Gérald Kierzek

Is mid-regional pro-atrial natriuretic peptide (MRproANP) an accurate marker of bacteremia in pyelonephritis?

Introduction: Mid-regional pro-atrial natriuretic peptide (MRproANP) increases during systemic infections and could possibly correlate with bacteremia. Methods: We determined the characteristics of MRproANP for accuracy to detect positive blood culture. Results: Bacteremia was positive in 58 (15%) of 347 patients. MRproANP levels increased in patients with bacteremia (98.4 pmol/L [interquartile range (IQR) 68.2–153.1] vs. 66.4 pmol/L [IQR 51.0-90.3], p < 0.01). Performance of MRproANP to predict bacteremia [AUC = 0.69, 95%CI: 0.61–0.77] was equivalent to C-reactive protein (0.66 [95%CI: 0.59–0.74], p = 0.53) but less accurate than procalcitonin (0.78 [95%CI: 0.72–0.84], p < 0.001). Conclusion: Although MRproANP increased in bacteremic patients with acute pyelonephritis, results of likelihood ratios discarded its use at bedside to predict bacteremia.

Serum sodium abnormalities during nonexertional heatstroke: incidence and prognostic values ☆,☆☆,★

BACKGROUND Although heatstroke is often associated with dehydration, the clinical significance of serum sodium abnormalities in patients with heat-related illness during heat wave has been poorly documented. METHOD We evaluated 1263 patients (age, 82±15 years; body temperature, 40.1°C+1.2°C) admitted to emergency departments during the August 2003 heat wave in Paris, having a core temperature greater than 38.5°C and measurement of serum sodium concentrations. Patients were classified according to our previously described risk score of death. RESULTS Hyponatremia (<135 mmol/L) was reported in 409 (32%) and hypernatremia (>145 mmol/L) in 220 patients (17%). One-year survival was significantly decreased in patients with hypernatremia (45%; P=.004) but not in those with hyponatremia (58%; P=.86) as compared with patients with serum sodium concentration in the reference range (57%). Using Cox regression, only hypernatremia was an independent prognostic factor (hazard ratio, 1.35; 95% confidence interval, 1.09-1.36) when risk score was taken into account. Using logistic regression, 2 variables were independently associated with hyponatremia (heatstroke severity score and blood urea nitrogen-creatinine ratio<100). Conversely, 5 variables were independently associated with hypernatremia (living in an institution, dementia, serum creatinine>120 μmol/L, a blood urea nitrogen-creatinine ratio >100, and absence of long-term diuretic intake). CONCLUSIONS Serum sodium abnormalities are frequently observed in patients with a nonexertional heatstroke during heat wave; however, only hypernatremia should be considered as an independent risk factor of death. Rapid measurement of serum sodium concentration is mandatory to appropriately guide electrolyte resuscitation.

Drowning: an overlooked cause of out-of-hospital cardiac arrest in Canada

INTRODUCTION Drowning is a major public health concern, yet little is known about the characteristics of drowning patients. The objectives of this study were to describe the demographic and clinical characteristics of out-of-hospital cardiac arrest (OHCA) attributed to drowning in Ontario and to compare the characteristics of OHCA attributed to drowning to those of presumed cardiac etiology. METHODS A retrospective, observational study was carried out of consecutive OHCA patients of drowning etiology in Ontario between August 2006 and July 2011. Bivariate analysis was used to evaluate differences between drowning and presumed cardiac etiologies. RESULTS A total of 31,763 OHCA patients were identified, and 132 (0.42%) were attributed to drowning. Emergency medical services treated 98 patients, whereas the remaining 34 met the criteria for legislative death. Overall, 5.1% of drowning patients survived to hospital discharge. When compared to patients of presumed cardiac etiology, drowning patients were younger and their arrest was more likely to be unwitnessed, present with a nonshockable initial rhythm, occur in a public location, and receive bystander cardiopulmonary resuscitation (CPR). A nonsignificant trend was noted for drowning cases to more frequently have a public access AED applied. There were no significant differences in the gender ratio or paramedic response times. Drowning patients were more likely to be transported to hospital but had a trend to be less likely to arrive with a return of spontaneous circulation. They were also more likely to be admitted to hospital but had no difference in survival to hospital discharge. CONCLUSIONS Significant differences exist between OHCA of drowning and presumed cardiac etiologies. Most drownings are unwitnessed, occur in public locations, and present with nonshockable initial rhythms, suggesting that treatment should focus on bystander CPR. Future initiatives should focus on strategies to improve supervision in targeted locations and greater emphasis on bystander-initiated CPR, both of which may reduce drowning mortality.

Understanding providers' offering and patients' acceptance of HIV screening in emergency departments: a multilevel analysis. ANRS 95008, Paris, France.

Objective We assessed the EDs’ characteristics associated with the offer and acceptance rates of a nontargeted HIV rapid-test screening in 29 Emergency Departments (EDs) in the metropolitan Paris region (11.7 million inhabitants), where half of France’s new HIV cases are diagnosed annually. Methods EDs nurses offered testing to all patients 18–64-year-old, able to provide consent, either with or without supplemental staff (hybrid staff model or indigenous staff model). The EDS’ characteristics collected included structural characteristics (location, type, size), daily workload (patients’ number and severity, length of stay in hours), staff’s participation (training, support to the intervention, leadership), type of week day (weekends vs weekdays) and time (in days). Associations between these variables and the staff model, the offer and acceptance rates were studied using multilevel modeling. Results Indigenous staff model was more frequent in EDs with a lower daily patient flow and a higher staff support score to the intervention. In indigenous-model EDs, the offer rate was associated with the patient flow (OR = 0.838, 95% CI = 0.773–0.908), was lower during weekends (OR = 0.623, 95% CI = 0.581–0.667) and decreased over time (OR = 0.978, 95% CI = 0.975–0.981). Similar results were found in hybrid-model EDs. Acceptance was poorly associated with EDs characteristics in indigenous-model EDs while in hybrid-model EDs it was lower during weekends (OR = 0.713, 95% CI = 0.623–0.816) and increased after the first positive test (OR = 1.526, 95% CI = 1.142–2.038). The EDs’ characteristics explained respectively 38.5% and 15% of the total variance in the offer rate across indigenous model-EDs and hybrid model-EDs vs 12% and 1% for the acceptance rate. Conclusion Our findings suggest the need for taking into account EDs’ characteristics while considering the implementation of an ED-based HIV screening program. Strategies allowing the optimization of human resources’ utilization such as HIV targeted screening in the EDs might be privileged.

New Combinational Assay Using Soluble Fibrin and D-Dimer Determinations: A Promising Strategy for Identifying Patients with Suspected Venous Thromboembolism

Aim To establish a new and reliable assay for quantification of the soluble fibrin (SF) in combination with that of D-dimer for early diagnosis of venous thromboembolism. Methods and Samples The SF assay is based on D-dimer generated after incubation of plasma with tissue-type plasminogen activator (t-PA). SF and standard D-dimer assays, run in blind, were used to test 119 untreated outpatients with clinically suspected deep-vein thrombosis (DVT, 49 patients) or pulmonary embolism (PE, 70 patients) consulting at the emergency unit of the hospital. Thromboses were confirmed by current imaging methods such as ultrasonography, scintigraphy, computed tomographic pulmonary angiography (CTPA) and ventilation/perfusion scan. Results SF assay was validated in 270 healthy volunteers [51.8% males; mean age years ± SD: 41±13; age range 19 to 65]. Among these normal plasmas, SF levels were ≤200 ng/mL in 97.8% of them, and 200–250 ng/mL in the remainder [26–46 years old; 50% males]. ROC curves were used to determine the SF cut-off value for plasma SF positivity, which was found to be 300 ng/mL. In patients with suspected venous thromboembolism, SF sensitivities for DVT and PE (92% and 94%, respectively) were comparable to those of D-dimer (96% and 94%), whereas SF specificities (86% and 95%) were higher than those of D-dimer (50% and 54%). Positive-predictive values for SF (89% and 94%) were again higher than those of D-dimer (70% and 65%) in DVT and PE. The amount of circulating SF normalized rapidly after anticoagulant therapy. Conclusion Results from this small group of patients suggest that the evaluation of plasma SF, in combination with that of D-dimer, represents a potentially useful tool for the early diagnosis of venous thromboembolism, provided that the patients have not been treated previously by anticoagulants.

A standardized procedure of information to improve comprehension of patients admitted in the emergency observation unit.

Our case provides additional information on the safety and efficacy of treatment with L-carnitine in acute VPA intoxication in the presence of hyperammonemic encephalopathy and absence of signs of liver failure. Therefore, L-carnitine should be considered as a treatment of VPA acute poisoning in patients with hyperammonemic encephalopathy, especially in those who are receiving chronic treatment with VPA or suffer other causes of carnitine deficiency.

Field intubation of patients with cardiac arrest: a dying art or just a question of timing?

We read with interest the article by Lyon et al 1 that questions the role of endotracheal intubation in a prehospital setting for patients with out-of-hospital cardiac arrest (OHCA). We fully agree that intubation can be challenging and is associated with complications. The optimal method of managing the airway during cardiac arrest has not yet been determined.2 The purpose …

Feasibility of a nontargeted active opt-in HIV, HBV, and HCV testing in an academic emergency department

HIV screening is recommended by Centers for Disease Control and Prevention (CDC) for all patients between 13 and 64 years of age in all healthcare settings [including emergency departments (EDs)] after the patient is notified that testing will be carried out, unless the patient declines (opt-out screening) [1,2]. In France, anonymous counseling and testing is provided in dedicated sites [Anonymous and Free Testing Centers, called Centres de dépistage anonymes et gratuits, (CDAG)] or by general practitioners. However, around 40% of cases identified are in people with advanced infection, and belong mostly to groups not focused on by the current testing policy [3]. As primary healthcare settings reach 14 million patients annually [4], EDs could be sites for improvement in testing policy. Despite the recommendations of the CDC, it remains unclear how best to approach the identification of undiagnosed HIV infection in the ED from the bare-minimum approach (diagnostic testing) to universal testing as an integrated part of routine health-care services in EDs, regardless of risk or clinical presentation [5,6]. Few data (no data in the European and French emergency system) are available on the feasibility, acceptability, and prevalence of virological screening in EDs; the aims of this study are to assess the spontaneous demand (active opt-in HIV, HBV, and HCV screening) and determine HIV, HBV, and HCV prevalence in an ED.

Ciguatera : recrudescence des symptômes d’une ancienne 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.

Survey of pre-hospital therapeutic hypothermia use in France

Fifty thousand out-of-hospital cardiac arrests (OHCA) occur in rance each year.1 As part of post-resuscitation care, therapeutic ypothermia (TH) is recommended for comatose OHCA survivors ith a shockable rhythm. Recent studies show that cooling can e initiated in the prehospital setting.2–4 We have evaluated the mplementation of prehospital TH by the French emergency medcal service system (EMS), the cooling methods used, and barriers o spread. In February and March 2010, we conducted a telephone urvey of the 105 regional EMS (SAMU: Service D’Aide Médicale rgente), using a web-based questionnaire. All 105 regional EMS answered our questionnaire (100% esponse). Thirty percent (n = 32) used TH and half of these (n = 16) ad a written cooling protocol. Twenty-seven of them (84%) iniiated TH for all initial arrest rhythms. Most (78%) started TH fter ROSC, 16% as soon as possible, and 6% before ROSC. To nitiate hypothermia 54% use cold fluids, most commonly by infusng 30 ml kg−1 of cold saline over 30 min. Eighteen percent used ce-packs and 28% only used passive cooling using exposure. Temerature was monitored with a tympanic thermometer (16%), an sophageal probe (14%), other means (51%), or not at all by 19%. Most EMS (70%) do not induce TH, and even though they thought t was interesting, most (84%) had no protocol or plan for a protocol n progress. There were two common themes regarding barriers to its impleentation: