Exploratory study: Evaluation of a symptom checker effectiveness for providing a diagnosis and evaluating the situation emergency compared to emergency physicians using simulated and standardized patients.

BACKGROUND: The overloading of health care systems is an international problem. In this context, new tools such as symptom checker (SC) are emerging to improve patient orientation and triage. This SC should be rigorously evaluated and we can take a cue from the way we evaluate medical students, using objective structured clinical examinations (OSCE) with simulated patients. OBJECTIVE: The main objective of this study was to evaluate the efficiency of a symptom checker versus emergency physicians using OSCEs as an assessment method. METHODS: We explored a method to evaluate the ability to set a diagnosis and evaluate the emergency of a situation with simulation. A panel of medical experts wrote 220 simulated patients cases. Each situation was played twice by an actor trained to the role: once for the SC, then for an emergency physician. Like a teleconsultation, only the patient's voice was accessible. We performed a prospective non-inferiority study. If primary analysis had failed to detect non-inferiority, we have planned a superiority analysis. RESULTS: The SC established only 30% of the main diagnosis as the emergency physician found 81% of these. The emergency physician was also superior compared to the SC in the suggestion of secondary diagnosis (92% versus 52%). In the matter of patient triage (vital emergency or not), there is still a medical superiority (96% versus 71%). We prove a non-inferiority of the SC compared to the physician in terms of interviewing time. CONCLUSIONS AND RELEVANCE: We should use simulated patients instead of clinical cases in order to evaluate the effectiveness of SCs.

Platelet-to-Lymphocyte Ratio (PLR) Is Not a Predicting Marker of Severity but of Mortality in COVID-19 Patients Admitted to the Emergency Department: A Retrospective Multicenter Study.

(1) Introduction: In the present study, we investigate the prognostic value of platelet-to-lymphocyte ratio (PLR) as a marker of severity and mortality in COVID-19 infection. (2) Methods: Between 1 March and 30 April 2020, we conducted a multicenter, retrospective cohort study of patients with moderate to severe coronavirus 19 (COVID-19), all of whom were hospitalized after being admitted to the emergency department (ED). (3) Results: A total of 1035 patients were included in our study. Neither lymphocytes, platelets or PLR were associated with disease severity. Lymphocyte count was significantly lower and PLR values were significantly higher in the group of patients who died, and both were associated with mortality in the univariate analysis (OR: 0.524, 95% CI: (0.336−0.815), p = 0.004) and (OR: 1.001, 95% CI: (1.000−1.001), p = 0.042), respectively. However, the only biological parameter significantly associated with mortality in the multivariate analysis was platelet count (OR: 0.996, 95% CI: (0.996−1.000), p = 0.027). The best PLR value for predicting mortality in COVID-19 was 356.6 (OR: 3.793, 95% CI: (1.946−7.394), p < 0.001). (4) Conclusion: A high PLR value is however associated with excess mortality.

Lymphopenia and Early Variation of Lymphocytes to Predict In-Hospital Mortality and Severity in ED Patients with SARS-CoV-2 Infection.

(1) Introduction: Multiple studies have demonstrated that lymphocyte count monitoring is a valuable prognostic tool for clinicians during inflammation. The aim of our study was to determine the prognostic value of delta lymphocyte H24 from admission from the emergency department for mortality and severity of SARS-CoV-2 infection. (2) Methods: We have made a retrospective and multicentric study in six major hospitals of northeastern France. The patients were hospitalized and had a confirmed diagnosis of SARS-CoV-2 infection. (3): Results: A total of 1035 patients were included in this study. Factors associated with infection severity were CRP > 100 mg/L (OR: 2.51, CI 95%: (1.40−3.71), p < 0.001) and lymphopenia < 800/mm3 (OR: 2.15, CI 95%: (1.42−3.27), p < 0.001). In multivariate analysis, delta lymphocytes H24 (i.e., the difference between lymphocytes values at H24 and upon admission to the ED) < 135 was one of the most significant biochemical factors associated with mortality (OR: 2.23, CI 95%: (1.23−4.05), p = 0.009). The most accurate threshold for delta lymphocytes H24 was 75 to predict severity and 135 for mortality. (4) Conclusion: Delta lymphocytes H24 could be a helpful early screening prognostic biomarker to predict severity and mortality associated with COVID-19.

Symptoms of Infarction in Women: Is There a Real Difference Compared to Men? A Systematic Review of the Literature with Meta-Analysis.

(1) Context: The management of acute coronary syndrome (ACS) is based on a rapid diagnosis. The aim of this study was to focus on the ACS symptoms differences according to gender, in order to contribute to the improvement of knowledge regarding the clinical presentation in women. (2) Methods: We searched for relevant literature in two electronic databases, and analyzed the symptom presentation for patients with suspected ACS. Fifteen prospective studies were included, with a total sample size of 10,730. (3) Results: During a suspected ACS, women present more dyspnea, arm pain, nausea and vomiting, fatigue, palpitations and pain at the shoulder than men, with RR (95%CI) of 1.13 [1.10; 1.17], 1.30 [1.05; 1.59], 1,40 [1.26; 1.56], 1.08 [1.01; 1.16], 1.67 [1.49; 1.86], 1.78 [1.02; 3.13], respectively. They are older by (95%CI) 4.15 [2.28; 6.03] years compared to men. The results are consistent in the analysis of the ACS confirmed subgroup. (4) Conclusions: We have shown that there is a gender-based symptomatic difference and a female presentation for ACS. The "typical" or "atypical" semiology of ACS symptoms should no longer be used.

Study protocol: hypnosis versus standard care for shoulder dislocation reduction in the emergency department - a multicentre, randomised, controlled study protocol.

INTRODUCTION: Anterior shoulder dislocation is a common reason for consultation at the emergency department (ED). Hypnosis could be a safe and effective alternative therapy for pain relief during shoulder dislocation reduction but nowadays, evidence is not sufficient. The main objective of this study is to show that reduction under hypnosis is associated with a decrease in the use of analgesic compared with usual care. METHODS AND ANALYSIS: We will conduct an interventional, controlled, multicentre, randomised study. A total of 44 patients with shoulder dislocation will be randomised in two groups: the hypnosis group (N=22) and the usual care group (N=22). The primary endpoint will be the comparison of morphine equivalent analgesic consumption during a shoulder dislocation reduction manoeuvre. Secondary endpoints will include haemodynamic parameters monitoring, patient and practitioner satisfaction using a Likert scale, use of coanalgesic or sedative drugs, number of reduction attempts and time spent at ED. Adverse events will be recorded. Statistical analysis will include parametric tests, multivariate linear regression and descriptive statistics. ETHICS AND DISSEMINATION: This study has received ethics approval from the Comité de Protection des Personnes of Sud-Est IV on 03/11/2021 (ANSM informed on 19 November 2021). The results will be published in scientific articles and communicated in national and international conferences. TRIAL REGISTRATION NUMBER: ClinicalTrial.gov: NCT04992598; National Clinical trial no ID RCB : 2021-A01382-39.

Prognostic Value of C-Reactive Protein to Lymphocyte Ratio (CLR) in Emergency Department Patients with SARS-CoV-2 Infection.

(1) Introduction: According to recent studies, the ratio of C-reactive-protein to lymphocyte is more sensitive and specific than other biomarkers associated to systemic inflammatory processes. This study aimed to determine the prognostic value of CLR on COVID-19 severity and mortality at emergency department (ED) admission. (2) Methods: Between 1 March and 30 April 2020, we carried out a multicenter and retrospective study in six major hospitals of northeast France. The cohort was composed of patients hospitalized for a confirmed diagnosis of moderate to severe COVID-19. (3) Results: A total of 1,035 patients were included in this study. Factors associated with infection severity were the CLR (OR: 1.001, CI 95%: (1.000-1.002), p = 0.012), and the lymphocyte level (OR: 1.951, CI 95%: (1.024-3.717), p = 0.042). In multivariate analysis, the only biochemical factor significantly associated with mortality was lymphocyte rate (OR: 2.308, CI 95%: (1.286-4.141), p = 0.005). The best threshold of CLR to predict the severity of infection was 78.3 (sensitivity 79%; specificity 47%), and to predict mortality, was 159.5 (sensitivity 48%; specificity 70%). (4) Conclusion: The CLR at admission to the ED could be a helpful prognostic biomarker in the early screening and prediction of the severity and mortality associated with SARS-CoV-2 infection.

Neutrophil-to-Lymphocyte Ratio and Early Variation of NLR to Predict In-Hospital Mortality and Severity in ED Patients with SARS-CoV-2 Infection.

(1) Introduction: The neutrophil-to lymphocyte ratio is valued as a predictive marker in several inflammatory diseases. For example, an increasing NLR is a risk factor of mortality in sepsis. It also appears to be helpful in other settings such as cancer. The aim of our work was to study the prognostic value of NLR for disease severity and mortality in patients infected with SARS-CoV-2 upon their admission to the Emergency Department (ED) and its early variation (ΔNLR) in the first 24 h of management (H-24). (2) Methods: Between 1 March and 30 April 2020, we conducted a multicenter and retrospective cohort study of patients with moderate or severe coronavirus disease 19 (COVID-19), who were all hospitalized after presenting to the ED. (3) Results: A total of 1035 patients were included in our study. Factors associated with infection severity were C-reactive protein level (OR: 1.007, CI 95%: [1.005-1.010], p < 0.001), NLR at H-24 (OR: 1.117, CI 95%: [1.060-1.176], p < 0.001), and ΔNLR (OR: 1.877, CI 95%: [1.160-3.036], p: 0.01). The best threshold of ΔNLR to predict the severity of infection was 0.222 (sensitivity 56.1%, specificity 68.3%). In multivariate analysis, the only biochemical factor significantly associated with mortality was again ΔNLR (OR: 2.142, CI 95%: ([1.132-4.056], p: 0.019). The best threshold of ΔNLR to predict mortality was 0.411 (sensitivity 53.3%; specificity 67.3%). (4) Conclusion: The NLR and its early variation (ΔNLR) could help physicians predict both severity and mortality associated with SARS-CoV-2 infection, hence contributing to optimized patient management (accurate triage and treatment).

[Acetaminophen: Knowledge, use and overdose risk in urban patients consulting their general practitioner. A prospective, descriptive and transversal study]. / Le paracétamol : connaissance, usage et risque de surdosage en patientèle urbaine de médecine générale. Étude prospective descriptive transversale.

INTRODUCTION: Acetaminophen is the most involved active substance in both unintentional and intentional drug poisoning. However, its availability outside community pharmacies is being debated in France. METHODS: We made, via a self-administered questionnaire, a prospective assessment of knowledge, use and acetaminophen overdose risk in patients consulting their general practitioner, in the Metz Métropole urban area, between May 2015 and February 2016. We estimated the prevalence of potential unintentional overdosage by capture-recapture method. RESULTS: Among 819 responding patients, only 17.9 % had a sufficient knowledge and 20.3 % were at risk for potential unintentional overdose. The risk was higher for patients aged over 55 years or belonging to socioprofessional categories of laborers and inactive. A good knowledge score was a protective factor for overdose risk (P<0.0001). The liver toxicity of acetaminophen was particularly unknown. The prevalence of potential unintentional acetaminophen overdose was estimated at 1 to2 % of the population. CONCLUSION: Proposing acetaminophen outside of pharmacies cannot be recommended in France in such conditions. Information campaigns are needed to limit the risk of unintentional overdose and its consequences on liver toxicity.