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PURPOSE: Our objective was to determine characteristics of electrocardiograms (ECG) that predict ventricular fibrillation (VF) among prehospital patients with suspected ST-segment elevation myocardial infarction (STEMI) in Québec. METHODS: We performed a matched case-control study of prehospital adult suspected with STEMI. Patients in case group (STEMI/VF+) were matched with controls (STEMI/VF-) for age and sex and then compared for ECG characteristics, including ST-segment elevations (STE) and depressions (STD), duration of interval complexes, general characteristics, and several calculated variables. Logistic regression was used to measure the association between ECG characteristics and VF development. RESULTS: Overall, 310 prehospital patients with suspected STEMI were included in the analysis (case group, n = 155; control group, n = 155). We confirmed that the presence of TW-pattern complex (OR 7.0, 95% CI 1.55-31.58), premature ventricular contraction (PVC) (OR 5.5, 95% CI 2.04-14.82), and STE in V2-V6 (OR 3.8, 95% CI 1.21-11.74) were electrocardiographic predictors of VF. We also observed that STD in V3-V5 (OR 6.5, 95% CI 1.42-29.39), atrial fibrillation (AF) ≥ 100 beats per minute (bpm) (OR 6.3, 95% CI 1.80-21.90), the combination of STE in V4 and V5, and STD in II, III and aVF (OR 4.8, 95% CI 1.01-22.35), and the presence of STD in ≥ 6 leads (OR 4.2, 95% CI 1.33-13.13) were also associated with VF development. Finally, simultaneous association of 2 (OR 2.3, 95% CI 1.13-4.06) and 3 (OR 11.6, 95% CI 3.22-41.66) predictors showed significant association with VF. CONCLUSIONS: In addition to some already known predictors, we have identified several ECG findings associated with the development of VF in patients with suspected STEMI. Early identification of patients with STEMI at increased risk of VF should help EMS providers anticipate adverse events and encourage use of defibrillation pads.

RéSUMé: OBJECTIF: Notre objectif était de déterminer les caractéristiques des électrocardiogrammes (ECG) qui prédisent la fibrillation ventriculaire (FV) chez les patients préhospitaliers suspectés d'infarctus du myocarde à élévation du segment ST (STEMI) au Québec. MéTHODES: Nous avons effectué une étude cas-témoin appariée de l'adulte préhospitalier suspecté avec STEMI. Les patients du groupe de cas (STEMI/VF+) ont été appariés avec les témoins (STEMI/VF-) pour l'âge et le sexe, puis comparés pour les caractéristiques ECG, y compris les élévations du segment ST (STE) et les dépressions (STD), la durée des complexes d'intervalles, les caractéristiques générales et plusieurs variables calculées. La régression logistique a été utilisée pour mesurer l'association entre les caractéristiques de l'ECG et le développement de la FV. RéSULTATS: Dans l'ensemble, 310 patients préhospitaliers présentant un STEMI suspecté ont été inclus dans l'analyse (groupe de cas, n = 155; groupe témoin, n = 155). Nous avons confirmé que la présence de complexes TW (OR 7,0, IC à 95% 1,55­31,58), de contraction ventriculaire prématurée (PVC) (OR 5,5, IC à 95% 2,04­14,82) et de STE dans V2­V6 (OR 3,8, IC à 95% 1,21­11,74) étaient des prédicteurs électrocardiographiques de la FV. Nous avons également observé que STD dans V3-V5 (OR 6,5, IC à 95% 1,42­29,39), fibrillation auriculaire (AF) 100 battements par minute (bpm) (OR 6,3, IC à 95% 1,80­21,90), la combinaison de STE dans V4 et V5, et STD dans II, III et aVF (OR 4,8, IC à 95% 1,01­22,35) et la présence de STD dans 6 dérivations (OR 4.2, IC à 95% 1.33­13.13) ont également été associés au développement de la FV. Enfin, l'association simultanée de 2 (OR 2,3, IC à 95% 1,13­4,06) et 3 (OR 11,6, IC à 95% 3,22­41,66) prédicteurs a montré une association significative avec la FV. CONCLUSIONS: En plus de certains prédicteurs déjà connus, nous avons identifié plusieurs résultats d'ECG associés au développement de la FV chez des patients présentant une STEMI suspectée. L'identification précoce des patients atteints de STEMI à risque accru de FV devrait aider les fournisseurs de soins médicaux d'urgence à anticiper les événements indésirables et à encourager l'utilisation de tampons de défibrillation.

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INTRODUCTION: Certification of out-of-hospital deaths is challenging as physicians are often unavailable at the scene. In these situations, emergency medical services will generally transport the decedent to the nearest hospital. In 2011, a remote death certification program was implemented in the province of Québec, Canada. The program was managed through an online medical control center and enabled death certification by a remote physician. We sought to evaluate the implementation and feasibility of the remote death certification program and to describe the challenges we experienced. METHODS: We retrospectively reviewed all remote death certification requests received at the online medical control center between 2011 and 2019. Data were collected from the online medical control center database and records. Feasibility was determined by evaluating the remote death certification rate. RESULTS: Overall, 84.1% of remote death certification requests were realized, producing a total of 9776 death certificates. Male decedents accounted for 61.5% of remote death certification requests and were more likely than females to undergo a coroner's investigation for cause of death (36.3% vs 20.8%, p = 0.017). Urban/mixed regions had higher rates of achieved remote death certifications (mean 87.3% vs 76.9%, p = 0.033) and putrefied bodies (mean 3.8% vs 2.2%, p = 0.137) compared to rural regions. Among unrealized remote death certification requests, the most common reason was failure of relatives to designate a funeral home (36.8%). CONCLUSION: Our 8-year experience with the remote death certification program demonstrates that despite facing numerous challenges, this process is feasible and offers a valuable option to manage out-of-hospital deaths. The remote death certification program is spreading in the remaining regions of Québec. Future studies will aim to quantify how much time this process saves for emergency medical services in each region of the province.

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Objective: Retrospective analysis evaluating and comparing the feasibility, effectiveness and safety of intranasal fentanyl (INF) and subcutaneous fentanyl (SCF) for pain management of patients with acute severe pain in a rural/suburban Emergency Medical Services (EMS) system. Methods: Pre- and post-pain management data of all patients (aged ≥14 years) who were transported to the emergency department (January 2015-August 2017) were extracted from EMS and online medical control center records, and compared for groups receiving INF or SCF. Kaplan-Meier analysis and the log-rank test were used to describe and compare the percentage of patients in both groups who experienced relief according to their clinically significant pain relief score. Subgroup analysis was performed by patient age (<70 years, ≥70 years). Results: 94.6% (SCF = 94.8%; INF = 94.4%) of patients successfully received fentanyl and 82.7% (SCF = 81.2%; INF = 84.0%) had complete data and were included in the analysis. No difference was observed in time to administration or in the effectiveness of INF and SCF, and neither route of administration resulted in major adverse events that required intervention by paramedics. Upon subgroup analysis, INF patients ≥70 years were more likely to experience relief compared to those <70 years. Conclusion: This retrospective analysis of prehospital patients in the Chaudière-Appalaches EMS system demonstrates that both IN and SC are feasible, effective and safe routes for administering fentanyl. The observed effects of INF were found to be greater among patients ≥70 years. Further research is required to compare these routes with more conventional methods of pain management.

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BACKGROUND: Prehospital 12­lead electrocardiogram (ECG) is the most widely used screening tool for recognition of ST-segment elevation myocardial infarction (STEMI). However, prehospital diagnosis of STEMI based solely on ECGs can be challenging. OBJECTIVES: To evaluate the ability of emergency department (ED) physicians to accurately interpret prehospital 12­lead ECGs from a remote location. METHODS: All suspected prehospital STEMI patients who were transported by EMS and underwent angiography between 2006 and 2014 were included. We reviewed prehospital ECGs and grouped them based on: 1) presence or absence of a culprit artery lesion following angiography; and 2) whether they met the 3rd Universal Definition of Myocardial Infarction. We also described characteristics of ECGs that were misinterpreted by ED physicians. RESULTS: A total of 625 suspected STEMI cases were reviewed. Following angiography, 94% (590/625) of patients were found having a culprit artery lesion, while 6% (35/625) did not. Among these 35 patients, 24 had ECGs that mimicked STEMI criteria and 9 had non-ischemic signs. Upon ECG reinterpretation, 92% (577/625) had standard STEMI criteria while 8% (48/625) did not. Among these 48 patients, 35 had ischemic signs ECGs and 13 did not. Characteristics of misinterpreted ECGs included pericarditis, early repolarization, STE > 1 mm (1­lead only), and negative T-wave. CONCLUSIONS: Remote interpretation of prehospital 12­lead ECGs by ED physicians was a useful diagnostic tool in this EMS system. Even if the rate of ECG misinterpretation is low, there is still room for ED physicians operating from a remote location to improve their ability to accurately diagnose STEMI patients.

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OBJECTIVE: Repeated or serial 12-lead electrocardiograms (ECGs) in the prehospital setting may improve management of patients with subtle ST-segment elevation (STE) or with a ST-segment elevation myocardial infarction (STEMI) that evolves over time. However, there is a minimal amount of scientific evidence available to support the clinical utility of this method. Our objective was to evaluate the use of serial 12-lead ECGs to detect STEMI in patients during transport in a Canadian emergency medical services (EMS) jurisdiction. METHODS: We performed a retrospective study of suspected STEMI patients transported by EMS in the Chaudière-Appalaches region (Québec, Canada) between August 2006 and December 2013. Patients were monitored by a serial 12-lead ECG system where an averaged ECG was transmitted every 2 minutes. Following review by an emergency physician, ECGs were grouped as having either a persistent STE or a dynamic STE that evolved over time. RESULTS: A total of 754 suspected STEMI patients were transported by EMS during the study period. Of these, 728 patients met eligibility criteria and were included in the analysis. A persistent STE was observed in 84.3% (614/728) of patients, while the remaining 15.7% (114/728) had a dynamic STE. Among those with dynamic STE, 11.1% (81/728) had 1 ST-segment change (41 no-STEMI to STEMI; 40 STEMI to no-STEMI) and 4.5% (33/728) had ≥ 2 ST-segment changes (17 no-STEMI to STEMI; 16 STEMI to no-STEMI). Overall, in 8.0% (58/728) of the cohort, STEMI was identified on a subsequent ECG following an initial no-STEMI ECG. CONCLUSIONS: Through recognition of transient ST-segment changes during transport via the prehospital serial 12-lead ECG system, STEMI was identified in 8% of suspected STEMI patients who had an initial no-STEMI ECG. Key words: electrocardiography; emergency medical services; ST-elevation myocardial infarction; prehospital dynamic ECG.

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The aim of the study was to determine the prevalence of false-positive and inappropriate cardiac catheterization laboratory (CCL) activation in patients suspected with ST-elevation myocardial infarction (STEMI) diverted to a percutaneous coronary intervention (PCI) facility after paramedics wireless 12-lead electrocardiogram transmission to an emergency physician at an online medical control center. This retrospective study collected data from medical records of patients with suspected STEMI from 2006 to 2014. It included demographics, coronaropathic risk factors, cardiac biomarkers, time from the first medical contact to treatment, and final diagnosis. Primary outcome was the rate of false-positive and inappropriate CCL activation. As secondary outcomes, we compared patient characteristics between cases of appropriate and inappropriate CCL activation, and we assessed the presence of cardiac biomarkers, time from first medical contact to start of PCI, and final diagnosis. Overall, 673 patients with suspected STEMI were included in the analysis. A total of 640 patients (95%) had coronarography, of which 10% (62 of 640) did not have a culprit coronary artery (false positive). Angiography was canceled for 5% (33 of 673) of patients. The total false-positive and inappropriate CCL activation rate was 14% (95 of 673). Average time from the first medical contact to the start of PCI was 47 ± 18.1 minutes. Unwanted CCL activations were more likely to involve men aged >65 years and patients with a history of coronary artery disease. In conclusion, our system of transmitted prehospital electrocardiography and STEMI interpretation by emergency physicians at an online medical control center showed a total false-positive and inappropriate CCL activation rate of 14% over the 8-year study period.

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Background/Study context: Determining whether C-reactive protein (CRP), blood lipids, total and trunk fat mass (FM), and waist circumference (WC) are associated with changes in physical capacity over 3 years (Δ) in elderly. METHODS: One hundred twenty-two men and women 68-83 years of age participated in a 3-year follow-up study. Physical capacity was measured using five objective tests: (1) Timed Up and Go (TUG), (2) chair stand (CS), (3) normal walking speed (NWS), (4) fast walking speed (FWS), and (5) one-leg stand (LS), along with physical performance score (PPS) at baseline (T1) and 3 years later (T4). Total and trunk FM, WC, blood lipids, and CRP measured at baseline, were considered as potential predictors. RESULTS: At baseline, CRP and total FM were significantly correlated with all physical capacity tests, whereas trunk FM was correlated with CS and LS, and blood lipids only with FSW. No significant correlation was observed for WC. Total and trunk FM measured at baseline were correlated with ΔTUG and ΔPPS, whereas trunk FM and WC measured at baseline were correlated with ΔNWS. CRP and blood lipids, measured at baseline, were not associated with any changes over 3 years. At the end, WC measured at baseline was the strongest independent predictor for all physical capacity measures at baseline (T1), and ΔPPS measured over 3 years could be predicted by baseline WC. CONCLUSION: FM distribution seems more useful to determine physical capacity than inflammation. Interestingly, over a short follow-up of 3 years, WC significantly predicted changes in a composite score of physical activity. More studies are needed to elucidate factors that may influence physical capacity decline over time.

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OBJECTIVE: To determine the feasibility, safety, and effectiveness of the subcutaneous route of fentanyl administration by Basic Life Support-Emergency Medical Technicians (BLS-EMT) in a rural and suburban region, with the support of an online pain management medical control center. METHODS: Retrospective study of patients who received subcutaneous fentanyl and were transported by BLS-EMT to the emergency department (ED) of an academic hospital between July 1, 2013 and January 1, 2014, inclusively. Fentanyl orders were obtained from emergency physicians via an online medical control (OLMC) center. Effectiveness was defined by changes in pain scores 15 minutes, 30 minutes, and 45+ minutes after initial fentanyl administration. Safety was evaluated by measuring vital signs, Ramsay sedation scores, and adverse events subsequent to fentanyl administration. Feasibility was defined as successful fentanyl administration by BLS-EMT. SPSS-20 was used for descriptive statistics, and independent t-tests and Mann-Whitney U tests were used to determine inter- and intra-group differences based on transport time. RESULTS: Two hundred and eighty-eight patients (288; 14 to 93 years old) with pain scores ≥7 were eligible for the study. Of the 284 (98.6%) who successfully received subcutaneous fentanyl, 35 had missing records or data, and 249 (86.5%) were included in analyses. Average pain score pre-fentanyl was 8.9 ± 1.1. Patients <70 years old received a higher dose of fentanyl than those ≥70 years old (1.4 ± 0.3 vs, 0.8 ± 0.2 mcg/kg, p < 0.05). Pain scores decreased significantly post-fentanyl administration and the proportion of patients achieving pain relief increased significantly (p < 0.05) over the course of transport to ED (15 minutes, 30 minutes, 45+ minutes). Only 1.6% of patients experienced adverse events, including hypotension (n = 2; 0.8%), nausea (n = 1; 0.4%), and Ramsay level >3 (n = 1; 0.4%). CONCLUSION: Prehospital subcutaneous fentanyl administration by BLS-EMT with the support of an OLMC center is a safe and feasible approach to pain relief in prehospital settings, and is not associated with major adverse events. Effectiveness, subsequent to subcutaneous fentanyl administration is characterized by a decrease in pain over the course of transport to ED. Further studies are needed to compare the effectiveness of SC administration by EMS with other routes of administration and other analgesics.

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OBJECTIVE: Isoflavones and exercise have been shown to affect C-reactive protein (CRP) and body composition and to act synergistically on trunk and total fat mass (FM), glucose metabolism, and lean body mass in postmenopausal women with a body mass index higher than 25 kg/m. We hypothesized that exercise and isoflavone supplementation (Ex + ISO) could reduce inflammation in the same subpopulation of women. The objective of this study was to investigate if 6 months of mixed exercise combined with isoflavones could have greater effects on specific inflammatory markers than exercise alone in overweight or obese postmenopausal women. METHODS: Thirty-four postmenopausal women aged 50 to 70 years were randomly assigned to exercise and placebo (Ex + PLA; n = 15) or Ex + ISO (n = 19). At baseline and after 6 months, waist circumference, hip circumference, total FM, trunk FM, leg FM, and muscle mass index (MMI; = total fat free mass [kg] / height [m]) were assessed (dual-energy x-ray absorptiometry). Inflammatory markers (CRP, tumor necrosis factor-α [TNF-α], and interleukin-6) were obtained by enzyme-linked immunosorbent assay. T tests were used to compare groups at baseline. RESULTS: The Ex + PLA group showed significant changes in MMI (+0.33 kg/m, P ≤ 0.009) and FM compartments (waist circumference, -5.13 cm; % FM, -1.31%; P ≤ 0.001), whereas inflammation remained unchanged. However, the Ex + ISO group showed significant changes in total FM (-1.70 kg, P < 0.0001), FM compartments (hip circumference [-2.51 cm, P = 0.019], leg FM [-1.16 kg, P = 0.037], and trunk FM [-0.72 kg, P = 0.006]), MMI (+0.39 kg, P = 0.011), and inflammation (CRP, -1.14 mg/L, P = 0.029; TNF-α, +0.29 pg/mL, P = 0.010). CONCLUSIONS: Despite an increase in TNF-α, the use of isoflavones-when body weight remains stable-seems to enhance the beneficial effects of mixed-exercise training on body composition and CRP in overweight or obese postmenopausal women.

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Phytoestrogens and training could be effective to reduce cardiovascular and type 2 diabetes mellitus risk factors in postmenopausal women. Nevertheless, the impact of their combination on adipokines and systemic inflammation was never investigated. The objective was to verify if 6 months of mixed training combined with phytoestrogens could have an additional effect on adipokine levels and systemic inflammation in obese postmenopausal women. Fifty-two obese women aged between 50 and 70 years were randomly assigned to (1) exercise with placebo (EX + PL; n = 25) or (2) exercise with phytoestrogens (EX + PHY; n = 27). Body weight, waist circumference, fat mass, and lean body mass (dual-energy x-ray absorptiometry) were assessed. Fasting plasma glucose and insulin, adiponectin, leptin, and C-reactive protein (CRP) levels were obtained after a 12-hour overnight fast. Total energy intake was measured with a 3-day dietary record. All measurements were performed before and after the 6-month intervention. Although energy intake remained unchanged, body composition was improved in all women (all Ps < .02). Plasma CRP and leptin levels decreased in both groups similarly (all Ps < .03), whereas plasma adiponectin and insulin did not change with exercise combined with placebo or phytoestrogens. Correlation analyses showed that homeostasis model assessment of insulin resistance (r = -0.58, P = .02) and fasting insulin levels (r = -0.42, P = .02) at baseline were both correlated with changes in leptin levels. Baseline fasting glucose (r = -0.36, P = .03) and adiponectin (r = 0.45, P = .005) levels were associated with changes in CRP concentrations. Although mixed exercise program combined with phytoestrogens does not seem to provide any additional effect, mixed training improves systemic inflammation and leptin concentrations in obese postmenopausal women.

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Laryngeal chemoreflexes (LCR) are triggered by the contact of liquids with the laryngeal mucosa. In the mature organism, LCR trigger lower airway protective responses (coughing, effective swallowing, and arousal) to prevent aspiration. General belief holds that LCR are responsible for apnea and bradycardia in the newborn mammal, including humans. Our laboratory has recently shown that LCR in full-term lambs are consistently analogous to the mature LCR reported in adult mammals, without significant apneas and bradycardias (St-Hilaire M, Nsegbe E, Gagnon-Gervais K, Samson N, Moreau-Bussiere F, Fortier PH, and Praud J-P. J Appl Physiol 98: 2197-2203, 2005). The aim of the present study was to assess LCR in nonsedated, newborn preterm lambs born at 132 days of gestation (term = 147 days). The preterm lambs were instrumented for recording glottal adductor electromyogram, electroencephalogram, eye movements, heart rate, respiration, and oximetry. A chronic supraglottal catheter was used for injecting 0.5 ml of saline, distilled water, and HCl (pH 2) during quiet sleep, active sleep, and wakefulness on postnatal days 7 (D7) and 14 (D14). Laryngeal stimulation by water or HCl on D7 induced significant apneas, bradycardia, and desaturation, which, at times, appeared potentially life-threatening. No significant apneas, bradycardias, or desaturation were observed on D14. No consistent effects of sleep state could be shown in the present study. In conclusion, laryngeal stimulation by liquids triggers potentially dangerous LCR in preterm lambs on D7, but not on D14. It is proposed that maturation of the LCR between D7 and D14 is partly involved in the disappearance of apneas/bradycardias of prematurity with postnatal age.

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