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The use of prothrombin complex concentrates and the role of plasma concentration of anticoagulants in the management of bleeding in patients treated with direct oral anticoagulants are still debated. Our aim was to describe management strategies and outcomes of severe bleeding events in patients treated with direct oral anticoagulants.We performed a prospective cohort study of 732 patients treated with dabigatran, rivaroxaban, or apixaban hospitalized for severe bleeding, included prospectively in the registry from June 2013 to November 2015.Bleeding was gastrointestinal or intracranial in 37% (212 of 732) and 24% (141 of 732) of the cases, respectively. Creatinine clearance was lower than 60 ml/min in 61% (449 of 732) of the cases. The plasma concentration of direct oral anticoagulants was determined in 62% (452 of 732) of the cases and was lower than 50 ng/ml or higher than 400 ng/ml in 9.2% (41 of 452) and in 6.6% (30 of 452) of the cases, respectively. Activated or nonactivated prothrombin complex concentrates were administered in 38% of the cases (281 of 732). Mortality by day 30 was 14% (95% CI, 11 to 16).Management of severe bleeding in patients treated with direct oral anticoagulants appears to be complex. The use of prothrombin complex concentrates differs depending on bleeding sites and direct oral anticoagulant plasma concentrations. Mortality differs according to bleeding sites and was similar to previous estimates.

Background Evidence-based recommendations do not adequately address the treatment of right heart thrombi in patients who present with acute symptomatic pulmonary embolism. Methods This study included patients who had acute pulmonary embolism associated with right heart thrombi and participated in the Registro Informatizado de la Enfermedad TromboEmbolica registry. We assessed the effectiveness of anticoagulation versus reperfusion treatment for the outcomes of all-cause mortality, pulmonary embolism–related mortality, recurrent venous thromboembolism, and major bleeding rates through 30 days after initiation of pulmonary embolism treatment. We used propensity score matching to adjust for the likelihood of receiving reperfusion treatment. Results Of 325 patients with pulmonary embolism and right heart thrombi, 255 (78%; 95% confidence interval, 74-83) received anticoagulation and 70 (22%; 95% confidence interval, 17-26) also received reperfusion treatment. Propensity score–matched pairs analyses did not detect a statistically lower risk of all-cause death (6.2% vs 14%, P = .15) or pulmonary embolism–related mortality (4.7% vs 7.8%; P = .47) for reperfusion compared with anticoagulation. Of the patients who received reperfusion treatment, 6.2% had a recurrence during the study follow-up period, compared with 0% of those who received anticoagulation ( P = .049). The incidence of major bleeding events was not statistically different between the 2 treatment groups (3.1% vs 3.1%; P = 1.00). Conclusions In patients with pulmonary embolism and right heart thrombi, no significant difference was found between reperfusion therapy and anticoagulant therapy for mortality and bleeding. The risk of recurrences was significantly higher for reperfusion therapy compared with anticoagulation. Right heart thrombi may not warrant riskier interventions than standard anticoagulation.

Background Binge drinking (BD) consists of heavy episodic alcohol use. Whereas the World Health Organization (WHO) defines BD as 60 g of alcohol or more per occasion, the National Institute on Alcoholism and Alcohol Abuse (NIAAA) conceives BD as drinking 70 g (men) or 56 g (women) in less than two hours. We compared the subjects delineated by each definition. Methods Eight-center cross-sectional study among 11,695 subjects hospitalized in emergency wards. Participants completed the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C), CAGE and Rapid Alcohol Problem Screen 4 (RAPS4-QF) questionnaires. The WHO criteria were investigated using the RAPS4-QF. Independent questions assessed the NIAAA criteria. The main medical admission motive was noted. The characteristics of subjects meeting respectively: 1) the exclusive WHO criteria (BD1); 2) the NIAAA criteria (BD2); and 3) no BD criteria (noBD) were compared using multinomial regression analyses. Binary age- and gender-adjusted regression analyses directly compared BD1 and BD2. Subjects with at least four drinking occasions per week were excluded from the analyses, to withdrawn regular heavy drinking. Results Compared to BD1, BD2 subjects were more frequently males (OR = 1.67 [1.39–2.0]), single (aOR = 1.64 [1.36–1.98]) and unemployed (aOR = 1.57 [1.27–1.90]). BD2 reported significantly more drinks per occasion, and higher heavy drinking frequencies. Previous alcohol-related remarks from family (aOR = 3.00 [2.53–3.56]), ever drinking on waking-up (aOR = 2.05 [1.37–2.72]), and admission for psychiatric motive (aOR = 2.27 [1.68–3.07]) were more frequent among BD2 subjects. Conclusions Compared to WHO criteria, NIAAA criteria for BD delineate subjects with more concerning drinking patterns and alcohol aftermaths.

Objective The aim of this study was to evaluate the usefulness of various laboratory results for differential diagnosis of bacterial (BM) and nonbacterial meningitis (NBM) with negative initial Gram stain. Design and Setting A prospective multicenter study was conducted in the emergency departments of 3 teaching hospitals. Participants and Methods Consecutive adult patients with a diagnosis of meningitis based on compatible clinical features and cerebrospinal fluid (CSF) culture findings with a CSF leukocyte count greater than 5/mm 3 were included in the study. Symptoms, examination findings, data from laboratory results, including CSF results and serum C-reactive protein (CRP) levels, and clinical outcome were assessed. Results One hundred fifty-one patients (age, 35 ± 15 years) with confirmed meningitis were admitted: 133 with NBM and 18 with BM. CRP and procalcitonin (PCT) levels, CSF white cell and absolute neutrophil counts, and CSF glucose/blood glucose and CSF protein levels were significantly higher in the BM group. However, as diagnostic indicators of BM, none of these variables except PCT was more efficient than that of the emergency physician. Values of the area under the receiver operating characteristic curve were 0.59 (95% confidence interval [CI], 0.21-0.82), 0.79 (95% CI, 0.47-0.92), 0.18 (95% CI, 0.0-0.43), 0.70 (95%CI, 0.30-0.89), 0.81 (95% CI, 0.58-0.92), and 0.98 (95% CI, 0.83-1.0) for CSF leukocyte count, percentage of CSF leukocyte, CSF/blood glucose ratio, CSF protein level, serum CRP, and serum PCT ( P Conclusion CSF results have a modest role in distinguishing BM from NBM in a negative Gram stain for bacteria. PCT serum levels seem to be an excellent predictor of BM.

Objectives. To determine the frequency, modalities of admission and management of terminally ill patients who died on a stretcher in an emergency department (ED). Design and setting. Retrospective study in an ED of a university hospital. Methods. Current place of residence, modalities of admission in ED, mortality probability scores and type of management were extracted for each patient in the terminal stage of chronic disease who died on a stretcher in our ED during a 3year period. Results. Of 159 deaths observed in the ED, 56 (35%) concerned terminally ill patients. The illness was a malignancy in 22 cases, a neurological disease in 22 cases and a cardiopulmonary disease in 12 cases. Most of the patients were referred by their regular doctor. Seventy-two percent of the malignancy patients were living at home, 55% of the neurological patients came from nursing facilities and 58% of the cardio-respiratory patients came from the hospital. In 73%, 83% and 23% of the patients with malignancy, cardiopulmonary and neurological diseases, respectively, admission was related to the evolution of the chronic disease. Severity of illness on admission was similar whatever the disease. Request for compassionate end-of-life care was expressed in only 12.5%. At the ED, 91% of patients with neurological diseases received palliative support care. Supportive therapy was undertaken in one third of patients with malignancy or cardiopulmonary disease. Conclusion.An ED may be used as a place for dying for some terminally ill patients. This could be related to the legal opposition to withdrawal or withholding of life-support therapies as well as the absence of guidelines from scientific bodies.

Objective: To examine the incidence and the bacteriological and clinical significance of endotoxaemia in ICU patients with severe sepsis or septic shock. Design: Prospective review. Setting: A 15-bed general ICU in a university hospital. Patients: One hundred sixteen patients hospitalised in our ICU fulfilling Bone's criteria for severe sepsis or septic shock and with an available early endotoxin assay (chromogenic limulus assay). Interventions: None. Measurements and results: The clinical characteristics of the population were: age 63.6 ± 11.4 years; SAPS II: 45.4 ± 15.6; mechanical ventilation: 72.4 %; septic shock: 51.7 % (n = 60); bacteraemia: 28.4 % (n = 33); gram-negative bacteria (GNB) infection 47.4 % (n = 55); ICU mortality: 39.6 % (n = 46). Detectable endotoxin occurred in 61 patients (51.2 %; mean level: 310 ± 810 pg/ml). There was no relationship between detectable endotoxin and severity of infection at the moment of the assay. Endotoxaemia was associated with a higher incidence of bacteraemia (39.3 % vs 16.3 %; p = 0.01). There was a trend (p = 0.09) towards an association between positive endotoxin and gram-negative bacteraemia or GNB infection but this was non-significant. This relationship became significant only in the case of bacteraemia associated with GNB infection irrespective of the site of infection. Conclusion: Early detection of endotoxaemia appeared to be associated with GNB infection only in cases of bacteraemic GNB infection. Early endotoxaemia correlated neither to occurrence of organ dysfunction nor mortality in patients with severe sepsis or septic shock. This study suggests that the use of endotoxaemia as a diagnostic or a prognostic marker in daily practice remains difficult.

It was shown in children that serum procalcitonin was the best marker to use to differentiate bacterial from viral meningitis. To evaluate procalcitonin in the diagnosis of acute bacterial and viral meningitis, we conducted a prospective study including adult patients who were suspected of having meningitis and who were admitted to an emergency department. Cerebrospinal fluid (CSF) and serum levels of procalcitonin were measured in 105 consecutive patients. The diagnosis of meningitis was based on clinical findings, gram staining, culture, and chemical analysis of CSF. Twenty-three patients had bacterial meningitis, 57 had viral meningitis, and 25 did not have meningitis. Bacteriologic and chemical analysis of CSF did not allow correct differentiation of viral from bacterial meningitis. On the other hand, a serum procalcitonin level >0.2 ng/mL had a sensitivity and specificity of up to 100% in the diagnosis of bacterial meningitis. Serum procalcitonin levels seem to be the best marker in differentiating between bacterial and viral meningitis in adults.

To analyse the factors influencing the time of admission of patients presenting an acute ischaemic stroke (AIS) to the emergency department.Between May 2006 and July 2007, all patients with suspected stroke admitted to the emergency department were included. Patients' characteristics and the nature and timing of the events following symptom detection were recorded in the emergency department. The symptoms observed, the person telephoning for help, the person or establishment contacted, the measures implemented (attendance of a physician, medical or paramedical intervention) and the means of transport to the hospital were noted. The overall population was analysed descriptively and patients admitted within 3 hours of symptom onset (group I) were compared with those admitted after a longer interval (group II). The final diagnosis of AIS was confirmed on patient discharge. The results were expressed as the mean (± SD) or median (interquartile range), Mann-Whitney and Chi(2) tests being used to analyse differences between the two groups (threshold of statistical significance: P0.05).Among the 678 patients admitted with suspected stroke, 536 were diagnosed as having experienced an AIS, 65 a haemorrhagic stroke, 3 a cerebral venous thrombosis and 74 an event other than an acute neurovascular event. The results therefore concern 536 patients (median age: 75 years), of whom 166 (31%, group I) were admitted within 3 hours of symptom onset and 370 after a longer interval (group II). The median time between symptom onset and the call for help was 15 min (1-26) in group I and 300 min (60-960) in group II (P0.0001). The median times to intervention of a physician (the patient's regular general practitioner, the physician on duty, or the SMUR [Mobile Emergency and Resuscitation Service] physician) ranged from 10 to 60 min. Median transport times ranged from 30 to 120 min depending on the type of transport employed. The two groups differed significantly with regard to intervention of a physician before admission to the emergency department (40% of patients in group I vs. 72% in group II, P0.0001), initial call to the emergency medical call centre ("15" in France) (42% vs. 17%, P0.001), presence of a relative or other person at the time of functional symptom onset (58% vs. 39%, P0.01), and immediate transport to hospital without medical intervention (49 vs. 11%). Finally, irrespective of the time to hospital admission, 12% of the patients studied were eligible for intravenous thrombolysis.In the event of a suspected stroke, these results favour contacting the emergency medical call centre and immediate transfer of the patient to an appropriate hospital establishment without waiting for prior medical intervention.

Meningitis is uncommon in elderly patients in emergency department (ED). The characteristics of bacterial meningitis (BM) and nonbacterial meningitis (NBM) occurring in older patients are compared. A prospective multicenter study was conducted in the EDs of three teaching hospitals. Consecutive adult patients (n=159) with a confirmed meningitis [cerebrospinal fluid (CSF) leukocyte count greater than 5 mm] were included in this study. Eighteen consecutive patients (11%) aged more than or equal to 60 years (median age of 67 years) presenting with confirmed meningitis were included. In the older group, the prevalence of BM was higher than in the younger group (50% vs. 11%, P

Acute pain still persists in patients under treatment after admission to emergency departments (ED). The objective of this study was to determine the efficacy of 1 g of paracetamol in patients presenting an osteoarticular injury.This prospective study included all patients admitted to the ED with an osteoarticular injury and a pain score above 30 on the visual analogue scale (VAS). Patients were selected on admission by the reception nurse and given paracetamol within 5 min of admission. VAS scores were recorded 30 and 60 min after admission. On discharge from the ED, the patients underwent a further VAS assessment and were asked a question about pain relief (yes/no answer). The primary endpoint was the VAS score at 60 min. The secondary endpoint was the pain relief expressed by the patient on discharge from the ED.Five hundred and seventy-one patients were included. The median stay in the ED was 90 min (75-120 min). The diagnoses at discharge were sprain or dislocation (ankle, knee, and wrist) for 287 patients, fracture for 102 patients, and other injury for 182 patients. In 69% of the patients, the injured limb was immobilized. The median VAS score on admission was 57. A significant difference was seen between the median VAS on admission and at 1 h after admission (57+/-18 vs. 30+/-18; P0.0001), and between the median VAS score at admission and the score at discharge from the ED (57+/-18 vs. 26+/-18, P0.0001). Finally, 81% of the patients expressed pain relief. On discharge from the ED, a gain of 20 mm on the VAS had a positive predictive value of 93% [area under curve (AUC): 89; CI: 86-92; P=0.001], for the endpoint 'patients stating pain relief'.A simple and easily applicable protocol of pain management permits the achievement of satisfactory analgesia during a patient's stay in the ED.

Objectives The objective of our study was to define the characteristics of patients admitted to the emergency department (ED) presenting with a methicillin-resistant Staphylococcus aureus (MRSA) infection. Patients and Methods The study included all patients admitted to the ED between January 2003 and December 2004 in whom a staphylococcal infection was documented. The risk factors associated with carriage of MRSA, the diagnosis made in the ED, and the treatment administered were established from the patients' medical files. The sites from which the bacteria were isolated, the spectrum of resistance of the staphylococci to different antibiotics, and the presence or absence of the gene coding for Panton-Valentin leukocidin for certain S aureus isolates were determined from the reports issued by the bacteriologic department. Two groups of patients were compared: those with an infection caused by MRSA and those with an infection due to methicillin-susceptible S aureus (MSSA). Results A total of 238 patients were included, 93 presenting with an infection caused by MRSA and 145 an infection due to MSSA. The patients harboring MRSA had a higher median age than those carrying MSSA (74 vs 61 years, P = .0001), experienced a greater loss of autonomy (according to the Knauss index), and had more comorbidity factors. Nine patients, younger than 40 years, presented with an infection due to MRSA in the absence of any comorbidity factor or any factor associated with carriage of these bacteria. Seven patients in the MRSA group were tested for Panton-Valentine leukocidin genes, and a positive result was obtained in 2 of them. Regardless of whether the infection was caused by MRSA or by MSSA, the bacteria were most frequently isolated from a cutaneous site, in 40% and 65% of the patients, respectively. Irrespective of the group, 28% of the patients presented with bacteremia. The spectrum of resistance of these MRSA strains suggested a hospital rather than community origin. The initial antibiotic therapy was rarely appropriate in the case of an infection due to MRSA. Conclusion Infections caused by MRSA accounted for a high proportion of the staphylococcal infections diagnosed in the ED, necessitating a rational approach to the prescription of antibiotics for infections of this type.

The incidence of drug-related adverse events increases with age. In approximately 20% of cases, these events necessitate hospitalization. By taking into account the physiological changes associated with aging when prescribing drugs, physicians can prevent some of these events. The objective of this study was to analyze the prescriptions written by general practitioners for elderly patients admitted to the emergency department in relation to the patient's creatinine clearance.Of 968 consecutive patients older than 70 years, 419 underwent a plasma creatinine assay on admission and were included in this study. Creatinine clearance was calculated with Cockcroft's formula. The patients were classified into two groups according to creatinine clearance:30 mL/min (group I) andor=30 mL/min (group II).Creatinine clearance was30 mL/min in 84 of the 419 patients (group I) andor=30 mL/min in 335 (group II). Mean age was significantly higher in group I than in group II (87 +/- 6 vs 81 +/- 6 years, p0.001), as was mean plasma creatinine concentration (113 +/- 23 vs 83 +/- 19 mmol/L, p0.001), while mean weight was significantly lower (57 +/- 10 vs 69 +/- 13 kg, p0.001. In group I, 82 drugs with precautions concerning renal function had been prescribed for 69 (82%) patients, and in group II, 331 such drugs for 174 (52%) patients. Of the 82 drugs prescribed in group I that required precaution, 47 (57%) were contraindicated or prescribed at an inappropriate dose in view of the creatinine clearance. Irrespective of pharmacokinetic parameters, the mean number of drugs taken per patient was 5 +/- 2 in group I and 6 +/-2 in group II.In prescribing drugs for elderly patients, especially those whose weight is low, careful attention should be paid to renal function.

Objective: To assess the potential role of procalcitonin and pro-inflammatory cytokines, TNF-α, and IL-6, in the diagnosis of spontaneous bacterial peritonitis (SBP). Design: Prospective study. Setting: The emergency unit of a teaching hospital. Patients: We included 21 patients with SBP and 40 patients with sterile ascitic fluid. Interventions: None. Measurements and main results: For the diagnosis of SBP, the best markers were serum levels of procalcitonin with a cut-off value of 0.75 ng/ml, a sensitivity of 95 %, a specificity of 98 %, and ascitic fluid levels of IL-6 with a cut-off value of 5000 ng/ml, a sensitivity of 100 %, and a specificity of 88 %. C-reactive protein and serum polymorphonuclear count have low sensitivity/specificity at 62/92 % and 57/90 %, respectively. From 21 patients with SBP, ascitic fluid to serum ratio of TNF-α and IL-6 was greater than to 2 in all cases with a mean at 6.2 ± 6.5 and 34 ± 31, respectively. By contrast, this ratio for procalcitonin was less than 1 in all cases with a mean at 0.31 ± 0.25. We found no correlation between procalcitonin levels and cytokine levels in either ascitic fluid or serum. Conclusions: Serum procalcitonin level may become a useful marker for the diagnosis of SBP in cirrhotic patients. The low ratio of ascitic fluid to serum procalcitonin supports the hypothesis that procalcitonin is not produced intraperitoneally.

The use of bicarbonates in the treatment of severe diabetic ketoacidosis remains controversial, especially regarding the benefit/risk ratio. The aim of this study was to assess the efficacy of bicarbonate therapy during severe diabetic ketoacidosis (pH7.10).Retrospective study.The emergency unit of a teaching hospital.The records of 39 patients consecutively admitted for severe diabetic ketoacidosis were analyzed (pH7.10). The patients were divided into two groups: group 1 (n = 24; patients with bicarbonate treatment) and group 2 (n = 15; patients without bicarbonate treatment).None.We compared two groups of patients presenting with severe diabetic ketoacidosis (pH values between 6.83 and 7.08) treated with or without bicarbonate. A group of 24 patients received 120+/-40 mmol sodium bicarbonate. The two groups were similar at admission with regard to clinical and biological parameters. No difference could be demonstrated between the two groups concerning the clinical parameters or the normalization time of biochemical parameters. If the number of patients with hypokalemia was comparable between the two groups, the potassium supply was significantly more important in group 1 compared with group 2 (366+/-74 mmol/L vs. 188+/-109 mmol/L, respectively; p.001).Data from the literature and this study are not in favor of the use of bicarbonate in the treatment of diabetic ketoacidosis with pH values between 6.90 and 7.10.

The purpose of this study was to evaluate adult first seizures in an emergency department by analyzing etiologic and epidemiological data and studying the usefulness of biological screening, electroencephalogram (EEG), and cerebral computed tomography (CT) scan. This was a retrospective study of a 3-year period during which 247 patients were admitted to an emergency department for a first generalized seizure. A CT scan had been performed in 247 patients and an EEG in 209. Etiologies were found to be (1) unknown, (2) alcohol abuse, (3) stroke, and (4) tumor. Early recurrence rate was 18.5%. EEG was of low interest in emergency. The rate of cerebral focal lesions on CT scan was significantly lower when both examination results and EEG were normal. The rate of metabolic abnormalities was 4.9%. It was concluded that (1) a short hospitalization is advisable because of recurrences, (2) recurrence rate does not increase significantly in patients with focal cerebral lesion, (3) metabolic screening is necessary, and (4) CT scan will be an outpatient procedure for most patients.

Introduction The objective of this study was to determine the ability of various parameters commonly used for the diagnosis of acute meningitis to differentiate between bacterial and viral meningitis, in adult patients with a negative direct cerebrospinal fluid (CSF) examination. Methods This was a prospective study, started in 1997, including all patients admitted to the emergency unit with acute meningitis and a negative direct CSF examination. Serum and CSF samples were taken immediately on admission. The patients were divided into two groups according to the type of meningitis: bacterial (BM; group I) or viral (VM; group II). The CSF parameters investigated were cytology, protein, glucose, and lactate; the serum parameters evaluated were C-reactive protein and procalcitonin. CSF/serum glucose and lactate ratios were also assessed. Results Of the 254 patients with meningitis with a negative direct CSF examination, 35 had BM and 181, VM. The most highly discriminative parameters for the differential diagnosis of BM proved to be CSF lactate, with a sensitivity of 94%, a specificity of 92%, a negative predictive value of 99%, a positive predictive value of 82% at a diagnostic cut-off level of 3.8 mmol/L (area under the curve (AUC), 0.96; 95% confidence interval (CI), 0.95 to 1), and serum procalcitonin, with a sensitivity of 95%, a specificity of 100%, a negative predictive value of 100%, and a positive predictive value of 97% at a diagnostic cut-off level of 0.28 ng/ml (AUC, 0.99; 95% CI, 0.99 to 1). Conclusions Serum procalcitonin and CSF lactate concentrations appear to be the most highly discriminative parameters for the differential diagnosis of BM and VM.