Gender-based differential management of acute low back pain in the emergency department: A survey based on a clinical vignette.

BACKGROUND: Women may receive suboptimal pain management compared with men, and this disparity might be related to gender stereotypes. OBJECTIVES: To assess the influence of patient gender on the management of acute low back pain. DESIGN: We assessed pain management by 231 physicians using an online clinical vignette describing a consultation for acute low back pain in a female or male patient. The vignette was followed by a questionnaire that assessed physicians' management decisions and their gender stereotypes. METHODS: We created an online clinical vignette presenting a patient with acute low back pain and assessed the influence of a patient's gender on pain management. We investigated gender-related stereotyping regarding pain care by emergency physicians using the Gender Role Expectation of Pain questionnaire. RESULTS: Both male and female physicians tended to consider that a typical man was more sensitive to pain, had less pain endurance, and was more willing to report pain than a typical woman. These stereotypes did not translate into significant differences in pain management between men and women. However, women tended to be referred less often for imaging examinations than men and were also prescribed lower doses of ibuprofen and opioids. The physician's gender had a modest influence on management decisions, female physicians being more likely to prescribe ancillary examinations. CONCLUSION: We observed gender stereotypes among physicians. Our findings support the hypothesis that social characteristics attributed to men and women influence pain management. Prospective clinical studies are needed to provide a deeper understanding of gender stereotypes and their impact on clinical management.

PLUS-IS-LESS project: Procalcitonin and Lung UltraSonography-based antibiotherapy in patients with Lower rESpiratory tract infection in Swiss Emergency Departments: study protocol for a pragmatic stepped-wedge cluster-randomized trial.

BACKGROUND: Lower respiratory tract infections (LRTIs) are among the most frequent infections and a significant contributor to inappropriate antibiotic prescription. Currently, no single diagnostic tool can reliably identify bacterial pneumonia. We thus evaluate a multimodal approach based on a clinical score, lung ultrasound (LUS), and the inflammatory biomarker, procalcitonin (PCT) to guide prescription of antibiotics. LUS outperforms chest X-ray in the identification of pneumonia, while PCT is known to be elevated in bacterial and/or severe infections. We propose a trial to test their synergistic potential in reducing antibiotic prescription while preserving patient safety in emergency departments (ED). METHODS: The PLUS-IS-LESS study is a pragmatic, stepped-wedge cluster-randomized, clinical trial conducted in 10 Swiss EDs. It assesses the PLUS algorithm, which combines a clinical prediction score, LUS, PCT, and a clinical severity score to guide antibiotics among adults with LRTIs, compared with usual care. The co-primary endpoints are the proportion of patients prescribed antibiotics and the proportion of patients with clinical failure by day 28. Secondary endpoints include measurement of change in quality of life, length of hospital stay, antibiotic-related side effects, barriers and facilitators to the implementation of the algorithm, cost-effectiveness of the intervention, and identification of patterns of pneumonia in LUS using machine learning. DISCUSSION: The PLUS algorithm aims to optimize prescription of antibiotics through improved diagnostic performance and maximization of physician adherence, while ensuring safety. It is based on previously validated tests and does therefore not expose participants to unforeseeable risks. Cluster randomization prevents cross-contamination between study groups, as physicians are not exposed to the intervention during or before the control period. The stepped-wedge implementation of the intervention allows effect calculation from both between- and within-cluster comparisons, which enhances statistical power and allows smaller sample size than a parallel cluster design. Moreover, it enables the training of all centers for the intervention, simplifying implementation if the results prove successful. The PLUS algorithm has the potential to improve the identification of LRTIs that would benefit from antibiotics. When scaled, the expected reduction in the proportion of antibiotics prescribed has the potential to not only decrease side effects and costs but also mitigate antibiotic resistance. TRIAL REGISTRATION: This study was registered on July 19, 2022, on the ClinicalTrials.gov registry using reference number: NCT05463406. TRIAL STATUS: Recruitment started on December 5, 2022, and will be completed on November 3, 2024. Current protocol version is version 3.0, dated April 3, 2023.

[Sex workers: when taboos get in the way of care in the emergency department]. / Travailleuses* du sexe aux urgences : quand le tabou entrave les soins.

In Switzerland, sex work has been legal under certain conditions since 1942, and the number of sex workers in 2011 was estimated at between 14'000 and 20'000 throughout the country, 96% of whom were migrants. These people are exposed to a wide range of vulnerabilities, both because of their profession and because of structural and institutional shortcomings. The complexity of their care has led over time to the creation of specialised structures and units, which are often unknown to healthcare professionals. The aim of this article is to shed light on these facilities and to offer healthcare professionals appropriate advice on how to improve the care provided to patients in the emergency department.

En Suisse, le travail du sexe est légal sous certaines conditions depuis 1942 et le nombre de travailleuses du sexe (TS) en 2011 était estimé entre 14 000 et 20 000 sur l'entier du territoire, dont 96 % de migrantes. Ces personnes sont exposées à de nombreuses vulnérabilités, de par leur métier mais également en raison de lacunes structurelles et institutionnelles. La complexité de leur prise en charge a mené au fil du temps à la création de structures et d'unités spécialisées, qui sont souvent méconnues des professionnels de la santé. L'objectif de cet article est de mettre en lumière ces lieux et de proposer aux soignants des conseils adaptés afin d'améliorer la prise en charge des TS au service d'urgences.

Computational fluid dynamics analysis of endoluminal aortic perfusion.

INTRODUCTION: In peripheral percutaneous (VA) extracorporeal membrane oxygenation (ECMO) procedures the femoral arteries perfusion route has inherent disadvantages regarding poor upper body perfusion due to watershed. With the advent of new long flexible cannulas an advancement of the tip up to the ascending aorta has become feasible. To investigate the impact of such long endoluminal cannulas on upper body perfusion, a Computational Fluid Dynamics (CFD) study was performed considering different support levels and three cannula positions. METHODS: An idealized literature-based- and a real patient proximal aortic geometry including an endoluminal cannula were constructed. The blood flow was considered continuous. Oxygen saturation was set to 80% for the blood coming from the heart and to 100% for the blood leaving the cannula. 50% and 90% venoarterial support levels from the total blood flow rate of 6 l/min were investigated for three different positions of the cannula in the aortic arch. RESULTS: For both geometries, the placement of the cannula in the ascending aorta led to a superior oxygenation of all aortic blood vessels except for the left coronary artery. Cannula placements at the aortic arch and descending aorta could support supra-aortic arteries, but not the coronary arteries. All positions were able to support all branches with saturated blood at 90% flow volume. CONCLUSIONS: In accordance with clinical observations CFD analysis reveals, that retrograde advancement of a long endoluminal cannula can considerably improve the oxygenation of the upper body and lead to oxygen saturation distributions similar to those of a central cannulation.

[Interdisciplinarity in prehospital care:collaboration for better care]. / Interdisciplinarité dans le préhospitalier : collaborer pour mieux soigner.

Multidisciplinary prehospital medicine is more than ever a challenging field of practice, with increasingly complex and polymorbid patients and numerous caregivers' participation. Throughout a clinical case, this paper offers a review of different tools currently in development (point of care ultrasonography, digital patient file) in order to improve solutions and outcomes for patients.

Travailler en interdisciplinarité dans le préhospitalier n'a jamais été aussi important, face à des patients de plus en plus complexes et polymorbides, et dont la prise en charge dépend de nombreux acteurs du système de santé. Au travers d'une vignette clinique, cet article propose des pistes de développement d'outils (ultrason point of care, dossier électronique du patient) permettant une prise en charge ambulatoire interprofessionnelle plus efficiente.

[Pulmonary embolism in the era of choosing wisely]. / Embolie pulmonaire à l'ère du choosing wisely.

The emergence of new management rules and algorithms for suspected pulmonary embolism (PE) allows clinicians to limit certain additional examinations. The PERC rule can « rule-out ¼ PE without complementary investigation. The revised Geneva and Wells scores, the YEARS algorithm, the use of age-adjusted D-dimers, and D-dimers adjusted to clinical probability can all reduce the need for CT scan. Finally, PESI and HESTIA provide help to choose which patient is eligible to be treated as out-patient.

L'émergence de nouvelles règles et algorithmes de prise en charge lors d'une suspicion d'embolie pulmonaire (EP) permet aux cliniciens de limiter certains examens complémentaires. La règle Pulmonary Embolism Rule-out Criteria (PERC) permet d'exclure l'EP sans autre investigation. Les scores de Genève révisés, de Wells, de même que l'algorithme YEARS et l'utilisation des D-dimères adaptés soit à l'âge soit à la probabilité clinique permettent également de diminuer le recours à une imagerie. Enfin, les scores Pulmonary Embolism Severity Index (PESI) et HESTIA aident à la décision d'un traitement ambulatoire ou hospitalier de l'EP.

Opiophobia in Emergency Department Healthcare Providers: A Survey in Western Switzerland.

Opiophobia contributes to oligoanalgesia in the emergency department (ED), but its definition varies, and its association to healthcare providers' personality traits has been scantly explored. Our purpose was to study the different definitions of opiophobia and their association with two personality traits of doctors and nurses working in EDs, namely the stress from uncertainty and risk-taking. We used three online questionnaires: the 'Attitude Towards Morphine Use' Score (ATMS), the Stress From Uncertainty Scale (SUS) and the Risk-Taking Scale (RTS). Doctors and nurses from nine hospital EDs in francophone Switzerland were invited to participate. The ATMS score was analyzed according to demographic characteristics, SUS, and RTS. The response rate was 56%, with 57% of respondents being nurses and 63% women. Doctors, less experienced and non-indigenous participants had a significantly higher ATMS (all p ≤ 0.01). The main contributors of the ATMS were the fear of side effects and of addiction. In multivariate analysis, being a doctor, less experience and non-indigenous status were predictive of the ATMS; each point of the SUS increased the ATMS by 0.24 point. The fear of side effects and of addiction were the major contributors of opiophobia among ED healthcare providers; opiophobia was also associated with their personality traits.

[Equestrian related injuries and pathologies]. / Traumatismes et pathologies liés à la pratique d'un sport équestre.

Equestrian sports are widely practiced in Switzerland as hobbies. Horses are imposing and unpredictable. As a result, traumatisms associated with horseback riding are common and cause serious injuries. Cranial traumatisms are among the most frequently encountered injuries and are associated with high rates of hospitalization and mortality. Helmet use decreases the severity of intracranial lesions. Close contact with horses can lead to the development of infectious diseases and respiratory allergies. Although infrequent in Europe, these infections occur sporadically and should be known by general practitioners. Finally, horse's allergens sensitization is frequent in allergic patients with or without direct contact with horses.

Les sports équestres sont largement pratiqués en Suisse comme loisirs. Le cheval est un animal imposant et imprédictible. De ce fait, les traumatismes liés à la pratique de l'équitation ne sont pas rares et causent de graves lésions. Les traumatismes crâniens sont parmi les lésions les plus fréquentes et sont associés à des taux d'hospitalisation et de mortalité élevés. Le port d'une bombe diminue la sévérité des lésions intracrâniennes. Le contact rapproché avec les chevaux peut mener au développement de certaines maladies infectieuses et d'allergies respiratoires. Bien que rares dans nos contrées, ces infections existent sporadiquement et devraient être connues des praticiens. Enfin, la sensibilisation aux allergènes du cheval est fréquente chez les patients allergiques, qu'ils soient en contact ou non avec ces animaux.

[Physiological respiratory changes and venous thromboembolic disease during pregnancy]. / Modifications respiratoires physiologiques et maladie thromboembolique veineuse lors de la grossesse.

During physiological pregnancy, changes in lung functions, ventilatory patterns and gas exchanges happen. Therefore, the dyspnea experienced by a majority of women is usually due to pregnancy itself and is very difficult to differentiate from a pathophysiological state. Anamnesis and clinical examination alone do not rule out dyspnea of ​​thromboembolic origin. Therefore, a structured approach, based on a thromboembolic risk assessment, the application of a specific management algorithm and the use of imaging exams is required for emergency management of dyspnea occurring during the pregnancy and in the postpartum.

Durant une grossesse physiologique, des modifications des fonctions pulmonaires, des paramètres ventilatoires et des échanges gazeux surviennent. Dès lors, la dyspnée ressentie par une majorité des femmes est généralement due à la grossesse elle-même et peut être difficile à différencier d'un état physiopathologique. L'anamnèse et l'examen clinique seuls ne permettent pas d'écarter une dyspnée d'origine thromboembolique. Par conséquent, lors de la prise en charge aux urgences d'une dyspnée survenant pendant la grossesse ou le postpartum, une approche structurée, basée sur une évaluation du risque thromboembolique, l'application d'un algorithme de prise en charge spécifique et des examens d'imagerie, est requise.

[Acute aortic dissection: diagnostic usefulness of D-dimer]. / Dissection aortique aiguë: utilité diagnostique des D-dimères.

Acute aortic dissection (AAD) is uncommon, and associated with high morbidity and mortality rates. Positive or negative likelihood ratios of clinical parameters, ECG and chest x-ray do not allow to rule in or rule out AAD. Angio-CT, transoesophageal echocardiography, and MRI are validated tools for AAD diagnosis, although they are invasive and associated with significant complications. In several studies, D-dimer level within the normal range appears to have a negative predictive value that is low enough to rule out AAD. However, flaws of study design, heterogeneity of D-dimer tests and of their cut-offs (from 100 to 900 microg/l), and the absence of a validated workup strategy are strong arguments against the current use of D-dimer as a unique test to rule out AAD in clinical practice.