Validation of an emergency triage scale for obstetrics and gynaecology: a prospective study.

OBJECTIVE: To evaluate the reliability of a four-level triage scale for obstetrics and gynaecology emergencies and to explore the factors associated with an optimal triage. DESIGN: Thirty clinical vignettes presenting the most frequent indications for obstetrics and gynaecology emergency consultations were evaluated twice using a computerised simulator. SETTING: The study was performed at the emergency unit of obstetrics and gynaecology at the Geneva University Hospitals. SAMPLE: The vignettes were submitted to nurses and midwives. METHODS: We assessed inter- and intra-rater reliability and agreement using a two-way mixed-effects intra-class correlation (ICC). We also performed a generalised linear mixed model to evaluate factors associated triage correctness. MAIN OUTCOME MEASURES: Triage acuity. RESULTS: We obtained a total of 1191 evaluations. Inter-rater reliability was good (ICC 0.748; 95% CI 0.633-0.858) and intra-rater reliability was almost perfect (ICC 0.812; 95% CI 0.726-0.889). We observed a wide variability: the mean number of questions varied from 6.9 to 18.9 across individuals and from 8.4 to 16.9 across vignettes. Triage acuity was underestimated in 12.4% of cases and overestimated in 9.3%. Undertriage occurred less frequently for gynaecology compared with obstetric vignettes [odds ratio (OR) 0.45; 95% CI 0.23-0.91; P = 0.035] and decreased with the number of questions asked (OR 0.94; 95% CI 0.88-0.99; P = 0.047). Certification in obstetrics and gynaecology emergencies was an independent factor for the avoidance of undertriage (OR 0.35; 95% CI 0.17-0.70; P = 0.003). CONCLUSION: The four-level triage scale is a valid and reliable tool for the integrated emergency management of obstetrics and gynaecology patients. TWEETABLE ABSTRACT: The Swiss Emergency Triage Scale is a valid and reliable tool for obstetrics and gynaecology emergency triage.

Early specialized care after a first unprovoked epileptic seizure.

A first seizure is a life-changing event with physical and psychological consequences. We aimed to assess the role of early comprehensive patient care after a first unprovoked seizure to improve diagnostic accuracy and follow-up adherence. From April 2011 to March 2012, patients presenting a first unprovoked epileptic seizure received standard patient care (SPC), i.e., a consultation in the ED, an EEG and a CT scan. The patients were notified of the follow-ups. We compared this protocol to subsequently acquired "early comprehensive patient care" (ECPC), which included a consultation by an epileptologist in the emergency department (ED), a routine or long-term monitoring electroencephalogram (LTM-EEG), magnetic resonance imaging and three follow-up consultations (3 weeks, 3 months, 12 months). 183 patients were included (113 ECPC, 70 SPC). LTM-EEG and MRI were performed in 51 and 85 %, respectively, of the patients in the ECPC group vs in 7 and 52 % of the patients in the SPC group (p < 0.001). A final diagnosis was obtained in 64 vs 43 % of the patients in the ECPC vs SPC group (p < 0.01). Patient attendance at 3-month was 84 % in the ECPC group vs 44 % in the SPC group (p < 0.001). At 12-month follow-up, the delay until the first recurrence was longer in the ECPC group (p = 0.008). An early epileptologist-driven protocol is associated with clinical benefit in terms of diagnostic accuracy, follow-up adherence and recurrence. This study highlights the need for epilepsy experts in the early assessment of a first epileptic seizure, starting already in the ED.

[Emergency medicine: updates 2012]. / Médecine d'urgence.

We review some of the most influential papers from 2012 in the different aspects of emergency medicine, such as prehospital medicine, resuscitation, early diagnosis and timely ED discharge and treatment. In particular, intramuscular benzodiazepines have been shown to be efficient in prehospital status epilepticus, epinephrines usefulness in cardiopulmonary resuscitation has been challenged, colloids have been shown to be deleterious in the treatment of severe sepsis and septic shock, the time window for thrombolysis in acute stroke will probably be extended, acute pyelonephritis treatment duration can be decreased, new D-dimers thresholds for older patients may prevent further diagnosis tests, and hs-Troponin may allow earlier discharge of low coronary risk patients.

Impact of lifestyle intervention on body weight and the metabolic syndrome in home-care providers.

AIM: The study evaluated the impact of lifestyle intervention on body weight, metabolic syndrome parameters, nutrition and physical activity in home-care providers (HCPs). METHODS: Of 551 screened employees of a nursing agency, 173 were eligible to participate and were assigned to either the intervention (n=129) or the control (n=44) group. Participants in the intervention group followed an educational programme that encouraged physical activity and healthy nutrition, and were equipped with bicycles free of charge. Anthropometric, biological and lifestyle parameters were assessed at baseline, and after 6 and 12 months. RESULTS: Body weight, waist circumference and systolic blood pressure significantly decreased at 12 months in both study groups. Incidence of the metabolic syndrome in the intervention group at 12 months was reduced by 50% (from 17 to 9.2%; P=0.04). There were also decreases in LDL cholesterol (-0.36 mmol/L; P<0.01), total cholesterol/HDL cholesterol ratio (-0.57; P<0.01) and fasting glucose (-0.4 mmol/L; P<0.05), and an increase in HDL cholesterol (+0.22 mmol/L; P<0.01) in the intervention group. At 12 months, a decrease in daily caloric intake (-391 kcal/day; P<0.001) and an increase in the percentage of participants engaging in physical activity (+3.4%; P<0.05) were also observed in the intervention group. CONCLUSION: Lifestyle changes among HCPs are possible with relatively modest behavioural education and within a short period of time. Educational strategies and workshops are effective, efficient and easy to perform, and should be encouraged in HCPs to promote the implementation of lifestyle modifications in their patients.

Hypothermia is a frequent sign of severe hypoglycaemia in patients with diabetes.

AIM: Hypothermia is a recognized complication of severe hypoglycaemia, but its prevalence and characteristics are poorly studied. For this reason, this study aimed to evaluate hypothermia in severely hypoglycaemic patients. METHODS: A retrospective chart review was performed including all patients discharged between 2007 and 2010 from the Emergency Department of the Geneva University Hospital with a diagnosis of severe hypoglycaemia. RESULTS: Hypothermia was identified in 30 (23.4%) out of 128 patients with severe hypoglycaemia. Its incidence was not affected by age, type of diabetes, season or time of day (day/night). Using linear regression, the lowest recorded temperature was associated with the Glasgow coma scale (GCS) score (r2 = 13.8%, P < 0.0001) and inversely associated with the leukocyte count (r2 = 13.1%, P = 0.001). CONCLUSION: Hypothermia is a frequent sign of severe hypoglycaemia in patients with diabetes. The associations between hypothermia and the GCS score and the leukocyte count suggest that it is a marker of hypoglycaemia severity and/or duration. Hypothermia may represent an important compensatory mechanism in severe hypoglycaemia, reflecting a decrease in energy demand during glucose deprivation.

[Emergency medicine: updates 2011]. / Médecine d'urgence.

Emergency medicine physicians aim to stabilize or restore vital functions, establish diagnosis, initiate specific treatments and adequately orientate patients. This year, new evidences have improved our knowledge about diagnostic strategy for patients with acute non traumatic headache, treatment of acute atrial fibrillation and outpatient management of acute pulmonary embolism. Reducing injection pain of local anesthetics, reducing irradiation by using alternative diagnostic tools in appendicitis suspicion, and identification of trauma patients who benefit from tranexamic acid administration are other illustrations of the efforts to improve efficacy, safety and comfort in the management of emergency patients.

Is atrial fibrillation associated with pulmonary embolism?

BACKGROUND: A pulmonary embolism (PE) is thought to be associated with atrial fibrillation (AF). Nevertheless, this association is based on weak data. OBJECTIVES: To assess whether the presence of AF influences the clinical probability of PE in a cohort of patients with suspected PE and to confirm the association between PE and AF. PATIENTS/METHODS: We retrospectively analyzed the data from two trials that included 2449 consecutive patients admitted for a clinically suspected PE. An electrocardiography (ECG) was systematically performed and a PE was diagnosed by computer tomography (CT). The prevalence of AF among patients with or without a PE was compared in a multivariate logistic regression model. RESULTS: The prevalence of PE was 22.8% (519/2272) in patients without AF and 18.8% (25/133) in patients with AF (P = 0.28). After adjustment for confounding factors, AF did not significantly modify the probability of PE (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.42-1.11). However, when PE suspicion was based on new-onset dyspnea, AF significantly decreased the probability of PE (OR 0.47, 95% CI 0.26-0.84). If isolated chest pain without dyspnea was the presenting complaint, AF tended to increase the probability of PE (OR 2.42, 95% CI 0.97-6.07). CONCLUSIONS: Overall, the presence of AF does not increase the probability of PE when this diagnosis is suspected. Nevertheless, when PE suspicion is based on new-onset dyspnea, AF significantly decreases the probability of PE, as AF may mimic its clinical presentation. However, in patients with chest pain alone, AF tends to increase PE probability.

Autoantibodies against apolipoprotein A-1 and phosphorylcholine for diagnosis of non-ST-segment elevation myocardial infarction.

OBJECTIVES: To explore the diagnostic accuracies of anti-apolipoproteinA-1 (anti-ApoA-1) IgG and anti-phosphorylcholine (anti-PC) IgM alone, expressed as a ratio (anti-ApoA-1 IgG/anti-PC IgM), and combined with the Thrombolysis In Myocardial Infarction (TIMI) score for non-ST-segment elevation myocardial infarction (NSTEMI) (NSTEMI-TIMI score) to create a new diagnostic algorithm - the Clinical Autoantibody Ratio (CABR) score - for the diagnosis of NSTEMI and subsequent cardiac troponin I (cTnI) elevation in patients with acute chest pain (ACP). METHODS: In this single-centre prospective study, 138 patients presented at the emergency department with ACP without ST-segment elevation myocardial infarction. Anti-ApoA-1 IgG and anti-PC IgM were assessed by enzyme-linked immunosorbent assay on admission. Post hoc determination of the CABR score cut-off was performed by receiver operating characteristics analyses. RESULTS: The adjudicated final diagnosis was NSTEMI in 17% (24/138) of patients. Both autoantibodies alone were found to be significant predictors of NSTEMI diagnosis, but the CABR score had the best diagnostic accuracy [area under the curve (AUC): 0.88; 95% confidence interval (CI): 0.82-0.95]. At the optimal cut-off of 3.3, the CABR score negative predictive value (NPV) was 97% (95% CI: 90-99). Logistic regression analysis showed that a CABR score >3.3 increased the risk of subsequent NSTEMI diagnosis 19-fold (odds ratio: 18.7; 95% CI: 5.2-67.3). For subsequent cTnI positivity, only anti-ApoA-1 IgG and CABR score displayed adequate predictive accuracies with AUCs of 0.80 (95% CI: 0.68-0.91) and 0.82 (95% CI: 0.70-0.94), respectively; the NPVs were 95% (95% CI: 90-98) and 99% (95% CI: 94-100), respectively. CONCLUSION: The CABR score, derived from adding the anti-ApoA-1 IgG/anti-PC IgM ratio to the NSTEMI-TIMI score, could be a useful measure to rule out NSTEMI in patients presenting with ACP at the emergency department without electrocardiographic changes.

[Critical pathway for community-acquired pneumonia]. / Itinéraire clinique et pneumonie acquise à domicile.

A clinical pathway is a methodological tool for standardizing medical practice, improving the quality and efficiency of care delivery, and enhancing the diffusion of evidence-based medicine. Despite the fact that a majority of trials have shown that the use of clinical pathways improves certain specific outcomes such as length of stay or complications, the overall impact of these pathways in the clinical setting has yet to be documented. In the setting of community-acquired pneumonia, a few observational and one large randomized trial have shown positive effects on various outcomes. We describe in this article the clinical pathway for community-acquired pneumonia developed at our institution.

[Emergency medicine: update 2010]. / Médecine d'urgence.

Several scores with predictive value for morbidity or mortality have been published this year. Their current purpose is to improve the direction of admissions and lengths of stay in hospital. Their use permits more directed care, especially for the elderly, and therefore could improve the proper orientation and admission of patients. Also this year, certain procedures are undergoing evaluation, namely: new assays for troponin, and non-contrast CT in the diagnosis of acute appendicitis. Furthermore in the therapeutic realm: the importance of cardiac massage and the advantages of therapeutic hypothermia in cardiac arrest, and the efficacy of oxygen therapy in cluster headache.

[Management of acute asthma in the emergency room]. / Prise en charge de l'asthme aigu aux urgences.

Acute asthma is a frequent occurrence in the emergency room. Early care includes gradation of severity and rapid administration of systemic corticosteroid and bronchodilators. After initial treatment, if the patient has no longer criteria for severe asthma, and no poor outcome risk factor, continuation of treatment at home is a possible option. It requires to schedule a close appointment for medical follow-up, establishment of an asthma treatment plan, prescription of a short course of oral corticosteroids together with a combination of inhaled corticosteroid and long acting beta-2-agonist for longer duration of treatment.

[Emergency medicine: update 2009]. / Médecine d'urgence.

Emergency medicine is a cross-discipline characterized by its ability to identify critical threats, as well as its ability to prioritize investigations and identify appropriate treatments. Recent publications have been published on upper gastrointestinal haemorrhage, elbow fracture or brain haemorrhage, to optimize and standardize the investigations. In parallel, conditions such as cardiopulmonary arrest, spontaneous pneumothorax or stroke, benefit from recent therapeutic advances. However, emergency physicians and primary care physicians must remain critical of the numerous medical publications, as evidenced by the contradictory results concerning the interaction between proton pump inhibitors and clopidogrel.

[Viral infections as a cause of chronic obstructive pulmonary disease (COPD) exacerbation]. / Infections virales à l'origine des exacerbations de la broncho-pneumopathie chronique obstructive.

COPD is a progressive disease whom course is characterized by repeated exacerbations, with a negative impact on quality of life and health costs. Although a causal link between the identification of viruses in the upper respiratory tract and exacerbation is not definitively established, there is growing evidence that viruses are important triggers of exacerbations in more than 50 percent of cases. Yet, neither clinical presentation nor biological markers permit to discriminate between viral and non viral exacerbations.

[How urgent is it to decrease high blood pressure?]. / Abaisser la pression artérielle: urgent ou pas urgent?

Severe hypertension represents a frequent problem for the general practitioner. One has to decide if the blood pressure needs to be decreased immediately (hypertensive emergency), or if the blood pressure maybe progressively decreased in a few hours and normalized in a few days (hypertensive crisis). Thus it is crucial to identify on the basis of the clinical history and a careful physical examination, the patients for whom the arterial blood pressure elevation represents an acute danger for organ damage or a vital threat in the absence of immediate blood pressure control. In the case of hypertensive crisis, oral medication is usually sufficient (slow release or GITS nifedipine, nitroglycerin, labetalol, captopril). The hypertensive emergency sometimes requires an oral medication before the admission to the emergency room, then followed by intravenous drug administration (sodium nitroprussiate, nitroglycerin, labetalol).

[Vertigo: it all revolves around the physical exam]. / Vertiges: tout tourne-t-il autour de la clinique?

Dizziness is a common complaint in an emergency department. True vertigo, characterized by subjective sensation of rotation of the subject or of objects around the subject, may be peripheral (85%) or central (15%). Patient's history and physical exam identify the etiology of vertigo in more than 70% of patients. Hallpike test is easily performed and crucial for the diagnosis of benign paroxysmal peripheral vertigo. Central vertigo should be suspected and brain imaging performed in the presence of neurological symptoms, in older patients, or when several risk factors for cerebrovascular disease are present.

[Headache: physical exam or CT?]. / Céphalées: clinique ou imagerie ?

The life time prevalence of headache is more than 90% in the general population. The majority of patients presenting to physicians suffer from migraine. A simple clinical predictive score based on five questions will allow clinicians to confirm this diagnosis and will prevent further investigations. In all other circumstances, evidence is not sufficient to develop prediction rules to exclude secondary headache. However, neuroimaging should be performed in patients with a unexplained abnormal finding on the neurological examination.

[Impact of urinary incontinence in community-dwelling women]. / Incontinence urinaire en pratique ambutatoire: impact sur ta qualité de vie des femmes.

Urinary incontinence (UI) is a frequent problem in an aging population and prevalence of urinary incontinence for elderly women may be up to 50% and imposes a huge burden on the health care system comparable to osteoporosis or osteoarthritis. The impact of UI shows clear associations between UI and depression and decline of quality of life comparable to congestive heart failure, major respiratory condition or gastrointestinal tract conditions. Some limited data suggest that UI is also a risk factor for institutionalization and hospitalization. Despite effective treatments, UI is significantly underdiagnosed by clinicians, and underreported by patients. This results in unmet needs for incontinence treatment, in particular for older individuals.

[Lake Geneva Region guidelines on management of adult asthma]. / Recommandations suisses romandes sur la prise en charge de l'asthme de l'adulte.

Asthma is a major cause of chronic morbidity throughout the world. In Switzerland, 6.9% of the adult population is suffering from asthma. The standards of treatment are unfortunately not met in most western countries, as well as in Switzerland. We put forward a complete guideline on management of adult asthma, inspired from GINA and BTS guidelines, and adapted to the specific needs of general practitioners working in french part of Switzerland. This guideline reflects a consensus between allergy, lung and emergency specialists, working in the 2 university hospitals of the Lake Geneva Region (HUG and CHUV).