Comparison of fondaparinux with low molecular weight heparin for venous thromboembolism prevention in patients requiring rigid or semi-rigid immobilization for isolated non-surgical below-knee injury.

BACKGROUND: In several small studies, anticoagulant therapy reduced the incidence of venous thromboembolism (VTE) in patients with isolated lower-limb injuries. OBJECTIVES: To compare the efficacy and safety of fondaparinux 2.5 mg (1.5 mg in patients with a creatinine clearance between 30 and 50 mL min(-1) ) over nadroparin 2850 anti-factor Xa IU. PATIENTS AND METHODS: In this international, multicenter, randomized, open-label study, patients with an isolated non-surgical unilateral below-knee injury having at least one additional major risk factor for VTE and requiring, in the Investigator's opinion, rigid or semi-rigid immobilization for 21-45 days with thromboprophylaxis up to complete mobilization received subcutaneously once-daily either fondaparinux or nadroparin. The primary efficacy outcome was the composite of VTE (symptomatic or ultrasonographically detected asymptomatic deep vein thrombosis of the lower limb or symptomatic pulmonary embolism) and death up to complete mobilization. The main safety outcome was major bleeding. RESULTS: We randomized 1349 patients (mean age 46 years): 88.7% had a bone fracture, and 83.8% had a plaster cast fitted (mean duration of immobilization, 34 days). The primary efficacy outcome occurred in 15 of 584 patients (2.6%) in the fondaparinux group and 48 of 586 patients (8.2%) in the nadroparin group (odds ratio, 0.30; 95% confidence interval [CI], 0.15-0.54; P < 0.001). A single major bleed was experienced by fondaparinux-treated patients and none by nadroparin-treated patients. These results were maintained up to the end of follow-up. CONCLUSIONS: Fondaparinux 2.5 mg day(-1) may be a valuable therapeutic option over nadroparin 2850 anti-FXa IU day(-1) for preventing VTE after below-knee injury requiring prolonged immobilization in patients with additional risk factors.

[Physician staffed ambulances are better for patients' analgesia on arrival at the emergency department]. / Le Smur meilleur vecteur pour une analgésie des patients traumatisés à l'arrivée aux urgences.

OBJECTIVES: To find out prehospital factors linked with low pain on arrival into a traumatic emergency unit. METHODS: A 4-month monocentric prospective study, including patients recruited at their arrival into a traumatic emergency unit. Pain (with a numerical rating scale [NRS]), anxiety, prehospital care including the type of transportation (physician staffed ambulances {service mobile d'urgence et de réanimation [Smur]}, emergency medical technicians, or firemen ambulances), immobilization and analgesics used were evaluated. These data were collected on arrival at the hospital by the ED orientation nurse. Uni- and multivariate analysis were performed to identify low pain's predictive factors (e.g. with a NRS ≤3). RESULTS: Three hundred and four patients were recruited, mean age=51±25, sex ratio=1.8, mean pain/10=5.8±2.9, 64% with a moderate or severe pain on arrival (NRS>3). For one third of patients, immobilizations hadn't been performed during the prehospital phase. Medical management by Smur is a low pain predictive factor (OR=5.8; CI 95%=1.4-24.16), anxiety is a pejorative factor (OR=0.53 CI 95%=0.38-0.75). CONCLUSION: Our study highlights the physician staffed ambulances' effectiveness in prehospital trauma victims' management and raises the question of anxiolysis as an adjuvant for traumatic pain management.

[Victims of general crimes. Prospective and longitudinal assessment of psychological injuries]. / Victimes d'agression physique: évaluation prospective et longitudinale des blessures psychologiques.

OBJECTIVE: The aim of this study was to assess the relations between acute psychological injury, particularly peritraumatic dissociation, and early development of posttraumatic stress disorder in victims of violence. METHODS: Thirty-five subjects were prospectively assessed in an emergency department, within 24 hours of the trauma, for acute dissociative experiences with the Peritraumatic Dissociative Experiences Questionnaire (PDEQ). All of them were followed longitudinally to assess post traumatic stress disorder (PTSD) 5 weeks after with the Clinician-administered PTSD scale (CAPS) and the Impact of event scale (IES). RESULTS: Of the 35 victims 10 (28%) were diagnosed with a posttraumatic stress disorder at 5 weeks. Among PTSD subjects mean PDEQ scores were significantly higher (3+/-1.1) than in those without PTSD (2.3+/-0.7) (t=2.24, df=33, p=0.029). The PTSD subjects reported more "out of body experience" (p=0.015) and more "sense of body distorsion" (p=0.03) than non PTSD subjects. CONCLUSION: High levels of peritraumatic dissociation following violent assault are risk factors for early posttraumatic stress disorder. Psychological assessment of acute traumatic dissociative experiences must be included in emergency departments.

[Acute community-acquired pneumonia of moderate and grave severity investigated by bronchoscopy. Analysis of 193 cases hospitalized in a general hospital]. / Pneumopathies aiguës communautaires préoccupantes ou graves explorées par fibroscopie bronchique. Analyse de 193 cas hospitalisés en hôpital général.

Between February 1989 and June 1994 193 cases of acute community acquired pneumonia (PAC) which were of intermediate or great severity were admitted to two hospitals in the South West of France. These patients were explored using bronchofibroscopy (FB) with a protected brush (BP) and alveolar microlavage (MLBA) and quantitative cultures were performed, also there were other specimens taken in a regular fashion. The percentage of positive examinations was 60% for brushings (BP), 59% for MLBA and 21% for blood cultures and 16% for serological tests. An aetiology was determined in 137 cases (70.9%). The organisms recovered were Streptococcus pneumoniae (49.6%), gram negative bacilli (17.4%), Haemophilus influenzae (11.7%), Mycoplasma pneumoniae (4.4%), Mycobacterium tuberculosis (4.4%), Staphylococcus aureus (3.6%), Chlamydia pneumoniae (2.2%), Legionella pneumophila (0.7%), and various 5.8%. The overall mortality was 15% despite immediate antibiotics based on the likely organism in 88% of cases. The study of prognostic factors confirmed the Fine score system (determined a posteriori) which constitutes a useful and practical index determining the management of PAC. On the other hand the role of bacteriological documentation in improving the vital prognosis remains to be confirmed. If bronchofibroscopy has appeared to us as a safe and useful means of investigation, the management of these disease remains to specified. We suggest that its use is reserved for subjects with life threatening disease (a Fine score equal to or greater than 3) or for those patients who are likely to have unusual germs: failure of previous antibiotics, diabetes, malnourishment, cancer, airflow obstruction and inhalation.