Aims The aim of this study is to compare the Hestia rule vs. the simplified Pulmonary Embolism Severity Index (sPESI) for triaging patients with acute pulmonary embolism (PE) for home treatment. Methods and results Normotensive patients with PE of 26 hospitals from France, Belgium, the Netherlands, and Switzerland were randomized to either triaging with Hestia or sPESI. They were designated for home treatment if the triaging tool was negative and if the physician-in-charge, taking into account the patient’s opinion, did not consider that hospitalization was required. The main outcomes were the 30-day composite of recurrent venous thrombo-embolism, major bleeding or all-cause death (non-inferiority analysis with 2.5% absolute risk difference as margin), and the rate of patients discharged home within 24 h after randomization (NCT02811237). From January 2017 through July 2019, 1975 patients were included. In the per-protocol population, the primary outcome occurred in 3.82% (34/891) in the Hestia arm and 3.57% (32/896) in the sPESI arm (P = 0.004 for non-inferiority). In the intention-to-treat population, 38.4% of the Hestia patients (378/984) were treated at home vs. 36.6% (361/986) of the sPESI patients (P = 0.41 for superiority), with a 30-day composite outcome rate of 1.33% (5/375) and 1.11% (4/359), respectively. No recurrent or fatal PE occurred in either home treatment arm. Conclusions For triaging PE patients, the strategy based on the Hestia rule and the strategy based on sPESI had similar safety and effectiveness. With either tool complemented by the overruling of the physician-in-charge, more than a third of patients were treated at home with a low incidence of complications.

Objective-To evaluate the clinical usefulness of genomic HLA typing during the first two years of established giant cell arteritis (GCA). Methods-HLA typing was performed by PCR-SSO in 41 selected white patients with GCA confirmed by biopsy. Patient data were compared with those of a control group of 384 bone marrow donors (relative risk, p value and 2 test for each allele). Clinical features at onset and response to treatment over a two year period were evaluated in relation to the genetic pattern. Results-DRB1*04 was significantly increased in the GCA group (frequency of 48.78% compared with 19.79% in controls, p < 0.001). The distribution of the DRB1*04 subtypes in the GCA group was similar to that in controls. No clinical or biological diVerences were found in association with HLA at the time of diagnosis. Over the two year follow up, nine patients presented resistance to corticosteroid treatment and eight of these (88.88%) had DRB1*04 (p < 0.001) Conclusions-GCA seems to be associated with HLA DRB1*04 (regardless of the subtype) and this association appears to be accompanied by corticosteroid resistance, suggesting that genomic typing may be useful to identify patients eligible for early alternative treatment to corticosteroid drugs.

Objectives: Heart-type fatty acid-binding protein (h-FABP), sensitive troponins, natriuretic peptides, and clinical scores such as the Pulmonary Embolism Severity Index (PESI) are candidates for risk stratification of patients with acute pulmonary embolism (PE). The aim was to compare their respective prognostic values to predict an adverse outcome at 1 month. Methods:The authors prospectively included 132 consecutive patients with confirmed acute PE. On admission to the emergency department (ED), plasma concentrations of h-FABP, sensitive cardiac troponin I-Ultra (cTnI-Ultra), and brain natriuretic peptide (BNP) were measured and the PESI calculated in all patients. The combined 30-day outcomes of interest were death, cardiac arrest, mechanical ventilation, use of catecholamines, and recurrence of acute PE.Results: During the first 30 days, 14 (10.6%) patients suffered complications. Among the biomarkers, h-FABP above 6 lg/L was a stronger predictor of an unfavorable outcome (odds ratio [OR] = 17.5, 95% confidence interval [CI] = 4.2 to 73.3) than BNP > 100 pg/mL (OR = 5.7, 95% CI = 1.6 to 20.4) or cTnIUltra > 0.05 lg/L (OR = 3.4, 95% CI = 1.1 to 10.9). The PESI classified 83 of 118 patients (70.3%) with favorable outcomes and only one of 14 (7%) with adverse outcomes in low class I or II (OR = 30.8, 95% CI = 3.2 to 299.7). The areas under the receiver operating characteristic (ROC) curves (AUCs) were 0.90 (95% CI = 0.81 to 0.98) for h-FABP, 0.89 (95% CI = 0.82 to 0.96) for PESI, 0.79 (95% CI = 0.67 to 0.90) for BNP, and 0.76 (95% CI = 0.64 to 0.87) for cTnI-Ultra. The combination of h-FABP with PESI was a particularly useful prognostic indicator because none of the 79 patients (59.8%) with h-FABP < 6 ng/mL and PESI class < III had an adverse outcome.Conclusions: h-FABP and the PESI are superior to BNP and cTnI-Ultra as markers for risk stratification of patients with acute PE. The high sensitivity of their combination identified a large number of low-risk patients in the ED.

Introduction : L'analyse des plaintes est un élément essentiel de la démarche qualité dans un service d'urgence. Notre étude a pour objectif de recenser les lettres de plaintes, d'analyser leur contenu et les réponses.Méthodologie : Il s'agit d'une étude rétrospective monocentrique des lettres de plaintes reçues entre 2002 et 2007. Les données concernant l'épidémiologie, la typologie des doléan-ces, les buts recherchés, les réponses apportées et les suites ont été analysées. Résultats : Cent lettres de plaintes ont été étudiées entre 2002 et 2007, correspondant à une incidence globale de 5,6/10 000 passages, avec des variations selon les années entre 3,5 et 8,6/10 000. Les plaignants étaient le plus souvent un parent (47 %) ou le patient (38 %). Dans ces 100 lettres, 153 doléan-ces étaient recensées. Elles étaient d'ordre médical (50 %), organisationnel ou relationnel (44 %), ou divers (6 %). Les plus fréquentes concernaient les erreurs diagnostiques (32), les prises en charge non appropriées (23), le comportement du personnel (21) et les atteintes à la dignité (14). Le signalement (71 %) était le but le plus recherché. Une lettre de réponse était adressée à 78 % des plaignants. Un tiers environ des erreurs diagnostiques ont été reconnues. Quatre-vingt-neuf plaintes n'ont pas eu de suite. Neuf conciliations, une indemnisation, une procédure au tribunal administratif ont eu lieu. Conclusion : L'incidence des plaintes aux urgences est faible. Elles sont autant médicales qu'organisationnelles ou relationnelles. Elles sont un indicateur de dysfonctionnement qui doit être utilisé pour améliorer la prise en charge des patients. Pour citer cette revue : Ann. Fr. Med. Urgence 1 (2011).Abstract Introduction: The analysis of complaint letters is essential for quality improvement in an ED. The purpose of this work was to study the content of complaint letters received in an ED over six years. Methodology: Retrospective study of complaint letters sent to an ED between 2002 and 2007. The items analyzed were epidemiology, complaints typology, purposes and hospital responses. Results: One hundred complaint letters were studied between 2002 and 2007, corresponding to a global incidence of 5.6/10,000 ED admissions. The annual incidence varied from 3.5 to 8.6 per 10,000 admissions. The letters were written by the relatives of patients (47%) or the patients themselves (38%). Among 153 grievances in the 100 letters, 50% concerned medical problems, 44% organization and communication problems and 46% other problems. The most frequent grievances were diagnostic errors (32), inappropriate care (23), relationship (21) and violation of human dignity (14). The aim of the letters was a warning (71%). A response to plaintiffs was sent in 78% of cases. One third of diagnostic errors were recognized. Eighty-nine complaints ended without consequences, nine in arbitration committee, one in administrative court and one was compensated. Conclusion: Complaints incidence in our ED was low. Complaints are related with medical and organizational probl...

No abstract