Teleconsultation at Sea and Acute Wound Management Onboard.

Introduction: The French Tele-Medical Assistance Service (TMAS) provides medical teleconsultation for any ship at sea. At the end of the consultation, the doctor decides whether the problem can be taken care of onboard or not. In this study, we determined the factors associated with the decision for disembarkation or evacuation in case of wounds. Methods: We conducted a retrospective epidemiological study between 2011 and 2019 from consultations with the French TMAS. The inclusion criterion was the presence of an acute wound. Results: One thousand six patients (n = 1,006) were analyzed and 586 (58%) patients were disembarked or evacuated. Factors associated with disembarkation or evacuation are wound characteristics (severity and location), the onboard staff's medical training, the availability of photography, and the ship's location. Wound severity is a risk factor for disembarkation or evacuation. The availability of photography, staff with advanced training, and being at >1 day of navigation from a harbor are protective factors against being disembarked or evacuated. Conclusion: The added value of photography and an update of medium medical training could increase the number of wounds taken care of onboard.

The COVID-19 pandemic and maritime telemedicine: 18-month report.

BACKGROUND: The onset of the coronavirus disease 2019 (COVID-19) pandemic has greatly impacted maritime telemedicine services. The aim of this study is to describe the impact of the pandemic, both quantitatively and qualitatively, by analysing the teleconsultations by doctors from the French Tele-Medical Assistance Service (TMAS). MATERIALS AND METHODS: We carried out a descriptive observational study of retrospective data from the TMAS files. The main inclusion criterion for the files was a diagnosis of "influenza due to an unidentified virus". We extracted the following data: type of ship, gender, age, nationality, role on board, reason for the call and symptoms, number of calls, navigation zone, severity, medical decision, whether or not a COVID-19 test had been carried out, and treatments prescribed on board. RESULTS: One hundred and ninety-nine files were included of which 39 (20%) were clusters. We were able to analyse data from 384 patients. The study population comprised 376 suspected COVID-19 patients, of whom 334 (87%) were symptomatic and 42 (10.9%) asymptomatic. Eight (2.1%) patients were not thought to have COVID-19 but their call was related to the pandemic. Of the symptoms presented by the patients, fever was the most frequent (n = 196; 59%), while 129 (39%) presented a cough, 60 (18%) a headache, 41 (12%) non-specific ear, nose, throat signs, and 40 (12%) dyspnoea. Two hundred fifty-two (75%) patients stayed on board, 55 (17%) were disembarked, for 14 (4%) a ship diversion was arranged, and 13 were evacuated including 4 medical evacuations. CONCLUSIONS: The most important problem encountered related to managing asymptomatic or pauci-symptomatic patients at sea, which was the subject of the majority of calls. The TMAS doctors played an important role in managing the pandemic by emphasising the need for social distancing and quarantine procedures at sea to limit the spread of the virus, while adapting to the sometimes difficult implementation conditions and logistics for medical decision and quarantine.

COVID-19 and French Medical Maritime Teleconsultation.

Introduction: The coronavirus disease 2019 (COVID-19) epidemic has impacted both land and maritime health services. The purpose of this study is to describe the calls received by the Tele-Medical Assistance Service (TMAS) in relation to this epidemic. Methods: From March 1 to 30 April 30, 2020, all records coded by TMAS doctors as "influenza due to an unidentified virus" were extracted. The following data were collected: patients' age, gender, nationality, role on board, type of ship, area of navigation, reason for the teleconsultation, patient's symptoms, whether or not a COVID test had been carried out, and treatment given. The data were analyzed in two groups, depending on the reason for the consultation: teleconsultation for suspected COVID patients and teleconsultation for non-COVID patients for whom the call was nevertheless related to the COVID pandemic. Results: Sixty-one records were included-51 for suspected COVID patients and 10 records for COVID-related problems (six patients whose treatment had stopped due to shortage of medication/one patient reporting a psychiatric problem associated with isolation, three patients followed up as contact cases). Forty-five patients presented with fever when the first call was made (88%) and 39 had a cough (76%). On closure of the medical records, 33 were receiving treatment on board (65%), 10 had disembarked (20%), 1 had been rerouted (2%), and 7 had been evacuated (13%). Discussion: TMAS was able to aid professional sailors as well as passengers/recreational sailors in terms of telemedicine (diagnosis and monitoring), logistics (barrier actions and isolation), and operations (evacuation and repatriation).

BIOMEDICAL EVALUATION OF A BROWN LEMUR (EULEMUR FULVUS SPP.) POPULATION FROM MBOUZI ISLET, MAYOTTE ISLAND.

The brown lemur population (Eulemur fulvus spp.) in Mbouzi islet is not native, and was introduced in 1997. Since then, the population has grown. In 2012 the National Council for Protection of Nature of Mayotte requested to remove this population of lemurs from Mbouzi, as they were suspected to be a threat to the protected endemic flora of the islet. The Association Francophone des Vétérinaires de Parcs Zoologiques (French-speaking Zoo Veterinarians Association, AFVPZ) was asked to conduct a biomedical evaluation of the population. Fifty-two animals were captured, anesthetized, and weighed. They all underwent a general physical examination. Feces were sampled for bacterial and parasitological screening. Hair was sampled for genetic studies and blood was sampled for hematology, biochemistry, viral serology, and haemoparasitology. Results showed that three individuals had a positive feces culture for Salmonella enterica and six had Lemuricola or Callistoura parasite infestations. Blood analyses for hematology and biochemistry showed 46 animals with elevated transferrin, 42 with low ferritin levels, 19 with hyperglycemia, and 10 with neutrophilia. Finally, 10 were positive for Toxoplasma serology, one was positive for α herpesvirus, five for pox virus, five for simian virus 40, and two for flavivirus. This publication reports the first complete biomedical evaluation of lemurs on Mayotte Island.

Slice profile effects on nCPMG SS-FSE.

PURPOSE: To determine the effects of the RF refocusing pulse profile on the magnitude of the transverse signal smoothness throughout the echo train in non-Carr-Purcell-Meiboom-Gill (nCPMG) single-shot fast spin echo (SS-FSE) imaging and to design an RF refocusing pulse that provides improved signal stability. THEORY AND METHODS: nCPMG SS-FSE quadratic phase modulation requires sufficiently high and uniform refocusing flip angle to achieve a stable signal. Typically, refocusing pulses used in SS-FSE sequences are designed for minimum duration to minimize echo spacing and as a consequence have poor selectivity. However, delay-insensitive variable rate excitation Shinnar-Le Roux (DV-SLR) refocusing pulses can achieve both improved selectivity as well as a short duration. This class of RF pulse is compared against a traditional low time-bandwidth refocusing pulse in a nCPMG SS-FSE in simulation, phantom, and in vivo. RESULTS: DV-SLR pulses achieve a more stable signal in simulation, phantom, and in vivo cases while maintaining an appropriately short duration as well as not dramatically increasing specific absorption rate (SAR) accumulation. CONCLUSION: The nCPMG SS-FSE method demonstrates improved robustness when a more selective refocusing pulse is used. Refocusing pulses that use a time-varying excitation gradient can achieve this selectivity while maintaining short echo spacing. Magn Reson Med 79:430-438, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Robust Self-Calibrating nCPMG Acquisition: Application to Body Diffusion-Weighted Imaging.

This paper demonstrates a robust diffusion-weighted single-shot fast spin echo (SS-FSE) sequence in the presence of significant off-resonance, which includes a variable-density acquisition and a self-calibrated reconstruction as improvements. A non-Carr-Purcell-Meiboom-Gill (nCPMG) SS-FSE acquisition stabilizes both the main and parasitic echo families for each echo. This preserves both the in-phase and quadrature components of the magnetization throughout the echo train. However, nCPMG SS-FSE also promotes aliasing of the quadrature component, which complicates reconstruction. A new acquisition and reconstruction approach is presented here, where the field-of-view is effectively doubled, but a partial k-space and variable density sampling is used to improve scan efficiency. The technique is presented in phantom scans to validate SNR and robustness against rapidly varying object phase. In vivo healthy volunteer examples and the clinical cases are demonstrated in abdominal imaging. This new approach provides comparable SNR to previous nCPMG acquisition techniques as well as providing more uniform apparent diffusion coefficient maps in phantom scans. In vivo scans suggest that this method is more robust against motion than previous approaches. The proposed reconstruction is an improvement to the nCPMG sequence as it is auto-calibrating and is justified to accurately treat the signal model for the nCPMG SS-FSE sequence.

Added value of sending photograph in diagnosing a medical disease declared at sea: experience of the French Tele-Medical Assistance Service.

The maritime medical tele-consultation carried out by a doctor from the Toulouse Tele-Medical Assistance Service is currently based on tele-consultation using radiotelegraphy and the complementary transmission of data (photographs, electrocardiogram) via the Internet. In a previous article, we presented the benefits of photograph transmission for trauma management in isolated areas. Through this new series of cases, we wanted to expose the aspect of the medical pathologies and the contribution of sending photographs in their management. CASE REPORTS: Case 1. Myocardial infarction. Case 2. Toxic epidermal necrolysis. Case 3. Tooth abscess. Case 4. Shingles. Case 5. Junctional tachycardia. The tele-transmission of photographs provides a real diagnostic and follow-up tool for patients suffering from medical pathologies. The constant increase in the number of tele-consultations with the exchange of photographs shows its necessity and the interest of the participants in the development of these technologies.

Absence of Evidence of Rift Valley Fever Infection in Eulemur fulvus (Brown Lemur) in Mayotte During an Interepidemic Period.

The potential role of Eulemur fulvus (brown lemur) in the epidemiology of Rift Valley fever (RVF) in Mayotte, during an interepidemic period, was explored. In February and March 2016, 72 animals were blood sampled and tested for RVF. No evidence of RVF genome or antibodies was found in the samples. The role of other wild mammals on the island should, however, be further investigated.

Body Diffusion Weighted Imaging Using Non-CPMG Fast Spin Echo.

SS-FSE is a fast technique that does not suffer from off-resonance distortions to the degree that EPI does. Unlike EPI, SS-FSE is ill-suited to diffusion weighted imaging (DWI) due to the Carr-Purcell-Meiboom-Geill (CPMG) condition. Non-CPMG phase cycling does accommodate SS-FSE and DWI but places constraints on reconstruction, which are resolved here through parallel imaging. Additionally, improved echo stability can be achieved by using short duration and highly selective DIVERSE radiofrequency pulses. Here, signal-to-noise ratio (SNR) comparisons between EPI and nCPMG SS-FSE acquisitions and reconstruction techniques give similar values. Diffusion imaging with nCPMG SS-FSE gives similar SNR to an EPI acquisition, though apparent diffusion coefficient values are higher than seen with EPI. In vivo images have good image quality with little distortion. This method has the ability to capture distortion-free DWI images near areas of significant off-resonance as well as preserve adequate SNR. Parallel imaging and DIVERSE refocusing RF pulses allow shorter ETL compared to previous implementations and thus reduces phase encode direction blur and SAR accumulation.

Benefits of photograph transmission for trauma management in isolated areas: cases from the French tele-medical assistance service.

French maritime tele-medical assistance is currently performed by a telephone consultation associated with complementary transmission of data (photographs, electrocardiograms, etc.) over the internet. Five case reports are presented to illustrate how photo transmission is useful to managing initial care and monitoring isolated patients. Case reports included: Case 1: management of a hand burn; Case 2: management of a finger wound; Case 3: management of an ocular foreign body; Case 4: management of a subungual haematoma; Case 5: management of phlegmon. In conclusions, photo transmission improves our practice of maritime tele-medical medicine. New high-definition technologies will help in the development of videoconferences on ships.

Assembly of Double-Hydrophilic Block Copolymers Triggered by Gadolinium Ions: New Colloidal MRI Contrast Agents.

Mixing double-hydrophilic block copolymers containing a poly(acrylic acid) block with gadolinium ions in water leads to the spontaneous formation of polymeric nanoparticles. With an average diameter near 20 nm, the nanoparticles are exceptionally stable, even after dilution and over a large range of pH and ionic strength. High magnetic relaxivities were measured in vitro for these biocompatible colloids, and in vivo magnetic resonance imaging on rats demonstrates the potential utility of such polymeric assemblies.

Use of morbidity and mortality conferences to analyze causes of death at sea: a useful tool in the process of training in maritime medicine.

BACKGROUND. Morbidity and mortality conferences (MandMC) are collective reviews of records of patients, whose evolution was marked by an undesirable event: death or the occurrence of complications. The MandMC aim to improve the quality of care. This article intends to present three cases analyzed in MandMC in the French Telemedical Assistance Service (TMAS). MATERIAL AND METHODS. Three cases were selected according to the occurrence of a death at sea or according to particular cases of pathology on board. The case presentation was done in plenary session in our French TMAS, describing the facts, analyzing the defective processes, and suggesting possible improvements for each case. RESULTS. Description of 3 cases: Gastroenteritis in Papua New Guinea with septic shock; traumatic brain injury on a training boat with organizational and evacuation problems, and fever in the Gulf of Guinea with negative thick blood smear test. CONCLUSIONS. The MandMC tend to develop in all medical fields and are of particular interest in maritime medicine. The achievement of MandMC in our TMAS highlighted some difficulties in our daily work: diagnosis difficulty in tele-consultation and organizational or operational difficulties related to maritime medicine. However, we hope that the proposals for improvement will be applied to improve the quality of maritime medical care.

Staging of hip avascular necrosis: is there a need for DWI?

BACKGROUND: No comprehensive study has been performed to stage avascular necrosis of the hip using diffusion-weighted imaging (DWI). PURPOSE: To determine apparent diffusion co-efficient (ADC) alterations in hip avascular necrosis (AVN) and to determine variations of ADC values according to stages of disease. MATERIAL AND METHODS: The study is approved by our institutional review board and local ethical committee. Written informed consent was present for each subject. Thirty-five femoral heads of 21 cases affected by AVN were included in the study. Control group consisted of both femoral heads of 10 healthy volunteers. The hips affected by AVN were staged according to Ficat and Arlet classification system from I to IV. All cases underwent to routine hip magnetic resonance imaging (MRI) and DWI performed with a single-shot fast spin echo sequence at a b value of 600 s/mm(2). The ADC values were calculated automatically by placing ROIs on AVN lesions in affected patients and both femoral heads of control group. The median ADC value obtained from femoral heads of control group and that from AVN lesions were compared by Mann-Whitney U test. The median ADC values of AVN lesions at different stages were compared by Kruskal-Wallis test. RESULTS: The median ADC value of normal bone measured in control group was 185.5 ± 133.2 x 10(-6) mm(2)/s. The median ADC value measured in hip avascular necrosis lesions was 988.0 ± 332.7 x 10(-6) mm(2)/s. ADC values in hip AVN lesions were statistically significantly higher than normal bone marrow (P<0.01). The median ADC values of hips with avascular necrosis at stage I, II, III, IV were 817.5 ± 172.1 x 10(-6) mm(2)/s, 902.0 ± 181.0 x 10(-6) mm(2)/s, 1200.0 ± 363.2 x 10(-6) mm(2)/s and 1024.0 ± 324.0 x 10(-6) mm(2)/s, respectively. There was no statistically significant difference among AVN lesions at stages I, II, III and IV (P>0.05). CONCLUSION: Although DWI is a promising imaging tool that provides valuable diagnostic information in hip AVN, it fails to distinguish between different stages, and therefore is of limited value.

T(2) relaxation times of (13)C metabolites in a rat hepatocellular carcinoma model measured in vivo using (13)C-MRS of hyperpolarized [1-(13)C]pyruvate.

A single-voxel Carr-Purcell-Meibloom-Gill sequence was developed to measure localized T(2) relaxation times of (13)C-labeled metabolites in vivo for the first time. Following hyperpolarized [1-(13)C]pyruvate injections, pyruvate and its metabolic products, alanine and lactate, were observed in the liver of five rats with hepatocellular carcinoma and five healthy control rats. The T(2) relaxation times of alanine and lactate were both significantly longer in HCC tumors than in normal livers (p < 0.002). The HCC tumors also showed significantly higher alanine signal relative to the total (13)C signal than normal livers (p < 0.006). The intra- and inter-subject variations of the alanine T(2) relaxation time were 11% and 13%, respectively. The intra- and inter-subject variations of the lactate T(2) relaxation time were 6% and 7%, respectively. The intra-subject variability of alanine to total carbon ratio was 16% and the inter-subject variability 28%. The intra-subject variability of lactate to total carbon ratio was 14% and the inter-subject variability 20%. The study results show that the signal level and relaxivity of [1-(13)C]alanine may be promising biomarkers for HCC tumors. Its diagnostic values in HCC staging and treatment monitoring are yet to be explored.

Specific circuit training in young judokas: effects of rest duration.

Ten adolescent judokas performed circuit training consisting of six 40-s periods ofjudo exercises separated by 40 s (CT1:1), 120 s (CT1:3), or 200 s (CT1:5) of rest. Heart rate, blood lactate concentration, and the number of repetitions were recorded. Heart rate reached approximately 180 beats x min(-1) at the end of work periods, with slightly lower values for CT1:5. Blood lactate concentration increased until the 6th and 5th work periods for CT1:1 and CT1:3, respectively, whereas the peak value was lower and achieved earlier for CT1:5. Conversely, the number of repetitions was greater during CT1:5. These results suggest that circuit training composed of judo exercises substantially affects aerobic and anaerobic metabolisms, with relative contributions depending on the rest duration.

Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation.

BACKGROUND: During the administration of advanced cardiac life support for resuscitation from cardiac arrest, a combination of vasopressin and epinephrine may be more effective than epinephrine or vasopressin alone, but evidence is insufficient to make clinical recommendations. METHODS: In a multicenter study, we randomly assigned adults with out-of-hospital cardiac arrest to receive successive injections of either 1 mg of epinephrine and 40 IU of vasopressin or 1 mg of epinephrine and saline placebo, followed by administration of the same combination of study drugs if spontaneous circulation was not restored and subsequently by additional epinephrine if needed. The primary end point was survival to hospital admission; the secondary end points were return of spontaneous circulation, survival to hospital discharge, good neurologic recovery, and 1-year survival. RESULTS: A total of 1442 patients were assigned to receive a combination of epinephrine and vasopressin, and 1452 to receive epinephrine alone. The treatment groups had similar baseline characteristics except that there were more men in the group receiving combination therapy than in the group receiving epinephrine alone (P=0.03). There were no significant differences between the combination-therapy and the epinephrine-only groups in survival to hospital admission (20.7% vs. 21.3%; relative risk of death, 1.01; 95% confidence interval [CI], 0.97 to 1.05), return of spontaneous circulation (28.6% vs. 29.5%; relative risk, 1.01; 95% CI, 0.97 to 1.06), survival to hospital discharge (1.7% vs. 2.3%; relative risk, 1.01; 95% CI, 1.00 to 1.02), 1-year survival (1.3% vs. 2.1%; relative risk, 1.01; 95% CI, 1.00 to 1.02), or good neurologic recovery at hospital discharge (37.5% vs. 51.5%; relative risk, 1.29; 95% CI, 0.81 to 2.06). CONCLUSIONS: As compared with epinephrine alone, the combination of vasopressin and epinephrine during advanced cardiac life support for out-of-hospital cardiac arrest does not improve outcome. (ClinicalTrials.gov number, NCT00127907.)

Rapidly reversible myocardial edema in patients with acromegaly: assessment with ultrafast T2 mapping in a single-breath-hold MRI sequence.

OBJECTIVE: The purpose of this study was to use a single-breath-hold T2-mapping MRI sequence to evaluate the reversibility of myocardial edema in patients treated for acromegaly. SUBJECTS AND METHODS: Before and after treatment, 15 patients with acromegaly underwent myocardial T2 mapping with an experimental single-breath-hold black-blood fast spin-echo sequence. Myocardial T2 mapping with both a multiple-breath-hold fast spinecho sequence and the experimental sequence also was performed on 14 volunteers. T2 relaxation times were calculated with a standard linear least-squares fit applied to myocardial signal intensity. The T2 relaxation times of patients were compared with those of volunteers and correlated with levels of serum growth hormone and insulinlike growth factor 1. Left ventricular function and mass index were determined with cine MRI. RESULTS: T2 values before treatment were higher in patients (71 +/- 12 milliseconds) than in volunteers (55.9 +/- 3.6 milliseconds) (p = 0.0003). These T2 values in patients decreased soon after treatment (57.6 +/- 6.6 milliseconds, p = 0.0007). This reduction correlates with successful reduction of levels of serum growth hormone and insulinlike growth factor 1. In volunteers, myocardial T2 values did not vary significantly between the single-breath-hold sequence and the multiple-breath-hold fast spin-echo sequence. In patients, myocardial mass and left ventricular function did not differ significantly before and after treatment. CONCLUSION: Patients with acromegaly have increased myocardial T2 values, which decrease soon after treatment, reflecting reversible myocardial edema. T2 value is more sensitive than left ventricular mass index in the detection of early reversal of acromegalic cardiomyopathy. These results highlight the potential role of MRI in direct assessment of the tissular effects of growth hormone and insulinlike growth factor 1 and in evaluation of the efficacy of treatment.

High temporal resolution functional MRI using parallel echo volumar imaging.

PURPOSE: To combine parallel imaging with 3D single-shot acquisition (echo volumar imaging, EVI) in order to acquire high temporal resolution volumar functional MRI (fMRI) data. MATERIALS AND METHODS: An improved EVI sequence was associated with parallel acquisition and field of view reduction in order to acquire a large brain volume in 200 msec. Temporal stability and functional sensitivity were increased through optimization of all imaging parameters and Tikhonov regularization of parallel reconstruction. Two human volunteers were scanned with parallel EVI in a 1.5T whole-body MR system, while submitted to a slow event-related auditory paradigm. RESULTS: Thanks to parallel acquisition, the EVI volumes display a low level of geometric distortions and signal losses. After removal of low-frequency drifts and physiological artifacts, activations were detected in the temporal lobes of both volunteers and voxelwise hemodynamic response functions (HRF) could be computed. On these HRF different habituation behaviors in response to sentence repetition could be identified. CONCLUSION: This work demonstrates the feasibility of high temporal resolution 3D fMRI with parallel EVI. Combined with advanced estimation tools, this acquisition method should prove useful to measure neural activity timing differences or study the nonlinearities and nonstationarities of the BOLD response.

Design of phase-modulated broadband refocusing pulses.

Broadband linear-phase refocusing pulses were designed with the Shinnar-Le Roux (SLR) transformation and verified experimentally. The design works in several steps: initially, a linear-phase B polynomial is created with the Parks-McClellan/Remez exchange algorithm. The complementary A polynomial required for the SLR transformation is generated with the Hilbert transformation, yielding the minimum-phase response. The phase response of the A polynomial is altered by zero-flipping, which changes the overall pulse shape while retaining its refocusing profile. Optimal pulses in terms of minimal B(1max) and hence broadest bandwidth were found with non-linear optimisation of the zero-flipping pattern. These pulses are generally phase modulated with a time-symmetric amplitude and anti-symmetric phase modulation. In this work, a whole range of pulses were designed to demonstrate the underlying relationships. Five exemplary pulses were implemented into a PRESS sequence and validated by acquiring images of a water-oil phantom and lactate spectra at TE = 144 ms.