[Impact of low-dose CT in the diagnosis and treatment of renal colic in emergency department]. / Impact de la tomodensitométrie faible dose sur le diagnostic et la prise en charge des coliques néphrétiques aux urgences.

OBJECTIVE: To evaluate the diagnostic performance and the benefit in terms of management of low-dose CT for the imaging assessment of renal colic (CN) emergencies. PATIENTS AND METHODS: Two hundred and ninety-one patients admitted to emergency for CN were included in this study. Eighty-seven had a low-dose CT and 40 an ASP and an ultrasound (ASPE). Different parameters evaluating the diagnostic performance and efficiency of care were compared between the two groups. The quantitative and qualitative variables were compared by Student t test and χ(2) test, respectively. RESULTS: CT and ASPE confirmed the diagnosis of CN in 76% and 54% of patients, respectively (p=0.013). The average lengths of stay were 408 minutes versus 520 (p=0.013) in group scanner and ASPE, respectively. The scan was obtained more rapidly (139 min versus 224, p=0.002). There were more requests for expert advice (30% versus 20%, p=0.18) and gestures endo-urology (9.5% versus 5%, p=0.31) in the CT group compared to the group ASPE. Finally, the patients in the scanner have less painful recurrences (6% versus 12.5%, p=0.18) and fewer imaging examinations of second-line (0% versus 30%, p<0.001). CONCLUSION: The low dose CT has been more efficient than the couple ASPE for a CN diagnosis. It optimizes the management of emergency patients by reducing their length of stay, waiting time and the rate of second consultation.

Pain intensity and imaging at the initial phase of acute pyelonephritis.

OBJECTIVE: To identify predictive factors of urological complication on imaging findings in women with pyelonephritis aged 18 to 65 years. METHODS: We performed an observational, retrospective, single-center study. The medical charts of women diagnosed with pyelonephritis at the emergency department from 2010 to 2015 were reviewed. Only patients who underwent an imaging study at the emergency department and with microbiologically confirmed pyelonephritis were included for analysis. The primary endpoint was the presence of urological complications on imaging findings. The secondary endpoint was treatment changes after imaging diagnosis. RESULTS: Of the 193 women enrolled, 88 (45.6%) had urological complication(s) on imaging findings. The multivariate analysis revealed that history of urolithiasis (OR=2.41; P=0.01) and pain requiring morphine use (OR=5.29; P=0.009) were predictive of urological complications on imaging findings. Of the 120 women with uncomplicated pyelonephritis who underwent imaging studies, 45% had urological complication, resulting in a treatment change in 36.7% of patients. The multivariate analysis revealed that age>40 years (OR=4.58; P=0.02) and pain requiring morphine use (OR=3.78; P=0.02) were predictive of urological complication(s) on imaging findings and of treatment change based on imaging findings (OR=6.76; P=0.005 and OR=4.19; P=0.01 respectively) in this subgroup. CONCLUSIONS: Pain requiring morphine use, age, and history of urolithiasis are independent predictors of urological complications on imaging findings in patients with acute pyelonephritis.

[Adverse drug effects: a prospective study by Apnet performed in seven emergency care units in France: propositions for preventive measures]. / Accidents médicamenteux. (A propos d'une étude prospective de l'Apnet réalisée dans sept services d'accueil et d'urgences français). Propositions pour des mesures préventives.

Various studies have shown that adverse drug effects (ADEs) are a substantial cause of hospital admissions. However, little is known about the incidence and severity of ADEs resulting in hospital visits. To address this issue, we conducted a prospective survey in primary care and emergency departments of French public hospitals. This study was performed over two periods of one week, one in January, February and one in June 2003, in primary care and emergengy departments of four university hospitals and three general hospitals throughout France. Out of a total of 1826 patients consulting, 1663 were taking at least one drug during the previous week and were included for analysis according to the protocol. Altogether, 370 (22.2%; IC 95: 20.2-24.3%) of these patients receiving at least one drug consulted because of an ADE. From these 370 patients, 263 (15.8%) where considered as touched by a probably (12), likely (13) or very likely (14) ADE. The sex ratio was the same in both groups with or without ADE (0.88%; P=0.95). Patients with ADE were older than those without (62.4 vs 53.8 years, P=0.0016). Furthermore, ADE patients were more likely to have a higher severity score than no-ADE group (P=0.0003). The outcome seemed to be worse in patients with an ADE. The percentage of patients treated with 2 or more drugs and the number of drug exposures were significantly higher in patients with ADE than in those without (93.2% vs 84.2%, P<0.0001, and 5.8 vs 4.5 P<0.0001, respectively). The most frequent causes of visits for ADE-patients were digestive (n=38: 14.4%), neurological (n=23: 10.6%), malaise (n=48: 18,2%) events. The most frequently incriminated drug classes were (1) psychotropic agents, (including anxiolytics, hypnotics, antidepressants and antipsychotics), (2) diuretics (3) anticoagulants, (4) other cardiovascular drugs and (5) analgesics, including non steroidal anti-inflammatory agents. In 150 cases (40.8%; IC 95: 33.7% - 45%), the ADE was considered to be preventable because a contra-indication or a warning about drug use had not been respected.

Trial of dexamethasone treatment for severe bacterial meningitis in adults. Adult Meningitis Steroid Group.

OBJECTIVE: To evaluate the clinical benefit of early adjunctive dexamethasone therapy for severe bacterial meningitis in adults. DESIGN: Multicenter, double-blind, randomized trial initiated in emergency or intensive care units in France and Switzerland. Within 3 h after initiation of an aminopenicillin therapy, patients received dexamethasone (10 mg q.i.d.) or placebo for 3 days. The primary end-point was the rate of patients cured without any neurologic sequelae on day 30. RESULTS: Sixty patients were enrolled, predominantly with a severe form since 85% required ICU stay and 43% mechanical ventilation. Streptococcus pneumoniae accounted for 31 cases and Neisseria meningitidis for 18 cases. The study had to be stopped prematurely because of a new national recommendation of experts to use third generation cephalosporin and vancomycin as a result of the increasing rate of penicillin-resistant S. pneumoniae in France. After the third sequential analysis by the triangular statistical test, the difference of rate of cured patients without any neurologic sequelae was not statistically significant (p = 0.0711) between the dexamethasone group (74.2%; n = 31) and the placebo group (51.7%; n = 29). Furthermore, the former group was younger and less sick at inclusion. CONCLUSION: Bacterial meningitis is still a severe disease in adults, since the overall observed rate of death or severe neurologic sequelae was 26.7%. The reported data are inconclusive regarding a systematic use of dexamethasone as an adjunctive therapy for bacterial meningitis in adults. Moreover this treatment impairs antibiotic penetration into the cerebrospinal fluid (CSF) that can lead to therapeutic failure, particularly in areas with high or increasing rates of penicillin-resistant S. pneumoniae.

Calcium free hemodialysis: experience in the treatment of 33 patients with severe hypercalcemia.

OBJECTIVE: To assess the efficacy, adverse effects and relevance of calcium-free hemodialysis (CFHD) in the treatment of major hypercalcemia. DESIGN: Retrospective chart review. SETTING: Medical ICU. PATIENTS: All patients admitted over a 9-year period for hypercalcemia requiring urgent treatment and who underwent hemodialysis. INTERVENTIONS: CFHD with an acetate dialysate. MAIN RESULTS: Thirty-three patients with severe hypercalcemia from various etiologies received CFHD. Marked and rapid decrease of serum total calcium was obtained during all sessions (mean decrease: 1.71 +/- 0.54 mmol/l). Calcium rebound within 24 h after CFHD was observed in all evaluable cases (1 +/- 0.45 mmol/l; mean delay 13.7 +/- 5.8 h). Adverse cardiovascular effects occurred in 17 of 48 sessions (35%) and in 13 of 30 evaluable patients (43%). CONCLUSIONS: Adverse effects are frequent during CFHD. After correction of hypovolemia, its use should be restricted to patients with severe clinical symptoms or advanced renal impairment.

Acute renal failure following collective intoxication by Cortinarius orellanus.

Twenty-six young men with no previous medical history all ingested mushroom soup, exclusively made with Cortinarius orellanus. They were hospitalized 10-12 days after the incident. On admission, 12 patients presented with acute tubulointerstitial nephritis with acute renal failure; 8 required haemodialysis. In addition to symptomatic treatment, 9 patients were given corticosteroids. In this group of 12 patients, 8 recovered rapidly, and the other 4 suffered from chronic renal failure for several months. In the other group of 14 patients, initial leukocyturia was observed in 12 cases, although renal function remained normal during a one-year follow-up. Hepatic acetylation and hydroxylation tests performed after 6 months in 22 patients did not provide any explanation for the strong individual sensitivity to the renal toxicity of this fungus.

[Study on myoglobinemia and its development during myocardial infarction (author's transl)]. / Etude de la myoglobinemie et de son évolution au cours de l'infarctus du myocarde.

Thirty six patients suffering from myocardial infarction were investigated by assay of their serum myoglobin, total creatine kinase and creatine kinase isoenzyme MB activities. Determination of serum myoblobin presents, with regard to creatine kinase MG, two major advantages: a very early increase after the onset of the pain (about three hours later) and a very quick clearance, allowing the diagnosis of a second episode of necrosis after about one day.

Analysis of time management in stroke patients in three French emergency departments: from stroke onset to computed tomography scan.

The aim of this study was to determine and identify the factors associated with shortening or lengthening time interval from stroke onset to performance of computed tomography (CT) scan in stroke patients admitted to three French emergency departments. All suspected stroke patients were eligible (n = 317). The time intervals between stroke onset and presentation to the emergency department and between CT scan request and CT scan performance were determined. Twelve variables likely to influence time interval before presentation to the emergency department, and five variables likely to influence time interval before CT scan performance were evaluated using stepwise regression analysis. Of the 317 patients included in the study, the mean time interval from stroke onset to CT scan performance for 180 patients was 7 hours 46 minutes (466 minutes). The mean time interval between stroke onset and presentation to the emergency department was 4 hours 36 minutes (276 minutes), varying according to the study site, level of initial severity, medical contact before admission, witnesses at stroke onset, and mode of transportation. The mean time interval between request and CT scan performance was 2 hours 14 minutes (134 minutes), varying upon the site, hour of CT scan request, type of stroke and level of severity at admission. It is concluded that current delays in stroke management are often incompatible with early treatment. The public needs to be informed and admission procedures reorganized. Improved response to the urgency of ischaemic stroke is required as well as direct access to the scanner during periods of scheduled use.

[Traumatic myocardial infarct]. / L'infarctus du myocarde traumatique.

Two cases of traumatic, closed chest, myocardial infarction in two young patients, aged 18 and 19 years respectively, are reported. They illustrate the two possible physiopathological mechanisms of this affection: in the first case, myocardial contusion after thoraco-abdominal trauma by crushing, probably complicated by a subendocardial tear of the inferior wall of the left ventricle, with a spontaneous favourable outcome; in the second case, a transmural myocardial infarction was observed secondary to a coronary lesion (? tearing of the adventitia of the left anterior descending artery) complicated by the early development of a large antero-apical aneurysm. Haemodynamic and arrhythmic complications necessitated infarctectomy and aorto coronary bypass surgery on the 35th day. The pathological lesions and their outcome are examined with respect to these two cases. The diagnostic, therapeutic and medieolegal problems associated with this condition are also discussed.

[Indications of partial interruption of the inferior vena cava in pulmonary embolism]. / Indications d'interruption partielle de la veine cave inférieure dans l'embolie pulmonaire.

Forty years after the first implantation of caval filters, there is still no indication for implantation validated by a controlled clinical trial. This fact may be explained by our poor understanding of the evolution of thromboembolic disease, especially in certain groups of patients. The absolute contra-indications to heparin therapy would seem to be a logical indication for a caval filter. In cases of a relative contra-indication to anticoagulants, the physician has to rely on his clinical judgement and the decision will be taken case by case. In patients with suspected pulmonary embolism under anticoagulant therapy, it is also logical to check that anticoagulation is effective, and to request proof of embolism, to assess its risk and that due to thrombosis before considering a caval filter. The prophylactic implantation of a caval filter is a very controversial indication whether the thrombus is proximal in the ilio-caval region, extensive, not uncommon despite treatment, or floating. For groups said to be at high risk of thromboembolism (elderly, malignant disease or multiple injuries), there is no consensus because of the discordant results in the literature. The implantation of a filter would seem to be justified in patients with chronic cor pulmonale after pulmonary embolectomy. The value of a temporary caval filter during thrombolysis has not been demonstrated; there are hopes that temporary filters "of long duration" will provide filtration of the vena cava during vulnerable periods. The results of the first controlled trial (PREPIC) are eagerly awaited and should rationalise the indications of inferior vena cava filters.

[Value of serum myoglobin in acute myocardial infarction. Kinetic study]. / Intérêt de la myoglobine sérique dans l'infarctus du myocarde aigu. Etude cinétique.

The rise in serum myoglobin (MGB), total CPK (CKT) and its MB isoenzyme (CK - MB) was studied and compared over the first three days of acute myocardial infarction (AMI) and correlations were sought between the peak values of these three parameters and haemodynamic and biological indices of left ventricular function. Blood was taken from MGB (radio immunological technique), CKT and CK - MB (spectrophotometry) estimation every 2 hours for 24 hours and then every 6 hours up to the 72nd hour in 36 patients with AMI less than 12 hours old. On admission, this protocol was completed by a haemodynamic study (right heart pressures, systemic blood pressure, cardiac output measurement by thermodilution), arterial gases and ECG recordings. The average delays before the pathological rise, the maximal peak value and the return to normal were significantly shorter (p less than 0.001) for MGB (2, 6 and 25 hours) than for CK - MB (5,16 and 34 hours) or CKT (5,21 and 57 hours). The sensitivity of the diagnosis of myocardial infarction was not significantly higher with MGB than CKT or CK - MB either in the whole group (sensitivity of 91.6 p. 100 for MGB and 86.1 p. 100 for CKT and CK - MB) or in a subgroup of ten patients without transmural infarction (70 p. 100 for MGB compared with 60 p. 100 for CKT and CK - MB). A significant correlation was found between the peak values of MGB (p less than 0.02) and CK- MB (p less than 0.02) and the indices of left ventricular function (PCP, PAO2 and LVSWI). This was not observed with CKT. In conclusion, apart form technical problems which remain unresolved time-consuming investigation), serum MGB gives a much earlier and as sensitive a biochemical diagnosis of AMI as CKT and CK - MB. MGB and CK - MB are much better prognostic indicators than CKT as judged by the indices of left ventricular function. Finally, MGB estimation should be of particular value in the diagnosis of secondary extension of infarction.

[Water intoxication in psychiatric patients. 13 cases of severe hyponatremia]. / Intoxication par l'eau chez des malades psychiatriques. Treize épisodes d'hyponatrémie sévère.

Water intoxication mostly occurs in psychiatric patients. We observed 13 episodes of severe hyponatremia (less than 120 mmol/l) following a period of increased water consumption in 10 psychiatric patients (5 men, 5 women, mean age 48.8 years) treated with neuroleptics and/or benzodiazepines. Other causes of hyponatremia were excluded. The initial clinical signs were associated with severe gastrointestinal and neurological disorders requiring intensive care. In every case a gradual return to normal of natremia was obtained by creating a negative water balance while compensating for the sodium loss. From a study of urine and plasma osmolality ratio (U/P osm) on admission, several physiopathological mechanisms could be envisaged. A U/P osm ratio lower than 1 (6 cases) suggested a water intake exceeding the maximum dilution capacity of the kidneys (20-25 1), or a lesser water intake with little or no osmolal intake, or again an intrarenal disorder of urine dilution. When the U/P osm ratio was higher than 1 (7 cases), reflecting inappropriate secretion of the antidiuretic hormone, the hyponatremia could be explained by the psychosis itself, the treatment taken by the patients, a disorder of thirst regulation and/or a non-osmotic stimulation of vasopressin. This population, therefore, was heterogeneous: the mechanisms which contribute to this pathology are not fully elucidated, and they probably involve several factors.

[Treatment of Guillain-Barré syndrome in adults: role of plasma exchange]. / Les traitements du syndrome de Guillain-Barré de l'adulte: place des échanges plasmatiques.

PURPOSE: To review recent data on treatment of Guillain-Barré syndrome, especially indications of plasma exchange. DATA SYNTHESIS: Guillain-Barré syndrome is the most common cause of acute flaccid paralysis. The current mortality is 5%, sever motor sequelae persist after 1 year in 10% of cases. Multidisciplinary teams are required to treat these patients, trained to all specific treatments. Oral and intravenous steroids have proven ineffective. Two large randomized clinical trials comparing plasma exchange (PE) with no treatment have shown a short-term and a 1-year benefit. Appropriate number of exchanges and indications are now more precisely known. In mild form (walking possible), patients should receive two PEs. A further two exchanges should be done in case of deterioration or in advanced forms (loss of walking ability, mechanical ventilation). More exchanges are not beneficial. Recently two new randomized trials have produced evidence that intravenous immune globulin (IVIg) (0.4 g/kg/d for 5 days) were as effective as five PEs in advanced forms. The combination of PE with IVIg did not confer a significant advantage, while increasing cost and risks. CONCLUSION: The combination of PE with IVIg did not confer, in advanced forms, the choice between PE and IVIg depends of the contra-indications of each treatment.

[Implication of emergency departments in the regulation of public hospitalizations]. / Place des services d'urgences dans la régulation des hospitalisations publiques.

PURPOSE: Emergency departments become a useful way to access to hospital care. Since these last years difficulties of hospitalization, mainly of the elderly, after visit to the emergency department, are on the increase. CURRENT KNOWLEDGE AND KEY POINTS: Emergency departments are an important mode of recruitment for hospital units, 4 patients to 10 are hospitalized from emergency departments. The difficulties of hospitalization starting at the emergency department are more important for the elderly. Actually, there are 2 type of hospital care, planed and non planed care. The development of observation units specific to the emergency departments allowed to resolve some of these difficulties. But they are limited by their small number of beds and the duration of hospitalization below to 36 h. Some hospitals developed polyvalent emergency short stay unit to hospitalize patients who visited emergency department without necessity to give them a specialized care. FUTURE PROSPECTS AND PROJECTS: This situation must allow us to purpose a better regulation of hospitalizations which includes emergency departments in a network system including the different hospital ways of taking care. A downstream way of care adapted to the emergency hospitalizations would be developed. This could include the emergency department, the observation unit and the emergency short stay unit in interface with internal medicine and general medicine units, geriatric unit and specialized units, all of them will be included in a town-hospital care network.

[Convulsive seizures of alcoholics in emergency situation]. / Crises convulsives de l'alcoolique en situation d'urgence.

Current medical practice in emergency rooms and epidemiologic studies show that ethylalcohol abuse both induces alcohol-related seizures and promotes seizures of other origin. Careful neurological examination, particular clinical signs and evolution over the first 24 hours constitute the first stage of the diagnosis. Only brain CT scan establishes the real cause of the seizures. Treatment of seizures is at first aetilogic. In alcohol-related seizures, the alcoholic condition does not warrant the use of anticonvulsivants. Abstinence prevents alcohol-related seizures while the persistence of the intoxication leads to hazardous observance of drug intake.

[Epidemic bacterial meningitis in adults and the elderly]. / Méningites bactériennes communautaires de l'adulte et du vieillard.

Epidemic bacterial meningitis in the adult and the elderly are essentially due to Streptococcus pneumoniae. Neisseria meningitidis and Listeria monocytogenes. Their poor prognosis is mainly due to the severity of the associated encephalitis, responsible for neurological sequelae and for mortality ranging from 20 to 30% in pneumonococcal and Listeria meningitis. Treatment associates an antibiotic having rapid antibactericidal action in the CSF, suppression of possible foci of primary infections and intensive care required by the frequency of associated visceral insufficiency. Present research is centered on: 1. the appearance and progression of pneumococcal lines resistant to penicillin; 2. the trials of modulators of the inflammatory response, notably dexamethasone; 3. the improvement of antibiotic concentrations in the CSF and the cerebral parenchyma, particularly in listeria infection.

[Bacterial meningitis: factors related to the delay before appropriate antibiotic administration in the emergency department]. / Méningites bactériennes : facteurs associés au délai d'instauration d'une antibiothérapie adaptée aux urgences.

OBJECTIVES: We had for aim to check the appropriateness of our practices according to French guidelines (17th consensus conference, SPILF 2008) and to identify variables associated with the delay before appropriate measures were implemented. METHODS: Our retrospective observational study (2009-2011) focused on acute bacterial meningitis (ABM) in adults. Data was collected on a standardized questionnaire from medical charts and nurse reports. RESULTS: We included 31 adults presenting with ABM; 29 (93.5%) received ceftriaxone or cefotaxime in the emergency department. Indications for corticosteroids and brain imaging complied with guidelines in respectively 71.0% and 83.9% of cases. The median delays (IQR) were: admission/lumbar puncture (LP), 2h43 [1h09-5h57]; admission/antimicrobials, 3h21 [1h34-5h11]. The indication of suspected ABM in the admission letter was associated with earlier LP (P=0.01), and was almost significantly associated also with faster initiation of adequate antibiotic therapy (P=0.05). CONCLUSIONS: Suspicion of ABM mentioned in the admission letter was associated to a better management in the emergency department.