Although mortality due to COVID-19 is, for the most part, robustly tracked, its indirect effect at the population level through lockdown, lifestyle changes, and reorganisation of health-care systems ...has not been evaluated. We aimed to assess the incidence and outcomes of out-of-hospital cardiac arrest (OHCA) in an urban region during the pandemic, compared with non-pandemic periods.
We did a population-based, observational study using data for non-traumatic OHCA (N=30 768), systematically collected since May 15, 2011, in Paris and its suburbs, France, using the Paris Fire Brigade database, together with in-hospital data. We evaluated OHCA incidence and outcomes over a 6-week period during the pandemic in adult inhabitants of the study area.
Comparing the 521 OHCAs of the pandemic period (March 16 to April 26, 2020) to the mean of the 3052 total of the same weeks in the non-pandemic period (weeks 12–17, 2012–19), the maximum weekly OHCA incidence increased from 13·42 (95% CI 12·77–14·07) to 26·64 (25·72–27·53) per million inhabitants (p<0·0001), before returning to normal in the final weeks of the pandemic period. Although patient demographics did not change substantially during the pandemic compared with the non-pandemic period (mean age 69·7 years SD 17 vs 68·5 18, 334 males 64·4% vs 1826 59·9%), there was a higher rate of OHCA at home (460 90·2% vs 2336 76·8%; p<0·0001), less bystander cardiopulmonary resuscitation (239 47·8% vs 1165 63·9%; p<0·0001) and shockable rhythm (46 9·2% vs 472 19·1%; p<0·0001), and longer delays to intervention (median 10·4 min IQR 8·4–13·8 vs 9·4 min 7·9–12·6; p<0·0001). The proportion of patients who had an OHCA and were admitted alive decreased from 22·8% to 12·8% (p<0·0001) in the pandemic period. After adjustment for potential confounders, the pandemic period remained significantly associated with lower survival rate at hospital admission (odds ratio 0·36, 95% CI 0·24–0·52; p<0·0001). COVID-19 infection, confirmed or suspected, accounted for approximately a third of the increase in OHCA incidence during the pandemic.
A transient two-times increase in OHCA incidence, coupled with a reduction in survival, was observed during the specified time period of the pandemic when compared with the equivalent time period in previous years with no pandemic. Although this result might be partly related to COVID-19 infections, indirect effects associated with lockdown and adjustment of health-care services to the pandemic are probable. Therefore, these factors should be taken into account when considering mortality data and public health strategies.
The French National Institute of Health and Medical Research (INSERM)
Summary Rheumatic heart disease, often neglected by media and policy makers, is a major burden in developing countries where it causes most of the cardiovascular morbidity and mortality in young ...people, leading to about 250 000 deaths per year worldwide. The disease results from an abnormal autoimmune response to a group A streptococcal infection in a genetically susceptible host. Acute rheumatic fever—the precursor to rheumatic heart disease—can affect different organs and lead to irreversible valve damage and heart failure. Although penicillin is effective in the prevention of the disease, treatment of advanced stages uses up a vast amount of resources, which makes disease management especially challenging in emerging nations. Guidelines have therefore emphasised antibiotic prophylaxis against recurrent episodes of acute rheumatic fever, which seems feasible and cost effective. Early detection and targeted treatment might be possible if populations at risk for rheumatic heart disease in endemic areas are screened. In this setting, active surveillance with echocardiography-based screening might become very important.
More than 40 years after the first implantable cardioverter-defibrillator (ICD) implantation, sudden cardiac death (SCD) still accounts for more than five million deaths worldwide every year. Huge ...efforts in the field notwithstanding, it is now increasingly evident that the current strategy of long-term prevention based on left ventricular ejection fraction as the key selection criterion is actually of very limited impact, also because the largest absolute numbers of SCD are encountered in the general population not known to be at risk. It has been recently reemphasized that SCD is often not so sudden, with almost half of the victims experiencing typical warning symptoms preceding the event. Importantly, heeded and prompt medical attention can dramatically improve survival. Essentially, such timely action increases the chances of the SCD event being witnessed by emergency medical services and provides the opportunity for early intervention. In addition, newer technologies incorporating digital data acquisition, transfer between interconnected devices, and artificial intelligence, should allow dynamic, real-time monitoring of diverse parameters and therefore better identification of subjects at short-term SCD risk. Along with warning symptoms, these developments allow a new approach of near-term prevention based on the hours and minutes preceding SCD. In the present review, we challenge the current paradigm of mid- and long-term prevention using ICD in patients at the highest risk of SCD, and introduce a complementary concept applicable to the entire population that would aim to pre-empt SCD by timely detection and intervention within the minutes or hours prior to the event.
Atrial fibrillation： the current epidemic Morillo, Carlos A; Banerjee, Amitava; Perel, Pablo ...
Journal of geriatric cardiology : JGC,
03/2017, Letnik:
14, Številka:
3
Journal Article
Odprti dostop
Atrial fibrillation （AF） is the most common arrhythmia diagnosed in clinical practice. The consequences of AF have been clearly estab- lished in multiple large observational cohort studies and ...include increased stroke and systemic embolism rates if no oral anticoagulation is prescribed, with increased morbidity and mortality. With the worldwide aging of the population characterized by a large influx of ＂baby boomers＂ with or without risk factors for developing AF, an epidemic is forecasted within the next 10 to 20 years. Although not all studies support this evidence, it is clear that AF is on the rise and a significant amount of health resources are invested in detecting and managing AF This review focuses on the worldwide burden of AF and reviews global health strategies focused on improving detection, prevention and risk stratification of AF, recently recommended by the World Heart Federation.
Antibody-mediated rejection (ABMR) can occur in patients with preexisting anti-HLA donor-specific antibodies (DSA) or in patients who develop
DSA. However, how these processes compare in terms of ...allograft injury and outcome has not been addressed. From a cohort of 771 kidney biopsy specimens from two North American and five European centers, we performed a systematic assessment of clinical and biologic parameters, histopathology, circulating DSA, and allograft gene expression for all patients with ABMR (
=205). Overall, 103 (50%) patients had preexisting DSA and 102 (50%) had
DSA. Compared with patients with preexisting DSA ABMR, patients with
DSA ABMR displayed increased proteinuria, more transplant glomerulopathy lesions, and lower glomerulitis, but similar levels of peritubular capillaritis and C4d deposition.
DSA ABMR was characterized by increased expression of IFN
-inducible, natural killer cell, and T cell transcripts, but less expression of AKI transcripts compared with preexisting DSA ABMR. The preexisting DSA ABMR had superior graft survival compared with the
DSA ABMR (63% versus 34% at 8 years after rejection, respectively;
<0.001). After adjusting for clinical, histologic, and immunologic characteristics and treatment, we identified
DSA ABMR (hazard ratio HR, 1.82 compared with preexisting DSA ABMR; 95% confidence interval 95% CI, 1.07 to 3.08;
=0.03); low eGFR (<30 ml/min per 1.73 m
) at diagnosis (HR, 3.27; 95% CI, 1.48 to 7.23;
<0.001); ≥0.30 g/g urine protein-to-creatinine ratio (HR, 2.44; 95% CI, 1.47 to 4.09;
<0.001); and presence of cg lesions (HR, 2.25; 95% CI, 1.34 to 3.79;
=0.002) as the main independent determinants of allograft loss. Our findings support the transplant of kidneys into highly sensitized patients and should encourage efforts to monitor patients for
DSA.
Survival after out-of-hospital cardiac arrest (OHCA) remains disappointingly low. Among patients admitted alive, early prognostication remains challenging. This study aims to establish a ...stratification score for patients admitted in intensive care unit (ICU) after OHCA, according to their neurological outcome.
The CAHP (Cardiac Arrest Hospital Prognosis) score was developed from the Sudden Death Expertise Center registry (Paris, France). The primary outcome was poor neurological outcome defined as Cerebral Performance Category 3, 4, or 5 at hospital discharge. Independent prognostic factors were identified using logistic regression analysis and thresholds defined to stratify low-, moderate-, and high-risk groups. The CAHP score was validated in both a prospective and an external data set (Parisian Cardiac Arrest Registry). The developmental data set included 819 patients admitted from May 2011 to December 2012. After multivariate analysis, seven variables were independently associated with poor neurological outcome and subsequently included in the CAHP score (age, non-shockable rhythm, time from collapse to basic life support, time from basic life support to return of spontaneous circulation, location of cardiac arrest, epinephrine dose, and arterial pH). Three risks groups were identified: low risk (score ≤150, 39% of unfavourable outcome), medium risk (score 150-200, 81% of unfavourable outcome) and high-risk group (score ≥200, 100% of unfavourable outcome). The AUC of the CAHP score were 0.93, and the discrimination value in the validation data sets was consistent (respectively, AUC 0.91 and 0.85).
The CAHP score represents a simple tool for early stratification of patients admitted in ICU after OHCA. A high-risk category of patients with very poor prognosis can be easily identified.
Since development of the Utstein style recommendations for the uniform reporting of cardiac arrest, increasing numbers of national and regional out-of-hospital cardiac arrest (OHCA) registries have ...been established worldwide. The International Liaison Committee on Resuscitation (ILCOR) created the Research and Registries Working Group and aimed to systematically report data collected from these registries.
We conducted two surveys of voluntarily participating national and regional registries. The first survey aimed to identify which core elements of the current Utstein style for OHCA were collected by each registry. The second survey collected descriptive summary data from each registry. We chose the data collected for the second survey based on the availability of core elements identified by the first survey.
Seven national and four regional registries were included in the first survey and nine national and seven regional registries in the second survey. The estimated annual incidence of emergency medical services (EMS)-treated OHCA was 30.0–97.1 individuals per 100,000 population. The combined data showed the median age varied from 64 to 79 years and more than half were male in all 16 registries. The provision of bystander cardiopulmonary resuscitation (CPR) and bystander automated external defibrillator (AED) use was 19.1–79.0% in all registries and 2.0–37.4% among 11 registries, respectively. Survival to hospital discharge or 30-day survival after EMS-treated OHCA was 3.1–20.4% across all registries. Favorable neurological outcome at hospital discharge or 30 days after EMS-treated OHCA was 2.8–18.2%. Survival to hospital discharge or 30-day survival after bystander-witnessed shockable OHCA ranged from 11.7% to 47.4% and favorable neurological outcome from 9.9% to 33.3%.
This report from ILCOR describes data on systems of care and outcomes following OHCA from nine national and seven regional registries across the world. We found variation in reported survival outcomes and other core elements of the current Utstein style recommendations for OHCA across nations and regions.
Summary Background Rejection of allografts has always been the major obstacle to transplantation success. We aimed to improve characterisation of different kidney-allograft rejection phenotypes, ...identify how each one is associated with anti-HLA antibodies, and investigate their distinct prognoses. Methods Patients who underwent ABO-compatible kidney transplantations in Necker Hospital and Saint-Louis Hospital (Paris, France) between Jan 1, 1998, and Dec 31, 2008, were included in our population-based study. We assessed patients who provided biopsy samples for acute allograft rejection, which was defined as the association of deterioration in function and histopathological lesions. The main outcome was kidney allograft loss—ie, return to dialysis. To investigate distinct rejection patterns, we retrospectively assessed rejection episodes with review of graft histology, C4d in allograft biopsies, and donor-specific anti-HLA antibodies. Findings 2079 patients were included in the main analyses, of whom 302 (15%) had acute biopsy-proven rejection. We identified four distinct patterns of kidney allograft rejection: T cell-mediated vascular rejection (26 patients 9%), antibody-mediated vascular rejection (64 21%), T cell-mediated rejection without vasculitis (139 46%), and antibody-mediated rejection without vasculitis (73 24%). Risk of graft loss was 9·07 times (95 CI 3·62–19·7) higher in antibody-mediated vascular rejection than in T cell-mediated rejection without vasculitis (p<0·0001), compared with an increase of 2·93 times (1·1–7·9; P=0·0237) in antibody-mediated rejection without vasculitis and no significant rise in T cell-mediated vascular rejection (hazard ratio HR 1·5, 95% CI 0·33–7·6; p=0·60). Interpretation We have identified a type of kidney rejection not presently included in classifications: antibody-mediated vascular rejection. Recognition of this distinct phenotype could lead to the development of new treatment strategies that could salvage many kidney allografts. Funding None.
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