G. Kierzek

Accuracy of C-reactive protein, procalcitonin, and mid-regional pro-atrial natriuretic peptide to guide site of care of community-acquired pneumonia

BackgroundThe use at bedside of C-reactive protein (CRP), procalcitonin (PCT) or mid-regional pro-atrial natriuretic peptide (ANP) has been advocated to help management of patients with community-acquired pneumonia (CAP) in emergency medicine.ObjectiveTo assess the effectiveness of CRP, PCT, and ANP measures in assisting emergency physicians deciding hospital admission for CAP with low risk of complication.DesignMulticenter, prospective, observational study with blind evaluation.SettingEmergency departments of 12 French hospitals.PatientsFive hundred forty-nine consecutive, immunocompetent adult patients with mild CAP.MeasurementsCentralized and blind measure of baseline CRP, PCT, and ANP; sensitivity, specificity, and positive and negative likelihood ratios for determining hospital admission. Gold standard for admission was defined by experts’ advice combined with admission requirement or death at 28xa0days. Optimal threshold values were determined by receiver operating characteristic (ROC) curves, and area under curve (AUC) of the three biomarkers was compared.ResultsAccording to gold standard, 310 (56%) patients required admission and 239 (44%) needed to be discharged. PCT and ANP levels increased with Pneumonia Severity Index risk categories. ANP (AUC 0.76 [95% CI 0.72–0.80]) more accurately predicted admission requirement than did PCT (AUC 0.65 [95% CI 0.61–0.70]) or CRP (AUC 0.59 [95% CI 0.54–0.64]) (both p values <0.01). We determined that 135xa0pmol/L was a threshold for ANP level to discriminate admission requirement (positive likelihood ratio 7.45 [95% CI 4.22–8.16]).ConclusionsIn a selected population of CAP with low risk of complication, a single ANP measurement was more accurate than CRP and PCT to predict appropriate admission. These results should be confirmed by additional studies.

Febrile neutropenia in French emergency departments: results of a prospective multicentre survey.

IntroductionFebrile neutropenia (FN) is common in cancer patients receiving myelotoxic therapy. The procedures to treat FN are well established in oncology, but it is unclear whether management is adequate in the emergency department (ED).MethodsThis prospective, multicentre, observational study was carried out in 47 French EDs for 6 months. Patients were adults presenting at the ED with FN after myelotoxic treatment for cancer. Severity of infection was defined according to Bone criteria for severe sepsis and septic shock (SS/SSh) and risk was determined according to Multinational Association of Supportive Care in Cancer (MASCC) criteria. The end point was the implementation of guidelines. Management of patients with SS/SSh required: (i) adequate intravenous (IV) antimicrobial therapy for the first 90 min (broad-spectrum beta-lactam with or without an aminoglycoside); (ii) fluid challenge (500 mL); (iii) lactate measurement; (iv) at least one blood culture; and (v) hospitalization. Management of patients without SS/SSh required: (1) no initiation of granulocyte - cell stimulating factor (G-CSF); (2) adequate IV antimicrobial therapy (broad-spectrum beta-lactam) and hospitalization if the patient was high-risk according to MASCC criteria; (3) adequate oral antimicrobial therapy (quinolone or amoxicillin/clavulanate or cephalosporin) and hospital discharge if the patient was low-risk.Results198 patients were enrolled; 89 patients had SS/SSh, of whom 19 received adequate antimicrobial therapy within 90 min and 42 received appropriate fluid challenge. Blood cultures were obtained from 87 and lactate concentration was measured in 29. Overall, only 6 (7%) patients with SS/SSh received adequate management. Among 108 patients without SS/SSh, 38 (35%) were high-risk and 70 (65%) low-risk. In the high-risk group, adequate antimicrobial therapy was given to 31 patients, G-CSF was initiated in 4 and 35 were hospitalized. In the low-risk group, 4 patients received adequate oral antimicrobial therapy, IV antimicrobial therapy was prescribed in 59, G-CSF was initiated in 12 and six patients were discharged. Adequate management was given to 26/38 (68%) high-risk and 1/70 low-risk patients. Factors associated with adequate management were absence of SS/SSh (P = 0.0009) and high-risk according to MASCC criteria (P < 0.0001).ConclusionsIn this French sample of cancer patients presenting to the ED with FN, management was often inadequate and severity was under-evaluated in the critically ill.

Can C-reactive protein, procalcitonin and mid-regional pro-atrial natriuretic peptide measurements guide choice of in-patient or out-patient care in acute pyelonephritis? Biomarkers In Sepsis (BIS) multicentre study

Whereas C-reactive protein (CRP), procalcitonin (PCT) and mid-regional pro-atrial natriuretic peptide (ANP) may be of use at the bedside in the management of adult patients with infectious disorders, their usefulness has not been established in the setting of acute pyelonephritis. To assess the effectiveness of CRP, PCT and ANP measurements in guiding emergency physicians decisions whether to admit to hospital patients with acute pyelonephritis, we conducted a multicentre, prospective, observational study in 12 emergency departments in France; 582 consecutive patients were included. The reference standard for admission was defined by experts advice combined with necessity of admission or death during the 28-day follow-up. Baseline CRP, PCT and ANP were measured and their accuracy in identifying the necessity of admission was analysed using area under curves (AUC) of receiver-operating characteristic (ROC) plots. According to the reference standard, 126 (22%) patients required admission. ANP (AUC 0.75, 95% CI 0.69-0.80) and PCT (AUC 0.75, 95% CI 0.71-0.80) more accurately predicted this than did CRP (AUC 0.69, 95% CI 0.64-0.74). The positive and negative likelihood ratios for each biomarker remained clinically irrelevant whatever the threshold. Our results did not support the use of these markers to help physicians in deciding about admission of patients experiencing acute pyelonephritis in daily practice.

Accuracy of D-Dimers to Rule Out Venous Thromboembolism Events across Age Categories

Background. Strategies combining pretest clinical assessment and D-dimers measurement efficiently and safely rule out venous thromboembolism events (VTE) in low- and intermediate-risk patients. Objectives. As process of ageing is associated with altered concentrations of coagulation markers including an increase in D-dimers levels, we investigated whether D-dimers could reliably rule out VTE across age categories. Method. We prospectively assessed the test performance in 1,004 patients visiting the emergency department during the 6-month period with low or intermediate risk of VTE who also received additional diagnostic procedures. Results. 67 patients had VTE with D-dimers levels above the threshold, and 3 patients displayed D-dimers levels below the threshold. We observed that specificity of D-dimers test decreased in an age-dependent manner. However, sensitivity and negative predictive value remained at very high level in each age category including older patients. Conclusion. We conclude that, even though D-dimers level could provide numerous false positive results in elderly patients, its high sensitivity could reliably help physicians to exclude the diagnosis of VTE in every low- and intermediate-risk patient.

Lettre à la rédactionCiguatera : recrudescence des symptômes d’une ancienne intoxicationCiguatera: Recrudescence of symptomatology of a previous intoxication

calcium, de sulfate de magnésium et de bicarbonates de sodium est recommandé [1,2]. Certains auteurs proposent une séance d’hémodialyse [1–3] ou d’hémodiafiltration [1]. Les solutions utilisées sont habituellement conçues pour prévenir tout bilan négatif en calcium, mais elles peuvent induire un bilan négatif en magnésium. Il peut donc être utile d’utiliser au début de l’hémodiafiltration une solution sans potassium, supplémentée en magnésium, voire en calcium. Enfin, il faut aussi garder en mémoire que ces ingestions de solutions caustiques entraı̂nent fréquemment une extravasation liquidienne dans les territoires brûlés, créant un véritable troisième secteur avec une hypovolémie sévère. En conclusion, les brûlures cutanées avec l’acide fluorhydrique nécessitent un traitement local et systémique apportant du calcium. Avec des mesures appropriées, elles ont un bon pronostic. En revanche, l’ingestion d’acide fluorhydrique est de très mauvais pronostic. La gravité des troubles ioniques, leur vitesse d’installation et l’efficacité de leur correction sont difficilement prévisibles. Les malades doivent être orientés vers des services spécialisés dotés de moyens permettant de mesurer fréquemment les principaux cations plasmatiques et de mettre en route une hémodialyse ou une hémodiafiltration.

View from France: coming full circle

Bird and Harris propose moving to presumed consent to increase organ donation in the United Kingdom.1 France moved to presumed consent 34 years ago.2 All people are considered to consent to organ donation after death unless they have recorded opposition while alive (Laws of Bioethics).3 …

Reproductibilité et validité prédictive d’une échelle de tri adaptée de la Canadian Triage and Acuity Scale (CTAS)

© 2019 Elsevi FC < 50/min, pouls difficilement palpable, obésité (BMI > 30), diabétiques de longue date (réseau artériel artéritique) ou après échec d’un GSA par un premier opérateur expert. Patients divisés en 2 groupes : groupe A = procédure classique par palpation de l’AR ; groupe B = utilisation de l’ED (sonosite) par un seul opérateur formé à la technique (50 GSA préalablement effectués avec ED). Résultats.— Soixante-huit patients inclus (âge médian : 74 ans), 34 patients par groupe. Les deux groupes sont comparables. Aucune différence significative entre les 2 groupes en termes de temps de réalisation de GSA (41 secondes vs 40 secondes), du nombre d’essais nécessaires (1,3 vs 1,4) et du taux de réussite final (82 % vs 88 %). Par contre, le taux de réussite du GSA au premier essai dans le groupe A (64,7 %) est inférieur de façon significative (p : 0,02) à celui de l’opérateur réalisant l’ED dans le groupe B (88,23 %). Enfin, un seul échec définitif dans le groupe utilisant l’ED était lié à l’impossibilité de visualiser l’artère radiale. Conclusions.— Cette étude préliminaire a montré la faisabilité de l’utilisation de l’ED comme aide à la ponction de l’AR par un opérateur entraı̂né auprès d’un patient présentant un risque a priori d’échec de ponction. Le taux de réussite de la ponction dès le premier essai est supérieur avec l’ED, information non négligeable en termes de qualité des soins. Cette étude renforce la place croissante de l’ED dans la pratique de la médecine d’urgence, à condition de former adéquatement les utilisateurs.

Acute appendicitis, an unusual presentation of Streptococcus pyogenes infection

The incidence of invasive streptococcal pyogenic infections has been on a worldwide increase. The most frequent clinical manifestations start with cutaneous septicemias. We report an unusual case of Streptococcus pyogenes-based septicemia, secondary to appendicitis with rapidly evolving peritonitis.