IMPORTANCE: Clinical guidelines for the early management of acute heart failure in the emergency department (ED) setting are based on only moderate levels of evidence, with subsequent low adherence ...to these guidelines. OBJECTIVE: To test the effect of an early guideline-recommended care bundle on short-term prognosis in older patients with acute heart failure in the ED. DESIGN, SETTING, AND PARTICIPANTS: Stepped-wedge cluster randomized trial in 15 EDs in France of 503 patients 75 years and older with a diagnosis of acute heart failure in the ED from December 2018 to September 2019 and followed up for 30 days until October 2019. INTERVENTIONS: A care bundle that included early intravenous nitrate boluses; management of precipitating factors, such as acute coronary syndrome, infection, or atrial fibrillation; and moderate dose of intravenous diuretics (n = 200). In the control group, patient care was left to the discretion of the treating emergency physician (n = 303). Each center was randomized to the order in which they switched to the “intervention period.” After the initial 4-week control period for all centers, 1 center entered in the intervention period every 2 weeks. MAIN OUTCOMES AND MEASURES: The primary end point was the number of days alive and out of hospital at 30 days. Secondary outcomes included 30-day all-cause mortality, 30-day cardiovascular mortality, unscheduled readmission, length of hospital stay, and kidney impairment. RESULTS: Among 503 patients who were randomized (median age, 87 years; 298 59% women), 502 were analyzed. In the intervention group, patients received a median (interquartile range) of 27.0 (9-54) mg of intravenous nitrates in the first 4 hours vs 4.0 (2.0-6.0) mg in the control group (adjusted difference, 23.8 95% CI, 13.5-34.1). There was a significantly higher percentage of patients in the intervention group treated for their precipitating factors than in the control group (58.8% vs 31.9%; adjusted difference, 31.1% 95% CI, 14.3%-47.9%). There was no statistically significant difference in the primary end point of the number of days alive and out of hospital at 30 days (median interquartile range, 19 0- 24 d in both groups; adjusted difference, −1.9 95% CI, −6.6 to 2.8; adjusted ratio, 0.88 95% CI, 0.64-1.21). At 30 days, there was no significant difference between the intervention and control groups in mortality (8.0% vs 9.7%; adjusted difference, 4.1% 95% CI, −17.2% to 25.3%), cardiovascular mortality (5.0% vs 7.4%; adjusted difference, 2.1% 95% CI, −15.5% to 19.8%), unscheduled readmission (14.3% vs 15.7%; adjusted difference, −1.3% 95% CI, −26.3% to 23.7%), median length of hospital stay (8 d in both groups; adjusted difference, 2.5 95% CI, −0.9 to 5.8), and kidney impairment (1% in both groups). CONCLUSIONS AND RELEVANCE: Among older patients with acute heart failure, use of a guideline-based comprehensive care bundle in the ED compared with usual care did not result in a statistically significant difference in the number of days alive and out of the hospital at 30 days. Further research is needed to identify effective treatments for acute heart failure in older patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03683212
One of the main issues in the analysis of clinical neonatal brain MRI is the low anisotropic resolution of the data. In most MRI analysis pipelines, data are first re-sampled using interpolation or ...single image super-resolution techniques and then segmented using (semi-)automated approaches. In other words, image reconstruction and segmentation are then performed separately. In this article, we propose a methodology and a software solution for carrying out simultaneously high-resolution reconstruction and segmentation of brain MRI data.
Our strategy mainly relies on generative adversarial networks. The network architecture is described in detail. We provide information about its implementation, focusing on the most crucial technical points (whereas complementary details are given in a dedicated GitHub repository). We illustrate the behavior of the proposed method for cortex analysis from neonatal MR images.
The results of the method, evaluated quantitatively (Dice, peak signal-to-noise ratio, structural similarity, number of connected components) and qualitatively on a research dataset (dHCP) and a clinical one (Epirmex), emphasize the relevance of the approach, and its ability to take advantage of data-augmentation strategies.
Results emphasize the potential of our proposed method/software with respect to practical medical applications. The method is provided as a freely available software tool, which allows one to carry out his/her own experiments, and involve the method for the super-resolution reconstruction and segmentation of arbitrary cerebral structures from any MR image dataset.
•End-to-end joint super-resolution and segmentation of 3D brain MRI data.•Comprehensive method evaluation on both research and clinical datasets.•Open-source software with detailed implementation description, available on Github.com.
In 2018, the French “Yellow Vest” social protest movement spread with weekly demonstrations resulting in confrontations between protesters and law enforcement. Non-lethal weapons, such as defensive ...bullet launchers (DBL) were used, and significant injuries have been reported through media, leading to public controversy regarding their use. These injuries are not well-known to civilian emergency physicians.
The aim of this study is to describe the injuries caused by DBL among Emergency Department (ED) patients during these demonstrations and to identify the characteristics that required specialized care and hospital admission.
A multicenter retrospective study was conducted in 7 EDs of academic hospitals in Paris, France. Adult ED patients who presented with DBL injuries during “yellow vest” strikes between November 2018 and May 2019 were included. The primary outcome was the rate of DBL patients requiring hospital admission. We also compared the characteristics of the injuries and the care provided between the admitted patients and other DBL patients.
152 patients were included. 17% were admitted to hospital, with 19% of them being transferred to intensive care units. 49% of all patients had head, face, eye or neck injuries including 4 cases of intracranial hemorrhage, 1 carotide dissection, 1 laryngeal edema, 1 pneumencephalus. 11% of all patients presented with multiple wounds, and 28% had fractures (77% of admitted patients vs 18%, p < 0.001). Surgery was required for 20% of all patients (62% of admitted patients vs 10%, p < 0.001). Maxillofacial surgery was performed on 38% of admitted patients, orthopedic surgery on 25%, and neurosurgery on 13%. No death were reported.
The use of DBL during the “yellow vest” civil strikes was associated with a high rate of head, face, eye or neck injuries among injured ED patients. Hospital admission was associated with a higher rate of fractures, with most of them requiring maxillofacial, orthopedic and neurosurgeries.
•During the social protest movement of the French “Yellow vests”,•H Half of the injuries caused by rubber bullets among Emergency Department patients were located in the head, face, eye or neck.•One-fifth of all patients needed surgery mostly in the fields of maxillofacial, orthopedic, and neurosurgery.•Hospital admission was necessary for 17% of all patients injured by rubber bullets.
The assessment of acute heart failure (AHF) prognosis is primordial in emergency setting. Although AHF management is exhaustively codified using mortality predictors, there is currently no ...recommended scoring system for assessing prognosis. The European Society of Cardiology (ESC) recommends a comprehensive assessment of global AHF prognosis, considering in-hospital mortality, early rehospitalization rates and the length of hospital stay.
We aimed to prospectively evaluate the performance of the Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF (MEESSI-AHF) score in estimating short prognosis according to the ESC guidelines.
A multicenter study was conducted between November 2020, and June 2021. Adult patients who presented to eleven French hospitals for AHF were prospectively included.
According to MEESSI-AHF score, patients were stratified in four categories corresponding to mortality risk: low-, intermediate-, high- and very high-risk groups. The primary outcome was the number of days alive and out of the hospital during the 30-day period following admission to the Emergency Department (ED).
In total, 390 patients were included. The number of days alive and out of the hospital decreased significatively with increasing MEESSI-AHF risk groups, ranging from 21.2 days (20.3-22.3 days) for the low-risk, 20 days (19.3-20.5 days) for intermediate risk,18.6 days (17.6-19.6 days) for the high-risk and 17.9 days (16.9-18.9 days) very high-risk category.
Among patients admitted to ED for an episode of AHF, the MEESSI-AHF score estimates with good performance the number of days alive and out of the hospital.
OBJECTIVEThe Bacterial Meningitis Score (BMS) is recommended by pediatric academic societies to rule out the diagnosis of bacterial meningitis. The aim of this study was to evaluate the performance ...of the BMS to identify adults at no risk for bacterial meningitis.
METHODSWe conducted a multicentric retrospective study including adults who consulted the emergency department (ED) for meningitis cerebrospinal fluid (CSF) white blood cells ≥5/mm with a ratio of white blood cells/red blood cells <1:900) during a 4-year period. The BMS variables wereCSF positive Gram stain, CSF absolute neutrophil count ≥1000 cells/μL, CSF protein ≥80 mg/dL, peripheral blood absolute neutrophil count ≥10 000 cells/μL, and seizures. Bacterial meningitis was defined for patients who had a lumbar puncture with CSF pleocytosis and positive bacterial analysis of CSF. The primary endpoint was the sensitivity of the BMS to rule out bacterial meningitis in adults. The secondary outcome was to assess the rate of patients for whom antibiotics could have been avoided using the BMS and the diagnostic performance of procalcitonin in patients with a BMS ≥1.
RESULTSOf 930 patients with meningitis, 626 were included in the analysis, and 27 (4.3%) were diagnosed with bacterial meningitis. A total of 384/626 (61.3%) patients had a BMS = 0, and none presented bacterial meningitis. BMS sensitivity was 100% 95% confidence interval (CI), 87.2–100%, and its negative predictive values were 100% (95% CI, 98.8–100%).
CONCLUSIONAmong patients with a diagnosis of meningitis in ED, a BMS of 0 may safely rule out bacterial meningitis.
Objective The Bacterial Meningitis Score (BMS) is recommended by pediatric academic societies to rule out the diagnosis of bacterial meningitis. The aim of this study was to evaluate the performance ...of the BMS to identify adults at no risk for bacterial meningitis.Methods We conducted a multicentric retrospective study including adults who consulted the emergency department (ED) for meningitis cerebrospinal fluid (CSF) white blood cells ≥5/mm3 with a ratio of white blood cells/red blood cells <1:900) during a 4-year period. The BMS variables were: CSF positive Gram stain, CSF absolute neutrophil count ≥1000 cells/μL, CSF protein ≥80 mg/dL, peripheral blood absolute neutrophil count ≥10 000 cells/μL, and seizures. Bacterial meningitis was defined for patients who had a lumbar puncture with CSF pleocytosis and positive bacterial analysis of CSF. The primary endpoint was the sensitivity of the BMS to rule out bacterial meningitis in adults. The secondary outcome was to assess the rate of patients for whom antibiotics could have been avoided using the BMS and the diagnostic performance of procalcitonin in patients with a BMS ≥1.Results Of 930 patients with meningitis, 626 were included in the analysis, and 27 (4.3%) were diagnosed with bacterial meningitis. A total of 384/626 (61.3%) patients had a BMS = 0, and none presented bacterial meningitis. BMS sensitivity was 100% 95% confidence interval (CI), 87.2–100%, and its negative predictive values were 100% (95% CI, 98.8–100%).Conclusion Among patients with a diagnosis of meningitis in ED, a BMS of 0 may safely rule out bacterial meningitis.
In this article, we present the $n$-dimensional version of the waterpixels, namely the watervoxels.Waterpixels constitute a simple, yet efficient alternative to standard superpixel paradigms, ...initially developed in the field of computer vision for reducing the space cost of input images without altering the accuracy of further image processing / analysis procedures.Waterpixels were initially proposed in a 2-dimensional version.Their extension to 3-dimensions---and more generally $n$-dimensions---is however possible, in particular in the Cartesian grid.Indeed, waterpixels mainly rely on a seeded watershed transformation applied on a saliency map defined as the linear combination of a gradient map and a distance map.We propose a description of the algorithmics of watervoxels in $n$-dimensional Cartesian grids.We also discuss its parameters and its time cost.A source code for 2- and 3-dimensional versions of watervoxels is provided, such as a 2-dimensional demonstrator.
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