Publications by authors named "Pierre Michelet"

92 Publications

CD169 and CD64 could help differentiate bacterial from CoVID-19 or other viral infections in the Emergency Department.

Cytometry A 2021 Jan 25. Epub 2021 Jan 25.

Aix Marseille University, INSERM, INRAE, Marseille, France.

The identification of a bacterial, viral, or even noninfectious cause is essential in the management of febrile syndrome in the emergency department (ED), especially in epidemic contexts such as flu or CoVID-19. The aim was to assess discriminative performances of two biomarkers, CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169), using a new flow cytometry procedure, in patients presenting with fever to the ED during epidemics. Eighty five adult patients presenting with potential infection were included during the 2019 flu season in the ED of La Timone Hospital. They were divided into four diagnostic outcomes according to their clinical records: no-infection, bacterial infection, viral infection and co-infection. Seventy six patients with confirmed SARS-CoV-2 infection were also compared to 48 healthy volunteers. For the first cohort, 38 (45%) patients were diagnosed with bacterial infections, 11 (13%) with viral infections and 29 (34%) with co-infections. mCD169 was elevated in patients with viral infections, with a majority of Flu A virus or Respiratory Syncytial Virus, while nCD64 was elevated in subjects with bacterial infections, with a majority of Streptococcus pneumoniae and Escherichia coli. nCD64 and mCD169 showed 90% and 80% sensitivity, and 78% and 91% specificity, respectively, for identifying patients with bacterial or viral infections. When studied in a second cohort, mCD169 was elevated in 95% of patients with SARS-CoV-2 infections and remained at normal level in 100% of healthy volunteers. nCD64 and mCD169 have potential for accurately distinguishing bacterial and acute viral infections. Combined in an easy and rapid flow cytometry procedure, they constitute a potential improvement for infection management in the ED, and could even help for triage of patients during emerging epidemics.
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http://dx.doi.org/10.1002/cyto.a.24314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014466PMC
January 2021

Hemodynamic Profiles of Cardiogenic Shock Depending on Their Etiology.

J Clin Med 2020 Oct 22;9(11). Epub 2020 Oct 22.

Cardiology Department, APHM, Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Centre for CardioVascular and Nutrition Research (C2VN), Aix-Marseille Univ, INSERM 1263, INRA 1260, Hopital Nord, 13015 Marseille, France.

The pathophysiology of cardiogenic shock (CS) varies depending on its etiology, which may lead to different hemodynamic profiles (HP) and may help tailor therapy. We aimed to assess the HP of CS patients according to their etiologies of acute myocardial infarction (AMI) and acute decompensated chronic heart failure (ADCHF). We included patients admitted for CS secondary to ADCHF and AMI. HP were measured before the administration of any inotrope or vasopressor. Systemic Vascular Resistances index (SVRi), Cardiac Index (CI), and Cardiac Power Index (CPI) were measured by trans-thoracic Doppler echocardiography on admission. Among 37 CS patients, 28 had CS secondary to ADCHF or AMI and were prospectively included. The two groups were similar in terms of demographic data and shock severity criteria. AMI CS was associated with lower SVRi compared to CS related to ADCHF: 2010 (interquartile range (IQR): 1895-2277) vs. 2622 (2264-2993) dynes-s·cm·m ( = 0.002). A trend toward a higher CI was observed: respectively 2.13 (1.88-2.18) vs. 1.78 (1.65-1.96) L·min·m ( = 0.067) in AMICS compared to ADCHF. CS patients had different HP according to their etiologies. AMICS had lower SVR and tended to have a higher CI compared to ADHF CS. These differences should be taken into account for patient selection in future research.
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http://dx.doi.org/10.3390/jcm9113384DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690259PMC
October 2020

Comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed COVID-19 pneumonia.

Intensive Care Med 2020 09 29;46(9):1707-1713. Epub 2020 Jul 29.

Department of Anesthesiology and Intensive Care Medicine, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille University, 13015, Marseille, France.

Purpose: The relationship between lung ultrasound (LUS) and chest computed tomography (CT) scans in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is not clearly defined. The primary objective of our study was to assess the performance of LUS in determining severity of SARS-CoV-2 pneumonia compared with chest CT scan. Secondary objectives were to test the association between LUS score and location of the patient, use of mechanical ventilation, and the pulse oximetry (SpO)/fractional inspired oxygen (FiO) ratio.

Methods: A multicentre observational study was performed between 15 March and 20 April 2020. Patients in the Emergency Department (ED) or Intensive Care Unit (ICU) with acute dyspnoea who were PCR positive for SARS-CoV-2, and who had LUS and chest CT performed within a 24-h period, were included.

Results: One hundred patients were included. LUS score was significantly associated with pneumonia severity assessed by chest CT and clinical features. The AUC of the ROC curve of the relationship of LUS versus chest CT for the assessment of severe SARS-CoV-2 pneumonia was 0.78 (CI 95% 0.68-0.87; p < 0.0001). A high LUS score was associated with the use of mechanical ventilation, and with a SpO/FiO ratio below 357.

Conclusion: In known SARS-CoV-2 pneumonia patients, the LUS score was predictive of pneumonia severity as assessed by a chest CT scan and clinical features. Within the limitations inherent to our study design, LUS can be used to assess SARS-CoV-2 pneumonia severity.
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http://dx.doi.org/10.1007/s00134-020-06186-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388119PMC
September 2020

Cannabinoid hyperemesis syndrome in two French emergency departments: a prospective cohort.

Fundam Clin Pharmacol 2021 Feb 7;35(1):186-191. Epub 2020 Jul 7.

APHM, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Hôpital Sainte Marguerite, Service de Pharmacologie Clinique Centre antipoison et de Toxicovigilance, Aix Marseille Univ, Marseille, France.

Chronic cannabis use can be associated with uncontrollable vomiting and abdominal pain. Diagnostic criteria for cannabinoid hyperemesis syndrome (CHS) were defined in 2012 by Simonetto et al. The objectives of this study were to describe the prevalence of CHS, the patients' epidemiological characteristics, and to show the difficulties encountered in caring for these patients in emergency departments, the extent of health care and an unsuitable follow-up in general practices. A prospective cohort of patients with CHS was recruited among a target population of patients leaving the adult emergency services of the Marseille hospitals Nord and La Timone between October 2017 and July 2018, with abdominal pain syndrome of unidentified etiology. Inclusion criteria for the CHS cohort were chronic cannabis use associated with nausea and vomiting. There were 48 patients included in the CHS cohort who took cannabis daily, in a target population of 2 848 patients (i.e. 1.6%). A hot shower was the most effective symptomatic treatment in 54.2% of cases. Patients suffering from CHS spent significantly more hours in emergency departments (11 vs. 6.5), and, on average, visits were more frequent (4.9 vs. 3). 20.3% of them were hospitalized to continue pain medication. Once out of hospital, follow-up was limited, and weaning off cannabis, the only etiological treatment, was difficult to set up. Informing patients about CHS is essential, and a hot shower could be systematically proposed, thus limiting an unnecessary extent of health care. CHS is genuine, medical staff should be made aware of it in occupational training, and it should be seriously considered in health policies.
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http://dx.doi.org/10.1111/fcp.12580DOI Listing
February 2021

Outbreak of pneumococcal pneumonia among shipyard workers in Marseille, France, January to February 2020.

Euro Surveill 2020 03;25(11)

Aix Marseille University, IRD, AP-HM, SSA, VITROME, Marseille, France.

We report the third outbreak of pneumococcal pneumonia within one year among workers in European shipyards. During January and February 2020, 37 cases of pneumonia were identified in a shipyard in Marseille, south-eastern France. Outbreak control measures were implemented, including a mass vaccination campaign with 23-valent pneumococcal polysaccharide vaccine targeting all shipyard workers. Given the high mobility of shipyard workers, coordinated responses between European public health institutes are necessary to avoid further outbreaks.
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http://dx.doi.org/10.2807/1560-7917.ES.2020.25.11.2000162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7096773PMC
March 2020

Drowning Classification: A Reappraisal of Clinical Presentation and Prognosis for Severe Cases.

Chest 2020 Aug 14;158(2):596-602. Epub 2020 Feb 14.

Emergency Department, Timone University Hospital, Aix-Marseille University, Marseille, France.

Background: Drowning is still a major cause of accidental death worldwide. In 1997, Szpilman proposed a classification of drowning that has become the reference. As considerable efforts have been made to improve prevention and care, it seemed appropriate to reassess the prognosis and clinical presentation of drowning patients more than 20 years after this first publication. The aim of this study is to provide a reappraisal of patients who need advanced health care and a precise description of their respective neurologic, respiratory, and hemodynamic profiles.

Methods: This retrospective study was conducted over four consecutive summer periods between 2014 and 2017 in ICUs located in France, French Polynesia, and the French Antilles. Patients were classified according to the drowning classification system proposed by Szpilman.

Results: During the study period, 312 drowning patients were admitted with severe clinical presentation (grades 2-6). All patients benefited from rapid extraction from the water (< 10 min for all) and specialized care (emergency medical services), starting from the prehospital period. Although the global hospital mortality was similar to that previously reported (18.5%), great differences existed among the severity grades. Respective grade mortalities were low for grades 2 through 5 (grade 2, 0%; grade 3, 3%; grade 4, 0%; grade 5, 2%), and the mortality for grade 6 remained similar to that previously reported (54%). These results confirmed that the occurrence of cardiac arrest after drowning is still bad prognosis. Conversely, for other grades, this study strengthens the importance of specialized intervention to interrupt the drowning process.

Conclusions: On the basis of these results, drowning-related cardiac arrest is still the prognosis cornerstone. For other victims, the prognosis was better than previously expected, which strengthens the importance of specialized intervention to interrupt the drowning process.
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http://dx.doi.org/10.1016/j.chest.2020.01.035DOI Listing
August 2020

Flow cytometry evaluation of infection-related biomarkers in febrile subjects in the emergency department.

Future Microbiol 2020 02 17;15:189-201. Epub 2020 Feb 17.

Adult Emergency Unit, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France.

In an Emergency Department (ED), the etiological identification of infected subjects is essential. 13 infection-related biomarkers were assessed using a new flow cytometry procedure. If subjects presented with febrile symptoms at the ED, 13 biomarkers' levels, including CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169), were tested and compared with clinical records. Among 50 subjects, 78% had bacterial infections and 8% had viral infections. nCD64 showed 82% sensitivity and 91% specificity for identifying subjects with bacterial infections. mCD169, HLA-ABC ratio and HLA-DR on monocytes had high values in subjects with viral infections. Biomarkers showed promising performances to improve the ED's infectious stratification.
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http://dx.doi.org/10.2217/fmb-2019-0256DOI Listing
February 2020

Complications of peripheral venous catheters: The need to propose an alternative route of administration.

Int J Antimicrob Agents 2020 Mar 8;55(3):105875. Epub 2020 Jan 8.

IHU-Méditerranée Infection, Marseille, France; Aix-Marseille Université, IRD, AP-HM, MEPHI, Marseille, France. Electronic address:

Use of peripheral venous catheters (PVCs) is very common in hospitals. According to the literature, after a visit to the emergency department >75% of hospitalised patients carry a PVC, among which almost 50% are useless. In this study, the presence and complications of PVCs in an infectious diseases (ID) unit of a French tertiary-care university hospital were monitored. A total of 614 patients were prospectively included over a 6-month period. Among the 614 patients, 509 (82.9%) arrived in the ID unit with a PVC, of which 260 (51.1%) were judged unnecessary and were removed as soon as the patients were examined by the ID team. More than one-half of PVCs were removed within 24 h in the unit (308/509; 60.5%). PVCs were complicated for 65 (12.8%) of the 509 patients, with complications including extravasation, cutaneous necrosis, lymphangitis, phlebitis, tearing off the patient, superficial venous thrombosis and arthritis. We must therefore continue to search for unjustified PVC insertion. Alternatives to the intravenous administration route must be proposed, such as subcutaneous infusion or oral antibiotic therapy.
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http://dx.doi.org/10.1016/j.ijantimicag.2020.105875DOI Listing
March 2020

Contribution of Capillary Refilling Time and Skin Mottling Score to Predict ICU Admission of Patients with Septic or haemorrhagic Shock Admitted to the Emergency Department: A TRCMARBSAU Study.

Turk J Anaesthesiol Reanim 2019 Dec 15;47(6):492-495. Epub 2019 Aug 15.

Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.

Objective: In the emergency department (ED), the severity assessment of shock is a fundamental step prior to the admission in the intensive care unit (ICU). As biomarkers are time consuming to evaluate the severity of micro- and macro-circulation alteration, capillary refill time and skin mottling score are two simple, available clinical criteria validated to predict mortality in the ICU. The aim of the present study is to provide clinical evidence that capillary refill time and skin mottling score assessed in the ED also predict ICU admission of patients with septic or haemorrhagic shock.

Methods: This trial is an observational, non-randomised controlled study. A total of 1500 patients admitted to the ED for septic or haemorrhagic shock will be enrolled into the study. The primary outcome is the admission to the ICU.

Results: The study will not impact the treatments provided to each patient. Capillary refill time and skin mottling score will not be taken into account to decide patient's treatments and/or ICU admission. Patients will be followed up during their hospital stay to determine their precise destination after the ED (home, ICU or ward) and the 28- and 90-day mortality after hospital admission.

Conclusion: The results from the present study will provide clinical evidence on the correlation between the ICU admission and the capillary refill time and the skin mottling score in septic or haemorrhagic shock admitted to the ED. The aim of the present study is to provide two simple, reliable and non-invasive tools for the triage and early orientation of these patients.
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http://dx.doi.org/10.5152/TJAR.2019.28459DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6886826PMC
December 2019

Clinical research assessment by flow cytometry of biomarkers for infectious stratification in an Emergency Department.

Biomark Med 2019 11 16;13(16):1373-1386. Epub 2019 Oct 16.

Adult Emergency Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France.

Management of patients with infections within the Emergency Department (ED) is challenging for practitioners, as the identification of infectious causes remains difficult with current techniques. A new combination of two biomarkers was tested with a new rapid flow cytometry technique. Subjects from the ED were tested for their CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169) levels and results were compared to their clinical records. Among 139 patients, 29% had confirmed bacterial infections and 5% viral infections. nCD64 and mCD169 respectively showed 88 and 86% sensitivity and 90 and 100% specificity for identifying subjects in bacterial or viral conditions. This point-of-care technique could allow better management of patients in the ED.
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http://dx.doi.org/10.2217/bmm-2019-0214DOI Listing
November 2019

Stress and burnout among professionals working in the emergency department in a French university hospital: Prevalence and associated factors.

Work 2019 ;63(1):57-67

EA 3279 - Public Health, Chronic Diseases and Quality of Life Research Unit, Aix-Marseille University, Marseille, France.

Background: Work-related stress is a significant health and safety concern.

Objectives: To assess the prevalence of burnout and occupational stress among emergency department (ED) professionals and to identify associated factors.

Methods: A cross-sectional study included all ED professionals of a French university hospital. Data were collected using the French versions of the Maslach Burnout Inventory and the Karasek Job Content Questionnaire.

Results: Of the 166 respondents (75.8%), 19.3% reported burnout and 27.1% job strain. Factors associated with burnout were work-related dissatisfaction, fear of making mistakes, lack of time to perform tasks, and being younger. Those factors associated with job strain were having at least one sick leave in the past year, being affected by hard work, interpersonal conflicts at workplace, and sleep disorders.

Conclusions: Compared to the literature, our results showed a lower prevalence of burnout among physicians but similar among paramedics. The proportion of professionals with job strain was higher than that of the whole French working population. Organizational factors and the work environment were the primary causes of burnout and job strain, while being younger was the only associated sociodemographic factor. The identification of professionals experiencing difficulty is essential to ensure patient safety, particularly in the high-risk field of emergency medicine.
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http://dx.doi.org/10.3233/WOR-192908DOI Listing
July 2019

Burnout Syndrome among Emergency Department Staff: Prevalence and Associated Factors.

Biomed Res Int 2019 21;2019:6462472. Epub 2019 Jan 21.

Equipe de Recherche EA 3279 "Santé Publique, Maladies Chroniques et Qualité de Vie", Faculté de Médecine, Aix-Marseille Université, 27 boulevard Jean Moulin, 13 385 Marseille Cedex 5, France.

Objectives: Emergency department (ED) professionals are exposed to burnout syndrome due to excessive workload and high demands for care. The objective of our study was to assess the prevalence burnout among all ED staff and to determine associated factors.

Methods: A cross-sectional survey was conducted in 3 EDs. The data were collected using a standardized questionnaire. It included demographical and occupational data, general health questions, burnout level (Maslach Burnout Inventory), job strain (Karasek), and quality of life (Medical Outcome Study Short Form).

Results: Of the 529 professionals working in EDs, 379 responses were collected (participation rate of 71.6%). Emotional exhaustion (EE) and depersonalization (DP), the major components of burnout, were reported, respectively, by 15.8% and 29.6% of the professionals. Burnout prevalence was 34.6%, defined as a severely abnormal level of either EE or DP. The medical category was significantly more affected by the burnout compared with their colleagues: nearly one ED physician out of two had a burnout (50.7%). In the multivariate analysis of covariance, job strain and a low mental component score were the two main factors independently associated with burnout (p < 0.05).

Conclusion: The results of our study show that ED professionals are a vulnerable group. Preventive approaches to stress and burnout are needed to promote quality of work life.
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http://dx.doi.org/10.1155/2019/6462472DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6360614PMC
June 2019

Patterns of invasive mechanical ventilation in patients with severe blunt chest trauma and lung contusion: A French multicentric evaluation of practices.

J Intensive Care Soc 2019 Feb 3;20(1):46-52. Epub 2018 Apr 3.

UMR MD2, Aix-Marseille University, School of Medicine, Marseille, France.

Introduction: This study investigated invasive mechanical ventilation modalities used in severe blunt chest trauma patients with pulmonary contusion. Occurrence, risk factors, and outcomes of early onset acute respiratory distress syndrome were also evaluated.

Methods: We performed a retrospective multicenter observational study including 115 adult patients hospitalized in six level 1 trauma intensive care units between April and September of 2014. Independent predictors of early onset acute respiratory distress syndrome were determined by multiple logistic regression analysis based on clinical characteristics and initial management.

Results: Protective ventilation principles were highly implemented, even prophylactically before acute respiratory distress syndrome occurrence. Early onset acute respiratory distress syndrome appeared to be associated with lung contusion of >20% of total lung volume and early onset pneumonia.

Conclusions: Predictors of early onset acute respiratory distress syndrome could help with identifying high-risk populations, potentially improving case management through specific protocol development for these patients.
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http://dx.doi.org/10.1177/1751143718767060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6376572PMC
February 2019

Real-time estimation of inpatient beds required in emergency departments.

Eur J Emerg Med 2019 Dec;26(6):440-445

Regional Emergency Department Network PACA, Hyères.

Background: Long boarding time in emergency department (ED) leads to increased morbidity and mortality. Prediction of admissions upon triage could improve ED care efficiency and decrease boarding time.

Objective: To develop a real-time automated model (MA) to predict admissions upon triage and compare this model with triage nurse prediction (TNP).

Patients And Methods: A cross-sectional study was conducted in four EDs during 1 month. MA used only variables available upon triage and included in the national French Electronic Emergency Department Abstract. For each patient, the triage nurse assessed the hospitalization risk on a 10-point Likert scale. Performances of MA and TNP were compared using the area under the receiver operating characteristic curves, the accuracy, and the daily and hourly mean difference between predicted and observed number of admission.

Results: A total of 11 653 patients visited the EDs, and 19.5-24.7% were admitted according to the emergency. The area under the curves (AUCs) of TNP [0.815 (0.805-0.826)] and MA [0.815 (0.805-0.825)] were similar. Across EDs, the AUCs of TNP were significantly different (P < 0.001) in all EDs, whereas AUCs of MA were all similar (P>0.2). Originally, using daily and hourly aggregated data, the percentage of errors concerning the number of predicted admission were 8.7 and 34.4%, respectively, for MA and 9.9 and 35.4%, respectively, for TNP.

Conclusion: A simple model using variables available in all EDs in France performed well to predict admission upon triage. However, when analyzed at an hourly level, it overestimated the number of inpatient beds needed by a third. More research is needed to define adequate use of these models.
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http://dx.doi.org/10.1097/MEJ.0000000000000600DOI Listing
December 2019

A lung ultrasound score for early triage of elderly patients with acute dyspnea.

CJEM 2019 05 25;21(3):399-405. Epub 2019 Jan 25.

*Department of Emergency Medicine and Intensive Care,Timone University Hospital,Marseille,France.

Objectives: Lung ultrasound has value in diagnosing dyspnea. The main objective of this study was to evaluate the accuracy of a modified lung ultrasound (MLUS) score to predict the severity of acute dyspnea in elderly patients.

Methods: This was an observational single-centre study including patients over age 64 admitted to the emergency department for acute dyspnea with hypoxia. Participants had an early lung ultrasound performed by a dedicated emergency physician, followed by the usual care by a team blinded to the lung ultrasound results. Patients were allocated by disposition to either a critical care (CC) group (patients who needed admission to the intensive care unit [ICU] and/or who died within 48 h) or a standard care group.

Results: Among 137 patients analysed (mean age 79 ± 13 years, 74 [54%] women), 43 (31%) were categorized into the CC group. The time taken to obtain the MLUS was 30 ± 22 min. The area under the receiver operating characteristic curve of the MLUS for predicting the CC group was 0.97 (0.92-0.99; p < 0.01) with a cut-off set strictly above 17 for 93% sensitivity (81-99), 99% specificity (94-100), a positive predictive value of 98% (87-100), a negative predictive value of 97% (91-99), a positive likelihood ratio of 86, a negative likelihood ratio of 0.07, and a diagnostic accuracy of 97% (93-99). In a multivariate analysis, the MLUS was the only independent associated factor for the CC group.

Conclusion: An early lung ultrasound score can predict the need for ICU admission and/or death within 48 hours in elderly dyspneic patients.
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http://dx.doi.org/10.1017/cem.2018.483DOI Listing
May 2019

Adenosine plasma level in patients with paroxysmal or persistent atrial fibrillation and normal heart during ablation procedure and/or cardioversion.

Purinergic Signal 2019 03 7;15(1):45-52. Epub 2018 Dec 7.

Department of Cardiology, Timone University Hospital, 13005, Marseille, France.

The mechanism of atrial fibrillation (AF) in patients with normal heart remains unclear. While exogenous adenosine can trigger AF, nothing is known about the behavior of endogenous adenosine plasma level (APL) at the onset of AF and during ablation procedure. Ninety-one patients (68 with paroxysmal AF: 40 males, 66 ± 16 years; 23 with persistent AF: 14 males, 69 ± 11 years) and 18 controls were included. Among paroxysmal patients: i) medical therapy alone was performed in 45 cases and ablation procedure in 23. AF was spontaneously resolutive in 6 cases; ii) 23 underwent ablation procedure and blood was collected simultaneously in a brachial vein and in the left atrium; 17 were spontaneously in sinus rhythm while 6 were in sinus rhythm after direct current cardioversion. Among persistent patients: i) in 17 patients, blood samples were collected in a brachial vein before and after direct current cardioversion; ii) in 6 patients, blood samples were collected simultaneously in a brachial vein and in left atrium before and after cardioversion during ablation procedure. CV-APL was higher in patients with persistent AF vs patients with paroxysmal AF (median [range]: 0.9[0.6-1.1] vs 0.7[0.4-1.1] μM; p < 0.001). In patients with paroxysmal AF, LA-APL increased during the AF episode (0.95[0.85-1.4] vs 2.7[1.5-7] μM; p = 0.03) and normalized in sinus rhythm after DCCV. In patients with persistent AF, LA-APL was higher than CV-APL (1.2[0.7-1.8] vs 0.9[0.6-1.1] μM; p < 0.001), and both normalized in sinus rhythm (CV-APL: 0.8[0.6-1.1] vs 0.75[0.4-1] μM; p = 0.03), (LA-APL: 1.95[1.3-3] vs 1[0.5-1.15] μM; p = 0.03). The occurrence of AF is associated with a strong increase of APL in the atrium. The cause of this increase needs further investigations.
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http://dx.doi.org/10.1007/s11302-018-9636-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439011PMC
March 2019

Process and organisation of in-hospital emergencies in France.

Anaesth Crit Care Pain Med 2018 12 9;37(6):629-631. Epub 2018 Oct 9.

Emergency department, Timone 2 hospital, Aix-Marseille university, 13000 Marseille, France.

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http://dx.doi.org/10.1016/j.accpm.2018.07.010DOI Listing
December 2018

Physicians' experience in decisions of withholding and withdrawing life-sustaining treatments: A multicenter survey into emergency departments.

Anaesth Crit Care Pain Med 2018 12 27;37(6):633-634. Epub 2018 Sep 27.

UMR 7268 ADéS Aix-Marseille université, EFS, CNRS, efaculté de médecine de Marseille , hôpital adultes La Timone, 27, boulevard Jean-Moulin 13005 Marseille, France. Electronic address:

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http://dx.doi.org/10.1016/j.accpm.2018.09.007DOI Listing
December 2018

Corrigendum to "Stress Cardiomyopathy Managed with Extracorporeal Support after Self-Injection of Epinephrine".

Case Rep Crit Care 2018 9;2018:3121408. Epub 2018 Aug 9.

Réanimation des Urgences et Médicale, Assistance Publique Hôpitaux de Marseille, CHU la Timone 2, Aix-Marseille Université, Marseille, France.

[This corrects the article DOI: 10.1155/2017/3731069.].
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http://dx.doi.org/10.1155/2018/3121408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6106969PMC
August 2018

Drowning in fresh or salt water: respective influence on respiratory function in a matched cohort study.

Eur J Emerg Med 2019 Oct;26(5):340-344

Emergency Department, Timone University Hospital.

Introduction: For the most severe drowned patients, hypoxemia represents one of the major symptoms. As the influence of the type of water (fresh or salt water) on respiratory function is still unclear, the primary endpoint of this multicenter study was to compare hypoxemia according to the type of water.

Methods: Medical records of adult patients who experienced a drowning event and were consequently admitted to 10 ICU for acute respiratory failure were analyzed retrospectively using data collected over three consecutive summer periods. From an initial cohort of acute respiratory failure drowned patients, patients were matched by age, sex, Glasgow Coma Scale, and occurrence of cardiac arrest (yes or no).

Results: Among an initial cohort of 242 patients, 38 pairs were matched correctly. At the initial assessment, carried out upon ICU admission, hypoxemia was found to be deeper in the fresh water group (PaO2/FiO2: 141 ± 76 vs. 220 ± 122, P < 0.05). However, there was no significant difference in tissue oxygenation (assessed by blood lactate level) between groups. In terms of biology results, sodium levels were higher in the salt water group in the initial assessment (144 ± 6.8 vs. 140 ±5.2 mmol/l, P = 0.004), but no difference was observed later. No difference was recorded in the outcome or length of stay in ICU between groups.

Conclusion: Drowning in fresh water was associated with deeper hypoxemia in the initial assessment. Despite this initial difference, latter respiratory and biological parameters or outcome were similar in both groups.
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http://dx.doi.org/10.1097/MEJ.0000000000000564DOI Listing
October 2019

Unmanned aerial vehicles (drones) to prevent drowning.

Resuscitation 2018 06 10;127:63-67. Epub 2018 Apr 10.

Emergency Department, Hôpital de la Timone, UMR MD2 P2COE, Aix-Marseille Université, Marseille, France. Electronic address:

Background: Drowning literature have highlighted the submersion time as the most powerful predictor in assessing the prognosis. Reducing the time taken to provide a flotation device and prevent submersion appears of paramount importance. Unmanned aerial vehicles (UAVs) can provide the location of the swimmer and a flotation device.

Objective: The objective of this simulation study was to evaluate the efficiency of a UAV in providing a flotation device in different sea conditions, and to compare the times taken by rescue operations with and without a UAV (standard vs UAV intervention). Several comparisons were made using professional lifeguards acting as simulated victims. A specifically-shaped UAV was used to allow us to drop an inflatable life buoy into the water.

Results: During the summer of 2017, 28 tests were performed. UAV use was associated with a reduction of time it took to provide a flotation device to the simulated victim compared with standard rescue operations (p < 0.001 for all measurements) and the time was reduced even further in moderate (81 ± 39 vs 179 ± 78 s; p < 0.001) and rough sea conditions (99 ± 34 vs 198 ± 130 s; p < 0.001). The times taken for UAV to locate the simulated victim, identify them and drop the life buoy were not altered by the weather conditions.

Conclusion: UAV can deliver a flotation device to a swimmer safely and quickly. The addition of a UAV in rescue operations could improve the quality and speed of first aid while keeping lifeguards away from dangerous sea conditions.
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http://dx.doi.org/10.1016/j.resuscitation.2018.04.005DOI Listing
June 2018

Early versus delayed invasive strategy for intermediate- and high-risk acute coronary syndromes managed without P2Y receptor inhibitor pretreatment: Design and rationale of the EARLY randomized trial.

Clin Cardiol 2018 Jan 22;41(1):5-12. Epub 2018 Jan 22.

Aix-Marseille Université, AP-HM, Unité INSERM 1076, Unité de Soins Intensifs Cardiologiques, Department of Cardiology, Hôpital Nord, Marseille, France.

According to recent literature, pretreatment with a P2Y ADP receptor antagonist before coronary angiography appears no longer suitable in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) due to an unfavorable risk-benefit ratio. Optimal delay of the invasive strategy in this specific context is unknown. We hypothesize that without P2Y ADP receptor antagonist pretreatment, a very early invasive strategy may be beneficial. The EARLY trial (Early or Delayed Revascularization for Intermediate- and High-Risk Non-ST-Segment Elevation Acute Coronary Syndromes?) is a prospective, multicenter, randomized, controlled, open-label, 2-parallel-group study that plans to enroll 740 patients. Patients are eligible if the diagnosis of intermediate- or high-risk NSTE-ACS is made and an invasive strategy intended. Patients are randomized in a 1:1 ratio. In the control group, a delayed strategy is adopted, with the coronary angiography taking place between 12 and 72 hours after randomization. In the experimental group, a very early invasive strategy is performed within 2 hours. A loading dose of a P2Y ADP receptor antagonist is given at the time of intervention in both groups. Recruitment began in September 2016 (n = 558 patients as of October 2017). The primary endpoint is the composite of cardiovascular death and recurrent ischemic events at 1 month. The EARLY trial aims to demonstrate the superiority of a very early invasive strategy compared with a delayed strategy in intermediate- and high-risk NSTE-ACS patients managed without P2Y ADP receptor antagonist pretreatment.
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http://dx.doi.org/10.1002/clc.22852DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6490048PMC
January 2018

Stress Cardiomyopathy Managed with Extracorporeal Support after Self-Injection of Epinephrine.

Case Rep Crit Care 2017 27;2017:3731069. Epub 2017 Aug 27.

Réanimation des Urgences et Médicale, Assistance Publique Hôpitaux de Marseille, CHU la Timone 2, Aix-Marseille Université, Marseille, France.

A 28-year-old man was admitted to the ICU for self-injection of Epinephrine. This injection resulted in the rapid development of a catecholamine-induced cardiomyopathy (inverted Takotsubo) with a severe cardiogenic shock. The importance of ventricular dysfunction required the implementation of a temporary arteriovenous circulatory support until the recovery of myocardial stunning. This case allows redefining the role of circulatory assistance during cardiotropic agents intoxication.
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http://dx.doi.org/10.1155/2017/3731069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5592012PMC
August 2017

Hospital and out-of-hospital mortality in 670 hypertensive emergencies and urgencies.

J Clin Hypertens (Greenwich) 2017 Nov 3;19(11):1137-1142. Epub 2017 Sep 3.

Unité d'Hypertension Artérielle, Assistance Publique Hôpitaux de Marseille - Hôpital de la Timone, Marseille, France.

Long-term mortality in patients with acute severe hypertension is unclear. The authors aimed to compare short-term (hospital) and long-term (12 months) mortality in these patients. A total of 670 adults presenting for acute severe hypertension between January 1, 2015, and December 31, 2015, were included. A total of 57.5% were hypertensive emergencies and 66.1% were hospitalized: 98% and 23.2% of those with hypertensive emergencies and urgencies, respectively (P = .001). Hospital mortality was 7.9% and was significantly higher for hypertensive emergencies (12.5% vs 1.8%, P = .001). At 12 months, 106 patients died (29.4%), mainly from hypertensive emergencies (38.9% vs 8.9%, P = .001). Median survival was 14 days for neurovascular emergencies and 50 days for cardiovascular emergencies. Patients with hypertensive emergencies or urgencies had bad long-term prognosis. Short-term mortality is mainly caused by neurovascular emergencies, but cardiovascular emergencies are severe, with high mortality at 12 months. These results justify better follow-up and treatment for these patients.
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http://dx.doi.org/10.1111/jch.13083DOI Listing
November 2017

From Expert Protocols to Standardized Management of Infectious Diseases.

Clin Infect Dis 2017 Aug;65(suppl_1):S12-S19

Aix Marseille Université, CNRS 7278, IRD 198, INSERM 1095, URMITE.

We report here 4 examples of management of infectious diseases (IDs) at the University Hospital Institute Méditerranée Infection in Marseille, France, to illustrate the value of expert protocols feeding standardized management of IDs. First, we describe our experience on Q fever and Tropheryma whipplei infection management based on in vitro data and clinical outcome. Second, we describe our management-based approach for the treatment of infective endocarditis, leading to a strong reduction of mortality rate. Third, we report our use of fecal microbiota transplantation to face severe Clostridium difficile infections and to perform decolonization of patients colonized by emerging highly resistant bacteria. Finally, we present the standardized management of the main acute infections in patients admitted in the emergency department, promoting antibiotics by oral route, checking compliance with the protocol, and avoiding the unnecessary use of intravenous and urinary tract catheters. Overall, the standardization of the management is the keystone to reduce both mortality and morbidity related to IDs.
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http://dx.doi.org/10.1093/cid/cix403DOI Listing
August 2017

WITHDRAWN: Chest Trauma: First 48 hours management.

Anaesth Crit Care Pain Med 2017 Jan 18. Epub 2017 Jan 18.

Services des Urgences Adultes, Hôpital de la Timone, UMR MD2 - Aix Marseille Université, Marseille, France.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in , http://dx.doi.org/10.1016/j.accpm.2017.01.003 . The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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http://dx.doi.org/10.1016/j.accpm.2017.01.004DOI Listing
January 2017

Chest trauma: First 48hours management.

Anaesth Crit Care Pain Med 2017 Apr 16;36(2):135-145. Epub 2017 Jan 16.

France.

Chest trauma remains an issue for health services for both severe and apparently mild trauma management. Severe chest trauma is associated with high mortality and is considered liable for 25% of mortality in multiple traumas. Moreover, mild trauma is also associated with significant morbidity especially in patients with preexisting conditions. Thus, whatever the severity, a fast-acting strategy must be organized. At this time, there are no guidelines available from scientific societies. These expert recommendations aim to establish guidelines for chest trauma management in both prehospital an in hospital settings, for the first 48hours. The "Société française d'anesthésie réanimation" and the "Société française de médecine d'urgence" worked together on the 7 following questions: (1) criteria defining severity and for appropriate hospital referral; (2) diagnosis strategy in both pre- and in-hospital settings; (3) indications and guidelines for ventilatory support; (4) management of analgesia; (5) indications and guidelines for chest tube placement; (6) surgical and endovascular repair indications in blunt chest trauma; (7) definition, medical and surgical specificity of penetrating chest trauma. For each question, prespecified "crucial" (and sometimes also "important") outcomes were identified by the panel of experts because it mattered for patients. We rated evidence across studies for these specific clinical outcomes. After a systematic Grade approach, we defined 60 recommendations. Each recommendation has been evaluated by all the experts according to the DELPHI method.
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http://dx.doi.org/10.1016/j.accpm.2017.01.003DOI Listing
April 2017

Timing of Coronary Invasive Strategy in Non-ST-Segment Elevation Acute Coronary Syndromes and Clinical Outcomes: An Updated Meta-Analysis.

JACC Cardiovasc Interv 2016 11;9(22):2267-2276

EA 3279-Public Health, Chronic Diseases and Quality of Life-Research Unit, Aix-Marseille University, Marseille, France.

Objectives: The aim of this study was to compare an early versus a delayed invasive strategy in non-ST-segment elevation acute coronary syndromes by performing a meta-analysis of all available randomized controlled clinical trials.

Background: An invasive approach is recommended to prevent death and myocardial infarction in non-ST-segment elevation acute coronary syndromes. However, the timing of angiography and the subsequent intervention, when required, remains controversial.

Methods: A previous meta-analysis of 7 randomized clinical trials comparing early and delayed invasive strategies in non-ST-segment elevation acute coronary syndromes with 3 new randomized clinical trials identified in a search of the published research (n = 10 trials, n = 6,397 patients) was updated.

Results: The median time between randomization and angiography ranged from 0.5 to 14.0 h in the early group and from 18.3 to 86.0 h in the delayed group. There was no difference in the primary endpoint of mortality (4% vs. 4.7%; random-effects odds ratio [OR]: 0.85; 95% confidence interval [CI]: 0.67 to 1.09; p = 0.20; I = 0%). The rate of myocardial infarction was also similar (6.7% vs. 7.7%; random-effects OR: 0.88; 95% CI: 0.53 to 1.45; p = 0.62; I = 77.5%). An early strategy was associated with a reduction in recurrent ischemia or refractory angina (3.8% vs. 5.8%; random-effects OR: 0.54; 95% CI: 0.40 to 0.74; p < 0.01; I = 28%) and a shorter in-hospital stay (median 112 h [interquartile range: 61 to 158 h] vs. 168 h [interquartile range: 90.3 to 192 h]; random-effects standardized mean difference -0.40; 95% CI: -0.59 to -0.21; p < 0.01; I = 79%). Major bleeding was similar in the 2 groups (3.9% vs. 4.2%; random-effects OR: 0.94; 95% CI: 0.73 to 1.22; p = 0.64; I = 0%).

Conclusions: An early invasive strategy does not reduce the risk for death or myocardial infarction compared with a delayed strategy. Recurrent ischemia and length of stay were significantly reduced with an early invasive strategy.
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http://dx.doi.org/10.1016/j.jcin.2016.09.017DOI Listing
November 2016

Short-term effects of low-volume resuscitation with hypertonic saline and hydroxyethylstarch in an experimental model of lung contusion and haemorrhagic shock.

Anaesth Crit Care Pain Med 2018 Apr 20;37(2):135-140. Epub 2016 Sep 20.

UMR MD2 "Dysoxie et Suractivité", Aix-Marseille University, School of Medicine, 13000 Marseille, France; Department of Emergency Medicine and Intensive Care, Timone University Hospital, 13000 Marseille, France.

Objectives: This study aimed to assess the short-term respiratory tolerance and haemodynamic efficiency of low-volume resuscitation with hypertonic saline and hydroxyethylstarch (HS/HES) in a pig model of lung contusion and controlled haemorrhagic shock. We hypothesised that a low-volume of HS/HES after haemorrhagic shock did not impact contused lungs in terms of extravascular lung water 3hours after trauma.

Methods: A lung contusion resulting from blunt chest trauma was induced in 28 anaesthetised female pigs with five bolt-shots to the right thoracic cage, followed by haemorrhagic shock and fluid resuscitation. Pigs were randomly allocated into two groups: fluid resuscitation by 4ml/kg of HS/HES, or fluid resuscitation by 10ml/kg of normal saline (NS). Monitoring was based on transpulmonary thermodilution and a pulmonary artery catheter. After 3h, animals were euthanized to measure extravascular lung water (EVLW) by gravimetry.

Results: Blunt chest trauma was followed by a transient collapse and hypoxaemia in both groups. Post-mortem gravimetric assessment demonstrated a significant difference between EVLW in the NS-group (8.1±0.7ml/kg) and in the HS/HES-group (6.2±0.6ml/kg, P=0.038). Based on a pathological EVLW threshold of > 7ml/kg, results indicated that only the NS-group experienced moderate pulmonary oedema, contrary to the HS/HES-group. After haemorrhagic shock, HS/HES infusion enabled the restoration of effective mean arterial pressure and cardiac index. Intrapulmonary shunting increased transiently after fluid resuscitation but there was no significant impairment of oxygenation.

Conclusion: In this pig model of lung contusion, the short-term assessment of fluid resuscitation after haemorrhagic shock with 4ml/kg of HS/HES showed that pulmonary oedema was avoided compared to fluid resuscitation with 10ml/kg of NS.
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http://dx.doi.org/10.1016/j.accpm.2016.05.010DOI Listing
April 2018

Prehospital and in-hospital course of care for patients with acute heart failure: Features and impact on prognosis in "real life".

Arch Cardiovasc Dis 2017 Feb 29;110(2):72-81. Epub 2016 Sep 29.

Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille (AP-HM), Unit of Heart Failure and Valvular Heart Disease, Department of Cardiology, Nord Hospital, 13915 Marseille cedex 20, France; Mediterranean Academic association for Research and Studies in Cardiology (MARS Cardio), Marseille, France. Electronic address:

Background: Acute heart failure (AHF) is a life-threatening medical emergency for which no new effective therapies have emerged in recent decades. No previous study has exhaustively described the entire course of care of AHF patients from first medical contact to hospital discharge or assessed its impact on prognosis.

Aim: To fully describe the course of care and analyze its influence on outcomes in patients hospitalized with an AHF syndrome in an academic university center.

Methods: One hundred and nineteen adults with AHF from three public academic university hospitals were consecutively enrolled in a multicenter prospective observational cohort study. All of the emergency departments, intensive care units, coronary care units, cardiology wards and other medical wards participated in the study.

Results: The composite primary outcome (6-month rate of cardiovascular death, readmission for acute heart failure, acute coronary syndrome or stroke) occurred in 59% of patients. This rate was high and similar regardless of first medical contact, type of transport, first medical department of admission and number of medical departments involved in the course of care. A cardiologist was involved in management in 80% of cases. The global median hospital stay was shorter with cardiology vs non-cardiology management (7 days [interquartile range 4-11] vs 10 days [interquartile range 7-18]; P=0.003). History of hypertension (P=0.004), need for non-invasive ventilation (P=0.023) and Lee prognostic score (P=0.028) were independently associated with the primary outcome.

Conclusions: Morbimortality and readmissions were high regardless of the course of care in patients admitted for AHF in real life. The reduction in hospital stay when cardiologists were involved in management encourages the creation of "mobile AHF cardiology teams".
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http://dx.doi.org/10.1016/j.acvd.2016.05.004DOI Listing
February 2017