Eric Batard

Aortic involvement in recent‐onset giant cell (temporal) arteritis: A case–control prospective study using helical aortic computed tomodensitometric scan

OBJECTIVE The prevalence of the involvement of large vessels in giant cell arteritis (GCA) is 3-13%. Aortitis is the most serious complication of GCA. Computed tomodensitometric (CT) scan allows analysis of both the aortic wall and endoluminal part of the aorta. Therefore, we conducted a study using CT scan to analyze aortic abnormalities in patients with recent-onset GCA. METHODS This prospective controlled study compared patients with biopsy-proven GCA with a matched control group based on sex, age, and cardiovascular risk factors. During the 4-week period following diagnosis of GCA, patients underwent an aortic CT scan. The aortic imaging results were blindly compared between both groups. RESULTS From January 5, 1998 to January 11, 1999, 22 patients and 22 controls were screened by CT scan for aortic involvement. Thickening of the aortic wall was more frequent among patients than controls (45.4% versus 13.6%; P = 0.02). Aortic thickening (mean 3.3 mm) was located on the ascending part of the thoracic aorta in 22.7% of the patients, with no evidence of thickening in the controls (P = 0.05). Thickening of the abdominal aortic wall was noted in 27.3% of the patients and none of the controls (P = 0.02). CONCLUSION This study suggests that inflammatory aortic thickening, detected by CT scan, occurs frequently at the time of diagnosis of GCA, and that this condition predominantly occurs on the ascending part of the aorta.

Palliative care for patients who died in emergency departments: analysis of a multicentre cross-sectional survey

Objectives A growing number of patients die each year in hospital emergency departments (EDs). Decisions to withhold or to withdraw life-support therapies occur in 80% of patients as described in a multicentre cross-sectional survey including 2420 patients. Palliative care has not been explored in patients dying in this setting. The aim of this study was to assess the incidence of palliative care and to describe this population. Methods The authors conducted a post-hoc analysis on a cohort of 2420 patients who died in 174 French and Belgian EDs. The authors identified patients who benefited from palliative care and described this population and the palliative care. Results Palliative therapies were administered to 1373 patients (56.7%). These therapies included administration of analgesics, sedation, mouth care, repositioning for comfort (as appropriate) and provision of emotional support to the patient and his/her relatives. These palliative measures were provided more frequently in the observation unit of the ED (n=908, 66.2%) than in an examination room (n=465, 33.8%). Median time interval between ED admission and death was longer in patients who received palliative care (n=1373) (median, 15 h; first quartile, 6 h; third quartile, 34 h) than in those who did not (n=1047) (median, 4 h; first quartile, 1 h; third quartile, 10 h) (p<10−4). Conclusions Palliative care is administered to about half of the patients who die in EDs. This is insufficient as the majority of the patients who died in EDs actually died after a decision to withhold or withdraw life-support therapies. End-of-life management must be improved in EDs.

Efficacy of alteplase thrombolysis for ED treatment of pulmonary embolism with shock

Our objective was to assess efficacy and tolerance of thrombolysis using 0.6 mg/kg of Alteplase in patients with massive pulmonary embolism defined as the association of a pulmonary embolism with shock. We retrospectively included 21 patients presenting with a massive pulmonary embolism confirmed by either scintigraphy or spiral computed tomography. Patients were treated on the basis of a standard rationale followed by thrombolysis with 0.6 mg/kg Alteplase over a period of 15 minutes. Hospital mortality, vital signs before and 2 hours after thrombolysis, and incidence of hemorrhagic events were recorded. Five patients (23.8%) died, 4 of these deaths occurred during the first 4 hours after hospital admission. Systolic and diastolic blood pressure (Sp02) were significantly improved 2 hours after the beginning of thrombolysis. Five minor hemorrhagic events occurred. This study demonstrates that for patients with pulmonary embolism and shock, a bolus treatment with Alteplase is potentially effective and well tolerated.

Mise en place d’une procédure de limitation ou d’arrêt des soins actifs dans un service d’urgence: Evaluation prospective sur 7 mois

Resume Les decisions de limitation ou d’arret de therapeutique de suppleance d’organe ont ete peu etudiees dans les services d’urgence. Objectif Evaluer la mise en place d’une procedure locale de limitation ou d’arret des therapeutiques actives (LATA) dans service d’urgence. Methodes Un groupe de travail medico-soignant a ecrit une procedure de prise de decision et d’application des decisions de limitation ou d’arret des soins actifs a partir des recommandations de la Societe Francophone de Medecine d’Urgence et de celles de la Societe de Reanimation de Langue Francaise. Apres soumission au comite d’ethique hospitalier, cette procedure a ete mise en place, et une evaluation apres 7 mois a ete realisee. Resultats Cent onze patients, soit 0,65 % des 16 939 patients admis dans l’unite d’accueil non traumatique, ont beneficie d’une decision de LATA. Il s’agissait de 59 femmes (87 ± 6 ans) et de 52 hommes (79 ± 11 ans). Les pathologies etaient essentiellement neurologique, septiques et metaboliques. La decision de LATA a ete discutee par le medecin et l’interne dans 69 % des cas, l’infirmier en charge du patient a ete implique dans 62 % des cas. La mediane du delai entre l’admission et la decision etait de 6 heures. Cette decision etait une limitation chez 82 patients (74 %), un arret chez 25 (22 %) et une limitation suivie d’un arret chez 4 patient (4 %). Quatre-vingt douze patients sont decedes a l’hopital (84 %), 12 sont rentres a domicile (11 %) et 6 ont ete mutes en moyen sejour (5 %). Conclusion Les decisions de limitation du niveau de soins actifs font integralement partie de l’activite de medecine d’urgence.

Antibiotics Against Endocarditis – Past, Present and Future (Experimental Data)

“Bacterial infections are becoming increasingly resistant to existing antibiotics, and as the number of patients who have succumbed to these infections rises, the number of new antibiotics being developed continues to plummet.” This extract from a letter addressed to President Barack Obama by the president of Infectious Diseases Society of America (IDSA) attests to the urgent need for new therapeutic options to fight multidrug-resistant (MDR) bacteria. Drug-resistant infections and related morbidity and mortality are on the rise in the United States and around the world. Despite the growing antibiotic resistance among Gram-positive and Gram-negative pathogens causing severe infections in hospital and community settings, the number of new antibacterial drugs approved for marketing in the United States continues to decrease. In addition to this worrying situation, only a few novel therapeutics for drug-resistant infections are in the drug development pipeline (Boucher et al., 2009; European Centre for Disease Prevention and Control, 2009). Reports of bacterial isolates resistant to almost all available antibiotics highlight the crucial need for new antibiotic therapies, especially for Gram-negative infections (Maltezou, 2009). Recently, IDSA and United States authorities have developed creative incentives to stimulate new antibacterial research and development (Infectious Diseases Society of America, 2010).