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International audience; Study objective: Assess the changes in anxiety, depression, and stress levels over time and identify risk factors among healthcare workers in French emergency departments (EDs) during the first COVID-19 outbreak.Method: A prospective, multicenter study was conducted in 4 EDs and an emergency medical service (SAMU). During 3 months, participants completed fortnightly questionnaires to assess anxiety, depression, and stress using the Hospital Anxiety and Depression and the Chamoux-Simard scale. The changes in anxiety, depression, and stress levels over time were modelled by a linear mixed model including a period effect and a continuous time effect within periods.Results: A total of 211 respondents (43.5 %) completed the survey at inclusion. There was a decrease in mean anxiety (from 7.33 to 5.05, p < 0.001), mean depression (from 4.16 to 3.05, p = 0.009), mean stress at work (from 41.2 to 30.2, p = 0.008), and mean stress at home (from 33.0 to 26.0, p = 0.031) at the beginning of each period. The mean anxiety level was higher for administrative staff (+0.53) and lower for paramedics (-0.61, p = 0.047) compared to physicians. The anxiety level increased with the number of day and night shifts (0.13/day, p < 0.001, 0.12/night, p = 0.025) as did stress at work (1.6/day, p < 0.001, 1.1/night, p = 0.007). Reassigned healthcare workers were at higher risk of stress particularly compared to SAMU workers (stress at work: p = 0.015, at home: p = 0.021, in life in general: p = 0.018).Conclusion: Although anxiety, depression, and stress decreased over time, anxiety was higher among physicians and administrative staff. Reassignment and working hours were identified as potential risk factors for mental health distress in EDs.Trial registration: ClinicalTrials.gov NCT04383886.

ntroduction: Few studies have investigated the management of COVID-19 cases from the operational perspective of the emergency department (ED), We sought to compare the management and outcome of COVID-19 positive and negative patients who presented to French EDs. Methods: We conducted a prospective, multicenter, observational study in four EDs. Included in the study were adult patients (≥18 years) between March 6–May 10, 2020, were hospitalized, and whose presenting symptoms were evocative of COVID-19. We compared the clinical features, management, and prognosis of patients according to their confirmed COVID-19 status. Results: Of the 2,686 patients included in this study, 760 (28.3%) were COVID-19 positive. Among them, 364 (48.0%) had hypertension, 228 (30.0%) had chronic cardiac disease, 186 (24.5%) had diabetes, 126 (16.6%) were obese, and 114 (15.0%) had chronic respiratory disease. The proportion of patients admitted to intensive care units (ICU) was higher among COVID-19 positive patients (185/760, 24.3%) compared to COVID-19 negative patients (206/1,926, 10.7%; P

Cardiopulmonary ultrasound imaging can be useful for diagnosing acute heart failure (AHF). We aimed to evaluate the diagnostic performance of an algorithm based on point-of-care ultrasound (POCUS) in patients coming to the emergency department with acute dyspnea.Prospective analysis of a convenience sample of patients with acute dyspnea in 2 hospital emergency departments. The POCUS algorithm included lung ultrasound findings and 3 echocardiographic measurements taken from an apical view of 4 chambers: mitral annular plane systolic excursion, Doppler mitral flow velocity, and tissue Doppler imaging of the lateral mitral annulus. The definitive diagnosis was made by 2 physicians blinded to the POCUS findings.A total of 103 adult patients with a mean (SD) age of 73 (12) years were included; about half (51 patients) were women. Forty-two patients (41%) were finally diagnosed with AHF. Interindividual agreement on the physicians' diagnoses was good (k = 0.82). The POCUS algorithm assigned an AHF diagnosis to 76 patients (74%); 56 of them (85%) were in sinus rhythm. The diagnostic performance indicators for the algorithm were as follows: area under the receiver operating characteristic curve, 0.94 (95% CI, 0.88-1.00); sensitivity 96% (95% CI, 78%-100%); specificity, 93% (95% CI, 8%-98%); positive predictive value, 85% (95% CI, 67%-100%); negative predictive value, 98% (95% CI, 88%-100%).The POCUS-based algorithm for diagnosing AHF performed well in patients coming to the emergency department with acute dyspnea.La ecografía cardiopulmonar puede ser útil para diagnosticar insuficiencia cardiaca aguda (ICA). Se evaluó el rendimiento diagnóstico de un algoritmo basado en ecografía cardiopulmonar a la cabecera del paciente (POCUS) para el diagnóstico de ICA en pacientes que consultan en urgencias por disnea aguda.Se evaluó prospectivamente una muestra de conveniencia de pacientes con disnea aguda en dos servicios de urgencias hospitalarios (SUH). El algoritmo POCUS incluía la ecografía pulmonar y tres mediciones ecocardiográficas realizadas en un plano apical de cuatro cámaras. Se midió el MAPSE (desplazamiento sistólico del plano del anillo mitral), doppler de flujo mitral y doppler tisular en el anillo mitral lateral. El diagnóstico final fue asignado por dos médicos ciegos entre sí y a los hallazgos ecográficos.Se incluyeron 103 pacientes adultos, la edad media fue 73 (12) años, 51 (50%) mujeres. El diagnóstico final fue ICA en 42 (41%) pacientes. La concordancia entre asignadores fue buena para el diagnóstico de ICA (k = 0,82). El algoritmo asignó un diagnóstico en 76 (74%) pacientes, 57 (85%) estaban en ritmo sinusal. El rendimiento diagnóstico del algoritmo de los 76 pacientes categorizados mostró un área bajo la curva de 0,94 (IC 95%: 0,88-1,00), sensibilidad 96% (IC 95%: 78-100%), especificidad 93% (IC 95%: 8-98%), valor predictivo positivo 85% (IC 95%: 67-100%), valor predictivo negativo 98% (IC 95%: 88-100%).El rendimiento de un algoritmo basado en ecografía cardiopulmonar POCUS fue bueno para diagnosticar ICA en pacientes que consultan en urgencias por disnea aguda.

Devant une fréquentation en perpétuelle augmentation sur plusieurs décennies, cette étude évalue l’impact des événements médiatiques inattendus et exceptionnels sur le recours aux services d’urgences d’Occitanie à partir de 14 situations (9 attentats ; 2 accidents ; 3 catastrophes naturelles).Matériel et méthode : il s’agit d’une étude rétrospective à partir des résumés de passages aux urgences où le nombre de passages dans l’ensemble des urgences occitanes au décours des 2 semaines suivant chaque épisode a été comparé au nombre de passages des 2 semaines précédant la même date ainsi qu’à la moyenne des 2 semaines de l’année suivante et précédente (test Student). La différence d’affluence selon le type d’évènement médiatique (Chi-2), le nombre de décès et la distance géographique de la localisation exacte (Régression Linéaire) ont également été analysés.Résultats : le nombre de passages aux urgences varie tantôt à la hausse, tantôt à la baisse suite aux événements étudiés et sans tendance décelable à l’échelle régionale. L’affluence augmente après les attentats et les accidents (p < 0.01) et décroit après les catastrophes naturelles (p < 0.01). Il n’existe pas d’association entre la différence de passages observée et le bilan des victimes ainsi qu’avec la distance géographique séparant l’événement du centre régional.Conclusion : les résultats globaux montrent des variations inconstantes et pauvres en effectif de l’affluence sur l’ensemble des SAU de la région Occitanie. Ces observations hétérogènes démontrent la complexité d’anticiper les fluctuations d’affluence au décours d’événements médiatiques inattendus et de grande ampleur.

International audience; Background: In acute stroke, large vessel occlusion (LVO) should be promptly identified to guide patient's transportation directly to comprehensive stroke centers (CSC) for mechanical thrombectomy (MT). In many cases, prehospital multi-parameter scores are used by trained emergency teams to identify patients with high probability of LVO. However, in several countries, the first aid organization without intervention of skilled staff precludes the on-site use of such scores. Here, we assessed the accuracy of LVO prediction using a single parameter (i.e. complete hemiplegia) obtained by bystander's telephone-based witnessing.Patients and methods: This observational, single-center study included consecutive patients who underwent intravenous thrombolysis at the primary stroke center and/or were directly transferred to a CSC for MT, from January 1, 2015 to March 1, 2020. We defined two groups: patients with initial hemiplegia (no movement in one arm and leg and facial palsy) and patients without initial hemiplegia, on the basis of a bystander's witnessing.Results: During the study time, 874 patients were included [mean age 73 years (SD 13.8), 56.7% men], 320 with initial hemiplegia and 554 without. The specificity of the hemiplegia criterion to predict LVO was 0.88, but its sensitivity was only 0.53.Conclusion: Our results suggest that the presence of hemiplegia as witnessed by a bystander can predict LVO with high specificity. This single criterion could be used for decision-making about direct transfer to CSC for MT when the absence of emergency skilled staff precludes the patient's on-site assessment, especially in regions distant from a CSC.

International audience; Since the first description of anaphylaxis in 1902, its clinical importance as an emergency condition has been recognized worldwide. Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity reaction characterized by rapid onset and the potential to endanger life through respiratory or circulatory compromise. It is usually, although not always, associated with skin and mucosal changes. Although the academic/scientific communities have advocated to promote greater awareness and protocols for the management of anaphylaxis based on best evidence, there are few efforts documenting feedback as to the success of these efforts. In this article, we review the key unmet needs related to the diagnosis and management of anaphylaxis, and propose a public health initiative for prevention measures and a timetable action plan that intends to strengthen the collaboration among health professionals and especially primary care physicians dealing with anaphylaxis, which can encourage enhanced quality of care of patients with anaphylaxis. More than calling for a harmonized action for the best management of anaphylaxis to prevent undue morbidity and mortality, the Montpellier World Health Organization Collaborating Centre here proposes an action plan as a baseline for a global initiative against anaphylaxis. We strongly believe that these collaborative efforts are a strong public health and societal priority that is consistent with the overarching goals of providing optimal care of allergic patients and best practices of allergology.

International audience; Lung ultrasound is commonly used for the diagnosis of pneumothorax. However, recognition of pleural sliding is subjective and can be difficult for novice. The primary objective was to compare a novices physician's performance in diagnosing pneumothorax from ultrasound (US) scans either with visual evaluation or with maximum longitudinal pleural strain (MLPS). The secondary objective was to compare the diagnostic relevance of US with visual evaluation or MLPS to diagnose pneumothorax with an intermediately experienced and an expert physician.Methods: We conducted a prospective, observational study in two emergency department and two intensive care unit, between February 2019 and June 2020. We included 99 adult patients with suspected pneumothorax, who received a chest computed tomography (CT). Three physicians with different experience of interpreting US scans (a novice physician, an intermediately experienced physician, and an expert) analyzed the US scans of 99 patients with suspected pneumothorax (50 (51%) with confirmed pneumothorax), which were confirmed by CT scan.Results: With a threshold of 5%, the MLPS sensitivity was 94% (95% CI [83%; 98%]), and the specificity was 100% (95% CI [93%; 100%]). The novice physician had an area under the curve (AUC) with visual analysis of 0.75 (95% CI [0.67; 0.83]) vs 0.86 (95% CI [0.79; 0.94]) with MLPS (p = 0.04). The intermediate physician's AUC for diagnosing pneumothorax with visual analysis was 0.93 (95% CI [0.88; 0.99]) vs 1.00 (95% CI [1.00; 1.00]) with MLPS (p < 0.01) and for the expert physician it was 0.98 (95% CI [0.95;1.00]) vs 0.97 (95% CI [0.93; 1.00]), respectively (p = 0.69).Conclusion: In our study, speckle tracking analysis improved the accuracy of US for the novice and the intermediate but not the expert sonographer in the diagnosis of pneumothorax.

Background Recent research has highlighted that patients with borderline personality disorder (BPD) could experience symptomatic remissions. This led to the production of guidelines concerning the most appropriate care. In addition, as BPD patients frequently present at an emergency department (ED), specific recommendations concerning how they should be cared for there have also been developed. The recommendations include the referral of patients to inpatient, outpatient or specific crisis care. However, an issue that has not been addressed is the capacity of ED services to apply the care recommendations. The objective of our study, therefore, was to identify the factors limiting their use in the ED of Toulouse University Hospital. Methods A panel of psychiatrists specializing in BPD care examined the medical files of 298 patients with a BPD diagnosis to determine which referrals were consistent or not, according to the care recommendations. A logistic regression was then performed to identify which sociodemographic, clinical, organizational or professional-training factors were associated with inconsistent referrals. Results 32% of patients experienced an inconsistent referral. Consultations performed during an on-call or day-off schedule were linked with inconsistent referrals, while an active follow-up was associated with the provision of consistent care. Conclusion Changing how evaluations of BPD patients in the ED are organized during on-call and day-off schedules could improve the application of the care recommendations regarding the most appropriate referrals.

International audience; The main objective of this study was to compare the medium-term results of nail bed repair in children using glue (2-octylcyanoacrylate) versus absorbable sutures. The secondary objective was to compare the results of treatment in the emergency room versus the operating room. This retrospective review of 74 fingertip nail bed lacerations (68 children) evaluated the appearance and pain at the last follow-up visit (minimum of 1 year), and the operating time. Mean age was 3.3 years at time of injury (range 10 months-13 years), with a mean follow-up of 2.6 (1-7) years. Thirty-six nail beds were repaired with glue; 38 were sutured. The clinical outcomes in the two groups were similar. The rate of nail dystrophy was 14% (5% major) regardless of the technique. Nail bed repair time was significantly shorter in the glue group (10.2 vs. 20.3min, p

International audience; BackgroundMaps of influenza activity are important tools to monitor influenza epidemics and inform policymakers. In France, the availability of a high-quality data set from the Oscour® surveillance network, covering 92% of hospital emergency department (ED) visits, offers new opportunities for disease mapping. Traditional geostatistical mapping methods such as Kriging ignore underlying population sizes, are not suited to non-Gaussian data and do not account for uncertainty in parameter estimates.ObjectiveOur objective was to create reliable weekly interpolated maps of influenza activity in the ED setting, to inform Santé publique France (the French national public health agency) and local healthcare authorities.MethodsWe used Oscour® data of ED visits covering the 2016-2017 influenza season. We developed a Bayesian model-based geostatistical approach, a class of generalized linear mixed models, with a multivariate normal random field as a spatially autocorrelated random effect. Using R-INLA, we developed an algorithm to create maps of the proportion of influenza-coded cases among all coded visits. We compared our results with maps obtained by Kriging.ResultsOver the study period, 45 565 (0.82%) visits were coded as influenza cases. Maps resulting from the model are presented for each week, displaying the posterior mean of the influenza proportion and its associated uncertainty. Our model performed better than Kriging.ConclusionsOur model allows producing smoothed maps where the random noise has been properly removed to reveal the spatial risk surface. The algorithm was incorporated into the national surveillance system to produce maps in real time and could be applied to other diseases.

Background Children with rare bone diseases (RBDs), whether medically complex or not, raise multiple issues in emergency situations. The healthcare burden of children with RBD in emergency structures remains unknown. The objective of this study was to describe the place of the pediatric emergency department (PED) in the healthcare of children with RBD. Methods We performed a retrospective single-center cohort study at a French university hospital. We included all children under the age of 18 years with RBD who visited the PED in 2017. By cross-checking data from the hospital clinical data warehouse, we were able to trace the healthcare trajectories of the patients. The main outcome of interest was the incidence (IR) of a second healthcare visit (HCV) within 30 days of the index visit to the PED. The secondary outcomes were the IR of planned and unplanned second HCVs and the proportion of patients classified as having chronic medically complex (CMC) disease at the PED visit. Results The 141 visits to the PED were followed by 84 s HCVs, giving an IR of 0.60 [95% CI: 0.48–0.74]. These second HCVs were planned in 60 cases (IR = 0.43 [95% CI: 0.33–0.55]) and unplanned in 24 (IR = 0.17 [95% CI: 0.11–0.25]). Patients with CMC diseases accounted for 59 index visits (42%) and 43 s HCVs (51%). Multivariate analysis including CMC status as an independent variable, with adjustment for age, yielded an incidence rate ratio (IRR) of second HCVs of 1.51 [95% CI: 0.98–2.32]. The IRR of planned second HCVs was 1.20 [95% CI: 0.76–1.90] and that of unplanned second HCVs was 2.81 [95% CI: 1.20–6.58]. Conclusion An index PED visit is often associated with further HCVs in patients with RBD. The IRR of unplanned second HCVs was high, highlighting the major burden of HCVs for patients with chronic and severe disease.

Background Hyponatremia is the most common electrolyte disorder in older adults and it can increase morbidity and mortality. Approximately one in three older adults fall each year; mild chronic hyponatremia can predispose this group to injurious falls and fractures and serum levels of sodium can also influence bone health. Little is known regarding the association between mild chronic hyponatremia and injurious fall prevalence in elderly patients admitted to the Emergency Department (ED). Therefore, the present study investigated the link between mild hyponatremia and the risk of injurious falls in elderly patients admitted to the Emergency Geriatric Medicine Unit (The MUPA Unit). Methods This cross-sectional study was conducted over 4 months and included patients ≥75 years of age who were admitted to the MUPA Unit of University Hospital Center of Limoges (France). Sociodemographic factors, fall events, comorbidities, medications, and sodium levels were assessed (hyponatremia was considered as sodium level < 136 mEq/L). Additionally, the short Comprehensive Geriatric Assessment (short-CGA), the Frailty score on the Short Emergency Geriatric Assessment (SEGA), and the Katz Activity of Daily Living (ADL) scale were administered. Results Of the 696 cases included in the final analysis, the mean age was 86.1 ± 5.6 years and 63.1% were female. The prevalence of falls was 27.9% (95% confidence interval [CI]: 24.6–31.2%) and that of mild hyponatremia was 15.9% (95% CI: 13.2–18.6%). The prevalence rate of mild hyponatremia was 13.2% (95% CI: 10.1–16.3%) in patients without falls and 26.1% (95% CI: 19.8–32.4%) in patients admitted for falls. Mild hyponatremia was significantly associated with falls (P < 0.001) and the adjusted odds ratio (OR) was 3.02 (95% CI: 1.84–4.96). Conclusions Because mild hyponatremia might be a risk factor for injurious falls and ED admission, determination of sodium levels during basic biomarker assessment on ED admission could be an important component of fall prevention strategies for the elderly.

International audience

International audience; Background: Very few studies have specifically addressed the role of the acute use of alcohol (AUA) in suicide attempts.Objective: Our study compared the suicide intent scores of self-poisoning patients with and without AUA in order to examine the role of alcohol in attempted suicides.Methods: We recruited 516 patients admitted to the emergency department for self-poisoning. We screened blood alcohol concentrations (BACs) to determine whether these were positive or negative in the two groups. We collected data about covariates such as psychiatric disorders and sociodemographic and suicide characteristics. We then compared suicide intent between the groups, adjusted according to the covariates.Results: The patients with AUA had lower scores for suicide intent, but this factor only reduced the self-reporting score, with the scores for objective circumstances and risk similar between the groups. There was a correlation between BACs and self-reported suicide intentionality, but this was not significant.Conclusion: Acute use of alcohol patients presented with lower suicide intent, as particularly explained by the self-report scores, but there were no differences between the groups in terms of risk and/or the objective circumstances. The role of alcohol in the self-reporting of suicide attempts must be addressed in future studies.

International audience; To derive and validate a clinical prediction rule of acute congestive heart failure obtainable in the emergency care setting.; Derivation of the score was performed on a retrospective 927 patients cohort admitted to our Emergency Department for dyspnea. The prediction model was externally validated on an independent 206-patient prospective cohort.; During the derivation phase, variables associated with acute congestive heart failure were included in a multivariate regression model. Logistic regression coefficients were used to assign scoring points to each variable. During the validation phase, every diagnosis was confirmed by an independent adjudication committee.; The score comprised 11 variables: age ≥65 years (1 point), seizure dyspnea (2 points), night outbreak (1 point), orthopnea (1 point), history of pulmonary edema (2 points), chronic pulmonary disease (-2 points), myocardial infarction (1 point), crackles (2 points), leg edema (1 point), ST-segment abnormality (1 point), atrial fibrillation/flutter (1 point) on electrocardiography. In the validation step, 30 patients (14.6%) had a low clinical probability of acute congestive heart failure (score ≤3), of which only 2 (6.7%) had a proven acute cardiogenic pulmonary edema. The prevalence of acute congestive heart failure was 58.5% in the 94 patients with an intermediate probability (score of 4-8) and 91.5% in the 82 patients (39.8%) with a high probability (score ≥9).; This score of acute congestive heart failure based on easily available and objective variables is entirely standardized. Applying the score to dyspneic adult emergency patients may enable a more rapid and efficient diagnostic process.

International audience; IMPORTANCE: D-dimer measurement is an important step in the diagnostic strategy of clinically suspected acute pulmonary embolism (PE), but its clinical usefulness is limited in elderly patients. OBJECTIVE: To prospectively validate whether an age-adjusted D-dimer cutoff, defined as age × 10 in patients 50 years or older, is associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. DESIGN, SETTINGS, AND PATIENTS: A multicenter, multinational, prospective management outcome study in 19 centers in Belgium, France, the Netherlands, and Switzerland between January 1, 2010, and February 28, 2013. INTERVENTIONS: All consecutive outpatients who presented to the emergency department with clinically suspected PE were assessed by a sequential diagnostic strategy based on the clinical probability assessed using either the simplified, revised Geneva score or the 2-level Wells score for PE; highly sensitive D-dimer measurement; and computed tomography pulmonary angiography (CTPA). Patients with a D-dimer value between the conventional cutoff of 500 µg/L and their age-adjusted cutoff did not undergo CTPA and were left untreated and formally followed-up for a 3-month period. MAIN OUTCOMES AND MEASURES: The primary outcome was the failure rate of the diagnostic strategy, defined as adjudicated thromboembolic events during the 3-month follow-up period among patients not treated with anticoagulants on the basis of a negative age-adjusted D-dimer cutoff result. RESULTS: Of the 3346 patients with suspected PE included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level lower than 500 µg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a D-dimer between 500 µg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%). The 3-month failure rate in patients with a D-dimer level higher than 500 µg/L but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI, 0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a nonhigh clinical probability, using the age-adjusted cutoff instead of the 500 µg/L cutoff increased the proportion of patients in whom PE could be excluded on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to 200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional false-negative findings. CONCLUSIONS AND RELEVANCE: Compared with a fixed D-dimer cutoff of 500 µg/L, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01134068.

The availability of short-stay beds for brief admission (less than 72 hours) of crisis patients presenting to the emergency room is a model that has gained a growing interest because it allows time for developing alternatives to psychiatric hospitalization and favors a maintained functioning in the community. The primary objective of this study was to determine the factors predicting aftercare dispositions: transfer for further hospitalization, or return to the community. All patients (n=255) admitted to the short-stay unit of the Emergency Department of Rambouillet General Hospital during a one year period were included in the study. Logistic regression analysis was used to determine which factors, among patients clinical and socio-demographic characteristics, were associated with further hospitalization decision at discharge. Statistically significant factors associated with a higher probability of hospitalization included the patient’s initial wish to be hospitalized, the presence of a comorbid disorder, a referral by family or friends, a history of psychiatric hospitalization and suicidal ideation on arrival in the emergency room. Conversely, significant factors associated with a lower probability of hospitalization were the presence of a personality disorder, a precipitating conflict situation, age between 20 and 39 years, being employed. Our study confirms that clinical factors such as the presence of a personality disorder or the context of a precipitating conflict situation are predictive of a community return. Interestingly, it points out the importance of the patient’s initial wish in the hospitalization decision.; L’hospitalisation psychiatrique de courte durée (HPCD) < 72h a montré son intérêt pour la prise en charge de patients en situation de crise, en favorisant la solution du suivi ambulatoire plutôt qu’une hospitalisation en milieu psychiatrique. Cependant les facteurs influençant la décision d’orientation à l’issue d’une HPCD sont encore peu connus. L’objectif de cette étude était de décrire les caractéristiques cliniques et socio-démographiques des patients admis en HPCD au sein des urgences d’un hôpital général et de déterminer les facteurs prédictifs d’une hospitalisation en psychiatrie à partir de celle-ci. Les données ont été collectées rétrospectivement à partir des dossiers informatisés des patients ayant bénéficié d’une HPCD (n=255) aux urgences de l’hôpital général de Rambouillet sur une période d’un an, puis analysés avec une méthode par régression logistique. Les facteurs associés de manière significative à une plus grande probabilité d’être hospitalisé étaient un souhait initial d’hospitalisation exprimé par le patient, l’existence d’une comorbidité, une demande de consultation émanant de l’entourage, un antécédent d’hospitalisation en psychiatrie, la présence d’idées suicidaires à l’arrivée aux urgences. Inversement, les facteurs associés à une probabilité plus faible d’hospitalisation étaient un diagnostic de trouble de la personnalité, un conflit avec l’entourage participant à la crise, un âge entre 20 et 39 ans, l’existence d’une activité professionnelle. Cette étude met ainsi en évidence les facteurs décisionnels d’intérêt orientant le devenir des patients admis en HPCD et notamment le poids de la demande initiale du patient.

International audience; IntroductionThe first aim of this study was to investigate the characteristics for elderly patients with acute heart failure presenting to the emergency department (ED). The second aim was to determine the characteristics of these elderly patients associated with serious adverse events.MethodsThe population was divided into 2 age groups

International audience; Surveillance of incident influenza-like illness (ILI) was implemented in two children and adult medical emergency departments during the influenza A (H1/N1) pandemic to assess correlations in the daily number of ILI-related emergency room visits (ERV) between these departments. A total of 7165 ILIs in children and 610 ILIs in adults were observed. We noticed a high linear correlation between the number of ERV involving ILI on day D in the pediatric department and the number of ERV because of ILI 2 days later in adults (R = 0*82, P < 10(-4)). Therefore, the rate of adult ILI-related ERV might be anticipated based on the rate of pediatric ERV.

International audience; OBJECTIVES: The objective was to compare outcomes associated with early, late, and no admission to the intensive care unit (ICU) for patients hospitalized with community-acquired pneumonia (CAP). METHODS: This was a post hoc analysis of the original data from the Emergency Department Community-Acquired Pneumonia (EDCAP) and Pneumocom-1 prospective multicenter cohort studies of adult patients hospitalized with CAP. Propensity score-adjusted analysis was used to compare 28-day mortality and hospital length of stay (LOS) for 199, 144, and 2,215 patients with early (i.e., ICU admission on the day of emergency department [ED] presentation), late, and no ICU admission. RESULTS: Unadjusted 28-day mortality rates were 13.1, 19.4, and 5.7% for early, late, and no ICU admissions, respectively (p < 0.001). After adjusting for quintile of propensity score, the odds of 28-day mortality were higher for late ICU admissions relative to early ICU admissions (odds ratio [OR] = 2.63; 95% confidence interval [CI] = 1.42 to 4.90), and no ICU admissions (OR = 3.40; 95% CI = 2.11 to 5.48), but did not differ between early and no ICU admissions (OR = 1.29; 95% CI = 0.79 to 2.09). The median hospital LOS was 10 days for early (interquartile range [IQR] = 7 to 18), 15 days for late (IQR 9 to 23), and 6 days (IQR 4 to 9) for no ICU admissions (p < 0.001). CONCLUSIONS: This study suggests that late but not early admission to the ICU is associated with higher 28-day mortality for patients hospitalized with CAP. Patients admitted to the ICU have longer hospital LOS in comparison to those managed on the wards, particularly if they are admitted late to the ICU.

International audience; INTRODUCTION: The diagnosis and treatment of chronic obstructive pulmonary disease (COPD) is suboptimal in many patients, which may impact on morbidity, mortality, use of healthcare resources and patients' overall quality of life. OBJECTIVES: To describe the management of COPD by respiratory physicians from the French mainland according to severity. METHODS: Observational cross-sectional survey performed in France in 2006-2007. 515 pulmonologists located throughout the national territory were involved and each of them had to recruit 5 patients with stable COPD. RESULTS: The study included 2494 patients (mean age 67 years, 78% males), of whom nearly 50% had severe to very severe COPD (GOLD stage III-IV). At inclusion, 93.2% of patients were receiving pharmacological treatment, most often non-nebulised bronchodilators (91.2%) and/or inhaled corticosteroids (73.7%). Pulmonary rehabilitation was scheduled or had been performed within the last 2 years in 26.9% of patients. Investigations and treatments were more frequent when the disease was more severe, but there was considerable overlap between severity grades. CONCLUSIONS: Differences in decisions about the investigation and treatment of COPD by pulmonologists can not be explained only by the severity of disease. Efforts must be made to identify other patient characteristics associated with these decisions, in order to help developing future recommendations.

Objective: To compare the 28-day mortality and hospital length of stay of patients with community-acquired pneumonia who were transferred to an intensive care unit on the same day of emergency department presentation (direct-transfer patients) with those subsequently transferred within 3 days of presentation (delayed-transfer patients). Design: Secondary analysis of the original data from two North American and two European prospective, multicenter, cohort studies of adult patients with community-acquired pneumonia. Patients: In all, 453 non-institutionalized patients transferred within 3 days of emergency department presentation to an intensive care unit were included in the analysis. Supplementary analysis was restricted to patients without an obvious indication for immediate transfer to an intensive care unit. Interventions: None. Measurements and Main Results: The sample consisted of 138 delayed-transfer and 315 direct-transfer patients, among whom 150 (33.1%) were considered to have an obvious indication for immediate intensive care unit admission. After adjusting for the quintile of propensity score, delayed intensive care unit transfer was associated with an increased odds ratio for 28-day mortality (2.07; 95% confidence interval, 1.12-3.85) and a decreased odds ratio for discharge from hospital for survivors (0.53; 95% confidence interval, 0.39-0.71). In a propensity-matched analysis, delayed-transfer patients had a higher 28-day mortality rate (23.4% vs. 11.7%; p = 0.02) and a longer median hospital length of stay (13 days vs. 7 days; p

Background Statistical algorithms are routinely used to detect outbreaks of well-defined syndromes, such as influenza-like illness. These methods cannot be applied to the detection of emerging diseases for which no preexisting information is available. This paper presents a method aimed at facilitating the detection of outbreaks, when there is no a priori knowledge of the clinical presentation of cases. Methods The method uses a visual representation of the symptoms and diseases coded during a patient consultation according to the International Classification of Primary Care 2nd version (ICPC-2). The surveillance data are transformed into color-coded cells, ranging from white to red, reflecting the increasing frequency of observed signs. They are placed in a graphic reference frame mimicking body anatomy. Simple visual observation of color-change patterns over time, concerning a single code or a combination of codes, enables detection in the setting of interest. Results The method is demonstrated through retrospective analyses of two data sets: description of the patients referred to the hospital by their general practitioners (GPs) participating in the French Sentinel Network and description of patients directly consulting at a hospital emergency department (HED). Informative image color-change alert patterns emerged in both cases: the health consequences of the August 2003 heat wave were visualized with GPs' data (but passed unnoticed with conventional surveillance systems), and the flu epidemics, which are routinely detected by standard statistical techniques, were recognized visually with HED data. Conclusion Using human visual pattern-recognition capacities to detect the onset of unexpected health events implies a convenient image representation of epidemiological surveillance and well-trained "epidemiology watchers". Once these two conditions are met, one could imagine that the epidemiology watchers could signal epidemiological alerts, based on "image walls" presenting the local, regional and/or national surveillance patterns, with specialized field epidemiologists assigned to validate the signals detected.

National audience; PRIMARY OBJECTIVE: To estimate the incidence of acute gastroenteritis (AGE) and rotavirus acute gastroenteritis (RVAGE) in children less than 5 years of age seeking medical care in primary care, emergency department, and hospital settings. SECONDARY OBJECTIVES: To compare the clinical profile of RVAGE and non-RVAGE and to describe the distribution of RV serotypes among RVAGE cases. METHODS: A prospective primary care, emergency ward and hospital-based observational study was conducted during 1 year in a selected city of France with 250,000 inhabitants. Children less than 5 years of age presenting with symptoms of AGE were included. Rotavirus was identified using an Elisa test in stools. RESULTS: The estimated annual incidence of RVAGE was 1.56% for AGE and 0.87% for RVAGE in hospital, 5.87% for AGE and 2.65% for RVAGE in emergency-wards, 7.39% for AGE and 1.45% for RVAGE in primary care. Total incidence was 14.82% for AGE and 4.96% for RVAGE among children less than 5 years of age. RVAGE were more clinically severe than the AGE: dehydration (26.8% vs. 14.7%, p

International audience; BACKGROUND: Although the Pneumonia Severity Index (PSI) has been extensively validated, little is known of the impact of its routine use as an aid to site-of-treatment decisions for patients with pneumonia who present to emergency departments (EDs). METHODS: A prospective, observational, controlled cohort study of patients with pneumonia was conducted in 8 EDs that used the PSI (PSI-user EDs) and 8 EDs that did not use the PSI (PSI-nonuser EDs) in France. The outcomes examined included the proportion of "low-risk" patients (PSI risk classes I-III) treated as outpatients, all-cause 28-day mortality, admission of inpatients to the intensive care unit, and subsequent hospitalization of outpatients. RESULTS: Of the 925 patients enrolled in the study, 472 (51.0%) were treated at PSI-user EDs, and 453 (49.0%) were treated at PSI-nonuser EDs; 449 (48.5%) of all patients were considered to be at low risk. In PSI-user EDs, 92 (42.8%) of 215 patients at low risk were treated as outpatients, compared with 56 (23.9%) of 234 patients at low risk in PSI-nonuser EDs. The adjusted odds ratios for outpatient treatment were higher for patients in PSI risk classes I and II who were treated in PSI-user EDs, compared with PSI-nonuser EDs (adjusted odds ratio, 7.0 [95% confidence interval, 2.0-25.0] and 4.6 [95% confidence interval, 1.3-16.2], respectively), whereas the adjusted odds ratio did not differ by PSI-user status among patients in risk class III or among patients at high risk. After adjusting for pneumonia severity, mortality was lower in patients who were treated in PSI-user EDs; other safety outcomes did not differ between patients treated in PSI-user and PSI-nonuser EDs. CONCLUSIONS: The routine use of the PSI was associated with a larger proportion of patients in PSI risk classes I and II who had pneumonia and who were treated in the outpatient environment without compromising their safety.

International audience; BACKGROUND: Adverse drug events (ADEs) are a substantial cause of hospital admissions. However, little is known about the incidence, preventability and severity of ADEs resulting in emergency department visits. To address this issue, we conducted a prospective survey in emergency departments of French public hospitals. METHODS: This study was performed over two periods of 1 week each, one in June 1999 and one in December 1999, in emergency departments of five university hospitals and five general hospitals throughout France. All patients aged>or=15 years presenting with medical complaints were included in the study. Trauma patients, those with gynaecological conditions and those with alcohol intoxication or intentional drug poisoning were excluded from the study. Each patient was assessed by two local emergency physicians to determine whether the visit was the result of an ADE. All medical records were subsequently validated by an independent group of medical lecturers in iatrogenic disorders. RESULTS: Out of a total of 1937 patients consulting, 1562 were taking at least one drug during the previous week and were included for analysis; 328 (21%; 95% CI 19, 23) of these patients consulted an emergency physician because of an ADE. Patients with ADEs were older than those without (mean age 63.5 vs 54.8 years; p

International audience; OBJECTIVE: To determine the effects over one year of contacting patients by telephone one month or three months after being discharged from an emergency department for deliberate self poisoning compared with usual treatment. DESIGN: Multicentre, randomised controlled trial. SETTING: 13 emergency departments in the north of France. PARTICIPANTS: 605 people discharged from an emergency department after attempted suicide by deliberate self poisoning. INTERVENTION: The intervention consisted of contacting patients by telephone at one month or three months after discharge from an emergency department for attempted suicide to evaluate the success of recommended treatment or to adjust treatment. Control patients received treatment as usual, in most cases referral back to their general practitioner. MAIN OUTCOME MEASURES: The primary outcome measures were proportion of participants who reattempted suicide, number of deaths by suicide, and losses to follow-up at 13 months' follow-up. Secondary outcome measures were types and number of contacts with health care. RESULTS: On an intention to treat basis, the three groups did not differ significantly for further suicide attempts, deaths by suicide, or losses to follow-up: contact at one month (intervention 23% (34/147) v controls 30% (93/312), difference 7%, 95% confidence interval - 2% to 15%), three months (25% (36/146) v 30%, difference 5%, - 4% to 14%). Participants contacted at one month were less likely at follow-up to report having reattempted suicide (12% v 22% in control group, difference 10%, 2% to 18%). CONCLUSION: Contacting people by telephone one month after being discharged from an emergency department for deliberate self poisoning may help reduce the number of reattempted suicides over one year.

International audience; BACKGROUND: D-dimer levels remain elevated in many patients after completion of a 6-month anticoagulant drug course for a first episode of venous thromboembolism (VTE), which may limit the clinical usefulness of D-dimer testing for ruling out a possible recurrence. METHODS: We assessed the safety and usefulness of D-dimer testing in patients with suspected pulmonary embolism (PE) who had experienced a previous VTE. We analyzed data from 2 outcome studies that enrolled 1721 consecutive emergency department patients with clinically suspected PE. Information on the existence of a previous episode of VTE was abstracted from the database. All the patients underwent a sequential diagnostic workup, including an enzyme-linked immunosorbent assay D-dimer test and a 3-month follow-up. RESULTS: The proportion of confirmed PE was 24.1% (415/1719); PE was ruled out by a negative D-dimer test result in 32.7% (462/1411) of the patients without previous VTE but in only 15.9% (49/308) of the patients with previous VTE (P

International audience; Various studies have shown that adverse drug events (ADE) are a substantial cause of hospital admissions. However, little is known about the incidence and severity of ADE resulting in hospital visits. To address this issue, we conducted a prospective survey in 10 primary care and emergency departments of French public hospitals. This study was performed over two periods of one week, one in June 1999 and one in December 1999, in primary care and emergency departments of five university hospitals and five general hospitals throughout France. Out of a total of 1,937 patients consulting, 1,562 were taking at least one drug during the previous week and were included for analysis according to the protocol. Altogether, 328 (21%; 95% confidence interval 19% to 23%) of these patients receiving at least one drug consulted because of an ADE. The sex ratio (M/F) was the same in both groups with or without ADE (1.04 vs 1.02, respectively, P = 0.83). Patients with ADE were older than those without (63.5 vs 54.8 years, P < 0.0001). Furthermore, ADR patients were more likely to have a higher severity score than no-ADE group (P = 0.019). The outcome seemed to be worse in patients with an ADE. The percentage of patients treated with 2 or more drugs and the number of drug exposures were significantly higher in patients with ADE than in those without (90.9% vs 75.0%, P < 0.0001, and 5.17 vs 3.82, P < 0.0001, respectively). The most frequent causes of visits for ADE-patients were digestive (n = 53, 16.2%), neurological (n = 52, 15.9%), cardiovascular (n = 49, 14.9%) and malaise (n = 49, 14.9%) events. In total, 410 drugs were incriminated in the occurrence of 328 ADE. The most frequently incriminated drug classes were (1) psychotropic agents, including anxiolytics and/or hypnotics, antidepressants and antipsychotics (n = 84, 20.5%), (2) diuretics (n = 48, 11.7%), (3) anticoagulants (n = 38, 9.3%), (4) other cardiovascular drugs (n = 63, 15.4%), and (5) analgesics, including non steroidal antiinflammatory agents (n = 57, 13.9%). The avoidability of ADE could be estimated by an external expert panel in 280 of the 328 cases. In 106 cases (37.9%), ADE was considered to be preventable because a contra-indication or a warning about drug use had not been respected.

International audience; BACKGROUND: Diagnosis of pulmonary embolism requires clinical probability assessment. Implicit assessment is accurate but is not standardized, and current prediction rules have shortcomings. OBJECTIVE: To construct a simple score based entirely on clinical variables and independent from physicians' implicit judgment. DESIGN: Derivation and external validation of the score in 2 independent management studies on pulmonary embolism diagnosis. SETTING: Emergency departments of 3 university hospitals in Europe. PATIENTS: Consecutive patients admitted for clinically suspected pulmonary embolism. MEASUREMENTS: Collected data included demographic characteristics, risk factors, and clinical signs and symptoms suggestive of venous thromboembolism. The variables statistically significantly associated with pulmonary embolism in univariate analysis were included in a multivariate logistic regression model. Points were assigned according to the regression coefficients. The score was then externally validated in an independent cohort. RESULTS: The score comprised 8 variables (points): age older than 65 years (1 point), previous deep venous thrombosis or pulmonary embolism (3 points), surgery or fracture within 1 month (2 points), active malignant condition (2 points), unilateral lower limb pain (3 points), hemoptysis (2 points), heart rate of 75 to 94 beats/min (3 points) or 95 beats/min or more (5 points), and pain on lower-limb deep venous palpation and unilateral edema (4 points). In the validation set, the prevalence of pulmonary embolism was 8% in the low-probability category (0 to 3 points), 28% in the intermediate-probability category (4 to 10 points), and 74% in the high-probability category (> or =11 points). LIMITATIONS: Interobserver agreement for the score items was not studied. CONCLUSIONS: The proposed score is entirely standardized and is based on clinical variables. It has sustained internal and external validation and should now be tested for clinical usefulness in an outcome study.