L'insuffisance cardiaque aiguë aux urgences : présentations cliniques, diagnostic et prise en charge thérapeutique

L’insuffisance cardiaque (IC) est une maladie fréquente dont l'incidence croît dans tous les pays développés et dont la morbimortalité est effroyable. Devant une dyspnée aiguë, maître symptôme de la décompensation, le diagnostic d’insuffisance cardiaque aiguë (ICA) reste difficile aux urgences. En effet, les connaissances ayant permis de comprendre les mécanismes physiopathologiques, le concept nosologique d’une seule entité clinique a évolué vers la notion de syndromes d’ICA (SICA) intégrant plusieurs cadres nosographiques de la décompensation d’une IC chronique au tableau de détresse respiratoire aiguë dans l’œdème aigu du poumon cardiogénique, voire au choc cardiogénique. Afin de poser le diagnostic devant ces différentes formes de décompensations aiguës, l'urgentiste a recours à des examens complémentaires qui permettent de déterminer l'étiologie de l'épisode d'IC. Si la réalisation de l'électrocardiogramme et celle de la radiographie thoracique restent indispensables, l’utilisation de biomarqueurs cardiaques, au premier rang desquels les peptides natriurétiques se sont imposés, fait aujourd'hui partie intégrante des outils nécessaires à l'élaboration de la démarche diagnostique. Par ailleurs, la généralisation progressive de l'échographie clinique au sein des services d'urgences permet aujourd'hui d'améliorer la démarche diagnostique et de proposer une approche thérapeutique plus rapide. Ainsi, le concept moderne de « Time-to-therapy » prend-il tout son sens aux urgences où l'utilisation optimisée des différents traitements médicamenteux doit s'associer aux supports d'oxygénothérapie souvent nécessaires à la prise en charge de la dyspnée aiguë. Cet article se propose de faire une revue de la littérature et des recommandations actuelles afin d'assurer une prise en charge optimale des SICA aux urgences et en extrahospitalier.

Caractéristiques des patients centenaires consultants dans un service d’accueil et d’urgences

Introduction : Le nombre de consultations des personnes âgées aux urgences est en constante augmentation. Cette étude avait pour but d’évaluer les caractéristiques des patients centenaires, consultants dans un service d’accueil d’urgences et leur devenir.

Patients et méthode : Etude monocentrique, rétrospective, sur la période de janvier 2012 à mars 2015, incluant tous les centenaires consultants aux urgences d’un hôpital universitaire. Les données ont été comparées à une première période d’étude 10 ans auparavant (2002-2005) (travail déjà publié).

Résultats : Durant cette période, 21 550 (14%) des patients ayant consulté avaient plus de 75 ans, et 129 (<1%) patients avaient 100 ans et plus. Sept dossiers incomplets ont été exclus, et un total de 122 dossiers a donc été retenu pour l’étude. L’âge moyen des patients était de 102 +/- 1,4 ans. En 2002-2005, 81% des patients centenaires ont été adressés au SAU après un premier contact de leur médecin traitant ou du médecin de garde, contre 56% en 2012-2015 (p<0,001). Les principaux motifs de consultation aux urgences restaient les chutes (42% vs. 39%, p=0,66), suivies des symptômes respiratoires (22% vs. 21%, p=0,88). La durée moyenne de séjour a diminué de 10 jours à 7 jours, entre les 2 périodes. Le taux d’hospitalisation restait stable (57% vs. 67%, p=0,06), ainsi que la mortalité hospitalière (24% sur les deux périodes, p=0,95).

Conclusion : Cette étude souligne la spécificité des besoins des patients centenaires aux urgences, en matière de prise en charge non programmée.

Intérêt du scanner abdominopelvien chez les patients âgés de plus de 75 ans consultant aux urgences pour douleurs abdominales

Introduction : Déterminer l’étiologie des syndromes abdominaux aigus (SAA) chez les personnes âgées nécessite souvent une imagerie abdominale. L’objectif de notre étude était d’étudier la place du scanner abdominal chez les patients âgés de plus de 75 ans consultant aux urgences, et de rechercher des facteurs prédictifs de scanner pathologique.

Patients et méthodes : Il s’agissait d’une étude rétrospective, monocentrique, observationnelle, effectuée aux urgences de l’hôpital Tenon entre le 1er janvier et le 31 décembre 2014, chez les patients âgés de plus de 75 ans consultant pour un SAA. Deux groupes distincts étaient définis et comparés : un groupe « scanner normal » et un groupe « scanner pathologique », défini selon le compte-rendu du radiologue.

Résultats : Cent soixante-dix-huit patients (d’âge moyen de 84 ans) ont été inclus. Cent quatre-vingt-six scanners ont été effectués durant l’année 2014, parmi lesquels 41 scanners (22 %) étaient normaux. Les pathologies retrouvées le plus fréquemment étaient les occlusions (40 %), les pathologies urinaires (23 %), et les pathologies biliopancréatiques (22 %). Il n’existe aucun facteur clinique ou biologique prédictif de scanner pathologique.

Conclusion : Le scanner semble être un examen d’une grande rentabilité diagnostique chez la personne âgée, dont l’indication doit être large, car aucune donnée clinicobiologique n’est associée à un scanner pathologique.

Orientation des traumatisés du membre supérieur (épaule exclue) dès l’accueil en radiologie par l’infirmière organisatrice : étude Ontario

Introduction : L’objectif principal de cette étude est de déterminer l’effet d’un protocole de demande anticipée de radiographies par l’infirmier organisateur de l’accueil (IOA) sur le temps de passage des patients au service d’accueil des urgences (SAU).

Patients et méthodes : Cette étude monocentrique prospective a été réalisée en deux phases : une phase-avant (de décembre 2016 à janvier 2017) et une phase-après (de mai à juin 2017), où les patients bénéficiaient d’une demande anticipée de radiographie dès l’IOA. Les patients de plus de 18 ans, valides, ayant consulté au SAU pour un traumatisme du membre supérieur (épaule exclue) de moins de 48 heures et présentant au moins deux critères parmi douleur, tuméfaction, déformation ou impotence fonctionnelle étaient inclus.

Résultats : Deux cent treize patients ont répondu aux critères d’inclusion : 112 en phase 1 et 101 en phase 2. Le temps médian de passage global a diminué de manière significative entre la phase 1 et la phase 2 (188 vs 124 min, p < 0,001) ainsi que le temps médian de prise en charge médicale (76 vs 17 min). Plus de 90 % des infirmiers diplômés d’État (IDE) et plus de 75 % des médecins estiment que le protocole a un intérêt pour diminuer le temps de passage. Un tiers des IDE considère que ce protocole entraîne une surcharge de travail pour l’IOA et une surprescription de radiographies.

Conclusion : Cette étude suggère que l’application d’un protocole de demande anticipée de radiographies par l’IOA chez les patients ayant un traumatisme du membre supérieur (épaule exclue) permet de réduire le temps de passage au SAU.

mHealth - an Ultimate Platform to Serve the Unserved

Objectives: To summarize major current developments and research in the field of mobile health (mHealth) services.

Methods: Reports on the unique characteristics of mHealth platform and its role in delivering health services to the resource poor settings. Also, it evaluates different mHealth applications and identifies key success factors and challenges.

Results and Conclusion: mHealth, based on the most ubiquitous and widely accepted technology, offers an unprecedented opportunity to serve the unserved by right time medical information services. There is growing evidence that it has already transformed healthcare delivery in many resource poor settings through its low cost, high reach and versatile applications. However, challenges still remain with regard to the development of consumer centric solutions, and services quality in terms of knowledge and competence of the provider, integration of the information systems and interoperability of the information services. Additional problems arise from the collaboration, partnership and regulation perspectives. There are noticeable trends towards solutions for these problems.

Évaluation de l'intérêt d'une consultation post-urgence d'urologie : étude rétrospective sur trois ans

Introduction : L'objectif principal de ce travail était d'évaluer l'intérêt de la consultation post-urgence d'urologie (CPUU) mise en place dans notre institution.

Patients et méthodes : Il s'agit d'une étude transversale, monocentrique et rétrospective sur trois années distinctes : 2014, 2015 et 2016 de trois mois consécutifs (janvier à mars). Seuls les patients de plus de 18 ans ayant consulté aux urgences pour un motif urologique et relevant de la CPUU ont été inclus.

Résultats : Au total, 465 patients ont été programmés en CPUU, dont 265 (57 %) se sont présentés à la consultation. Deux cent vingt-deux patients (48 %) ont finalement répondu aux critères d'inclusion. Les principaux diagnostics relevant de la CPUU étaient principalement les coliques néphrétiques (45 %), la rétention aiguë d'urine (14 %) et les infections de l'appareil urinaire (16 %). On note une diminution significative du délai de CPUU passant à moins de deux semaines pour 60 % des patients en 2016 contre 30 et 38 % respectivement en 2014 et 2015 (p = 0,003). Le nombre de modifications diagnostiques à la sortie de la CPUU reste faible (6 % sur les trois ans ; p = 0,94). La modification thérapeutique par les urologues était principalement chirurgicale (22 % ; p = 0,75). La CPUU a permis d'instaurer un suivi au long cours pour plus de la moitié des patients (60 % ; p = 0,31).

Conclusion : La CPUU semble démontrer un intérêt tant sur le plan diagnostique que sur le plan du suivi spécialisé dans notre centre.

Exhaustive sampling of the fragment space associated to a molecule leading to the generation of conserved fragments

The first step in hit optimization is the identification of the pharmacophore, which is normally achieved by deconstruction of the hit molecule to generate "deletion analogues." In silico fragmentation approaches often focus on the generation of small fragments that do not describe properly the fragment space associated to the deletion analogues. We present significant modifications to the molecular fragmentation programme molBLOCKS, which allows the exhaustive sampling of the fragment space associated with a molecule to generate all possible molecular fragments. This generates larger fragments, by combining the smallest fragments. Additionally, it has been modified to deal with the problem of changing pharmacophoric properties through fragmentation, by highlighting bond cuts. The modified molBLOCKS programme was used on a set of drug compounds, where it generated more unique fragments than standard fragmentation approaches by increasing the number of fragments derived per compound. This fragment set was found to be more diverse than those generated by standard fragmentation programmes and was relevant to drug discovery as it contains the key fragments representing the pharmacophoric elements associated with ligand recognition. The use of dummy atoms to highlight bond cuts further increases the information content of fragments by visualizing their previous bonding pattern.

Quality Assessments of HMO Diagnosis Databases Used to Monitor Childhood Vaccine Safety

Objective: To assess the quality of automated diagnoses extracted from medical care databases by the Vaccine Safety Datalink (VSD) study.

Methods: Two methods are used to assess quality of VSD diagnosis data. The first method compares common automated and abstracted diagnostic categories (“outcomes”) in 1-2% simple random samples of study populations. The second method estimates positive predictive values of automated diagnosis codes used to identify potential cases of rare conditions (e.g., acute ataxia) for inclusion in nested case-control medical record abstraction studies.

Results: There was good agreement (64-68%) between automated and abstracted outcomes in the 1-2% simple random samples at 3 of the 4 VSD sites and poor agreement (44%) at 1 site. Overall at 3 sites, 56% of children with automated cerebella ataxia codes (ICD-9 = 334) and 22% with “lack of coordination” codes (ICD-9 = 781.3) met objective clinical criteria for acute ataxia.

Conclusions: The misclassification error rates for automated screening outcomes substantially reduce the power of screening analyses and limit usefulness of screening analyses to moderate to strong vaccine-outcome associations. Medical record verification of outcomes is needed for definitive assessments.

The Personal Genome Project Canada: findings from whole genome sequences of the inaugural 56 participants

BACKGROUND

The Personal Genome Project Canada is a comprehensive public data resource that integrates whole genome sequencing data and health information. We describe genomic variation identified in the initial recruitment cohort of 56 volunteers.

METHODS

Volunteers were screened for eligibility and provided informed consent for open data sharing. Using blood DNA, we performed whole genome sequencing and identified all possible classes of DNA variants. A genetic counsellor explained the implication of the results to each participant.

RESULTS

Whole genome sequencing of the first 56 participants identified 207 662 805 sequence variants and 27 494 copy number variations. We analyzed a prioritized disease-associated data set (n = 1606 variants) according to standardized guidelines, and interpreted 19 variants in 14 participants (25%) as having obvious health implications. Six of these variants (e.g., in BRCA1 or mosaic loss of an X chromosome) were pathogenic or likely pathogenic. Seven were risk factors for cancer, cardiovascular or neurobehavioural conditions. Four other variants - associated with cancer, cardiac or neurodegenerative phenotypes - remained of uncertain significance because of discrepancies among databases. We also identified a large structural chromosome aberration and a likely pathogenic mitochondrial variant. There were 172 recessive disease alleles (e.g., 5 individuals carried mutations for cystic fibrosis). Pharmacogenomics analyses revealed another 3.9 potentially relevant genotypes per individual.

INTERPRETATION

Our analyses identified a spectrum of genetic variants with potential health impact in 25% of participants. When also considering recessive alleles and variants with potential pharmacologic relevance, all 56 participants had medically relevant findings. Although access is mostly limited to research, whole genome sequencing can provide specific and novel information with the potential of major impact for health care.

Safe limit of arsenic in soil in relation to dietary exposure of arsenicosis patients from Malda district, West Bengal- A case study

Safe limit of arsenic in soil in relation to dietary exposure of arsenicosis patients was established in Malda district of West Bengal. Out of 182 participants examined, 80 (43.9%) participants showed clinical features of arsenicosis, characterized by arsenical skin lesion (pigmentation and keratosis), while 102 participants did not have any such lesion (control). Experimental results of the twenty eight soils (own field) of the participants showed the mean Olsen extractable and total arsenic concentration of 0.206 and 6.70mgkg^-1, respectively. Arsenic concentration in rice grain ranged from 2.00 to 1260μgkg^-1 with the mean value of 146μgkg^-1. The hazard quotient (HQ) for intake of As by human through consumption of rice varied from 0.03 to 3.52. HQ exceeds 1.0 for drinking water and rice grain grown in the study area in many cases. As high as 77.6% variation in As content in rice grain could be explained by the solubility-free ion activity model. Toxic limit of extractable As in soil for rice in relation to soil properties and human health hazard, associated with consumption of rice grain by human, was established. For example, the permissible limit of Olsen extractable As in soil would be 0.43mgkg^-1 for rice cultivation, if soil pH and organic carbon content were 7.5% and 0.50%, respectively. However, the critical limit of Olsen extractable As in soil would be 0.54mgkg^-1, if soil pH and organic carbon were 8.5% and 0.75%, respectively. The conceptual framework of fixing the toxic limit of arsenic in soils with respect to soil properties and human health under modeling-framework was established.

Wilms tumour in Beckwith-Wiedemann Syndrome and loss of methylation at imprinting centre 2: revisiting tumour surveillance guidelines

Beckwith-Wiedemann Syndrome (BWS) is an overgrowth syndrome caused by a variety of molecular changes on chromosome 11p15.5. Children with BWS have a significant risk of developing Wilms tumours with the degree of risk being dependent on the underlying molecular mechanism. In particular, only a relatively small number of children with loss of methylation at the centromeric imprinting centre (IC2) were reported to have developed Wilms tumour. Discontinuation of tumour surveillance for children with BWS and loss of methylation at IC2 has been proposed in several recent publications. We report here three children with BWS reported to have loss of methylation at IC2 on clinical testing who developed Wilms tumour or precursor lesions. Using multiple molecular approaches and multiple tissues, we reclassified one of these cases to paternal uniparental disomy for chromosome 11p15.5. These cases highlight the current challenges in definitively assigning tumour risk based on molecular classification in BWS. The confirmed cases of loss of methylation at IC2 also suggest that the risk of Wilms tumour in this population is not as low as previously thought. Therefore, we recommend that for now, all children with a clinical or molecular diagnosis of BWS be screened for Wilms tumour by abdominal ultrasonography until the age of eight years regardless of the molecular classification.

Molecular characterisation of antimicrobial resistance in Pseudomonas aeruginosa and Acinetobacter baumannii during 2014 and 2015 collected across India

BACKGROUND

Surveillance of antimicrobial resistance (AMR) is of great importance. Pseudomonas aeruginosa and Acinetobacter baumannii are important pathogens and emergence of resistance in these have increased the morbidity and mortality rates. This surveillance study was initiated by the Government of India - Indian Council of Medical Research. The aim of this study is to determine the antimicrobial susceptibility profile and to characterise the enzyme mediated antimicrobial resistance such as extended spectrum beta-lactamases (ESBLs) and carbapenemases among multidrug-resistant (MDR) P. aeruginosa and A. baumannii.

MATERIALS AND METHODS

A multi-centric study was conducted from January 2014 to December 2015 with a total number of 240 MDR P. aeruginosa and 312 MDR A. baumannii isolated from blood, cerebrospinal fluid, respiratory, pus, urine and intra-abdominal infections. Kirby-Bauer disc diffusion was done to determine the antimicrobial susceptibility profile. Further, MDR isolates were characterised by multiplex polymerase chain reaction to determine the resistance genes for ESBLs and carbapenemases.

RESULTS

Among the ESBLs, blaVEB (23%), blaTEM (5%) and blaSHV (0.4%) in P. aeruginosa and blaPER (54%), blaTEM (16%) and blaSHV (1%) in A. baumannii were the most prevalent. Likewise, blaVIM (37%), blaNDM (14%), blaGES (8%) and blaIMP (2%) in P. aeruginosa and blaOXA-23like (98%), blaOXA-58like (2%), blaNDM (22%) and blaVIM (3%) in A. baumannii were found to be the most prevalent carbapenemases. blaOXA-51like gene, intrinsic to A. baumannii was present in all the isolates tested.

CONCLUSION

The data shown highlight the wide difference in the molecular mechanisms of AMR profile between P. aeruginosa and A. baumannii. In P. aeruginosa, plasmid-mediated mechanisms are much lesser than the chromosomal mediated mechanisms. In A. baumannii, class D oxacillinases are more common than other mechanisms. Continuous surveillance to monitor the trends in AMR among MDR pathogens is important for implementation of infection control and to guide appropriate empirical antimicrobial therapy.

Fixed-dose combinations of antimicrobials: A need for special attention

OBJECTIVE

To highlight the issue of freely available fixed-dose combinations (FDCs) of antimicrobials.

METHODS

A critique of two such antimicrobial FDCs was undertaken wherein the following aspects were assessed - rational and regulatory issues and justification for clinical use. Available in vitro, in vivo (animals and humans) evidence from published literature was analysed.

CONCLUSIONS

There are several inadequately addressed aspects of the considered FDCs which are available in Indian market. In view of the growing problem of antimicrobial resistance, this issue must get the required attention.

Recent Worldwide Developments in eHealth and mHealth to more Effectively Manage Cancer and other Chronic Diseases - A Systematic Review

OBJECTIVES

This paper is a systematic literature review intended to gain an understanding of the most original, excellent, stateof- the-art research in the application of eHealth (including mHealth) in the management of chronic diseases with a focus on cancer over the past two years.

METHOD

This review looks at peer-reviewed papers published between 2013 and 2015 and examines the background and trends in this area. It systematically searched peer-reviewed journals in databases PubMed, Proquest, Cochrane Library, Elsevier, Sage and the Institute of Electrical and Electronic Engineers (IEEE Digital Library) using a set of pre-defined keywords. It then employed an iterative process to filter out less relevant publications.

RESULTS

From an initial search return of 1,519,682 results returned, twenty nine of the most relevant peer reviewed articles were identified as most relevant.

CONCLUSIONS

Based on the results we conclude that innovative eHealth and its subset mHealth initiatives are rapidly emerging as an important means of managing cancer and other chronic diseases. The adoption is following different paths in the developed and developing worlds. Besides governance and regulatory issues, barriers still exist around information management, interoperability and integration. These include medical records available online information for clinicians and consumers on cancer and other chronic diseases, mobile app bundles that can help manage co-morbidities and the capacity of supporting communication technologies.

Unusual case of failure to thrive: Type III Bartter syndrome

Bartter syndrome Type III is a rare autosomal recessive disorder resulting from an inherited defect in the thick ascending limb of the loop of henle of the nephrons in kidney. The typical clinical manifestations in childhood are failure to thrive and recurrent episodes of vomiting. Typical laboratory findings which help in the diagnosis are hypokalemic metabolic alkalosis, hypomagnesemia and hypercalciuria. We report a case of Type III Bartter syndrome not responding to repeated conventional treatment of failure to thrive.

Prediction of Drug Penetration in Tuberculosis Lesions

The penetration of antibiotics in necrotic tuberculosis lesions is heterogeneous and drug-specific, but the factors underlying such differential partitioning are unknown. We hypothesized that drug binding to macromolecules in necrotic foci (or caseum) prevents passive drug diffusion through avascular caseum, a critical site of infection. Using a caseum binding assay and MALDI mass spectrometry imaging of tuberculosis drugs, we showed that binding to caseum inversely correlates with passive diffusion into the necrotic core. We developed a high-throughput assay relying on rapid equilibrium dialysis and a caseum surrogate designed to mimic the composition of native caseum. A set of 279 compounds was profiled in this assay to generate a large data set and explore the physicochemical drivers of free diffusion into caseum. Principle component analysis and modeling of the data set delivered an in silico signature predictive of caseum binding, combining 69 molecular descriptors. Among the major positive drivers of binding were high lipophilicity and poor solubility. Determinants of molecular shape such as the number of rings, particularly aromatic rings, number of sp(2) carbon counts, and volume-to-surface ratio negatively correlated with the free fraction, indicating that low-molecular-weight nonflat compounds are more likely to exhibit low caseum binding properties and diffuse effectively through caseum. To provide simple guidance in the property-based design of new compounds, a rule of thumb was derived whereby the sum of the hydrophobicity (clogP) and aromatic ring count is proportional to caseum binding. These tools can be used to ensure desirable lesion partitioning and guide the selection of optimal regimens against tuberculosis.