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Integration of a Palliative Approach in the Care of Older Adults with Dementia in Primary Care Settings: A Scoping Review | Novembre 2022 H

Article | Veille Gériatrie-gérontologie (Gériatrie - gérontologie)

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L’approche palliative vise à répondre aux besoins des patients ayant certaines maladies chroniques et à ceux de leurs aidants tout au long de la trajectoire de soins. Elle peut être dispensée par des spécialistes non palliatifs. Une lacune importante subsiste dans la compréhension des perspectives et des expériences des prestataires de soins de première ligne pour ce qui est de l’approche palliative en soins intégrés pour les personnes atteintes de démence, ainsi que concernant l’impact des programmes et des modèles existants. Pour y remédier, nous avons réalisé une revue de la portée. Cinq bases de données ont été consultées et des approches descriptives numériques et de synthèse narrative ont été utilisées pour l’analyse des données. Nous avons constaté que : 1) les difficultés associées à la détermination du pronostic et le manque de collaboration interdisciplinaire et intersectorielle constituent des obstacles à l’utilisation d’une approche palliative dans les soins de première ligne ; 2) l’approche palliative a un impact statistiquement et cliniquement significatif sur les personnes avec démence vivant dans la communauté, particulièrement à un stade avancé. Des recherches de haute qualité sont requises sur les modèles de l’approche palliative intégrée et sur leur implantation à des stades moins avancés de la maladie, pour les personnes vivant dans la communauté et souffrant de démence précoce ou légère.
L’approche palliative vise à répondre aux besoins des patients ayant certaines maladies chroniques et à ceux de leurs aidants tout au long de la trajectoire de soins. Elle peut être dispensée par des spécialistes non palliatifs. Une lacune importante subsiste dans la compréhension des perspectives et des expériences des prestataires de soins de première ligne pour ce qui est de l’approche palliative en soins intégrés pour les personnes atteintes ...

Vieillissement ; Personnes âgées ; Démence ; Soins palliatifs

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Strategies used by care home staff to manage behaviour that challenges in dementia: A systematic review of qualitative studies | Septembre 2022 H

Article | Veille Gériatrie-gérontologie (Gériatrie - gérontologie)

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Background
Psychotropic drugs are often prescribed to manage behaviour that challenges in care home residents with dementia but contravene guidelines as evidence shows their use increases the risk of strokes and death. Therefore, a review is needed that conceptualises understanding of the pharmacological and non-pharmacological strategies implemented by care home staff to manage behaviour that challenges in dementia and the factors that influence decision-making. This knowledge is important to develop dementia guidelines to implement a sustainable non-pharmacological approach to support residents with behaviour that challenges.

Aim
To review qualitative studies to synthesise understanding of strategies implemented by care home staff to manage behaviour that challenges in dementia.

Methods
This systematic review involved a synthesis of qualitative data (PROSPERO protocol registration CRD42020165948). Searches of three electronic databases, PubMed, PsycINFO and CINAHL were conducted from inception until July 2021, supplemented by grey literature searches. Studies were included if they used qualitative methods and explored how care home staff respond to behaviour that challenges; data exploring other aspects of dementia care were excluded. Study quality was assessed using the Critical Appraisal Skills Programme checklist. Thematic synthesis was used to conceptualise understanding of the strategies implemented by care home staff to manage behaviour that challenges in dementia.

Findings
In total 1151 records were identified of which 34 studies were included in the review. Three themes emerged, ‘Putting out the fires’, refers to reactive strategies, implemented by staff to quell behaviour that challenges. However, if these strategies fail, staff may resort to pharmacological approaches for convenience to suppress these behaviours. The theme ‘Personhood, human rights and respect’ highlights the need for people with dementia to feel valued and useful by engaging residents in meaningful activities. Furthermore, the theme “Person focused approach – A paradigm shift” reflects changes in culture, required to implement non-pharmacological strategies to behaviour management these include staff training, collaboration and equitable decision-making.

Conclusions
This review has identified strategies used by care home staff to manage behaviour that challenges. Non-pharmacological approaches to support residents with behaviour that challenges require staff training in behaviour management and psychotropic medicine management as part of their formal education program, and enhanced opportunities for collaboration and decision-making. In addition, residents should receive person focused support to facilitate participation in meaningful activities. These findings will be beneficial in developing guidelines to implement sustainable non-pharmacological approaches to manage behaviour that challenges in dementia.
Background
Psychotropic drugs are often prescribed to manage behaviour that challenges in care home residents with dementia but contravene guidelines as evidence shows their use increases the risk of strokes and death. Therefore, a review is needed that conceptualises understanding of the pharmacological and non-pharmacological strategies implemented by care home staff to manage behaviour that challenges in dementia and the factors that ...

Personnes âgées ; Démence

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Transcatheter edge-to-edge repair in patients with mitral regurgitation and cardiogenic shock: a new therapeutic target | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

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Purpose of review: Cardiogenic shock with significant mitral regurgitation portends a poor prognosis with limited therapeutic options. Herein, we review the available evidence regarding the patient characteristics, management, impact of transcatheter edge-to-edge repair (TEER) on hemodynamics, and clinical outcomes of patients with cardiogenic shock and mitral regurgitation.

Recent findings: Several observational studies and systematic reviews have demonstrated the feasibility and safety of TEER in cardiogenic shock complicated by degenerative or functional mitral regurgitation. Surgical interventions for mitral regurgitation remain limited owing to the risk profile of patients in cardiogenic shock. TEER has been studied in both degenerative and functional mitral regurgitation and remains feasible in the critically ill population. Moreover, TEER is associated with reduction in mitral regurgitation and improvement in-hospital and long-term mortality.

Summary: TEER remains a promising therapeutic option in cardiogenic shock complicated by significant mitral regurgitation, but additional research is required to identify patient and procedural characteristics, hemodynamic parameters, and the optimal time for intervention. Moreover, future randomized controlled trials are in progress to evaluate the potential benefit of TEER against medical management in cardiogenic shock and mitral regurgitation.
Purpose of review: Cardiogenic shock with significant mitral regurgitation portends a poor prognosis with limited therapeutic options. Herein, we review the available evidence regarding the patient characteristics, management, impact of transcatheter edge-to-edge repair (TEER) on hemodynamics, and clinical outcomes of patients with cardiogenic shock and mitral regurgitation.

Recent findings: Several observational studies and systematic reviews ...

Appareil cardiovasculaire - Maladies ; Soins intensifs

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Poor physical recovery after critical illness: Incidence, features, risk factors, pathophysiology, and evidence-based therapies | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

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Purpose of review: To summarize the incidence, features, pathogenesis, risk factors, and evidence-based therapies of prolonged intensive care unit (ICU) acquired weakness (ICU-AW). We aim to provide an updated overview on aspects of poor physical recovery following critical illness.

Recent findings: New physical problems after ICU survival, such as muscle weakness, weakened condition, and reduced exercise capacity, are the most frequently encountered limitations of patients with postintensive care syndrome. Disabilities may persist for months to years and frequently do not fully recover. Hormonal and mitochondrial disturbances, impaired muscle regeneration due to injured satellite cells and epigenetic differences may be involved in sustained ICU-AW. Although demographics and ICU treatment factors appear essential determinants for physical recovery, pre-ICU health status is also crucial. Currently, no effective treatments are available. Early mobilization in the ICU may improve physical outcomes at ICU-discharge, but there is no evidence for benefit on long-term physical recovery.

Summary: Impaired physical recovery is observed frequently among ICU survivors. The pre-ICU health status, demographic, and ICU treatment factors appear to be important determinants for physical convalescence during the post-ICU phase. The pathophysiological mechanisms involved are poorly understood, thereby resulting in exiguous evidence-based treatment strategies to date.
Purpose of review: To summarize the incidence, features, pathogenesis, risk factors, and evidence-based therapies of prolonged intensive care unit (ICU) acquired weakness (ICU-AW). We aim to provide an updated overview on aspects of poor physical recovery following critical illness.

Recent findings: New physical problems after ICU survival, such as muscle weakness, weakened condition, and reduced exercise capacity, are the most frequently ...

Soins intensifs ; Rehabilitation

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Nutrition before, during and after critical illness | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

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Purpose of review: This review describes considerations preintensive care unit (ICU), within ICU and in the post-ICU period regarding nutrition management and the current state of the literature base informing clinical care.

Recent findings: Within ICU, studies have focussed on the first 5-7 days of illness in mechanically ventilated patients who are heterogeneous and with minimal consideration to premorbid nutrition state. Many evidence gaps in the period within ICU remain, with the major ones being the amount of protein to provide and the impact of longer-term nutrition interventions. Personalised nutrition and nutrition in the post-ICU period are becoming key areas of focus.

Summary: Nutrition for the critically ill patient should not be viewed in isolated time periods; what happens before, during and after ICU is likely important to the overall recovery trajectory. It is critical that the impact of nutrition on clinical and functional outcomes across hospitalisation is investigated in specific groups and using interventions in ways that are biologically plausible to impact. Areas that show promise for the future of critical care nutrition include interventions delivered for a longer duration and inclusion of oral nutrition support, individualised nutrition regimes, and use of emerging bedside body composition techniques to identify patients at nutritional risk.
Purpose of review: This review describes considerations preintensive care unit (ICU), within ICU and in the post-ICU period regarding nutrition management and the current state of the literature base informing clinical care.

Recent findings: Within ICU, studies have focussed on the first 5-7 days of illness in mechanically ventilated patients who are heterogeneous and with minimal consideration to premorbid nutrition state. Many evidence gaps ...

Nutrition ; Alimentation ; Soins intensifs

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Update on vitamin C administration in critical illness | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

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Purpose of review: Several studies have recently explored the effects of intravenous vitamin C in sepsis. We aimed to summarize their findings to provide perspectives for future research.

Recent findings: Sepsis trials examined 6 g/day of intravenous vitamin C with or without the thiamine and/or hydrocortisone compared with placebo or hydrocortisone. Network meta-analysis reported that intravenous vitamin C, thiamine, hydrocortisone, or combinations of these drugs was not proven to reduce long-term mortality. However, the component network meta-analysis suggested an association of high-dose (>6 g/day) and very-high dose vitamin C (>12 g/day) and decreased mortality but with low certainty. The preclinical investigations have, however, advanced to much higher doses of intravenous vitamin C therapy since a scoping review on harm reported that mega-doses of intravenous vitamin C (50-100 g/day) had been administered without any conclusive adverse effects. In a Gram-negative sheep model, renal tissue hypoperfusion was reversed, followed by improvements in kidney function when a mega-dose of vitamin C (150 g/day equivalent) was administered.

Summary: The effect of intravenous vitamin C in critically ill patients has yet to be determined and might be dose-dependent. Clinical studies of very high or mega doses of vitamin C are justified by preclinical data.
Purpose of review: Several studies have recently explored the effects of intravenous vitamin C in sepsis. We aimed to summarize their findings to provide perspectives for future research.

Recent findings: Sepsis trials examined 6 g/day of intravenous vitamin C with or without the thiamine and/or hydrocortisone compared with placebo or hydrocortisone. Network meta-analysis reported that intravenous vitamin C, thiamine, hydrocortisone, or ...

Vitamines ; Soins intensifs

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Pediatric Urgent Care Center Management of Traumatic Injuries in Infants and Children: Adherence to Evidence-Based Practice Guidelines | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

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Objectives: To determine pediatric urgent care (PUC) clinician adherence to evidence-based practice guidelines in the management of pediatric trauma and to evaluate PUC emergency preparedness for conditions such as severe hemorrhage.

Methods: A questionnaire covering acute management of 15 pediatric traumatic injuries, awareness of the Stop the Bleed initiative, and presence of emergency equipment and medications was electronically distributed to members of the Society for Pediatric Urgent Care. Clinician management decisions were evaluated against evidence-based practice guidelines.

Results: Eighty-three completed questionnaires were returned (25% response rate). Fifty-three physician and 25 advanced practice provider (APP) questionnaires were analyzed. Most respondents were adherent to evidence-based practice guidelines in the following scenarios: cervical spine injury; head injury without neurologic symptoms; blunt abdominal injury; laceration without bleeding, foreign body, or signs of infection; first-degree burn; second-degree burn with less than 10% total body surface area; animal bite with and without probable tenosynovitis; and orthopedic fractures. Fever respondents were adherent in the following scenarios: head injury with altered mental status (adherence: physicians, 64%; APPs, 44%) and laceration with foreign body and persistent hemorrhage (adherence: physicians, 52%; APPs, 41%). Most respondents (56%) were unaware of Stop the Bleed and only 48% reported having a bleeding control kit/tourniquet at their urgent care.

Conclusions: Providers in our sample demonstrated adherence with pediatric trauma evidence-based practice guidelines. Increased PUC provider trauma care certification, PUC incorporation of Stop the Bleed education, and PUC presence of equipment and medications would further improve emergency preparedness.
Objectives: To determine pediatric urgent care (PUC) clinician adherence to evidence-based practice guidelines in the management of pediatric trauma and to evaluate PUC emergency preparedness for conditions such as severe hemorrhage.

Methods: A questionnaire covering acute management of 15 pediatric traumatic injuries, awareness of the Stop the Bleed initiative, and presence of emergency equipment and medications was electronically distributed ...

Traitement ambulatoire ; Hémorragies ; Traumatisme cranio-cérébral ; ENFANTS

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Predictors of Emergency Department Opioid Use Among Adolescents and Young Adults | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

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Objective: It is well established that adolescents and young adults are increasingly vulnerable to the effects of early opioid exposures, with the emergency department (ED) playing a critical role in such introduction. Our objective was to identify predictors of ED opioid administration (ED-RX) and prescribing at discharge (DC-RX) among adolescent and young adults using a machine learning approach.

Methods: We conducted a secondary analysis of ED visit data from the National Hospital Ambulatory Medical Care Survey from 2014 to 2018. Visits where patients were aged 10 to 24 years were included. Predictors of ED-RX and DC-RX were identified via machine learning methods. Separate weighted logistic regressions were performed to determine the association between each predictor, and ED-RX and DC-RX, respectively.

Results: There were 12,693 ED visits identified within the study time frame, with the majority being female (58.6%) and White (70.7%). Approximately 12.3% of all visits were administered an opioid during the ED visit, and 11.5% were prescribed one at discharge. For ED-RX, the strongest predictors were fracture injury (odds ratio [OR], 5.24; 95% confidence interval [CI], 3.73-7.35) and Southern geographic region (OR, 3.01; 95% CI, 2.14-4.22). The use of nonopioid analgesics significantly reduced the odds of ED-RX (OR, 0.46; 95% CI, 0.37-0.57). Fracture injury was also a strong predictor of DC-RX (OR, 5.91; 95% CI, 4.24-8.25), in addition to tooth pain (OR, 5.47; 95% CI, 3.84-7.69).

Conclusions: Machine learning methodologies were able to identify predictors of ED-RX and DC-RX, which can be used to inform ED prescribing guidelines and risk mitigation efforts among adolescents and young adults.
Objective: It is well established that adolescents and young adults are increasingly vulnerable to the effects of early opioid exposures, with the emergency department (ED) playing a critical role in such introduction. Our objective was to identify predictors of ED opioid administration (ED-RX) and prescribing at discharge (DC-RX) among adolescent and young adults using a machine learning approach.

Methods: We conducted a secondary analysis of ...

Opioïdes ; Toxicomanie ; Adolescents ; Jeunes adultes

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Impact of COVID-19 on Pediatric Mental and Behavioral Health Visits to the Emergency Department | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

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Objectives: This study aimed to describe changes in pediatric emergency department (ED) mental and behavioral health (MBH) visits before and during the early COVID-19 pandemic.

Methods: We retrospectively reviewed medical records of patients aged from 5 to 17 years presenting to the pediatric ED of a major tertiary care hospital with MBH-related concerns from March 2017 to September 2020. We evaluated trends in MBH ED visits over the study period, specifically comparing patient demographics, diagnosis categories, and ED disposition between the pre-COVID (2019) and COVID (2020) periods using pairwise Pearson [chi]2 analyses with reported odds ratios (ORs) in SAS statistical software version 9.4 (SAS Institute Inc, Cary, NC).

Results: Of 8093 MBH-related visits, 58.5% were females, 85.4% were adolescents, and 62.7% self-identified as non-Hispanic. The proportion of MBH-related ED visits increased from 3.8% to 7.5% over the study period (P < 0.0001). Although total MBH visits decreased by 17.3% from 2019 to 2020, there was a proportionate increase in MBH-to-total-ED visits, representing a 42.8% increase through 2019. Compared with 2019, there was a proportionate increase in MBH-related ED visits by females (10.6%, P < 0.0001), older adolescents (18.2%, P < 0.0001), and non-Hispanic patients (6.1%, P = 0.017) in 2020. The MBH visits in 2020 were more likely related to suicidality/self-harm (OR, 1.2; confidence interval [CI], 1.1-1.4) or substance use (OR, 1.4; CI, 1.1-1.9). Compared with 2019, there were significantly higher odds of admission (OR, 1.6; CI, 1.3-2.1) or transfer for inpatient psychiatric care (OR, 1.8; CI, 1.6-2.1) in 2020.

Conclusions: Our data suggest that the early COVID-19 pandemic had a significant impact on MBH-related ED visits. Compared with 2019, we observed a significant increase in the proportion of MBH-to-total-ED visits primarily affecting older adolescent, non-Hispanic girls with suicidality/self-harm and substance-related disorders in 2020, despite an overall decrease in the number of MBH visits during this period. There was also an increase in the proportion of visits resulting in admission or transfer for inpatient psychiatric care in 2020.
Objectives: This study aimed to describe changes in pediatric emergency department (ED) mental and behavioral health (MBH) visits before and during the early COVID-19 pandemic.

Methods: We retrospectively reviewed medical records of patients aged from 5 to 17 years presenting to the pediatric ED of a major tertiary care hospital with MBH-related concerns from March 2017 to September 2020. We evaluated trends in MBH ED visits over the study ...

COVID-19 ; Médecine d'urgence ; Hôpitaux - Services des urgences ; Enfants - Santé mentale

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Liquid Nicotine, E-Cigarettes, and Vaping: Information for the Pediatric Emergency Medicine Provider | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

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Abstract: E-cigarettes, or electronic cigarettes, are electronic nicotine delivery systems that are marketed as a healthier alternative to tobacco cigarettes. There has been an exponential increase in their use among youth since their introduction to the United States market in 2007. With increased use and popularity, there has been an increase in calls to poison control centers regarding liquid nicotine toxicity in children and adolescents. Recent US Food and Drug Administration and other federal regulations of e-cigarettes have attempted to limit availability to youth. This article reviews trends in e-cigarette use among youth, the background and mechanism of action of e-cigarettes, liquid nicotine toxicity, management of liquid nicotine toxicity, and recent policy updates regarding e-cigarettes.
Abstract: E-cigarettes, or electronic cigarettes, are electronic nicotine delivery systems that are marketed as a healthier alternative to tobacco cigarettes. There has been an exponential increase in their use among youth since their introduction to the United States market in 2007. With increased use and popularity, there has been an increase in calls to poison control centers regarding liquid nicotine toxicity in children and adolescents. ...

Cigarettes électroniques ; Toxicomanie ; Médecine d'urgence

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Prevalence of Adverse Childhood Experiences in a Pediatric Emergency Department: Support for Trauma-Informed Pediatric Emergency Care | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

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Objectives: Data from the 2019 National Survey of Children's Health revealed that 39.8% of children in the United States have been exposed to adverse childhood experiences (ACEs), which are risk factors for long-term negative health outcomes. This study aimed to determine the prevalence of ACE exposure in a pediatric emergency department (ED) patients and describe the association between ACE exposure and ED recidivism.

Methods: Five hundred children aged 0 to 17 years were evaluated for ACE exposure in an academic, urban, tertiary-care, pediatric ED via convenience sampling. The 2019 National Survey of Children's Health section on ACEs was administered to define ACE exposure. A prospective chart review was conducted on all children enrolled in the study to collect data on ED utilization for 1-year postsurvey. The relationship between ACE exposure and ED recidivism was examined by calculating relative risk.

Results: We found that 40.2% (confidence interval [CI], 36.5%-45.3%) of respondents had ACE exposure. The most frequently reported ACEs were poverty (20.8%; CI, 17.3%-24.6%), divorce/separation (18.2%; CI, 14.9%-21.9%), and mental illness within the household (7.2%; CI, 5.1%-9.8%). Adverse childhood experience exposure in this pediatric ED was similar to the national prevalence. There was no significant relationship between ACE exposure and high ED recidivism as an adverse outcome.

Conclusions: Adverse childhood experience exposure in this population matched the prevalence reported in the national population. Our results suggest that this group is particularly important when mitigating these risk factors for long-term adverse health outcomes. Adverse childhood experience exposure did not appear to impact recidivism in a period of unprecedented low ED volumes during the coronavirus disease pandemic.
Objectives: Data from the 2019 National Survey of Children's Health revealed that 39.8% of children in the United States have been exposed to adverse childhood experiences (ACEs), which are risk factors for long-term negative health outcomes. This study aimed to determine the prevalence of ACE exposure in a pediatric emergency department (ED) patients and describe the association between ACE exposure and ED recidivism.

Methods: Five hundred ...

Traumatisme psychique chez l'enfant ; Enfants - Protection, assistance, etc ; Enfants maltraités - Protection, assistance, etc. ; Médecine d'urgence ; Hôpitaux - Services des urgences

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Intranasal Fentanyl to Reduce Pain and Improve Oral Intake in the Management of Children With Painful Infectious Mouth Lesions | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

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Objectives: Painful infectious mouth conditions such as herpangina, hand-foot-and-mouth disease, and herpetic gingivostomatitis can cause pain, dehydration, and hospitalization in young children. Treatment for these conditions is generally supportive and directed toward pain relief from ulcerative lesions, thus facilitating oral intake, and preventing dehydration. Attempts at oral therapy at home and in the emergency department are often refused and immediately spit back out. This study evaluated the efficacy of intranasal fentanyl (INF) compared with a commonly used oral (PO) acetaminophen/hydrocodone formulation for the treatment of children with painful infectious mouth conditions.

Methods: This study was a prospective, nonblinded, randomized controlled noninferiority trial conducted in an academic tertiary care pediatric emergency department. The study enrolled children between the ages of 6 months and 18 years with painful infectious mouth lesions and poor oral intake. Patients were randomized to receive either INF (1.5 [mu]g/kg, intervention) or PO acetaminophen/hydrocodone (0.15 mg/kg, control) based on the dose of hydrocodone. The primary outcome was volume of fluid intake per body weight (in milliliters per kilogram) 60 minutes after analgesic administration. Secondary outcomes included pain scores using a validated visual assessment scale (VAS; 1, no pain; 10, worst pain), hydration score (VAS; 1, well hydrated; 4, very dehydrated), admission rate and overall satisfaction score (VAS; 1, worst; 7, best). A priori power analysis indicated that 34 patients would achieve an 81% power with an [alpha] value of 0.05.

Results: Of the 34 patients enrolled, 17 were randomized to INF and 17 to PO. The demographics between both groups were similar in age, weight, sex, and race. There were no significant differences in parental perception of pain (P = 0.69) or hydration status (P = 0.78). Oral fluid intake at 60 minutes was 20 mL/kg for INF versus 18 mL/kg for PO (P = 0.53). Pain scores at 15 and 30 minutes were 1.7 versus 2.9 (P = 0.09) and 0.6 versus 1.6 (P = 0.59). Parental perceptions of pain and hydration status at 60 minutes were 2.2 versus 2.4 (P = 0.77) and 1.7 versus 1.5 (P = 0.37). Overall parental satisfaction was 6.4 for INF versus 6.5 for PO (P = 0.71), and admission rate was 0 vs 12% (P = 0.49). There were no adverse events such as respiratory, cardiac, or central nervous system depression in either group.

Conclusions: Intranasal fentanyl seems to be a safe and effective alternative to acetaminophen with hydrocodone in reducing pain and improving hydration status in children with painful infectious mouth lesions and poor oral intake.
Objectives: Painful infectious mouth conditions such as herpangina, hand-foot-and-mouth disease, and herpetic gingivostomatitis can cause pain, dehydration, and hospitalization in young children. Treatment for these conditions is generally supportive and directed toward pain relief from ulcerative lesions, thus facilitating oral intake, and preventing dehydration. Attempts at oral therapy at home and in the emergency department are often refused ...

Douleur ; Urgences en pédiatrie

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Neurologic Outcomes of Survivors of COVID-19-Associated Acute Respiratory Distress Syndrome Requiring Intubation | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

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OBJECTIVES: To describe 3-6-month neurologic outcomes of survivors of COVID-19-associated acute respiratory distress syndrome, invasively ventilated in the ICU.

DESIGN: A bicentric prospective study during the two first waves of the pandemic (March to May and September to December, 2020).

SETTING: Two academic hospital ICUs, Paris, France.

PATIENTS: Adult COVID-19-associated acute respiratory distress syndrome survivors, invasively ventilated in the ICU, were eligible for a neurologic consultation between 3 and 6 months post ICU discharge.

INTERVENTIONS: Follow-up by face-to-face neurologic consultation.

MEASURES AND MAIN RESULTS: The primary endpoint was favorable functional outcome defined by a modified Rankin scale score less than 2, indicating survival with no significant disability. Secondary endpoints included mild cognitive impairment (Montreal Cognitive Assessment score < 26), ICU-acquired weakness (Medical Research Council score < 48), anxiety and depression (Hospital Anxiety and Depression score > 7), and posttraumatic stress disorder (posttraumatic stress disorder checklist for Diagnostic and Statistical Manual of Mental Disorders 5 score > 30). Of 54 eligible survivors, four non-French-speaking patients were excluded, eight patients were lost-to-follow-up, and one died during follow-up. Forty-one patients were included. Time between ICU discharge and neurologic consultation was 3.8 months (3.6-5.9 mo). A favorable functional outcome was observed in 16 patients (39%) and mild cognitive impairment in 17 of 33 patients tested (52%). ICU-acquired weakness, depression or anxiety, and posttraumatic stress disorder were reported in six of 37 cases (16%), eight of 31 cases (26%), and two of 27 cases (7%), respectively. Twenty-nine patients (74%) required rehabilitation (motor, cognitive, or psychologic). ICU and hospital lengths of stay, tracheostomy, and corticosteroids were negatively associated with favorable outcome. By contrast, use of alpha-2 agonists during ICU stay was associated with favorable outcome.

CONCLUSIONS: COVID-19-associated acute respiratory distress syndrome requiring intubation led to slight-to-severe functional disability in about 60% of survivors 4 months after ICU discharge. Cognitive impairment, muscle weakness, and psychologic symptoms were frequent. A large multicenter study is warranted to allow identification of modifiable factors for improving long-term outcome.
OBJECTIVES: To describe 3-6-month neurologic outcomes of survivors of COVID-19-associated acute respiratory distress syndrome, invasively ventilated in the ICU.

DESIGN: A bicentric prospective study during the two first waves of the pandemic (March to May and September to December, 2020).

SETTING: Two academic hospital ICUs, Paris, France.

PATIENTS: Adult COVID-19-associated acute respiratory distress syndrome survivors, invasively ventilated ...

Appareil respiratoire - Maladies ; COVID-19 ; Cognition

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OBJECTIVE: To evaluate the impact of health information technology (HIT) for early detection of patient deterioration on patient mortality and length of stay (LOS) in acute care hospital settings.

DATA SOURCES: We searched MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from 1990 to January 19, 2021.

STUDY SELECTION: We included studies that enrolled patients hospitalized on the floor, in the ICU, or admitted through the emergency department. Eligible studies compared HIT for early detection of patient deterioration with usual care and reported at least one end point of interest: hospital or ICU LOS or mortality at any time point.

DATA EXTRACTION: Study data were abstracted by two independent reviewers using a standardized data extraction form.

DATA SYNTHESIS: Random-effects meta-analysis was used to pool data. Among the 30 eligible studies, seven were randomized controlled trials (RCTs) and 23 were pre-post studies. Compared with usual care, HIT for early detection of patient deterioration was not associated with a reduction in hospital mortality or LOS in the meta-analyses of RCTs. In the meta-analyses of pre-post studies, HIT interventions demonstrated a significant association with improved hospital mortality for the entire study cohort (odds ratio, 0.78 [95% CI, 0.70-0.87]) and reduced hospital LOS overall.

CONCLUSIONS: HIT for early detection of patient deterioration in acute care settings was not significantly associated with improved mortality or LOS in the meta-analyses of RCTs. In the meta-analyses of pre-post studies, HIT was associated with improved hospital mortality and LOS; however, these results should be interpreted with caution. The differences in patient outcomes between the findings of the RCTs and pre-post studies may be secondary to confounding caused by unmeasured improvements in practice and workflow over time.
OBJECTIVE: To evaluate the impact of health information technology (HIT) for early detection of patient deterioration on patient mortality and length of stay (LOS) in acute care hospital settings.

DATA SOURCES: We searched MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from 1990 to January 19, ...

Soins intensifs ; Hospitalisation

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Probiotics in Critical Illness: A Systematic Review and Meta-Analysis of Randomized Controlled Trials | Août 2022 H Nouveau

Article | Veille Urgence et soins intensifs (Urgence et soins intensifs)

y

OBJECTIVES: To determine the safety and efficacy of probiotics or synbiotics on morbidity and mortality in critically ill adults and children.

DATA SOURCES: We searched MEDLINE, EMBASE, CENTRAL, and unpublished sources from inception to May 4, 2021.

STUDY SELECTION: We performed a systematic search for randomized controlled trials (RCTs) that compared enteral probiotics or synbiotics to placebo or no treatment in critically ill patients. We screened studies independently and in duplicate.

DATA EXTRACTION: Independent reviewers extracted data in duplicate. A random-effects model was used to pool data. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach.

DATA SYNTHESIS: Sixty-five RCTs enrolled 8,483 patients. Probiotics may reduce ventilator-associated pneumonia (VAP) (relative risk [RR], 0.72; 95% CI, 0.59 to 0.89 and risk difference [RD], 6.9% reduction; 95% CI, 2.7-10.2% fewer; low certainty), healthcare-associated pneumonia (HAP) (RR, 0.70; 95% CI, 0.55-0.89; RD, 5.5% reduction; 95% CI, 8.2-2.0% fewer; low certainty), ICU length of stay (LOS) (mean difference [MD], 1.38 days fewer; 95% CI, 0.57-2.19 d fewer; low certainty), hospital LOS (MD, 2.21 d fewer; 95% CI, 1.18-3.24 d fewer; low certainty), and duration of invasive mechanical ventilation (MD, 2.53 d fewer; 95% CI, 1.31-3.74 d fewer; low certainty). Probiotics probably have no effect on mortality (RR, 0.95; 95% CI, 0.87-1.04 and RD, 1.1% reduction; 95% CI, 2.8% reduction to 0.8% increase; moderate certainty). Post hoc sensitivity analyses without high risk of bias studies negated the effect of probiotics on VAP, HAP, and hospital LOS.

CONCLUSIONS: Low certainty RCT evidence suggests that probiotics or synbiotics during critical illness may reduce VAP, HAP, ICU and hospital LOS but probably have no effect on mortality.
OBJECTIVES: To determine the safety and efficacy of probiotics or synbiotics on morbidity and mortality in critically ill adults and children.

DATA SOURCES: We searched MEDLINE, EMBASE, CENTRAL, and unpublished sources from inception to May 4, 2021.

STUDY SELECTION: We performed a systematic search for randomized controlled trials (RCTs) that compared enteral probiotics or synbiotics to placebo or no treatment in critically ill patients. We ...

Probiotiques ; Soins intensifs

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COVID-19 Vaccines in Older Adults: Challenges in Vaccine Development and Policy Making | Août 2022 H

Article | Veille Gériatrie-gérontologie (Gériatrie - gérontologie)

y

Older adults are a vulnerable group with a high need for coronavirus disease 2019 (COVID-19) vaccines, but these individuals are also more prone to the development of vaccine-related adverse events.

Older adults with frailty, disability, dementia or living in long-term care facilities need special attention in COVID-19 vaccination programs because supporting evidence for the safety and efficacy of COVID-19 vaccines in these individuals is limited.

The active involvement of geriatricians in vaccine development and related public-policy development is important for the success of adult vaccination strategies against COVID-19 and other communicable and noncommunicable diseases.

The completion of a primary series of COVID-19 vaccines with a heterologous booster dose remains the best strategy to reduce the impact of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections and transmission.
Older adults are a vulnerable group with a high need for coronavirus disease 2019 (COVID-19) vaccines, but these individuals are also more prone to the development of vaccine-related adverse events.

Older adults with frailty, disability, dementia or living in long-term care facilities need special attention in COVID-19 vaccination programs because supporting evidence for the safety and efficacy of COVID-19 vaccines in these individuals is ...

COVID-19 ; Coronavirus ; Vaccination ; Personnes âgées

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Behavioural side effects of inhaled corticosteroids among children and adolescents with asthma | 28 Jul 2022 H Nouveau

Article | Veille Pneumologie (Pneumologie)

UH

Inhalation corticosteroids (ICS) are prescribed for treatment of asthma in approximately 3% of all children in Denmark. Despite limited evidence, case reports suggest that ICS-related behavioural adverse drug ...ResearchThu, 28 Jul 2022 00:00:00 GMT

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Abstract Background Tuberculosis (TB) is a chronic infectious disease caused by the Mycobacterium tuberculosis complex (MTBC), which is the leading cause of death from infectious diseases. The rapid and accurate microbiological detection of the MTBC is crucial for the diagnosis and treatment of TB. Metagenomic next-generation sequencing (mNGS) has been shown to be a promising and satisfying application of detection in infectious diseases. However, relevant research about the difference in MTBC detection by mNGS between bronchoalveolar lavage fluid (BALF) and lung biopsy tissue specimens remains scarce. Methods We used mNGS to detect pathogens in BALF and lung biopsy tissue obtained by CT-guide percutaneous lung puncture (CPLP) or radial endobronchial ultrasound transbronchial lung biopsy (R-EBUS-TBLB) from 443 hospitalized patients in mainland China suspected of pulmonary infections between May 1, 2019 and October 31, 2021. Aim to evaluate the diagnostic performance of mNGS for detecting MTBC and explore differences in the microbial composition in the 2 specimen types. Results Among the 443 patients, 46 patients finally were diagnosed with TB, of which 36 patients were detected as MTBC positive by mNGS (8.93%). Striking differences were noticed in the higher detection efficiency of lung biopsy tissue compared with BALF (P = 0.004). There were no significant differences between the 2 specimen types in the relative abundance among the 27 pathogens detected by mNGS from the 36 patients. Conclusions This study demonstrates that mNGS could offer an effective detection method of MTBC in BALF or lung tissue biopsy samples in patients suspected of TB infections. When it comes to the situations that BALF samples have limited value to catch pathogens for special lesion sites or the patients have contraindications to bronchoalveolar lavage (BAL) procedures, lung biopsy tissue is an optional specimen for MTBC detection by mNGS. However, whether lung tissue-mNGS is superior to BALF-mNGS in patients with MTBC infection requires further prospective multicenter randomized controlled studies with more cases.
Abstract Background Tuberculosis (TB) is a chronic infectious disease caused by the Mycobacterium tuberculosis complex (MTBC), which is the leading cause of death from infectious diseases. The rapid and accurate microbiological detection of the MTBC is crucial for the diagnosis and treatment of TB. Metagenomic next-generation sequencing (mNGS) has been shown to be a promising and satisfying application of detection in infectious diseases. ...

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Influenza and Other Respiratory Viruses, EarlyView.AbstractBackgroundWith the emergence of SARS‐CoV‐2, influenza surveillance systems in Spain were transformed into a new syndromic sentinel surveillance system. The Acute Respiratory Infection Surveillance System (SiVIRA in Spanish) is based on a sentinel network for acute respiratory infection (ARI) surveillance in primary care and a network of sentinel hospitals for severe ARI (SARI) surveillance in hospitals.MethodsUsing a test‐negative design and data from SARI admissions notified to SiVIRA between January 1 and October 3, 2021, we estimated COVID‐19 vaccine effectiveness (VE) against hospitalization, by age group, vaccine type, time since vaccination, and SARS‐CoV‐2 variant.ResultsVE was 89% (95% CI: 83–93) against COVID‐19 hospitalization overall in persons aged 20 years and older. VE was higher for mRNA vaccines, and lower for those aged 80 years and older, with a decrease in protection beyond 3 months of completing vaccination, and a further decrease after 5 months. We found no differences between periods with circulation of Alpha or Delta SARS‐CoV‐2 variants, although variant‐specific VE was slightly higher against Alpha.ConclusionsThe SiVIRA sentinel hospital surveillance network in Spain was able to describe clinical and epidemiological characteristics of SARI hospitalizations and provide estimates of COVID‐19 VE in the population under surveillance. Our estimates add to evidence of high effectiveness of mRNA vaccines against severe COVID‐19 and waning of protection with time since vaccination in those aged 80 or older. No substantial differences were observed between SARS‐CoV‐2 variants (Alpha vs. Delta).AbstractBackgroundWith the emergence of SARS-CoV-2, influenza surveillance systems in Spain were transformed into a new syndromic sentinel surveillance system. The Acute Respiratory Infection Surveillance System (SiVIRA in Spanish) is based on a sentinel network for acute respiratory infection (ARI) surveillance in primary care and a network of sentinel hospitals for severe ARI (SARI) surveillance in hospitals.MethodsUsing a test-negative design and data from SARI admissions notified to SiVIRA between January 1 and October 3, 2021, we estimated COVID-19 vaccine effectiveness (VE) against hospitalization, by age group, vaccine type, time since vaccination, and SARS-CoV-2 variant.ResultsVE was 89% (95% CI: 83–93) against COVID-19 hospitalization overall in persons aged 20 years and older. VE was higher for mRNA vaccines, and lower for those aged 80 years and older, with a decrease in protection beyond 3 months of completing vaccination, and a further decrease after 5 months. We found no differences between periods with circulation of Alpha or Delta SARS-CoV-2 variants, although variant-specific VE was slightly higher against Alpha.ConclusionsThe SiVIRA sentinel hospital surveillance network in Spain was able to describe clinical and epidemiological characteristics of SARI hospitalizations and provide estimates of COVID-19 VE in the population under surveillance. Our estimates add to evidence of high effectiveness of mRNA vaccines against severe COVID-19 and waning of protection with time since vaccination in those aged 80 or older. No substantial differences were observed between SARS-CoV-2 variants (Alpha vs. Delta).
Influenza and Other Respiratory Viruses, EarlyView.AbstractBackgroundWith the emergence of SARS‐CoV‐2, influenza surveillance systems in Spain were transformed into a new syndromic sentinel surveillance system. The Acute Respiratory Infection Surveillance System (SiVIRA in Spanish) is based on a sentinel network for acute respiratory infection (ARI) surveillance in primary care and a network of sentinel hospitals for severe ARI (SARI) surveilla...

Influenza

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Home based pulmonary tele-rehabilitation under telemedicine system for COPD: a cohort study | 2022-07-24 H Nouveau

Article | Veille Pneumologie (Pneumologie)

UH

Abstract Background Pulmonary tele-rehabilitation can improve adherence to pulmonary rehabilitation. However, there are few reports on home based pulmonary tele-rehabilitation. We assessed the effectiveness of home based pulmonary tele-rehabilitation under telemedicine system in patients with chronic obstructive pulmonary disease (COPD). Methods This cohort study enrolled 174 patients with COPD who received home based pulmonary tele-rehabilitation under telemedicine system. The follow-up time was 12 weeks. Patients were grouped according to pulmonary rehabilitation weeks, number of rehabilitation times and total duration time, and when these three data were inconsistent, the two lowest values were grouped: control group (total rehabilitation weeks < 1 week, total number of rehabilitation times < 5, total duration time < 150 min, n = 46), pulmonary rehabilitation group 1 (PR-1) (1 week ≤ rehabilitation weeks < 4 weeks, 5 ≤ total number of rehabilitation times < 20, 150 min ≤ total duration time  < 1200 min, n = 31), pulmonary rehabilitation group 2 (PR-2) (4 weeks ≤ rehabilitation weeks < 8 weeks, 20 ≤ total number of rehabilitation times < 40, 600 min ≤ total duration time < 2400 min, n = 23), pulmonary rehabilitation group 3 (PR-3) (8 weeks ≤ rehabilitation weeks < 12 weeks, 40 ≤ total number of rehabilitation times < 60, 1200 min ≤ total duration time < 3600 min, n = 40) and pulmonary rehabilitation group 4 (PR-4) (rehabilitation weeks = 12 weeks, total number of rehabilitation times = 60, total duration time = 3600 min, n = 34). The clinical data before and after rehabilitation were collected and evaluated, including dyspnea symptoms, 6-min walk distance (6MWD), diaphragmatic mobility, anxiety and depression. Results There was no significance difference between control group and PR-1 group. PR-2 group after rehabilitation had significantly decreased CAT and HAMA scores than control (P < 0.05). Compared with control, PR-3 group and PR-4 group after rehabilitation had significantly higher 6MWD and diaphragmatic motility during deep breathing, but significantly lower CAT score, mMRC score, HAMA score, and HAMD score (P < 0.05). Compared with before pulmonary rehabilitation, in PR-3 and PR-4 groups, the 6MWD and the diaphragmatic motility during deep breathing were significantly higher, while CAT score, mMRC score, HAMA score, and HAMD score (for PR-4 only) were significantly lower after pulmonary rehabilitation (P  0.05). In the 12-week pulmonary rehabilitation program, patients who completed at least 8 weeks, namely those in the PR-3 and PR-4 groups, accounted for 42.5% of the total number. Education, income and response rate to telemedicine system reminders were the main risk factors associated with home based pulmonary tele-rehabilitation. Conclusions Home based pulmonary tele-rehabilitation under telemedicine system for more than 8 weeks can significantly improve the dyspnea symptoms, 6MWD, diaphragmatic mobility during deep breathing, and negative emotions of patients with moderate to severe stable COPD. Trial registration: This study was registered at Chinese Clinical Trial Registry under registration number of ChiCTR2200056241CTR2200056241.
Abstract Background Pulmonary tele-rehabilitation can improve adherence to pulmonary rehabilitation. However, there are few reports on home based pulmonary tele-rehabilitation. We assessed the effectiveness of home based pulmonary tele-rehabilitation under telemedicine system in patients with chronic obstructive pulmonary disease (COPD). Methods This cohort study enrolled 174 patients with COPD who received home based pulmonary tele-reh...

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