Prevalence of neuropathic pain in emergency patients: an observational study.

OBJECTIVE: Neuropathic pain (NP) in acute conditions has been poorly investigated. A diagnostic score, the DN4 scale (DN4), has been developed to help physicians to detect and treat NP appropriately. DN4 is a 10-item questionnaire. If you have 4 or more positive responses out of 10 items, the answer to the questionnaire is positive and you have a neuropathic pain. We aimed to determine the prevalence of NP in emergency department (ED) patients and to describe this population. METHODS: We used the DN4 in the patients with NP visiting the adult ED of a university hospital. Patients were asked about the characteristics of their pain using a face-to-face questionnaire. RESULTS: Among 533 patients with a DN4 score, 114 (21.4%) had NP. Neuropathic pain was independently negatively associated with age of 65 years of older (odds ratio [OR], 0.2, 95% confidence interval [CI], 0.05-0.8) and positively associated with intense pain (OR, 5.2; 95% CI, 1.5-18.2), located to the limbs (OR, 2.3; 95% CI, 1.2-4.0). CONCLUSION: Neuropathic pain was common in ED patients and associated to a higher level of pain.

How emergency departments might alert for prehospital heat-related excess mortality?

INTRODUCTION: A major issue raised by the public health consequences of a heat wave is the difficulty of detecting its direct consequences on patient outcome, particularly because of the delay in obtaining definitive mortality results. Since emergency department (ED) activity reflects the global increase of patients' health problems during this period, the profile of patients referred to EDs might be a basis to detect an excess mortality in the catchment area. Our objective was to develop a real-time surveillance model based on ED data to detect excessive heat-related mortality as early as possible. METHODS: A day-to-day composite indicator was built using simple and easily obtainable variables related to patients referred to the ED during the 2003 heat-wave period. The design involved a derivation and validation study based on a real-time surveillance system of two EDs at Cochin Hospital and Hôtel-Dieu Hospital, Paris, France. The participants were 99,976 adult patients registered from 1 May to 30 September during 2001, 2002 and 2003. Among these participants, 3,297, 3,580 and 3,851 patients were referred to the EDs from 3 August to 19 August for 2001, 2002 and 2003, respectively. Variables retained for the indicator were selected using the receiver operating characteristic curve methodology and polynomial regression. RESULTS: The indicator was composed of only three variables: the percentage of patients older than 70 years, the percentage of patients with body temperature above 39 degrees C, and the percentage of patients admitted to or who died in the ED. The curve of the indicator with time appropriately fitted the overall mortality that occurred in the region of interest. CONCLUSION: A composite and simple index based on real-time surveillance was developed according to the profile of patients who visited the ED. It appeared suitable for determining the overall mortality in the corresponding region submitted to the 2003 heat wave. This index should help early warning of excessive mortality and monitoring the efficacy of public health interventions.

Pain in an emergency department: an audit.

OBJECTIVE: To evaluate the quality of care in patients with pain who visit the emergency department of a university hospital and the evolution of their pain during their emergency department stay. METHODS: A cross-sectional survey was performed using two valid scales (a numerical descriptor scale or a verbal pain intensity scale), and a structured questionnaire to patients and use of patient charts to collect information on pain intensity on arrival and before discharge, characteristics of pain and of its management. RESULTS: In the 726 participating patients, median age was 37 years (range: 18-97), and 54% of the patients were men. Upon arrival, 563 patients presented with pain (78%), rated > or =7 in 35% of the 390 patients evaluated using numerical descriptor scale. Forty-four percent had taken analgesics before arrival. Their median waiting time before initial medical examination was 30 min. Pain was identified by triage nurses (70%) or by physicians (77%) and was rated by nurses (23%) and physicians (11%). Forty-seven percent also experienced pain during care and 27% received analgesics during their stay. Pain intensity remained unchanged in 70% of patients, increased in 7% and decreased in 23%. Of the 480 patients with pain on arrival evaluated before discharge, 395 (82%) patients were unrelieved before going home, rated > or =7 in 32% of the 390 patients evaluated using numerical descriptor scale. Analgesics were ordered before leaving the emergency department in 81%. CONCLUSION: Even if pain has been identified, its assessment and management remains inadequate. The quality of care may be improved by educating the personnel in developing protocols and in evaluating pain management.

Management and relief of pain in an emergency department from the adult patients' perspective.

To estimate the prevalence of pain in adult patients attending an emergency department (ED) and to identify risk markers for insufficient pain relief, a cross-sectional survey was conducted for 16 days, 24 hours each day, in the ED of a Paris university hospital. A structured questionnaire was used to collect characteristics of pain and its management from patients. Pain intensity was evaluated both on arrival and before discharge using two scales (a numerical descriptor scale or a verbal pain intensity scale). On arrival, 78% of the patients complained of pain; among them, 54% complained of intense pain and 47% suffered procedural pain. Insufficient pain relief was assessed in 289 (77%) patients. We identified the following risk markers for insufficient pain relief: moderate or low pain intensity, no intervention in the ED before the medical examination, and no use of medication before arrival.

Unprecedented heat-related deaths during the 2003 heat wave in Paris: consequences on emergency departments.

In August 2003, France sustained an unprecedented heat wave that resulted in 14,800 excess deaths. The consequences were maximal in the Paris area. The Assistance Publique-Hôpitaux de Paris reported more than 2600 excess emergency department visits, 1900 excess hospital admissions, and 475 excess deaths despite a rapid organization. Indeed, simple preventice measures before hospital admissions are only able to reduce mortality which mostly occurred at home and in nursing homes.

Variability of intensive care admission decisions for the very elderly.

UNLABELLED: Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83-91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear. TRIAL REGISTRATION: ClinicalTrials.gov NCT00912600.

Alcohol use disorders in the emergency ward: choice of the best mode of assessment and identification of at-risk situations.

BACKGROUND: This study aims to identify the prevalence and at-risk situations of alcohol use disorders among patients examined in the emergency department and to compare the scales commonly used to identify alcohol use disorders. METHODS: We used the CAGE and AUDIT questionnaires and a structured interview, the MINI. FINDINGS: Of the presenting patients, 9.5% met the DSM-IV criteria for alcohol use disorders. The CAGE questionnaire was less sensitive (75%) and more specific (92%) than the AUDIT (87 and 80%, respectively). The typical alcohol-dependent patient is a young man who is unemployed and brought to the emergency department by the police. During the past 24 h, he has consumed alcohol, nicotine, cocaine, sedatives or cannabis. CONCLUSION: Of the patients, 9.5% examined in the emergency department present with alcohol abuse or dependence without asking spontaneously for treatment for their addiction. These results support the importance of systematically identifying alcohol use disorders with a simple and rapid questionnaire such as the CAGE questionnaire.