patient were incidentally captured in 29.6% (107/362) of video recordings. Although video recordings were infrequently referenced in notes corresponding to the clinical encounter (12.2%; 44/362), 7.7% (22/286) of patients were video recorded in subsequent clinical encounters, with 82% (18/22) of these corresponding to the same finding seen in the index video. Store-and-forward telemedicine was documented in clinical notes in only 2 cases (0.5%; 2/362). Videos appeared to be of acceptable quality for clinical purposes. CONCLUSIONS: Video recordings were captured in a variety of clinical settings. Documentation of consent was inconsistent, and other individuals were incidentally included in videos. Although clinical impact was not always clearly evident through retrospective review because of limited documentation, potential uses include documentation for future reference and store-and-forward telemedicine. Repeat video recordings of the same finding provide evidence of use to track the findings over time. Clinical video recordings have the potential to support clinical care; however, documentation of consent requires standardization.

An operational approach to high resolution agro-ecological zoning in West-Africa.

The objective of this work is to develop a simple methodology for high resolution crop suitability analysis under current and future climate, easily applicable and useful in Least Developed Countries. The approach addresses both regional planning in the context of climate change projections and pre-emptive short-term rural extension interventions based on same-year agricultural season forecasts, while implemented with off-the-shelf resources. The developed tools are applied operationally in a case-study developed in three regions of Guinea-Bissau and the obtained results, as well as the advantages and limitations of methods applied, are discussed. In this paper we show how a simple approach can easily generate information on climate vulnerability and how it can be operationally used in rural extension services.

Effectiveness of low speed autonomous emergency braking in real-world rear-end crashes.

This study set out to evaluate the effectiveness of low speed autonomous emergency braking (AEB) technology in current model passenger vehicles, based on real-world crash experience. The validating vehicle safety through meta-analysis (VVSMA) group comprising a collaboration of government, industry consumer organisations and researchers, pooled data from a number of countries using a standard analysis format and the established MUND approach. Induced exposure methods were adopted to control for any extraneous effects. The findings showed a 38 percent overall reduction in rear-end crashes for vehicles fitted with AEB compared to a comparison sample of similar vehicles. There was no statistical evidence of any difference in effect between urban (≤60 km/h) and rural (>60 km/h) speed zones. Areas requiring further research were identified and widespread fitment through the vehicle fleet is recommended.

Understorey fire frequency and the fate of burned forests in southern Amazonia.

Recent drought events underscore the vulnerability of Amazon forests to understorey fires. The long-term impact of fires on biodiversity and forest carbon stocks depends on the frequency of fire damages and deforestation rates of burned forests. Here, we characterized the spatial and temporal dynamics of understorey fires (1999-2010) and deforestation (2001-2010) in southern Amazonia using new satellite-based estimates of annual fire activity (greater than 50 ha) and deforestation (greater than 10 ha). Understorey forest fires burned more than 85 500 km(2) between 1999 and 2010 (2.8% of all forests). Forests that burned more than once accounted for 16 per cent of all understorey fires. Repeated fire activity was concentrated in Mato Grosso and eastern Pará, whereas single fires were widespread across the arc of deforestation. Routine fire activity in Mato Grosso coincided with annual periods of low night-time relative humidity, suggesting a strong climate control on both single and repeated fires. Understorey fires occurred in regions with active deforestation, yet the interannual variability of fire and deforestation were uncorrelated, and only 2.6 per cent of forests that burned between 1999 and 2008 were deforested for agricultural use by 2010. Evidence from the past decade suggests that future projections of frontier landscapes in Amazonia should separately consider economic drivers to project future deforestation and climate to project fire risk.

Endocrine disrupters: a review of some sources, effects, and mechanisms of actions on behaviour and neuroendocrine systems.

Some environmental contaminants interact with hormones and may exert adverse consequences as a result of their actions as endocrine disrupting chemicals (EDCs). Exposure in people is typically a result of contamination of the food chain, inhalation of contaminated house dust or occupational exposure. EDCs include pesticides and herbicides (such as dichlorodiphenyl trichloroethane or its metabolites), methoxychlor, biocides, heat stabilisers and chemical catalysts (such as tributyltin), plastic contaminants (e.g. bisphenol A), pharmaceuticals (i.e. diethylstilbestrol; 17α-ethinylestradiol) or dietary components (such as phytoestrogens). The goal of this review is to address the sources, effects and actions of EDCs, with an emphasis on topics discussed at the International Congress on Steroids and the Nervous System. EDCs may alter reproductively-relevant or nonreproductive, sexually-dimorphic behaviours. In addition, EDCs may have significant effects on neurodevelopmental processes, influencing the morphology of sexually-dimorphic cerebral circuits. Exposure to EDCs is more dangerous if it occurs during specific 'critical periods' of life, such as intrauterine, perinatal, juvenile or puberty periods, when organisms are more sensitive to hormonal disruption, compared to other periods. However, exposure to EDCs in adulthood can also alter physiology. Several EDCs are xenoestrogens, which can alter serum lipid concentrations or metabolism enzymes that are necessary for converting cholesterol to steroid hormones. This can ultimately alter the production of oestradiol and/or other steroids. Finally, many EDCs may have actions via (or independent of) classic actions at cognate steroid receptors. EDCs may have effects through numerous other substrates, such as the aryl hydrocarbon receptor, the peroxisome proliferator-activated receptor and the retinoid X receptor, signal transduction pathways, calcium influx and/or neurotransmitter receptors. Thus, EDCs, from varied sources, may have organisational effects during development and/or activational effects in adulthood that influence sexually-dimorphic, reproductively-relevant processes or other functions, by mimicking, antagonising or altering steroidal actions.

Acute psychiatric syndrome leading young patients to ICU: consider anti-NMDA-receptor antibodies.

We report on a case of anti-N-Methyl-D-Aspartate receptor antibody encephalitis, and review cases and series previously published in the literature. Anti-N-Methyl-D-Aspartate receptor antibody encephalitis usually occurs in young female patients with no past medical history, in whom an ovarian teratoma is often detected. They subacutely develop predominantly psychiatric symptoms, followed by severe neurological disorders requiring transfer to the intensive care unit and prolonged ventilatory support. Complete or substantial recovery depends on early diagnosis, removal of the teratoma and immunotherapy. Our purpose is to focus intensivists' attention on this potentially lethal disorder, which should always be considered in young women admitted to the intensive care unit with characteristic neuropsychiatric disorders.

Early regulation of brain aromatase (cyp19a1b) by estrogen receptors during zebrafish development.

Early expression of estrogen receptors (esr) and their role in regulating early expression of cyp19a1b encoding brain aromatase were examined in the brain of zebrafish. Using in toto hybridization and quantitative reverse transcriptase-polymerase chain reaction (RT-PCR), a significant increase in the expression of esr1, esr2a, and esr2b was observed between 24 and 48 hours postfertilization (hpf). In toto hybridization demonstrated that esr2a and esr2b, but not esr1, are found in the hypothalamus. Using real-time RT-PCR, an increase in cyp19a1b mRNAs occurs between 24 and 48 hpf, indicating that expression of cyp19a1b is temporally correlated with that of esr. This increase is blocked by the pure anti-estrogen ICI182,780. Furthermore, E2 treatment of cyp19a1b-GFP (green fluorescent protein) transgenic embryos results in appearance of GFP expression in the brain as early as 25 hpf. These results indicate that basal expression of cyp19a1b expression in the brain of developing zebrafish most likely relies upon expression of esr that are fully functional before 25 hpf.

LAVIA--an evaluation of the potential safety benefits of the French intelligent speed adaptation project.

This paper presents the potential safety benefits of the experimental French LAVIA Intelligent Speed Adaptation system, according to road network and system mode, based on observed driving speeds, distributions of crash severity and crash injury risk. Results are given for car frontal and side impacts that together, represent 80% of all serious and fatal injuries in France. Of the three system modes tested (advisory, driver select, mandatory), our results suggest that driver select would most significantly reduce serious injuries and death. We estimate this 100% utilization of cars equipped with this type of speed adaptation system would decrease injury rates by 6% to 16% over existing conditions depending on the type of crash (frontal or side) and road environment considered. Some limitations associated with the analysis are also identified. LAVIA is the acronym for Limiteur s'Adaptant à la VItesse Autorisée, a French Intelligent Speed Adaptation (ISA) project that was set up towards the end of 1999. At the time, 1998 French national road safety statistics recorded 8437 road related deaths, a figure which had shown virtually no positive evolution since 1994. Detailed analysis of the contributory factors involved in fatal road crashes highlighted the time-honoured crash and injury causation mechanisms - alcohol, speed and seatbelts. Of the three, excessive speed (over and above the posted speed limit) was a contributory factor in half of all fatal crashes Inappropriate behaviour such as excessive speeding can be dealt with either by legislative or driver-incentive programmes. The first of these two solutions involves the introduction of new legislation and/or the enforcement of existing laws. This is the domain of Public Authorities and will not be discussed in detail here. Alternatively, incentive schemes can involve the implementation of speed related driver assistance systems, categorised according to their voluntary or mandatory character and the degree of autonomy proposed to or imposed on the driver. The LAVIA project set out to address several possible combinations of these two factors. The generic term Intelligent Speed Adaptation (ISA) encompasses a wide range of different technologies aimed at improving road safety by reducing traffic speed and homogenising traffic flow, within the limit of posted speed limits. "Fixed speed limit" systems inform the vehicle of the posted speed limit whereas "variable speed limit" systems take into account certain locations on the road network where a speed below the posted limit is desirable, such as sharp curves, pedestrian crossings or crash black spots. Taken one step further, speed limit systems may also take into account weather and traffic flow conditions. These systems are known as "dynamic speed limit" systems and benefit from real time updates for a specific location. The different ISA systems are generally characterised by the degree of freedom of choice given to the driver in moderating his or her speed. Speed limit technologies may be advisory (informing drivers of the current speed limit and speed limit changes), voluntary (allowing the driver to decide whether or not to implement speed limitation) or mandatory (imposing the current speed limit). The information supplied may be provided by way of the road infrastructure (and associated equipment), may be acquired autonomously by the vehicle or may be based on an interaction between the infrastructure and the vehicle. Even the most basic of these systems should be considered as a very useful driver aid, helping the driver to stay within the posted speed limit, avoiding "unnecessary" speeding fines through inattention, modelling driver behaviour through the long term reduction of speeds and reducing driver workload by limiting visual speedometer controls. Vehicle-based ISA systems should not be confused with internal systems. These latter systems rely upon the driver entering the desired travel speed, which is then maintained by cruise control or set as a maximum value by automatic speed regulators. Although these systems will not be discussed in detail here, it should be noted that the engine management technologies that they employ are a vital component of ISA systems.

A Bayesian Neural Network approach to estimating the Energy Equivalent Speed.

To reduce the number and the gravity of accidents, it is necessary to analyse and reconstruct them. Accident modelling requires the modelling of the impact which in turn requires the estimation of the deformation energy. There are several tools available to evaluate the deformation energy absorbed by a vehicle during an impact. However, there is a growing demand for more precise and more powerful tools. In this work, we express the deformation energy absorbed by a vehicle during a crash as a function of the Energy Equivalent Speed (EES). The latter is a difficult parameter to estimate because the structural response of the vehicle during an impact depends on parameters concerning the vehicle, but also parameters concerning the impact. The objective of our work is to design a model to estimate the EES by using an original approach combining Bayesian and Neural Network approaches. Both of these tools are complementary and offer significant advantages, such as the guarantee of finding the optimal model and the implementation of error bars on the computed output. In this paper, we present the procedure for implementing this Bayesian Neural Network approach and the results obtained for the modelling of the EES: our model is able to estimate the EES of the car with a mean error of 1.34 m s(-1). Furthermore, we built a sensitivity analysis to study the relevance of model's inputs.

Analysis of the estrogen regulation of the zebrafish estrogen receptor (ER) reveals distinct effects of ERalpha, ERbeta1 and ERbeta2.

We have previously cloned and characterized three estrogen receptors (ER) in the zebrafish (zfERalpha, zfERbeta1 and zfERbeta2). We have also shown that they are functional in vitro and exhibit a distinct expression pattern, although partially overlapping, in the brain of zebrafish. In this paper, we have shown that the hepatic expression of these zfER genes responds differently to estradiol (E2). In fact, a 48-h direct exposure of zebrafish to E2 resulted in a strong stimulation of zfERalpha gene expression while zfERbeta1 gene expression was markedly reduced and zfERbeta2 remained virtually unchanged. To establish the potential implication of each zfER in the E2 upregulation of the zfERalpha gene, the promoter region of this gene was isolated and characterized. Transfection experiments with promoter-luciferase reporter constructs together with different zfER expression vectors were carried out in different cell contexts. The data showed that in vivo E2 upregulation of the zfERalpha gene requires ERalpha itself and a conserved transcription unit sequence including at least an imperfect estrogen-responsive element (ERE) and an AP-1/ERE half site at the proximal transcription initiation site. Interestingly, although in the presence of E2 zfERalpha was the most potent at inducing the expression of its own gene, the effect of E2 mediated by zfERbeta2 represented 50% of the zfERalpha activity. In contrast, zfERbeta1 was unable to upregulate the zfERalpha gene whereas this receptor form was able to tightly bind E2 and activate a reporter plasmid containing a consensus ERE. Altogether, these results indicated that the two ERbeta forms recently characterized in teleost fish could have partially distinct and not redundant functions.

A statistical model to compare road mortality in OECD countries.

The objective of this paper is to compare safety levels and trends in OECD countries from 1980 to 1994 with the help of a statistical model and to launch international discussion and further research about international comparisons. Between 1980 and 1994, the annual number of fatalities decreased drastically in all the selected countries except Japan (+ 12%), Greece (+ 56%) and ex-East Germany (+ 50%). The highest decreases were observed in ex-West Germany (- 48%), Switzerland (- 44%), Australia (- 40%), and UK (- 39%). In France, the decrease in fatalities over the same period reached 34%. The fatality rate, an indicator of risk, decreased in the selected countries from 1980 to 1994 except in the east-European countries during the motorization boom in the late 1980s. As fatality rates are not sufficient for international comparisons, a statistical multiple regression model is set up to compare road safety levels in 21 OECD countries over 15 years. Data were collected from IRTAD (International Road Traffic and Accident Database) and other OECD statistical sources. The number of fatalities is explained by seven exogenous (to road safety) variables. The model, pooling cross-sectional and time series data, supplies estimates of elasticity to the fatalities for each variable: 0.96 for the population; 0.28 for the vehicle fleet per capita; -0.16 for the percentage of buses and coaches in the motorised vehicle fleet; 0.83 for the percentage of youngsters in the population; - 0.41 for the percentage of urban population; 0.39 for alcohol consumption per capita; and 0.39 for the percentage of employed people. The model also supplies a rough estimate of the safety performance of a country: the regression residuals are supposed to contain the effects of essentially endogenous and unobserved variables, independent to the exogenous variables. These endogenous variables are safety performance variables (safety actions, traffic safety policy, network improvements and social acceptance). A new indicator, better than the mortality rate, is then set upon the residuals. Mean estimates of this indicator for the years 1980-1982 and the years 1992-1994 rank the countries in the beginning and at the end of the study period. Countries showing the best ranks (and thus the best performance) in 1980 and 1994 are Sweden, the Netherlands and Norway. The UK and Switzerland reach the top 5 in 1994. Greece, Belgium, Portugal and Spain are the last countries in the classification along with, surprisingly, the USA. France was ranked 18th in 1980 and 15th in 1994 but is ranked amongst the five countries that most improved from 1980 to 1994. This model remains non definitive because it is not able to distinguish between safety performance and unobserved exogenous variables although these exogenous variables could explain more about the differences in levels and trends between the countries. More complex models, particularly highly sophisticated models regarding the number of fatalities with breakdowns by road users or road classes would be needed to give a precise and profound ranking of safety levels and safety improvements between countries.

Comparison of Thoracic Injury Risk in Frontal Car Crashes for Occupant Restrained without Belt Load Limiters and Those Restrained with 6 kN and 4 kN Belt Load Limiters.

In France, as in other countries, accident research studies show that a large proportion of restrained occupants who sustain severe or fatal injuries are involved in frontal impacts (65% and 50%, respectively). In severe frontal impacts with restrained occupants and where intrusion is not preponderant, the oldest occupants very often sustain severe thoracic injuries due to the conventional seat belt. As we have been observing over the last years, we will expect in the coming years developments which include more solidly-built cars, as offset crash test procedures are widely used to evaluate the passive safety of production vehicles. The reduction of intrusion for the most severe frontal impacts, through optimization of car deformation, usually translates into an increase in restraint forces and hence thoracic injury risk with a conventional retractor seat belt for a given impact severity. It is, therefore essential to limit the restraint forces exerted by the seat belt on the thorax in order to reduce the number of road casualties. In order to address thoracic injury risk in frontal impact, Renault cars have been equipped with the Programmed Restraint System (PRS) since 1995. The PRS is a restraint system that combines belt load limitation and pyrotechnic belt pretension. In an initial design of the Programmed Restraint System (PRS1), the belt load limiter was a steel component designed to shear at a given shoulder force, namely 6 kN. It was mounted between the retractor and the lower anchorage point of the belt. The design of the PRS was modified in 1998 (PRS2), but the principle of load limitation was maintained. The threshold was decreased to 4 kN and this lower belt belt-force limiter has been combined with a specially designed airbag. This paper reports on 347 real-world frontal accidents where the EES (Equivalent Energy Speed) ranged from 35 to 75 km/h. One hundred and ninety-eight (198) of these accidents involved cars equipped with the 6 kN load limiter, and 149 involved cars equipped with the 4 kN load limiter. Based on this accident data, the study compares the thoracic injury risk for two occupant populations: belted occupants involved in accidents in which the vehicle was not equipped with a load limiter (378 cases with pyrotechnic pretensioners), and belted occupants involved in accidents in which the vehicles were equipped with 4 or 6 kN load limiters and pyrotechnic pretensioners (347 cases). One observes that a 4 kN load limitation results in a very important reduction of thoracic injury risk for all AIS levels, compared to others samples. 50 to 60% reduction for AIS 2+ was observed, as well as 75 to 85% for AIS 3+. The complete absence of AIS 4+ with a 4 kN load limiter must be stressed, though it remains more than 8% for the other samples (no limiter and 6 kN limiter).

COUP-TFI (chicken ovalbumin upstream promoter-transcription factor I) regulates cell migration and axogenesis in differentiating P19 embryonal carcinoma cells.

The developmental expression patterns of the nuclear orphan receptors COUP-TFs (chicken ovalbumin upstream promoter-transcription factors) have been correlated to neurogenesis in several animal species. Nevertheless, the role of COUP-TFs in neurogenesis remains unknown. We have studied the functional involvement of COUP-TFI in retinoic acid (RA)-induced neuronal differentiation of P19 embryonal carcinoma cells through two complementary approaches: 1) deregulated expression of COUP-TFI, and 2) inactivation of endogenous COUP-TFs by means of a dominant-negative COUP-TFI mutant. Low levels of wild-type (wt)COUP-TFI transgene expression did not inhibit neural cell fate and primarily enhanced neuron outgrowth from RA-treated P19 aggregates. In contrast, high COUP-TFI expression impeded the neuronal differentiation of P19 cells induced with RA, resulting in cell cultures lacking neurons. This morphological effect was correlated to an elevated level of E-cadherin mRNA. The dominant-negative COUP-TFI mutant induced cell packing after RA treatment and inhibited neurite extension and neuron outgrowth from aggregates. A RGD peptide interference assay indicated that endogenous COUP-TFs could favor migration of neurons through an integrin-dependent mechanism. Accordingly, vitronectin mRNA levels were shown to be up-regulated by COUP-TFI by RT-PCR analysis, and COUP-TFI stimulated the mouse vitronectin promoter activity in transient transfection assays. Taken together, these data indicate that COUP-TFI is not simply a global repressor of retinoid functions, but shows a high selectivity for regulating genes involved in cellular adhesion and migration processes that are particularly important for neuronal differentiation.

[Rapid diagnosis of the type of meningitis (bacterial or viral) by the assay of serum procalcitonin]. / Diagnostic rapide du type de méningite (bactérienne ou virale) par le dosage de la procalcitonine sérique.

OBJECTIVE: It has been shown that serum procalcitonin (PCT) can be used to differentiate bacterial from viral meningitis in children in all cases. The aim of this study was to demonstrate the interest of PCT in the management of suspected meningitis in adults. PATIENTS AND METHODS: We conducted a prospective study including 179 consecutive patients admitted to the emergency department for suspected meningitis. All samples were taken at patient admission. The discriminant potential between bacterial and viral meningitis was studied for cerebrospinal fluid parameters (cytology, protein, glucose, lactate) and serum parameters (C reactive protein, PCT). RESULTS: Thirty-two patients had bacterial meningitis, 90 had viral meningitis and meningitis was ruled out in 57. Among all studied parameters, the most discriminant for distinguishing between bacterial and viral meningitis in 100% of the cases proved to be serum procalcitonin with a threshold value of 0.93 ng/ml. CONCLUSION: Serum procalcitonin is an interesting parameter in the emergency department for management of meningitis suspicion in adults.

[Diagnosis and development of heparin-induced thrombocytopenia. Biological and clinical aspects]. / Diagnostic et gestion des thrombopénies induites par l'héparine. Aspects biologiques et cliniques.

Two types of thrombocytopenia occur during treatment with heparin: type I and type II heparin-induced thrombocytopenia (HIT). Type I HIT is due to a direct interaction between heparin and platelets. They are asymptomatic, occur early, mild and transitory. Type II HIT which is immunoallergic in nature is the most important complication of this treatment. The thrombocytopenia has a different presentation, acute with a fall in platelets over 30 per cent and is often associated with the occurrence or worsening of a venous or arterial thrombotic episode. The major problems of this secondary type are threefold: its recognition, its confirmation and its management should be as early as possible to avoid the development of often dramatic complications which compromise the prognosis. Laboratory investigations are required by highly reliable specialist laboratories following a careful clinical history. The natural history of the platelet count should enable the difficult diagnosis of HIT to be made more accurately. The treatment of confirmed HIT and/or symptomatic HIT often requires a multidisciplinary approach from a specialized team involving clinicians and hematologists. Two therapies with the benefit of large experience have just been obtained in France with marketing approval (AMM) for the management of HIT: danaparoid (Orgaran) and recombinant hidurin, lepirudin (Refludan). A declaration to the regional drugs monitoring center should not be omitted. In addition, each patient should be given a certificate confirming the immunallergy thus avoiding any further exposure with potentially dramatic consequences.

Does bicarbonate therapy improve the management of severe diabetic ketoacidosis?

OBJECTIVE: The use of bicarbonates in the treatment of severe diabetic ketoacidosis remains controversial, especially regarding the benefit/risk ratio. The aim of this study was to assess the efficacy of bicarbonate therapy during severe diabetic ketoacidosis (pH <7.10). DESIGN: Retrospective study. SETTING: The emergency unit of a teaching hospital. PATIENTS: The records of 39 patients consecutively admitted for severe diabetic ketoacidosis were analyzed (pH <7.10). The patients were divided into two groups: group 1 (n = 24; patients with bicarbonate treatment) and group 2 (n = 15; patients without bicarbonate treatment). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared two groups of patients presenting with severe diabetic ketoacidosis (pH values between 6.83 and 7.08) treated with or without bicarbonate. A group of 24 patients received 120+/-40 mmol sodium bicarbonate. The two groups were similar at admission with regard to clinical and biological parameters. No difference could be demonstrated between the two groups concerning the clinical parameters or the normalization time of biochemical parameters. If the number of patients with hypokalemia was comparable between the two groups, the potassium supply was significantly more important in group 1 compared with group 2 (366+/-74 mmol/L vs. 188+/-109 mmol/L, respectively; p < .001). CONCLUSIONS: Data from the literature and this study are not in favor of the use of bicarbonate in the treatment of diabetic ketoacidosis with pH values between 6.90 and 7.10.