Effect of patient gender on the decision of ceiling of care: a European study of emergency physicians' treatment decisions in simulated cases.

BACKGROUND AND IMPORTANCE: Gender bias in healthcare can significantly influence clinical decision-making, potentially leading to disparities in treatment outcomes. This study addresses the impact of patient gender on the decision-making process for establishing a ceiling of care in emergency medicine, particularly the decision to limit tracheal intubation. OBJECTIVE: To determine whether patient gender influences emergency physicians' decisions regarding the recommendation for tracheal intubation in critically ill patients. DESIGN: A European survey-based study was conducted using a standardized clinical scenario to assess physicians' decisions in a controlled setting. SETTINGS AND PARTICIPANTS: The survey targeted European emergency physicians over a 2-week period in April 2024. A total of 3423 physicians participated, with a median age of 40 years and a distribution of 46% women. Physicians were presented with a clinical vignette of a 75-year-old patient in acute respiratory distress. The vignettes were randomized to vary only by the patient's gender (woman/man) and level of functional status: (1) can grocery shop alone, (2) cannot grocery shop alone but can bathe independently, or (3) cannot perform either task independently. OUTCOME MEASURES AND ANALYSIS: The primary outcome was the recommendation for intubation, with secondary analyses exploring the influence of patient functional status levels. Multivariable logistic regression was used to adjust for potential confounders, including physician gender, age, experience, and practice setting. MAIN RESULTS: A total of 3423 physicians responded, mostly from France, Spain, Italy, and the UK (1,532, 494, 247, and 245 respectively). Women patients were less likely to be intubated compared to male patients [67.9% vs. 71.7%; difference 3.81%; 95% confidence interval (CI), 0.7-6.9%]. The likelihood of recommending intubation decreased with lower levels of patient functional status. Women physician gender was also associated with a reduced likelihood of recommending intubation. CONCLUSION: This study suggests a significant gender-based disparity in emergency care decision-making, with women patients being less likely to receive recommendations for intubation. However, these results should be interpreted with caution due to potential limitations in the representativity of respondents and the uncertain applicability of survey responses to real-life clinical practice.

Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial.

Importance: Tracheal intubation is recommended for coma patients and those with severe brain injury, but its use in patients with decreased levels of consciousness from acute poisoning is uncertain. Objective: To determine the effect of intubation withholding vs routine practice on clinical outcomes of comatose patients with acute poisoning and a Glasgow Coma Scale score less than 9. Design, Setting, and Participants: This was a multicenter, randomized trial conducted in 20 emergency departments and 1 intensive care unit (ICU) that included comatose patients with suspected acute poisoning and a Glasgow Coma Scale score less than 9 in France between May 16, 2021, and April 12, 2023, and followed up until May 12, 2023. Intervention: Patients were randomized to undergo conservative airway strategy of intubation withholding vs routine practice. Main Outcomes and Measures: The primary outcome was a hierarchical composite end point of in-hospital death, length of ICU stay, and length of hospital stay. Key secondary outcomes included adverse events resulting from intubation as well as pneumonia within 48 hours. Results: Among the 225 included patients (mean age, 33 years; 38% female), 116 were in the intervention group and 109 in the control group, with respective proportions of intubations of 16% and 58%. No patients died during the in-hospital stay. There was a significant clinical benefit for the primary end point in the intervention group, with a win ratio of 1.85 (95% CI, 1.33 to 2.58). In the intervention group, there was a lower proportion with any adverse event (6% vs 14.7%; absolute risk difference, 8.6% [95% CI, -16.6% to -0.7%]) compared with the control group, and pneumonia occurred in 8 (6.9%) and 16 (14.7%) patients, respectively (absolute risk difference, -7.8% [95% CI, -15.9% to 0.3%]). Conclusions and Relevance: Among comatose patients with suspected acute poisoning, a conservative strategy of withholding intubation was associated with a greater clinical benefit for the composite end point of in-hospital death, length of ICU stay, and length of hospital stay. Trial Registration: ClinicalTrials.gov Identifier: NCT04653597.

Usefulness of serum procalcitonin and point-of-care multiplex PCR gastro-intestinal panel in acute diarrhoea or colitis in the emergency department.

INTRODUCTION: Acute infectious diarrhoea is one of the most common diseases worldwide. Procalcitonin (PCT) is useful for antibiotic stewardship in lower respiratory tract infections but has been poorly studied in infectious diarrhoea. Our objective is to describe the PCT concentrations according to diarrhoea aetiology. METHODS: This is a single-center prospective cohort study involving adults consulting the emergency department (ED) for an acute diarrhoea or colitis. Serum PCT was measured and a stool sample was tested with FilmArray® Gastro-Intestinal Panel. The primary endpoint is the PCT concentration according to each type of pathogen identified using Gastro-Intestinal-panel and/or stool cultures at ED admission. RESULTS: 125 patients were included: 80 had an acute infectious diarrhoea, 21 an acute colitis and 24 another illness causing diarrhoea. The median (interquartile ranges) PCT values (ng/ml) were 0.13 (0.08-0.28), 0.07 (0.06-0.54), 0.13 (0.09-0.26) and 0.05 (0.03-0.17), respectively if there was a bacteria (n = 41), parasite (n = 3), virus (n = 10) or no pathogen identified and 0.34 (0.13-1.03) if the diarrhoea was due to another illness (n = 24). CONCLUSION: In patients admitted to the ED with an acute infectious diarrhoea or acute colitis, PCT remained low when a bacteria was identified. It may not be informative in current practice to guide antibiotic therapy.