Background and importance Diagnosing acute heart failure (AHF) is difficult in elderly patients presenting with acute dyspnea to the emergency department. Objectives To assess the diagnostic accuracy of NT-proBNP, high-sensitivity cardiac troponin-I (Hs-cTnI), soluble ST2 (ST2), galectin-3 and CD146 alone and in combination for diagnosing AHF in elderly patients presenting with acute dyspnea to the emergency department. Design, settings and participants This was a prospective, multicenter study performed between September 2016 and January 2020, including elderly patients presenting with acute dyspnea to the emergency department of 6 French hospitals. Intervention Measurement of NT-proBNP, hs-cTnI, ST2, galectin-3 and CD146. Outcome measure and analysis The reference standard, AHF, was adjudicated by two independent physicians based on ED and hospitalization clinical, biological (excluding biomarkers), radiological and echocardiography data (performed by a cardiologist in the cardiology department specifically for this study). Three exploratory methods (two using a cross-sectional approach with logistic regression and counting all biomarker combinations, and one using a sequential approach with gray zone optimizations) were applied to create comprehensive combinations of the 5 biomarkers for measuring diagnostic accuracy. Main results Two hundred thirty-eight patients (median age of 85 years, IQR = 8) were analyzed, and 110 (46%) were diagnosed with AHF. The accuracies of NT-proBNP, CD146, hs-cTnI, galectin-3, and ST2 were 0.72 [95% confidence interval (CI) 0.66–0.77], 0.63 (95% CI 0.57–0.69), 0.59 (95% CI 0.53–0.65), 0.55 (95% CI 0.49–0.61) and 0.51 (95% CI 0.45–0.57), respectively. Regardless of the approach used or how the 5 biomarkers were combined, the best accuracy for diagnosing AHF (0.73, 95% CI 0.67–0.78) did not differ from that of NT-proBNP alone. Conclusion In this study, NT-proBNP alone exhibited the best diagnostic accuracy for diagnosing AHF in elderly patients presenting with acute dyspnea to the emergency departments. None of the other biomarkers alone or combined improved the accuracy compared to NT-proBNP, which is the only biomarker to use in this setting.

Significant changes were observed in the lung imaging of hospitalised COVID-19 patients from 2020 to 2023, with the emergence of more signs of co-infection https://bit.ly/3TaQlJ2.

After a review of inappropriate admissions of residents of residential care facilities for the dependent elderly (Ehpad) to the emergency room, we propose ways to reduce them. They include giving the coordinating physician a clinical role, organizing continuity and permanence of care in all Ehpad, signing agreements between Ehpad and hospital for direct hospitalization and collaboration with mobile teams and geriatric hotlines, generalizing the level of medical intervention in Ehpad, and deepening the training of Ehpad caregivers in geriatrics.

IntroductionWhether a delayed diagnosis of community-acquired pneumonia (CAP) in the emergency department (ED) is associated with worse outcome is uncertain. We sought factors associated with a delayed diagnosis of CAP in the ED and those associated with in-hospital mortality.MethodsRetrospective study including all inpatients admitted to an ED (Dijon University Hospital, France) from 1 January to 31 December 2019, and hospitalized with a diagnosis of CAP. Patients diagnosed with CAP in the ED (n = 361, early diagnosis) were compared with those diagnosed later, in the hospital ward, after the ED visit (n = 74, delayed diagnosis). Demographic, clinical, biological and radiological data were collected upon admission to the ED, as well as administered therapies and outcomes including in-hospital mortality.Results435 inpatients were included: 361 (83%) with an early and 74 (17%) with a delayed diagnosis. The latter less frequently required oxygen (54 vs. 77%; p < 0.001) and were less likely to have a quick-SOFA score ≥ 2 (20 vs. 32%; p = 0.056). Absence of chronic neurocognitive disorders, of dyspnea, and of radiological signs of pneumonia were independently associated with a delayed diagnosis. Patients with a delayed diagnosis less frequently received antibiotics in the ED (34 vs. 75%; p < 0.001). However, a delayed diagnosis was not associated with in-hospital mortality after adjusting on initial severity.ConclusionDelayed diagnosis of pneumonia was associated with a less severe clinical presentation, lack of obvious signs of pneumonia on chest X-ray, and delayed antibiotics initiation, but was not associated with worse outcome.

Introduction Bacterial co-infection was infrequent in first waves of COVID-19. Our study aimed to describe how radiological findings have evolved among patients hospitalized with COVID-19. Methods We retrospectively included all COVID-19 patients hospitalized in the department of infectious diseases of the Dijon University Hospital (France) between February 27, 2020, and May 15, 2023. We recorded patient characteristics and standardized chest CT findings, in particular typical COVID-19 patterns and superimposed signs of co-infection. We analyzed data according to chronological periods in 6-month increments. Results 878 patients were included (median age 72 (interquartile range 58–83), 745 (85%) required oxygen. 743 (85%) patients had at least one chest CT scan. Radiologists reported typical signs of COVID-19 in 624 (84%) patients and signs of co-infection in 118 (16%) patients. Between the first semester of 2020 and July 2022-May 2023, there was a significant decrease in the proportion of typical signs of COVID-19 (82% versus 11%, p<0.001), but a significant increase of atypical signs suggestive of bacterial co-infection (4% versus 57%, p<0.001). Conclusion We observed significant changes in the lung imaging of hospitalized COVID-19 patients, with the emergence of more features of co-infection. This may suggest a transition toward the model of influenza and bacterial co-infection.

A deep dissecting hematoma is the most serious complication of dermatoporosis, consisting of a rapidly expanding blood collection that splits the hypodermis from the muscle fascia. A several-week time lapse between a minor trauma-induced superficial hematoma and its sudden evolution into a rapidly spreading deep dissecting hematoma is unusual. We report the case of a 70-year-old woman with long-term oral anticoagulation and dermatoporosis who suddenly developed a rapidly spreading right-leg deep dissecting hematoma 1 month after minor trauma, for which a surgical debridement and drainage were performed. Only local care and absorbent dressings were used to manage the post-operative wound, and within 4 months, the wound had healed. In this report, we emphasize the importance of preventing deep dissecting hematoma in patients who are at risk as well as the need to weigh the benefits and risks of anticoagulants when dermatoporosis cutaneous signs are present. A limb-threatening deep dissecting hematoma may develop suddenly, even weeks after a minor impact. In order to prevent skin necrosis from occurring, caregivers, patients, and carers must be able to identify this condition early on.

État de la questionLe diagnostic d'insuffisance cardiaque aiguë (ICA) est difficile chez les patients âgés admis aux urgences pour dyspnée aiguë (SAUDA). READ-MA avait pour objectif d’évaluer la précision diagnostique de cinq biomarqueurs (5-BM) : NT-proBNP, troponine-I ultrasensible (Hs-cTnI), ST2, galectine-3 et CD146, seuls et combinés pour ce diagnostic.Matériel et méthodesREAD-MA était une étude prospective et multicentrique menée entre septembre 2016 et janvier 2020 incluant des SAUDA de six hôpitaux français évalués avec les 5-BM et une échocardiographie. Le diagnostic d'ICA était déterminé par deux experts en double aveugle suivant toutes les données (à l'exclusion des biomarqueurs), recueillies aux urgences et en hospitalisation. Plusieurs approches statistiques ont permis l’étude de combinaisons exhaustives des 5-BM (Fig. 1).RésultatsDeux cent trente-huit patients (âge moyen de 85 ± 5 ans) ont été analysés, 110 (46 %) diagnostiqués avec une ICA. L'AUC et la précision étaient de 0,79 IC95 % [0,73-0,84] et 0,72 IC95 % [0,66-0,77], 0,67 IC95 % [0,60-0,72] et 0,63 IC95 % [0,57-0,69], 0,62 IC95 % [0,56-0,68] et 0,59 IC95 % [0,53-0. 65], 0,56 IC95 % [0,49-0,62] et 0,55 IC95 % [0,49-0,61] et 0,52 IC95 %[0,45-0,85] et 0,51 IC95 %[0,45-0,57] pour le NT-proBNP, le CD146, le Hs-cTnI, la galectine-3 et le ST2, respectivement (Fig. 2). Quelles que soient l'approche et la méthode de combinaison, la meilleure précision diagnostique 0,73, IC95 % [0,67-0,78] ne différait pas de celle du NT-proBNP seul.ConclusionLe NT-proBNP est le seul biomarqueur discriminant pour diagnostiquer l'ICA chez les SAUDA.

Abstract Objective Early identification of sepsis is mandatory. However, clinical presentation is sometimes misleading given the lack of infection signs. The objective of the study was to evaluate the impact on the 28-day mortality of the so-called “vague” presentation of sepsis. Design Single centre retrospective observational study. Setting One teaching hospital Intensive Care Unit. Subjects All the patients who presented at the Emergency Department (ED) and were thereafter admitted to the Intensive Care Unit (ICU) with a final diagnosis of sepsis were included in this retrospective observational three-year study. They were classified as having exhibited either “vague” or explicit presentation at the ED according to previously suggested criteria. Baseline characteristics, infection main features and sepsis management were compared. The impact of a vague presentation on 28-day mortality was then evaluated. Interventions None. Measurements and main results Among the 348 included patients, 103 (29.6%) had a vague sepsis presentation. Underlying chronic diseases were more likely in those patients [e.g., peripheral arterial occlusive disease: adjusted odd ratio (aOR) = 2.01, (1.08–3.77) 95% confidence interval (CI); p = 0.028], but organ failure was less likely at the ED [SOFA score value: 4.7 (3.2) vs. 5.2 (3.1), p = 0.09]. In contrast, 28-day mortality was higher in the vague presentation group (40.8% vs. 26.9%, p = 0.011), along with longer time-to-diagnosis [18 (31) vs. 4 (11) h, p < 0.001], time-to-antibiotics [20 (32) vs. 7 (12) h, p < 0.001] and time to ICU admission [71 (159) vs. 24 (69) h, p < 0.001]. Whatever, such a vague presentation independently predicted 28-day mortality [aOR = 2.14 (1.24–3.68) 95% CI; p = 0.006]. Conclusions Almost one third of septic patient requiring ICU had a vague presentation at the ED. Despite an apparent lower level of severity when initially assessed, those patients had an increased risk of mortality that could not be fully explained by delayed diagnosis and management of sepsis.

Abstract Introduction: An inadequate antibiotics’ prescription was found to be associated with worse prognosis in some infections. Emergency departments (ED) are pivotal for the initial prescription of antibiotics. However, its appropriateness and consequences have been rarely assessed. Methods: A retrospective, monocentric study included patients who consulted to the ED of our center and who were hospitalized with an advocated diagnosis of infection. Initial antibiotic therapy was graded as optimal, adapted, or inadequate. If reevaluation of this therapy was performed at day 2 (D2), the appropriateness of antibiotic therapy was again graded. The primary endpoint was the onset of an unfavorable event (i.e., death, transfer to intensive care unit, or re-hospitalization). Prognosis factors associated with survival without unfavorable event were assessed by multivariate analysis. Results: We included 484 patients. Respiratory (153, 40.4%), urinary-tract (83, 21.9%), and abdominal (76, 20.1%) infections were mostly diagnosed after reevaluation. Optimal, adapted, and inadequate initial prescriptions concerned respectively 328 (67.8%), 110 (22.7%) and 46 (9.5%) patients. Compared to an optimal prescription, an initial adapted prescription was associated with a poorer prognosis (HR = 1.95, CI95% [1.18-3.22]; p = 0.01). The reevaluation was performed in 436 (90.1%) patients. After reevaluation, optimal, adapted, and inadequate prescriptions concerned 326 (74.8%), 64 (14.7%), and 46 (10.5%) patients. After reevaluation, compared with optimal prescriptions, an inadequate prescription was associated with unfavorable events (HR = 3.52, CI95% [1.42-8.72]; p = 0.003). Conclusion: The appropriateness of both initial and D2 antibiotic therapies are associated with a better prognosis.

After a review of inappropriate admissions of residents of residential care facilities for the dependent elderly (Ehpad) to the emergency room, we propose ways to reduce them. They include giving the coordinating physician a clinical role, organizing continuity and permanence of care in all Ehpad, signing agreements between Ehpad and hospital for direct hospitalization and collaboration with mobile teams and geriatric hotlines, generalizing the level of medical intervention in Ehpad, and deepening the training of Ehpad caregivers in geriatrics.

Objectifs : Environnements stimulants mais stressants et exigeants, les structures d’urgences exposent les professionnels de santé à un risque accru de syndrome d’épuisement professionnel (SEP). Notre étude avait pour but d’évaluer la prévalence du SEP chez les internes et jeunes médecins urgentistes de Bourgogne-Franche-Comté. Méthodes : Étude épidémiologique descriptive, prospective, multicentrique réalisée de juin à août 2020. Les internes de médecine d’urgence (DES MU 1, 2, 3) et médecins urgentistes (senior diplômé du DESC MU ≤ 3 ans) dépendant des universités de Besançon et de Dijon ont répondu à un questionnaire comprenant des outils d’évaluation du SEP, de l’anxiété et de la dépression. Résultats : Le taux de réponse a été de 70 % (respectivement de 62 % pour Besançon et de 77 % pour Dijon). Quatrevingt-un praticiens (âge moyen de 29 ans) ont répondu, 41 internes de DES MU et 40 médecins urgentistes. Quarante-trois d’entre eux (53 %) présentaient des critères de SEP, 31 (38 %) des marqueurs d’anxiété et cinq des critères de dépression. On relevait un taux plus important de critères de SEP chez les jeunes seniors versus les internes (16 vs 27, p = 0,02). Il n’y avait pas de différence selon l’âge, le lieu d’exercice ou l’absence de congés récents. Il existait une faible concordance entre les marqueurs de SEP et les marqueurs d’anxiété ou de dépression. Conclusion : La majorité des jeunes praticiens urgentistes interrogés présente des critères de SEP. Cette problématique doit être prise en compte afin d’améliorer la qualité de vie au travail.

Acute cardiogenic pulmonary oedema in the elderly does not differ fundamentally from that seen in the young patient. Appropriate pathways must be established, with regular nursing follow-up, to enable rapid detection and treatment of episodes of acute heart failure. The paramedical team plays an essential role in liaising with families, providing nursing care and listening to the patient at the bedside.

Aims: Stimulating but stressful and demanding environments, emergency structures expose healthcare professionals to an increased risk of burnout syndrome. Our study aimed to assess the prevalence of burnout among residents and young emergency doctors in Bourgogne-Franche-Comte. Procedure: The descriptive, prospective, multicenter epidemiological study was conducted from June to August 2020. Emergency medicine residents (DES MU 1, 2, 3) and emergency physicians (senior <= 3 years) at the universities of Besancon and Dijon responded to a questionnaire including assessment tools for burnout, anxiety, and depression. Results: The response rate was 70% (respectively 62% for Besancon and 77% for Dijon). 81 practitioners (average age of 29 years) responded, 41 residents of DESMU and 40 emergency physicians. 43 of them (53%) had criteria for burnout, 31 (38%) for anxiety markers, and 5 for depression. There was a higher rate of burnout criteria among young seniors compared to interns (16 vs 27, P = 0.02). There was no difference depending on age, place of practice or lack of recent vacations. There was poor agreement between markers of burnout and markers of anxiety or depression. Conclusion: The majority of young emergency practitioners interviewed present criteria for burnout.

Introduction: Soluble urokinase plasminogen activator receptor (suPAR) is a prognostic biomarker of cardiovascular disease. Objectives: We aimed to evaluate the early prognostic value of suPAR in patients presenting to the emergency department (ED) with chest pain suggestive of acute coronary syndrome (ACS). Patients and methods: In a post-hoc analysis from a multicenter study including patients with a chest pain < 6 h, suPAR concentrations at ED admission were studied according to the outcome at 30-days. Results: 198 patients (median age 56 years) in whom 16% had an ACS, were included. Fifteen (7.3%) patients presented a 30-day event. At ED admission, median (IQR) suPAR concentrations were higher in patients with a 30-day event in comparison to patients without event (4.54 (3.09-8.61) vs. 2.72 (2.10-3.43) ng/mL, p < 0.001). The ROC curve AUC of suPAR for the prediction of a 30-days event was 0.775 [95%CI: 0.710-0.831]. The optimal threshold was 3.3 ng/mL, with a sensitivity of 73 [45-92] % and a specificity of 72 [65-79] %. The association of a suPAR < 3.3 ng/mL AND a NT-proBNP < 160 ng/L AND a HEART score < 4 had a negative predictive value of 99 [91-100] %. A suPAR value at admission above 3.3 ng/mL was independently and significantly associated with a 30-day event in chest pain emergency patients (OR 4.87 [1.35-17.51], p = 0.015). Conclusion: suPAR is a promising biomarker for early prediction of events in chest pain emergency patients.

Objectives. We aimed to evaluate the effectiveness of a multifaceted procedure in improving pneumococcal and influenza vaccinations 6 months after an emergency department (ED) visit among patients aged 65 years and older. Methods. We conducted a cluster-randomized, controlled, parallel-group, open-label implementation trial in 18 EDs in France and Monaco. Participants were recruited from November 2015 to September 2016. EDs were randomly assigned with a 1:1 ratio to provide either a multifaceted procedure that combined structured information about pneumococcal and influenza vaccines and three text message reminders sent to patients every two weeks (intervention arm) or nonstructured information only (control arm). The outcomes were self-reported pneumococcal vaccination and influenza vaccination rates within 6 months of enrollment. Results. A total of 9 EDs were randomized to the intervention arm (n = 780 patients) and 9 to the control arm (n = 695 patients). The median age for all enrolled patients was 74 years (25–75th percentiles, 69 to 82): 50.1% were male, 34.9% had at least one underlying condition, and 30.7% were at risk for invasive pneumococcal infection. In the intention-to-treat analysis, the multifaceted intervention did not alter the pneumococcal vaccination rate (6.4% versus 4.6%, absolute difference: 1.8; 95% CI: [−0.9 to 4.4]; p = 0.19), whereas it improved the influenza vaccination rate (52.1% versus 40.0%, absolute difference: 12.1; 95% CI: [2.4 to 21.8]; p = 0.01). At 12 months, mortality did not differ between the intervention (9.7%) and control (11.2%) arms (p = 0.35). Conclusions. A multifaceted intervention based on text message reminders provides an opportunity to increase anti-influenza vaccination among elderly patients visiting the ED. Efforts are warranted to provide better information on pneumococcal diseases and the benefits of pneumococcal vaccines, especially in the elderly.

Deberdt, Eric; Timsit, Eleonore; Avondo, Aurélie; Mariet, Anne-Sophie; Ray, Patrick Author Information

Background: Deep dissecting hematoma is a rapidly extending blood collection that splits the hypodermis from muscle fascia, constituting a medical surgical emergency. The natural history of this condition includes trauma (even minor physical injury) shortly before onset of the lesion, occurring in a patient with advanced dermatoporosis. Case presentation: We report the admission of a 70-year-old woman to the emergency department of our hospital for the onset of a deep dissecting hematoma one month after a negligible trauma in the right leg, complicating secondary iatrogenic dermatoporosis. Bedside ultrasound examination was used to eliminate differential or additional diagnoses and to assess the main features of the hematoma (dimensions, existence of blood supply). Surgical debridement and hematoma drainage were performed due to rapid horizontal extension of the hematoma and unresolved pain, with the operative report confirming the diagnosis. Conclusion: This observation emphasises that in patients with severe dermatoporosis, several weeks can elapse between a minor impact and the sudden development of a limb-threatening deep dissecting hematoma.