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Background: Little is known about the impact of hospital trajectory on survival and functional decline of older critically ill patients. We evaluate 6-month outcomes after admission to: intensive care units (ICU), intermediate care units (IMCU) or acute medical wards (AMW)., Methods: Data from the randomised prospective multicentre clinical trial ICE-CUB2 was secondarily analysed. Inclusion criteria were: presenting at emergency departments in critical condition; age ≥ 75 years; activity of daily living (ADL) ≥ 4; preserved nutritional status; and no active cancer. A Cox model was fitted to compare survival according to admission destination adjusting for patient characteristics. Sensitivity analysis using multiple imputation for missing data and propensity score matching were performed., Results: Among 3036 patients, 1675 (55%) were women; median age was 85 [81-99] years; simplified acute physiology score (SAPS-3) 62 [55-69]; 1448 (47%) were hospitalised in an ICU, 504 in IMCU (17%), and 1084 (36%) in AMW. Six-month mortality was 629 (44%), 155 (31%) and 489 (45%) after admission in an ICU, IMCU and AMW (p < 0.001), respectively. In multivariate analysis, AMW admission was associated with worse 6-month survival (HR 1.31, 95% CI 1.04-1.63) in comparison with IMCU admission, after adjusting for age, gender, comorbidities, ADL, SAPS-3 and diagnosis. Survival was not significantly different between patients admitted in an ICU and an IMCU (HR 1.17, 95% CI 0.95-1.46). Sensitivity analysis using multiple imputation for missing data and propensity score matching found similar results. Hospital destination was not significantly associated with the composite criterion loss of 1-point ADL or mortality. Physical and mental components of the 12-Item Short-Form Health Survey were significantly lower in the acute medical ward group (34.3 [27.5-41.7], p = 0.037 and 44.3 [38.6-48.6], p = 0.028, respectively) than in the ICU group (34.7 [28.4-45.3] and 45.5 [40.0-50.0], respectively) and IMCU group (35.7 [29.7-43.8] and 44.5 [39.7-48.4], respectively)., Conclusions: Admission in an AMW was associated with worse 6-month survival in older critically ill patients in comparison with IMCU admission, with no difference of survival between ICU and IMCU admission. There were no clinically relevant differences in quality of life in each group. These results should be confirmed in specific studies and raise the question of dedicated geriatric IMCUs., (© 2022. The Author(s).)

Background: The first COVID-19 wave started in February 2020 in France. The influx of patients requiring emergency care and high-level technicity led healthcare professionals to fear saturation of available care. In that context, the multidisciplinary E thics- S upport C ell (EST) was created to help medical teams consider the decisions that could potentially be sources of ethical dilemmas., Objectives: The primary objective was to prospectively collect information on requests for EST assistance from 23 March to 9 May 2020. The secondary aim was to describe the Cell's functions during that period., Research Design: This observational, real-time study of requests for Cell consultations concerned ethical dilemmas arising during a public health crisis. The EST created a grid to collect relevant information (clinical, patient's/designated representative's preferences and ethical principles strained by the situation), thereby assuring that each EST asked the same questions, in the same order., Participants and Research Context: Only our university hospital's clinicians could request EST intervention., Ethical Considerations: The hospital Research Ethics Committee approved this study (no. CER-2020-107). The patient, his/her family, or designated representative was informed of this ethics consultation and most met with EST members, which enabled them to express their preferences and/or opposition., Findings/results: 33 requests (patients' mean age: 80.8 years; 29 had COVID-19: 24 with dyspnea, 30 with comorbidities). 17 Emergency Department solicitations concerned ICU admission, without reference to resource constraints; others addressed therapeutic proportionality dilemmas., Discussion: Intervention-request motives concerned limited resources and treatment intensity. Management revolved around three axes: the treatment option most appropriate for the patient, the feasibility of implementation, and dignified care for the patient., Conclusions: COVID-19 crisis forced hospitals to envisage prioritization of ICU access. Established decision-making criteria and protocols do not enable healthcare professionals to escape ethical dilemmas. That acknowledgement highlights ethical risks, enhances the added-value of nursing and encourages all players to be vigilant to pursue collective deliberations to achieve clear and transparent decisions.

Objective: Hemorrhage is the leading cause of death after terrorist attack, and the immediacy of labile blood product (LBP) administration has a decisive impact on patients' outcome. The main objective of this study was to evaluate the transfusion patterns of the Paris terrorist attack victims, November 13, 2015., Methods: We performed a retrospective analysis including all casualties admitted to hospital, aiming to describe the transfusion patterns from admission to the first week after the attack., Results: Sixty-eight of 337 admitted patients were transfused. More than three quarters of blood products were consumed in the initial phase (until November 14, 11:59 PM), where 282 packed red blood cell (pRBC) units were transfused along with 201 plasma and 25 platelet units, to 55 patients (16% of casualties). Almost 40% of these LBPs (134 pRBC, 73 plasma, 8 platelet units) were transfused within the first 6 hours after the attack. These early transfusions were massive transfusion (MT) for 20 (6%) of 337 patients, and the average plasma/red blood cell ratio was 0.8 for MT patients who received 366 (72%) of 508 LBPs.The median time from admission to pRBC transfusion was 57 (25-108) minutes and 208 (52-430) minutes for MT and non-MT patients, respectively. These same time intervals were 119 (66-202) minutes and 222 (87-381) minutes for plasma and 225 (131-289) minutes and 198 (167-230) minutes for platelets., Conclusion: Our data suggest that improving transfusion procedures in mass casualty setting should rely more on shortening the time to bring LBP to the bedside than in increasing the stockpile., Level of Evidence: Epidemiological study, Therapeutic IV.

SARS-CoV-2 has caused a global pandemic unprecedented in size, spread, severity, and mortality. The influx of patients with severe or life-threatening disease means that in some cases, the available medical resources are not sufficient to meet the needs of all patients. Hence, healthcare providers may be forced to make difficult choices about which patients should be referred to the ICU. This document is intended to provide conceptual support to all healthcare teams currently engaged in the frontline management of the COVID-19 pandemic. It aims to assist physicians in the decision-making process for ICU admission and to help them provide uninterrupted and high-quality care.

Purpose: The majority of terrorist acts are carried out by explosion or shooting. The objective of this study was first, to describe the management implemented to treat a large number of casualties and their flow together with the injuries observed, and second, to compare these resources according to the mechanism of trauma., Methods: This retrospective cohort study collected medical data from all casualties of the attacks on November 13th 2015 in Paris, France, with physical injuries, who arrived alive at any hospital within the first 24 h after the events. Casualties were divided into two groups: explosion injuries and gunshot wounds., Results: 337 casualties were admitted to hospital, 286 (85%) from gunshot wounds and 51 (15%) from explosions. Gunshot casualties had more severe injuries and required more in-hospital resources than explosion casualties. Emergency surgery was required in 181 (54%) casualties and was more frequent for gunshot wounds than explosion injuries (57% vs. 35%, p < 0·01). The types of main surgery needed and their delay following hospital admission were as follows: orthopedic [n = 107 (57%); median 744 min]; general [n = 27 (15%); 90 min]; vascular [n = 19 (10%); median 53 min]; thoracic [n = 19 (10%); 646 min]; and neurosurgery [n = 4 (2%); 198 min]., Conclusion: The resources required to deal with a terrorist attack vary according to the mechanism of trauma. Our study provides a template to estimate the proportion of various types of surgical resources needed overall, as well as their time frame in a terrorist multisite and multitype attack., Funding: Assistance Publique-Hôpitaux de Paris.

Introduction: This study protocol describes a trial designed to investigate whether antihistamine alone in patients with acute urticaria does not increase the 7-day Urticaria Activity Score (UAS7) in comparison with an association of antihistamine and glucocorticoids and reduces short-term relapses and chronic-induced urticaria., Methods and Analysis: This is a prospective, double-blind, parallel-group, multicentre non-inferiority randomised controlled trial. Two-hundred and forty patients with acute urticaria admitted to emergency department will be randomised in a 1:1 ratio to receive levocetirizine or an association of levocetirizine and prednisone. Randomisation will be stratified by centre. The primary outcome will be the UAS7 at day 7. The secondary outcomes will encompass recurrence of hives and/or itch at day 7; occurrence of spontaneous hives or itch for >6 weeks; patients with angioedema at day 7, and 2, 6, 12 and 24 weeks; new emergency visits for acute urticaria recurrences at days 7 and 14, and 3 months; Dermatology Life Quality Index at days 7 and 14, and 3 and 6 months; and Chronic Urticaria Quality of Life Questionnaire at 6 weeks., Ethics and Dissemination: The protocol has been approved by the Comité de Protection des Personnes Sud-Méditerranée II and will be carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. A steering committee will oversee the progress of the study. Findings will be disseminated through national and international scientific conferences and publication in peer-reviewed journals., Trial Registration Number: NCT03545464., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Life threatening complications can occur at any stage of cirrhosis progression. There are few studies on the prognosis of cirrhotic patients managed in an Emergency Department (ED) although management of patients will occur in the ED. The objective of our study was to determine the risk factors for mortality in cirrhotic patients who visited to the ED., Methods: All cirrhotic patients attending ED in three different university hospitals of Assistance Publique - Hôpitaux de Paris between January 2014 and June 2015 were identified by a retrospective analysis of digital records and included in the study. The primary end-point was 30-day mortality in all cirrhotic patients who visited the ED., Results: A total of 609 ED visits were analyzed among 224 patients: 115 (51%) presented a cirrhosis of alcoholic origin, 43 (19%) were caused by Hepatitis C, 28 (13%) of mixed origin (viral and alcoholic), 17 (8%) were caused by Hepatitis B and 21 (9%) of other origins. Fifty-five (25%) of these patients died within 30 days of their initial presentation to the ED. In multivariate analysis, the age (Odds Ratio: 1.04 [1.01-1.07]), cirrhosis associated with hepatocellular carcinoma (OR: 3.07 [1.37-6.91]), serum creatinine at admission (OR: 1.01 [1.01-1.02]), serum bilirubin at admission (OR: 1.01 [1.01-1.02]) and health impairment (OR: 2.57 [1.28-5.16]) were associated with mortality., Conclusions: The mortality rate of cirrhotic patients attending an ED was high. The prognosis of cirrhotic patients admitted to the ED depended on the severity of the liver and other organ dysfunction. The presence of a hepatocellular carcinoma on admission was also a risk factor for death., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Some studies have demonstrated an association between poor continuity of care, high likelihood of 'inappropriate' use of emergency departments (EDs) and avoidable hospitalization. However, we lack data concerning primary care use after an ED visit., Objective: Identify the determinants of a visit to the general practitioner (GP) after an ED visit.Methods., Design: Observational study (single-centre cohort)., Setting: One emergency department in Paris, France., Subjects: All adult patients who presented at the ED and were discharged., Main Outcome Measure: We collected data by the use of a standardized questionnaire, patients' medical records and a telephonic follow-up. Descriptive analyses were performed to compare individuals with and without a GP. Then, for those with a GP, multivariate logistic regression was used to identify the determinants of the GP consultation., Results: We included 243 patients (mean age 45 years [±19]); 211 (87%) reported having a GP. Among those who reported having a GP, 52% had consulted their GP after the ED visit. Not having a GP was associated with young age, not having complementary health insurance coverage, and being single. GP consultation was associated with increasing age [adjusted odds ratios (aOR) = 1.03], poor self-reported health status (aOR = 2.25), medical complaints versus traumatic injuries (aOR = 2.24) and prescription for sick note (aOR = 5.74)., Conclusion: Not having a GP was associated with factors of social vulnerability such as not having complementary health insurance coverage. For patients with a GP, consultation in the month after an ED visit seems appropriate, because it was associated with poor health status and medical complaints., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Interest in ultrasonography in emergency medicine has increased in recent years, as reflected by a marked increase in publications on the topic. The aim of this study was to 1) describe and evaluate methodological characteristics of randomized controlled trials (RCTs) evaluating an ultrasound intervention in emergency department and 2) estimate whether the reports adequately described the intervention to allow replication., Methods: We searched MEDLINE via PubMed for RCTs published in 2015 assessing an ultrasound intervention, regardless of type, that were performed in an emergency department or evaluated in an emergency situation. Two researchers independently screened titles, abstracts and full texts. Data from all included studies were independently extracted. The Cochrane Collaboration Risk of Bias tool was used to assess risk of bias of reports, and the intervention reporting was evaluated by using the Template for Intervention Description and Replication checklist., Results: We identified 11 reports. The most frequent topic was vascular access/identification (n = 4). Random sequence generation and allocation concealment were performed correctly in 55% and 27% trials. Three quarters of reports (73%) showed improper reporting or absence of participant blinding. Risk of bias due to assessor blinding was rated low for 3 RCTs (27%), risk of attrition bias low for all reports, and risk of selective outcome reporting unclear for most reports (n = 10). Only 3 reports (27%) provided an optimal description of the intervention., Conclusion: The quality of these trials raises questions. In our sample, the authors did not correctly report blinding of participants and assessors or allocation concealment., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The objective of this study was to characterize retracted publications in emergency medicine. We searched MEDLINE, Web of Science and Cochrane Central Register of Controlled Trials to identify all retracted publications in the field of emergency medicine. We also searched an independent website that reports and archives retracted scientific publications. Two researchers independently screened titles, abstracts and full text of search results. Data from all included studies were then independently extracted. We identified 28 retraction notes. Eleven (39%) articles were published by authors from Europe. The oldest retracted article was published in 2001. The 28 retracted papers were published by 22 different journals. Two authors were named on multiples retractions. The median impact factor of journals was 1.03 (0.6-1.9). Almost all studies were available online [26/28 (93%)], but only 40% had watermarking on the article. The retraction notification was available for all articles. Three (11%) retraction notices did not clearly report the retraction reasons, and most retraction notices were issued by the editors [14 (56%)]. The most frequent retraction reasons were plagiarism [eight (29%)], duplicate publication [three (11%)] and overlap [two (2%)]. Retracted articles were cited on average 14 times. In most cases, the retraction cause did not invalidate the study's results [17 (60%)]. The most common reason for retraction was related to a misconduct by the authors. These results can question the necessity to normalize retraction procedures among the large number of biomedical editors and to educate future researchers on research integrity.

Study Objective: This study compares the effectiveness and cost-effectiveness of nurse-driven targeted HIV screening alongside physician-directed diagnostic testing (intervention strategy) with diagnostic testing alone (control strategy) in 8 emergency departments., Methods: In this cluster-randomized, 2-period, crossover trial, 18- to 64-year-old patients presenting for reasons other than potential exposure to HIV were included. The strategy applied first was randomly assigned. During both periods, diagnostic testing was prescribed by physicians following usual care. During the intervention periods, patients were asked to complete a self-administered questionnaire. According to their answers, the triage nurse suggested performing a rapid test to patients belonging to a high-risk group. The primary outcome was the proportion of new diagnoses among included patients, which further refers to effectiveness. A secondary outcome was the intervention's incremental cost (health care system perspective) per additional diagnosis., Results: During the intervention periods, 74,161 patients were included, 16,468 completed the questionnaire, 4,341 belonged to high-risk groups, and 2,818 were tested by nurses, yielding 13 new diagnoses. Combined with 9 diagnoses confirmed through 97 diagnostic tests, 22 new diagnoses were established. During the control periods, 74,166 patients were included, 92 were tested, and 6 received a new diagnosis. The proportion of new diagnoses among included patients was higher during the intervention than in the control periods (3.0 per 10,000 versus 0.8 per 10,000; difference 2.2 per 10,000, 95% CI 1.3 to 3.6; relative risk 3.7, 95% CI 1.4 to 9.8). The incremental cost was €1,324 per additional new diagnosis., Conclusion: The combined strategy of targeted screening and diagnostic testing was effective., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

The number of trials assessing Simulation-Based Medical Education (SBME) interventions has rapidly expanded. Many studies show that potential flaws in design, conduct and reporting of randomized controlled trials (RCTs) can bias their results. We conducted a methodological review of RCTs assessing a SBME in Emergency Medicine (EM) and examined their methodological characteristics. We searched MEDLINE via PubMed for RCT that assessed a simulation intervention in EM, published in 6 general and internal medicine and in the top 10 EM journals. The Cochrane Collaboration risk of Bias tool was used to assess risk of bias, intervention reporting was evaluated based on the "template for intervention description and replication" checklist, and methodological quality was evaluated by the Medical Education Research Study Quality Instrument. Reports selection and data extraction was done by 2 independents researchers. From 1394 RCTs screened, 68 trials assessed a SBME intervention. They represent one quarter of our sample. Cardiopulmonary resuscitation (CPR) is the most frequent topic (81%). Random sequence generation and allocation concealment were performed correctly in 66 and 49% of trials. Blinding of participants and assessors was performed correctly in 19 and 68%. Risk of attrition bias was low in three-quarters of the studies (n = 51). Risk of selective reporting bias was unclear in nearly all studies. The mean MERQSI score was of 13.4/18.4% of the reports provided a description allowing the intervention replication. Trials assessing simulation represent one quarter of RCTs in EM. Their quality remains unclear, and reproducing the interventions appears challenging due to reporting issues.

Importance: The high mortality rate in critically ill elderly patients has led to questioning of the beneficial effect of intensive care unit (ICU) admission and to a variable ICU use among this population., Objective: To determine whether a recommendation for systematic ICU admission in critically ill elderly patients reduces 6-month mortality compared with usual practice., Design, Setting, and Participants: Multicenter, cluster-randomized clinical trial of 3037 critically ill patients aged 75 years or older, free of cancer, with preserved functional status (Index of Independence in Activities of Daily Living ≥4) and nutritional status (absence of cachexia) who arrived at the emergency department of one of 24 hospitals in France between January 2012 and April 2015 and were followed up until November 2015., Interventions: Centers were randomly assigned either to use a program to promote systematic ICU admission of patients (n=1519 participants) or to follow standard practice (n=1518 participants)., Main Outcomes and Measures: The primary outcome was death at 6 months. Secondary outcomes included ICU admission rate, in-hospital death, functional status, and quality of life (12-Item Short Form Health Survey, ranging from 0 to 100, with higher score representing better self-reported health) at 6 months., Results: One patient withdrew consent, leaving 3036 patients included in the trial (median age, 85 [interquartile range, 81-89] years; 1361 [45%] men). Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%; relative risk [RR], 1.16; 95% CI, 1.07-1.26) despite an increased ICU admission rate (61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95). After adjustments for baseline characteristics, patients in the systematic strategy group were more likely to be admitted to an ICU (RR, 1.68; 95% CI, 1.54-1.82) and had a higher risk of in-hospital death (RR, 1.18; 95% CI, 1.03-1.33) but had no significant increase in risk of death at 6 months (RR, 1.05; 95% CI, 0.96-1.14). Functional status and physical quality of life at 6 months were not significantly different between groups., Conclusions and Relevance: Among critically ill elderly patients in France, a program to promote systematic ICU admission increased ICU use but did not reduce 6-month mortality. Additional research is needed to understand the decision to admit elderly patients to the ICU., Trial Registration: clinicaltrials.gov Identifier: NCT01508819.

Pain in children is underestimated and undertreated because of lack of pain assessment tools. Pain assessment depends on the cognitive development of the child being tested, clinical context, and pain typology. For children older than age 6 years, pain assessment is based on a self-report. For children younger than age 6 years, behavioral pain scales are needed to assess pain. Numerous pain scales exist. Many are reliable and some are recommended, but all have specific conditions for their use. In this article, we review the available pain scales for children from birth to adolescence. We provide the validity criteria of each pain scale to help caregivers use the adapted tools. We then propose a synthesis of the reliable tools to use based on the pain context. [Pediatr Ann. 2017;46(10):e387-e395.]., (Copyright 2017, SLACK Incorporated.)

Background: Upper gastrointestinal bleeding (UGB) is common in emergency departments (EDs) and can be caused by many eso-gastro-duodenal lesions. Most available epidemiological data and data on the management of UGB comes from specialized departments (intensive care units or gastroenterology departments), but little is known from the ED perspective. We aimed to determine the distribution of symptoms revealing UGB in EDs and the hemorrhagic lesions identified by endoscopy. We also describe the characteristics of patients consulting for UGB, UGB management in the ED and patients outcomes., Method: This was a prospective, observational, multicenter study covering 4 consecutive days in November 2013. Participating EDs were part of the Initiatives de Recherche aux Urgences network coordinated by the French Society of Emergency Medicine. All patients with suspected UGB in these EDs were included., Results: In total, 110 EDs participated, including 194 patients with suspected UGB (median age 66 years [Q1-Q3: 51-81]). Overall, 104 patients (54%) had hematemesis and 75 (39%) melena. Endoscopy revealed lesions in 121 patients, mainly gastroduodenal ulcer or ulcerations (41%) or bleeding lesions due to portal hypertension (20%). The final diagnosis of UGB was reversed by endoscopy in only 3% of cases. Overall, 67 patients (35%) had at least one severity sign. Twenty-one patients died (11%); 40 (21%) were hospitalized in intensive care units and 126 (65%) in medicine departments; 28 (14%) were outpatients. Mortality was higher among patients with clinical and biological severity signs., Conclusion: Most of the UGB cases in EDs are revealed by hematemesis. The emergency physician diagnosis of UGB is rarely challenged by the endoscopic findings.

The aim of the present study was to investigate the epidemiological characteristics of blood or fluid exposure (BFE) and occupational infection risk among emergency medicine (EM) residents and young physicians (<35 years old) in France. We led a cross-sectional, anonymous, online survey. 1779 participants were contacted with a response rate of 36 % (n = 633). Among the respondents, 459 (72 %) reported at least one BFE. Among participants with at least one BFE, 35 % (n = 163) never reported the exposure to the relevant medical authorities or support. Among participants who reported exposure, 63 % (n = 232) did it immediately. Among participants who never or not systematically reported their BFE, most of them (62 %, n = 181/289) did not do so because the procedure was too long, and 28 % (n = 82/289) estimated the risk as low even if only one-third (n = 166/458) checked their HIV status even though the BFE was at a transmission risk. Circumstances in which the participants had the most BFE were: suturing 57 % (n = 262/457) and when making precipitated gestures 24 % (n = 111/457). The latest exposures were caused by a solid needle in 42 % (n = 191/455) or hollow-bore needle in 27 % (n = 123/455). Post-exposure reporting rates were low. Reporting procedure itself and self-management were the main reasons for BFE underreporting. Simplifying procedures might increase BFE reporting, and allow appropriate post-exposure counseling and/or prophylaxis.

Background: The benefit of ICU admission for elderly patients remains controversial. This report highlights the methodology, the feasibility of and the ethical and logistical constraints in designing and conducting a cluster-randomized trial of intensive care unit (ICU) admission for critically ill elderly patients., Methods: We designed an interventional open-label cluster-randomized controlled trial in 24 centres in France. Clusters were healthcare centres with at least one emergency department (ED) and one ICU. Healthcare centres were randomly assigned either to recommend a systematic ICU admission (intervention group) or to follow standard practices regarding ICU admission (control group). Clusters were stratified by the number of ED annual visits (<44,616 or >44,616 visits), the presence or absence of a geriatric ward and the geographical area (Paris area vs other regions in France). All elderly patients (≥75 years of age) who got to the ED were assessed for eligibility. Patients were included if they had one of the pre-established critical conditions, a preserved functional status as assessed by an ADL scale ≥4 (0 = very dependent, 6 = independent), a preserved nutritional status (subjectively assessed by physicians) and without active cancer. Exclusion criteria were an ED stay >24 h, a secondary referral to the ED and refusal to participate. The primary outcome was the mortality at 6 months calculated at the individual patient level. Secondary outcomes were ICU and hospital mortality, as well as ADL scale and quality of life (as assessed by the SF-12 Health Survey) at 6 months., Results: Between January 2012 and April 2015, 3036 patients were included in the trial, 1518 patients in 11 clusters allocated to intervention group and 1518 patients in 13 clusters allocated to standard care. There were 51 protocol violations., Conclusions: The ICE-CUB 2 trial was deemed feasible and ethically acceptable. The ICE-CUB 2 trial will be the first cluster-randomized trial to assess the benefits of ICU admission for selected elderly patients on long-term mortality. Trial registration Clinical trials.gov identifier: NCT01508819.

Objectives: Hospital at home (HAH) care is becoming increasingly popular in France and requires the involvement of general practitioners (GPs) in the care of their patients. The objective of this study was to identify the incentives and barriers to the involvement of general practitioners in HAH. Materials and methods: A qualitative study was carried out using semi-structured interviews during a focus group with 12 GPs. All interviews were recorded and then transcribed verbatim and data analysis used the grounded theory method. Results: General practitioners appeared to be familiar with the indications and places of care for HAH, but they highlighted the difficulties associated with the HAH request circuit. GPs identified difficulties determining their exact role in HAH, which were improved by their clinical expertise in home visits. Doctors stressed the complexity of home care, but they were assisted by the coordinating physician and they requested specific training. Conclusion: We identified incentives and barriers to the participation of GPs in HAH. The request circuit needs to be simplified, home visits need to be strengthened and support must be provided to GPs in their management of complex care.

Prior to traveling, and when seeking medical pretravel advice, patients consult their personal physicians. Inflight medical issues are estimated to occur up to 350 times per day worldwide (1/14,000-40,000 passengers). Specific characteristics of the air cabin environment are associated with hypoxia and the expansion of trapped gases into body cavities, which can lead to harm. The most frequent medical events during air travel include abdominal pain; ear, nose, and throat pathologies; psychiatric disorders; and life-threatening events such as acute respiratory failure or cardiac arrest. Physicians need to be aware of the management of these conditions in this unusual setting. Chronic respiratory and cardiovascular diseases are common and are at increased risk of acute exacerbation. Physicians must be trained in these conditions and inform their patients about their prevention., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Emergency medicine (EM) has been a fellowship program (supra-specialty) in France since 2004. Even though the program can be accessed after completion of one of several primary specialties, the vast majority (97%) of its residents enter the program after having completed training in family medicine. A change to develop a primary EM specialty is being discussed. Our objective was to assess French residents and young EM physicians' attitudes toward EM as a primary specialty. We conducted a brief cross-sectional online survey among young EM physicians and trainees in November and December 2012. There were 288 respondents to the survey. Forty-nine percent (n=142) of respondents would have chosen EM if it was a primary specialty, but 73% (n=209) prefer maintaining the status quo, offering EM training as a supra-specialty fellowship program. Work-related quality of life was the main reason for those not choosing EM as a primary specialty.

Objectives: The length of stay in the emergency department (ED) has been proposed as an indicator of performance in many countries. We conducted a survey of length of stay in two large areas in France and tested the hypothesis that patient and ED-related variables may influence it., Patients and Methods: During 2007, we examined lengths of stay in ambulatory patients, that is, excluding admitted patients. The following variables were considered: (a) at the patient level, age, sex, the day and month of the visit, and the French clinical classification of emergency patients (CCEP) class; (b) at the ED level, annual ED total number of visits, mean age, the proportions of patients less than 15 and more than 75 years, and the proportions of admitted and clinically stable patients with CCEP class 1 and 2. A multilevel hierarchical analysis was carried out., Results: We analyzed 988 591 visits in 53 EDs. The ED-specific median length of stay was 98 (IQR: 62-137) min and the ED-specific median proportion of patients with length of stay of more than 4 h was 15 (5-24) %. There was a strong correlation between the ED-specific median length of stay and the ED-specific proportion of patients with a length of stay of more than 4 h (R=0.96, P<0.001). Using a multilevel analysis, only three variables were associated significantly with the length of stay: the age and the CCEP class of the patient, and the ED census., Conclusion: We observed that the length of stay in the ED needs to be stratified by case mix and the total number of visits of the ED.

Emergency departments use has been constantly increasing over the world. Overcrowding is defined as a situation which compromises patient safety because of delayed cares. This situation is often reached. Emergency departments have to continuously improve their organization to be able to ensure the same quality of care to a higher number of patients. Thus a good organization is essential: it doesn't always avoid overcrowding. The rest of the hospital has to be involved in this process to ensure efficiency. We examine the various interventions and procedures that can be found in medical literature for improving patients flow and management in emergency departments.

Study Objectives: The Pulmonary Embolism Rule-out Criteria (PERC) score has shown excellent negative predictive value; however, its use in the European population with high prevalence of PE is controversial. In Europe, PERC is not part of routine practice. For low-risk patients, guidelines recommend D-dimer testing, followed if positive by imaging study. We aimed to study the rate of diagnosis of PE after D-dimer testing in PERC-negative patients that could have been discharged if PERC was applied., Method: This was a multicenter retrospective study in Paris, France. We included all patients with a suspicion of PE who had D-dimer testing in the emergency department, low pre-test probability, and a negative PERC score (that was retrospectively calculated). Patients with insufficient record to calculate PERC score were excluded. The primary end point was the rate of PE diagnosis before discharge in this population. Secondary end points included rate of invasive imaging studies and subsequent adverse events., Results: We screened 4301 patients who had D-dimer testing, 1070 of whom were PERC negative and could be analyzed. The mean age was 35 years and 46% were men. D-dimer was positive (>500 ng/L) in 167 (16%) of them; CTPA or V/Q scan was performed in 153 (14%) cases. PE was confirmed in 5 cases (total rate 0.5%, 95% confidence interval 0.1%-1.1%). Fifteen patients (1%) experienced non-severe adverse events., Conclusion: D-dimer testing in PERC-negative patients led to a diagnosis of PE in 0.5% of them, with 15% of patients undergoing unnecessary irradiative imaging studies., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: To identify the diseases that are associated with a high plasma concentration of vitamin B12 and to measure the strength of this association., Patients and Methods: Retrospective study including all admissions between 1st May, 2005 and 30th April, 2008 in the UMAG pole departments (emergency, internal medicine, acute geriatrics and medical intensive care) with a test for plasma vitamin B12. The association between each of medical information system codes (solid tumors, malignant hematologic process, and renal disease) and a high or low vitamin B12 concentration was measured by odds ratios (OR) from logistic models taking into account repeated admissions, with adjustment for age and the weighted Charlson index., Results: Among 3702 admissions, 12% had a B12 more than 820pg/ml, 10.4% a B12 less than 180pg/ml and 77.6% a normal B12 concentration. After adjustment for age and the weighted Charlson index, high concentration of vitamin B12 was associated with interstitial renal diseases (OR 2.7; 95% CI: [1.7-4.2]), and cirrhosis or hepatitis (OR 4.3; [2.9-6.4]). After additional adjustment for these parameters, it was still associated with tumors (OR 1.8; [1.2-2.6]), malignant hematologic diseases (OR 2.1; [1.3-3.5]), metastasis (OR 2.9; [1.5-5.9]), liver metastasis (OR 6.2; [2.7-14.5]), liver carcinoma (LC) (OR 3.3; [1.1-10.4]), liver tumors other than LC (OR 4.7; [1.2-17.9]) and lymphoma (OR 3.2; [1.6-6.4]) but not with myeloma (OR 1.9; [0.6-1.4]). Low concentration of B12 was associated with myeloma (OR 2.9; [1.3-6.6])., Conclusion: Finding a high plasma concentration of vitamin B12 should lead to a systematic search for a hepatic disease or a tumor, and particularly for a hepatic localization of a tumor., (Copyright © 2012 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Objective: We assessed the EDs' characteristics associated with the offer and acceptance rates of a nontargeted HIV rapid-test screening in 29 Emergency Departments (EDs) in the metropolitan Paris region (11.7 million inhabitants), where half of France's new HIV cases are diagnosed annually., Methods: EDs nurses offered testing to all patients 18-64-year-old, able to provide consent, either with or without supplemental staff (hybrid staff model or indigenous staff model). The EDS' characteristics collected included structural characteristics (location, type, size), daily workload (patients' number and severity, length of stay in hours), staff's participation (training, support to the intervention, leadership), type of week day (weekends vs weekdays) and time (in days). Associations between these variables and the staff model, the offer and acceptance rates were studied using multilevel modeling., Results: Indigenous staff model was more frequent in EDs with a lower daily patient flow and a higher staff support score to the intervention. In indigenous-model EDs, the offer rate was associated with the patient flow (OR = 0.838, 95% CI = 0.773-0.908), was lower during weekends (OR = 0.623, 95% CI = 0.581-0.667) and decreased over time (OR = 0.978, 95% CI = 0.975-0.981). Similar results were found in hybrid-model EDs. Acceptance was poorly associated with EDs characteristics in indigenous-model EDs while in hybrid-model EDs it was lower during weekends (OR = 0.713, 95% CI = 0.623-0.816) and increased after the first positive test (OR = 1.526, 95% CI = 1.142-2.038). The EDs' characteristics explained respectively 38.5% and 15% of the total variance in the offer rate across indigenous model-EDs and hybrid model-EDs vs 12% and 1% for the acceptance rate., Conclusion: Our findings suggest the need for taking into account EDs' characteristics while considering the implementation of an ED-based HIV screening program. Strategies allowing the optimization of human resources' utilization such as HIV targeted screening in the EDs might be privileged.

Background: To lower the number of undiagnosed infections and to improve early detection, international health agencies have promoted nontargeted human immunodeficiency virus (HIV) screening in health care settings, including emergency departments (EDs). This strategy remains controversial and has yet to be tested on a large scale. We assessed the public health impact of nontargeted HIV-rapid test (RT) screening among ED patients in the metropolitan area of Paris (11.7 million inhabitants), where half of France's new HIV cases are diagnosed annually., Methods: During a randomly assigned 6-week period for each of the 29 participating EDs, 18- to 64-year-old patients who were able to provide consent for HIV testing were offered a fingerstick whole-blood HIV RT. Main outcome measures were the number of patients tested for HIV and their characteristics vs those of the general metropolitan Paris population and the proportion of newly diagnosed HIV-positive patients among those tested and their characteristics vs those from the national HIV case surveillance., Results: Among 138,691 visits, there were 78,411 eligible patients, 20,962 of whom (27.0%) were offered HIV RT; 13,229 (63.1%) accepted testing and 12,754 (16.3%) were tested. The ED patients' characteristics reflected the general population distribution. Eighteen patients received new HIV diagnoses (0.14%; 95% confidence interval, 0.08%-0.22%). Like national HIV case surveillance patients, they belonged to a high-risk group (n = 17), were previously tested (n = 12), and were either symptomatic or had a CD4 lymphocyte count lower than 350/μL, suggesting late-stage infections (n = 8); 12 patients were linked to care., Conclusions: Nontargeted HIV testing in EDs was feasible but identified only a few new HIV diagnoses, often at late stages, and, unexpectedly, most patients belonged to a high-risk group. Our findings do not support the implementation of nontargeted screening of the general population in EDs.

Unlabelled: Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83-91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear., Trial Registration: ClinicalTrials.gov NCT00912600.

Objective: To assess the sensitivity and specificity of emergency physicians in detecting anxiety and depression in patients requiring admission to the emergency department (ED) observation care unit for complementary investigations/treatment., Methods: 339 consecutive patients admitted to the emergency observation care unit of 14 EDs were interviewed with standardised questionnaires. The characteristics of the patients, EDs and attending ED physicians were collected. Patients' anxiety and depression were identified using the Hospital Anxiety and Depression Scale (HADS), a self-administered questionnaire. ED physicians were blind to the HADS score and were asked to declare whether they perceived anxiety and depression in each patient. The judgement of ED physicians and the HADS score were compared using sensitivity, specificity, positive and negative likelihood ratios., Results: The HADS questionnaire was correctly completed by 310 patients who comprised the study population. HADS detected symptoms of anxiety in 148 patients (47%) and symptoms of depression in 70 patients (23%). ED physicians determined the presence or absence of anxiety with a sensitivity of 48% (95% CI 40% to 56%) and a specificity of 69% (95% CI 61% to 75%). Positive and negative likelihood ratios were 1.54 (95% CI 1.16 to 2.06) and 0.75 (95% CI 1.28 to 3.28) for anxiety. They detected the presence or absence of depression with a sensitivity of 39% (95% CI 28% to 51%) and a specificity of 78% (95% CI 72% to 83%). Positive and negative likelihood ratios were 1.75 (95% CI 1.20 to 2.56) and 0.78 (95% CI 1.26 to 3.87) for depression., Conclusion: Although patients presenting to the ED often experience anxiety and depression, these symptoms are poorly detected by ED physicians.

Study Objective: The quality of endoscopy depends on the quality of upper gastrointestinal tract preparation. We determine whether in acute upper gastrointestinal bleeding the frequency of satisfactory stomach visualization was different after intravenous erythromycin, a nasogastric tube with gastric lavage, or both., Methods: We performed a prospective, randomized, multicenter (6 emergency departments) study in patients with acute upper gastrointestinal bleeding presenting with hematemesis or melena. The patients were randomized into 3 groups: (1) intravenous erythromycin infusion without nasogastric tube placement (erythromycin group), (2) nasogastric tube placement without erythromycin (nasogastric group), and (3) intravenous erythromycin infusion combined with nasogastric tube placement (nasogastric-erythromycin group). The main outcome measure was the proportion of satisfactory stomach visualization., Results: Two hundred fifty-three patients (181 men, mean age 61 years [SD 15 years], 84 with cirrhosis) were randomized: 84 (erythromycin group), 85 (nasogastric group), and 84 (nasogastric-erythromycin group). Overall, there was 85% satisfactory stomach visualization; between-group differences were not significant: -4% (95% confidence interval [CI] -15% to 6%) for the erythromycin group and nasogastric-erythromycin group, 2% (95% CI -14% to 9%) for the erythromycin group and nasogastric group, and -6.5% (95% CI -17% to 4%) for the nasogastric group and nasogastric-erythromycin group. The duration of the endoscopic procedure, rebleeding frequency, the need for a second endoscopy, the number of transfused blood units, and mortality at days 2, 7, and 30 did not differ significantly between groups., Conclusion: In acute upper gastrointestinal bleeding, administration of intravenous erythromycin provides satisfactory endoscopic conditions, without the need for a nasogastric tube and gastric lavage., (Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Objective: To describe intensive care unit referral decisions by emergency room physicians in patients aged > or =80 yrs., Design: Prospective, observational cohort study of patients aged > or =80 yrs who were triaged in the emergency room, using a list of intensive care unit admission criteria selected by emergency physicians among 76 preliminary criteria adapted from the 1999 Society of Critical Care Medicine guidelines. The Delphi method was used to select the criteria., Setting: Fifteen French hospitals., Patients: A total of 2646 patients aged > or =80 yrs with at least one criterion., Interventions: None., Measurements and Main Results: In the Delphi process, level of agreement was assessed as follows: when all answers fell within a single interval (7-9 = definite admission criteria; 4-6 = equivocal admission criteria or 1-3 = inappropriate admission), agreement was strong; when answers spanned two intervals, agreement was fair; and when answers spanned all three intervals, agreement was poor. Of the 76 preliminary criteria, two were removed; 44 were selected as definite intensive care unit admission criteria; and 30 were selected as equivocal intensive care unit admission criteria. Of the 1426 patients meeting definite admission criteria, 441 (30.9%) were referred for intensive care unit admission and 231 of 441 (52.4%) were admitted to the intensive care unit. Of the 1041 patients with equivocal admission criteria, 181 (17.3%) were referred for intensive care unit admission; and, of these, 79 (43.6%) were admitted to the intensive care unit. Factors associated independently with no intensive care unit referral were age odds ratio [OR], 1.04; 95% confidence interval [CI], 1.04-1.07), active cancer (OR, 1.61; 95% CI, 1.09-1.38), unknown hospitalization status (OR, 1.53; 95% CI, 1.11-2.11), unknown living arrangements (OR, 1.69; 95% CI, 1.19-2.42), regular psychotropic medications (OR, 1.42; 95% CI, 1.10-1.81), low severity at referral (OR, 0.60; 95% CI, 0.53-0.68), low activity in daily living score (OR, 0.93; 95% CI, 0.88-0.99)., Conclusions: Emergency and intensive care unit physicians were extremely reluctant to consider intensive care unit admission of patients aged > or =80 yrs, despite the presence of criteria indicating that intensive care unit admission was certainly or possibly appropriate.

Troponin (I or T) has become the gold-standard marker in acute coronary syndromes during the last few years, as confirmed by a national survey realized within french clinical chemists, cardiologists and emergency practitioners. The importance of this marker and the heterogeneousness of circulating forms of troponin after myocardial necrosis fully justify international studies about standardization of this assay, which is a central bulk to reach a global market coherence. Checking analytical problems, although necessary, must be absolutely associated with an informed clinical interpretation. The knowledge of the crucial thresholds of each assay, the kinetic curves and the specificity limits of troponin assays allow the best use of their potential in diagnosis and prognosis together with an optimal patient care in very different clinical settings, in addition to others clinical and technical arguments. The quality improvement through successive generations of assay kits must nowadays persuade the physicians never to ignore a significant and valid troponin increase, which mainly reveals a cardiac injury, whatever its origin.

Introduction: The "Collégiale des radiologistes" of the Paris public hospital system (Assistance Publique-Hôpitaux de Paris, AP-HP) has participated since 1998 in a collaborative quality improvement program for the 49 radiology departments. They work together with the AP-HP college of emergency physicians on one part of this program, which focuses on emergency radiologic work-ups. Analysis of the dysfunctions in this sector underlined the lack of agreement between clinicians and radiologists on the examinations required., Objective: The aim of this project was to establish operational and consensual guidelines for physicians, radiologists and emergency teams for the use of diagnostic radiology in emergency situations in adults., Method: The working group of radiologists and emergency physicians drafted this document, largely from documentary sources. A large panel of physicians validated the draft during successive review sessions, and the two colleges then approved them., Results: The guidelines are presented in 3 columns: clinical situations, quality aims (type of imaging, time within which the examination should be performed) and comments. The clinical situations were regrouped by anatomical area or system: head, neck, thorax, heart, gynecology, abdomen, urinary, non-traumatic bone and spine disorders, multiple trauma, and isolated trauma of the spine and limbs and of the head, trunk, abdomen, and pelvis., Conclusion: These guidelines based on consensus within the institution make it possible to harmonize the requests for and practices of radiologic examinations in emergency situations. Their implementation is an integral part of the ongoing development of operating agreements between the radiology and emergency departments.

Objectives: Little is known about the epidemiology of acute upper gastrointestinal haemorrhage hospitalized in Emergency Departments. Most of the studies concerning digestive bleeding have been carried out by Gastroenterology Departments. This multicentre study included consecutive patients with acute upper gastrointestinal haemorrhage hospitalized after an initial management at Emergency Departments in France, to describe the initial medical management and to determine the causes of acute upper gastrointestinal haemorrhage. We also studied the relationship between the use of non-steroidal anti-inflammatory drugs or aspirin and the occurrence of an acute upper gastrointestinal haemorrhage by a case-control comparison., Results: A total of 180 patients (112 men, 59+/-18 years) were included during 23 days, and 353 controls (222 men, 57+/-13 years) were selected at the same time. The delay between the first clinical signs of acute upper gastrointestinal haemorrhage and arrival at the Emergency Department was 33+/-42 h, and endoscopy was performed 14+/-16 h after admission to the Emergency Department. Sixty-six percent of patients with cirrhosis could benefit from a specific vasoactive treatment. Endoscopy was performed in 160 patients. Bleeding was caused by ulcers and gastritis in 88 patients (49%) and portal hypertension in 59 (32%). The relationship between the use of non-steroidal anti-inflammatory drugs or aspirin and acute upper gastrointestinal haemorrhage was confirmed, odds ratio, (OR) 1.69 [95% confidence interval (CI) 1.15-2.33], but not among cirrhotic patients, odds ratio 1.12 (95% CI 0.65-1.86)., Conclusion: Hospitalized acute upper gastrointestinal haemorrhage in Emergency Departments in France is more often caused by cirrhosis than in other countries. Decreasing the delay between the first signs of bleeding and arrival at the Emergency Department is the main challenge in the management of acute upper gastrointestinal haemorrhage.

Background & Aims: In rats with portal vein stenosis, the initial cause of aortic nitric oxide (NO) overproduction might be overactivation of endothelial NO synthase (eNOS) related to increased shear stress. Cardiac output is higher in cirrhosis than in extrahepatic portal hypertension. The aims of this study were to evaluate the role of shear stress, vascular endothelial growth factor (VEGF), and cytokines in aortic eNOS up-regulation in rats with biliary cirrhosis and to compare these results with those in rats with portal vein stenosis., Methods: NOS activities, NOS protein, heat shock protein (Hsp) 90, and VEGF expressions were studied in rat aortas. Propranolol was administered to rats with cirrhosis to reduce cardiac output and thus shear stress., Results: In cirrhotic rats, the aortic eNOS protein was 3.0 and 1.7 times higher than in control and portal vein-stenosed rats, respectively. In cirrhotic rats, the Hsp90 content was 3.2 and 2.2 times higher than in control and portal vein-stenosed rats, respectively. Propranolol decreased NOS activity by 47% and eNOS and Hsp90 expression by 75% and 72%, respectively. Aortic VEGF expression was decreased in cirrhotic rats. VEGF-induced stimulation of NOS activity was greater in aortas from control rats than in aortas from portal vein-stenosed or cirrhotic rat aortas. eNOS expression was up-regulated after VEGF incubation. After lipopolysaccharide administration, eNOS expression did not change in portal vein-stenosed or cirrhotic rats., Conclusions: This study shows that in aortas from rats with biliary cirrhosis, systemic vasodilation depends mainly on eNOS up-regulation related to shear stress.

In patients with acute gastrointestinal bleeding, initial management includes emergency cares to restore or maintain circulatory stability, while the endoscopic examinations often determine the origin of bleeding. The most recent advances in this management concern early administration of proton pump inhibitors in bleeding ulcers, early administration of vasoactive drugs in patients with acute bleeding related to portal hypertension and the development of endoscopic therapy reducing the need for surgery. In all cases, an efficient collaboration between emergency physicians, gastroenterologist and surgeon is needed.

Background: In patients with cirrhosis, glucose may induce splanchnic and renal vasodilation. Since the antidiabetic sulfonylurea glibenclamide is known to induce splanchnic and renal vasoconstriction in portal hypertensive animals, this drug may inhibit glucose-induced hemodynamic responses in patients with cirrhosis. The aim of the present study was to investigate, in patients with cirrhosis, the short-term effects of glibenclamide on hemodynamic and humoral responses to glucose., Methods: Patients were randomly assigned to receive either glibenclamide (5-mg tablet) or a placebo. All patients received an infusion of 10% glucose (62.5 ml/h for 12 h) that was started at the same time as glibenclamide or placebo administration. Studies were performed prior to and 90 min after glibenclamide or placebo., Results: Glibenclamide (i.e. glibenclamide plus glucose) significantly increased plasma insulin concentrations and glycemia while placebo (i.e. glucose alone) significantly increased glycemia but did not change plasma insulin levels. Glibenclamide did not significantly change the hepatic venous pressure gradient while this value was significantly increased following glucose alone. Glibenclamide did not significantly change renal blood flow and glomerular filtration rate while glucose alone significantly increased renal blood flow without affecting the glomerular filtration rate. Glibenclamide significantly decreased cardiac index while glucose alone did not change this value., Conclusions: In patients with cirrhosis receiving glucose, glibenclamide blunted glucose-induced splanchnic and renal vasodilation. In addition, glibenclamide per se induced a decrease in cardiac index. These findings should be taken into account when glibenclamide is administered to patients with cirrhosis and type 2 diabetes.

Objective: In patients with cirrhosis, the relationships between haemodynamic alterations and the development of ascites or the occurrence of refractory ascites are unknown. The aim of the present study was to compare haemodynamic measurements obtained in patients with non-refractory ascites to haemodynamic measurements obtained in patients without ascites and in patients with refractory ascites., Methods: A cohort of 121 patients was prospectively studied, of whom 29 patients did not have ascites, 45 had non-refractory ascites and 47 had refractory ascites. Splanchnic, renal and systemic haemodynamics were measured in all patients., Results: The hepatic venous pressure gradient was significantly higher in patients with non-refractory ascites than in patients without ascites (18.5 +/- 0.8 mmHg versus 15.8 +/- 0.7 mmHg). Renal and systemic haemodynamics did not significantly differ between patients with non-refractory ascites and patients without ascites. The glomerular filtration rate and renal blood flow were significantly lower in patients with refractory ascites than in patients with non-refractory ascites (77 +/- 4 versus 107 +/- 5 ml/min and 867 +/- 62 versus 1,008 +/- 68 ml/min, respectively). Splanchnic and systemic haemodynamics did not significantly differ between patients with refractory ascites and patients with non-refractory ascites., Conclusions: In patients with cirrhosis, an increase in portal hypertension was the sole haemodynamic alteration related to the development of ascites. Renal vasoconstriction (and subsequent renal hypoperfusion and hypofiltration) was the only haemodynamic alteration related to the occurrence of refractory ascites. The development of ascites or refractory ascites was not associated with any alteration in systemic haemodynamics.

Background and Aims: Cirrhosis is associated with a hyperdynamic syndrome and arterial vasodilation that is related to nitric oxide (NO) synthase 3 overactivity. Septic shock is frequently associated with cirrhosis and with a vascular induction of NO synthase 2. The aims of this study were to compare the effects of lipopolysaccharide (LPS) in normal and cirrhotic rats, and to test the effects of a nonsteroidal anti-inflammatory drug (NSAID) coupled with a (NO) donor., Methods: Cirrhotic rats received NO-flurbiprofen, flurbiprofen or vehicle followed by LPS or placebo 15 min later. The heart rate and mean arterial pressure of rats were monitered for 5 h. Thoracic aortic rings were removed and contracted with the use of norepinephrine. Nitric oxide synthase activity was measured in the aorta and stomach of cirrhotic rats., Results: Arterial pressure decreased in cirrhotic rats in the vehicle/LPS and flurbiprofen/LPS groups. After LPS administration, the heart rate of rats increased in all groups. In the aortic rings, LPS induced hyporeactivity to norepinephrine in all groups except the NO-flurbiprofen group. This hyporeactivity was abolished after preincubation with Nw-nitro-L-arginine (L-NNA). Nw-nitro-L-arginine had no effect on norepinephrine-induced vasoconstriction in the NO-flurbiprofen/LPS group. Nitric oxide synthase 2 activity in the stomach and aorta of cirrhotic rats was increased in each group except in the NO-flurbiprofen group after LPS administration. Pretreatment with NO NSAID prevented aortic hyporeactivity to norepinephrine in cirrhotic rats treated with LPS as it probably inhibited the NO synthase 2 induction., Conclusions: These findings suggest that NO-flurbiprofen has a beneficial hemodynamic effect in cirrhotic rats and may help to prevent LPS aortic hyporeactivity.

Failure to control bleeding and early rebleeding account for the high mortality associated with variceal hemorrhage in cirrhosis. We compared endoscopic sclerotherapy to terlipressin, a drug that effectively controls acute bleeding while reducing in-hospital mortality. This multicenter randomized controlled trial included 219 cirrhotic patients admitted for endoscopy-proven acute variceal bleeding and randomized to receive repeated injections of terlipressin during 6 days (n = 105) or emergency sclerotherapy (n = 114). Success was defined as obtaining control of bleeding (24-hour bleeding-free period during the first 48 hours) and lack of early rebleeding (any further bleeding from initial control to 5 days later) and survival during the study. Both groups were similar at inclusion. Failure rate for terlipressin was 33% and 32% for sclerotherapy (not significant [NS]). Early rebleeding was responsible for 43% and 44% of failures, respectively. This high efficacy was observed in both Child-Pugh class A + B and Child-Pugh class C patients. Both treatments were similar regarding transfusion requirements, in-hospital stay, and 6-week mortality (26 vs. 19 patients). Side effects appeared in 20% of patients receiving terlipressin and in 30% of those on sclerotherapy (P =.06); being serious in 4% and 7%, respectively (NS). In conclusion, terlipressin and sclerotherapy are equally highly effective therapies achieving the initial control of variceal bleeding and preventing early rebleeding. Both treatments are safe, but terlipressin is better tolerated. Therefore, terlipressin may represent a first-line treatment in acute variceal bleeding until the administration of elective therapy, especially in hospitals where a skilled endoscopist is not available 24 hours a day.

Background & Aims: In portal hypertension, the mechanisms responsible for nitric oxide (NO) overproduction and vasodilation have not yet been clearly identified. One hypothesis is that NO synthase (NOS) 3 is overactivated because of shear stress in endothelial cells caused by hyperkinetic circulation. The aim of this study was to evaluate aortic NOS3 after a reduction of blood flow by long-time beta-adrenoceptor antagonist administration., Methods: Propranolol or atenolol was administered by gavage in portal vein-stenosed and sham-operated rats. The vascular reactivity of thoracic aortic rings to phenylephrine, total aortic NOS activity, and aortic NOS3 messenger RNA and protein expressions were studied., Results: After propranolol or atenolol administration, the aortic hyporesponse returned to normal in portal vein-stenosed rats. Total aortic NOS activity was higher in portal vein-stenosed aortas and significantly decreased after beta-blocker administration. Aortic NOS3 expressions were more marked in portal vein-stenosed aortas than in controls, but NOS3 expressions were reduced after propranolol administration., Conclusions: In portal hypertension, aortic NOS3 activity and expressions are enhanced but return to normal after beta-blocker administration. These results suggest that in portal hypertension, increased shear stress, related to high blood flow, induces enhanced aortic NOS3.

In cirrhosis there is a hyperdynamic circulation, which occurs mainly in the systemic and splanchnic regions. Using isolated-vessel models, previous studies have shown reduced aortic reactivity to vasoconstrictors in rats with cirrhosis. The aim of the present study was to evaluate and compare the vascular responsiveness to phenylephrine in arterial rings and the blood flows from different regions in rats with cirrhosis and controls. Reactivity was studied in isolated thoracic aortic, superior mesenteric arterial and carotid arterial rings from sham-operated and bile-duct-ligated rats by measuring the cumulative concentration-dependent tension induced by phenylephrine (10(-9)-10(-4) M). Blood flows were measured by the radioactive microsphere method. In rats with cirrhosis, a significant hyporeactivity to phenylephrine was observed in both the aorta and the superior mesenteric artery compared with the corresponding arteries of normal rats. This hyporesponsiveness was corrected by N(omega)-nitro-L-arginine (0.1 mM). In contrast, carotid artery reactivity and the responses to N(omega)-nitro-L-arginine were similar in the cirrhotic and control groups. In each case, cardiac output and mesenteric arterial blood flow were significantly higher in cirrhotic than in normal rats. Cerebral blood flows were not significantly different between the two groups. In cirrhotic rats, arterial hyporeactivity may be a consequence of increased regional blood flow and increased production of nitric oxide.

It has been shown that certain patients with cirrhosis have asymptomatic cardiac abnormalities that have not yet been explained. Thus, cardiac troponin I, a specific marker of myocardial injury, has been measured in patients with cirrhosis without previous cardiac disease. Thirty-two consecutive patients (age 49 +/- 11) with cirrhosis and normal ECG were selected, 22 of which were alcoholic. Hemodynamic investigations were performed. Left ventricular function and mass were evaluated by echocardiography. Serum creatine kinase MB mass, myoglobin, and cardiac troponin I concentrations were measured. Cardiac troponin I concentrations were elevated in 10 patients (32%) (range 0.06-0.25 microg/L) whereas creatine kinase MB mass and myoglobin were normal in all patients. Abnormal troponin I values were not related to the severity of cirrhosis, to the degree of portal hypertension, or to other hemodynamic values. In contrast, elevated serum cardiac troponin I concentrations were related to a decreased stroke-volume index (P <. 05) and a decreased left ventricular mass (P <.05). These results show a high prevalence of slightly elevated serum cardiac troponin I in patients with cirrhosis, especially in those with alcoholic cirrhosis. Elevated troponin I is associated with subclinical left ventricular myocardial damage. These findings may be linked to a lack of left ventricular adaptation in certain patients with cirrhosis and alcoholic cardiomyopathy.