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Montalescot G.,Institut Universitaire de France | Zeymer U.,Herzzentrum Klinikum Ludwigshafen | Silvain J.,Institut Universitaire de France | Boulanger B.,SAMU | And 19 more authors.
The Lancet | Year: 2011

Background Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction has traditionally been supported by unfractionated heparin, which has never been directly compared with a new anticoagulant using consistent anticoagulation and similar antiplatelet strategies in both groups. We compared traditional heparin treatment with intravenous enoxaparin in primary PCI. Methods In a randomised open-label trial, patients presenting with ST-elevation myocardial infarction were randomly assigned (1:1) to receive an intravenous bolus of 0·5 mg/kg of enoxaparin or unfractionated heparin before primary PCI. Wherever possible, medical teams travelling in mobile intensive care units (ambulances) selected, randomly assigned (using an interactive voice response system at the central randomisation centre), and treated patients. Patients who had received any anticoagulant before randomisation were excluded. Patients and caregivers were not masked to treatment allocation. The primary endpoint was 30-day incidence of death, complication of myocardial infarction, procedure failure, or major bleeding. The main secondary endpoint was the composite of death, recurrent acute coronary syndrome, or urgent revascularisation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT00718471. Findings 910 patients were assigned to treatment with enoxaparin (n=450) or unfractionated heparin (n=460). The primary endpoint occurred in 126 (28) patients after anticoagulation with enoxaparin versus 155 (34) patients on unfractionated heparin (relative risk [RR] 0·83, 95 CI 0·68-1·01, p=0·06). The incidence of death (enoxaparin, 17 [4] vs heparin, 29 [6] patients; p=0·08), complication of myocardial infarction (20 [4] vs 29 [6]; p=0·21), procedure failure (100 [26] vs 109 [28]; p=0·61), and major bleeding (20 [5] vs 22 [5]; p=0·79) did not differ between groups. Enoxaparin resulted in a significantly reduced rate of the main secondary endpoint (30 [7] vs 52 [11] patients; RR 0·59, 95 CI 0·38-0·91, p=0·015). Death, complication of myocardial infarction, or major bleeding (46 [10] vs 69 [15] patients; p=0·03), death or complication of myocardial infarction (35 [8] vs 57 [12]; p=0·02), and death, recurrent myocardial infarction, or urgent revascularisation (23 [5] vs 39 [8]; p=0·04) were all reduced with enoxaparin. Interpretation Intravenous enoxaparin compared with unfractionated heparin significantly reduced clinical ischaemic outcomes without differences in bleeding and procedural success. Therefore, enoxaparin provided an improvement in net clinical benefit in patients undergoing primary PCI. Funding Direction de la Recherche Clinique, Assistance Publique-Hôpitaux de Paris; Sanofi-Aventis. © 2011 Elsevier Ltd.


The aims of the study are to compare the outcome with and without major bleeding and to identify the independent correlates of major bleeding complications and mortality in patients described in the ATOLL study.The ATOLL study included 910 patients randomly assigned to either 0.5 mg/kg intravenous enoxaparin or unfractionated heparin before primary percutaneous coronary intervention. Incidence of major bleeding and ischemic end points was assessed at 1 month, and mortality, at 1 and 6 months. Patients with and without major bleeding complication were compared. A multivariate model of bleeding complications at 1 month and mortality at 6 months was realized. Intention-to-treat and per-protocol analyses were performed.The most frequent bleeding site appears to be the gastrointestinal tract. Age >75 years, cardiac arrest, and the use of insulin or >1 heparin emerged as independent correlates of major bleeding at 1 month. Patients presenting with major bleeding had significantly higher rates of adverse ischemic complications. Mortality at 6 months was higher in bleeders. Major bleeding was found to be one of the independent correlates of 6-month mortality. The addition or mixing of several anticoagulant drugs was an independent factor of major bleeding despite the predominant use of radial access.This study shows that major bleeding is independently associated with poor outcome, increasing ischemic events, and mortality in primary percutaneous coronary intervention performed mostly with radial access.


Silvain J.,Institut Universitaire de France | Beygui F.,Institut Universitaire de France | Barthelemy O.,Institut Universitaire de France | Pollack Jr. C.,University of Pennsylvania | And 8 more authors.
BMJ (Online) | Year: 2012

Objective: To determine the efficacy and safety of enoxaparin compared with unfractionated heparin during percutaneous coronary intervention. Design: Systematic review and meta-analysis. Data sources: Medline and Cochrane database of systematic reviews, January 1996 to May 2011. Study selection: Randomised and non-randomised studies comparing enoxaparin with unfractionated heparin during percutaneous coronary intervention and reporting on both mortality (efficacy end point) and major bleeding (safety end point) outcomes. Data extraction: Sample size, characteristics, and outcomes, extracted independently and analysed. Data synthesis: 23 trials representing 30 966 patients were identified, including 10 243 patients (33.1%) undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction, 8750 (28.2%) undergoing secondary percutaneous coronary intervention after fibrinolysis, and 11 973 (38.7%) with non-ST elevation acute coronary syndrome or stable patients scheduled for percutaneous coronary intervention. A total of 13 943 patients (45.0%) received enoxaparin and 17 023 (55.0%) unfractionated heparin. Enoxaparin was associated with significant reductions in death (relative risk 0.66, 95% confidence interval 0.57 to 0.76; P<0.001), the composite of death or myocardial infarction (0.68, 0.57 to 0.81; P<0.001), and complications of myocardial infarction (0.75, 0.6 to 0.85; P<0.001), and a reduction in incidence of major bleeding (0.80, 0.68 to 0.95; P=0.009). In patients who underwent primary percutaneous coronary intervention, the reduction in death (0.52, 0.42 to 0.64; P<0.001) was particularly significant and associated with a reduction in major bleeding (0.72, 0.56 to 0.93; P=0.01). Conclusion: Enoxaparin seems to be superior to unfractionated heparin in reducing mortality and bleeding outcomes during percutaneous coronary intervention and particularly in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction.


PubMed | Federal University of Minas Gerais, SAMU and Hospital Joao XXIII
Type: Journal Article | Journal: Revista Brasileira de terapia intensiva | Year: 2014

Present a critical review of traumatic brain injury (TBI) in children and adolescents, focusing on severe TBI, the mortality and the factors related with poor outcome.It was made a systematic review in MEDLINE, SciElo e Lilacs, with the key words: traumatic brain injury, craniocerebral trauma, children and mortality. The most important articles related in the Guidelines of Brain Trauma Foundation (2000 e 2003) were selected too. TBI is one of the most important causes of mortality and morbidity in children and adolescents, and morbidity in children and adolescents. The mortality variation was between 10% and 55%, depending of the patients select criteria, trauma severity and units where the studies were made. The children mortality was, in general, lower than that found in adults and the most important factors related with an increased mortality were: Glasgow Coma Score, hypotension, cerebral swelling and lower cerebral perfusion press. Severe TBI endpoint treatment is to correct the secondary brain lesions related factors.The factors related with better outcomes in children with severe TBI are still obscures, despite the large number of studies, large numbers of studies. Many of these factors can be avoided or correct by aggressive fluid resuscitation, surgery treatment, monitoration and adequate intensive care.


Arvieux C.,Grenoble University Hospital Center | Thony F.,Grenoble University Hospital Center | Broux C.,Grenoble University Hospital Center | Ageron F.-X.,Samu 74 | And 5 more authors.
Journal de Chirurgie Viscerale | Year: 2012

Mortality associated with pelvic and perineal trauma (PPT) has fallen from 25 to 10% in the last decade thanks to progress accomplished in medical, surgical and interventional radiology domains (Dyer and Vrahas, 2006 [1]). The management strategy depends on the hemodynamic status of the patient (stable, unstable or extremely unstable). Open trauma requires specific treatment in addition to control of bleeding. All surgical centers can be confronted some day with patients with hemorrhagic PPT and for this reason, all surgeons should be familiar with the initial management. In expert centers, management of patients with severe PPT is complex, multidisciplinary and often requires several re-interventions (Eckroth-Bernard and Davis, 2010 [2]). Obstetrical and sexual trauma, also requiring specific management, will not be dealt with herein. © 2012 Elsevier Masson SAS. All rights reserved.


Maillaud C.,SAMU | Lefebvre S.,SAMU | Sebat C.,SAMU | Barguil Y.,Territorial Hospital of New Caledonia | And 6 more authors.
Toxicon | Year: 2010

We report a double lethal coconut crab Birgus latro L. poisoning in New Caledonia. Both patients died after showing gastro-intestinal symptoms, major bradycardia with marked low blood pressure, and finally asystolia. Both had significative hyperkaliemia, suggesting a digitaline-like substance intoxication. Traditional knowledge in the Loyalty Islands relates coconut crab toxicity to the consumption of the Cerbera manghas fruit by the crustacean. Elsewhere previous descriptions of human poisoning with the kernel of fruits of trees belonging to the genus Cerbera, known to contain cardiotoxic cardenolides, appear to be very similar to our cases. Cardenolides assays were performed on patient's serum samples, fruit kernel and on the crustacean guts, which lead us to suppose these two fatal cases were the result of a neriifolin intoxication, this toxin having been transmitted through the coconut crab. © 2009.


Objectives. To describe the reported incidents and adverse events in the emergency medical services of Asturias, Spain, and assess their consequences, delays caused, and preventability. Methods. Prospective, observational study of incidents reported by the staff of the emergency medical services of Asturias after implementation of a system devised by the researchers. Results. Incident reports were received for 0.48% (95% CI, 0.41%–0.54%) of the emergencies attended. Patient safety was compromised in 74.7% of the reported incidents. Problems arising in the emergency response coordination center (ERCC) accounted for 37.6% of the incidents, transport problems for 13.4%, vehicular problems for 10.8%, and communication problems for 8.8%. Seventy percent of the reported incidents caused delays in care; 55% of the reported incidents that put patients at risk (according to severity assessment code ratings) corresponded to problems related to human or material resources. A total of 88.1% of the incidents reported were considered avoidable. Some type of intervention was required to attenuate the effects of 46.2% of the adverse events reported. The measures that staff members most often proposed to prevent adverse events were to increase human and material resources (28.3%), establish protocols (14.5%), and comply with quality of care recommendations (9.7%). Conclusions. It is important to promote a culture of safety and incident reporting among health care staff in Asturias given the number of serious adverse events. Reporting is necessary for understanding the errors made and taking steps to prevent them. The ERCC is the point in the system where incidents are particularly likely to appear and be noticed and reported. © 2016, Grupo Saned. All rights reserved.


Rachel H.-C.,Center dEpidemiologie | Rafaelle T.,Center Hospitalier Of Fort Of France | Marie L.Q.,Institute Pasteur Paris | Gerard C.,Port-au-Prince University | And 5 more authors.
Journal of Travel Medicine | Year: 2012

A cluster of 21 cases of watery diarrhea suspected to be cholera that involved French military policemen and young volunteers occurring in the context of the Haiti cholera outbreak is described. The attack rate (AR) was higher among young volunteers (71.4%) than among policemen (15.3%) (p < 0.0001). There was a significant association between raw vegetables consumption and watery diarrhea in the young volunteer group. If we consider the raw vegetables consumers only, AR was lower among doxycycline-exposed subjects (relative risk: 0.2; 95% confidence interval: 0.1-0.4). The main aspect that is of scientific interest is the potential prophylactic effect of doxycycline used for malaria prophylaxis on the watery diarrhea AR. © 2012 International Society of Travel Medicine.


PubMed | Angers University Hospital Center, Anatomopathologie, Itun Institute Of Transplantation, Coordination des prelevements dorgane et de tissus and SAMU
Type: Journal Article | Journal: Transplant international : official journal of the European Society for Organ Transplantation | Year: 2016

The aim of this study was to compare the outcomes of kidney transplants from uncontrolled DCD (uDCD) with kidney transplants from extended (ECD) and standard criteria donors (SCD). In this multicenter study, we included recipients from uDCD (n = 50), and from ECD (n = 57) and SCD (n = 102) who could be eligible for a uDCD program. We compared patient and graft survival, and kidney function between groups. To address the impact of preservation procedures in uDCD, we compared in situ cold perfusion (ICP) with normothermic regional perfusion (NRP). Patient and graft survival rates were similar between the uDCD and ECD groups, but were lower than the SCD group (P < 0.01). Although delayed graft function (DGF) was more frequent in the uDCD group (66%) than in the ECD (40%) and SCD (27%) groups (P = 0.08 and P < 0.001), graft function was comparable between the uDCD and ECD groups at 3 months onwards post-transplantation. The use of NRP in the uDCD group (n = 19) was associated with a lower risk of DGF, and with a better graft function at 2 years post-transplantation, compared to ICP-uDCD (n = 31) and ECD. In conclusion, the use of uDCD kidneys was associated with post-transplantation results comparable to those of ECD kidneys. NRP preservation may improve the results of uDCD transplantation.


PubMed | SAMU
Type: Comparative Study | Journal: European journal of emergency medicine : official journal of the European Society for Emergency Medicine | Year: 2011

Coronary angiography is often performed in survivors of out-of-hospital cardiac arrest, but little is known about the factors predictive of a positive coronary angiography. Our aim was to determine these factors.In this 7-year retrospective study (January 2000-December 2006) conducted by a French out-of-hospital emergency medical unit, data were collected according to Utstein style guidelines on all out-of-hospital cardiac arrest patients with suspected coronary disease who recovered spontaneous cardiac activity and underwent early coronary angiography. Coronary angiography was considered positive if a lesion resulting in more than a 50% reduction in luminal diameter was observed or if there was a thrombus at an occlusion site.Among the 4621 patients from whom data were collected, 445 were successfully resuscitated and admitted to hospital. Of these, 133 were taken directly to the coronary angiography unit, 95 (71%) had at least one significant lesion, 71 (53%) underwent a percutaneous coronary intervention, and 30 survived [23%, 95% confidence interval (CI): 16-30]. According to multivariate analysis, the factors predictive of a positive coronary angiography were a history of diabetes [odds ratio (OR): 7.1, 95% CI: 1.4-36], ST segment depression on the out-of-hospital ECG (OR: 5.4, 95% CI: 1.1-27.8), a history of coronary disease (OR: 5.3, 95% CI: 1.4-20.1), cardiac arrest in a public place (OR: 3.7, 95% CI: 1.3-10.7), and ventricular fibrillation or ventricular tachycardia as initial rhythm (OR: 3.1, 95% CI: 1.1-8.6).Among the factors identified, diabetes and a history of coronary artery were strong predictors for a positive coronary angiography, whereas ST segment elevation was not as predictive as expected.

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