European Journal of Emergency Medicine最新文献

Background: Undiagnosed HIV-infected patients are mainly responsible for viral transmission in Western countries. Emergency departments (EDs) could represent a strategic point in healthcare systems to uncover HIV infection.

Objective: This study aimed to analyze the time trends of HIV testing in EDs in Barcelona (Spain) and investigate if EDs have changed HIV screening patterns after the implementation of a targeted opt-in strategy for HIV testing.

Design: This is a quasiexperimental (pre/post) study.

Setting and participants: Monthly HIV tests performed by Microbiology Departments of four hospitals in Barcelona were recorded over 78 months, classified as ordered by ED or at other healthcare levels. Monthly ED attendances were compiled, along with new HIV diagnoses.

Intervention: Implementation of an opt-in strategy to test every ED patient with targeted conditions (community-acquired pneumonia, herpes zoster, mononucleosis syndrome, chemsex, postexposure prophylaxis, sexually transmitted diseases) in addition to other classical reasons for HIV testing.

Outcome measures and analysis: Determination of trends over time in HIV screening and new diagnoses in EDs during the 60-month preintervention and 18-month postimplementation periods, and estimation of the impact of intervention using interrupted time series analyses.

Main results: A total of 659 885 HIV tests were performed, with 11 442 (1.7%) being ordered by EDs (0.29% of ED comers were tested), and 287 new HIV diagnoses made (positivity rate: 2.8%). During the preintervention period, HIV testing increased over time (overall and in EDs), new HIV diagnoses in EDs remained stable, and the rate of positive HIV tests decreased. The intervention increased the monthly average of HIV tests ordered in the ED by 106 (95% CI = 86-125), proportion of ED comers screened by 0.075% (95% CI = 0.032-0.118), and proportion of HIV tests made in Barcelona performed by EDs by 0.728% (95% CI = 0.424-1.032), but had no impact on new HIV diagnoses and rate of positive HIV tests in the EDs.

Conclusion: In the last years, HIV screening in Barcelona increased, with EDs having a significant and increasing role in the overall HIV testing in Barcelona. The implementation of a targeted opt-in strategy for HIV screening in EDs increased the number of HIV tests performed, but not the number of HIV diagnoses made in EDs.

Background and importance: Access to healthcare remains a persistent challenge. Socially disadvantaged populations often encounter barriers to care and may frequently seek out emergency departments (EDs), including for nonurgent medical care.

Objective: The objective of this study is to study the association between nonurgent presentations to pediatric EDs and patients' socioeconomic environment in an urban setting.

Design, setting, and participants: A retrospective study of all visits to a pediatric ED in eight participating centers of the Paris metropolitan area (France) between 1 January 2017 and 31 December 2021 was carried out. Routinely collected data were analyzed.

Exposure: Socioeconomic status was evaluated using ecological variables defined at the municipality level. These variables were collected from public sources and included a social deprivation index, the accessibility to general practitioners, the proportion of single-parent families, and the proportion of immigrants.

Outcome measure and analysis: The primary endpoint was a nonurgent ED presentation, defined as being assigned one of the two lowest triage categories on a five-point scale. A multilevel logistic model assessed the association between nonurgent ED presentations and patients' characteristics, socioeconomic environment, and healthcare accessibility.

Main results: Nonurgent visits accounted for 51.6% of the 1 499 108 visits during the study period. The admission rate was 2.1% for nonurgent presentations and 18.8% for urgent presentations. In the final multivariate model ( n  = 1 412 895 visits), after adjustment for sex, age, time of day, day of the week, month, and year, the risk of nonurgent presentation was significantly higher for children living in less advantaged areas and in areas where the rate of single-parent families was high. It was also higher for children living close to the ED.

Conclusion: This extensive retrospective multicenter study emphasizes the increased risk of visiting EDs for nonurgent medical care among children from disadvantaged urban areas.

Background: The Sepsis-3 2016 definition defined sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Procalcitonin (PCT) and C-reactive protein (CRP) have been widely studied for the detection of sepsis according to the former definitions. This study aimed to evaluate the diagnostic performances of PCT and CRP for sepsis, according to the Sepsis-2 and Sepsis-3 definitions.

Methods: PubMed, Embase, and the Cochrane Library were searched. Original articles that reported both diagnostic performances of PCT and CRP for sepsis were included. The pooled sensitivity, specificity, diagnostic odds ratio, likelihood ratio, and the area under the summary receiver operating characteristic curve (AUC) were calculated using the multiple thresholds model.

Results: Forty-four studies with 10 755 patients between 1997 and 2024 were included. PCT exhibited a higher pooled AUC of 0.74 [95% confidence interval (CI), 0.62-0.84] compared with CRP, which had an AUC of 0.67 (95% CI, 0.56-0.77). Using sensitivity weighting of 50%, the optimal PCT and CRP cutoffs were 0.54 ng/ml (sensitivity: 0.70; specificity: 0.67) and 48 mg/L (sensitivity: 0.72; specificity: 0.55), respectively. The pooled AUC of PCT did not significantly differ between the Sepsis-2 and Sepsis-3 criteria. Sensitivity analyses showed overall performance was higher using the traditional bivariate model than the multiple thresholds model.

Conclusions: Although PCT seems to slightly outperform CRP for the diagnosis of sepsis, its discriminatory power remains limited, highlighting the need for additional tools to improve sepsis diagnosis.

Background and importance: Traumatic brain injury (TBI) in patients on vitamin K antagonists (VKAs) is linked to a high rate of intracranial hemorrhage (ICH). Rapid reversal can reduce ICH progression and mortality, but its effectiveness depends on the time between bleeding onset and coagulation normalization.

Objective: The PREVACT study aimed to assess the efficacy and safety of prompt systematic reversal of anticoagulation in patients presenting to emergency departments (EDs) for recent mild-TBI while receiving a VKA.

Intervention: A randomized, open-label, blinded-endpoint clinical trial was conducted in 21 French EDs. Patients receiving a VKA, having experienced a TBI within the last 6 h, and presenting a Glasgow Coma Score ≥13 were included. Patients were randomized to systematic immediate VKA reversal with 25 IU/kg of four-factor prothrombin complex concentrate (4f-PCC) before any investigation (intervention group) or standard-of-care signifying reversal only if the initial cranial computed tomography (CT) scan indicated ICH (control group). The primary outcome was the rate of ICH detected on a cranial CT scan 24 h post-inclusion.

Results: The study was prematurely stopped for logistic reasons after the randomization of 202 patients (101 and 101 in the intervention and control groups, respectively, mean age 90; 51.8% female). On the 24-h cranial CT scan, 6 of 98 patients (6.1%) in the intervention group manifested ICH vs. 12 of 99 patients (12.1%) in the control group [odds ratio: 0.47 (95% confidence interval: 0.14-1.44); P  = 0.215].

Conclusion: In patients with recent mild-TBI receiving a VKA, systematic prompt reversal with 4f-PCC did not statistically significantly reduce ICH rate at 24 h. However, the study was prematurely stopped and does not exclude a clinically relevant benefit of the strategy tested.

Trial registration: Clinicaltrials.gov (NCT01961804).

Background and importance: Patients living with social deprivation, and those with experiences of violence, substance misuse, mental ill-health and homelessness are known to use emergency departments (EDs) more often. It is not known whether a programme of social support initiated during ED attendance may lead to a reduction in healthcare use.

Objectives: The objective of this study is to determine the change in emergency, inpatient and outpatient healthcare use following a social support programme, Navigator, initiated during an ED attendance.

Design: Retrospective before-and-after study.

Settings and participants: Adult patients ≥16 years, attending EDs in the West of Scotland from 14 th September 2016 to 10 th March 2023, with a Navigator programme encounter.

Intervention or exposure if any: The Navigator social support programme, delivered by trained support workers, initiated during ED attendance, and targeting patients affected by issues including violence, substance misuse, mental ill-health, domestic abuse and homelessness.

Outcome measures and analysis: Healthcare use rates in the 365 days following intervention, as change compared to those in the 365 days prior to the intervention. The primary outcome was the number of ED attendances in the year following intervention compared with the year prior to intervention. Secondary outcomes included inpatient admissions, inpatient bed days, outpatient appointments and outpatient appointments where the patient did not attend. Changes in use rates were analysed with negative binomial regression and reported as incidence rate ratios for interpretation as percentage change. Analysis was repeated for a subgroup of frequent attenders to the ED.

Main results: Of 1421 Navigator programme encounters, 1056 were included for analysis. Median attendance in the year prior to intervention was 3 [interquartile range (IQR) 1-5], and in the year following intervention was 2 (IQR 0-4). Negative binomial regression demonstrated that in the year following Navigator intervention, there was a 29% (95% confidence interval: 24-33%) reduction in ED attendances.

Conclusion: The Navigator programme was associated with reduced emergency and acute healthcare use in the year following intervention, with increased scheduled outpatient care. There is the potential for a social support programme, delivered from the ED, to change patterns of healthcare use, and future work should consider prospectively assessing the impact of such an intervention.