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Supplemental Digital Content is available in the text., Objective The aim of this study was to assess the effect of prehospital noninvasive ventilation for acute cardiogenic pulmonary edema on endotracheal intubation rate and on ICU admission rate. Methods We carried out a retrospective study on patients’ prehospital files between 2007 and 2010 (control period), and between 2013 and 2016 (intervention period). Adult patients were included if a diagnosis of acute cardiogenic pulmonary edema was made by the prehospital physician. Exclusion criteria were a Glasgow coma scale score less than 9 or any other respiratory diagnosis. We analyzed the association between noninvasive ventilation implementation and endotracheal intubation or ICU admission with univariable and multivariable regression models. The primary outcome was prehospital endotracheal intubation rate. Secondary outcomes were admission to an ICU, prehospital intervention length, and 30-day mortality. Results A total of 1491 patients were included. Noninvasive ventilation availability was associated with a significant decrease in endotracheal intubation rate (2.6% in the control versus 0.7% in the intervention period), with an adjusted odds ratio (OR) of 0.3 [95% confidence interval (CI), 0.1–0.7]. There was a decrease in ICU admissions (18.6% in the control versus 13.0% in the intervention period) with an adjusted OR of 0.6 (95% CI, 0.5–0.9). There was no significant change in 30-day mortality (11.2% in the control versus 11.0% in the intervention period, P = 0.901). Conclusion In our physician-staffed prehospital system, use of noninvasive ventilation for acute cardiogenic pulmonary edema decreased both endotracheal intubation and ICU admission rates.

Diagnosis of pulmonary embolism (PE) relies on the sequential use of pretest probability (PTP), plasma D-dimer, and computed tomography pulmonary angiography. D-dimer

Background Ultrasound-guided fascia iliaca compartment block (US-FICB) is not part of the learning curriculum of the emergency physicians (EP) and is usually performed by anesthesiologists. However, several studies promote EP to use this procedure. The goal of this study was to assess the feasibility of a training concept for non-anesthesiologists for the US-FICB on a simulator based on a validating learning path. Method This was a feasibility study. Emergency physicians and medical students received a 1-day training with a learning phase (theoretical and practical skills), followed by an assessment phase. The primary outcome at the assessment phase was the number of attempts before successfully completing the procedure. The secondary outcomes were the success rate at first attempt, the length of procedure (LOP), and the stability of the probe, corresponding to the visualization of the needle tip (and its tracking) throughout the procedure, evaluated on a Likert scale. Results A total of 25 participants were included. The median number of attempts was 2.0 for emergency physicians and 2.5 for medical students, and this difference was not significant (p = 0.140). Seven participants (28%) succeeded at the first attempt of the procedure; the difference between emergency physicians and medical students was not significant (37% versus 21%; p = 0.409). The average LOP was 19.7 min with a significant difference between emergency physicians and medical students (p = 0.001). There was no significant difference regarding the stability of the probe between the two groups. Conclusion Our 1-day training for non-anesthesiologists with or without previous skills in ultrasound seems to be feasible for learning the US-FICB procedure on a simulator.

Background The clinical decisions of emergency department triage nurses need to be of the highest accuracy. However, studies have found repeatedly that these nurses over- or underestimate the severity of patient health conditions. This has major consequences for patient safety and patient flow management. Workplace distractors such as noise and task interruptions have been pointed to as factors that might explain this inaccuracy. The use of a serious game reproducing the work environment during triage affords the opportunity to explore the impact of these distractors on nurse emergency triage accuracy, in a safe setting. Methods/design A pilot study with a factorial design will be carried out to test the acceptability and feasibility of a serious game developed specifically to simulate the triage process in emergency departments and to explore the primary effects of distractors on nurse emergency triage accuracy. Eighty emergency nurses will be randomized into four groups: three groups exposed to different distractors (A, noise; B, task interruptions; C, noise and task interruptions) and one control group. All nurses will have to complete 20 clinical vignettes within 2 h. For each vignette, a gold standard assessment will be determined by experts. Pre-tests will be conducted with clinicians and certified emergency nurses to evaluate the appeal of the serious game. Discussion Study results will inform the design of large-scale investigations and will help identify teaching, training, and research areas that require further development.

Plain abdominal radiography (PAR) is routinely performed in emergency departments (EDs). This study aimed to (1) identify the indications for PAR in EDs and compare them against international guidelines, (2) uncover predictors of non-compliance with guidelines, and (3) describe the use of additional radiological examinations in EDs. Retrospective cohort study in the EDs of two hospitals in Geneva, Switzerland, including all adult patients who underwent PAR in the EDs. Indications were considered “appropriate” if complying with guidelines. Predictors of non-compliance were identified by univariate and multivariate analyses. Over 1 year, PAR was performed in 1997 patients (2.2% of all admissions). Their mean age was 59.7 years, with 53.1% of female patients. The most common indications were constipation (30.8%), suspected ileus (28.9%), and abdominal pain (15.3%). According to the French and American guidelines, only 11.8% of the PARs were indicated, while 46.2% of them complied with the Australian and British guidelines. On multivariate analysis, admission to the private hospital ED (odds ratio [OR] 3.88, 95% CI 1.78–8.45), female gender (OR 1.95, 95% CI 1.46–2.59), and an age > 65 years (OR 2.41, 95%CI 1.74–3.32) were associated with a higher risk of inappropriate PAR. Additional radiological examinations were performed in 73.7% of patients. Most indications for PAR did not comply with guidelines and elderly women appeared particularly at risk of being exposed to inappropriate examination. PAR did not prevent the need for additional examinations. Local guidelines should be developed, and initiatives should be implemented to reduce unnecessary PARs. ClinicalTrials.gov , identifier NCT02980081 .

Acute ethanol intoxication (AEI) is frequent in emergency departments (EDs). These patients are at risk of mistriage, and to leave the ED without being seen. This study's objective was to describe the process and performance of triage and trajectory for patients with suspected AEI. Retrospective, observational study on adults admitted with a suspected AEI within 1 year at the ED of an urban teaching hospital. Data on the triage process, patients' characteristics, and their ED stay were extracted from electronic patient records. Predictors for leaving without being seen were identified using logistic regression analyzes. Of 60,488 ED patients within 1 year, 776 (1.3%) were triaged with suspected AEI. This population was young (mean age 38), primarily male (64%), and professionally inactive (56%). A large proportion were admitted on weekends (45%), at night (46%), and arrived by ambulance (85%). The recommendations of our triage scale were entirely respected in a minority of cases. In 22.7% of triage situations, a triage reason other than "alcohol abuse/intoxication" (such as suicidal ideation, head trauma or other substance abuse) should have been selected. Nearly, half of the patients (49%) left without being seen (LWBS). This risk was especially high amongst men (OR 1.56, 95% CI 1.12-2.19), younger patients (

To evaluate non-intravenously enhanced low-dose computed tomography with oral contrast (LDCT) for the assessment of pregnant women with right lower quadrant pain, when magnetic resonance imaging (MRI) is not immediately available. One hundred and thirty-eight consecutive pregnant women with acute abdominal pain were admitted in our emergency centre. Thirty-seven (27%) of them, with clinical suspicion of acute appendicitis, underwent abdominal ultrasonography (US). No further examination was recommended when US was positive for appendicitis, negative with low clinical suspicion or showed an alternative diagnosis which explained the clinical presentation. All other patients underwent LDCT (

At patient intake in emergency departments, triage is a key step in ensuring optimal patient care and good use of hospital resources. Triage nurses must be able to make correct clinical judgements and triage decisions despite extremely stressful working conditions including noise and task interruptions. This article presents a new serious game designed to closely reproduce the conditions of a typical emergency department. Its purpose is to provide a generic testbed both for teaching and for research, notably in order to enable studying the impact of stressors on the quality of decisions made. A study involving 49 professional triage nurses shows that, despite its relatively modest technological requirements, this serious game is considered by the participants as highly attractive and very close to their professional experience.

BACKGROUND Acute pain is the most common complaint of patients presenting to emergency departments (EDs). Effective pain management is a core ED mission, but numerous studies have pointed to insufficient pain treatment or oligoanalgesia. According to a 1997 national survey in Swiss EDs, a validated pain scale was used in only 14%, an analgesia protocol in

Opiophobia contributes to oligoanalgesia in the emergency department (ED), but its definition varies, and its association to healthcare providers’ personality traits has been scantly explored. Our purpose was to study the different definitions of opiophobia and their association with two personality traits of doctors and nurses working in EDs, namely the stress from uncertainty and risk-taking. We used three online questionnaires: the ‘Attitude Towards Morphine Use’ Score (ATMS), the Stress From Uncertainty Scale (SUS) and the Risk-Taking Scale (RTS). Doctors and nurses from nine hospital EDs in francophone Switzerland were invited to participate. The ATMS score was analyzed according to demographic characteristics, SUS, and RTS. The response rate was 56%, with 57% of respondents being nurses and 63% women. Doctors, less experienced and non-indigenous participants had a significantly higher ATMS (all p ≤ 0.01). The main contributors of the ATMS were the fear of side effects and of addiction. In multivariate analysis, being a doctor, less experience and non-indigenous status were predictive of the ATMS, each point of the SUS increased the ATMS by 0.24 point. The fear of side effects and of addiction were the major contributors of opiophobia among ED healthcare providers, opiophobia was also associated with their personality traits.

Aim To identify the predictive signs of aortic valve involvement on the non-electrocardiogram (ECG)-gated admission computed tomography (CT) of patients with Type A aortic dissection (AD) according to the Stanford classification. Materials and methods We retrospectively analyzed the non-ECG-gated CT examinations of patients admitted to the emergency department who underwent surgery for Type A AD over a period of 4 years. The diameter of the following structures was calculated as the mean of the smallest and largest diameters (mm) measured in two different planes: aortic annulus, sinus of Valsalva, sinotubular junction, and proximal ascending aorta. These parameters were compared against operative reports in order to determine whether they were predictive of aortic valve involvement. Results In total, 20 patients (13 men and 7 women) of a mean age of 59.5 years (29–80) were included, 55% of patients (11/20) having surgically proven valvular involvement. The mean diameters (in mm) of the aortic annulus, sinus of Valsalva, sinotubular junction and proximal ascending aorta in the group with (and without, respectively) valvular involvement was 27.7 (26.7), 44.3 (38.1), 42.6 (36.6), and 47.8 (45.9). Only the measurement of the mean diameter of the sinuses of Valsalva was significantly predictive (p = 0.02) of aortic valve involvement. Conclusion Our findings suggest that measuring the diameter of the sinuses of Valsalva on non-ECG-gated admission CT examinations allows for predicting aortic valve involvement in Type A AD patients.

Background Acute abdominal pain accounts for about 10% of emergency department visits and has progressively become the primary indication for CT scanning in most centers. The goal of our study is to identify biological or clinical variables able to predict or rule out significant pathology (conditions requiring urgent medical or surgical treatment) on abdominal CT in patients presenting to an emergency department with acute abdominal pain. Methods This was a retrospective cohort study performed in the emergency department of an academic center with an annual census of 60′000 patients. One hundred and-nine consecutive patients presenting with an acute non-traumatic abdominal pain, not suspected of appendicitis or renal colic, during the first semester of 2013, who underwent an abdominal CT were included. Two medical students, completing their last year of medical school, extracted the data from patients’ electronic health record. Ambiguities in the formulations of clinical symptoms and signs in the patients’ records were solved by consulting a board certified emergency physician. Nine clinical and biological variables were extracted: shock index, peritonism, abnormal bowel sounds, fever (> 38 °C), intensity and duration of the pain, leukocytosis (white blood cell count >11G/L), relative lymphopenia (

Objective Overcrowding is common in most emergency departments (ED). Despite the use of validated triage systems, some patients are at risk of delayed medical evaluation. The objective of this study was to assess the impact of a patient-flow physician coordinator (PFPC) on the proportion of patients offered medical evaluation within time limits imposed by the Swiss Emergency Triage Scale (SETS) and on patient flow within the emergency department of a teaching urban hospital. Methods In this before-after retrospective cohort study, we compared the proportions of patients who received their first medical contact within SETS-imposed time limits, mean waiting times before first medical consultation, mean length of stay, and number of patients who left without being seen by a physician, between two periods before and after introducing a PFPC. The PFPC was a senior physician charged with quickly assessing in the waiting area patients who could not immediately be seen and managing patient flow within the department. Results Before introducing the PFPC position, 33,605 patients were admitted, versus 36,288 after. Introducing a PFPC enabled the department to increase the proportion of patients seen within the SETS-imposed time limits from 60.1% to 69.0% (p

Background The Swiss Emergency Triage Scale (SETS) is a four-level emergency scale that previously showed moderate reliability and high rates of undertriage due to a lack of standardization. It was revised to better standardize the measurement and interpretation of vital signs during the triage process. Objective The aim of this study was to explore the inter-rater and test–retest reliability, and the rate of correct triage of the revised SETS. Patients and methods Thirty clinical scenarios were evaluated twice at a 3-month interval using an interactive computerized triage simulator by 58 triage nurses at an urban teaching emergency department admitting 60 000 patients a year. Inter-rater and test–retest reliabilities were determined using κ statistics. Triage decisions were compared with a gold standard attributed by an expert panel. Rates of correct triage, undertriage, and overtriage were computed. A logistic regression model was used to identify the predictors of correct triage. Results A total of 3387 triage situations were analyzed. Inter-rater reliability showed substantial agreement [mean κ: 0.68; 95% confidence interval (CI): 0.60–0.78] and test–retest almost perfect agreement (mean κ: 0.86; 95% CI: 0.84–0.88). The rate of correct triage was 84.1%, and rates of undertriage and overtriage were 7.2 and 8.7%, respectively. Vital sign measurement was an independent predictor of correct triage (odds ratios for correct triage: 1.29 for each additional vital sign measured, 95% CI: 1.20–1.39). Conclusion The revised SETS incorporating standardized vital sign measurement and interpretation during the triage process resulted in high reliability and low rates of mistriage.

BACKGROUND: Respiratory viruses frequently are recovered in the upper-respiratory tract during acute exacerbations of COPD (AECOPD), but their role as contributing pathogens remains unclear. The usefulness of procalcitonin and C-reactive protein as indicators of the presence or absence of viral infection in this setting also needs to be evaluated. METHODS: The study was of a prospective cohort of patients with COPD admitted to the ED for AECOPD. Reverse transcriptase-polymerase chain reaction (RT-PCR) for 14 respiratory viruses was performed on nasopharyngeal swabs collected at admission and after recovery in stable condition. RESULTS: Eighty-six patients (mean age, 72 years; male, 64%) were included. During AECOPD, upper-respiratory viral infections were detected in 44 (51%) patients: picornavirus in 22, metapneumovirus in seven, coronavirus in eight, influenza A/B in two, parainfluenza in two, and respiratory syncytial virus in three. A dual infection was present in three patients. After recovery, viruses were detected in only eight (11%) of 71 patients (P < .001 compared with AECOPD phase). In five of these patients, no virus had been identified during the initial exacerbation, thus suggesting a new viral infection acquired during follow-up. During AECOPD, procalcitonin and C-reactive protein levels did not differ significantly between patients with or without a proven viral infection. CONCLUSIONS: Prevalence of upper-respiratory viral infection, as detected from nasopharyngeal swab by RT-PCR, is high in AECOPD and low after clinical recovery, suggesting that AECOPD frequently are triggered by viral infections initiated in the upper-respiratory tract. In our study, serum procalcitonin and C-reactive protein did not discriminate virus-associated exacerbations from others. TRIAL REGISTRATION: clinicaltrials.gov; Identifier: NCT00448604.

Background Pelvic binders are routinely used in the prehospital setting for stabilization of pelvic injuries in patients with trauma. Emergency department trauma management relies on primary and secondary survey assessment and imaging, most often computed tomography, in hemodynamically stable patients. Maintaining the pelvic binder in situ allows stabilization of pelvic injuries during imaging but may hinder the visualization of some pelvic lesions. We report a very rare case of severe pelvic disruption with an absolutely normal computed tomography scan due to the effective placement of a pelvic binder. Case presentation We report the case of a 49-year-old Caucasian man referred to our Emergency Department after a high velocity motorcycle accident. Primary assessment revealed a left wrist deformation and pelvic pain, and a pelvic binder was applied by paramedics. A total body computed tomography scan was performed after arrival in our Emergency Department and did not reveal any pelvic injury. The pelvic binder was removed and because of persisting symphyseal pain, pelvic plain radiography was performed revealing a pelvic disruption with an opening of the pubic symphysis and of the left sacroiliac joint (“open book” type pelvic injury) requiring surgical stabilization. Conclusions Pelvic binders may mask pelvic disruption in patients with trauma. Pelvic plain radiography should be repeated after pelvic binder removal in patients with high velocity trauma and pelvic symptoms or neurological alterations limiting the reliability of clinical examination.

Objectives No general emergency department triage scale has been evaluated for prehospital triage. The objective of this study was to evaluate the reliability and the performance of the Swiss Emergency Triage Scale (SETS) used by paramedics to determine the emergency level and orientation of simulated patients. Patients and methods In a prospective cross-sectional study, 23 paramedics evaluated 28 clinical scenarios with the SETS using interactive computerized triage software simulating real-life triage. The primary outcome was inter-rater reliability regarding the triage level among participants measured by intraclass correlation coefficient (ICC). Secondary outcomes were the accuracy of triage level and the reliability and accuracy of orientation of patients of at least 75 years to a dedicated geriatric emergency centre. Results Twenty-three paramedics completed the evaluation of the 28 scenarios (644 triage decisions). Overall, ICC for triage level was 0.84 (95% confidence interval: 0.77-0.99). Correct emergency level was assigned in 89% of cases, overtriage rate was 4.8%, and undertriage was 6.2%. ICC regarding orientation in the subgroup of simulated patients of at least 75 years was 0.76 (95% confidence interval: 0.61-0.89), with 93% correct orientation. Conclusion Reliability of paramedics rating simulated emergency situations using the SETS was excellent, and the accuracy of their rating was very high. This suggests that in Switzerland, the SETS could be safely used in the prehospital setting by paramedics to determine the level of emergency and guide patients to the most appropriate hospital.

Purpose To determine parameters related to hyperdensity (>40 HU) of intra-corporeal cocaine packets on low-dose CT (LDCT); hyperdensity increases detectability on abdominal radiographs. Methods LDCT showing drug packets (n = 46) were analyzed for mean radiological density and packets volume. Following expulsion, packets weight and cocaine concentration were measured. Hypercompaction was defined as >0.9 g/cm3. Results Packets were hyperdense in 33 cases (72%). Mean compaction was 1.0 g/cm3, mean density 118.5 HU and mean cocaine concentration 44.2%. On multivariate analysis, only high compaction remained significantly related to hyperdensity (p = 0.001). Conclusion Compaction >0.9 g/cm3 is the only parameter significantly associated with hyperdense packets.

Background We aimed to describe clinical characteristics of patients with community-acquired acute kidney injury (CA-AKI), the effectiveness of initial management of CA-AKI, its prognosis and the impact of medication on its occurrence in patients with previous chronic kidney injury (CKI). Methods We undertook a prospective observational study within the Emergency Department (ED) of a University Hospital, screening for any patient >16 years admitted with an eGFR

Drink-driving remains a major problem of public health (Alvarez and Del Rio, 1996). One of the most controversial issues is the choice of legal limit, as the ability to drive can be affected by alcohol levels well below current legal limits (Dunbar et al. , 1987; Howat et al. , 1991; Guppy, 1994). This study addressed the questions of the self-estimation of ability to drive, and its correlation with blood-alcohol concentration (BAC) measured with a breath-ethanol analyser in a population of non-professional male soldiers. In November 1997, at 23:00, during the last evening of a 3-week military course, in Geneva barracks, soldiers were asked to fill in a questionnaire including birth date, CAGE test, self-evaluation of ability to drive, and self-estimation of BAC. All gave informed consent and were instructed that the legal Swiss …

International audience; IMPORTANCE: D-dimer measurement is an important step in the diagnostic strategy of clinically suspected acute pulmonary embolism (PE), but its clinical usefulness is limited in elderly patients. OBJECTIVE: To prospectively validate whether an age-adjusted D-dimer cutoff, defined as age × 10 in patients 50 years or older, is associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. DESIGN, SETTINGS, AND PATIENTS: A multicenter, multinational, prospective management outcome study in 19 centers in Belgium, France, the Netherlands, and Switzerland between January 1, 2010, and February 28, 2013. INTERVENTIONS: All consecutive outpatients who presented to the emergency department with clinically suspected PE were assessed by a sequential diagnostic strategy based on the clinical probability assessed using either the simplified, revised Geneva score or the 2-level Wells score for PE; highly sensitive D-dimer measurement; and computed tomography pulmonary angiography (CTPA). Patients with a D-dimer value between the conventional cutoff of 500 µg/L and their age-adjusted cutoff did not undergo CTPA and were left untreated and formally followed-up for a 3-month period. MAIN OUTCOMES AND MEASURES: The primary outcome was the failure rate of the diagnostic strategy, defined as adjudicated thromboembolic events during the 3-month follow-up period among patients not treated with anticoagulants on the basis of a negative age-adjusted D-dimer cutoff result. RESULTS: Of the 3346 patients with suspected PE included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level lower than 500 µg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a D-dimer between 500 µg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%). The 3-month failure rate in patients with a D-dimer level higher than 500 µg/L but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI, 0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a nonhigh clinical probability, using the age-adjusted cutoff instead of the 500 µg/L cutoff increased the proportion of patients in whom PE could be excluded on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to 200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional false-negative findings. CONCLUSIONS AND RELEVANCE: Compared with a fixed D-dimer cutoff of 500 µg/L, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01134068.

Objective To evaluate urinary incontinence (UI) as a predictor of nursing home admission, hospitalization or death in patients receiving home care services. Subjects and Methods A total of 699 community-dwelling participants receiving home care services in Geneva were evaluated in Autumn 2004 using the Minimal Data Set-Home Care, a validated instrument that includes grading of UI. Data on death, hospitalization and nursing home admission were collected up until June 2007. The impact of UI on time-dependent outcomes was analysed using survival analysis and multivariate regression Cox models to adjust for age, gender, body mass index, cardiac failure, cognitive impairment, delirium, depression, disability, alcohol and tobacco use, self-rated health, faecal incontinence and number of medications. Results We found that UI was present in 193 participants (27.8%). After adjustment for confounding factors, UI was associated with a longer length of hospital stay: +36.7 days, (95% confidence interval [CI]: 1.2–72.3) and a higher mortality rate (hazard ratio [HR] 1.6; 95% CI: 1.1–2.6). The HR for death was 1.5 (95% CI: 0.9–2.5) for participants complaining of one episode of urinary leakage per week at most, 2.0 (95% CI: 1.2–3.5) for those presenting with two or more episodes per week and 4.2 (95% CI: 2.3–7.7; P for trend

AIMS OF THE STUDY Profound hyponatremia (

Background The association between early antibiotic administration and outcomes remains controversial in patients hospitalized for community-acquired pneumonia. Methods We performed a secondary analysis of a randomized controlled trial comparing two antibiotic treatment strategies for patients hospitalized for moderately severe CAP. The univariate and multivariate associations between time to antibiotic administration (TTA) and time to clinical stability were assessed using a Cox proportional hazard model. Secondary outcomes were death, intensive care unit admission and hospital readmission up to 90 days. Results 371 patients (mean age 76 years, CURB-65 score ≥ 2 in 52%) were included. Mean TTA was 4.35 h (SD 3.48), with 58.5% of patients receiving the first antibiotic dose within 4 h. In multivariate analysis, number of symptoms and signs (HR 0.876, 95% CI 0.784–0.979, p = 0.020), age (HR 0.986, 95% CI 0.975–0.996, p = 0.007), initial heart rate (HR 0.992, 95% CI 0.986–0.999, p = 0.023), and platelets count (HR 0.998, 95% CI 0.996–0.999, p = 0.004) were associated with a reduced probability of reaching clinical stability. The association between TTA and time to clinical stability was not significant (HR 1.009, 95% CI 0.977–1.042, p = 0.574). We found no association between TTA and the risk of intensive care unit admission, death or readmission up to 90 days after the initial admission. Conclusion In patients hospitalized for moderately severe CAP, a shorter time to antibiotic administration was not associated with a favorable outcome. These findings support the current recommendations that do not assign a specific time frame for antibiotics administration.

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

A first seizure is a life-changing event with physical and psychological consequences. We aimed to assess the role of early comprehensive patient care after a first unprovoked seizure to improve diagnostic accuracy and follow-up adherence. From April 2011 to March 2012, patients presenting a first unprovoked epileptic seizure received standard patient care (SPC), i.e., a consultation in the ED, an EEG and a CT scan. The patients were notified of the follow-ups. We compared this protocol to subsequently acquired "early comprehensive patient care" (ECPC), which included a consultation by an epileptologist in the emergency department (ED), a routine or long-term monitoring electroencephalogram (LTM-EEG), magnetic resonance imaging and three follow-up consultations (3 weeks, 3 months, 12 months). 183 patients were included (113 ECPC, 70 SPC). LTM-EEG and MRI were performed in 51 and 85 %, respectively, of the patients in the ECPC group vs in 7 and 52 % of the patients in the SPC group (p

To determine if radiation dose delivered by contrast-enhanced CT (CECT) for acute abdominal pain can be reduced to the dose administered in abdominal radiography (

Development of a dysregulated immune response discriminates sepsis from uncomplicated infection. Currently used biomarkers fail to describe simultaneously occurring pro- and anti-inflammatory responses potentially amenable to therapy. Marker candidates were screened by microarray and, after transfer to a platform allowing point-of-care testing, validated in a confirmation set of 246 medical and surgical patients. We identified up-regulated pathways reflecting innate effector mechanisms, while down-regulated pathways related to adaptive lymphocyte functions. A panel of markers composed of three up- (Toll-like receptor 5; Protectin; Clusterin) and 4 down-regulated transcripts (Fibrinogen-like 2; Interleukin-7 receptor; Major histocompatibility complex class II, DP alpha1; Carboxypeptidase, vitellogenic-like) described the magnitude of immune alterations. The created gene expression score was significantly greater in patients with definite as well as with possible/probable infection than with no infection (median (Q25/Q75): 80 (60/101)) and 81 (58/97 vs. 49 (27/66), AUC-ROC = 0.812 (95%-CI 0.755–0.869), p, Highlights • Pro- and anti-inflammatory signaling occurs simultaneously in the host response to infection. • This response is currently monitored using biomarkers restricted to the pro-inflammatory component of innate immunity. • We developed a biomarker panel consisting of 7 transcripts that can assess both facets at the point of care. The concept that a selective, overwhelming systemic inflammation, the “Systemic Inflammatory Response Syndrome (SIRS)”, triggers organ failure subsequent to infection has lately been abandoned as it neglects parallel occurring anti-inflammatory responses or defects in the adaptive immune system. The present findings suggest that a compound panel of nucleic acid biomarkers that was developed in independent training and verification cohorts and transferred to a point-of-care platform can more comprehensively describe the host response. Quantification of an enhanced innate immunity might inform studies of anti-inflammatory therapies, while measurement of derangements in specific immunity might guide strategies to restore immune effector functions.

To explore the diagnostic accuracies of anti-apolipoproteinA-1 (anti-ApoA-1) IgG and anti-phosphorylcholine (anti-PC) IgM alone, expressed as a ratio (anti-ApoA-1 IgG/anti-PC IgM), and combined with the Thrombolysis In Myocardial Infarction (TIMI) score for non-ST-segment elevation myocardial infarction (NSTEMI) (NSTEMI-TIMI score) to create a new diagnostic algorithm - the Clinical Autoantibody Ratio (CABR) score - for the diagnosis of NSTEMI and subsequent cardiac troponin I (cTnI) elevation in patients with acute chest pain (ACP).

Objectives: To evaluate an algorithm integrating ultrasound and low-dose unenhanced CT with oral contrast medium (LDCT) in the assessment of acute appendicitis, to reduce the need of conventional CT. Methods: Ultrasound was performed upon admission in 183 consecutive adult patients (111 women, 72 men, mean age 32) with suspicion of acute appendicitis and a BMI between 18.5 and 30 (step 1). No further examination was recommended when ultrasound was positive for appendicitis, negative with low clinical suspicion, or demonstrated an alternative diagnosis. All other patients underwent LDCT (30mAs) (step 2). Standard intravenously enhanced CT (180mAs) was performed after indeterminate LDCT (step 3). Results: No further imaging was recommended after ultrasound in 84 (46%) patients; LDCT was obtained in 99 (54%). LDCT was positive or negative for appendicitis in 81 (82%) of these 99 patients, indeterminate in 18 (18%) who underwent standard CT. Eighty-six (47%) of the 183 patients had a surgically proven appendicitis. The sensitivity and specificity of the algorithm were 98.8% and 96.9%. Conclusions: The proposed algorithm achieved high sensitivity and specificity for detection of acute appendicitis, while reducing the need for standard CT and thus limiting exposition to radiation and to intravenous contrast media

Introduction Data acquisition is still one of the important challenges to be met in clinical settings. This is even more critic in settings with high cognitive workloads, such as emergency room (ER). Observations in these settings are difficult to realize without biases and there is little means to trace fine acquisition activities done in natural environments, using pen and papers. This study is based on the usage of a digital pen and paper (DPP) technology for the acquisition of triage information by nurses in ER. The DPP technology has been used to ease acquisition using a natural mechanism; it also minimizes the external influence of observation during acquisition activities. The aim of this study is to determine whether data recorded by the DPP technology allows explaining how ER triage nurses use the triage forms in real working conditions. Methodology The chief physicians of the ER service wanted to have answers about three main concerns pertaining to the triage process: (1) the average time spent during the triage process; (2) the sequence in which the fields of the forms were filled and; (3) the contribution of objective measurements, such as vital signs, to the triage emergency level and decisions. In order to answer these questions, detailed log data recorded by the DPP during form filling as been analyzed and allowed to built several representations of the triage process. In addition, we completed this analysis with ethnographical-like observations. Results For seven consecutive days, 1183 triage forms have been recorded in the ER for all patients admitted. Among them, 954 forms have been digitalized and 906 forms have been considered as valid and complete. Based on this set of data, the median duration of the triage process is 143 s. There are no converging habits in filling the forms and the sequence of filling fields present a high variability. The emphasis of the objective measurements in the decisional process is rather low, as vital signs are recorded in less than 17% of the cases. Conclusion The DPP technology is an original approach to study data acquisition processes in unbiased conditions. The technical raw data recorded by the DPP allows building the time series of all activities on the paper, therefore letting to constructing several representations of the process. However, the technology is not able to provide information about the context of use, for example interruptions of the form filling processes due to calls or other activities. Therefore, it is necessary to complete these analyses with qualitative approaches such as observational studies and interviews. Noticeably, as a result of this study, the head physicians of ER have redesigned the triage form to enforce the use of objective measurements and ease the data acquisition process.

The aim of this study was to evaluate a low-dose CT with oral contrast medium (LDCT) for the diagnosis of acute appendicitis and compare its performance with standard-dose i.v. contrast-enhanced CT (standard CT) according to patients’ BMIs. Eighty-six consecutive patients admitted with suspicion of acute appendicitis underwent LDCT (30 mAs), followed by standard CT (180 mAs). Both examinations were reviewed by two experienced radiologists for direct and indirect signs of appendicitis. Clinical and surgical follow-up was considered as the reference standard. Appendicitis was confirmed by surgery in 37 (43%) of the 86 patients. Twenty-nine (34%) patients eventually had an alternative discharge diagnosis to explain their abdominal pain. Clinical and biological follow-up was uneventful in 20 (23%) patients. LDCT and standard CT had the same sensitivity (100%, 33/33) and specificity (98%, 45/46) to diagnose appendicitis in patients with a body mass index (BMI) ≥ 18.5. In slim patients (BMI < 18.5), sensitivity to diagnose appendicitis was 50% (2/4) for LDCT and 100% (4/4) for standard CT, while specificity was identical for both techniques (67%, 2/3). LDCT may play a role in the diagnostic workup of patients with a BMI ≥ 18.5.

International audience; BACKGROUND: Multislice CT (MSCT) combined with D-dimer measurement can safely exclude pulmonary embolism in patients with a low or intermediate clinical probability of this disease. We compared this combination with a strategy in which both a negative venous ultrasonography of the leg and MSCT were needed to exclude pulmonary embolism. METHODS: We included 1819 consecutive outpatients with clinically suspected pulmonary embolism in a multicentre non-inferiority randomised controlled trial comparing two strategies: clinical probability assessment and either D-dimer measurement and MSCT (DD-CT strategy [n=903]) or D-dimer measurement, venous compression ultrasonography of the leg, and MSCT (DD-US-CT strategy [n=916]). Randomisation was by computer-generated blocks with stratification according to centre. Patients with a high clinical probability according to the revised Geneva score and a negative work-up for pulmonary embolism were further investigated in both groups. The primary outcome was the 3-month thromboembolic risk in patients who were left untreated on the basis of the exclusion of pulmonary embolism by diagnostic strategy. Clinicians assessing outcome were blinded to group assignment. Analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT00117169. FINDINGS: The prevalence of pulmonary embolism was 20.6% in both groups (189 cases in DD-US-CT group and 186 in DD-CT group). We analysed 855 patients in the DD-US-CT group and 838 in the DD-CT group per protocol. The 3-month thromboembolic risk was 0.3% (95% CI 0.1-1.1) in the DD-US-CT group and 0.3% (0.1-1.2) in the DD-CT group (difference 0.0% [-0.9 to 0.8]). In the DD-US-CT group, ultrasonography showed a deep-venous thrombosis in 53 (9% [7-12]) of 574 patients, and thus MSCT was not undertaken. INTERPRETATION: The strategy combining D-dimer and MSCT is as safe as the strategy using D-dimer followed by venous compression ultrasonography of the leg and MSCT for exclusion of pulmonary embolism. An ultrasound could be of use in patients with a contraindication to CT.

Objective: This study aimed to investigate whether, for an identical diagnosis, patients who were transferred to apostacute care (PAC) facility had a higher biopsychosocial complexity than patients who were discharged home. Methods: This prospective study employed group comparison that included 166 patients who were consecutively admitted to an acute care internal medicine ward for acute congestive heart failure, pneumonia or exacerbation of chronic obstructive pulmonary disease, and malaise or fall. Patients were evaluatedwithin their first48hofstay.Biomedical, functional, quality of life, and case complexity data were collected. Factors associated with a transfer to the PAC facility were identified through logistic regression modeling. Results: Fifty-eight patients (34.9%) were transferred. In the multivariate analyses, case complexity score [per point: odds ratio (OR)=1.29; 95% CI=1.18–1.41] and nursing workload (OR=1.06; 95% CI=1.01–1.12) were associated with the transfer. At a cutoff point of z33, the case complexity score predicted transfer to the PAC facility with a sensitivity of 79% and a specificity of 84% (positive predictive value=73.0%; negative predictive value=88.4%) and correctly classified 83% of the cases. Conclusions: Biomedical characteristics alone did not differentiate patients who were transferred versus those who were discharged home, nor did it predict PAC use. This was also true for specific severity scores of cardiac failure and pneumonia as well as for the comorbidity index. Psychosocial parameters were significantly associated to this process as well as a higher nursing workload.

Background: The cause of acute exacerbation of chronic obstructive pulmonary disease (COPD) is often difficult to determine. Pulmonary embolism may be a trigger of acute dyspnoea in patients with COPD. Aim: To determine the prevalence of pulmonary embolism in patients with acute exacerbation of COPD. Methods: 123 consecutive patients admitted to the emergency departments of two academic teaching hospitals for acute exacerbation of moderate to very severe COPD were included. Pulmonary embolism was investigated in all patients (whether or not clinically suspected) following a standardised algorithm based on d-dimer testing, lower-limb venous ultrasonography and multidetector helical computed tomography scan. Results: Pulmonary embolism was ruled out by a d-dimer value Conclusions: The prevalence of unsuspected pulmonary embolism is very low in patients admitted in the emergency department for an acute exacerbation of their COPD. These results argue against a systematic examination for pulmonary embolism in this population.

To evaluate a low-dose abdominal computed tomography (LDCT) protocol, delivering a radiation dose close to that delivered by an abdominal plain film (APF), in patients with a clinical suspicion of renal colic.A total of 139 patients for whom an APF was requested for suspicion of renal colic were randomized into two groups. The patients in group 1 (n = 68) underwent an admission LDCT scan delivering a 2.1-mSv radiation dose to women and 1.6 mSv to men, instead of the APF. Patients in group 2 (n = 71) underwent an APF. Clinical and radiologic follow-up data were obtained for each patient. The number of additional abdominal ultrasound and CT scans performed to reach a confident final diagnosis and determine the proper treatment was compared between the two groups. A mean effective radiation dose was obtained in each group.Of the 68 patients in group 1 (LDCT), 10 (15%) underwent ultrasonography, 9 (13%) conventional abdominal CT, and 2 (3%) both. In group 2 (APF), the corresponding percentages were 27% (19 of 71), 28% (20 of 71), and 23% (16 of 71). Of the 68 patients in group 1, 47 (69%) did not require any additional examinations compared with 16 (23%) of the 71 patients in group 2 (P0.0001). The mean effective dose was 3.5 and 6.9 mSv in groups 1 and 2, respectively (P0.0001).In patients with suspicion of renal colic, replacing the admission APF with our LDCT protocol will significantly reduce the need for additional CT or ultrasonography. Also, our LDCT protocol decreases by almost 50% the mean radiation dose per patient.

Von Januar bis Mitte Februar 2005 wurden dem Kantonsarzt von Genf 15 Fälle von bestätigten Masern gemeldet; verglichen zu einem einzelnen Fall im 2004. Ungewöhnlich an dieser Epidemie war das Alter der betroffenen Personen von 17 bis 44 Jahren. Vier unter ihnen waren Mitarbeiter eines öffentlichen Spitals, die sich nach Kontakt zu einem einzigen, 44-jährigen Patienten ansteckten und die Infektion zum Teil weiter übertrugen. Die Annahme, dass Masern eine pädiatrische Infektion sind, erschwerte die Diagnose. Keiner der betroffenen Erwachsenen war immun nach dem heutigen Stand der Empfehlungen. Trotz vorhandenem Impfplan, behördlichen Empfehlungen, Kostenübernahme durch die Krankenkassen und den guten Impfergebnissen mit den heute zur Verfügung stehenden Vakzinen, ist die freiwillige Durchimpfungsrate in der Schweiz unter Kindern und Erwachsenen zu gering um den Ausbruch von Epidemien zu verhindern. Im Gegensatz zu den Zielen des Bundesamt für Gesundheit (BAG) und der Weltgesundheitsorganisation (WHO) sind wir in der Schweiz aus verschiedenen Gründen noch nicht so weit eine genügend hohe Herdimmunität aufzubauen, um gesundheitliche und volkswirtschaftliche Schäden durch aufflackernde Epidemien zu verhindern.

Study objective We compare the performance of a wrist blood pressure oscillometer with the mercury standard in the triage process of an emergency department (ED) and evaluate the impact of wrist blood pressure measurement on triage decision. Methods Blood pressure was successively measured with the standard mercury sphygmomanometer and with the OMRON-RX-I wrist oscillometer in a convenience sample of 2,493 adult patients presenting to the ED with non–life-threatening emergencies. Wrist and mercury measures were compared using criteria of the Association for the Advancement of Medical Instrumentation (AAMI) and the British Hypertension Society (BHS). The impact on triage decisions was evaluated by estimating the rate of changes in triage decisions attributable to blood pressure results obtained with the wrist device. Results Wrist oscillometer failed to meet the minimal requirements for recommendation by underestimating diastolic and systolic blood pressure. Mean (±SD) differences between mercury and wrist devices were 8.0 mm Hg (±14.7) for systolic and 4.2 mm Hg (±12.0) for diastolic measures. The cumulative percentage of blood pressure readings within 5, 10, and 15 mm Hg of the mercury standard was 32%, 58%, and 72% for systolic, and 40%, 67%, and 83% for diastolic measures, respectively. Using the wrist device would have erroneously influenced the triage decision in 7.6% of the situations. The acuity level would have been overestimated in 2.2% and underestimated in 5.4% of the triage situations. Conclusion The performance of the OMRON-RX-I wrist oscillometer does not fulfill the minimum criteria of AAMI and BHS compared with mercury standard in the ED triage setting.

Summary Objectives: To evaluate the efficiency and acceptance of digital pen and paper technology for real-time clinical data acquisition. Methods: A prospective interventional unblinded study involving consecutive patients in two clinical settings during a defined time-frame was proposed. The first trial was designed as a stress test to evaluate acceptance in a workload-intensive environment. Acceptance was assessed using observations and a satisfaction questionnaire. The second trial was intended to determine the reliability of data acquisition in a controlled environment. Reliability was assessed by comparing the performance of the digital pen against scanner analysis and a double human blinded acquisition. Results: Overall, users were satisfied with the use of the digital pen (median 3 on a Likert-scale (–5, 5)). Without any specific user training, successful data acquisition was greater than 80%. Use of this technology required less adaptation than standard computer devices, and was easy to learn and use. Ergonomic problems shaded the perception of the technology by inducing an increased cognitive load. Digitalized data was missing either because of a bug or due to lack of data validation. The reliability obtained with the digital pen was significantly lower to that obtained with the scanner. Conclusions: Natural technology such as the digital pen proved to be a good tool in stressful clinical environments without interfering with the normal workload or increasing the time for data acquisition. However, in order to improve quality of data acquisition, designing acquisition forms specifically for the use of digital pens is of paramount importance.

Objectives : To evaluate primary care physicians' knowledge of guidelines for the management of COPD. Method : Survey to 455 primary care physicians in private practice in the state of Geneva, Switzerland, and to 243 physicians practicing in Geneva University Hospital. Results : Although 75% of respondents identified that the prevalence of COPD was increasing and 33% recognized it as a major public health issue, only 55% of physicians used spirometric criteria to define COPD, and one-third knew the correct GOLD criteria. Fifty-two percent felt uncomfortable with smoking cessation counselling. Sixty-two percent administered influenza vaccination annually and 29% had immunized their patients against Pneumococcus . Beta2-agonists were the first-line treatment for 89% of physicians, but 10% overestimated their clinical benefit. Twenty-five percent of respondents used systematically inhaled corticosteroids, but 46% ignored their indications. Oral corticosteroids were used by 42% of physicians outside of acute exacerbations. Seventy-nine percent thought that oral steroids had a beneficial effect on stable COPD. Finally, pulmonary rehabilitation was underused by 72% of physicians. Conclusions : This study shows major gaps in the knowledge of all core elements of guidelines for the management of COPD and identifies targets for future educational programs.

To assess the operating characteristics of positron emission tomography (PET) by using fluorine 18 fluorodeoxyglucose (FDG) in the diagnosis of Alzheimer disease.Articles published between 1989 and 2003 were identified in the MEDLINE, CINAHL, and HealthSTAR databases. Articles were selected if FDG PET was performed with a dedicated scanner and the resolution was specified, if standard criteria were used for the diagnosis of Alzheimer disease, if at least 12 human subjects with Alzheimer disease were enrolled in the study, if clinical diagnosis or histopathologic findings were used as the reference standard, and if sufficient data were provided to construct a 2 x 2 table. Two reviewers independently abstracted data regarding the operating characteristics (sensitivity and specificity) of PET and evaluated the study quality. A meta-analysis was performed by constructing a summary receiver operating characteristic curve and by combining the sensitivity and specificity values by using a random-effects model.Fifteen articles that met the inclusion criteria showed heterogeneity in sensitivity and specificity estimates that were not related to quality features with no plausible explanations. The summary sensitivity of PET was 86% (95% CI: 76%, 93%), and the summary specificity was 86% (95% CI: 72%, 93%).The specificity and sensitivity of FDG PET are limited by both study design and patient characteristics. Therefore, the clinical value of these parameters is uncertain; future research on the use of PET in the diagnosis of Alzheimer disease needs to focus on current limitations to be of practical relevance in clinical settings.

Background Community-acquired pneumonia (CAP) induces lung and systemic inflammation, leading to high morbidity and mortality. We systematically reviewed the risks and benefits of adjunctive corticotherapy in the management of patients with CAP. Methods We systematically searched Pubmed, Embase and the Cochrane Library for randomized controlled trials comparing adjunctive corticotherapy and antimicrobial therapy with antimicrobial therapy alone in patients with CAP. The primary outcome was 30-day mortality. Secondary outcomes were length of hospital stay, time to clinical stability and severe complications. Results 14 trials (2077 patients) were included. The reported 30-day mortality was 7.9% (80/1018) among patients treated with adjunctive corticotherapy versus 8.3% (85/1028) among patients treated with antimicrobial therapy alone (RR 0.84; 95%CI 0.55 to1.29). Adjunctive corticotherapy was associated with a reduction of severe complications (RR 0.36; 95%CI 0.23 to 0.56), a shorter length of stay (9.0 days; 95%CI 7.6 to 10.7 vs 10.6 days; 95%CI 7.4 to 15.3) and a shorter time to clinical stability (3.3 days; 95% CI 2.8 to 4.1 vs 4.3 days; 95%CI 3.6 to 5.1). The risk of hyperglycemia was higher among patients treated with adjunctive corticotherapy (RR 1.59; 95%CI 1.06 to 2.38), whereas the risk of gastro-intestinal bleeding was similar (RR 0.83; 95%CI 0.35 to 1.93). In the subgroup analysis based on CAP severity, a survival benefit was found among patients with severe CAP (RR 0.47; 95%CI 0.23 to 0.96). Conclusion Adjunctive corticotherapy is associated with a reduction of length of stay, time to clinical stability, and severe complications among patients with CAP, but the effect on mortality remains uncertain.

IMPORTANCE: The clinical benefit of adding a macrolide to a β-lactam for empirical treatment of moderately severe community-acquired pneumonia remains controversial. OBJECTIVE: To test noninferiority of a β-lactam alone compared with a β-lactam and macrolide combination in moderately severe community-acquired pneumonia. DESIGN, SETTING, AND PARTICIPANTS: Open-label, multicenter, noninferiority, randomized trial conducted from January 13, 2009, through January 31, 2013, in 580 immunocompetent adult patients hospitalized in 6 acute care hospitals in Switzerland for moderately severe community-acquired pneumonia. Follow-up extended to 90 days. Outcome assessors were masked to treatment allocation. INTERVENTIONS: Patients were treated with a β-lactam and a macrolide (combination arm) or with a β-lactam alone (monotherapy arm). Legionella pneumophila infection was systematically searched and treated by addition of a macrolide to the monotherapy arm. MAIN OUTCOMES AND MEASURES: Proportion of patients not reaching clinical stability (heart rate 90 mm Hg, temperature 90% on room air) at day 7. RESULTS: After 7 days of treatment, 120 of 291 patients (41.2%) in the monotherapy arm vs 97 of 289 (33.6%) in the combination arm had not reached clinical stability (7.6% difference, P = .07). The upper limit of the 1-sided 90% CI was 13.0%, exceeding the predefined noninferiority boundary of 8%. Patients infected with atypical pathogens (hazard ratio [HR], 0.33; 95% CI, 0.13-0.85) or with Pneumonia Severity Index (PSI) category IV pneumonia (HR, 0.81; 95% CI, 0.59-1.10) were less likely to reach clinical stability with monotherapy, whereas patients not infected with atypical pathogens (HR, 0.99; 95% CI, 0.80-1.22) or with PSI category I to III pneumonia (HR, 1.06; 95% CI, 0.82-1.36) had equivalent outcomes in the 2 arms. There were more 30-day readmissions in the monotherapy arm (7.9% vs 3.1%, P = .01). Mortality, intensive care unit admission, complications, length of stay, and recurrence of pneumonia within 90 days did not differ between the 2 arms. CONCLUSIONS AND RELEVANCE: We did not find noninferiority of β-lactam monotherapy in patients hospitalized for moderately severe community-acquired pneumonia. Patients infected with atypical pathogens or with PSI category IV pneumonia had delayed clinical stability with monotherapy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00818610.

Objective and methods: In 1998 we reported on a randomized comparison between stavudine plus didanosine plus placebo versus stavudine plus didanosine plus hydroxyurea (HU), in patients with a CD4 count of 200‐500 3 10 6 cells/l. After 3 months, the HU group had a higher proportion of patients with viral load , 200 3 10 6 cells/l. At the end of the 3 months blinded period, patients in the placebo group had the option to add HU if their viral load remained . 200 3 10 6 cells/l. We report results after 24 months. Results: Seventy-two patients were randomized to the HU arm, and a further 30 elected to add HU after 12 weeks. Twenty-four months after the start of the trial, only 25% of the 72 patients originally randomized to HU, and 20% of the 30 who added HU after week 12, were still taking it. The reasons for stopping HU were: lack of efficacy (45%), adverse events (37%) and patient or physician preference (18%). Side effects were more frequent in the didanosine/stavudine/HU group than in the didanosine/stavudine group: neuropathy (35 versus 15%, P , 0.02), fatigue (22 versus 7%, P , 0.01), and nausea or vomiting (26 versus 9%, P ,0.01). Of those who had discontinued HU, 73% were taking three drugs including a protease inhibitor. Patients who had started HU were compared with similar patients who had started protease inhibitors in the Swiss cohort. The probability of stopping HU was higher than the probability of stopping nelfinavir or indinavir, and similar to the probability of stopping ritonavir. Conclusion: HU increased the antiviral effect of stavudine plus didanosine. However, side effects were more frequent, and after 24 months the majority of patients had switched to protease inhibitor regimens.

A polymerase chain reaction (PCR) method, which amplifies a fragment of the 16S ribosomal RNA (rRNA) gene present in all mycobacterial species, was developed and tested on 84 formalin-fixed paraffin-embedded tissue specimens from 51 patients with human immunodeficiency (HIV) infection. The PCR products were characterized either by sequencing or by hybridization with nonradioactive oligonucleotide probes specific for Mycobacterium tuberculosis complex, M. avium, or M. genavense. Sequencing was successful for 26 samples compared with the 45 samples for probe hybridization. The sensitivity of DNA amplification compared with microscopic examination was 79.5%. A mixed infection was detected with M. genavense for only one patient who was infected with M. tuberculosis complex. In the group of 22 control patients, where no diagnosis of mycobacterial infection was made during life and no acid-fast bacteria were seen during the autopsy, four samples of one patient were positive by hybridization with the M. tuberculosis probe. This patient had a clinical history compatible with tuberculosis. This PCR method may be a powerful tool for the precise diagnosis of mycobacterial infections from histopathologic material, provided that several sections from the same specimen block are tested.

OBJECTIVE: To explore the short-term effects on surrogate markers for HIV progression of didanosine (ddl) plus stavudine (d4T), with or without hydroxyurea. DESIGN: Randomized, double-blinded, prospective study. SETTING: Swiss HIV Cohort Study. PATIENTS: A total of 144 patients (75% antiretroviral-naive) were studied (mean baseline HIV-1 RNA, 4.53 log10 copies/ml; mean CD4 cell count, 370 x 10(6)/l). INTERVENTION: Patients received ddl (200 mg twice daily) plus d4T (40 mg twice daily), with additional hydroxyurea (500 mg twice daily) or placebo. MAIN OUTCOME MEASURES: The primary endpoint was a reduction of viraemia below 200 copies/ml after 12 weeks. At that time, patients who did not reach the primary endpoint were withdrawn in the hydroxyurea arm, whereas patients in the placebo group had the option of adding hydroxyurea to ddl and d4T. All patients were followed until week 24. RESULTS: After 12 weeks, 54% of the patients randomized to hydroxyurea had viraemia below 200 copies/ml, compared with 28% on placebo (P < 0.001). Using an ultrasensitive assay with a limit of detection of 20 copies/ml, 19% of patients receiving hydroxyurea had viraemia levels below 20 copies/ml, compared with 8% on placebo (P = 0.05). Mean decrease in HIV-1 RNA was 2.3 and 1.7 log10 copies/ml for hydroxyurea and placebo groups, respectively (P = 0.001). Hydroxyurea was found to induce lymphopenia (-124 x 10(6)/l). Increase in CD4 cell counts was +28 x 10(6)/l during hydroxyurea treatment compared with +107 x 10(6)/l on placebo (P = 0.001). CONCLUSIONS: Hydroxyurea improved the antiviral activity of d4T and ddl over a 12-week period, but was associated with a smaller increase in CD4 cell counts due to hydroxyurea-induced lymphopenia.

Background: There is a growing interest in better defining risk factors associated with increased susceptibility to exacerbation in patients with COPD. Introduction: The aim of the study was to determine whether identification of a respiratory virus during a severe acute exacerbation of COPD (AECOPD) increases the risk of subsequent exacerbations and mortality during a one-year followup. Methods: Secondary analysis of 86 COPD patients admitted for AECOPD between June 2007 and December 2008 at Geneva’s University Hospital who were followed up for 1 year. Fifty-one percent of index AECOPD were related to viral infection. Rate of AECOPD, time to next AECOPD, and all-cause mortality were compared between patients with vs without viral index AECOPD. Results: Eighty-one cases were included in this secondary follow-up analysis. Mean exacerbation rate was 1.9 AECOPD per person-year for patients with viral index AECOPD vs 4.0 AECOPD per person year for those with non-viral index AECOPD. Incidence rate ratio (IRR) for subsequent AECOPD during one year follow up was lower for patients with viral index AECOPD (IRR 0.57; [CI 95% 0.39-0.84]), after controlling for previous exacerbations, and was strongly associated with the number of exacerbations in the year preceding the index AECOPD. During the one-year follow-up period, 16 patients (19%) died. In a Cox regression model, patients with a proven viral infection did not have a higher mortality (HR 0.56 [CI 95% 0.20 -1.58]). Conclusion: Viral AECOPD was not associated with a higher rate of subsequent exacerbations or mortality during the following year.

OBJECTIVE: To assess the safety, efficacy and plasma drug levels of the combination of ritonavir plus saquinavir for the treatment of advanced HIV infection. DESIGN: Multicentre pilot study. PATIENTS: Eighteen protease inhibitor-naive patients, with intolerance or contraindication to reverse transcriptase inhibitors, a median CD4 cell count of 12 x 10(6)/l (range, 1-50 x 10(6)/l), and a median HIV viraemia of 5.25 log10 copies/ml (range, 4.00-6.13 log10 copies/ml). METHODS: Patients received 600 mg twice daily of both ritonavir and saquinavir. Viraemia was measured at baseline and at weeks 5, 9 and 13. Response was defined as a drop of viraemia of more than 1 log10 at week 5. Plasma drug levels were determined after at least 3 weeks of combined treatment: samples were collected before and 1, 2, and 4 h after the morning ingestion of both drugs. The protease gene was sequenced at baseline and under treatment. RESULTS: Among the 16 patients evaluable at week 5, 11 were responders, and among these patients, six remained responders at week 13 (two with undetectable viraemia). Study discontinuations were due to side-effects (n = 4), patient choice (n = 3), protocol violation (n = 1) and death (n = 1). Responders had higher drug levels than non-responders (P < 0.01 for saquinavir, P = 0.04 for ritonavir). In two non-responders, development of multiple new mutations at positions 10, 20, 48, 82, 84 and 90 was observed after 5-13 weeks. CONCLUSION: The response to ritonavir plus saquinavir in advanced HIV infection is unpredictable. A minority of patients respond with disappearance of HIV viraemia. In other patients, rapid cumulative emergence of protease mutations conferring resistance to treatment cannot always be prevented by good compliance and relatively high plasma drug levels.

Aims: Pulmonary embolism (PE) associated with haemodynamic instability has exceedingly high mortality. While intravenous thrombolysis is considered the therapy of choice, percutaneous mechanical thrombectomy may represent an alternative treatment. Methods and results: The impact of AngioJet® rheolytic thrombectomy (RT) in PE associated with cardiogenic shock was assessed in a single-centre prospective pilot study. Ten consecutive PE patients in cardiogenic shock were included in the study. Six patients had thrombolysis contraindications, eight were intubated before the RT procedure and six had experienced cardiac arrest prior to the RT procedure. The RT procedure was technically successful in all cases. The Miller index improved from 25 to 20 (p=0.002). The shock index decreased from 1.22 to 0.9 (p=0.129). Thrombolytic agents were administered during or after the procedure in four patients because of progressive clinical deterioration. Seven patients died in the first 24 hours: two from multi-organ failure, one from post-anoxic cerebral oedema, and four from progressive right heart failure. The three survivors had favourable outcomes at one year. Conclusions: This study suggests that the AngioJet® RT procedure may be safely performed in PE patients with cardiogenic shock. However, despite angiographic and haemodynamic improvements, the procedure does not appear to influence the dismal prognosis of these high-risk patients.

The study evaluated the impact of lifestyle intervention on body weight, metabolic syndrome parameters, nutrition and physical activity in home-care providers (HCPs).Of 551 screened employees of a nursing agency, 173 were eligible to participate and were assigned to either the intervention (n=129) or the control (n=44) group. Participants in the intervention group followed an educational programme that encouraged physical activity and healthy nutrition, and were equipped with bicycles free of charge. Anthropometric, biological and lifestyle parameters were assessed at baseline, and after 6 and 12 months.Body weight, waist circumference and systolic blood pressure significantly decreased at 12 months in both study groups. Incidence of the metabolic syndrome in the intervention group at 12 months was reduced by 50% (from 17 to 9.2%; P=0.04). There were also decreases in LDL cholesterol (-0.36 mmol/L; P0.01), total cholesterol/HDL cholesterol ratio (-0.57; P0.01) and fasting glucose (-0.4 mmol/L; P0.05), and an increase in HDL cholesterol (+0.22 mmol/L; P0.01) in the intervention group. At 12 months, a decrease in daily caloric intake (-391 kcal/day; P0.001) and an increase in the percentage of participants engaging in physical activity (+3.4%; P0.05) were also observed in the intervention group.Lifestyle changes among HCPs are possible with relatively modest behavioural education and within a short period of time. Educational strategies and workshops are effective, efficient and easy to perform, and should be encouraged in HCPs to promote the implementation of lifestyle modifications in their patients.