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Background Renal and splenic infarctions are close entities, with few data concerning their clinical, biological and radiological features. Aim The aim of this study was to compare the clinical presentations, etiologies and outcomes of acute renal infarctions (RI) and splenic infarctions (SI). Design A retrospective multicentric cohort study included patients of the 6 university hospitals in Lyon with RI, SI, or associated RI-SI infarctions was conducted. Methods All consecutive cases diagnosed by CT imaging, between January 2013 and October 2016, were included. The exclusion criteria were causes of infarction that did not require additional investigations. Results A total of 161 patients were selected for analysis: 34 patients with RI, 104 patients with SI and 23 patients with both RI-SI. Mean ± SD age of patients was 63.2 ± 16.6 years; 59.6% were male. Only 5/161 (3.1%) were healthy prior to the event. The main symptoms were diffuse abdominal pain (26.4%), followed by nausea/vomiting (18.3%) and fever (16.4%).The causes of RI or SI varied significantly within the three groups. Hypercoagulable state was associated with SI, and embolic disease and arterial injury were associated with RI. Extensive (i.e.>2/3 of organ volume) (OR 6.22, 95%CI 2.0119.22) and bilateral infarctions (OR 15.05, 95%CI 1.79–126.78) were significantly associated with hemodynamic shocks. The survival at 1 month follow-up did not significantly differ between the three groups. Conclusion Acute RI and SI are heterogenous entities in regards to their clinical presentation, etiology, associated venous or arterial thrombosis, but prognoses were not different at short term follow-up. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization refers to stroke, the second most frequent cause of death in the world, in terms of pandemic. Present treatments are only effective within precise time windows. Only 10% of thrombolysis patients are eligible. Late assessment of the patient resulting from admission and lack of knowledge of the symptoms is the main explanation of lack of eligibility. Methods: The aim is the measurement of the time of access to treatment facilities for stroke victims, using ambulances (firemen ambulances or EMS ambulances) and private car. The method proposed analyses the potential geographic accessibility of stroke care infrastructure in different scenarios. The study allows better considering of the issues inherent to an area: difficult weather conditions, traffic congestion and failure to respect the distance limits of emergency transport. Results: Depending on the scenario, access times vary considerably within the same commune. For example, between the first and the second scenario for cities in the north of Rhône county, there is a 10 min difference to the nearest Primary Stroke Center (PSC). For the first scenario, 90% of the population is 20 min away of the PSC and 96% for the second scenario. Likewise, depending on the modal vector (fire brigade or emergency medical service), overall accessibility from the emergency call to admission to a Comprehensive Stroke Center (CSC) can vary by as much as 15 min. Conclusions: The setting up of the various scenarios and modal comparison based on the calculation of overall accessibility makes this a new method for calculating potential access to care facilities. It is important to take into account the specific pathological features and the availability of care facilities for modelling. This method is innovative and recommendable for measuring accessibility in the field of health care. This study makes possible to highlight the patients' extension of care delays. Thus, this can impact the improvement of patient care and rethink the healthcare organization. Stroke is addressed here but it is applicable to other pathologies. [ABSTRACT FROM AUTHOR]

Background This study aimed to evaluate the accuracy of prehospital parameters, including vital signs and resuscitation (fluids, vasopressor), to predict trauma-induced coagulopathy ( TIC, fibrinogen <1·5 g/l or PTratio > 1·5 or platelet count <100 × 109/l), and a massive transfusion ( MT, ≥10 RBC units within the first 24 h). Methods From a trauma registry (2011-2015), in which patients are prospectively included, we retrospectively retrieved the heart rate ( HR), systolic blood pressure ( SBP), volume of prehospital fluids and administration of noradrenaline. We calculated the shock index ( SI: HR/ SBP), the MGAP prehospital triage score and the Injury Severity Score ( ISS). We also identified patients who had positive criteria from the Resuscitation Outcome Consortium ( ROC, SBP < 70 mmHg or SBP 70-90 and HR > 107 pulse/min). For these parameters, we drew a ROC curve and defined a cut-off value to predict TIC or MT. The strength of association between prehospital parameters and TIC as well as MT was assessed using logistic regression, and cut-off values were determined using ROC curves. Results Among the 485 patients included in the study, TIC was observed in 112 patients (23%) and MT in 22 patients (5%). For the prediction of TIC, ISS had good accuracy ( AUC: 0·844, 95% confidence interval, CI: 0·799-0·879), as did the volume of fluids (>1000 ml) given during prehospital care ( AUC: 0·801, 95% CI: 0·752-0·842). For the prediction of MT, ISS had excellent accuracy ( AUC: 0·932, 95% CI: 0·866-0·966), whereas good accuracy was found for SI (> 0·9; AUC: 0·859, 95% CI: 0·705-0·936), vasopressor administration ( AUC: 0·828, 95% CI: 0·736-0·890) and fluids (>1000 ml; AUC: 0·811, 95% CI: 0·737-0·867). Vasopressor administration, ISS and SI were independent predictors of TIC and MT, whereas fluid volume and ROC criteria were independent predictor of TIC but not MT. No independent relationship was found between MGAP and TIC or MT. Conclusions Prehospital parameters including the SI and resuscitation may help to better identify the severity of bleeding in trauma patients and the need for blood product administration at admission. [ABSTRACT FROM AUTHOR]

Objectives: To assess outcome and predicting factors 1 year after a severe traumatic brain injury (TBI). Methods: Multi-centre prospective inception cohort study of patients aged 15 or older with a severe TBI in the Parisian area, France. Data were collected prospectively starting the day of injury. One-year evaluation included the relatives-rating of the Dysexecutive Questionnaire (DEX-R), the Glasgow Outcome Scale-Extended (GOSE) and employment. Univariate and multivariate tests were computed. Results: Among 257 survivors, 134 were included (mean age 36 years, 84% men). Good recovery concerned 19%, moderate disability 43% and severe disability 38%. Among patients employed pre-injury, 42% were working, 28% with no job change. DEX-R score was significantly associated with length of education only. Among initial severity measures, only the IMPACT prognostic score was significantly related to GOSE in univariate analyses, while measures relating to early evolution were more significant predictors. In multivariate analyses, independent predictors of GOSE were length of stay in intensive care (LOS), age and education. Independent predictors of employment were LOS and age. Conclusions: Age, education and injury severity are independent predictors of global disability and return to work 1 year after a severe TBI. [ABSTRACT FROM AUTHOR]

Objective. – To evaluate the effectiveness of prehospital medical care in head-injured patients.Patients and methods. – All head-injured patients admitted in Biceˆtre hospital from 1995 to 1999 were retrospectively studied. Glasgow Coma Scale (GCS) score, mean arterial pressure (MAP) and SpO2 measured on the field were compared to GCS, MAP and SpO2 on arrival in the hospital. All treatments given during transport and first data recorded in the hospital were noted. Each parameter was compared to outcome at 6 months. Then, significant parameters were compared with a multivariate analysis.Results. – Three hundred and four patients were included, 80% had a GCS ≤ 8 and 45% a GCS = 3. At 6 months, 43% of the patients had no or mild sequelae and 45% died. Prehospital time was 2 h 55 min ± 1 h 40 min. During transport, 75% of hypoxemic events were corrected, but GCS and MAP decreased significantly. None of the patients with non-reactive mydriasis received any osmotherapy and all patients with non-reactive mydriasis until hospital admission died (n = 55). After multivariate analysis, parameters significantly related to outcome were, on the field, MAP (p < 0.025) and at hospital SAPS II (p < 0,001), GCS (p < 0.001), non-reactive mydriasis (p < 0.025), hyperglycemia (p < 0.025) and low haemoglobinemia (p < 0.001).Conclusion. – Respect of guidelines is important to improve medical care. Prehospital management corrected hypoxemia but not hypotension. The lack of osmotherapy after mydriasis cannot be explained and is probably an error. Patient route must be simplified to decrease time delay from field to hospital. Improvement in prehospital care may decrease mortality in head-injured patients. [Copyright &y& Elsevier]

Background and Importance: Traumatic brain injury (TBI) in patients on vitamin K antagonists (VKAs) is linked to a high rate of intracranial hemorrhage (ICH). Rapid reversal can reduce ICH progression and mortality, but its effectiveness depends on the time between bleeding onset and coagulation normalization., Objective: The PREVACT study aimed to assess the efficacy and safety of prompt systematic reversal of anticoagulation in patients presenting to emergency departments (EDs) for recent mild-TBI while receiving a VKA., Intervention: A randomized, open-label, blinded-endpoint clinical trial was conducted in 21 French EDs. Patients receiving a VKA, having experienced a TBI within the last 6 h, and presenting a Glasgow Coma Score ≥13 were included. Patients were randomized to systematic immediate VKA reversal with 25 IU/kg of four-factor prothrombin complex concentrate (4f-PCC) before any investigation (intervention group) or standard-of-care signifying reversal only if the initial cranial computed tomography (CT) scan indicated ICH (control group). The primary outcome was the rate of ICH detected on a cranial CT scan 24 h post-inclusion., Results: The study was prematurely stopped for logistic reasons after the randomization of 202 patients (101 and 101 in the intervention and control groups, respectively, mean age 90; 51.8% female). On the 24-h cranial CT scan, 6 of 98 patients (6.1%) in the intervention group manifested ICH vs. 12 of 99 patients (12.1%) in the control group [odds ratio: 0.47 (95% confidence interval: 0.14-1.44); P = 0.215]., Conclusion: In patients with recent mild-TBI receiving a VKA, systematic prompt reversal with 4f-PCC did not statistically significantly reduce ICH rate at 24 h. However, the study was prematurely stopped and does not exclude a clinically relevant benefit of the strategy tested., Trial Registration: Clinicaltrials.gov (NCT01961804)., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Influenza can be associated with nonrespiratory disease presentation, but these are less well documented due to the lack of routine testing for influenza in the healthcare system, especially if patients do not present with influenza-like illness (ILI). We aimed to measure the proportion of influenza cases seeking care at emergency department (ED) for a nontraumatic cause, to describe their clinical presentation and their ED-discharge diagnosis., Methods: The study was conducted at seven hospitals in France, Spain, Italy and Germany during the 2019-20 influenza season, for a period of 10 weeks. Patients (≥ 18 years) consulting for nontraumatic causes at the ED were invited to participate. Consenting patients provided upper respiratory swab samples for influenza testing by reverse transcription polymerase chain reaction. Clinical and demographic data were collected., Results: There were 8678 patients included, 50.7% were female and the median age was 57 years. Among them, 494 (5.7%) were laboratory-confirmed influenza (LCI) cases. Nonetheless, only 24.3% of LCI cases had an ED-discharge of influenza. Of all cases confirmed as influenza, 47.6% had a nonrespiratory discharge diagnosis, which frequency increased with age. ILI case definition from the European Centre for Disease Prevention and Control was the most frequently met among influenza cases (68.6%). Older patients (≥ 65 years) were less frequently identified based on any ILI signs/symptoms., Conclusion: Our findings indicate that the impact of influenza among patients seeking care at the ED cannot be easily assessed based on clinical presentation and medical records alone. Preventing influenza among adult population may reduce healthcare utilization., (© 2024 The Author(s). Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Because 20-30% of patients with sepsis deteriorate to critical illness, biomarkers that provide accurate early prognosis may identify which patients need more intensive treatment versus safe early discharge. The objective was to test the performance of sVEGFR2, suPAR and PCT, alone or combined with clinical signs and symptoms, for the prediction of clinical deterioration. This prospective observational study enrolled patients with suspected infection who met SIRS criteria without organ dysfunction (delta SOFA <2 from baseline) from 16 emergency departments. The primary endpoint was clinical deterioration (increased SOFA score ≥2 points, new or increased organ support, or death) within 72 hours of enrollment. Diagnosis and classification of infection status were adjudicated. 724 patients were enrolled, (54% men, median age 55 [38-70] y-o). Infection origin was abdominopelvic (21%), skin and soft tissues (17%), urinary (16%) and pulmonary (15%). 176 (24%) patients deteriorated, with a 28-day mortality of 1.4%. They had lower sVEGFR2 level (6.17 [5.00-7.40] vs 6.52 [5.40-7.84], p=0.024), higher circulating suPAR (5.25 [3.86-7.50] vs 4.18 [3.16-5.68], p<0.001) and higher PCT level (0.32 [0.08-1.80] vs 0.18 [0.05-0.98], p=0.004). suPAR demonstrated superior performance (AUC=0.65 [0.60-0.70]), compared to other biomarkers (PCT, AUC=0.57 [0.52-0.62] and sVEGFR2, AUC=0.58 [0.53-0.64]). Maximum accuracy was achieved from the combination of clinical information, sVEGFR2 and suPAR, yielding an AUC of 0.74 [0.69-0.78] and NPV 0.90 [0.88-0.94]. sVEGFR2 and suPAR were insufficiently accurate to rule out clinical deterioration. Panels of biomarkers will likely be needed to capture the heterogeneous mechanistic pathways involved in sepsis-related organ failure., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Background: In France, the COVID-19 vaccination campaign started in January 2021. This study reports the one-year experience of a multidisciplinary team from university hospital in operating a vaccination center created in a metropolitan sports arena., Materials and Methods: Some of the data derive from an online appointment scheduling software. Daily traceability sheets were utilized as a formalized method to gather data on non-conformities, adverse events, and to estimate the duration of the vaccination pathway. The professional satisfaction assessment was carried out via an anonymous online questionnaire. The collected data were examined with descriptive statistics., Results: We propose strengths of our organization to obtain efficient and safe vaccination pathway. In one year, 572,491 immunization shots were administered. The operational team size increased from 31 (500 vaccinations per day) to 71 (3000 vaccinations per day). In March 2021, the average duration to vaccination (excluding post-vaccination monitoring) was 12 [5-37] minutes for patients without medical consultation vs 16 [5-45] minutes for patients with medical consultation. 0.11 % non-conformities on vaccines got notified not allowing them to be used for vaccination. One error regarding the volume administered got reported. Among the professionals working in the vaccination center, 97 % were satisfied with the organization and 88 % with the quality of the information received from team leader or team project. Main difficulties encountered were managing the leftover doses at night and communicating with patients., Conclusions: Overall, the ability to vaccinate a population efficiently and safely on a large scale during a pandemic is based on the engagement of skilled multidisciplinary teams and securing the vaccination pathway., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Assess the changes in post-traumatic stress disorder (PTSD), burnout, anxiety, depression, jobstrain, and isostrain levels over time among healthcare workers in emergency departments (EDs) after successive outbreaks of COVID-19. A prospective, multicenter study was conducted in 3 EDs and an emergency medical service. Healthcare workers who participated in our previous study were invited to participate in a follow-up 16 and 18 months and completed the questionnaires to assess symptoms of PTSD, burnout, anxiety, depression, jobstrain, and isostrain. Among the 485 healthcare workers asked to participate, 211 (43.5%) completed the survey at inclusion (122 were followed up at 3 months) and 59 participate to the follow-up study. At 16 months, 10.9% of healthcare workers had symptoms of PTSD and 17.4% at 18 months. At inclusion, 33.5% and 11.7% of healthcare workers had symptoms of anxiety and depression, respectively. A decrease in anxiety between inclusion and 16 months (p = 0.02) and an increase between 16 and 18 months (p = 0.009) was observed. At inclusion, 40.8% of all healthcare workers had symptoms of burnout. There was an increase in symptoms of burnout between inclusion and 18 months (p = 0.006). At inclusion, 43.2% and 29.5% of healthcare workers were exposed to jobstrain and isostrain, respectively. Jobstrain were higher among paramedics and administrative staff compared to physicians (p = 0.001 and p = 0.026, respectively). Successive outbreaks of COVID-19 led to long-term mental health consequences among ED healthcare workers that differed according to occupation. This must be taken into account to rethink the management of teams., (© 2024 The Author(s). Stress and Health published by John Wiley & Sons Ltd.)

Background: Cannabis use frequently starts during adolescence and young adulthood and can induce psychosocial and health consequences. Young people constitute hard-to-reach populations. Emergency departments could constitute a key care setting to identify cannabis use and its consequences among young people., Objectives: To estimate the rate of cannabis use in the 16- to 25-year-old population visiting the emergency department for any reason and to assess the psychosocial factors associated with cannabis use., Methods: This was a cross-sectional study among young people who attended the emergency department, over 5-months. Data were sociodemographic characteristics, self-administered questionnaires for problematic substance use screening, and urine drug screening samples. They were classified in the cannabis use (CU) group if they had a positive urine screen or reported cannabis use in the previous month. Characteristics of individuals in the CU and non-CU groups were compared., Results: A total of 460 participants were included, of whom 105 were in the CU group. Cannabis users were more likely to be male (aOR = 1.85; [1.18-2.90]), to be unemployed (aOR = 1.77; [1.03-3.04]), to have a lower mental health status score (aOR = 0. 82; [0.75-0.90]), to report a history of sexual abuse (aOR = 2.99; [1.70-5.25]), and to have a positive AUDIT screen (aOR = 4.23; [2.61-6.86])., Conclusions: The emergency department is a primary care setting for young people, which is conducive to screening for substance use. Cannabis users can be assessed and referred to adapt their treatment, given their lack of adherence to the traditional addictology care system.

Study Objective: The present study is aimed at providing an assessment of the changes in burnout, job strain, isostrain, sleepiness, and fatigue levels over time and identifying factors associated with these symptoms among healthcare workers in French emergency departments (EDs). Method: We conducted a prospective, multicenter study in four EDs and an emergency medical service. Participants completed questionnaires at inclusion and at 90 days to assess burnout, job strain, isostrain, sleepiness, and fatigue. Results : A total of 211 respondents (43.5%) completed the questionnaires at inclusion. At the beginning of the study, 84 (40.8%) participants presented symptoms of burnout, 86 (43.2%) had symptoms of job strain, and 58 (29.4%) of isostrain. Forty-two (20.1%) healthcare workers presented symptoms of sleepiness, and 8 (3.8%) had symptoms of fatigue. We found that symptoms of burnout were more frequent for healthcare workers with a previous psychiatric history (55.3% vs. 39.1%, p = 0.02) and were lower among participants who had at least one dependent child (33.1% vs. 48.3%, p = 0.013). Symptoms of job strain were higher among administrative staff compared to physicians (55.6% vs. 28.7%, p = 0.01) and among healthcare workers with managerial responsibilities compared to those without (45.6% vs. 28.8%, p = 0.015). Symptoms of isostrain were higher among administrative staff (42.3%) compared to paramedics (34.1%) and physicians (19.8%, p = 0.026). Conclusion: We identified that potential factors associated with the emergence of symptoms of burnout and job strain are suggested, underlining several areas of improvement for the prevention against mental health disorders in the specific population of ED healthcare workers. Trial Registration: ClinicalTrials.gov identifier: NCT04383886., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Marion Douplat et al.)

Introduction: The decisions of withholding or withdrawing life-sustaining treatments are difficult to make in the context of emergency departments (EDs) because most patients are unable to communicate. Relatives are thus asked to participate in the decision-making process, although they are unprepared to face such situations. We therefore aimed to develop a standardised intervention for announcing decisions of withholding or withdrawing life-sustaining treatments in EDs and assess the efficacy of the intervention on the stress of relatives., Methods and Analysis: The DISCUSS trial is a multicentre stepped-wedge cluster randomised study and will be conducted at nine EDs in France. A standardised intervention based on human simulation will be codesigned with partner families and implemented at three levels: the relatives, the healthcare professionals (HCP) and the EDs. The intervention will be compared with a control based on treatment as usual. A total of 538 families are planned to be included: 269 in the intervention group and 269 in the control group. The primary endpoint will be the symptoms of post-traumatic stress disorder (PTSD) at 90 days. The secondary endpoints will be symptoms of PTSD at 7 and 30 days, diagnosis of PTSD at 90 days and anxiety and depression scores at 7, 30 and 90 days. Satisfaction regarding the training, the assertiveness in communication and real-life stress of HCPs will be measured at 90 days., Ethics and Dissemination: This study was approved by the ethics committee Est III from Nancy and the French national data protection authority. All relatives and HCPs will be informed regarding the study objectives and data confidentiality. Written informed consent will be obtained from participants, as required by French law for this study type. The results from this study will be disseminated at conferences and in a peer-reviewed journal., Trial Registration Number: NCT06071078., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Indonesia and French Guiana share many geographic and medical concerns regarding access to care. The organisational needs in emergency management, particularly in the prehospital phase, are similar. Whereas emergency medicine (EM) is an academic and entire speciality in France, it is still under construction in Indonesia. In the framework of the French and Indonesian academic cooperation, the Medical school in Jakarta University and the French Guiana University in Cayenne signed a Memorandum of Understanding encompassing education programmes, joint research work and students' and health professionals' exchanges in EM. This partnership represented the first medical cooperation programme between the two countries. The first student class was launched in August 2022 and involved 50 Indonesian doctors who graduated in August 2023. The implementation and success of this Franco-Indonesian cooperation were supported by political and academic partners from the two sides. Given the first student class's success, we aim to continue this programme, in line with Indonesia and World Health Organization's plan to establish a multi-country training hub for health emergency operational readiness and Emergency Medical Teams., (© 2024 Australasian College for Emergency Medicine.)

Background: Out of hospital cardiac arrest (OHCA) survival rates are very low. An association between institutional OHCA case volume and patient outcomes has been documented. However, whether this applies to prehospital emergency medicine services (EMS) is unknown., Objectives: To investigate the association between the volume of interventions by mobile intensive care units (MICU) and outcomes of patients experiencing an OHCA., Methods: A retrospective cohort study including adult patients with OHCA managed by medical EMS in five French centers between 2013 and 2020. Two groups were defined depending on the overall annual numbers of MICU interventions: low and high-volume MICU. Primary endpoint was 30-day survival. Secondary endpoints were prehospital return of spontaneous circulation (ROSC), ROSC at hospital admission and favorable neurological outcome. Patients were matched 1:1 using a propensity score. Conditional logistic regression was then used., Results: 2,014 adult patients (69% male, median age 68 [57-79] years) were analyzed, 50.5% (n = 1,017) were managed by low-volume MICU and 49.5% (n = 997) by high-volume MICU. Survival on day 30 was 3.6% in the low-volume group compared to 5.1% in the high-volume group. There was no significant association between MICU volume of intervention and survival on day 30 (OR = 0.92, 95%CI [0.55;1.53]), prehospital ROSC (OR = 1.01[0.78;1.3]), ROSC at hospital admission (OR = 0.92 [0.69;1.21]), or favorable neurologic prognosis on day 30 (OR = 0.92 [0.53;1.62])., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background and Importance: Several studies reported that violent behaviours were committed by patients against healthcare professionals in emergency departments (EDs). The presence of mediators could prevent or resolve situations of tension., Objective: To evaluate whether the presence of mediators in EDs would have an impact on violent behaviours committed by patients or their relatives against healthcare professionals. Design, settings and participants A 6-period cluster randomised crossover trial was performed in 4 EDs during 12 months. Patients aged ≥18 and their relatives were included., Intervention: In order to prevent or resolve situations of tension and conflict, four mediators were recruited.Outcome measure and analysis Using a logistic regression mixed model, the rate of ED visits in which at least one act of violence was committed by a patient or their relatives, reported by healthcare professionals, was compared between the intervention group and the control group., Results: A total of 50 429 ED visits were performed in the mediator intervention group and 50 851 in the control group. The mediators reported 1365 interventions; >50% of the interventions were to answer questions about clinical management or waiting time. In the intervention group, 173 acts of violence were committed during 129 ED visits, and there were 145 acts of violence committed during 106 ED visits in the control group. The rate of ED visits in which at least one act of violence was committed, was 0.26% in the intervention group and 0.21% in the control group (OR = 1.23; 95% CI [0.73-2.09]); on a 4-level seriousness scale, 41.6% of the acts of violence were rated level-1 (acts of incivility or rudeness) in the intervention group and 40.0% in the control group., Conclusion: The presence of mediators in the ED was not associated with a reduction in violent or uncivil behaviours committed by patients or their relatives. However, the study highlighted that patients had a major need for information regarding their care; improving communication between patients and healthcare professionals might reduce the violence in EDs., Trial Registration: Clinicaltrials.gov (NCT03139110)., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Shortness of breath is a common complaint among individuals contacting emergency communication center (EMCCs). In some prehospital system, emergency medical services include an advanced life support (ALS)-capable team. Whether such team should be dispatched during the phone call or delayed until the BLS-capable paramedic team reports from the scene is unclear. We aimed to evaluate the impact of delayed MMT dispatch until receiving the paramedic review compared to immediate dispatch at the time of the call on patient outcomes., Methods: A cross-sectional study conducted in Lyon, France, using data obtained from the departmental EMCC during the period from January to December 2019. We included consecutive calls related to adult patients experiencing acute respiratory distress. Patients from the two groups (immediate mobile medical team (MMT) dispatch or delayed MMT dispatch) were matched on a propensity score, and a conditional weighted logistic regression assessed the adjusted odds ratios (ORs) for each outcome (mortality on days 0, 7 and 30)., Results: A total of 870 calls (median age 72 [57-84], male 466 53.6%) were sought for analysis [614 (70.6%) "immediate MMT dispatch" and 256 (29.4%) "delayed MMT" groups]. The median time before MMT dispatch was 25.1 min longer in the delayed MMT group (30.7 [26.4-36.1] vs. 5.6 [3.9-8.8] min, p < 0.001). Patients subjected to a delayed MMT intervention were older (median age 78 [66-87] vs. 69 [53-83], p < 0.001) and more frequently highly dependent (16.3% vs. 8.6%, p < 0.001). A higher proportion of patients in the delayed MMT group required bag valve mask ventilation (47.3% vs. 39.1%, p = 0.03), noninvasive ventilation (24.6% vs. 20.0%, p = 0.13), endotracheal intubation (7.0% vs. 4.1%, p = 0.07) and catecholamine infusion (3.9% vs. 1.3%, p = 0.01). After propensity score matching, mortality at day 0 was higher in the delayed MMT group (9.8% vs. 4.2%, p = 0.002). Immediate MMT dispatch at the call was associated with a lower risk of mortality on day 0 (0.60 [0.38;0.82], p < 0.001) day 7 (0.50 [0.27;0.72], p < 0.001) and day 30 (0.56 [0.35;0.78], p < 0.001) CONCLUSIONS: This study suggests that the deployment of an MMT at call in patients in acute respiratory distress may result in decreased short to medium-term mortality compared to a delayed MMT following initial first aid assessment., (© 2024. The Author(s).)

Introduction: Young individuals constitute a key population for the screening of problematic use of substances (PUS), but they are not likely to seek support and are hard to reach. Targeted screening programs should thus be developed in the places of care they may attend for other reasons, including emergency departments (EDs). We aimed to explore the factors associated with PUS in young people attending an ED; we measured the subsequent access to addiction care after ED screening., Methods: This was a prospective interventional single-arm study which included any individual aged between 16 and 25 years who attended the main ED of Lyon, France. Baseline data were sociodemographic characteristics, PUS status using self-report questionnaires and biological measures, level of psychological health, and history of physical/sexual abuse. Quick medical feedback was provided to the individuals presenting a PUS; they were advised to consult an addiction unit, and contacted by phone at three months to ask whether they had sought treatment. Baseline data were used to compare PUS and non-PUS groups using multivariable logistic regressions, to provide adjusted odds ratios (aORs) and 95% confidence intervals (95% CI), with age, sex, employment status, and family environment as the adjustment variables. The characteristics of PUS subjects who subsequently sought treatment were also assessed using bivariable analyses., Results: In total, 460 participants were included; 320 of whom (69.6%) were presenting current substance use, and 221 (48.0%) with PUS. Compared to non-PUS individuals, PUS ones were more likely to be males (aOR=2.06; 95% CI [1.39-3.07], P<0.001), to be older (per one-year increase: aOR=1.09; 95% CI [1.01-1.17], P<0.05), to have an impaired mental health status (aOR=0.87; 95% CI [0.81-0.94], P<0.001), and to have a history of sexual abuse (aOR=3.33; 95% CI [2.03-5.47], P<0.0001). Only 132 (59.7%) subjects with PUS could be reached by phone at 3 months, among whom only 15 (11.4%) reported having sought treatment. Factors associated with treatment seeking were social isolation (46.7% vs. 19.7%; P=0.019), previous consultation for psychological disorders (93.3% vs. 68.4%; P=0.044), lower mental health score (2.8±1.6 vs. 5.1±2.6; P<0.001), and post-ED hospitalization in a psychiatric unit (73.3% vs. 19.7%; P<0.0001)., Discussion/conclusion: EDs are relevant places to screen PUS in youth, but the level of seeking further treatment needs to be substantially improved. Offering systematic screening during an emergency room visit could allow for more appropriate identification and management of youth with PUS., (Copyright © 2023 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

The transmission risk of SARS-CoV-2 within hospitals can exceed that in the general community because of more frequent close proximity interactions (CPIs). However, epidemic risk across wards is still poorly described. We measured CPIs directly using wearable sensors given to all present in a clinical ward over a 36-h period, across 15 wards in three hospitals in April-June 2020. Data were collected from 2114 participants and combined with a simple transmission model describing the arrival of a single index case to the ward to estimate the risk of an outbreak. Estimated epidemic risk ranged four-fold, from 0.12 secondary infections per day in an adult emergency to 0.49 per day in general paediatrics. The risk presented by an index case in a patient varied 20-fold across wards. Using simulation, we assessed the potential impact on outbreak risk of targeting the most connected individuals for prevention. We found that targeting those with the highest cumulative contact hours was most impactful (20% reduction for 5% of the population targeted), and on average resources were better spent targeting patients. This study reveals patterns of interactions between individuals in hospital during a pandemic and opens new routes for research into airborne nosocomial risk., (© 2024. The Author(s).)

Background and Importance: Although shoulder dislocation diagnosis is often solely based on clinical examination, physicians may order a radiograph to rule out a concomitant shoulder fracture before performing reduction. The Fresno-Québec decision rule aims to identify patients requiring a radiograph before reduction to avoid unnecessary systematic imaging. However, this novel approach needs further validation., Objective: To evaluate the performance of the Fresno-Québec rule in identifying patients who do not require a prereduction radiograph and assess the variables associated with a clinically significant fracture., Design, Settings, and Participants: A multicenter, retrospective cohort study from 2015 to 2021. Data were extracted from three ED university-affiliated tertiary-care centers. Patients aged ≥18 years with a final diagnosis of anterior glenohumeral dislocation were included., Outcomes Measure and Analysis: Accuracy metrics [sensitivity (Se), specificity (Sp), positive (PPV), negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ratio (NLR)] of the Fresno-Québec rule were measured. Multivariable logistic regression model was used to identify variables associated with the presence of a concomitant clinically significant fracture., Main Results: A total of 2129 patients were included, among whom 9.7% had a concomitant fracture. The performance metrics of the Fresno-Québec rule were as follows: Se 0.96 95% confidence interval (0.92-0.98), Sp 0.36 (0.34-0.38), PPV 0.14 (0.12-0.16), NPV 0.99 (0.98-0.99), PLR 1.49 (1.42-1.55) and NLR 0.12 (0.06-0.23). A total of 678 radiographs could have been avoided, corresponding to a reduction of 35.2%. Age ≥40 years, first dislocation episode [odds ratio (OR) = 3.18 (1.95-5.38); P  < 0.001], the following mechanisms: road collision [OR = 6.26 (2.65-16.1)], low-level fall [OR = 3.49 (1.66-8.28)], high-level fall [OR = 3.95 (1.62-10.4)], and seizure/electric shock [OR = 10.6 (4.09-29.2)] were associated with the presence of a concomitant fracture., Conclusion: In this study, the Fresno-Québec rule has excellent Se in identifying concomitant clinically significant fractures in patients with an anterior glenohumeral dislocation. The use of this clinical decision rule may be associated with a reduction of approximately a third of unnecessary prereduction radiographs., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Patients in the emergency department (ED) who are waiting for hospital admission on a wheeled cot may be subject to harm. However, mortality and morbidity among older patients who spend the night in the ED while waiting for a bed in a medical ward are unknown., Objective: To assess whether older adults who spend a night in the ED waiting for admission to a hospital ward are at increased risk of in-hospital mortality., Design, Settings, and Participants: This was a prospective cohort study of older patients (≥75 years) who visited the ED and were admitted to the hospital on December 12 to 14, 2022, at 97 EDs across France. Two groups were defined and compared: those who stayed in the ED from midnight until 8:00 am (ED group) and those who were admitted to a ward before midnight (ward group)., Main Outcomes and Measures: The primary end point was in-hospital mortality, truncated at 30 days. Secondary outcomes included in-hospital adverse events (ie, falls, infection, bleeding, myocardial infarction, stroke, thrombosis, bedsores, and dysnatremia) and hospital length of stay. A generalized linear-regression mixed model was used to compare end points between groups., Results: The total sample comprised 1598 patients (median [IQR] age, 86 [80-90] years; 880 [55%] female and 718 [45%] male), with 707 (44%) in the ED group and 891 (56%) in the ward group. Patients who spent the night in the ED had a higher in-hospital mortality rate of 15.7% vs 11.1% (adjusted risk ratio [aRR], 1.39; 95% CI, 1.07-1.81). They also had a higher risk of adverse events compared with the ward group (aRR, 1.24; 95% CI, 1.04-1.49) and increased median length of stay (9 vs 8 days; rate ratio, 1.20; 95% CI, 1.11-1.31). In a prespecified subgroup analysis of patients who required assistance with the activities of daily living, spending the night in the ED was associated with a higher in-hospital mortality rate (aRR, 1.81; 95% CI, 1.25-2.61)., Conclusions and Relevance: The findings of this prospective cohort study indicate that for older patients, waiting overnight in the ED for admission to a ward was associated with increased in-hospital mortality and morbidity, particularly in patients with limited autonomy. Older adults should be prioritized for admission to a ward.

Background: Inter-facility transport of patients with acute respiratory distress syndrome (ARDS) in the prone position (PP) is a high-risk situation, compared to other strategies. We aimed to quantify the prevalence of complications during transport in PP, compared to transports with veno-venous extracorporeal membrane oxygenation (VV-ECMO) or in the supine position (SP)., Methods: We performed a retrospective, single center cohort study in Lyon university hospital, France. We included patients ≥ 16 years with ARDS (Berlin definition) transported to an ARDS referral center between 01/12/2016 and 31/12/2021. We compared patients transported in PP, to those transported in SP without VV-ECMO, and those transported with VV-ECMO (in SP), by a multidisciplinary and specialized medical transport team, including an emergency physician and an intensivist. The primary outcome was the rate of transport-related complications (hypoxemia, hypotension, cardiac arrest, cannula or tube dislodgement) in each study groups, compared using a Fisher test., Results: One hundred thirty-four patients were enrolled (median PaO 2 /FiO 2 70 [58-82] mmHg), of which 11 (8%) were transported in PP, 44 (33%) with VV-ECMO, and 79 (59%) in SP. The most frequent risk factor for ARDS in the PP group was bacterial pneumonitis, and viral pneumonitis in the other 2 groups. Transport-related complications occurred in 36% (n = 4) of transports in PP, compared to 39% (n = 30) in SP and 14% (n = 6) with VV-ECMO, respectively (p = 0.33). VV-ECMO implantation after transport was not different between SP and PP patients (n = 7, 64% vs. n = 31, 39%, p = 0.19)., Conclusions: In the context of a specialized multi-disciplinary ARDS transport team, transport-related complication rates were similar between patients transported in PP and SP, while there was a trend of lower rates in patients transported with VV-ECMO., (© 2023. The Author(s).)

Background: The population of older trauma patients is increasing. Those patients have heterogeneous presentations and need senior-friendly triaging tools. Systolic blood pressure (SBP) is commonly used to assess injury severity, and some authors advocated adjusting SBP threshold for older patients. We aimed to describe and compare the relationship between mortality and SBP in older trauma patients and their younger counterparts., Methods: We included patients admitted to three level-I trauma centres and performed logistic regressions with age and SBP to obtain mortality curves. Multivariable Logistic regressions were performed to measure the association between age and mortality at different SBP ranges. Subgroup analyses were conducted for major trauma and severe traumatic brain injury admissions., Results: A total of 47,661 patients were included, among which 12.9% were aged 65-74 years and 27.3% were ≥ 75 years. Overall mortality rates were 3.9%, 8.1%, and 11.7% in the groups aged 16-64, 65-74, and ≥ 75 years, respectively. The relationship between prehospital SBP and mortality was nonlinear (U-shape), mortality increased with each 10 mmHg SBP decrement from 130 to 50 mmHg and each 10-mmHg increment from 150 to 220 mmHg across all age groups. Older patients were at higher odd for mortality in all ranges of SBP. The highest OR in patients aged 65-74 years was 3.67 [95% CI: 2.08-6.45] in the 90-99 mmHg SBP range and 7.92 [95% CI: 5.13-12.23] for those aged ≥ 75 years in the 100-109 mmHg SBP range., Conclusion: The relationship between SBP and mortality is nonlinear, regardless of trauma severity and age. Older age was associated with a higher odd of mortality at all SBP points. Future triage tools should therefore consider SBP as a continuous rather than a dichotomized predictor., (© 2023. BioMed Central Ltd., part of Springer Nature.)