J.-L. Pourriat

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.

Prevalence of neuropathic pain in emergency patients: an observational study.

OBJECTIVE Neuropathic pain (NP) in acute conditions has been poorly investigated. A diagnostic score, the DN4 scale (DN4), has been developed to help physicians to detect and treat NP appropriately. DN4 is a 10-item questionnaire. If you have 4 or more positive responses out of 10 items, the answer to the questionnaire is positive and you have a neuropathic pain. We aimed to determine the prevalence of NP in emergency department (ED) patients and to describe this population. METHODS We used the DN4 in the patients with NP visiting the adult ED of a university hospital. Patients were asked about the characteristics of their pain using a face-to-face questionnaire. RESULTS Among 533 patients with a DN4 score, 114 (21.4%) had NP. Neuropathic pain was independently negatively associated with age of 65 years of older (odds ratio [OR], 0.2, 95% confidence interval [CI], 0.05-0.8) and positively associated with intense pain (OR, 5.2; 95% CI, 1.5-18.2), located to the limbs (OR, 2.3; 95% CI, 1.2-4.0). CONCLUSION Neuropathic pain was common in ED patients and associated to a higher level of pain.

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.

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 …

Anemia e Pronto Soccorso

Pochi studi si sono interessati all’anemia in Pronto Soccorso, mentre questo problema e pluriquotidiano al letto del paziente per ogni urgentista. L’anemia puo essere la causa del sintomo che conduce il paziente a visita e l’oggetto stesso della visita o essere scoperta al momento della presa in carico del paziente. La presenza di un’anemia pone numerose domande nel contesto dell’urgenza: quali eziologie ricercare e con quali tempi, qual e la ripercussione dell’anemia, il paziente deve essere sottoposto a una trasfusione? Lo scopo di questo capitolo e di fornire degli elementi di risposta a ciascuna di queste domande che si pone legittimamente l’urgentista di fronte all’anemia nella sua pratica clinica.

Les douleurs neuropathiques, un facteur de douleur aux urgences ?

© 2018 Elsevi proportion de patients soulagés (EVA < 4) à la sortie est de 65 %, mais plus faible pour ceux ayant des douleurs sévères à l’admission (60 %). Discussion.— La douleur aux urgences est un symptôme fréquent. La méthode du recueil prospectif, incitative, entraı̂ne de forts taux d’évaluation initiale mais la réévaluation au cours de la prise en charge est trop souvent oubliée. Son traitement reste insuffisant et souvent inadapté, avec notamment un recours insuffisant aux morphiniques. Cette enquête nationale réalisée sur un nombre important de centres montre que l’oligoanalgésie est un problème fréquent et que sur le terrain, les recommandations ne sont pas appliquées de façon optimale. Ceci incite à mettre en place un programme d’assurance qualité national ciblé sur la douleur.

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.