[Comprehensive geriatric assessment in the emergency department: some usefull screening tools]. / Evaluation gériatrique aux urgences: boîte à outils pour les nuls.

Emergency department (ED) admissions of patients 75 years and older are consistently increasing. Older patients suffer from atypical symptomatology, spend more time, and are more at risk of adverse outcomes (early readmission, functional decline, institutionalization and death) than younger people. The identification of geriatric syndromes like cognitive decline can improve the management of such patients and decrease the rate of the outcomes. In ED, screening tools developed to detect these geriatric problems have to be quick, easy to use and to present a high sensibility. This article aims at reviewing the literature about the ED-validated screening tools that could be applied in practice.

[Efficacy and safety of probiotics]. / Probiotiques: efficacité et dangerosité.

Probiotics are bacteria or fungi, which modulate pathogenic growth and invasion of the bowel. The most frequently used are Lactobacillus and Saccharomyces cerevisiae. They are widely used as dietary supplements or for the treatment and prevention of various types of diarrhoea. Probiotics are generally considered as safe, but some cases of invasive infections have been described in different patient populations. This article reviews the literature about the indications and risks of probiotics, especially in immunocompromised patients.

[How to reduce reperfusion time in ST elevation myocardial infarction?]. / Comment réduire le délai de reperfusion dans l'infarctus du myocarde avec sus-décalage du segment ST?

For patients with ST elevation myocardial infarction (STEMI), most hospitals do not achieve recommended reperfusion time delay. The goal of this article is to discuss the several strategies allowing to reduce delay to reperfusion (e.g., pre-hospital ECG, early activation of catheterisation laboratory), in order to help each institution to develop its own protocol.

[Initial management of acute heart failure in the emergency department]. / Insuffisance cardiaque aiguë décompensée: prise en charge initiate aux urgences.

Acute decompensated heart failure is one of the most leading diseases among elderly patients presenting in the emergency department with a chief complaint of dyspnea. Initial management is crucial for the patient's outcome. In this article we propose a review of diagnosis, treatment, stratification and orientation of patients admitted to emergency department with acute heart failure in light of recent recommendations.

[Alternative to hospitalization for patients diagnosed with acute congestive heart failure]. / Patients avec insuffisance cardiaque décompensée aux urgences: existe-t-it une alternative à l'hospitalisation?

Heart failure is the first cause of hospital admission in patients above 65 years of age and represents a major health problem given demographic projections. Rapid admission of selected patients in specialized heart failure observation units in the emergency departments providing therapeutic monitoring and multiple educative interventions may obviate the need for hospitalization. This strategy may reduce the overall incidence of hospitalization and subsequent readmissions as well as save costs. Outcome studies are needed before a widespread implementation of such strategies.

[Should B-type natriuretic peptide (BNP) be used in daily practice?]. / Adoption d'un test diagnostique dans la pratique quotidienne: à propos du peptide natriurétique de type B (BNP).

Each diagnostic test should be systematically evaluated before acceptation for use in daily practice. The principles for validating a diagnostic test are reviewed using B-type natriuretic peptide (BNP) as an example. BNP seems promising to diagnose symptomatic left-sided heart failure in the emergency department, especially when the diagnosis remains uncertain (intermediate clinical probability). However, before its widespread use, its efficacy on clinical outcome measures such as reduction of time to treatment or in-hospital length of stay should be more clearly demonstrated through pragmatic studies.

[Acute dyspnea: what is the diagnostic role of B-type natriuretic peptide?]. / Dyspnée aiguë: quel est l'apport diagnostique du peptide natriurétique de type B?

Bedside dosage of B-type natriuretic peptide as a marker of congestive heart failure is of major interest in the evaluation of acute dyspnea. However, this test remains difficult to use because its interpretation depends upon the probability of disease and upon its diagnostic performance (sensitivity and specificity), varying with each BNP level. When the clinical probability of heart failure is low or high, BNP level doest not modify significantly the probability of disease. The test is useful when the diagnostic is uncertain (intermediate clinical probability), because a BNP value < 100 pg/ml makes the diagnosis of heart failure unlikely (high negative predictive value), and a value > 500 pg/ml very likely.

[Anaphylaxis: initial management]. / Anaphylaxie: prise en charge initiale.

Anaphylaxis is an immediate systemic reaction caused by an external agent. Its initial management depends on the severity of the reaction. In case of benign to moderate reaction, anti-histamine and steroid treatment are sufficient to control the process, and management is ambulatory. A severe reaction (hypotension, dyspnea) can be life threatening and adrenalin administration by the intramuscular route is indicated. In this case, it is advocated to observe the evolution for 24 hours in the hospital and the patient should be prescribed adrenaline auto-injectors. It is recommended that individuals who have experienced anaphylaxis should receive consultation from an allergist regarding diagnosis, prevention and treatment.

[Non invasive ventilation in emergency settings]. / Indication a la ventilation non invasive (VNI) dans les services d'urgence.

The use of non invasive ventilation (NIV) in the emergency setting to treat acute respiratory failure (ARF) has received much attention. To date, large studies support the early administration of continuous positive airway pressure (CPAP) in patients with cardiogenic acute pulmonary edema; and 2) non-invasive positive pressure ventilation (NPPV) for exacerbations of chronic obstructive pulmonary disease (COPD). NIV could also be useful in other types of ARF, but its success rate is dependent on the cause of ARF and patient's characteristics. Use of NIV in the emergency setting should take into account validated indications and local expertise of the nursing staff to minimize the risk of complications.

Is measurement of D-dimer useful in the diagnosis of cerebral venous thrombosis?

BACKGROUND: The diagnosis of cerebral venous thrombosis (CVT) is a challenge because its clinical presentation is variable, brain CT may be normal, and MRI is not always available. Furthermore, early treatment may be effective. As D-dimer (DD) measurement is a sensitive test for the exclusion of venous thromboembolism, the authors studied whether this test could be useful in the diagnosis of CVT. METHODS: A prospective study of 54 consecutive patients with headaches suggestive of CVT was conducted between October 2000 and September 2002. DD levels were tested for all patients in the emergency room before brain CT or MRI was performed. RESULTS: Twelve (22%) of the 54 patients had CVT, and 10 (83%) of these 12 patients had DD level of >500 ng/mL (sensitivity of 83% and negative predictive value of 95%). Two patients with confirmed CVT and DD of <500 ng/mL had a history of chronic headache of >30 days' duration. In the 42 patients without confirmed CVT, only 4 patients had DD level of >500 ng/mL (specificity of 90% and positive predictive value of 71%). CONCLUSIONS: DD test is useful in the diagnosis of acute CVT. A value below 500 ng/mL makes acute thrombosis unlikely.

Relationship between hospital length of stay and quality of care in patients with congestive heart failure.

OBJECTIVE: To determine the relationship between hospital length of stay (LOS) and quality of care in patients admitted for congestive heart failure (CHF). METHODS: This observational study was conducted in the medical wards of the Geneva University Hospitals, Geneva, Switzerland. A random sample of 371 patients was drawn from the 1084 patients discharged alive with a principal diagnosis of CHF between January 1997 and December 1998. Explicit criteria grouped into three scores were used to assess the quality of processes of care: admission work-up (admission score); evaluation and treatment during the stay (treatment score); and readiness for discharge (discharge score). The association between LOS and quality of care was analysed using linear regression with adjustment for clinical characteristics. RESULTS: The mean proportion of criteria met were 80% for the admission score, 66% for the treatment score, and 76% for the discharge score. Mean (SD) LOS was 13.2 (8.8) days. The admission score was not associated with LOS, but the treatment score increased by 0.5% (95% CI 0.3 to 0.7; p < 0.001) with each additional day in hospital and the discharge score increased by 2.5% (95% CI 1.6 to 3.3; p < 0.001) per day from admission to day 10 but remained unchanged thereafter. Adjustment for potential confounders did not substantially modify these relationships. CONCLUSIONS: In patients with CHF there is a significant association between LOS and the quality of the treatment provided, as well as with readiness for discharge. Appropriate reorganisation of processes of care should accompany attempts at reducing LOS to avoid detrimental effects on quality of care.

Role of echocardiography in the evaluation of syncope: a prospective study.

OBJECTIVE: To study the role of echocardiography in the stepwise evaluation of syncope. DESIGN: A prospective observational study with an 18 month follow up. SETTING: University teaching hospital providing primary and tertiary care. SUBJECTS: 650 consecutive patients with syncope and clinical suspicion of an obstructive valvar lesion, or with syncope not explained by history, physical examination, or a 12 lead ECG, who underwent bidimensional Doppler transthoracic echocardiography. MAIN OUTCOME MEASURES: The causes of syncope were assigned using published diagnostic criteria. Echocardiography was considered diagnostic when confirming a suspected diagnosis, or when revealing occult cardiac disease explaining the syncope. RESULTS: A systolic murmur was identified in 61 of the 650 patients (9%). Severe aortic stenosis was suspected in 20 of these and was confirmed by echocardiography in eight. Follow up excluded further cases of aortic stenosis. In patients with unexplained syncope (n = 155), routine echocardiography showed no abnormalities that established the cause of the syncope. Echocardiography was normal or non-relevant in all patients with a negative cardiac history and a normal ECG (n = 67). In patients with a positive cardiac history or an abnormal ECG (n = 88), echocardiography showed systolic dysfunction (left ventricular ejection fraction < or = 40%) in 24 (27%) and minor non-relevant findings in the remaining 64. Arrhythmias were diagnosed in 12 of the 24 patients with systolic dysfunction (50%), and in 12 of the 64 remaining patients (19%) (p < 0.01). CONCLUSIONS: Echocardiography was most useful for assessing the severity of the underlying cardiac disease and for risk stratification in patients with unexplained syncope but with a positive cardiac history or an abnormal ECG.

Prospective evaluation of patients with syncope: a population-based study.

PURPOSE: To determine the diagnostic yield of a standardized sequential evaluation of patients with syncope in a primary care teaching hospital. PATIENTS AND METHODS: All consecutive patients who presented to the emergency department with syncope as a chief complaint were enrolled. Their evaluation included initial and routine clinical examination, including carotid sinus massage, as well as electrocardiography and basic laboratory testing. Targeted tests, such as echocardiography, were used when a specific entity was suspected clinically. Other cardiovascular tests (24-hour Holter monitoring, ambulatory loop recorder ECG, upright tilt test, and signal-averaged electrocardiography) were performed in patients with unexplained syncope after the initial steps. Electrophysiologic studies were performed in selected patients only as clinically appropriate. Follow-up information on recurrence and mortality were obtained every 6 months for as long as 18 months for 94% (n = 611) of the patients. RESULTS: After the initial clinical evaluation, a suspected cause of syncope was found in 69% (n = 446) of the 650 patients, including neurocardiogenic syncope (n = 234, 36%), orthostatic hypotension (n = 156, 24%), arrhythmia (n = 24, 4%), and other diseases (n = 32, 5%). Of the 67 patients who underwent targeted tests, suspected diagnoses were confirmed in 49 (73%) patients: aortic stenosis (n = 8, 1%), pulmonary embolism (n = 8, 1%), seizures/stroke (n = 30, 5%), and other diseases (n = 3). Extensive cardiovascular workups, which were performed in 122 of the 155 patients in whom syncope remained unexplained after clinical assessment, provided a suspected cause of syncope in only 30 (25%) patients, including arrhythmias in 18 (60%), all of whom had abnormal baseline ECGs. The 18-month mortality was 9% (n = 55, including 8 patients with sudden death); syncope recurred in 15% (n = 95) of the patients. CONCLUSION: The diagnostic yield of a standardized clinical evaluation of syncope was 76%, greater than reported previously in unselected patients. Electrocardiogram-based risk stratification was useful in guiding the use of specialized cardiovascular tests.

Living donor liver transplantation for early hepatocellular carcinoma: A life-expectancy and cost-effectiveness perspective.

Cadaveric liver transplantation (CLT) is an excellent treatment for early hepatocellular carcinoma (HCC). Its use, however, is limited by the shortage of grafts, with up to 30% of patients developing contraindications to the procedure while waiting for a donor. Living donor liver transplantation (LDLT) has emerged as an alternative to overcome this limitation. We compared the consequences of LDLT versus CLT using a Markov model balancing the gains and losses in life expectancy among donors and recipients. For a 60-year-old recipient with a 70% 5-year survival after transplantation, a 4% monthly drop-out rate, and a donor with 1% mortality, LDLT became more effective than CLT after 3.5 months on the waiting list. These results varied with the probability of developing contraindications to transplantation, the survival after transplantation, and the donor's mortality. For a 12-month delay saved on the waiting list, the gain in survival provided by LDLT compared with CLT ranged between 0 and 2.8 life years depending on survival after transplantation, time spent on the waiting list, and drop-out rate. LDLT was cost-effective (less than $50,000 per quality-adjusted life year saved) in all scenarios of waiting lists exceeding 7 months, and this figure ranged from 2 to 16 months when varying the drop-out rate. LDLT for early HCC offered substantial gains in life expectancy with acceptable cost-effectiveness ratios when the waiting list exceeds 7 months. The gain in life expectancy and the cost-effectiveness of LDLT were more dependent on the drop-out rate and the outcome after transplantation than on donor's mortality.

Economic evaluation of celecoxib, a new cyclo-oxygenase 2 specific inhibitor, in Switzerland.

OBJECTIVE: The aim of this study was to predict the cost effectiveness of celecoxib, a cyclo-oxygenase 2 (COX-2) specific inhibitor, in the treatment of arthritis patients in Switzerland. METHODS: We applied a decision analytical model to compare the effects of 6 months' treatment with the following: (i) celecoxib; (ii) nonsteroidal anti-inflammatory drug (NSAID) alone; NSAID protected with (iii) proton pump inhibitor (PPI), (iv) histamine H2 receptor antagonist (H2RA), or (v) misoprostol; and (vi) diclofenac/misoprostol. Treatment costs included drug acquisition and the management of gastrointestinal (GI) adverse effects, classified as GI discomfort, symptomatic ulcer, anaemia and serious GI events (requiring hospitalisation). Probabilities were derived from celecoxib clinical trials and the literature. Drug utilisation patterns and treatment costs reflecting Swiss practice were obtained from local sources. Analysis was from the public health insurers' perspective. A range of sensitivity analyses was performed. RESULTS: For the base case of patients at typical risk (0.56% per 6 months) of serious GI events, the total expected costs of 6 months' treatment were as follows: celecoxib 435 Swiss francs (SwF); NSAID alone SwF510; diclofenac/misoprostol SwF522; and other protected NSAID regimens between SwF1034 and SwF1415. Celecoxib remained the lowest costing treatment over all categories of GI risk. Celecoxib generated 115 expected adverse events per 1000 patients per 6 months, followed by NSAID + PPI (119), NSAID + H2RA (154), NSAID + misoprostol (202), diclofenac/misoprostol (203), and NSAID alone (220), again for the base case. The cost per adverse event averted for celecoxib compared with NSAIDs alone was estimated in a stochastic version of the model using Monte Carlo simulation. In 95% of 500 iterations, celecoxib was predicted to save both costs and adverse events, thus dominating NSAIDs alone; the maximum cost per adverse event averted was SwF440. CONCLUSIONS: Celecoxib is predicted to be the most cost effective of the treatments considered for managing arthritis patients in Switzerland. A policy of switching patients from NSAIDs to celecoxib is predicted to be cost saving for public health insurers, while reducing the burden of iatrogenic GI side effects. Greater cost savings would be realised when patients are switched from NSAIDs used with gastroprotective agents. Models such as this can provide a useful but simplified view of treatment outcomes and predicted results require prospective validation in clinical practice.

Decision analysis and its application in clinical medicine.

Decision analysis is increasingly used to address difficult medical problems. Case-by-case models designed for individual patients facing complex trade-offs in their medical care often help individual clinical decision making, but are expensive and time consuming. On the other hand, generic models addressing broad clinical questions that can be adapted from one patient to another, can often make valid projections about specific outcomes, such as life expectancy, quality-adjusted life expectancy, and cost-effectiveness issues, and represent a useful approach to clinical decision making.

Unplanned readmissions of patients with congestive heart failure: do they reflect in-hospital quality of care or patient characteristics?

PURPOSE: To determine if early unplanned readmissions of patients hospitalized for heart failure are associated with suboptimal in-hospital care or with the clinical and demographic characteristics of the patient. SUBJECT AND METHODS: We performed a case-control study among patients discharged with a principal diagnosis of heart failure. Cases included all patients unexpectedly readmitted within 31 days of discharge; controls were randomly selected from among those not readmitted. Quality of care was measured using explicit criteria reflecting the admission work-up, evaluation and treatment, and readiness for discharge. RESULTS: Ninety-one cases and 351 controls were included. There was no significant association between early unplanned readmissions and the scores for quality of the admission work-up or evaluation and treatment during the stay. There was a significant association between readiness for discharge and subsequent early readmission: for each 10% decrease in the proportion of fulfilled criteria, the odds of readmission increased by 14% (95% confidence interval [CI] 1. 01 to 1.28, P = 0.04) for all-cause readmissions and by 19% (95% CI: 1.04 to 1.36, P = 0.01) for heart-failure-related readmissions. In a multiple logistic regression model, previous diagnosis of heart failure (odds ratio [OR] = 2.9, 95% CI: 1.7 to 4.8, P <0.001), age (OR = 3.3, 95% CI: 1.3 to 8.5, P = 0.01 for patients aged 65 to 79 years and OR = 4.1, 95% CI: 1.6 to 11, P = 0.004 for patients aged 80 years and older), and history of cardiac revascularization (OR = 2.1, 95% CI: 1.2 to 3.9, P = 0.01) showed a stronger association with early unplanned all-cause readmissions than the readiness-for-discharge score (OR = 1.16, 95% CI: 1.02 to 1.31, P = 0.02). Similar findings were seen for heart failure-related readmissions. CONCLUSIONS: Among patients with heart failure, early unplanned readmissions were not associated with suboptimal admission work-up or evaluation and treatment but were weakly associated with readiness for discharge. However, they were strongly associated with the patients' clinical and demographic characteristics.

Cost-effectiveness of new antiplatelet regimens used as secondary prevention of stroke or transient ischemic attack.

BACKGROUND: Compared with aspirin alone, use of the new antiplatelet regimens, including aspirin combined with dipyridamole and clopidogrel bisulfate, has been found to further reduce the risk of stroke and other vascular events in patients who have experienced stroke or transient ischemic attack. However, their cost-effectiveness ratios relative to aspirin alone have not been estimated. METHODS: We developed a Markov model to measure the clinical benefits and the economic consequences of the following strategies to treat high-risk patients aged 65 years or older: (1) aspirin, 325 mg/d; (2) aspirin, 50 mg/d, and dipyridamole, 400 mg/d; and (3) clopidogrel bisulfate, 75 mg/d. Input data were obtained by literature review. Outcomes were expressed as US dollars per quality-adjusted life-year (QALY). RESULTS: The use of aspirin combined with dipyridamole was more effective and less costly compared with the use of aspirin alone, providing a gain of 0.3 QALY for a 65-year-old patient. This regimen remained cost-effective despite wide sensitivity analyses. Clopidogrel was more effective and more costly compared with aspirin alone, yielding a gain of 0.2 QALY with a marginal cost-effectiveness ratio of $26,580 per each additional QALY (patient aged 65 years). Sensitivity analyses demonstrated that the efficacy of clopidogrel and its cost were key factors in determining its cost-effectiveness ratio compared with aspirin, which exceeded $50,000 when its efficacy decreased by half or its cost doubled. CONCLUSION: To prevent stroke in high-risk patients, dipyridamole combined with aspirin was more effective and less costly than aspirin alone, and clopidogrel was cost-effective compared with current standards of medical practice, except in extreme scenarios.

Prophylactic antithrombotic therapy for patients with systemic lupus erythematosus with or without antiphospholipid antibodies: do the benefits outweigh the risks? A decision analysis.

BACKGROUND: A high incidence of both arterial and venous thromboembolic events has been reported in patients with systemic lupus erythematosus (SLE), but the risks and benefits of primary prophylactic antithrombotic therapy have not been assessed. We measured the clinical benefit of 3 antithrombotic regimens in patients with SLE without antiphospholipid antibodies, with anticardiolipin antibodies, or with lupus anticoagulant. METHODS: A Markov decision analysis was used to evaluate prophylactic aspirin therapy, prophylactic oral anticoagulant therapy, and observation. Input data were obtained by literature review. Clinical practice was simulated in a hypothetical cohort of patients with SLE who had not experienced any previous episode of arterial or venous thromboembolic events. For each strategy, we measured numbers of thromboembolic events prevented and major bleeding episodes induced, and quality-adjusted survival years. RESULTS: Prophylactic aspirin therapy was the preferred strategy in all settings, the number of prevented thrombotic events exceeding that of induced bleeding episodes. In the baseline analysis (40-year-old patients with SLE), the gain in quality-adjusted survival years achieved by prophylactic aspirin compared with observation ranged from 3 months in patients without antiphospholipid antibodies to 11 months in patients with anticardiolipin antibodies or lupus anticoagulant. Prophylactic oral anticoagulant therapy provided better results than prophylactic aspirin only in patients with lupus anticoagulant and an estimated bleeding risk of 1% per year or less. CONCLUSIONS: Prophylactic aspirin should be given to all patients with SLE to prevent both arterial and venous thrombotic manifestations, especially in patients with antiphospholipid antibodies. In selected patients with lupus anticoagulant and a low bleeding risk, prophylactic oral anticoagulant therapy may provide a higher utility.

Primary liver resection and salvage transplantation or primary liver transplantation in patients with single, small hepatocellular carcinoma and preserved liver function: an outcome-oriented decision analysis.

Two treatments are accepted for patients with solitary hepatocellular carcinoma