[Paracetamol overdose]. / Intoxication aiguë au paracétamol.

Acetaminophen is the most widely used analgesic-antipyretic and is available as an over-the-counter medication in many countries. Although generally safe at usual therapeutic doses, acetaminophen may cause hepatic toxicity in case of chronic or acute overuse and even at therapeutic doses in susceptible individuals. The aim of this article is to review the mechanisms of acetaminophen toxicity and to review the critical steps in the management of acute or chronic acetaminophen intoxication.

[Comprehensive geriatric assessment in the emergency department: some usefull screening tools]. / Evaluation gériatrique aux urgences: boîte à outils pour les nuls.

Emergency department (ED) admissions of patients 75 years and older are consistently increasing. Older patients suffer from atypical symptomatology, spend more time, and are more at risk of adverse outcomes (early readmission, functional decline, institutionalization and death) than younger people. The identification of geriatric syndromes like cognitive decline can improve the management of such patients and decrease the rate of the outcomes. In ED, screening tools developed to detect these geriatric problems have to be quick, easy to use and to present a high sensibility. This article aims at reviewing the literature about the ED-validated screening tools that could be applied in practice.

[Efficacy and safety of probiotics]. / Probiotiques: efficacité et dangerosité.

Probiotics are bacteria or fungi, which modulate pathogenic growth and invasion of the bowel. The most frequently used are Lactobacillus and Saccharomyces cerevisiae. They are widely used as dietary supplements or for the treatment and prevention of various types of diarrhoea. Probiotics are generally considered as safe, but some cases of invasive infections have been described in different patient populations. This article reviews the literature about the indications and risks of probiotics, especially in immunocompromised patients.

[How to reduce reperfusion time in ST elevation myocardial infarction?]. / Comment réduire le délai de reperfusion dans l'infarctus du myocarde avec sus-décalage du segment ST?

For patients with ST elevation myocardial infarction (STEMI), most hospitals do not achieve recommended reperfusion time delay. The goal of this article is to discuss the several strategies allowing to reduce delay to reperfusion (e.g., pre-hospital ECG, early activation of catheterisation laboratory), in order to help each institution to develop its own protocol.

[Initial management of acute heart failure in the emergency department]. / Insuffisance cardiaque aiguë décompensée: prise en charge initiate aux urgences.

Acute decompensated heart failure is one of the most leading diseases among elderly patients presenting in the emergency department with a chief complaint of dyspnea. Initial management is crucial for the patient's outcome. In this article we propose a review of diagnosis, treatment, stratification and orientation of patients admitted to emergency department with acute heart failure in light of recent recommendations.

[Alternative to hospitalization for patients diagnosed with acute congestive heart failure]. / Patients avec insuffisance cardiaque décompensée aux urgences: existe-t-it une alternative à l'hospitalisation?

Heart failure is the first cause of hospital admission in patients above 65 years of age and represents a major health problem given demographic projections. Rapid admission of selected patients in specialized heart failure observation units in the emergency departments providing therapeutic monitoring and multiple educative interventions may obviate the need for hospitalization. This strategy may reduce the overall incidence of hospitalization and subsequent readmissions as well as save costs. Outcome studies are needed before a widespread implementation of such strategies.

Early specialized care after a first unprovoked epileptic seizure.

A first seizure is a life-changing event with physical and psychological consequences. We aimed to assess the role of early comprehensive patient care after a first unprovoked seizure to improve diagnostic accuracy and follow-up adherence. From April 2011 to March 2012, patients presenting a first unprovoked epileptic seizure received standard patient care (SPC), i.e., a consultation in the ED, an EEG and a CT scan. The patients were notified of the follow-ups. We compared this protocol to subsequently acquired "early comprehensive patient care" (ECPC), which included a consultation by an epileptologist in the emergency department (ED), a routine or long-term monitoring electroencephalogram (LTM-EEG), magnetic resonance imaging and three follow-up consultations (3 weeks, 3 months, 12 months). 183 patients were included (113 ECPC, 70 SPC). LTM-EEG and MRI were performed in 51 and 85 %, respectively, of the patients in the ECPC group vs in 7 and 52 % of the patients in the SPC group (p < 0.001). A final diagnosis was obtained in 64 vs 43 % of the patients in the ECPC vs SPC group (p < 0.01). Patient attendance at 3-month was 84 % in the ECPC group vs 44 % in the SPC group (p < 0.001). At 12-month follow-up, the delay until the first recurrence was longer in the ECPC group (p = 0.008). An early epileptologist-driven protocol is associated with clinical benefit in terms of diagnostic accuracy, follow-up adherence and recurrence. This study highlights the need for epilepsy experts in the early assessment of a first epileptic seizure, starting already in the ED.

Antithrombotic strategy after total hip replacement. A cost-effectiveness analysis comparing prolonged oral anticoagulants with screening for deep vein thrombosis.

BACKGROUND: Deep vein thrombosis (DVT) in the lower limbs is a major postoperative complication in patients undergoing total hip replacement. However, even with the most effective perioperative antithrombotic prophylactic methods, its incidence at the time of hospital discharge remains as high as 15 to 25. METHODS: We used a decision analysis model to determine the clinical and economic effects of the following interventions: (1) stopping prophylactic antithrombotic therapy after the in-hospital perioperative period (7-14 days), (2) extending prophylactic antithrombotic therapy with oral anticoagulants up to 6 weeks or 3 months, and (3) screening for DVT at the time of hospital discharge by compression ultrasonography or venography. We measured for a hypothetical cohort of 10 000 patients the risk of developing recurrent DVT and symptomatic pulmonary embolism, the risk of major bleeding complications, and the costs associated with each strategy. Data were drawn from the published literature (MEDLINE search) and from our hospital cost manager. RESULTS: Compared with stopping prophylaxis at the time of hospital discharge, a 6-week course of prophylactic oral anticoagulant therapy would reduce the number of cases of recurrent DVT from 1172 to 493 and the number of symptomatic pulmonary embolisms from 234 to 99, and would be less costly. This gain would be achieved at the cost of 29 major bleeding complications if the bleeding risk is low (0.2 per month) and 71 if the bleeding risk is moderate (0.5 per month). Compared with stopping prophylaxis at discharge, ultrasound screening would reduce symptomatic pulmonary embolisms from 234 to 142, induce only 13 major bleeding episodes, and be cost-effective, with marginal costs per additional pulmonary embolism averted ranging from $3000 to $7000, depending on ultrasound sensitivity. Venography screening would be the most effective strategy; however, compared with ultrasound, its marginal costs per additional pulmonary embolism averted would exceed $80 000. CONCLUSIONS: After hip replacement with conventional perioperative antithrombotic prophylaxis, oral anticoagulation administered for 6 weeks is effective in preventing recurrent DVT and symptomatic pulmonary embolism, unless the bleeding risk is very high. Moreover, this strategy is less costly compared with stopping antithrombotic prophylaxis at the time of hospital discharge. Alternatively, ultrasound screening is also effective, minimizes the risks of bleeding, and has a low marginal cost-effectiveness ratio.

Cost-effectiveness of new antiplatelet regimens used as secondary prevention of stroke or transient ischemic attack.

BACKGROUND: Compared with aspirin alone, use of the new antiplatelet regimens, including aspirin combined with dipyridamole and clopidogrel bisulfate, has been found to further reduce the risk of stroke and other vascular events in patients who have experienced stroke or transient ischemic attack. However, their cost-effectiveness ratios relative to aspirin alone have not been estimated. METHODS: We developed a Markov model to measure the clinical benefits and the economic consequences of the following strategies to treat high-risk patients aged 65 years or older: (1) aspirin, 325 mg/d; (2) aspirin, 50 mg/d, and dipyridamole, 400 mg/d; and (3) clopidogrel bisulfate, 75 mg/d. Input data were obtained by literature review. Outcomes were expressed as US dollars per quality-adjusted life-year (QALY). RESULTS: The use of aspirin combined with dipyridamole was more effective and less costly compared with the use of aspirin alone, providing a gain of 0.3 QALY for a 65-year-old patient. This regimen remained cost-effective despite wide sensitivity analyses. Clopidogrel was more effective and more costly compared with aspirin alone, yielding a gain of 0.2 QALY with a marginal cost-effectiveness ratio of $26,580 per each additional QALY (patient aged 65 years). Sensitivity analyses demonstrated that the efficacy of clopidogrel and its cost were key factors in determining its cost-effectiveness ratio compared with aspirin, which exceeded $50,000 when its efficacy decreased by half or its cost doubled. CONCLUSION: To prevent stroke in high-risk patients, dipyridamole combined with aspirin was more effective and less costly than aspirin alone, and clopidogrel was cost-effective compared with current standards of medical practice, except in extreme scenarios.

Prophylactic antithrombotic therapy for patients with systemic lupus erythematosus with or without antiphospholipid antibodies: do the benefits outweigh the risks? A decision analysis.

BACKGROUND: A high incidence of both arterial and venous thromboembolic events has been reported in patients with systemic lupus erythematosus (SLE), but the risks and benefits of primary prophylactic antithrombotic therapy have not been assessed. We measured the clinical benefit of 3 antithrombotic regimens in patients with SLE without antiphospholipid antibodies, with anticardiolipin antibodies, or with lupus anticoagulant. METHODS: A Markov decision analysis was used to evaluate prophylactic aspirin therapy, prophylactic oral anticoagulant therapy, and observation. Input data were obtained by literature review. Clinical practice was simulated in a hypothetical cohort of patients with SLE who had not experienced any previous episode of arterial or venous thromboembolic events. For each strategy, we measured numbers of thromboembolic events prevented and major bleeding episodes induced, and quality-adjusted survival years. RESULTS: Prophylactic aspirin therapy was the preferred strategy in all settings, the number of prevented thrombotic events exceeding that of induced bleeding episodes. In the baseline analysis (40-year-old patients with SLE), the gain in quality-adjusted survival years achieved by prophylactic aspirin compared with observation ranged from 3 months in patients without antiphospholipid antibodies to 11 months in patients with anticardiolipin antibodies or lupus anticoagulant. Prophylactic oral anticoagulant therapy provided better results than prophylactic aspirin only in patients with lupus anticoagulant and an estimated bleeding risk of 1% per year or less. CONCLUSIONS: Prophylactic aspirin should be given to all patients with SLE to prevent both arterial and venous thrombotic manifestations, especially in patients with antiphospholipid antibodies. In selected patients with lupus anticoagulant and a low bleeding risk, prophylactic oral anticoagulant therapy may provide a higher utility.

Risk factors for a medically inappropriate admission to a Department of Internal Medicine.

OBJECTIVE: To identify patient- and admission-related risk factors for a medically inappropriate admission to a department of internal medicine. METHODS: Cross-sectional study of a systematic sample of 500 admissions to the department of internal medicine of an urban teaching hospital. The appropriateness of each admission and reasons for inappropriate admissions were assessed using the Appropriateness Evaluation Protocol. Risk factors included the time (day of week and holidays) and manner (through emergency department or direct admission) of admission, patient age and sex, health status of patient and spouse, living arrangements, formal home care services, and informal support from family or friends. RESULTS: Overall, 76 (15.2%) hospital admissions were rated as medically inappropriate by the Appropriateness Evaluation Protocol. In multivariate analysis, the likelihood of an inappropriate admission was increased by better physical functioning of the patient (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.1 [for 1 SD in Physical Functioning scores]), lower mental health status of the patient's spouse (OR, 2.6; 95% CI, 1.3-5.6), receipt of informal help from family or friends (OR, 3.3; 95% CI, 1.5-7.2), and hospitalization by one's physician (OR, 3.6; 95% CI, 1.7-7.5). Receiving formal adult home care was not associated with inappropriateness of hospitalization. CONCLUSIONS: Inappropriate admissions to internal medicine wards are determined by a mix of factors, including the patient's health and social environment. In addition, the private practitioners' discretionary ability to hospitalize their patients directly may also favor medically inappropriate admissions.

[Acute dyspnea: what is the diagnostic role of B-type natriuretic peptide?]. / Dyspnée aiguë: quel est l'apport diagnostique du peptide natriurétique de type B?

Bedside dosage of B-type natriuretic peptide as a marker of congestive heart failure is of major interest in the evaluation of acute dyspnea. However, this test remains difficult to use because its interpretation depends upon the probability of disease and upon its diagnostic performance (sensitivity and specificity), varying with each BNP level. When the clinical probability of heart failure is low or high, BNP level doest not modify significantly the probability of disease. The test is useful when the diagnostic is uncertain (intermediate clinical probability), because a BNP value < 100 pg/ml makes the diagnosis of heart failure unlikely (high negative predictive value), and a value > 500 pg/ml very likely.

[Should B-type natriuretic peptide (BNP) be used in daily practice?]. / Adoption d'un test diagnostique dans la pratique quotidienne: à propos du peptide natriurétique de type B (BNP).

Each diagnostic test should be systematically evaluated before acceptation for use in daily practice. The principles for validating a diagnostic test are reviewed using B-type natriuretic peptide (BNP) as an example. BNP seems promising to diagnose symptomatic left-sided heart failure in the emergency department, especially when the diagnosis remains uncertain (intermediate clinical probability). However, before its widespread use, its efficacy on clinical outcome measures such as reduction of time to treatment or in-hospital length of stay should be more clearly demonstrated through pragmatic studies.

[Non invasive ventilation in emergency settings]. / Indication a la ventilation non invasive (VNI) dans les services d'urgence.

The use of non invasive ventilation (NIV) in the emergency setting to treat acute respiratory failure (ARF) has received much attention. To date, large studies support the early administration of continuous positive airway pressure (CPAP) in patients with cardiogenic acute pulmonary edema; and 2) non-invasive positive pressure ventilation (NPPV) for exacerbations of chronic obstructive pulmonary disease (COPD). NIV could also be useful in other types of ARF, but its success rate is dependent on the cause of ARF and patient's characteristics. Use of NIV in the emergency setting should take into account validated indications and local expertise of the nursing staff to minimize the risk of complications.

[Anaphylaxis: initial management]. / Anaphylaxie: prise en charge initiale.

Anaphylaxis is an immediate systemic reaction caused by an external agent. Its initial management depends on the severity of the reaction. In case of benign to moderate reaction, anti-histamine and steroid treatment are sufficient to control the process, and management is ambulatory. A severe reaction (hypotension, dyspnea) can be life threatening and adrenalin administration by the intramuscular route is indicated. In this case, it is advocated to observe the evolution for 24 hours in the hospital and the patient should be prescribed adrenaline auto-injectors. It is recommended that individuals who have experienced anaphylaxis should receive consultation from an allergist regarding diagnosis, prevention and treatment.

Asymptomatic severe carotid stenosis: immediate surgery or watchful waiting? A decision analysis.

OBJECTIVE: To analyze, for patients with asymptomatic severe carotid stenosis, the risks and benefits of two strategies: (1) immediate prophylactic carotid endarterectomy (CEA), and (2) medical management followed by CEA only after a transient ischemic attack (TIA) or a minor stroke has occurred. DESIGN: A Markov-based decision analysis model that simulates and counts the possible clinical outcomes (deaths, TIAs, and major strokes) of the two strategies. Data were drawn from the current literature. SUBJECTS: A hypothetical cohort of asymptomatic patients with severe (> 75% diameter reduction) carotid stenosis identified by noninvasive diagnostic tests. MAIN RESULTS: Given the immediate surgery-related risks, patients with a stroke incidence without preceding TIA of 3% per year will benefit from prophylactic CEA only if they survive more than 4 years after the procedure, whereas those with a higher stroke incidence (5% per year) will benefit from prophylactic CEA after just 2 years. However, the gain yielded by prophylactic CEA remains small. As age- or cardiovascular-related mortality increases, the maximum tolerated combined surgical mortality and morbidity rate below which prophylactic CEA yields an improved 5-year stroke- and surgery-related-event-free survival decreases--from 5% for patients aged 55 years to 2% for patients aged 85 years with a stroke incidence of 3% per year, and from 8.5% for patients aged 55 years to 4% for patients aged 85 years with a stroke incidence of 5% per year. On the other hand, for risk-intolerant patients who value the 2-year stroke- and surgery-related-event-free survival more than life in the distant future, the combined surgical morbidity and mortality rate below which prophylactic CEA remains the preferred strategy is below 3% at any age. CONCLUSION: Risk-intolerant patients should not undergo prophylactic CEA. On the other hand, for risk-tolerant patients willing to accept an immediate and dangerous procedure to decrease the future risk of death or chronic disability due to stroke, assessment of both perioperative risk and the risk of premature death from coexistent coronary artery disease should guide individual therapeutic decision-making.