Jean-Louis Pourriat

How emergency departments might alert for prehospital heat-related excess mortality?

IntroductionA major issue raised by the public health consequences of a heat wave is the difficulty of detecting its direct consequences on patient outcome, particularly because of the delay in obtaining definitive mortality results. Since emergency department (ED) activity reflects the global increase of patients health problems during this period, the profile of patients referred to EDs might be a basis to detect an excess mortality in the catchment area. Our objective was to develop a real-time surveillance model based on ED data to detect excessive heat-related mortality as early as possible.MethodsA day-to-day composite indicator was built using simple and easily obtainable variables related to patients referred to the ED during the 2003 heat-wave period. The design involved a derivation and validation study based on a real-time surveillance system of two EDs at Cochin Hospital and Hôtel-Dieu Hospital, Paris, France. The participants were 99,976 adult patients registered from 1 May to 30 September during 2001, 2002 and 2003. Among these participants, 3,297, 3,580 and 3,851 patients were referred to the EDs from 3 August to 19 August for 2001, 2002 and 2003, respectively. Variables retained for the indicator were selected using the receiver operating characteristic curve methodology and polynomial regression.ResultsThe indicator was composed of only three variables: the percentage of patients older than 70 years, the percentage of patients with body temperature above 39°C, and the percentage of patients admitted to or who died in the ED. The curve of the indicator with time appropriately fitted the overall mortality that occurred in the region of interest.ConclusionA composite and simple index based on real-time surveillance was developed according to the profile of patients who visited the ED. It appeared suitable for determining the overall mortality in the corresponding region submitted to the 2003 heat wave. This index should help early warning of excessive mortality and monitoring the efficacy of public health interventions.

Midregional Pro–Atrial Natriuretic Peptide for the Diagnosis of Cardiac-Related Dyspnea according to Renal Function in the Emergency Department: A Comparison with B-Type Natriuretic Peptide (BNP) and N-Terminal ProBNP

BACKGROUNDnAlthough renal dysfunction influences the threshold values of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in diagnosis of cardiac-related dyspnea (CRD), its effects on midregional pro-atrial natriuretic peptide (MR-proANP) threshold values are unknown. We evaluated the impact of renal function on MR-proANP concentrations and compared our results to those of BNP and NT-proBNP.nnnMETHODSnMR-proANP, BNP, and NT-proBNP concentrations were measured in blood samples collected routinely from dyspneic patients admitted to the emergency department. Patients were subdivided into tertiles based on their estimated glomerular filtration rate [eGFR, in mL · min(-1) · (1.73 m(2))(-1)]: tertiles 1 (<44.3), 2 (44.3-58.5), and 3 (≥58.6).nnnRESULTSnOf 378 patients studied, 69% (n = 260) had impaired renal function [<60 mL · min(-1) · (1.73 m(2))(-1)] and 30% (n = 114) had CRD. MR-proANP, BNP, and NT-proBNP concentrations were significantly increased in patients with impaired renal function. In each tertile, all peptides remained significantly increased in CRD patients by comparison with non-CRD patients. By ROC analysis, MR-proANP, BNP, and NT-proBNP threshold values for the diagnosis of CRD increased as eGFR decreased from tertile 3 to tertile 1. Areas under the ROC curve for all peptides were significantly lower in tertile 1. Using adapted thresholds, MR-proANP, BNP, and NT-proBNP remained independently predictive of CRD, even in tertile 1 patients.nnnCONCLUSIONSnRenal function influences optimum cutoff points of MR-proANP for the diagnosis of CRD. With use of an optimum threshold value adapted to the eGFR category, MR-proANP remains as effective as BNP and NT-proBNP in independently predicting a diagnosis of CRD in the emergency department.

Bacteremia and MR-proANP changes in mild community-acquired pneumonia

Background: Mid-regional pro-atrial natriuretic peptide (MR-proANP) increases with severity in community-acquired pneumonia (CAP). We investigated whether changes of MR-proANP correlated to bacteremia. Methods: 392 adult patients with CAP visiting emergency department from a prospective observational multicenter study. Results: MR-proANP levels increased in patients with positive bacteremia (92.8 pmol/L vs. 84.3 pmol/L, pu2009=u20090.04). Performance of MR-proANP to detect bacteremia (0.60) was equivalent to CRP (0.59) but less accurate than PCT (0.69). Conclusion: MR-ANP poorly predicts bacteremia in CAP patients.

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.

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:

A functional ‘three-joint limb’

A 57-year-old homeless man presented to the emergency room for poor performance status.nnIn 2006, he suffered a closed right forearm fracture, treated by open reduction …

Local Media Influence on Opting Out From an Exception From Informed Consent Trial

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Péritonites bactériennes du patient cirrhotique

Les consequences d’une cirrhose sont variables en fonction du degre d’insuffisance hepatique et du niveau d’hypertension portale. Elles sont principalement metaboliques et hemodynamiques et sont responsables des complications evolutives qui emaillent l’histoire naturelle d’une cirrhose : hemorragies digestives, coagulopathies, survenue d’une ascite ou d’une encephalopathie, evolution vers un syndrome hepato-pulmonaire ou hepato-renal. Toutes ces consequences et toutes ces complications sont interdependantes, d’ou l’existence d’un equilibre fragile, que de nombreux evenements iatrogenes ou evolutifs peuvent remettre en cause, le plus souvent au prix d’une aggravation de l’insuffisance hepatocellulaire (fig. 1). Dans ce contexte, les infections jouent un role important et ont une influence directe sur l’evolution de la maladie et sur son pronostic a court et a moyen termes (1, 2, 3). Par rapport a une population standard, le risque d’infection est multiplie par 2,6 et celui de deces au decours d’un sepsis par 2. Elles sont d’autant plus frequentes et plus graves que l’insuffisance hepatocellulaire est severe. Elles sont responsables de 10% des deces des cirrhotiques et trois quarts de ceux qui decedent sont infectes. La moitie d’entre elles surviennent dans un contexte nosocomial. La survenue d’une infection marque souvent un tournant dans l’evolution de la maladie hepatique et devant toute aggravation d’une cirrhose, il faut suspecter une infection. Il existe un veritable « cercle vicieux » : plus la cirrhose est grave, plus le risque infectieux augmente, alors que la survenue de toute infection risque d’aggraver l’insuffisance hepatique.

Séroprévalence du virus de l'hépatite C aux urgences médicojudiciaires

Au cours de lannee 2005, 42 525 personnes ont consulte aux urgences medicojudiciaires (UMJ) de lHotel-Dieu de Paris. Cette unite examine, sur requisition judiciaire, lensemble A des personnes âgees de quinze ans revolus victimes ou auteurs de violences survenues sur le departement de Paris. A la difference des unites de consultations et de soins ambulatoires (UCSA), et a la suite du rapport parlementaire dOlivier Jarde [1], les UMJ ne sont pas incluses dans les MIGAC. Elles sont dotees dun financement propre et ont un fonctionnement tres different dun centre hospitalier a lautre. La seroprevalence du virus de lhepatite C (VHC) chez les personnes qui consultent aux UMJ est inconnue. Le but de cette etude retrospective a ete de determiner la seroprevalence pour le VHC chez les sujets ayant consulte au moins une fois dans cette unite en 2005 pour un accident dexposition au sang ou aux liquides biologiques, et de comparer cette prevalence a celle observee dans la population generale et danalyser les caracteristiques epidemiologiques et le motif de consultation de la population positive pour le VHC.