Predictors of Risk Stratification and Value of Point-of-Care of High-Sensitivity Cardiac Troponin-I in EMS Management of Non-ST-Segment Elevation Myocardial Infarction: A Retrospective Study.

INTRODUCTION: The European Society of Cardiology (ESC) 2020 guidelines propose an algorithm for in-hospital management of non-ST-elevation myocardial infarction (NSTEMI) based on risk stratification according to clinical, electrocardiographic, and biological data. However, out-of-hospital management is not codified. STUDY OBJECTIVE: The objective of the present study was to evaluate the role of high-sensitivity cardiac troponin-I in out-of-hospital management of NSTEMI by Emergency Medical Services (EMS). METHODS: This monocentric, retrospective, observational study analyzed the files of all patients having received a troponin assay in the EMS of Beaujon University Hospital, AP-HP (Paris region, France) from January 1, 2020 through December 31, 2020. Patients were classified as low risk, high risk, or very high risk according to the ESC 2020 algorithm at the time of their hospital treatment. The relationship between troponin in point-of-care and risk level according to time to onset of pain was analyzed using logistic regression. A search for predictors of risk level was performed using multivariate analysis. A P value <.05 was considered significant. RESULTS: Out of 309 patients in the file, 233 were included. Men were 61% and the median age was 63 years. A positive troponin assay was associated with high-risk or very high-risk stratification regardless of the time to onset of pain (P <.0001). Predictive factors for being classified as high or very high risk in hospital were: a history of atrial fibrillation (P = .03), electrocardiogram (ECG) modifications such as negative T wave or ST-segment depression (P <.0001), and positive troponin (P <.0001). CONCLUSION: The use of point-of-care troponin in EMS, combined with clinical and electrical criteria, allows risk stratification of NSTEMI patients from the prehospital management stage and optimization of referral to an appropriate care pathway. Patients classified as low risk should be referred to the emergency department (ED) and patients classified as high risk or very high risk to the cardiac intensive care unit or percutaneous coronary intervention (PCI) center.

Características de la exposición al VIH y factores predictores del tiempo de acceso a la profilaxis posexposición: estudio observacional prospectivo / Characteristics of human immunodeficiency virus exposure and predictors of time until access to postexposure prophylaxis: a prospective observational study

OBJETIVOS: La eficacia de la profilaxis posexposición al virus de la inmunodeficiencia humana (VIH) depende de un tiempo inferior a 4 horas entre la exposición y la administración del tratamiento. Este estudio evalúa los factores predictores del tiempo entre la exposición al VIH y la llegada a urgencias. MÉTODOS: Estudio observacional, prospectivo, realizado en el Hospital Universitario de Bichat (París, Francia). Se incluyeron todas las consultas en urgencias en 2016 y 2017 por exposición al VIH -ocupacional y no ocupacional-. RESULTADOS: Se incluyeron 1.475 pacientes, de los que 598 completaron una encuesta de seguimiento. El retraso ($4horas) entre la exposición al VIH y la consulta en urgencias se asoció con el tipo de exposición al VIH: trabajadores sanitarios, otras exposiciones y sexuales (p < 0,001). Se encontraron diferencias entre la exposición sexual y otras: conocimiento del circuito de PEP: 65,2% y 46,9% (p < 0,001), uso previo de PEP: 23,9% y 13,1% (p = 0,001), uso de alcohol: 36,2% y 18,5% (p < 0,001), uso de drogas: 34,6% y 8,6% (p < 0,001), y chemsex: 26,1% y 0% (p < 0,001).En la exposición sexual, los siguientes factores predicen el retraso: conocimiento y uso previo del circuito de PEP(p < 0,001) disminuyen el riesgo de retraso > 4 horas, y uso de drogas (p = 0,03) y chemsex (p < 0,001) lo aumentan; en la exposición ocupacional, el conocimiento del programa PEP lo disminuye y el uso de drogas lo aumenta(p < 0,001). CONCLUSIÓN:El retraso en la consulta posexposición al VIH es mayor en la exposición sexual. El conocimiento del programa de PEP y su uso previo determinaban un retraso menor. En la exposición sexual, el consumo de alcohol, drogas y chemsex, implican un retraso mayor, en especial en hombres que tienen relaciones sexuales con hombres

BACKGROUND AND OBJECTIVE: The efficacy of postexposure prophylaxis (PEP) after human immunodeficiency virus (HIV)contact relies on administering the treatment within 4 hours of contact with the virus. This study aimed to evaluate predictors of the time that elapses between HIV exposure and emergency department arrival. METHODS: Prospective observational study carried out at Hôpital Bichat, a university teaching hospital in Paris, France. All emergency visits for occupational or non occupational exposure to HIV in 2016 and 2017 were included. RESULTS: A total of 1475 cases were studied; 598 patients responded to the follow-up survey. A delay of 4 hours or more between HIV exposure and the emergency department visit was associated with type of contact: health care occupational exposure, other occupational exposure, or sexual intercourse (P< .001). We found significant differences between individuals exposed during sexual contact versus occupational exposure with respect to knowledge of the PEP program pathway (65.2%vs 46.9%, respectively), previous use of PEP (23.9%vs 13.1%), alcohol intake (36.2%vs 18.5%), drug use (34.6%vs 8.6%), and chemsex (sexualized drug use) (26.1%vs 0%) (P< .001, all comparisons).Predictors of time until start of PEP among individuals exposed during sexual intercourse were knowledge and prioruse of the PEP pathway (P< .001), drug use (P= .03), and chemsex (P< .001). Predictors among occupationally exposed individuals were prior knowledge of the PEP pathway and drug use (P< .001). CONCLUSIONS: Delay in seeking PEP after HIV exposure is greater among individuals exposed during sexual intercourse. Knowledge of the PEP program and prior use of it are associated with less delay. Exposure during sexual intercourse, alcohol and drug use, and chemsex are associated with longer delays, especially in men who have sex with men

Characteristics of human immunodeficiency virus exposure and predictors of time until access to postexposure prophylaxis: a prospective observational study. / Características de la exposición al VIH y factores predictores del tiempo de acceso a la profilaxis posexposición: estudio observacional prospectivo.

OBJECTIVES: The efficacy of postexposure prophylaxis (PEP) after human immunodeficiency virus (HIV) contact relies on administering the treatment within 4 hours of contact with the virus. This study aimed to evaluate predictors of the time that elapses between HIV exposure and emergency department arrival. MATERIAL AND METHODS: Prospective observational study carried out at Hôpital Bichat, a university teaching hospital in Paris, France. All emergency visits for occupational or nonoccupational exposure to HIV in 2016 and 2017 were included. RESULTS: A total of 1475 cases were studied; 598 patients responded to the follow-up survey. A delay of 4 hours or more between HIV exposure and the emergency department visit was associated with type of contact: health care occupational exposure, other occupational exposure, or sexual intercourse (P .001). We found significant differences between individuals exposed during sexual contact versus occupational exposure with respect to knowledge of the PEP program pathway (65.2% vs 46.9%, respectively), previous use of PEP (23.9% vs 13.1%), alcohol intake (36.2% vs 18.5%), drug use (34.6% vs 8.6%), and chemsex (sexualized drug use) (26.1% vs 0%) (P .001, all comparisons). Predictors of time until start of PEP among individuals exposed during sexual intercourse were knowledge and prior use of the PEP pathway (P .001), drug use (P = .03), and chemsex (P .001). Predictors among occupationally exposed individuals were prior knowledge of the PEP pathway and drug use (P .001). CONCLUSION: Delay in seeking PEP after HIV exposure is greater among individuals exposed during sexual intercourse. Knowledge of the PEP program and prior use of it are associated with less delay. Exposure during sexual intercourse, alcohol and drug use, and chemsex are associated with longer delays, especially in men who have sex with men.

OBJETIVO: La eficacia de la profilaxis posexposición al virus de la inmunodeficiencia humana (VIH) depende de un tiempo inferior a 4 horas entre la exposición y la administración del tratamiento. Este estudio evalúa los factores predictores del tiempo entre la exposición al VIH y la llegada a urgencias. METODO: Estudio observacional, prospectivo, realizado en el Hospital Universitario de Bichat (París, Francia). Se incluyeron todas las consultas en urgencias en 2016 y 2017 por exposición al VIH ­ocupacional y no ocupacional­. RESULTADOS: Se incluyeron 1.475 pacientes, de los que 598 completaron una encuesta de seguimiento. El retraso (4 horas) entre la exposición al VIH y la consulta en urgencias se asoció con el tipo de exposición al VIH: trabajadores sanitarios, otras exposiciones y sexuales (p 0,001). Se encontraron diferencias entre la exposición sexual y otras: conocimiento del circuito de PEP: 65,2% y 46,9% (p 0,001), uso previo de PEP: 23,9% y 13,1% (p = 0,001), uso de alcohol: 36,2% y 18,5% (p 0,001), uso de drogas: 34,6% y 8,6% (p 0,001), y chemsex: 26,1% y 0% (p 0,001). En la exposición sexual, los siguientes factores predicen el retraso: conocimiento y uso previo del circuito de PEP (p 0,001) disminuyen el riesgo de retraso > 4 horas, y uso de drogas (p = 0,03) y chemsex (p 0,001) lo aumentan; en la exposición ocupacional, el conocimiento del programa PEP lo disminuye y el uso de drogas lo aumenta (p 0,001). CONCLUSIONES: El retraso en la consulta posexposición al VIH es mayor en la exposición sexual. El conocimiento del programa de PEP y su uso previo determinaban un retraso menor. En la exposición sexual, el consumo de alcohol, drogas y chemsex, implican un retraso mayor, en especial en hombres que tienen relaciones sexuales con hombres.

Observer agreement and clinical significance of chest CT reporting in patients suspected of COVID-19.

OBJECTIVES: To assess interobserver agreement and clinical significance of chest CT reporting in patients suspected of COVID-19. METHODS: From 16 to 24 March 2020, 241 consecutive patients addressed to hospital for COVID-19 suspicion had both chest CT and SARS-CoV-2 RT-PCR. Eight observers (2 thoracic and 2 general senior radiologists, 2 junior radiologists, and 2 emergency physicians) retrospectively categorized each CT into one out of 4 categories (evocative, compatible for COVID-19 pneumonia, not evocative, and normal). Observer agreement for categorization between all readers and pairs of readers with similar experience was evaluated with the Kappa coefficient. The results of a consensus categorization were correlated to RT-PCR. RESULTS: Observer agreement across the 4 categories was good between all readers (κ value 0.61 95% CI 0.60-0.63) and moderate to good between pairs of readers (0.54-0.75). It was very good (κ 0.81 95% CI 0.79-0.83), fair (κ 0.32 95% CI 0.29-0.34), moderate (κ 0.56 95% CI 0.54-0.58), and moderate (0.58 95% CI 0.56-0.61) for the categories evocative, compatible, not evocative, and normal, respectively. RT-PCR was positive in 97%, 50%, 31%, and 11% of cases in the respective categories. Observer agreement was lower (p < 0.001) and RT-PCR positive cases less frequently categorized evocative in the presence of an underlying pulmonary disease (p < 0.001). CONCLUSION: Interobserver agreement for chest CT reporting using categorization of findings is good in patients suspected of COVID-19. Among patients considered for hospitalization in an epidemic context, CT categorized evocative is highly predictive of COVID-19, whereas the predictive value of CT decreases between the categories compatible and not evocative. KEY POINTS: • In patients suspected of COVID-19, interobserver agreement for chest CT reporting into categories is good, and very good to categorize CT "evocative." • Chest CT can participate in estimating the likelihood of COVID-19 in patients presenting to hospital during the outbreak, CT categorized "evocative" being highly predictive of the disease whereas almost a third of patients with CT "not evocative" had a positive RT-PCR in our study. • Observer agreement is lower and CTs of positive RT-PCR cases less frequently "evocative" in presence of an underlying pulmonary disease.

Feedback to Prepare EMS Teams to Manage Infected Patients with COVID-19: A Case Series.

Coronavirus Disease 2019 (COVID-19), a new respiratory disease, is spreading globally. In France, Emergency Medical Service (EMS) teams are mobile medicalized resuscitation teams composed of emergency physician, nurse or anesthesiologist nurse, ambulance driver, and resident. Four types of clinical cases are presented here because they have led these EMS teams to change practices in their management of patients suspected of COVID-19 infection: cardiac arrest, hypoxia on an acute pneumonia, acute chronic obstructive pulmonary disease (COPD) exacerbation with respiratory and hemodynamic disorders, and upper function disorders in a patient in a long-term care facility. The last case raised the question of COVID-19 cases with atypical forms in elderly subjects. Providers were contaminated during the management of these patients. These cases highlighted the need to review the way these EMS teams are responding to the COVID-19 pandemic, in view of heightening potential for early identification of suspicious cases, and of reinforcing the application of staff protection equipment to limit risk of contamination.

Prevalence and predictive factors for renouncing medical care in poor populations of Cayenne, French Guiana.

BACKGROUND: Access to health care is a global public problem. In French Guiana, there exists social inequalities which are specially marked amongst immigrants who make up a third of the population. Health care inequalities are prevalent. The objective of this study was to determine factors associated with why health care amongst the poor population of Cayenne was renounced. The study was cross sectional. It focused on knowledge, attitudes, practices and beliefs of the population living in poor neighborhoods of the Cayenne area. METHODS: Populations coming at the Red Cross mobile screening unit in poor urban areas of Cayenne were surveyed from July 2013 to June 2014. Structured questionnaires consisted of 93 questions. Written informed consent was requested at the beginning of the questionnaire. The predictors for renouncing medical care were determined using logistic regression models and tree analysis. RESULTS: Twenty percent of persons had renounced care. Logistic regression showed that renouncement of health care was negatively associated with having no regular physician Adjusted Odds Ratio (AOR) = 0.43 (95 % CI = 0.24-0.79) and positively associated with being embarrassed to ask certain questions AOR = 6.81 (95 % CI = 3.98-11.65) and having been previously refused health care by a doctor AOR = 3.08 (95 % CI = 1.43-6.65). Tree analysis also showed that three of these variables were linked to renouncement, with feeling shy to ask certain questions as the first branching. CONCLUSION: Although most people felt it was easy to see a doctor, one in five had renounced health care. The variables identified by the models suggest vulnerable persons generally had previous negative encounters with the health system and felt unwanted or non eligible for healthcare. Health care mediation and welcoming staff may be simple solutions to the above problems which were underscored in our observations.