Antimicrobial for 7 or 14 Days for Febrile Urinary Tract Infection in Men: A Multicenter Noninferiority Double-Blind, Placebo-Controlled, Randomized Clinical Trial.

BACKGROUND: The optimal duration of antimicrobial therapy for urinary tract infections (UTIs) in men remains controversial. METHODS: To compare 7 days to 14 days of total antibiotic treatment for febrile UTIs in men, this multicenter randomized, double-blind. placebo-controlled noninferiority trial enrolled 282 men from 27 centers in France. Men were eligible if they had a febrile UTI and urine culture showing a single uropathogen. Participants were treated with ofloxacin or a third-generation cephalosporin at day 1, then randomized at day 3-4 to either continue ofloxacin for 14 days total treatment, or for 7 days followed by placebo until day 14. The primary endpoint was treatment success, defined as a negative urine culture and the absence of fever and of subsequent antibiotic treatment between the end of treatment and 6 weeks after day 1. Secondary endpoints included recurrent UTI within weeks 6 and 12 after day 1, rectal carriage of antimicrobial-resistant Enterobacterales, and drug-related events. RESULTS: Two hundred forty participants were randomly assigned to receive antibiotic therapy for 7 days (115 participants) or 14 days (125 participants). In the intention-to-treat analysis, treatment success occurred in 64 participants (55.7%) in the 7-day group and in 97 participants (77.6%) in the 14-day group (risk difference, -21.9 [95% confidence interval, -33.3 to -10.1]), demonstrating inferiority. Adverse events during antibiotic therapy were reported in 4 participants in the 7-day arm and 7 in the 14-day arm. Rectal carriage of resistant Enterobacterales did not differ between both groups. CONCLUSIONS: A treatment with ofloxacin for 7 days was inferior to 14 days for febrile UTI in men and should therefore not be recommended. CLINICAL TRIALS REGISTRATION: NCT02424461; Eudra-CT: 2013-001647-32.

The Response of Emergency Departments (EDs) to the COVID-19 Pandemic: The Experience of 5 EDs in a Paris-Based Academic Hospital Trust.

The coronavirus disease-2019 (COVID-19) pandemic has imposed unforeseen and unprecedented constraints on emergency departments (EDs). In this study, we detail the organizational and managerial tools recently implemented among 5 academic EDs in a French region particularly affected by COVID-19 and analyze how EDs responded to the COVID-19-related disease burden during different phases of the epidemic. Initially, they focused on the early detection of suspected cases by identifying 3 predominant COVID-19 syndromes. During this diagnostic process, patients were placed in respiratory isolation (facial mask before triage) and droplet isolation (ED rooms). A 3-level strategy for triage, clinical pathways in the EDs, and the organization of hospital spaces was based on the real-time polymerase chain reaction (RT-PCR) COVID-19 positivity rate, with ED strategies adapted to the exigencies of each level. This crisis demonstrated hospitals' adaptability and capacity to mobilize in the face of new risks, with hospitals and EDs coordinating their management to reallocate resources, optimize interoperability, and rethink patient pathways. This report on their processes may assist hospitals and EDs in areas currently spared by the new variants.

Impact of Fast SARS-CoV-2 Molecular Point-Of-Care Testing on Patients' Length of Stay in an Emergency Department.

The ID NOW COVID-19 system (IDNOW) is a point-of-care test (POCT) providing results within 15 min. We evaluated the impact of IDNOW use on patient length of stay (LOS) in an emergency department (ED). In the ED of Saint-Louis Hospital, Paris, France, adult patients requiring a rapid diagnosis of SARS-CoV-2 were tested with Cepheid Xpert Xpress SARS-CoV-2 or FilmArray respiratory panel RP2 in the virology laboratory between 18 October and 3 November 2020 (period 1) and with IDNOW between 4 November and 30 November 2020 (period 2). A total of 676 patients participated in the study, 337 during period 1 and 339 during period 2. The median LOS in ED was significantly higher in period 1 than in period 2 (276 versus 208 min, P < 0.0001). More patients spent less than 4 h in the ED in period 2 (61.3%) than in period 1 (38.3%) (P < 0.0001). By univariate analysis, factors associated with ED LOS were hypertension, anosmia/ageusia, number of patients per day, and ID NOW implementation in period 2. By multivariate analysis, the period of testing remained significantly associated with ED LOS. Rapid molecular SARS-CoV-2 POCT was associated with a reduced LOS for patients admitted to an ED. IMPORTANCE During COVID-19 pandemic upsurges, emergency departments had to deal with a massive flow of incoming patients. The need for COVID-19 infection status determination before medical ward admission worsened ED overcrowding. The development of molecular point-of-care testing gave new opportunities for getting faster results of SARS-CoV-2 genome detection 24 h a day. In our study, we show, with a multivariate analysis, that the use of the POCT COVID-19 IDNOW reduced the ED length of stay by 1 h. The rate of patients who waited less than 4 h in the ED increased significantly. Our study highlights the benefit of COVID-19 molecular POCT for preventing ED overcrowding and facilitating bed allocation and SARS-CoV-2-infected patient isolation.

Effect of a delayed admission to the intensive care unit on survival after emergency department visit in patients with cancer: a retrospective observational study.

BACKGROUND AND IMPORTANCE: Delayed admission to the ICU is reported to be associated with worse outcomes in cancer patients. OBJECTIVE: The main objective of this study was to compare the 180-day survival of cancer patients whether they were directly admitted to the ICU from the emergency department (ED) or secondarily from the wards after the ED visit. DESIGN, SETTINGS AND PARTICIPANTS: This was a retrospective observational study including all adult cancer patients that visited the ED in 2018 and that were admitted to the ICU at some point within 7 days from the ED visit. EXPOSURE: Delayed ICU admission. OUTCOME MEASURE AND ANALYSIS: Survival at day 180 was plotted using Kaplan-Meier curves, and hazard ratio (HR) from Cox proportional-hazard models was used to quantify the association between admission modality (directly from the ED or later from wards) and survival at day 180, after adjustment to baseline characteristics. RESULTS: During the study period, 4560 patients were admitted to the hospital following an ED visit, among whom 136 (3%) patients had cancer and were admitted to the ICU, either directly from the ED in 101 (74%) cases or secondarily from the wards in 35 (26%) cases. Patients admitted to the ICU from the ED had a better 180-day survival than those admitted secondarily from wards (log-rank P = 0.006). After adjustment to disease status (remission or uncontrolled malignancy), survival at day 180 was significantly improved in the case of admission to the ICU directly from the ED with an adjusted HR of 0.50 (95% confidence interval, 0.26-0.95), P = 0.03. CONCLUSION: In ED patients with cancer, a direct admission to the ICU was associated with better 180-day survival compared with patients with a delayed ICU admission secondary from the wards. However, several confounders were not taken into account, which limits the validity of this result.

Red Blood Cell Transfusion in the Emergency Department: An Observational Cross-Sectional Multicenter Study.

BACKGROUND: We aimed to describe red blood cell (RBC) transfusions in the emergency department (ED) with a particular focus on the hemoglobin (Hb) level thresholds that are used in this setting. METHODS: This was a cross-sectional study of 12 EDs including all adult patients that received RBC transfusion in January and February 2018. Descriptive statistics were reported. Logistic regression was performed to assess variables that were independently associated with a pre-transfusion Hb level ≥ 8 g/dL. RESULTS: During the study period, 529 patients received RBC transfusion. The median age was 74 (59-85) years. The patients had a history of cancer or hematological disease in 185 (35.2%) cases. Acute bleeding was observed in the ED for 242 (44.7%) patients, among which 145 (59.9%) were gastrointestinal. Anemia was chronic in 191 (40.2%) cases, mostly due to vitamin or iron deficiency or to malignancy with transfusion support. Pre-transfusion Hb level was 6.9 (6.0-7.8) g/dL. The transfusion motive was not notified in the medical chart in 206 (38.9%) cases. In the multivariable logistic regression, variables that were associated with a higher pre-transfusion Hb level (≥8 g/dL) were a history of coronary artery disease (OR: 2.09; 95% CI: 1.29-3.41), the presence of acute bleeding (OR: 2.44; 95% CI: 1.53-3.94), and older age (OR: 1.02/year; 95% CI: 1.01-1.04). CONCLUSION: RBC transfusion in the ED was an everyday concern and involved patients with heterogeneous medical situations and severity. Pre-transfusion Hb level was rather restrictive. Almost half of transfusions were provided because of acute bleeding which was associated with a higher Hb threshold.

Cancer Patients' Prehospital Emergency Care: Post Hoc Analysis from the French Prospective Multicenter Study EPICANCER.

BACKGROUND: Very little data are available concerning the prehospital emergency care of cancer patients. The objective of this study is to report the trajectories and outcomes of cancer patients attended by prehospital emergency services. METHODS: This was an ancillary study from a three-day cross-sectional prospective multicenter study in France. Adult patients with cancer were included if they called the emergency medical dispatch center Service d'Aide Médicale Urgente (SAMU). The study was registered on ClinicalTrials.gov (NCT03393260, accessed on 8th January 2018). RESULTS: During the study period, 1081 cancer patients called the SAMU. The three most frequent reasons were dyspnea (20.2%), neurological disorder (15.4%), and fatigue (13.1%). Among those patients, 949 (87.8%) were directed to the hospital, among which 802 (90.8%) were directed to an emergency department (ED) and 44 (5%) were transported directly to an intensive care unit (ICU). A mobile intensive care unit (MICU) was dispatched 213 (31.6%) times. The decision to dispatch an MICU seemed generally based on the patient's reason for seeking emergency care and the presence of severity signs rather than on the malignancy or the patient general health status. Among the patients who were directed to the ED, 98 (16.1%) were deceased on day 30. Mortality was 15.4% for those patients directed to the ED but who were not admitted to the ICU in the next 7 days, 28.2% for those who were admitted to ICU in the next 7 days, and 56.1% for those patients transported by the MICU directly to the ICU. CONCLUSION: Cancer patients attending prehospital emergency care were most often directed to EDs. Patients who were directly transported to the ICU had a high mortality rate, raising the question of improving triage policies.

Analysis of Emergency Department Visits and Hospital Activity during Influenza Season, COVID-19 Epidemic, and Lockdown Periods in View of Managing a Future Disaster Risk: A Multicenter Observational Study.

ED-visits and through-ED admissions to medical/surgical wards (MSW) and intensive care unit (ICU) during influenza, COVID-19 and lockdown periods were evaluated in a four-hospital prospective observational study from November 2018 to March 2020. ED visit characteristics and main diagnostic categories were assessed. Analysis of 368,262 ED-visits highlighted a significantly increasing trend in ED-visits during influenza followed by a significantly decreasing trend after lockdown. For MSW-admissions, a pattern of growth during influenza was followed by a fall that began during COVID-19 pandemic and intensified during the lockdown. For ICU-admissions, a significant rise during the COVID-19 pandemic was followed by diminution during the lockdown period. During lockdown, significantly diminishing trends were shown for all diagnostic categories (between -40.8% and -73.6%), except influenza-like illness/COVID cases (+31.6%), Pulmonary embolism/deep vein thrombosis (+33.5%) and frequent users (+188.0%). The present study confirms an increase in demand during the influenza epidemic and during the initial phase of the COVID-19 epidemic, but a drop in activity during the lockdown, mainly related to non-COVID conditions. Syndromic surveillance of ILI cases in ED is a tool for monitoring influenza and COVID-19, and it can predict ED activity and the need for MSW and ICU beds.

Surfaces and equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the emergency department at a university hospital.

OBJECTIVES: Environmental contamination by patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through respiratory droplets suggests that surfaces and equipment could be a medium of transmission. We aimed to assess the surface and equipment contamination by SARS-COV-2 of an emergency department (ED) during the coronavirus infectious disease-2019 (COVID-19) outbreak. METHODS: We performed multiple samples from different sites in ED patients care and non-patient care areas with sterile premoistened swabs and used real-time reverse transcriptase polymerase chain reaction (RT-PCR) to detect the presence of SARS-CoV-2 ribonucleic acid (RNA). We also sampled the personal protective equipment (PPE) from health care workers (HCWs). RESULTS: Among the 192 total samples, 10 (5.2%) were positive. In patient care areas, 5/46 (10.9%) of the surfaces directly in contact with COVID-19 patients revealed the presence of SARS-CoV-2 RNA, and 4/56 (7.1%) of the surfaces that were not directly in contact with COVID-19 patients were positive. SARS-CoV-2 RNA was present only in the patients' examination and monitoring rooms. Before decontamination SARS-CoV-2 RNA was present on the saturation clip, the scuff for blood pressure measurement, the stretcher, the plastic screens between patients and the floor. After decontamination, SARS-CoV-2 RNA remained on the scuff, the stretcher and the trolleys. All samples from non-patient care areas or staff working rooms were negative. Only one sample from the PPE of the HCWs was positive. CONCLUSIONS: Our findings suggest that surfaces and equipment contamination by SARS-CoV-2 RNA in an ED during the COVID-19 outbreak is low and concerns exclusively patients' examination and monitoring rooms, preserving non-patient care areas.

Accuracy of Emergency Department Clinical Findings for Diagnosis of Coronavirus Disease 2019.

STUDY OBJECTIVE: We seek to describe the medical history and clinical findings of patients attending the emergency department (ED) with suspected coronavirus disease 2019 (COVID-19) and estimate the diagnostic accuracy of patients' characteristics for predicting COVID-19. METHODS: We prospectively enrolled all patients tested for severe acute respiratory syndrome coronavirus 2 by reverse-transcriptase polymerase chain reaction in our ED from March 9, 2020, to April 4, 2020. We abstracted medical history, physical examination findings, and the clinical probability of COVID-19 (low, moderate, and high) rated by emergency physicians, depending on their clinical judgment. We assessed diagnostic accuracy of these characteristics for COVID-19 by calculating positive and negative likelihood ratios. RESULTS: We included 391 patients, of whom 225 had positive test results for severe acute respiratory syndrome coronavirus 2. Reverse-transcriptase polymerase chain reaction result was more likely to be negative when the emergency physician thought that clinical probability was low, and more likely to be positive when he or she thought that it was high. Patient-reported anosmia and the presence of bilateral B lines on lung ultrasonography had the highest positive likelihood ratio for the diagnosis of COVID-19 (7.58, 95% confidence interval [CI] 2.36 to 24.36; and 7.09, 95% CI 2.77 to 18.12, respectively). The absence of a high clinical probability determined by the emergency physician and the absence of bilateral B lines on lung ultrasonography had the lowest negative likelihood ratio for the diagnosis of COVID-19 (0.33, 95% CI 0.25 to 0.43; and 0.26, 95% CI 0.15 to 0.45, respectively). CONCLUSION: Anosmia, emergency physician estimate of high clinical probability, and bilateral B lines on lung ultrasonography increased the likelihood of identifying COVID-19 in patients presenting to the ED.

EPICANCER-Cancer Patients Presenting to the Emergency Departments in France: A Prospective Nationwide Study.

BACKGROUND: We aimed to estimate the prevalence of cancer patients who presented to Emergency Departments (EDs), report their chief complaint and identify the predictors of 30-day all-cause mortality. PATIENTS AND METHODS: we undertook a prospective, cross-sectional study during three consecutive days in 138 EDs and performed a logistic regression to identify the predictors of 30-day mortality in hospitalized patients. RESULTS: A total of 1380 cancer patients were included. The prevalence of cancer patients among ED patients was 2.8%. The most frequent reasons patients sought ED care were fatigue (16.6%), dyspnea (16.3%), gastro-intestinal disorders (15.1%), trauma (13.0%), fever (12.5%) and neurological disorders (12.5%). Patients were admitted to the hospital in 64.9% of cases, of which 13.4% died at day 30. Variables independently associated with a higher mortality at day 30 were male gender (Odds Ratio (OR), 1.63; 95% CI, 1.04-2.56), fatigue (OR, 1.65; 95% CI, 1.01-2.67), poor performance status (OR, 3.00; 95% CI, 1.87-4.80), solid malignancy (OR, 3.05; 95% CI, 1.26-7.40), uncontrolled malignancy (OR, 2.27; 95% CI, 1.36-3.80), ED attendance for a neurological disorder (OR, 2.38; 95% CI, 1.36-4.19), high shock-index (OR, 1.80; 95% CI, 1.03-3.13) and oxygen therapy (OR, 2.68; 95% CI, 1.68-4.29). CONCLUSION: Cancer patients showed heterogeneity among their reasons for ED attendance and a high need for hospitalization and case fatality. Malignancy and general health status played a major role in the patient outcomes. This study suggests that the emergency care of cancer patients may be complex. Thus, studies to assess the impact of a dedicated oncology curriculum for ED physicians are warranted.

Antibiotic prescribing and outcomes in cancer patients with febrile neutropenia in the emergency department.

INTRODUCTION: The benefit of reducing the time of antibiotic initiation in the emergency department (ED) for neutropenic patients is controversial and the research on the impact of antibiotic adherence to international guidelines in the ED is scarce. We aimed to investigate the effect of antibiotic timing and appropriateness on outcomes in patients with febrile neutropenia (FN) and to assess the performance of the MASCC risk-index to risk-stratify such patients in the ED. METHODS: We prospectively identified patients with FN who presented to our ED and assessed their Multinational Association of Supportive Care in Cancer (MASCC) risk-index. The time to parenteral antibiotic initiation and the appropriateness of the antibiotic regimen according to international guidelines were retrospectively abstracted. The performance of the MASCC risk-index in predicting the absence of complication was assessed with sensitivity, specificity and the area under the receiver operating characteristics curve (AUC). We investigated the effect of the time to antibiotic initiation and the appropriateness of the antibiotic regimen on the outcome (ICU admission or death) by logistic regression analyses. RESULTS: We included 249 patients. Median age was 60 years and 67.9% had hematological malignancies, 26 (10.4%) were admitted to the ICU and 23 (9.8%) died during hospital stay. Among the 173 patients at low risk according to the MASCC risk-index, 56 (32.4%) presented at least one complication including 11 deaths. The MASCC risk-index had a sensitivity and a specificity of 0.78% and 0.43%, respectively, in predicting the absence of complication and the AUC was 0.67. The time to antibiotic initiation in the ED was not associated with the outcome after adjusting for performance status and shock-index. Conversely, an inadequate ED antibiotic regimen was associated with higher ICU admission or death during hospital stay (OR = 3.50; 95% CI = 1.49 to 8.28). CONCLUSION: An inadequate ED antibiotic regimen in patients with FN was significantly associated with higher ICU admission or death during hospital stay.

Fulminant diabetes due to immune checkpoint inhibitors in the emergency department.

Immune checkpoint inhibitors (ICIs) are of growing importance in new cancer therapies, exposing patients to various and potentially severe immune-related adverse events and placing emergency physicians on the front line when they occur. If endocrine toxicity is a well-known complication of ICIs, fulminant diabetes with diabetic ketoacidosis is exceptional. We present a case of fulminant diabetes after only two cycles of pembrolizumab in a 53-year-old man with a history of metastatic lung cancer who presented to our emergency department with coma and acidosis revealing diabetic ketoacidosis. The patient was rehydrated and treated with insulin and recovered quickly. Lung toxicity was also suspected on CT-scan findings. This rare and life-threatening complication that developed unusually early during the treatment course may be challenging in a cancer patient. Therefore, emergency physicians should investigate symptoms in patients treated with checkpoint inhibitors and consider toxicity when they present to the ED with complaints compatible with an immune-related adverse event.

Glucocorticoids for acute urticaria: study protocol for a double-blind non-inferiority randomised controlled trial.

INTRODUCTION: This study protocol describes a trial designed to investigate whether antihistamine alone in patients with acute urticaria does not increase the 7-day Urticaria Activity Score (UAS7) in comparison with an association of antihistamine and glucocorticoids and reduces short-term relapses and chronic-induced urticaria. METHODS AND ANALYSIS: This is a prospective, double-blind, parallel-group, multicentre non-inferiority randomised controlled trial. Two-hundred and forty patients with acute urticaria admitted to emergency department will be randomised in a 1:1 ratio to receive levocetirizine or an association of levocetirizine and prednisone. Randomisation will be stratified by centre. The primary outcome will be the UAS7 at day 7. The secondary outcomes will encompass recurrence of hives and/or itch at day 7; occurrence of spontaneous hives or itch for >6 weeks; patients with angioedema at day 7, and 2, 6, 12 and 24 weeks; new emergency visits for acute urticaria recurrences at days 7 and 14, and 3 months; Dermatology Life Quality Index at days 7 and 14, and 3 and 6 months; and Chronic Urticaria Quality of Life Questionnaire at 6 weeks. ETHICS AND DISSEMINATION: The protocol has been approved by the Comité de Protection des PersonnesSud-Méditerranée II and will be carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. A steering committee will oversee the progress of the study. Findings will be disseminated through national and international scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03545464.

Immune checkpoint blockade toxicity among patients with cancer presenting to the emergency department.

OBJECTIVES: We sought to estimate the prevalence of patients with cancer presenting to the emergency department (ED) who are undergoing treatment with immune checkpoint blockade (ICB) therapy; report their chief complaints; describe and estimate the prevalence of immune-related adverse events (IRAEs). METHODS: Four abstractors reviewed the medical records of patients with cancer treated with ICB who presented to an ED in Paris, France between January 2012 and June 2017. Chief complaints, underlying malignancy and ICB characteristics, and the final diagnoses according to the emergency physician were recorded. Abstractors noted if an emergency physician identified that a patient was receiving an ICB and if the emergency physician considered the possibility of an IRAE. The gold standard as to whether an IRAE was the cause was the patients' referring oncologist's opinion that the ED symptoms were attributed to ICB and IRAE according to post-ED medical records. Descriptive statistics were reported. RESULTS: Among the 409 patients treated with ICB at our institution, 139 presented to the ED. Chief complaints were fatigue (25.2%), fever (23%), vomiting (13.7%), diarrhoea (13.7%), dyspnoea (12.2%), abdominal pain (11.5%), confusion (8.6%) and headache (7.9%). Symptoms were due to IRAEs in 20 (14.4%) cases. The most frequent IRAEs were colitis (40%), endocrine toxicity (30%), hepatitis (25%) and pulmonary toxicity (5%). Patients with IRAEs compared with those without them more frequently had melanoma; had received more distinct courses of ICB treatment, an increased number of ICB medications and ICB cycles; and had a shorter time course since the last infusion of ICB. Emergency physicians considered the possibility of an IRAE in 24 (17.3%) of cases and diagnosed IRAE in 10 (50%) of those with later confirmed IRAE. IRAE was more likely to be missed when the referring oncologist was not contacted or when the patient had respiratory symptoms, fatigue or fever. CONCLUSIONS: ICB exposes patients to potentially severe IRAEs. Emergency physicians must identify patients treated with ICB and consider their toxicity when patients present to the ED with symptoms compatible with IRAEs.

Central venous oxygen saturation is not predictive of early complications in cancer patients presenting to the emergency department.

Central venous oxygen saturation (ScvO2) is easily observable in oncology patients with long-term central venous catheters (CVC), and has been studied as a prognostic factor in patients with sepsis. We sought to investigate the association between ScvO2 and early complications in cancer patients presenting to the ED. We prospectively enrolled adult cancer patients with pre-existing CVC who presented to the ED. ScvO2 was measured on their CVC. The outcome was admission to the intensive care unit (ICU) or mortality by day 7. ScvO2 was first studied as a continuous variable (%) with a ROC analysis and as a categorical variable (cut-off at < 70%) with a multivariate analysis. A total of 210 cancer patients were enrolled. At baseline, ScvO2 showed no significant difference between patients who were admitted to the ICU or died before day 7, and patients who did not (67%; IQR 62-68% vs. 71%; IQR 65-78% respectively, P = 0.3). The ROC analysis showed the absence of discrimination accuracy for ScvO2 to predict the outcome (AUC = 0.56). By multivariate analysis, ScvO2 < 70% was not associated with the outcome (OR 1.67; 95% CI 0.64-4.36). Variables that were associated with ICU admission or death by day 7 included a shock-index (heart rate/systolic blood pressure) > 1 and a performance status > 2 (OR 4.76; 95% CI 1.81-12.52 and OR 6.23, 95% CI 2.40-16.17, respectively). This study does not support the use of ScvO2 to risk stratify cancer patients presenting to the ED.

Monitoring Personalized Learning Curves for Emergency Ultrasound With Risk-adjusted Learning-curve Cumulative Summation Method.

BACKGROUND: Ultrasound (US) has been a regular practice in emergency departments for several decades. Thus, train our students to US is of prime interest. Because US image acquisition ability can be very different from a patient to another (depending on image quality), it seems relevant to adapt US learning curves (LCs) to patient image quality using tools based on cumulative summation (CUSUM) as the risk-adjusted LC CUSUM (RLC). OBJECTIVES: The aim of this study was to monitor LC of medical students for the acquisition of abdominal emergency US views and to adapt these curves to patient image quality using RLC. METHODS: We asked medical students to perform abdominal US examinations with the acquisition of 11 views of interest on emergency patients after a learning session. Emergency physicians reviewed the student examinations for validation. LCs were plotted and the student was said proficient for a specific view if his LC reached a predetermined limit fixed by simulation. RESULTS: Seven students with no previous experience in US were enrolled. They performed 19 to 50 examinations of 11 views each. They achieve proficiency for a median of 9 (6-10) views. Aorta and right pleura views were validated by seven students; inferior vena cava, right kidney, and bladder by six; gallbladder and left kidney by five; portal veins and portal hilum by four; and subxyphoid and left pleura by three. The number of US examinations required to reach proficiency ranged from five to 41 depending on the student and on the type of view. LC showed that students reached proficiency with different learning speeds. CONCLUSIONS: This study suggests that, when monitoring LCs for abdominal emergency US, there is some heterogeneity in the learning process depending on the student skills and the type of view. Therefore, rules based on a predetermined number of examinations to reach proficiency are not satisfactory.