Antiseizure medication ≤48 hours portends better prognosis in new-onset epilepsy.

BACKGROUND: Several studies found that patients with new-onset epilepsy (NOE) have higher seizure recurrence rates if they presented already prior seizures. These observations suggest that timing of antiseizure medication (ASM) is crucial and should be offered immediately after the first seizure. Here, we wanted to assess whether immediate ASM is associated with improved outcome. METHODS: Single-center study of 1010 patients (≥16 years) who presented with a possible first seizure in the emergency department between 1 March 2010 and 1 March 2017. A comprehensive workup was launched upon arrival, including routine electroencephalography (EEG), brain computed tomography/magnetic resonance imaging, long-term overnight EEG and specialized consultations. We followed patients for 5 years comparing the relapse rate in patients treated within 48 h to those with treatment >48 h. RESULTS: A total of 487 patients were diagnosed with NOE. Of the 416 patients (162 female, age: 54.6 ± 21.1 years) for whom the treatment start could be retrieved, 80% (333/416) were treated within 48 h. The recurrence rate after immediate treatment (32%; 107/333) was significantly lower than in patients treated later (56.6%; 47/83; p < 0.001). For patients for whom a complete 5-year-follow-up was available (N = 297, 123 female), those treated ≤48 h (N = 228; 76.8%) had a significantly higher chance of remaining seizure-free compared with patients treated later (N = 69; 23.2%; p < 0.001). CONCLUSIONS: In this retrospective study, immediate ASM therapy (i.e., within 48 h) was associated with better prognosis up to 5 years after the index event. Prospective studies are required to determine the value of immediate workup and drug therapy in NOE patients.

Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest.

The objective of this study was to identify the key elements used by prehospital emergency physicians (EP) to decide whether or not to attempt advanced life support (ALS) in asystolic out-of-hospital cardiac arrest (OHCA). From 1 January 2009 to 1 January 2017, all adult victims of asystolic OHCA in Geneva, Switzerland, were retrospectively included. Patients with signs of "obvious death" or with a Do-Not-Attempt-Resuscitation order were excluded. Patients were categorized as having received ALS if this was mentioned in the medical record, or, failing that, if at least one dose of adrenaline had been administered during cardiopulmonary resuscitation (CPR). Prognostic factors known at the time of EP's decision were included in a multivariable logistic regression model. Included were 784 patients. Factors favourably influencing the decision to provide ALS were witnessed OHCA (OR = 2.14, 95% CI: 1.43-3.20) and bystander CPR (OR = 4.10, 95% CI: 2.28-7.39). Traumatic aetiology (OR = 0.04, 95% CI: 0.02-0.08), age > 80 years (OR = 0.14, 95% CI: 0.09-0.24) and a Charlson comorbidity index greater than 5 (OR = 0.12, 95% CI: 0.06-0.27) were the factors most strongly associated with the decision not to attempt ALS. Factors influencing the EP's decision to attempt ALS in asystolic OHCA are the relatively young age of the patients, few comorbidities, presumed medical aetiology, witnessed OHCA and bystander CPR.

Reliability and performance of the Swiss Emergency Triage Scale used by paramedics.

OBJECTIVES: No general emergency department triage scale has been evaluated for prehospital triage. The objective of this study was to evaluate the reliability and the performance of the Swiss Emergency Triage Scale (SETS) used by paramedics to determine the emergency level and orientation of simulated patients. PATIENTS AND METHODS: In a prospective cross-sectional study, 23 paramedics evaluated 28 clinical scenarios with the SETS using interactive computerized triage software simulating real-life triage. The primary outcome was inter-rater reliability regarding the triage level among participants measured by intraclass correlation coefficient (ICC). Secondary outcomes were the accuracy of triage level and the reliability and accuracy of orientation of patients of at least 75 years to a dedicated geriatric emergency centre. RESULTS: Twenty-three paramedics completed the evaluation of the 28 scenarios (644 triage decisions). Overall, ICC for triage level was 0.84 (95% confidence interval: 0.77-0.99). Correct emergency level was assigned in 89% of cases, overtriage rate was 4.8%, and undertriage was 6.2%. ICC regarding orientation in the subgroup of simulated patients of at least 75 years was 0.76 (95% confidence interval: 0.61-0.89), with 93% correct orientation. CONCLUSION: Reliability of paramedics rating simulated emergency situations using the SETS was excellent, and the accuracy of their rating was very high. This suggests that in Switzerland, the SETS could be safely used in the prehospital setting by paramedics to determine the level of emergency and guide patients to the most appropriate hospital.

Pitfalls in the triage and evaluation of patients with suspected acute ethanol intoxication in an emergency department.

Acute ethanol intoxication (AEI) is frequent in emergency departments (EDs). These patients are at risk of mistriage, and to leave the ED without being seen. This study's objective was to describe the process and performance of triage and trajectory for patients with suspected AEI. Retrospective, observational study on adults admitted with a suspected AEI within 1 year at the ED of an urban teaching hospital. Data on the triage process, patients' characteristics, and their ED stay were extracted from electronic patient records. Predictors for leaving without being seen were identified using logistic regression analyzes. Of 60,488 ED patients within 1 year, 776 (1.3%) were triaged with suspected AEI. This population was young (mean age 38), primarily male (64%), and professionally inactive (56%). A large proportion were admitted on weekends (45%), at night (46%), and arrived by ambulance (85%). The recommendations of our triage scale were entirely respected in a minority of cases. In 22.7% of triage situations, a triage reason other than "alcohol abuse/intoxication" (such as suicidal ideation, head trauma or other substance abuse) should have been selected. Nearly, half of the patients (49%) left without being seen (LWBS). This risk was especially high amongst men (OR 1.56, 95% CI 1.12-2.19), younger patients (< 26 years of age; OR 1.97, 95% CI 1.16-3.35), night-time admissions (OR 1.97, 95% CI 1.16-3.35), and patients assigned a lower emergency level (OR 2.32, 95% CI 1.58-3.42). Despite a standardized triage protocol, patients admitted with suspected AEI are at risk of poor assessment, and of not receiving optimal care.

Reliability of the revised Swiss Emergency Triage Scale: a computer simulation study.

BACKGROUND: The Swiss Emergency Triage Scale (SETS) is a four-level emergency scale that previously showed moderate reliability and high rates of undertriage due to a lack of standardization. It was revised to better standardize the measurement and interpretation of vital signs during the triage process. OBJECTIVE: The aim of this study was to explore the inter-rater and test-retest reliability, and the rate of correct triage of the revised SETS. PATIENTS AND METHODS: Thirty clinical scenarios were evaluated twice at a 3-month interval using an interactive computerized triage simulator by 58 triage nurses at an urban teaching emergency department admitting 60 000 patients a year. Inter-rater and test-retest reliabilities were determined using κ statistics. Triage decisions were compared with a gold standard attributed by an expert panel. Rates of correct triage, undertriage, and overtriage were computed. A logistic regression model was used to identify the predictors of correct triage. RESULTS: A total of 3387 triage situations were analyzed. Inter-rater reliability showed substantial agreement [mean κ: 0.68; 95% confidence interval (CI): 0.60-0.78] and test-retest almost perfect agreement (mean κ: 0.86; 95% CI: 0.84-0.88). The rate of correct triage was 84.1%, and rates of undertriage and overtriage were 7.2 and 8.7%, respectively. Vital sign measurement was an independent predictor of correct triage (odds ratios for correct triage: 1.29 for each additional vital sign measured, 95% CI: 1.20-1.39). CONCLUSION: The revised SETS incorporating standardized vital sign measurement and interpretation during the triage process resulted in high reliability and low rates of mistriage.

Impact of a patient-flow physician coordinator on waiting times and length of stay in an emergency department: A before-after cohort study.

OBJECTIVE: Overcrowding is common in most emergency departments (ED). Despite the use of validated triage systems, some patients are at risk of delayed medical evaluation. The objective of this study was to assess the impact of a patient-flow physician coordinator (PFPC) on the proportion of patients offered medical evaluation within time limits imposed by the Swiss Emergency Triage Scale (SETS) and on patient flow within the emergency department of a teaching urban hospital. METHODS: In this before-after retrospective cohort study, we compared the proportions of patients who received their first medical contact within SETS-imposed time limits, mean waiting times before first medical consultation, mean length of stay, and number of patients who left without being seen by a physician, between two periods before and after introducing a PFPC. The PFPC was a senior physician charged with quickly assessing in the waiting area patients who could not immediately be seen and managing patient flow within the department. RESULTS: Before introducing the PFPC position, 33,605 patients were admitted, versus 36,288 after. Introducing a PFPC enabled the department to increase the proportion of patients seen within the SETS-imposed time limits from 60.1% to 69.0% (p <0.0001). Waiting times until first medical consultation were reduced on average by 27.7 minutes (95% confidence interval [95% CI]: 25.9-29.5, p < .0001). No significant differences were observed as to length of stay or number of patients who left without being seen between the two study periods. CONCLUSIONS: Introducing a physician dedicated to managing patient flow enabled waiting times until first medical consultation to be reduced, yet had no significant benefit for patient flow within the ED, nor did it reduce the number of patients who left without being seen.

I.v. N-acetylcysteine and emergency CT: use of serum creatinine and cystatin C as markers of radiocontrast nephrotoxicity.

OBJECTIVE: The purpose of this study was to assess the effect of i.v. administration of N-acetylcysteine (NAC) on serum levels of creatinine and cystatin C, two markers of renal function, in patients with renal insufficiency who undergo emergency contrast-enhanced CT. SUBJECTS AND METHODS: Eighty-seven adult patients with renal insufficiency who underwent emergency CT were randomized to two groups. In the first group, in addition to hydration, patients received a 900-mg injection of NAC 1 hour before and another immediately after injection of iodine contrast medium. Patients in the second group received hydration only. Serum levels of creatinine and cystatin C were measured at admission and on days 2 and 4 after CT. Nephrotoxicity was defined as a 25% or greater increase in serum creatinine or cystatin C concentration from baseline value. RESULTS: A 25% or greater increase in serum creatinine concentration was found in nine (21%) of 43 patients in the control group and in two (5%) of 44 patients in the NAC group (p = 0.026). A 25% or greater increase in serum cystatin C concentration was found in nine (22%) of 40 patients in the control group and in seven (17%) of 41 patients in the NAC group (p = 0.59). CONCLUSION: On the basis of serum creatinine concentration only, i.v. administration of NAC appears protective against the nephrotoxicity of contrast medium. No effect is found when serum cystatin C concentration is used to assess renal function. The effect of NAC on serum creatinine level remains unclear and may not be related to a renoprotective action.

Interactive triage simulator revealed important variability in both process and outcome of emergency triage.

BACKGROUND AND OBJECTIVES: (1) to evaluate the performance of emergency department triage; (2) to explore the variability of the triage process; and (3) to examine the reliability of a four-level triage scale, using an interactive triage simulator. METHODS: We developed 22 interactive computerized vignettes describing patients presenting at the Emergency Department. Each vignette displayed the presenting complaint and offered the possibility to ask questions and obtain vital signs before deciding on the triage severity rating. The vignettes were rated twice by 45 nurses and 8 physicians. RESULTS: (1) The concordance between the observed triage decision and an expert-attributed emergency level was perfect in 58% of the situations. Triage acuity was overestimated in 11%, and underestimated in 31%. (2) There was a wide variability in the triage process across observers and vignettes. The mean number of questions varied from 1.77 to 18.95 across individuals, and from 3.96 to 11.60 across vignettes. (3) Finally, the test-retest reliability of our instrument was good (weighted kappa = 0.82) but the interrater reliability was moderate (weighted kappa = 0.41). CONCLUSIONS: The computerized triage simulator is an innovative tool to evaluate the process and the performance of triage and to evaluate the reliability of a triage instrument.

Profound hyponatraemia in the emergency department: seasonality and risk factors.

AIMS OF THE STUDY: Profound hyponatremia (<125 mmol/l) is frequent in the emergency department. Its incidence appears to increase during hot weather. Our objectives were to investigate seasonal variations in the incidence of profound hyponatraemia and identify its risk factors. METHODS: The incidence of profound hyponatremia among patients admitted to the emergency department of a university hospital was compared between summer and winter periods over two successive years. Risk factors for profound hyponatraemia were analysed in a case-control retrospective study. Each adult patient admitted during the study periods with a blood sodium level <125 mmol/l was matched with two patients who had normal blood sodium concentrations. RESULTS: Of 28 734 analysed patients, 264 cases of profound hyponatraemia (0.92%) were identified. The incidence of profound hyponatraemia was higher in summer than in winter (1.29% vs 0.54%; odds ratio [OR] 2.39, 95% confidence interval [CI] 1.83-3.12). In a multivariate analysis, age (OR 1.02, 95% CI 1.01-1.03), psychiatric disorders (OR 2.69, 95% CI 1.86-3.89), and use of thiazide diuretics (OR 7.79, 95% CI 4.73-12.85) or potassium-sparing diuretics (OR 4.69, 95% CI 2.31-9.52) were associated with increased risk. Mortality was higher in cases than in controls (11.7% vs 6.9%, OR 1.75, 95% CI 1.05-2.92). CONCLUSIONS: The incidence of profound hyponatraemia was higher during the summer than the winter and was associated with excess risk of overall mortality. The use of thiazide and potassium-sparing diuretics was associated with the highest risk of hyponatraemia.

Can wrist blood pressure oscillometer be used for triage in an adult emergency department?

STUDY OBJECTIVE: We compare the performance of a wrist blood pressure oscillometer with the mercury standard in the triage process of an emergency department (ED) and evaluate the impact of wrist blood pressure measurement on triage decision. METHODS: Blood pressure was successively measured with the standard mercury sphygmomanometer and with the OMRON-RX-I wrist oscillometer in a convenience sample of 2,493 adult patients presenting to the ED with non-life-threatening emergencies. Wrist and mercury measures were compared using criteria of the Association for the Advancement of Medical Instrumentation (AAMI) and the British Hypertension Society (BHS). The impact on triage decisions was evaluated by estimating the rate of changes in triage decisions attributable to blood pressure results obtained with the wrist device. RESULTS: Wrist oscillometer failed to meet the minimal requirements for recommendation by underestimating diastolic and systolic blood pressure. Mean (+/-SD) differences between mercury and wrist devices were 8.0 mm Hg (+/-14.7) for systolic and 4.2 mm Hg (+/-12.0) for diastolic measures. The cumulative percentage of blood pressure readings within 5, 10, and 15 mm Hg of the mercury standard was 32%, 58%, and 72% for systolic, and 40%, 67%, and 83% for diastolic measures, respectively. Using the wrist device would have erroneously influenced the triage decision in 7.6% of the situations. The acuity level would have been overestimated in 2.2% and underestimated in 5.4% of the triage situations. CONCLUSION: The performance of the OMRON-RX-I wrist oscillometer does not fulfill the minimum criteria of AAMI and BHS compared with mercury standard in the ED triage setting.

Usefulness of 24-h Holter monitoring in patients with unexplained syncope and a high likelihood of arrhythmias.

AIMS: To analyze the diagnostic yield of 24-h electrocardiographic monitoring (Holter) as a function of cardiac disease and electrocardiography (ECG) status in patients with unexplained syncope. METHODS: Patients were considered as having unexplained syncope when a careful clinical history, physical and neurological examination, 12-lead ECG and testing for orthostatic hypotension were negative. All patients underwent 24-h Holter. According to the type of arrhythmias that occurred during monitoring, Holter was classified as: (1) normal, in the absence of significant arrhythmias; (2) abnormal, in the presence of significant (e.g. atrial fibrillation) but non-diagnostic arrhythmias; or (3) diagnostic, in the presence of serious arrhythmia (e.g. complete AV block) with simultaneous symptoms. Clinical features, ECG and echocardiography were used to stratify patients and identify those in whom electrophysiological studies (EPS) were indicated. RESULTS: 140 consecutive patients with unexplained syncope underwent 24-h Holter and 44 of them (31%) had non-diagnostic arrhythmias. These occurred more frequently in patients with a positive cardiac history or an abnormal ECG (31/73, 42%), compared to patients without these features (13/67, 19%, p<0.05). Nine of the 140 patients (6%) had serious arrhythmias during Holter considered as diagnostic because of the presence of simultaneous symptoms. These occurred exclusively in patients with a positive cardiac history or an abnormal ECG (9/67, 12%). All diagnostic arrhythmias recorded during Holter occurred in patients in whom EPS was beforehand deemed indicated based on the presence of structural heart disease and/or an abnormal ECG. CONCLUSIONS: When restricted to high-risk patients, 24-h Holter remained a useful initial step in the evaluation of unexplained syncope with a symptoms and arrhythmias correlation occurring in 12% of patients. When performed first, this procedure might avoid doing EPS.

Pitfalls in the emergency department triage of frail elderly patients without specific complaints.

QUESTION UNDER STUDY: Elderly patients represent an increasing proportion of emergency department (ED) admissions. When no specific complaint is identified, the reason for referral is commonly called "home care impossible". The aim of this study was to describe a population of elderly patients who present to the ED of a 1200-bed university hospital without specific complaint, and to assess how they were evaluated in the ED. METHODS: Data on triage, mode of admission and discharge were collected. After the initial evaluation in the ED, patients were classified in two categories: (1) patients identified with a medical problem requiring rapid care or investigation, (2) patients without a medical problem considered as true "home care impossible". These latter patients underwent a complete assessment using the Minimal Data Set-Home Care (MDS-HC). RESULTS: During the 10-week study period 253 patients (mean age 81 years) were referred because of "home care impossible". An acute medical problem was identified in 129 of those patients (51%). All these patients were triaged in lower acuity categories. 33 (26%) were undertriaged due to (1) absence of vital signs measurement, (2) poor recognition of neurological symptoms, (3) atypical clinical presentation. The remaining patients were considered as true "home care impossible". The MDS-HC evaluation revealed a high level of biopsychosocial comorbidities. CONCLUSIONS: Frail elderly patients admitted without specific complaints are at risk of inappropriate or delayed evaluation due to undertriage at the door of the ED. A more specific geriatric assessment should be integrated early in the triage process of these patients.

Effects of a structured patient-centered discharge interview on patients' knowledge about their medications.

PURPOSE: Many recently hospitalized patients lack knowledge about important aspects of their medications. We evaluated whether a structured discharge interview could improve medication knowledge. METHODS: Patients discharged with at least one discharge medication were recruited from two general internal medicine services (one experimental and one control) of a teaching hospital. During a 3-month baseline period, usual care at discharge was provided in both services. During the ensuing 3-month period, observation was continued in the control service; residents in the experimental service implemented the intervention, which consisted of a structured patient-centered discharge interview during which a computer-generated individualized treatment card was discussed with and provided to patients. One week after discharge, patients' knowledge about their medications was assessed by telephone. RESULTS: We enrolled a total of 809 patients. After adjustment for patients' characteristics and for the effect of time, the intervention significantly increased the percentage of medications for which patients correctly knew the purposes (adjusted difference = 6%; 95% confidence interval [CI]: 3% to 8%; P <0.001), possible side effects (adjusted difference = 19%; 95% CI: 9% to 29%; P <0.001), and precautions to observe (adjusted difference = 9%; 95% CI: 2% to 19%; P <0.001). However, the number of medications that patients discontinued after discharge was not modified. Patients with a better knowledge of side effects of their active treatment were less likely to discontinue their medications, but there were no associations with other types of knowledge. CONCLUSION: A structured patient-centered discharge interview, performed by residents using a standardized treatment card, significantly increased patients' knowledge about their medications. Its effects on compliance require further study.

Out of hospital antithrombotic prophylaxis after total hip replacement: low-molecular-weight heparin, warfarin, aspirin or nothing? A cost-effectiveness analysis.

Several studies have suggested that after hip replacement the risk of deep vein thrombosis and subsequent pulmonary embolism (PE) may persist for some weeks. Antithrombotic prophylaxis, however, is generally stopped at hospital discharge. Using a Markov-based decision analysis, we measured the clinical and economical consequences of extending prophylaxis after hospital discharge up to 4 weeks and 6 weeks, using either low-molecular-weight heparin (LMWH), warfarin, or aspirin. In the reference strategy, antithrombotic prophylaxis was stopped at hospital discharge. Outcome measures included the number of PE prevented, major haemorrhages induced, overall costs in Euro (EUR) and specific costs generated by each PE prevented for all strategies. Extending prophylaxis up to 4 weeks after discharge was safe and cost saving for all prophylactic regimens, although LMWH was the most effective strategy. Our results were most sensitive to the rate of haemorrhages, the efficacy of treatment and its costs. Specifically, the number of PEs prevented exceeded that of haemorrhages induced if the efficacy of antithrombotic prophylaxis was > or = 40% (assuming a low rate of haemorrhages of 0.1% per week), and > or = 70% (assuming a high rate of haemorrhages of 0.25% per week). LMWH and warfarin remained cost saving unless their costs were more than doubled compared to that of baseline value. Although less effective than LMWH and warfarin, prophylaxis with aspirin was cost saving in all scenarios tested. Extending prophylaxis up to 6 weeks was also effective (the number of PEs prevented overwhelmed that of major haemorrhages induced), but only for the scenario of a low bleeding risk (0.1%/week). In this strategy, aspirin remained cost saving, while the costs for each PE prevented became high (EUR 10,000 to EUR 20,000) if the costs of LMWH and warfarin increased. After hip replacement, extending antithrombotic prophylaxis up to 4 weeks after hospital discharge is effective and cost saving. Although LMWH is the most effective strategy, warfarin, and to a lesser extent aspirin may be alternate options if ressources are a major concern. Extending prophylaxis up to 6 weeks is more risky in patients at high bleeding risk, and generates additional costs.

Knowledge of guidelines for the management of COPD: a survey of primary care physicians.

OBJECTIVES: To evaluate primary care physicians' knowledge of guidelines for the management of COPD. METHOD: Survey to 455 primary care physicians in private practice in the state of Geneva, Switzerland, and to 243 physicians practicing in Geneva University Hospital. RESULTS: Although 75% of respondents identified that the prevalence of COPD was increasing and 33% recognized it as a major public health issue, only 55% of physicians used spirometric criteria to define COPD, and one-third knew the correct GOLD criteria. Fifty-two percent felt uncomfortable with smoking cessation counselling. Sixty-two percent administered influenza vaccination annually and 29% had immunized their patients against Pneumococcus. Beta2-agonists were the first-line treatment for 89% of physicians, but 10% overestimated their clinical benefit. Twenty-five percent of respondents used systematically inhaled corticosteroids, but 46% ignored their indications. Oral corticosteroids were used by 42% of physicians outside of acute exacerbations. Seventy-nine percent thought that oral steroids had a beneficial effect on stable COPD. Finally, pulmonary rehabilitation was underused by 72% of physicians. CONCLUSIONS: This study shows major gaps in the knowledge of all core elements of guidelines for the management of COPD and identifies targets for future educational programs.

A risk score to predict arrhythmias in patients with unexplained syncope.

OBJECTIVES: To develop and validate a risk score predicting arrhythmias for patients with syncope remaining unexplained after emergency department (ED) noninvasive evaluation. METHODS: One cohort of 175 patients with unexplained syncope (Geneva, Switzerland) was used to develop and cross-validate the risk score; a second cohort of 269 similar patients (Pittsburgh, PA) was used to validate the system. Arrhythmias as a cause of syncope were diagnosed by cardiac monitoring or electrophysiologic testing. Data from the patient's history and 12-lead emergency electrocardiography (ECG) were used to identify predictors of arrhythmias. Logistic regression was used to identify predictors for the risk-score system. Risk-score performance was measured by comparing the proportions of patients with arrhythmias at various levels of the score and receiver operating characteristic (ROC) curves. RESULTS: The prevalence of arrhythmic syncope was 17% in the derivation cohort and 18% in the validation cohort. Predictors of arrhythmias were abnormal ECG (odds ratio [OR]: 8.1, 95% confidence interval [CI]=3.0 to 22.7), a history of congestive heart failure (OR: 5.3, 95% CI=1.9 to 15.0), and age older than 65 (OR: 5.4, 95% CI=1.1 to 26.0). In the derivation cohort, the risk of arrhythmias ranged from 0% (95% CI=0 to 6) in patients with no risk factors to 6% (95% CI=1 to 15) for patients with one risk factor, 41% (95% CI=26 to 57) for patients with two risk factors, and 60% (95% CI = 32 to 84) for those with three risk factors. In the validation cohort, these proportions varied from 2% (95% CI=0 to 7) with no risk factors to 17% (95% CI=10 to 27) with one risk factor, 35% (95% CI=24 to 46) with two risk factors, and 27% (95% CI=6 to 61) with three risk factors. Areas under the ROC curves ranged from 0.88 (95% CI=0.84 to 0.91) for the derivation cohort to 0.84 (95% CI=0.77 to 0.91) after cross-validation within the same cohort and 0.75 (95% CI=0.68 to 0.81) for the external validation cohort. CONCLUSIONS: In patients with unexplained syncope, a risk score based on clinical and ECG factors available in the ED identifies patients at risk for arrhythmias.

Patients leaving the emergency department without being seen by a physician: a retrospective database analysis.

QUESTIONS UNDER STUDY: To describe characteristics of patients leaving the emergency department (ED) before being seen by a physician and to identify factors associated with a greater risk of leaving the ED too early. DESIGN: retrospective database analysis. SETTING: emergency department (ED) of an urban teaching hospital admitting 60,000 patients per year. STUDY SUBJECTS: all patients older than 18 years admitted to the ED over one year. Collected data: patient's and ED visit characteristics. RESULTS: Among the 57,645 patients admitted, we identified 2,413 patients (4.2%) who left without being seen (LWBS). LWBS patients were more likely to be male (odds ratio [OR] 1.13, 95% confidence interval [CI 95%]: 1.03-1.23), single (OR 1.12, CI 95%: 1.01-1.23), unemployed (OR 1.27, CI 95%: 1.13-1.44), dependent on welfare (OR 1.29, CI 95%: 1.12-1.50) or Muslim (OR 1.19, CI 95%: 1.00-1.42). LWBS patients were also more likely to present with less acute emergency triage levels. As complaints, alcohol and/or other substance abuse (OR 6.08, CI 95%: 5.04-7.34), neurological problems (OR 2.23, CI 95%: 1.88-2.64) or dermatological problems (OR 1.63, CI 95%: 1.37-1.94) were over-represented in this population. Patients admitted at week-ends (OR 1.27, 95% CI: 1.16-1.39) and/or during the night (OR = 2.67, 95% C: 2.35-3.02) also were at higher risk of leaving the ED prematurely. CONCLUSIONS: LWBS patients share some characteristics and a better understanding of these characteristics as well as time and logistic issues could ease to implement strategies to reduce premature leaving from the ED.

AngioJet rheolytic thrombectomy in patients presenting with high-risk pulmonary embolism and cardiogenic shock: a feasibility pilot study.

AIMS: Pulmonary embolism (PE) associated with haemodynamic instability has exceedingly high mortality. While intravenous thrombolysis is considered the therapy of choice, percutaneous mechanical thrombectomy may represent an alternative treatment. METHODS AND RESULTS: The impact of AngioJet® rheolytic thrombectomy (RT) in PE associated with cardiogenic shock was assessed in a single-centre prospective pilot study. Ten consecutive PE patients in cardiogenic shock were included in the study. Six patients had thrombolysis contraindications, eight were intubated before the RT procedure and six had experienced cardiac arrest prior to the RT procedure. The RT procedure was technically successful in all cases. The Miller index improved from 25 to 20 (p=0.002). The shock index decreased from 1.22 to 0.9 (p=0.129). Thrombolytic agents were administered during or after the procedure in four patients because of progressive clinical deterioration. Seven patients died in the first 24 hours: two from multi-organ failure, one from post-anoxic cerebral oedema, and four from progressive right heart failure. The three survivors had favourable outcomes at one year. CONCLUSIONS: This study suggests that the AngioJet® RT procedure may be safely performed in PE patients with cardiogenic shock. However, despite angiographic and haemodynamic improvements, the procedure does not appear to influence the dismal prognosis of these high-risk patients.

Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the Emergency Department with syncope: an international meta-analysis.

BACKGROUND: Syncope remains challenging for Emergency Department (ED) physicians due to difficulties in assessing the risk of future adverse outcomes. The aim of this meta-analysis is to establish the incidence and etiology of adverse outcomes as well as the predictors, in patients presenting with syncope to the ED. METHODS: A systematic electronic literature review was performed looking for eligible studies published between 1990 and 2010. Studies reporting multivariate predictors of adverse outcomes in patients presenting with syncope to the ED were included and pooled, when appropriate, using a random-effect method. Adverse events were defined as 'incidence of death, or of hospitalization and interventional procedures because of arrhythmias, ischemic heart disease or valvular heart disease'. RESULTS: 11 studies were included. Pooled analysis showed 42% (CI 95%; 32-52) of patients were admitted to hospital. Risk of death was 4.4% (CI 95%; 3.1-5.1) and 1.1% (CI 95%; 0.7-1.5) had a cardiovascular etiology. One third of patients were discharged without a diagnosis, while the most frequent diagnosis was 'situational, orthostatic or vasavagal syncope' in 29% (CI 95%; 12-47). 10.4% (CI 95%; 7.8-16) was diagnosed with heart disease, the most frequent type being bradyarrhythmia, 4.8% (CI 95%; 2.2-6.4) and tachyarrhythmia 2.6% (CI 95%; 1.1-3.1). Palpitations preceding syncope, exertional syncope, a history consistent of heart failure or ischemic heart disease, and evidence of bleeding were the most powerful predictors of an adverse outcome. CONCLUSION: Syncope carries a high risk of death, mainly related to cardiovascular disease. This large study which has established the most powerful predictors of adverse outcomes, may enable care and resources to be better focused at high risk patients.