Sainte-Foy-lès-Lyon, France
Sainte-Foy-lès-Lyon, France

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Meyer G.,University of Paris Descartes | Meyer G.,French Institute of Health and Medical Research | Vicaut E.,University Paris Diderot | Danays T.,Boehringer Ingelheim | And 36 more authors.
New England Journal of Medicine | Year: 2014

BACKGROUND: The role of fibrinolytic therapy in patients with intermediate-risk pulmonary embolism is controversial. METHODS: In a randomized, double-blind trial, we compared tenecteplase plus heparin with placebo plus heparin in normotensive patients with intermediate-risk pulmonary embolism. Eligible patients had right ventricular dysfunction on echocardiography or computed tomography, as well as myocardial injury as indicated by a positive test for cardiac troponin I or troponin T. The primary outcome was death or hemodynamic decompensation (or collapse) within 7 days after randomization. The main safety outcomes were major extracranial bleeding and ischemic or hemorrhagic stroke within 7 days after randomization. RESULTS: Of 1006 patients who underwent randomization, 1005 were included in the intention-to-treat analysis. Death or hemodynamic decompensation occurred in 13 of 506 patients (2.6%) in the tenecteplase group as compared with 28 of 499 (5.6%) in the placebo group (odds ratio, 0.44; 95% confidence interval, 0.23 to 0.87; P = 0.02). Between randomization and day 7, a total of 6 patients (1.2%) in the tenecteplase group and 9 (1.8%) in the placebo group died (P = 0.42). Extracranial bleeding occurred in 32 patients (6.3%) in the tenecteplase group and 6 patients (1.2%) in the placebo group (P<0.001). Stroke occurred in 12 patients (2.4%) in the tenecteplase group and was hemorrhagic in 10 patients; 1 patient (0.2%) in the placebo group had a stroke, which was hemorrhagic (P = 0.003). By day 30, a total of 12 patients (2.4%) in the tenecteplase group and 16 patients (3.2%) in the placebo group had died (P = 0.42). CONCLUSIONS: In patients with intermediate-risk pulmonary embolism, fibrinolytic therapy prevented hemodynamic decompensation but increased the risk of major hemorrhage and stroke. Copyright © 2014 Massachusetts Medical Society. All rights reserved.


Decre D.,Laboratoire Of Microbiologie | Verdet C.,Laboratoire Of Bacteriologie | Emirian A.,Laboratoire Of Microbiologie | Le Gourrierec T.,Service dAccueil des Urgences | And 5 more authors.
Journal of Clinical Microbiology | Year: 2011

Severe infections caused by hypermucoviscous Klebsiella pneumoniae have been reported in Southeast Asian countries over the past several decades. This report shows their emergence in France, with 12 cases observed during a 2-year period in two university hospitals. Two clones (sequence type 86 [ST86] and ST380) of serotype K2 caused five rapidly fatal bacteremia cases, three of which were associated with pneumonia, whereas seven liver abscess cases were caused by K1 strains of ST23. Copyright © 2011, American Society for Microbiology. All Rights Reserved.


Gentile S.,Aix - Marseille University | Lacroix O.,Service de Medicine Interne Geriatrie | Durand A.C.,Aix - Marseille University | Cretel E.,Unite Mobile de Geriatrie | And 4 more authors.
Journal of Nutrition, Health and Aging | Year: 2013

Objectives: To identify independent risk factors of mortality among elderly patients in the 3 months after their visit (T3) to an emergency department (ED). Design: Prospective cohort study. Setting: University hospital ED in an urban setting in France. Participants: One hundred seventy-three patients aged 75 and older were admitted to the ED over two weeks (18.7% of the 924 ED visits). Of these, 164 patients (94.8%) were included in our study, and 157 (95.7%) of them were followed three months after their ED visit. Measurements: During the inclusion period (T0), a standardized questionnaire was used to collect data on socio-demographic and environmental characteristics, ED visit circumstances, medical conditions and geriatric assessment including functional and nutritional status. Three months after the ED visits (T3), patients or their caregivers were interviewed to collect data on vital status, and ED return or hospitalization. Results: Among the 157 patients followed at T3, 14.6% had died, 19.9% had repeated ED visits, and 63.1% had been hospitalized. The two independent predictive factors for mortality within the 3 months after ED visit were: malnutrition screened by the Mini Nutritional Assessment short-form (MNA-SF) (OR=20.2; 95% CI: 5.74-71.35; p<.001) and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) score (OR=1.1; 95% CI: 1.01-1.22; p=.024). Conclusion: Malnutrition is the strongest independent risk factor predicting short-term mortality in elderly patients visiting the ED, and it was easily detected by MNA-SF and supported from the ED visit. © 2013 Serdi and Springer-Verlag France.


Lenglet H.,Publique Hopitaux de Paris APHP | Sztrymf B.,Publique Hopitaux de Paris APHP | Leroy C.,Service dAccueil des Urgences | Brun P.,Service dAccueil des Urgences | And 4 more authors.
Respiratory Care | Year: 2012

OBJECTIVE: Heated and humidified high flow nasal cannula oxygen therapy (HFNC) represents a new alternative to conventional oxygen therapy that has not been evaluated in the emergency department (ED). We aimed to study its feasibility and efficacy in patients exhibiting acute respiratory failure presenting to the ED. METHODS: Prospective, observational study in a university hospital's ED. Patients with acute respiratory failure requiring > 9 L/min oxygen or with ongoing clinical signs of respiratory distress despite oxygen therapy were included. The device of oxygen administration was then switched from non-rebreathing mask to HFNC. Dyspnea, rated by the Borg scale and a visual analog scale, respiratory rate, and SpO2 were collected before and 15, 30, and 60 min after beginning HFNC. Feasibility was assessed through caregivers' acceptance of the device in terms of practicality and perceived effect on the subjects, evaluated by questionnaire. RESULTS: Seventeen subjects, median age 64 y (46-84.7 y), were studied. Pneumonia was the most common reason for oxygen therapy (n = 9). HFNC was associated with a significant decrease in both dyspnea scores: Borg scale from 6 (5-7) to 3 (2-4) (P <.001), and visual analog scale from 7 (5-8) to 3 (1-5) (P <.01). Respiratory rate decreased from 28 breaths/min (25-32 breaths/min) to 25 breaths/min (21-28 breaths/min) (P <.001), and SpO2 increased from 90% (88.5-94%) to 97% (92.5-100%) (P <.001). Fewer subjects exhibited clinical signs of respiratory distress (10/17 vs 3/17, P =.03). HFNC was well tolerated and no adverse event was noted. Altogether, 76% of healthcare givers declared preferring HFNC, as compared to conventional oxygen therapy. CONCLUSIONS: HFNC is possible in the ED, and it alleviated dyspnea and improved respiratory parameters in subjects with acute hypoxemic respiratory failure. © 2012 Daedalus Enterprises.


Demonchy E.,University of Nice Sophia Antipolis | Dufour J.-C.,Aix - Marseille University | Gaudart J.,Aix - Marseille University | Cervetti E.,ORU PACA | And 4 more authors.
The Journal of antimicrobial chemotherapy | Year: 2014

OBJECTIVES: Urinary tract infections (UTIs) are one of the leading reasons for antibiotic prescriptions in emergency departments (EDs), with half of these antibiotics being inappropriately prescribed. Our objective was to assess the impact of a computerized decision support system (CDSS) on compliance with guidelines on empirical antibiotic prescriptions (antibiotic and duration) for UTIs in EDs.METHODS: A multicentre prospective before-and-after controlled interventional study was conducted from 19 March to 28 October 2012. All adults diagnosed with community-acquired UTIs (cystitis, pyelonephritis or prostatitis) at three French EDs were included. The antibiotic therapy was considered compliant with guidelines if the antibiotic and the duration prescribed were in accordance with the national guidelines. Data were collected using electronic medical records. Paired tests were used when comparing periods within each ED and global analyses used multivariate logistic mixed models.RESULTS: Nine hundred and twelve patients were included during the 30 week study period. The CDSS was used in 59% of cases (182/307). The CDSS intervention improved the compliance of antibiotic prescriptions in only one ED in a bivariate analysis (absolute increase +20%, P = 0.007). The choice of the antibiotic was improved in multivariate analyses but only when the CDSS was used [OR = 1.94 (95% CI 1.13-3.32)]. The CDSS also changed the initial diagnosis in 23% of cases, in all three EDs.CONCLUSIONS: The CDSS only partially improved compliance with guidelines on antibiotic prescriptions in UTIs. © The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.


Durand A.-C.,Equipe Of Recherche Ea 3279 Evaluation Hospitaliere Mesure Of La Sante Percue | Palazzolo S.,Equipe Of Recherche Ea 3279 Evaluation Hospitaliere Mesure Of La Sante Percue | Tanti-Hardouin N.,Equipe Of Recherche Ea 3279 Evaluation Hospitaliere Mesure Of La Sante Percue | Gerbeaux P.,Service DAccueil des Urgences | And 2 more authors.
BMC Research Notes | Year: 2012

Background: For several decades, overcrowding in emergency departments (EDs) has been intensifying due to the increased number of patients seeking care in EDs. Demand growth is partly due to misuse of EDs by patients who seek care for nonurgent problems. This study explores the reasons why people with nonurgent complaints choose to come to EDs, and how ED health professionals perceive the phenomenon of nonurgency. Results: Semi-structured interviews were conducted in 10 EDs with 87 nonurgent patients and 34 health professionals. Interviews of patients revealed three themes: (1) fulfilled health care needs, (2) barriers to primary care providers (PCPs), and (3) convenience. Patients chose EDs as discerning health consumers: they preferred EDs because they had difficulties obtaining a rapid appointment. Access to technical facilities in EDs spares the patient from being overwhelmed with appointments with various specialists. Four themes were identified from the interviews of health professionals: (1) the problem of defining a nonurgent visit, (2) explanations for patients use of EDs for nonurgent complaints, (3) consequences of nonurgent visits, and (4) solutions to counter this tendency. Conclusions: Studies on the underlying reasons patients opt for the ED, as well as on their decision-making process, are lacking. The present study highlighted discrepancies between the perceptions of ED patients and those of health professionals, with a special focus on patient behaviour. To explain the use of ED, health professionals based themselves on the acuity and urgency of medical problems, while patients focused on rational reasons to initiate care in the ED (accessibility to health care resources, and the context in which the medical problem occurred). In spite of some limitations due to the slightly outdated nature of our data, as well as the difficulty of categorizing nonurgent situations, our findings show the importance of conducting a detailed analysis of the demand for health care. Understanding it is crucial, as it is the main determining factor in the utilization of health care resources, and provides promising insights into the phenomenon of ED usage increase. For reforms to be successful, the process of decision-making for unscheduled patients will have to be thoroughly investigated. © 2012 Durand et al.; licensee BioMed Central Ltd.


Durand A.-C.,Equipe Of Recherche Ea 3279 Evaluation Hospitaliere Mesure Of La Sante Percue | Gentile S.,Equipe Of Recherche Ea 3279 Evaluation Hospitaliere Mesure Of La Sante Percue | Devictor B.,Equipe Of Recherche Ea 3279 Evaluation Hospitaliere Mesure Of La Sante Percue | Palazzolo S.,Equipe Of Recherche Ea 3279 Evaluation Hospitaliere Mesure Of La Sante Percue | And 3 more authors.
American Journal of Emergency Medicine | Year: 2011

Nonurgent visits to emergency departments (ED) are a controversial issue; they have been negatively associated with crowding and costs. We have conducted a critical review of the literature regarding methods for categorizing ED visits into urgent or nonurgent and analyzed the proportions of nonurgent ED visits. We found 51 methods of categorization. Seventeen categorizations conducted prospectively in triage areas were based on somatic complaint and/or vital sign collection. Categorizations conducted retrospectively (n = 34) were based on the diagnosis, the results of tests obtained during the ED visit, and hospital admission. The proportions of nonurgent ED visits varied considerably: 4.8% to 90%, with a median of 32 %. Comparisons of methods of categorization in the same population showed variability in levels of agreement. Our review has highlighted the lack of reliability and reproducibility © 2011 Elsevier Inc. All rights reserved.


Beaudeux J.-L.,Hopital University Necker Enfants Malades | Laribi S.,Service dAccueil des Urgences
Annales de Biologie Clinique | Year: 2013

S100B is a small protein selectively synthesized by cerebral astro-glial cells. S100B participates physiologically in the regulation of intracellular free calcium levels, and exerts a neurotrophic activity on cerebral cells. The interest of S100B protein in clinical biology results from its physiological presence in biological fluids (cerebrospinal fluid, blood, urine) and from significant increased levels when an acute brain injury occurred, from vascular (intracra-nial hemorrhage, ischemic stroke) or traumatic (traumatic brain injury) origins. Thus, elevated plasma concentrations of S100B were significantly increased in patients with a minor, moderate and of course severe traumatic brain injury. By contrast, serum S100B levels remained unchanged in patients with negative craniocerebral tomography results, confirming the diagnostic value of this bio-marker. A prognostic value of the biomarker in the context of minor head injury is also reported.


Desmettre T.,Service daccueil des urgences
Revue des Maladies Respiratoires Actualites | Year: 2013

In France, spontaneous pneumothoraxes represent 78% of cases of pneumothorax in emergency units. The severity of pneumothorax varies from simple apical pneumothorax, to compressive suffocating pneumothorax. Treatment methods are multiple (abstention, monitoring, exsufflation, thoracic drainage, and thoracic surgery) with different treatment issues for the physician (recognized indication, feasibility and ease of technique, benefit/risk balance) and the patient (pain, efficiency, hospitalization). The indication of the first-line treatment of spontaneous pneumothorax is still not consensual between the thoracic drainage and the exsufflation. Although exsufflation is an efficient method, easy, simple, reproducible and with an economic benefit (length of stay) and recommended by BTS (British Thoracic Society), it is still rarely used in the treatment of spontaneous pneumothorax unlike conventional chest tube drainage which is associated with higher costs and more complications. The reasons for this limited use are the lack of: literature data, consensus and technical training of physicians. The EXPRED study, a prospective, randomized trial evaluating exsufflation versus drainage in first-line treatment of primary spontaneous pneumothorax, is underway. © 2013 Elsevier Masson SAS.


Raphael M.,Service daccueil des urgences
Annales Francaises de Medecine d'Urgence | Year: 2012

No clear evidence exists supporting the superiority of any one of the many methods used to reduce anterior shoulder dislocations. Success rates range from 70 to 90%, provided that the technique is perfectly controlled. The differences relate to the bio mechanical principle used, the position of the patient, the use of an assistant or equipment and the pain caused by the technique. Traction-countertraction techniques are associated with a high rate of fractures, nervous injury and vascular injury compared with other techniques and should be avoided. The choice depends on the practitioner's usual and presentation of the patient. Techniques that are quick, simple, painless and sure are ideal. They must be known and preferred whenever possible. © 2012 Société française de médecine d'urgence and Springer-Verlag France.

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