RESUMO
BACKGROUND: Electrocardiogram (ECG) is one of the most commonly performed examinations in emergency medicine. The literature suggests that one-third of ECG interpretations contain errors and can lead to clinical adverse outcomes. The purpose of this study was to assess the quality of real-time ECG interpretation by senior emergency physicians compared to cardiologists and an ECG expert. METHODS: This was a prospective study in two university emergency departments and one emergency medical service. All ECGs were performed and interpreted over five weeks by a senior emergency physician (EP) and then by a cardiologist using the same questionnaire. In case of mismatch between EP and the cardiologist our expert had the final word. The ratio of agreement between both interpretations and the kappa (k) coefficient characterizing the identification of major abnormalities defined the reading ability of the emergency physicians. RESULTS: A total of 905 ECGs were analyzed, of which 705 (78%) resulted in a similar interpretation between emergency physicians and cardiologists/expert. However, the interpretations of emergency physicians and cardiologists for the identification of major abnormalities coincided in only 66% (k: 0.59 (95% confidence interval (CI): 0.54-0.65); P-value = 1.64e-92). ECGs were correctly classified by emergency physicians according to their emergency level in 82% of cases (k: 0.73 (95% CI: 0.70-0.77); P-value ≈ 0). Emergency physicians correctly recognized normal ECGs (sensitivity = 0.91). CONCLUSION: Our study suggested gaps in the identification of major abnormalities among emergency physicians. The initial and ongoing training of emergency physicians in ECG reading deserves to be improved.
Assuntos
Cardiologistas , Serviços Médicos de Emergência , Humanos , Estudos Prospectivos , Eletrocardiografia , CogniçãoRESUMO
BACKGROUND: Virus-associated respiratory infections are in the spotlight with the emergence of SARS-CoV-2 and the expanding use of multiplex PCR (mPCR). The impact of molecular testing as a point-of-care test (POCT) in the emergency department (ED) is still unclear. OBJECTIVES: To compare the impact of a syndromic test performed in the ED as a POCT and in the central laboratory on length of stay (LOS), antibiotic use and single-room assignment. METHODS: From 19 November 2019 to 9 March 2020, adults with acute respiratory illness seeking care in the ED of a large hospital were enrolled, with mPCR performed with a weekly alternation in the ED as a POCT (week A) or in the central laboratory (week B). RESULTS: 474 patients were analysed: 275 during A weeks and 199 during B weeks. Patient characteristics were similar. The hospital LOS (median 7 days during week A versus 7 days during week B, Pâ=â0.29), the proportion of patients with ED-LOS <1 day (63% versus 60%, Pâ=â0.57) and ED antibiotic prescription (59% versus 58%, Pâ=â0.92) were not significantly different. Patients in the POCT arm were more frequently assigned a single room when having a positive PCR for influenza, respiratory syncytial virus and metapneumovirus [52/70 (74%) versus 19/38 (50%) in the central testing arm, Pâ=â0.012]. CONCLUSIONS: Syndromic testing performed in the ED compared with the central laboratory failed to reduce the LOS or antibiotic consumption in patients with acute respiratory illness, but was associated with an increased single-room assignment among patients in whom a significant respiratory pathogen was detected.
Assuntos
COVID-19 , Sistemas Automatizados de Assistência Junto ao Leito , Adulto , Serviço Hospitalar de Emergência , Humanos , Tempo de Internação , Testes Imediatos , SARS-CoV-2RESUMO
BACKGROUND: The individual factors associated to Frequent Users (FUs) in Emergency Departments are well known. However, the characteristics of their geographical distribution and how territorial specificities are associated and intertwined with ED use are limited. Investigating healthcare use and territorial factors would help targeting local health policies. We aim at describing the geographical distribution of ED's FUs within the Paris region. METHODS: We performed a retrospective analysis of all ED visits in the Paris region in 2015. Data were collected from the universal health insurance's claims database. Frequent Users (FUs) were defined as having visited ≥3 times any ED of the region over the period. We assessed the FUs rate in each geographical unit (GU) and assessed correlations between FUs rate and socio-demographics and economic characteristics of GUs. We also performed a multidimensional analysis and a principal component analysis to identify a typology of territories to describe and target the FUs phenomenon. RESULTS: FUs accounted for 278,687 (11.7%) of the 2,382,802 patients who visited the ED, living in 232 GUs. In the region, median FUs rate in each GU was 11.0% [interquartile range: 9.5-12.5]. High FUs rate was correlated to the territorial markers of social deprivation. Three different categories of GU were identified with different profiles of healthcare providers densities. CONCLUSION: FUs rate varies between territories and is correlated to territorial markers of social deprivation. Targeted public policies should focus on disadvantaged territories.
Assuntos
Serviço Hospitalar de Emergência , Populações Vulneráveis , Política de Saúde , Humanos , Política Pública , Estudos RetrospectivosRESUMO
Acute intermittent porphyria (AIP) is a disease affecting the heme biosynthesis pathway caused by mutations of the hydroxymethylbilane synthase (HMBS) gene. AIP is thought to display autosomal dominant inheritance with incomplete penetrance. We evaluated the prevalence, penetrance and heritability of AIP, in families with the disease from the French reference center for porphyria (CFP) (602 overt patients; 1968 relatives) and the general population, using Exome Variant Server (EVS; 12 990 alleles) data. The pathogenicity of the 42 missense variants identified was assessed in silico, and in vitro, by measuring residual HMBS activity of the recombinant protein. The minimal estimated prevalence of AIP in the general population was 1/1299. Thus, 50 000 subjects would be expected to carry the AIP genetic trait in France. Penetrance was estimated at 22.9% in families with AIP, but at only 0.5-1% in the general population. Intrafamily correlation studies showed correlations to be strong overall and modulated by kinship and the area in which the person was living, demonstrating strong influences of genetic and environmental modifiers on inheritance. Null alleles were associated with a more severe phenotype and a higher penetrance than for other mutant alleles. In conclusion, the striking difference in the penetrance of HMBS mutations between the general population and the French AIP families suggests that AIP inheritance does not follow the classical autosomal dominant model, instead of being modulated by strong environmental and genetic factors independent from HMBS. An oligogenic inheritance model with environmental modifiers might better explain AIP penetrance and heritability.
Assuntos
Bases de Dados de Ácidos Nucleicos , Interação Gene-Ambiente , Hidroximetilbilano Sintase/genética , Mutação de Sentido Incorreto , Penetrância , Porfiria Aguda Intermitente/genética , Feminino , França/epidemiologia , Humanos , Masculino , Porfiria Aguda Intermitente/enzimologia , Porfiria Aguda Intermitente/epidemiologia , PrevalênciaRESUMO
In the race to contain severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), efficient detection and triage of infected patients must rely on rapid and reliable testing. In this work, we performed the first evaluation of the QIAstat-Dx respiratory SARS-CoV-2 panel (QIAstat-SARS) for SARS-CoV-2 detection. This assay is the first rapid multiplex PCR (mPCR) assay, including SARS-CoV-2 detection, and is fully compatible with a non-PCR-trained laboratory or point-of-care (PoC) testing. This evaluation was performed using 69 primary clinical samples (66 nasopharyngeal swabs [NPS], 1 bronchoalveolar lavage fluid sample [BAL], 1 tracheal aspirate sample, and 1 bronchial aspirate sample) comparing SARS-CoV-2 detection with the currently WHO-recommended reverse transcription-PCR (RT-PCR) (WHO-RT-PCR) workflow. Additionally, a comparative limit of detection (LoD) assessment was performed for QIAstat-SARS and WHO-RT-PCR using a quantified clinical sample. Compatibility of sample pretreatment for viral neutralization or viscous samples with the QIAstat-SARS system were also tested. The QIAstat-Dx respiratory SARS-CoV-2 panel demonstrated a sensitivity comparable to that of the WHO-recommended assay with a limit of detection at 1,000 copies/ml. The overall percent agreement between QIAstat-Dx SARS and WHO-RT-PCR on 69 clinical samples was 97% with a sensitivity of 100% (40/40) and specificity at 93% (27/29). No cross-reaction was encountered for any other respiratory viruses or bacteria included in the panel. The QIAstat-SARS rapid multiplex PCR panel provides a highly sensitive, robust, and accurate assay for rapid detection of SARS-CoV-2. This assay allows rapid decisions even in non-PCR-trained laboratory or point-of-care testing, allowing innovative organization.
Assuntos
Betacoronavirus/isolamento & purificação , Técnicas de Laboratório Clínico/métodos , Infecções por Coronavirus/diagnóstico , Reação em Cadeia da Polimerase Multiplex/métodos , Pneumonia Viral/diagnóstico , Betacoronavirus/genética , COVID-19 , Teste para COVID-19 , Humanos , Pandemias , Sistema Respiratório/virologia , SARS-CoV-2 , Sensibilidade e Especificidade , Fatores de TempoRESUMO
OBJECTIVES: To determine whether the impact of a thoracic CT scan on community-acquired pneumonia (CAP) diagnosis and patient management varies according to emergency physician's experience (≤10 vs >10 years). METHODS: Early thoracic CT Scan for Community-Acquired Pneumonia at the Emergency Department is an interventional study conducted from November 2011 to January 2013 in four French emergency departments, and included suspected patients with CAP. We analysed changes in emergency physician CAP diagnosis classification levels before and after CT scan; and their agreement with an adjudication committee. We performed univariate analysis to determine the factors associated with modifying the diagnosis classification level to be consistent with the radiologist's CT scan interpretation. RESULTS: 319 suspected patients with CAP and 136 emergency physicians (75% less experienced with ≤10 years, 25% with >10 years of experience) were included. The percentage of patients whose classification was modified to become consistent with CT scan radiologist's interpretation was higher among less-experienced than experienced emergency physicians (54.2% vs 40.2%; p=0.02). In univariate analysis, less emergency physician experience was the only factor associated with changing a classification to be consistent with the CT scan radiologist's interpretation (OR 1.77, 95% CI 1.01 to 3.10, p=0.04). After CT scan, the agreement between emergency physicians and adjudication committee was moderate for less-experienced emergency physicians and slight for experienced emergency physicians (k=0.457 and k=0.196, respectively). After CT scan, less-experienced emergency physicians modified patient management significantly more than experienced emergency physicians (36.1% vs 21.7%, p=0.01). CONCLUSIONS: In clinical practice, less-experienced emergency physicians were more likely to accurately modify their CAP diagnosis and patient management based on thoracic CT scan than more experienced emergency physicians. TRIAL REGISTRATION NUMBER: NCT01574066.
Assuntos
Competência Clínica/normas , Infecções Comunitárias Adquiridas/terapia , Medicina de Emergência/normas , Acontecimentos que Mudam a Vida , Adulto , Competência Clínica/estatística & dados numéricos , Infecções Comunitárias Adquiridas/complicações , Tomada de Decisões , Medicina de Emergência/métodos , Medicina de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia/complicações , Pneumonia/terapia , Estudos Prospectivos , Estatísticas não Paramétricas , Fatores de Tempo , Tomografia Computadorizada por Raios X/métodos , Tomografia Computadorizada por Raios X/normas , Tomografia Computadorizada por Raios X/estatística & dados numéricosRESUMO
BACKGROUND: Myiasis designates the infestation of live human and vertebrate animals with dipterous (two-winged) larvae (maggots) and is the fourth most common travel-associated skin disease. Furuncle is the most common aspect of cutaneous myiasis. CASE PRESENTATION: A 24-year-old Caucasian female had been back from Cap-Vert. She described pruritus, slight pain, and the sensation of a foreign body moving in the eyelid. Physical examination showed a single furuncle-like nodule with surrounding erythema and a central pore of the upper eyelid through which a serosanguinous fluid was exuding. A larval end was visible to the naked eye through the aforementioned pore. Treatment consisted of the application of petroleum jelly (Vaseline®) to produce localized hypoxia. A transparent occlusive dressing was set for a duration of 2 h. The larva, Cordylobia antropophaga, spontaneously externalized to breathe and was extracted. DISCUSSION: There is an increase in travelers returning from tropical countries. Consequently, travel-associated dermatoses are increasing in non-endemic countries. Context of travel and typical clinical presentation strongly suggested to evoke a cutaneous myiasis. The typical furuncular lesion is a papule or nodule with a central punctum that exudes serosanguinous or purulent fluid. Ultrasound can be used to confirm the diagnosis. Treatment consists of three techniques: methods producing localized hypoxia to force emergence of the larvae, application of toxic substances to the eggs and larvae, and mechanical or surgical debridement. Surgery and antibiotics are usually unnecessary. Prevention of furunculous myiasis is based on vector control and individual actions to improve hygiene.
Assuntos
Blefarite/diagnóstico , Miíase/diagnóstico , Curativos Oclusivos , Vaselina , Viagem , Blefarite/terapia , Serviço Hospitalar de Emergência , Feminino , França , Humanos , Miíase/terapia , Senegal , Adulto JovemRESUMO
BACKGROUND: Hospitalization is usually recommended for imported malaria. The goal of the present study is to evaluate the evolution in clinical pathways while measuring their impact on mortality. METHODS: This is a 14-year prospective observational study divided into three periods. We evaluated for adult (≥15 years) and paediatric (<15 years) case trends in severity, clinical pathways (hospitalization in medical ward (MW) or intensive care unit (ICU), ambulatory care) and mortality. RESULTS: In total, 21,386 imported malaria cases were included, 4269 of them were paediatrics (20 %). Rises in severe forms for adults [from 8 % in period 1-14 % in period 3 (p = 0.0001)] and paediatrics [from 12 to 18 % (p < 0.0001)] were found. For adults, MW admission rates decreased [-15 % (CI 95 % -17; -13)] while ambulatory care [+7 % (CI 95 % 5-9)] and ICU admission rates [+4 % (CI 95 % 3-5)] increased. For paediatrics, increase in ICU admissions (+3 %) was shown. We did not observe any change in overall mortality during the study periods, whether among adults or children, regardless of care pathway. CONCLUSIONS: The present study indicates a changing management of imported malaria in adults, with an increasing trend for ambulatory care. The absence of change in mortality for adults indicates that ambulatory care can be proposed for adults presenting non-severe imported malaria.
Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Hospitalização , Malária/mortalidade , Malária/patologia , Viagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Humanos , Lactente , Recém-Nascido , Pessoa de Meia-Idade , Estudos Prospectivos , Análise de Sobrevida , Adulto JovemRESUMO
Objectives: Hospital at home (HAH) care is becoming increasingly popular in France and requires the involvement of general practitioners (GPs) in the care of their patients. The objective of this study was to identify the incentives and barriers to the involvement of general practitioners in HAH. Materials and methods: A qualitative study was carried out using semi-structured interviews during a focus group with 12 GPs. All interviews were recorded and then transcribed verbatim and data analysis used the grounded theory method. Results: General practitioners appeared to be familiar with the indications and places of care for HAH, but they highlighted the difficulties associated with the HAH request circuit. GPs identified difficulties determining their exact role in HAH, which were improved by their clinical expertise in home visits. Doctors stressed the complexity of home care, but they were assisted by the coordinating physician and they requested specific training. Conclusion: We identified incentives and barriers to the participation of GPs in HAH. The request circuit needs to be simplified, home visits need to be strengthened and support must be provided to GPs in their management of complex care.
Assuntos
Atitude do Pessoal de Saúde , Clínicos Gerais/organização & administração , Serviços Hospitalares de Assistência Domiciliar/organização & administração , Serviços de Assistência Domiciliar/organização & administração , Visita Domiciliar , Motivação , Barreiras de Comunicação , Procedimentos Clínicos/organização & administração , Feminino , França/epidemiologia , Clínicos Gerais/psicologia , Serviços Hospitalares de Assistência Domiciliar/estatística & dados numéricos , Visita Domiciliar/estatística & dados numéricos , Humanos , Masculino , Recursos HumanosRESUMO
INTRODUCTION: We aimed to determine the rate of preventable death in patients who died early and unexpectedly following hospital admission from the emergency department (ED). METHODS: We conducted a retrospective multicenter study in four centers from the Paris metropolitan area. Inclusion criteria were medical patients who died in hospital within 72 hours of ED attendance and were not admitted to the intensive care unit (unexpected death). Exclusion criteria were limitations of care determined by treating physicians. The existence of a limitation of care decision was adjudicated by two independent chart abstractors. Preventable death was defined as death occurring as a result of medical error. For each selected patient with unexpected death, charts were examined for medical errors and rated on a 1 to 5 preventability scale (from very unlikely to very likely) for the preventability of the death. The primary endpoint was the likely preventable death, rated as 4 or 5 on the preventability scale. RESULTS: We retrieved 555 charts; 47 unexpected deaths were analysed; 24 (51%) were considered as preventable. There was a median number of medical errors of two. The most common process breakdowns were incorrect choice of treatment (47% of patients) and failure to order appropriate diagnostic tests (38% of patients). The most common medical error was a severe delay or absence of recommended treatment for severe sepsis, which occurred in 10 (42%) patients. CONCLUSIONS: In our sample, more than half of unexpected deaths are related to a medical error, and could have been prevented.
Assuntos
Serviço Hospitalar de Emergência , Mortalidade Hospitalar , Erros Médicos/estatística & dados numéricos , Admissão do Paciente , Idoso , Auditoria Clínica , Feminino , França , Humanos , Masculino , Qualidade da Assistência à Saúde , Estudos Retrospectivos , Sepse/mortalidade , Tempo para o TratamentoRESUMO
BACKGROUND: Tétanos Quick Stick® (TQS) is a test for tetanus immunity screening for wounded patients in emergency departments (EDs), but represents additional costs compared with a medical interview on vaccination history. The study objective was to assess the effectiveness and cost of the TQS in French EDs. METHODS: We performed a model-based analysis that simulates screening of tetanus immunity and risk of tetanus based on prophylaxis administration. Strategies compared were: i) diagnosis of tetanus immunity by "TQS"; ii) "Medical Interview" (current practice). The study population was 1,658,000 French adults seeking ED care for a wound in 2012. Model parameters were estimated based on French national surveillance data, and published literature. Outcome measures were number of tetanus cases, life years gained and costs (2012 ) from a societal perspective. RESULTS: Use of TQS had negligible impact on health outcomes (0.02 tetanus cases/year in France vs. 0.41 for "Medical Interview"), but resulted in a decrease in annual costs of 2,203,000 (-42%). Base case and sub-group analysis showed that with the same effectiveness, the average cost per patient was: 13 with "Medical Interview" vs. 11.7 with TQS for the overall cohort; 28.9 with "Medical Interview" vs. 21 with "TQS" for tetanus-prone wounds; 15 with "Medical Interview" vs. 14.1 with "TQS" for patients aged ≥65 years; and 6.2 with "Medical Interview" vs. 7.8 with "TQS" for non-tetanus-prone wounds. CONCLUSIONS: Use of TQS is as effective and less costly than "Medical Interview" when applied in ED to wounded patients with tetanus-prone wounds or aged ≥65 years. However, it is more expensive in patients with non-tetanus-prone wounds.
Assuntos
Anticorpos Antibacterianos/imunologia , Clostridium tetani/imunologia , Toxoide Tetânico/uso terapêutico , Tétano/prevenção & controle , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Simulação por Computador , Serviço Hospitalar de Emergência , França , Humanos , Pessoa de Meia-Idade , Tétano/imunologia , Toxoide Tetânico/economia , Toxoide Tetânico/imunologia , Adulto JovemAssuntos
Serviço Hospitalar de Emergência/organização & administração , Medição da Dor/métodos , Treinamento por Simulação/organização & administração , Serviço Hospitalar de Emergência/normas , Humanos , Medição da Dor/normas , Educação de Pacientes como Assunto/organização & administração , Participação do Paciente/métodos , Triagem/organização & administraçãoAssuntos
Fibrilação Atrial/diagnóstico , Diagnóstico Precoce , Monitorização Fisiológica/métodos , Software , Telemedicina/métodos , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Infecções Comunitárias Adquiridas/complicações , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Serviço Hospitalar de Emergência , Feminino , Humanos , Pneumonia Pneumocócica/complicações , Pneumonia Pneumocócica/diagnóstico , Pneumonia Pneumocócica/tratamento farmacológicoAssuntos
Diagnóstico por Computador/instrumentação , Diagnóstico Precoce , Monitorização Ambulatorial/instrumentação , Insuficiência Respiratória/diagnóstico , Doença Aguda , Adulto , Diagnóstico por Computador/métodos , Humanos , Masculino , Monitorização Ambulatorial/métodos , Oxigenoterapia , Telemedicina , Dispositivos Eletrônicos VestíveisRESUMO
BACKGROUND: It has been reported that emergency department length of stay (ED-LOS) for older patients is longer than average. Our objective was to determine the effect of age, patient's clinical acuity and complexity, and care pathways on ED-LOS and ED plus observation unit (EDOU) LOS (EDOU-LOS). METHODS: This was a prospective, multicentre, observational study including all patients attending in 2011. Age groups were: I, <50; II, ≥50-64; III, ≥65-74; IV, ≥75-84; V, ≥85â years. Univariate and multivariate analyses were performed. RESULTS: Of 125â 478 attendances, 20â 845(16.6%) were of patients aged ≥65â years. Multivariate analysis found significant predictors for ED-LOS (C-statistics 0.79, p<0.0000001) to be: arrival mode (ambulance, OR 1.13 (95% CI 1.08 to 1.18)); acuity level (level 4, OR 1.24 (95% CI 1.21 to 1.28); level 1-3, OR 1.54 (95% CI 1.5 to 1.59)); haematological examinations (OR 3.34 (95% CI 3.15 to 3.56)); intravenous treatment (OR 1.58 (95% CI 1.47 to 1.69)); monitoring of vital signs (OR 1.89 (95% CI 1.69 to 2.10)); x-ray examinations (OR 1.53 (95% CI 1.45 to 1.61)); CT/MRI/ultrasound (OR 2.60 (95% CI 2.39 to 2.82)); and specialist advice (OR 1.39 (95% CI 1.30 to 1.48)). For EDOU-LOS (C-statistics 0.81, p<0.0000001) we found: age group (II, OR 1.19 (95% CI 1.16 to 1.22); III, OR 1.42 (95% CI 1.38 to 1.46); IV, OR 1.69 (95% CI 1.65 to 1.74); V, 2.01 (95% CI 1.96 to 2.07)); acuity level (level 4, OR 1.31 (95% CI 1.27 to 1.35); level 1-3, OR 1.71 (95% CI 1.66 to 1.77)); haematological examinations (OR 7.81 (95% CI 7.23 to 8.43)); intravenous treatment (OR 1.95 (95% CI 1.8 to 2.12)); x-ray examinations (OR 1.95 (95% CI 1.85 to 2.06)); CT/MRI/ultrasound (OR 6.74 (95% CI 5.98 to 7.6)); specialist advice (OR 2.24 (95% CI 2.07 to 2.42)); admission to a medical or surgical ward (OR 0.61 (95% CI 0.54 to 0.68)); and transfer (OR 1.79 (95% CI 1.54 to 2.07)). CONCLUSIONS: Whereas ED-LOS and EDOU-LOS seem to be directly related to patients' acuity and complexity, notably the need for diagnostic and therapeutic interventions, only EDOU-LOS was significantly associated with age and proposed care pathways. We propose that EDOU-LOS measurement should be made in EDs with an OU.
Assuntos
Procedimentos Clínicos , Serviço Hospitalar de Emergência , Tempo de Internação , Gravidade do Paciente , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Adulto JovemRESUMO
BACKGROUND: Chloroquine (CQ) was the main malaria therapy worldwide from the 1940s until the 1990s. Following the emergence of CQ-resistant Plasmodium falciparum, most African countries discontinued the use of CQ, and now promote artemisinin-based combination therapy as the first-line treatment. This change was generally initiated during the last decade in West and Central Africa. The aim of this study is to describe the changes in CQ susceptibility in this African region, using travellers returning from this region as a sentinel system. METHODS: The study was conducted by the Malaria National Reference Centre, France. The database collated the pfcrtK76T molecular marker for CQ susceptibility and the in vitro response to CQ of parasites from travellers' isolates returning from Senegal, Mali, Ivory Coast or Cameroon. As a proxy of drug pressure, data regarding CQ intake in febrile children were collated for the study period. Logistic regression models were used to detect trends in the proportions of CQ resistant isolates. RESULTS: A total of 2874 parasite isolates were genotyped between 2000-2011. The prevalence of the pfcrt76T mutant genotype significantly decreased for Senegal (from 78% to 47%), Ivory Coast (from 63% to 37%), Cameroon (from 90% to 59%) and remained stable for Mali. The geometric mean of the 50% inhibitory concentration (IC50) of CQ in vitro susceptibility and the proportion of resistant isolates (defining resistance as an IC50 value > 100 nM) significantly decreased for Senegal (from 86 nM (59%) to 39 nM (25%)), Mali (from 84 nM (50%) to 51 nM (31%)), Ivory Coast (from 75 nM (59%) to 29 nM (16%)) and Cameroon (from 181 nM (75%) to 51 nM (37%)). Both analyses (molecular and in vitro susceptibility) were performed for the 2004-2011 period, after the four countries had officially discontinued CQ and showed an accelerated decline of the resistant isolates for the four countries. Meanwhile, CQ use among children significantly deceased in this region (fixed effects slope = -0.3, p < 10-3). CONCLUSIONS: An increase in CQ susceptibility following official withdrawal of the drug was observed in travellers returning from West and Central African countries. The same trends were observed for molecular and in vitro analysis between 2004-2011 and they correlated to the decrease of the drug pressure.
Assuntos
Antimaláricos/uso terapêutico , Cloroquina/uso terapêutico , Malária Falciparum/tratamento farmacológico , Plasmodium falciparum/efeitos dos fármacos , Adolescente , Adulto , África Central , África Ocidental , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Resistência a Medicamentos , Feminino , Genótipo , Humanos , Lactente , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Testes de Sensibilidade Parasitária , Plasmodium falciparum/genética , Plasmodium falciparum/isolamento & purificação , Viagem , Adulto JovemRESUMO
The study aimed to evaluate the response time (RT) of a French physician-staffed emergency medical service unit in both first-line and second-line service zones a part of its performance and how best to integrate it into its geographical specificity and showed acceptable RTs (mostly <10 min). Interestingly, because of the particular location next to other districts, RTs are in the same range for some municipalities that are adjacent to the first-line and area. In a new system in which catching areas would not only be based on administrative criteria anymore but also on performance evaluation, RTs for emergency medical service might be optimised.
Assuntos
Serviço Hospitalar de Emergência/normas , Serviço Hospitalar de Emergência/estatística & dados numéricos , França , Pesquisa sobre Serviços de Saúde/métodos , Hospitais de Ensino , Humanos , Estudos Retrospectivos , Fatores de TempoRESUMO
OBJECTIVE: Emergency department (ED) crowding impacts negatively on quality of care. The aim was to determine the association between ED quality and input, throughput and output-associated variables. METHODS: This 1-year, prospective, observational, cohort study determined the daily percentage of patients leaving the ED in <4 h (ED quality and performance indicator; EDQPI). According to the median EDQPI two groups were defined: best-days and bad-days. Hospital and ED variables and time interval metrics were evaluated as predictors. RESULTS: Data were obtained for 67â307 patients over 364 days. Differences were observed between the two groups in unadjusted analysis: number of daily visits, number of patients as a function of final disposition, number boarding in the ED, and time interval metrics including wait time to triage nurse and ED provider, time from ED admission to decision, time from decision to departure and length of stay (LOS) as a function of final disposition. Five variables remained significant predictors for bad-days in multivariate analysis: wait time to triage nurse (OR 2.36; 95% CI 1.36 to 4.11; p=0.002), wait time to ED provider (OR 1.93; 95% CI 1.05 to 3.54; p=0.03), number of patients admitted to hospital (OR 1.86; 95% CI 1.09 to 3.19; p=0.02), LOS of non-admitted patients (OR 9.5; 95% CI 5.17 to 17.48; p<0.000001) and LOS of patients admitted to hospital (OR 2.46; 95% CI 1.44 to 4.2; p=0.0009). CONCLUSIONS: Throughput is the major determinant of EDQPI, notably time interval reflecting the work dynamics of medical and nursing teams and the efficacy of fast-track routes for low-complexity patients. Output also significantly impacted on EDQPI, particularly the capacity to reduce the LOS of admitted patients.