Prevalence of Thoracic Aortic Aneurysms in Patients with Degenerative Abdominal Aortic Aneurysms: Results from the Prospective ACTA Study.

OBJECTIVE: There are no recommendations for screening for thoracic aortic aneurysms (TAAs), even in patients with infrarenal abdominal aortic aneurysms (AAAs). The aims of this study were to determine the prevalence of TAAs in patients with AAAs and to analyse the risk factors for this association. METHODS: This was a multicentre prospective study. The Aortic Concomitant Thoracic and Abdominal Aneurysm (ACTA) study included 331 patients with infrarenal AAAs > 40 mm between September 2012 and May 2016. These patients were prospectively enrolled in three French academic hospitals. RESULTS: Patients were classified as having a normal, aneurysmal, or ectatic (non-normal, non-aneurysmal) thoracic aorta according to their maximum aortic diameter indexed by sex, age, and body surface area. Thoracic aortic ectasia (TAE) was defined as above or equal to the 90th percentile of normal aortic diameters according to gender and body surface area. Descending TAA was defined as ≥ 150% of the mean normal value, and ascending TAA as > 47 mm in men and 42 mm in women; 7.6% (n = 25) had either an ascending (seven cases; 2.2%) or descending aortic TAA (18 cases; 5.4%), and 54.6% (n = 181) had a TAE. Among the 25 patients with TAAs, five required surgery; two patients had TAAs related to penetrating aortic ulcers < 60 mm in diameter, and three had a TAA > 60 mm. In the multinomial regression analysis, atrial fibrillation (AF) (odds ratio [OR] 11.36, 95% confidence interval [CI] 2.18 - 59.13; p = .004) and mild aortic valvulopathy (OR 2.89, 1.04-8.05; p = .042) were independent factors associated with TAAs. Age (OR 1.06, CI 1.02 - 1.09; p = .003) and AF (OR 4.36, 1.21 - 15.61; p = .024) were independently associated with ectasia. CONCLUSION: This study confirmed that TAAs coexisting with AAAs are not rare, and one fifth of these TAAs are treated surgically. Systematic screening by imaging the whole aorta in patients with AAAs is clinically relevant and should lead to an effective prevention policy.

Nonurgent patients in emergency departments: rational or irresponsible consumers? Perceptions of professionals and patients.

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.

ED patients: how nonurgent are they? Systematic review of the emergency medicine literature.

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.