Publications by authors named "Nicolas Javaud"

39 Publications

Prognosis of non-severely comorbid elderly patients admitted to emergency departments: A prospective study.

Am J Emerg Med 2020 10 28;38(10):2034-2040. Epub 2020 Jun 28.

AP-HP, Urgences, CréAk, Hôpital Louis Mourier, Université Paris Diderot, Université de Paris, Colombes, France. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2020.06.064DOI Listing
October 2020

Reducing pain by using venous blood gas instead of arterial blood gas (VEINART): a multicentre randomised controlled trial.

Emerg Med J 2020 Dec 5;37(12):756-761. Epub 2020 Aug 5.

UFR de Médecine Paris Nord, Université de Paris, Paris, Île-de-France, France

Introduction: Venous sampling for blood gas analysis has been suggested as an alternative to arterial sampling in order to reduce pain. The main objective was to compare pain induced by venous and arterial sampling and to assess whether the type of sampling would affect clinical management or not.

Methods: We performed an open-label randomised multicentre prospective study in four French EDs during a 4-week period. Non-hypoxaemic adults, whose medical management required blood gas analysis, were randomly allocated using a computer-generated randomisation list stratified by centres with an allocation ratio of 1:1 using random blocks to one of the two arms: venous or arterial sampling. The primary outcome was the maximal pain during sampling, using the visual analogue scale. Secondary outcomes pertained to ease of sampling as rated by the nurse drawing the blood, and physician satisfaction regarding usefulness of biochemical data.

Results: 113 patients were included: 55 in the arterial and 58 in the venous sampling group. The mean maximal pain was 40.5 mm±24.9 mm and 22.6 mm±20.2 mm in the arterial group and the venous group, respectively, accounting for a mean difference of 17.9 mm (95% CI 9.6 to 26.3) (p<0.0001). Ease of blood sampling was greater in the venous group as compared with the arterial group (p=0.02). The usefulness of the results, evaluated by the prescriber, did not significantly differ (p=0.25).

Conclusions: Venous blood gas is less painful for patients than ABG in non-hypoxaemic patients. Venous blood gas should replace ABG in this setting.

Trial Registration Number: NCT03784664.
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http://dx.doi.org/10.1136/emermed-2019-209287DOI Listing
December 2020

Association Between Pulmonary Embolism and COVID-19 in Emergency Department Patients Undergoing Computed Tomography Pulmonary Angiogram: The PEPCOV International Retrospective Study.

Acad Emerg Med 2020 09 4;27(9):811-820. Epub 2020 Sep 4.

and the, Emergency Department, European Georges Pompidou Hospital, APHP, Paris, France.

Background: There have been reports of procoagulant activity in patients with COVID-19. Whether there is an association between pulmonary embolism (PE) and COVID-19 in the emergency department (ED) is unknown. The aim of this study was to assess whether COVID-19 is associated with PE in ED patients who underwent a computed tomographic pulmonary angiogram (CTPA).

Methods: A retrospective study in 26 EDs from six countries. ED patients in whom a CTPA was performed for suspected PE during a 2-month period covering the pandemic peak. The primary endpoint was the occurrence of a PE on CTPA. COVID-19 was diagnosed in the ED either on CT or reverse transcriptase-polymerase chain reaction. A multivariable binary logistic regression was built to adjust with other variables known to be associated with PE. A sensitivity analysis was performed in patients included during the pandemic period.

Results: A total of 3,358 patients were included, of whom 105 were excluded because COVID-19 status was unknown, leaving 3,253 for analysis. Among them, 974 (30%) were diagnosed with COVID-19. Mean (±SD) age was 61 (±19) years and 52% were women. A PE was diagnosed on CTPA in 500 patients (15%). The risk of PE was similar between COVID-19 patients and others (15% in both groups). In the multivariable binary logistic regression model, COVID-19 was not associated with higher risk of PE (adjusted odds ratio = 0.98, 95% confidence interval = 0.76 to 1.26). There was no association when limited to patients in the pandemic period.

Conclusion: In ED patients who underwent CTPA for suspected PE, COVID-19 was not associated with an increased probability of PE diagnosis. These results were also valid when limited to the pandemic period. However, these results may not apply to patients with suspected COVID-19 in general.
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http://dx.doi.org/10.1111/acem.14096DOI Listing
September 2020

Professional practice assessment for minor head injury management in emergency department and clinical impact of a simulation-based training: Interventional study (before/after).

Ulus Travma Acil Cerrahi Derg 2020 07;26(4):545-554

Emergency Department and EMS, University Hospital of Bichat, Paris-France.

Background: Minor head injury is a frequent reason for consultation in the emergency department. The use of computed tomography (CT) has increased dramatically in patients' care. Good time management implementation and interpretation are required. To study the level of agreement with recommendations for a minor head injury in emergency department management and the impacts of simulation-based training (SBT) on professional practice changes.

Methods: Evaluation of professional practice for patient care in an emergency department according to the recommendations of the French Emergency Medicine Society (SFMU) established in 2012 before and after an SBT, including theoretical and simulation courses. It was based on the analysis of time to carry out a CT scan. It was also based on analysis of adherence to brain and spine scan indications and to hospitalization criteria.

Results: The SBT carried out in the evaluation of the professional practices makes it possible to acquire the notion of urgency to obtain the CT Scan within one hour when the criteria are met (p=0.007). Rater reliability for agreement with the hospitalization recommendations was better after SBT (p=0.03, increased Kappa from 0.73 to 0.93). On the other hand, there appeared to be a lack of essential information in the medical file, such as time of onset of head trauma.

Conclusion: Management of this type of patient appeared to be satisfactory. It can be improved by SBT on the basis of the SFMU 2012 consensus conference. There is a need to improve the software used by the emergency departments, which should include the time of trauma and recommendations. The association of the clinic and the biomarkers could help to limit the indications of the CT scan, and thus to have it organized more rapidly.
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http://dx.doi.org/10.14744/tjtes.2020.91589DOI Listing
July 2020

Glucocorticoids for acute urticaria: study protocol for a double-blind non-inferiority randomised controlled trial.

BMJ Open 2019 08 21;9(8):e027431. Epub 2019 Aug 21.

Urgences-SAMU 93-Unité Recherche-Enseignement-Qualité, APHP, Hôpital Avicenne, Bobigny, France.

Introduction: This study protocol describes a trial designed to investigate whether antihistamine alone in patients with acute urticaria does not increase the 7-day Urticaria Activity Score (UAS7) in comparison with an association of antihistamine and glucocorticoids and reduces short-term relapses and chronic-induced urticaria.

Methods And Analysis: This is a prospective, double-blind, parallel-group, multicentre non-inferiority randomised controlled trial. Two-hundred and forty patients with acute urticaria admitted to emergency department will be randomised in a 1:1 ratio to receive levocetirizine or an association of levocetirizine and prednisone. Randomisation will be stratified by centre. The primary outcome will be the UAS7 at day 7. The secondary outcomes will encompass recurrence of hives and/or itch at day 7; occurrence of spontaneous hives or itch for >6 weeks; patients with angioedema at day 7, and 2, 6, 12 and 24 weeks; new emergency visits for acute urticaria recurrences at days 7 and 14, and 3 months; Dermatology Life Quality Index at days 7 and 14, and 3 and 6 months; and Chronic Urticaria Quality of Life Questionnaire at 6 weeks.

Ethics And Dissemination: The protocol has been approved by the and will be carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. A steering committee will oversee the progress of the study. Findings will be disseminated through national and international scientific conferences and publication in peer-reviewed journals.

Trial Registration Number: NCT03545464.
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http://dx.doi.org/10.1136/bmjopen-2018-027431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707704PMC
August 2019

Longer symptom onset to aspiration time predicts success of needle aspiration in primary spontaneous pneumothorax.

Thorax 2019 08 12;74(8):780-786. Epub 2019 Jun 12.

Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Louis Mourier, F-92700, Colombes, France

Background: Needle aspiration (NA) is recommended as first-line treatment of primary spontaneous pneumothorax (PSP). We aimed to assess NA success and the effect of a longer symptom onset to NA time.

Methods: A discovery phase was retrospectively conducted in the intensive care unit of Louis Mourier Hospital (January 2000 to December 2011) followed by a prospective validation cohort (January 2012 to August 2015). The primary outcome was immediate NA success defined by the absence of need for chest tube insertion within 24 hours of the procedure.

Results: In the discovery phase, 130 patients were admitted for PSP and 98 had NA as first-line treatment (75%). The immediate success rate of NA was 34.7% and was higher when it was performed ≥48 hours after symptom onset (57.7% vs 25%; p=0.004). In the prospective cohort, 87 patients were admitted for PSP; 71 (82%) had NA as first-step treatment. The immediate success rate was 40.8%. NA was more successful when it was performed after 48 hours of symptoms' onset (34.5% vs 7.1%; p=0.005). A delay between the first symptom and NA procedure ≥48 hours was associated with a higher success of NA (OR=13.54; 95% CI 1.37 to 133). A smaller pneumothorax estimated by Light's index was associated with NA success (OR=0.95; 95% CI 0.92 to 0.98). To what extent some of these pneumothoraces would have had a spontaneous resolution remains unknown.

Conclusion: When managing PSP with NA, a longer symptom onset to NA time was associated with NA success.

Trial Registration Number: NCT02528734.
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http://dx.doi.org/10.1136/thoraxjnl-2019-213168DOI Listing
August 2019

Hereditary angioedema, emergency management of attacks by a call center.

Eur J Intern Med 2019 Sep 18;67:42-46. Epub 2019 May 18.

AP-HP, Urgences - Samu 93, Hôpital Avicenne, Université Paris 13, Inserm U942, 93000 Bobigny, France. Electronic address:

Objective: Hereditary angiœdema (HAE) is a rare autosomal dominant disease characterized by recurrent, unpredictable, potentially life-threatening swelling. Objective is to assess the management of the acute HAE attacks in the real life setting through a call center in France.

Methods: A pre-specified ancillary study of SOS-HAE, a cluster-randomized prospective multicenter trial, was conducted. HAE patients were recruited from 8 participating reference centers. The outcome of interest was the rate of hospitalization.

Results: onerhundred patients were included. The median (quartile) age was 38 (29-53) years, and 66 (66%) were female. Eighty (80%) patients had HAE type I, 8 (8%) had HAE type II and 12 (12%) patients had FXII-HAE. Fifty-one (51%) patients had experienced at least one time the call center during the follow-up. Nine over 166 (5%) attacks for 9 different patients resulted in hospital admission to the hospital (in the short-stay unit, ie, <24 h) during the follow-up period. During 2 years, there were 166 calls to call center for 166 attacks. All attacks were treated at home after call center contact.

Conclusions: Use of emergency departments and hospitalizations are reduced by the use of a coordinated national call center in HAE after therapeutic education program that promoted self-administration of specific treatment and use of call to call center.

Trial Registration: clinicalTrials.gov identifier: NCT01679912.
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http://dx.doi.org/10.1016/j.ejim.2019.05.007DOI Listing
September 2019

Interventional studies performed in emergency medical communication centres: systematic review.

Eur J Emerg Med 2020 Feb;27(1):21-26

INSERM U1153, Statistic and Epidemiologic Research Center Sorbonne Paris Cité, METHODS Team, Hotel-Dieu Hospital.

We aimed to both quantitatively and qualitatively describe interventional research performed in emergency medical communication centres. We conducted a systematic review of articles published in MEDLINE, Cochrane Central Register of Controlled Trials and Web of Science. Studies evaluating therapeutic or organizational interventions directed by call centres in the context of emergencies were included. Studies of call centre management for general practice or nonhealthcare agencies were excluded. We assessed general characteristics and methodological information for each study. Quality was evaluated by the Cochrane Risk of Bias tool or the Newcastle-Ottawa Scale. Among 3896 articles screened, we retained 59; 41 studies were randomized controlled trials (69%) and 18 (31%) were before-after studies; 41 (69%) took place in a single centre. For 33 (56%), 22 (37%) and 4 (7%) studies, the models used were simulation training, patient-based or experimental, respectively. The main topic was cardiac arrests (n = 45, 76%), with outcome measures of cardiopulmonary resuscitation quality and dispatch assistance. Among randomized controlled trials, risk of bias was unclear or high for selective reporting for 37 (90%) studies, low for blinding of outcomes for 34 (83%) and low for incomplete outcomes for 31 (76%). Regarding before-after studies, quality was high in 9 (50%) studies. Few interventional studies have been performed in call centres. Studies mainly involved simulation and focussed on cardiac arrest. The quality of studies needs improvement to allow for a better recognition and understanding of emergency medical call control.
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http://dx.doi.org/10.1097/MEJ.0000000000000608DOI Listing
February 2020

Factors associated with relapses among patients treated for acute urticaria.

J Dermatol 2019 May 28;46(5):383-388. Epub 2019 Feb 28.

AP-HP, Urgences, Centre de Référence sur les Angiœdèmes à kinines (CRéAk), Hôpital Louis Mourier, Université Paris 7, Colombes, France.

The benefit of corticosteroids in acute urticaria is controversial. Our objective was to determine the factors associated with relapses in patients presenting with acute urticaria. A retrospective observational study, including all patients with acute urticaria who visited the angioedema reference center of Academic Public Hospitals - Saint-Antoine in Paris between January 2015 and June 2017, was conducted. The study inclusion criterion was a diagnosis of acute urticaria in an adult patient. The urticaria was spontaneous or inducible urticaria. The primary outcome was relapse at day 7 and the secondary outcome was relapse at week 6. A total of 184 patients with a first episode of acute urticaria were included. Most of the patients were female (66%) with a mean age of 42 ± 16 years. Corticosteroid administration for treatment of acute urticaria was used in 102 (55%) patients. Overall, 85 (46%) patients had relapses after less than 7 days whereas 168 (91%) patients had relapses after more than 6 weeks. In univariate analysis, the rate of corticosteroid administration was significantly higher in cases of relapse after less than 7 days. No difference in relapse rates after more than 6 weeks appeared. In the multivariate analysis, the independent factor associated with relapses after less than 7 days was the administration of corticosteroids as treatment of acute urticaria (odds ratio, 1.93; 95% confidence interval, 1.06-3.57; P = 0.03). The prevalence of corticosteroid administration for patients with acute urticaria was high. Corticosteroid administration was an independent risk factor associated with relapses after less than 7 days.
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http://dx.doi.org/10.1111/1346-8138.14830DOI Listing
May 2019

Diagnostic biologique des angioedèmes bradykiniques : les recommandations du CREAK.

Presse Med 2019 Jan 8;48(1 Pt 1):55-62. Epub 2018 Nov 8.

Centre de référence national des angioedèmes (CREAK), 38043 Grenoble, France; Service d'immunologie, CHUGA, 38043 Grenoble, France.

Bradykinin mediated angioedema (BK-AE) can be associated either with C1Inhibitor deficiency (hereditary and acquired forms), either with normal C1Inh (hereditary form and drug induced AE as angiotensin converting enzyme inhibitors…). In case of high clinical suspicion of BK-AE, C1Inh exploration must be done at first: C1Inh function and antigenemy as well as C4 concentration. C1Inh deficiency is significant if the tests are below 50 % of the normal values and controlled a second time. In case of C1Inh deficiency, you have to identify hereditary from acquired forms. C1q and anti-C1Inh antibody tests are useful for acquired BK-AE. SERPING1 gene screening must be done if a hereditary angioedema is suspected, even if there is no family context (de novo mutation 15 %). If a hereditary BK-AE with normal C1Inh is suspected, F12 and PLG gene screening is suitable.
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http://dx.doi.org/10.1016/j.lpm.2018.06.015DOI Listing
January 2019

Prognosis of cirrhotic patients admitted to Emergency Departments: A multicenter study.

Am J Emerg Med 2019 07 12;37(7):1317-1321. Epub 2018 Oct 12.

AP-HP, Urgences - Samu 93, UF Recherche-Enseignement-Qualité, hôpital Avicenne, Université Paris 13, Inserm U942, 93000 Bobigny, France.

Objectives: Life threatening complications can occur at any stage of cirrhosis progression. There are few studies on the prognosis of cirrhotic patients managed in an Emergency Department (ED) although management of patients will occur in the ED. The objective of our study was to determine the risk factors for mortality in cirrhotic patients who visited to the ED.

Methods: All cirrhotic patients attending ED in three different university hospitals of Assistance Publique - Hôpitaux de Paris between January 2014 and June 2015 were identified by a retrospective analysis of digital records and included in the study. The primary end-point was 30-day mortality in all cirrhotic patients who visited the ED.

Results: A total of 609 ED visits were analyzed among 224 patients: 115 (51%) presented a cirrhosis of alcoholic origin, 43 (19%) were caused by Hepatitis C, 28 (13%) of mixed origin (viral and alcoholic), 17 (8%) were caused by Hepatitis B and 21 (9%) of other origins. Fifty-five (25%) of these patients died within 30 days of their initial presentation to the ED. In multivariate analysis, the age (Odds Ratio: 1.04 [1.01-1.07]), cirrhosis associated with hepatocellular carcinoma (OR: 3.07 [1.37-6.91]), serum creatinine at admission (OR: 1.01 [1.01-1.02]), serum bilirubin at admission (OR: 1.01 [1.01-1.02]) and health impairment (OR: 2.57 [1.28-5.16]) were associated with mortality.

Conclusions: The mortality rate of cirrhotic patients attending an ED was high. The prognosis of cirrhotic patients admitted to the ED depended on the severity of the liver and other organ dysfunction. The presence of a hepatocellular carcinoma on admission was also a risk factor for death.
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http://dx.doi.org/10.1016/j.ajem.2018.10.008DOI Listing
July 2019

Hereditary angioedema: Clinical presentation and socioeconomic cost of 200 French patients.

J Allergy Clin Immunol Pract 2019 01 22;7(1):328-330. Epub 2018 Jun 22.

AP-HP, URCEco Ile de France, Hôpital de l'Hôtel-Dieu, Université Paris 12, Paris, France.

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http://dx.doi.org/10.1016/j.jaip.2018.05.036DOI Listing
January 2019

Specialist Advice Support for Management of Severe Hereditary Angioedema Attacks: A Multicenter Cluster-Randomized Controlled Trial.

Ann Emerg Med 2018 08 2;72(2):194-203.e1. Epub 2018 Mar 2.

AP-HP, Urgences-Samu 93, hôpital Avicenne, Université Paris 13, Inserm U942, Bobigny, France; Inserm U942.

Study Objective: Hereditary angioedema is a rare disease associated with unpredictable, recurrent attacks of potentially life-threatening edema. Management of severe attacks is currently suboptimal because emergency medical teams are often unaware of new specific treatments. The objective of this trial is to test whether a dedicated national telephone care-management strategy would reduce resource use during severe hereditary angioedema attacks.

Methods: We conducted a cluster-randomized multicenter prospective trial of patients with a documented diagnosis of hereditary angioedema (type I, II or FXII hereditary angioedema). Participants were enrolled between March 2013 and June 2014 at 8 participating reference centers. The randomized units were the reference centers (clusters). Patients in the intervention arm were given a national free telephone number to call in the event of a severe attack. Emergency physicians in the SOS-hereditary angiœdema (SOS-HAE) call center were trained to advise or prescribe specific treatments. The primary outcome was number of admissions for angioedema attacks. Economic evaluation was also performed.

Results: We included 100 patients in the SOS-HAE group and 100 in the control group. During the 2 years, there were 2,368 hereditary angioedema attacks among 169 patients (85%). Mean number of hospital admissions per patient in the 2-year period was significantly greater in the usual-practice group (mean 0.16 [range 0 to 2] versus 0.03 [range 0 to 1]); patient risk difference was significant: -0.13 (95% confidence interval -0.22 to -0.04; P=.02). Probabilistic sensitivity graphic analysis indicated a trend toward increased quality-adjusted life-years in the SOS-HAE group.

Conclusion: A national dedicated call center for management of severe hereditary angioedema attacks is associated with a decrease in hospital admissions and may be cost-effective if facilities and staff are available to deliver the intervention alongside existing services.
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http://dx.doi.org/10.1016/j.annemergmed.2018.01.053DOI Listing
August 2018

Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial.

JAMA 2018 02;319(8):779-787

AP-HP, SAMU 93, Hôpital Avicenne, Inserm U942, Bobigny, France.

Importance: Bag-mask ventilation (BMV) is a less complex technique than endotracheal intubation (ETI) for airway management during the advanced cardiac life support phase of cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest. It has been reported as superior in terms of survival.

Objectives: To assess noninferiority of BMV vs ETI for advanced airway management with regard to survival with favorable neurological function at day 28.

Design, Settings, And Participants: Multicenter randomized clinical trial comparing BMV with ETI in 2043 patients with out-of-hospital cardiorespiratory arrest in France and Belgium. Enrollment occurred from March 9, 2015, to January 2, 2017, and follow-up ended January 26, 2017.

Intervention: Participants were randomized to initial airway management with BMV (n = 1020) or ETI (n = 1023).

Main Outcomes And Measures: The primary outcome was favorable neurological outcome at 28 days defined as cerebral performance category 1 or 2. A noninferiority margin of 1% was chosen. Secondary end points included rate of survival to hospital admission, rate of survival at day 28, rate of return of spontaneous circulation, and ETI and BMV difficulty or failure.

Results: Among 2043 patients who were randomized (mean age, 64.7 years; 665 women [32%]), 2040 (99.8%) completed the trial. In the intention-to-treat population, favorable functional survival at day 28 was 44 of 1018 patients (4.3%) in the BMV group and 43 of 1022 patients (4.2%) in the ETI group (difference, 0.11% [1-sided 97.5% CI, -1.64% to infinity]; P for noninferiority = .11). Survival to hospital admission (294/1018 [28.9%] in the BMV group vs 333/1022 [32.6%] in the ETI group; difference, -3.7% [95% CI, -7.7% to 0.3%]) and global survival at day 28 (55/1018 [5.4%] in the BMV group vs 54/1022 [5.3%] in the ETI group; difference, 0.1% [95% CI, -1.8% to 2.1%]) were not significantly different. Complications included difficult airway management (186/1027 [18.1%] in the BMV group vs 134/996 [13.4%] in the ETI group; difference, 4.7% [95% CI, 1.5% to 7.9%]; P = .004), failure (69/1028 [6.7%] in the BMV group vs 21/996 [2.1%] in the ETI group; difference, 4.6% [95% CI, 2.8% to 6.4%]; P < .001), and regurgitation of gastric content (156/1027 [15.2%] in the BMV group vs 75/999 [7.5%] in the ETI group; difference, 7.7% [95% CI, 4.9% to 10.4%]; P < .001).

Conclusions And Relevance: Among patients with out-of-hospital cardiorespiratory arrest, the use of BMV compared with ETI failed to demonstrate noninferiority or inferiority for survival with favorable 28-day neurological function, an inconclusive result. A determination of equivalence or superiority between these techniques requires further research.

Trial Registration: clinicaltrials.gov Identifier: NCT02327026.
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http://dx.doi.org/10.1001/jama.2018.0156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5838565PMC
February 2018

Icatibant for ACE-inhibitor angioedema, an opportunity to treat the patients?

J Allergy Clin Immunol Pract 2017 Nov - Dec;5(6):1803

AP-HP, Urgences, Samu 93, Hôpital Avicenne, Université Paris 13, Bobigny, France.

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http://dx.doi.org/10.1016/j.jaip.2017.07.039DOI Listing
May 2019

Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial.

JAMA 2017 10;318(15):1450-1459

Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France.

Importance: The high mortality rate in critically ill elderly patients has led to questioning of the beneficial effect of intensive care unit (ICU) admission and to a variable ICU use among this population.

Objective: To determine whether a recommendation for systematic ICU admission in critically ill elderly patients reduces 6-month mortality compared with usual practice.

Design, Setting, And Participants: Multicenter, cluster-randomized clinical trial of 3037 critically ill patients aged 75 years or older, free of cancer, with preserved functional status (Index of Independence in Activities of Daily Living ≥4) and nutritional status (absence of cachexia) who arrived at the emergency department of one of 24 hospitals in France between January 2012 and April 2015 and were followed up until November 2015.

Interventions: Centers were randomly assigned either to use a program to promote systematic ICU admission of patients (n=1519 participants) or to follow standard practice (n=1518 participants).

Main Outcomes And Measures: The primary outcome was death at 6 months. Secondary outcomes included ICU admission rate, in-hospital death, functional status, and quality of life (12-Item Short Form Health Survey, ranging from 0 to 100, with higher score representing better self-reported health) at 6 months.

Results: One patient withdrew consent, leaving 3036 patients included in the trial (median age, 85 [interquartile range, 81-89] years; 1361 [45%] men). Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%; relative risk [RR], 1.16; 95% CI, 1.07-1.26) despite an increased ICU admission rate (61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95). After adjustments for baseline characteristics, patients in the systematic strategy group were more likely to be admitted to an ICU (RR, 1.68; 95% CI, 1.54-1.82) and had a higher risk of in-hospital death (RR, 1.18; 95% CI, 1.03-1.33) but had no significant increase in risk of death at 6 months (RR, 1.05; 95% CI, 0.96-1.14). Functional status and physical quality of life at 6 months were not significantly different between groups.

Conclusions And Relevance: Among critically ill elderly patients in France, a program to promote systematic ICU admission increased ICU use but did not reduce 6-month mortality. Additional research is needed to understand the decision to admit elderly patients to the ICU.

Trial Registration: clinicaltrials.gov Identifier: NCT01508819.
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http://dx.doi.org/10.1001/jama.2017.13889DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710364PMC
October 2017

Diagnosis and treatment of upper airway oedema caused by acute angio-oedema in the emergency department: a French consensus statement.

Eur J Emerg Med 2017 Oct;24(5):318-325

aDepartment of Anaesthesiology and Intensive care, Edouard Herriot University Hospital bDepartment of Clinical Research and Innovation, Hospices Civils de Lyon, Lyon cEmergency Department, Louis Mourier University Hospital, Paris 7 University dDepartment of Internal Medicine, Saint Antoine University Hospital, Paris 6 University, Assistance Publique-Hôpitaux de Paris, Paris eDepartment of Internal Medicine, Grenoble University Hospital, Grenoble-Alpes University, Grenoble fDepartment of Dermatology, Gabriel-Montpied University Hospital, Clermont-Ferrand gDepartment of Internal Medicine, Niort Hospital, Niort hDepartment of Internal Medicine, Archet 1 University Hospital, Nice Sophia-Antipolis University, Nice iDepartment of Medicine, Saint Louis University Hospital, Saint Pierre, Réunion jDepartment of Internal Medicine, Caen University Hospital, Caen kDepartment of Dermatology and Allergology, Grenoble University Hospital, Grenoble lDepartment of Internal Medicine, Timone University Hospital, Assistance Publique-Hôpitaux de Marseille, Marseille mDepartment of Dermatology, Saint Eloi University Hospital, Montpellier nDepartment of Dermatology, Besançon University Hospital, Franche-Comté University, INSERM UMR 1098, Besançon oDepartment of Internal Medicine Toulouse University Hospital, Toulouse University, Toulouse pDepartment of Internal Medicine, Lille University Hospital, Lille University, INSERM U995 Lille, Lille, France.

Angio-oedema is a transitory, localized, noninflammatory oedema of subcutaneous tissue or mucous. When the oedema affects the mouth, lips, tongue or larynx, it can result in fatal asphyxiation in the absence of specific treatment. Oedema secondary to plasma extravasation is usually mediated by either histamine or bradykinin. As laboratory tests are not available in an emergency setting, the implicated mediator cannot be readily determined. The challenge for the emergency physician is to determine the aetiological type, evaluate severity and initiate adapted treatment by means of a structured approach. A team of experts from the French Reference Centre for Angio-oedema reached a consensus for recommendations for the diagnostic and therapeutic strategy to be adopted by emergency departments faced with angio-oedema of the upper airways in adults. The experts defined 11 important questions. Responses were rated using a two-round Delphi methodology. The 11 recommendations were related to triage on admission, a step-by-step diagnostic protocol, definition of attack severity, discouragement of instrumental examination, prioritization of treatment for severe attacks according to clinical signs and anticipation of access to specific treatments by the hospital. Angio-oedema of the upper airways can be fatal and requires anticipation by the emergency department. A search for the aetiology, an evaluation of clinical symptoms and the availability of the treatments are challenges justifying these recommendations.
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http://dx.doi.org/10.1097/MEJ.0000000000000446DOI Listing
October 2017

Cardiopulmonary resuscitation duration and survival in out-of-hospital cardiac arrest patients.

Resuscitation 2017 02 14;111:74-81. Epub 2016 Dec 14.

AP-HP, Hôpital Saint Louis, University Paris Diderot, Sorbonne Paris Cité, UMR1153 CRESS, Biostatistics and Clinical Epidemiology Research Team (ECSTRA), F-75010, Paris, France.

Aim: Relationship between cardiopulmonary arrest and resuscitation (CPR) durations and survival after out-of-hospital cardiac arrest (OHCA) remain unclear. Our primary aim was to determine the association between survival without neurologic sequelae and cardiac arrest intervals in the setting of witnessed OHCA.

Methods: We analyzed 27,301 non-traumatic, witnessed OHCA patients in France included in the national registry from June 1, 2011 through December 1, 2015. We analyzed cardiac arrest intervals, designated as no-flow (NF; from collapse to start of CPR) and low-flow (LF; from start of CPR to cessation of resuscitation) in relation to 30-day survival without sequelae. We determined the influence of recognized prognostic factors (age, gender, initial rhythm, location of cardiac arrest) on this relation.

Results: For the entire cohort, the area delimited by a value of NF greater than 12min (95% confidence interval: 11-13min) and LF greater than 33min (95% confidence interval: 29-45min), yielded a probability of 30-day survival of less than 1%. These sets of values were greatly influenced by initial cardiac arrest rhythm, age, sex and location of cardiac arrest. Extended CPR duration (greater than 40min) in the setting of initial shockable cardiac rhythm is associated with greater than 1% survival with NF less than 18min. The NF interval was highly influential on the LF interval regardless of outcome, whether return of spontaneous circulation (p<0.001) or death (p<0.001).

Conclusion: NF duration must be considered in determining CPR duration in OHCA patients. The knowledge of (NF, LF) curves as function of age, initial rhythm, location of cardiac arrest or gender may aid in decision-making vis-à-vis the termination of CPR or employment of advanced techniques.
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http://dx.doi.org/10.1016/j.resuscitation.2016.11.024DOI Listing
February 2017

Family Presence during Resuscitation: A Qualitative Analysis from a National Multicenter Randomized Clinical Trial.

PLoS One 2016 2;11(6):e0156100. Epub 2016 Jun 2.

AP-HP, Urgences, Samu 93, hôpital Avicenne, 93000 Bobigny, France.

Background: The themes of qualitative assessments that characterize the experience of family members offered the choice of observing cardiopulmonary resuscitation (CPR) of a loved one have not been formally identified.

Methods And Findings: In the context of a multicenter randomized clinical trial offering family members the choice of observing CPR of a patient with sudden cardiac arrest, a qualitative analysis, with a sequential explanatory design, was conducted. The aim of the study was to understand family members' experience during CPR. All participants were interviewed by phone at home three months after cardiac arrest. Saturation was reached after analysis of 30 interviews of a randomly selected sample of 75 family members included in the trial. Four themes were identified: 1- choosing to be actively involved in the resuscitation; 2- communication between the relative and the emergency care team; 3- perception of the reality of the death, promoting acceptance of the loss; 4- experience and reactions of the relatives who did or did not witness the CPR, describing their feelings. Twelve sub-themes further defining these four themes were identified. Transferability of our findings should take into account the country-specific medical system.

Conclusions: Family presence can help to ameliorate the pain of the death, through the feeling of having helped to support the patient during the passage from life to death and of having participated in this important moment. Our results showed the central role of communication between the family and the emergency care team in facilitating the acceptance of the reality of death.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0156100PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4890739PMC
July 2017

Dedicated call center (SOS-HAE) for hereditary angioedema attacks: study protocol for a randomised controlled trial.

Trials 2016 Apr 30;17(1):225. Epub 2016 Apr 30.

SAMU-SMUR 93, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Université Paris 13, 93 000, Bobigny, France.

Background: Despite the availability of guidelines for the specific treatment of hereditary angioedema (HAE) attacks, HAE morbidity and mortality rates remain substantial. HAE attacks are a major medical issue requiring specific treatment as well as a considerable socio-economic burden. We report a protocol designed to test whether a dedicated call centre is more effective than usual practice in the management of patients experiencing an HAE attack.

Methods/design: This prospective, cluster-randomised, single-blind, parallel-group, multicentre trial evaluates the morbidity and consequent socio-economic costs of the management of patients experiencing an HAE attack by a dedicated call centre as compared to usual practice. The trial aims to recruit 200 patients. Patients in the intervention arm are provided with an SOS-HAE card with the call centre's freephone number that they can access in the case of an attack. The centre's mission is to provide recommended expert advice on early home treatment. The centre can route the call to a local emergency medical service with competency in HAE management or even arrange for the drugs needed for the specific treatment of an HAE attack to be sent to the emergency department of the local hospital. The primary outcome measure is the number of hospital admissions for an HAE attack. Each patient will be followed up every 2 months for 2 years. The study has been approved by the ethics committee (Comité de Protection des Personnes d'Ile de France 10; registration number: 2012-A00044-39; date of approval: 19 January 2012).

Discussion: The SOS-HAE protocol has been designed to address the handling of attacks experienced by patients with HAE in the home. The proposed trial will determine whether the setting up of a dedicated call centre is more effective than usual practice in terms of reducing morbidity as given by the numbers of hospital admissions. The results are also anticipated to have important implications in terms of socio-economic costs for both healthcare services and patients.

Trial Registration: ClinicalTrials.gov NCT01679912 .
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http://dx.doi.org/10.1186/s13063-016-1350-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4853856PMC
April 2016

[Henna tattoo].

Rev Prat 2015 Dec;65(10):1287

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December 2015

Angioedema Related to Angiotensin-Converting Enzyme Inhibitors: Attack Severity, Treatment, and Hospital Admission in a Prospective Multicenter Study.

Medicine (Baltimore) 2015 Nov;94(45):e1939

Service des Urgences, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Université Paris 7, 92 700 Colombes (NJ, JA); Urgences et (P-GR, FL, LH, FA); SAMU-SMUR 93, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Université Paris 13, 93 000 Bobigny (P-GR, FL, FA); Urgences, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Université Paris 13, 93 140 Bondy (AL, AK); Urgences, Hôpital d'Eaubonne, 95 600 Eaubonne (AL); Urgences, Hôpital de Gonesse, 95 500 Gonesse (MY); Service de Médecine Interne, DHUi2B, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, Université Paris 6, 75 012 Paris, France (OF).

The number of cases of acquired angioedema related to angiotensin converting enzyme inhibitors induced (ACEI-AAE) is on the increase, with a potential concomitant increase in life-threatening attacks of laryngeal edema. Our objective was to determine the main characteristics of ACEI-AAE attacks and, in doing so, the factors associated with likelihood of hospital admission from the emergency department (ED) after a visit for an attack.A prospective, multicenter, observational study (April 2012-December 2014) was conducted in EDs of 4 French hospitals in collaboration with emergency services (SAMU 93) and a reference center for bradykinin-mediated angioedema. For each patient presenting with an attack, emergency physicians collected demographic and clinical presentation data, treatments, and clinical course. They recorded time intervals from symptom onset to ED arrival and to treatment decision, from ED arrival to specific treatment with plasma-derived C1-inhibitor (C1-INH) or icatibant, and from specific treatment to onset of symptom relief. Attacks requiring hospital admission were compared with those not requiring admission.Sixty-two eligible patients with ACEI-AAE (56% men, median age 63 years) were included. Symptom relief occurred significantly earlier in patients receiving specific treatment than in untreated patients (0.5 [0.5-1.0] versus 3.9 [2.5-7.0] hours; P < 0.0001). Even though icatibant was injected more promptly than plasma-derived C1-INH, there, however, was no significant difference in median time to onset of symptom relief between the 2 drugs (0.5 [0.5-1.3] versus 0.5 [0.4-1.0] hours for C1-INH and icatibant, respectively, P = 0.49). Of the 62 patients, 27 (44%) were admitted to hospital from the ED. In multivariate analysis, laryngeal involvement and progressive swelling at ED arrival were independently associated with admission (Odds ratio [95% confidence interval] = 6.2 [1.3-28.2] and 5.9 [1.3-26.5], respectively). A favorable course was observed in all patients. Three patients (5%) experienced a recurrence after angiotensin-converting enzyme inhibitor discontinuation after a median follow-up of 18 (11-30) months.Two severity criteria-laryngeal edema and the progression of the edema-were independent factors associated with likelihood of hospital admission. Appropriate specific treatments (plasma-derived C1-INH or icatibant) should be available in EDs to prevent possibly life-threatening complications.
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http://dx.doi.org/10.1097/MD.0000000000001939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4912256PMC
November 2015

Angiotensin-converting enzyme inhibitor-induced angioedema and hereditary angioedema: a comparison study of attack severity.

Intern Med 2015 15;54(20):2583-8. Epub 2015 Oct 15.

Emergency Department, Angioedema Reference Center (CRéAk), Public Assistance Hospital of Paris, University Hospital of Jean Verdier, France.

Objective There appears to be differences in the clinical presentation of hereditary angioedema (HAE) and angiotensin-converting enzyme inhibitor-induced (ACE-I) angioedema (AE). The aim of this study was to compare the clinical characteristics of these two AE forms. Methods We conducted a retrospective study of consecutive patients with HAE or ACE-I AE. The attack characteristics experienced by the patients were compared by a logistic regression analysis using generalized estimating equations. Results A total of 56 patients were included in this study (ACE-I AE, n=25; HAE, n=31). A total of 534 attacks were documented. Severe attacks were more common in the patients who had an acute episode of ACE-I AE than HAE. Swelling of the tongue, lips and larynx were significantly associated with ACE-I AE [OR: 8.70 (95% CI, 1.04-73.70), OR: 20.4 (95% CI, 4.9-84.2) and OR: 7.50 (95% CI, 1.20-48.30), respectively]. Conclusion Swelling of the tongue, lips and larynx are significantly more frequent in drug-induced AE than HAE.
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http://dx.doi.org/10.2169/internalmedicine.54.4181DOI Listing
April 2016

Factors associated with hospital admission in hereditary angioedema attacks: a multicenter prospective study.

Ann Allergy Asthma Immunol 2015 Jun 29;114(6):499-503. Epub 2015 Apr 29.

Service de Médecine Interne, Centre de Référence associé sur les angioedèmes à kinines (CRéAk), Assistance Publique-Hôpitaux de Paris, Hôpital Jean Verdier, Université Paris 13, Bondy, France.

Background: Acute attacks of hereditary angioedema are characterized by recurrent localized edema. These attacks can be life threatening and are associated with substantial morbidity and mortality.

Objective: To determine factors associated with hospital admission of patients with an acute attack of hereditary angioedema presenting at the emergency department.

Methods: This was a multicenter prospective observational study of consecutive patients (January 2011 through December 2013) experiencing an acute hereditary angioedema attack and presenting at the emergency department at 1 of 4 French reference centers for bradykinin-mediated angioedema. Attacks requiring hospital admission were compared with those not requiring admission.

Results: Of 57 attacks in 29 patients, 17 (30%) led to hospital admission. In multivariate analysis, laryngeal and facial involvements were associated with hospital admission (odds ratio 18.6, 95% confidence interval 3.9-88; odds ratio 7.7, 95% confidence interval 1.4-43.4, respectively). Self-injection of icatibant at home was associated with non-admission (odds ratio 0.06, 95% confidence interval 0.01-0.61). The course was favorable in all 57 cases. No upper airway management was required.

Conclusion: Most patients attended the emergency department because they were running out of medication and did not know that emergency treatment could be self-administered. Risk factors associated with hospital admission were laryngeal and facial involvement, whereas self-injection of icatibant was associated with a return home.
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http://dx.doi.org/10.1016/j.anai.2015.04.005DOI Listing
June 2015

Bradykinin-mediated angioedema: factors associated with admission to an intensive care unit, a multicenter study.

Eur J Emerg Med 2016 Jun;23(3):219-23

aEmergency Department bInternal Medicine, Reference Center for Angioedema (CRéAk), Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Groupe hospitalier Hôpitaux Universitaires Paris Seine-Saint-Denis, Université Paris Bondy cSAMU-SMUR 93 dClinical Research Department, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Groupe hospitalier Hôpitaux Universitaires Paris Seine-Saint-Denis, Université Paris Bobigny eDepartment of Anesthesiology and Intensive care Unit fInternal Medicine, Reference Center for Angioedema (CRéAk), Hôpital Edouard-Herriot, Hospices civils de Lyon gInternal Medicine, Reference Center for Angioedema (CRéAk), CHU de Grenoble, Grenoble hDepartment of Dermatology iIntensive Care Unit, Reference Center for Angioedema (CRéAk), UNAM Université, Hôpital d'Angers, Cedex jDepartment of Dermatology, Reference Center for Angioedema (CRéAk), CHU Gabriel-Montpied, Clermont-Ferrand kInternal Medicine, Centre Hospitalier du Centre de Bretagne, Pontivy lInternal Medicine, CHU de Caen, Caen, France.

Objective: Bradykinin-mediated angioedema is characterized by transient attacks of localized edema of subcutaneous or submucosal tissues and can be life-threatening when involving the upper airways. The aim of this study was to determine the features of acute attacks that might be associated with admission to an ICU.

Patients And Methods: We carried out a retrospective, multicenter, observational study in consecutive patients attending one of six reference centers in France for acute bradykinin-mediated angioedema attacks. Patients had been hospitalized for an acute episode at least once previously. Acute attacks requiring ICU admission were compared with acute attacks that had not required ICU admission.

Results: Overall, 118 acute attacks in 31 patients were analyzed (10 patients with hereditary angioedema, 19 patients with angiotensin-converting enzyme inhibitor-induced angioedema, and two patients with acquired C1-inhibitor deficiency angioedema). In multivariate analysis, upper airway involvement, corticosteroid, and C1-inhibitor concentrate administration were associated with ICU admission. Seven episodes (18%) needed airway protection. The evolution was favorable in 38 of 39 attacks warranting ICU admission: patients were able to get out of the service (mean ICU stay 4±5 days). One death was observed by asphyxiation because of laryngeal swelling.

Conclusion: Upper airway involvement is an independent risk factor for ICU admission. Corticosteroid use, which is an ineffective treatment, and C1-inhibitor concentrate use are factors for ICU admission. The presence of upper airway involvement should be a warning signal that the attack may be severe.
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http://dx.doi.org/10.1097/MEJ.0000000000000252DOI Listing
June 2016

Early invasive strategy in high-risk acute coronary syndrome without ST-segment elevation. The Sisca randomized trial.

Int J Cardiol 2015 Mar 27;182:414-8. Epub 2014 Dec 27.

Service des Urgences et Service d'Aide Médicale Urgente, Centre Hospitalier Universitaire Avicenne, Assistance Publique-Hôpitaux de Paris, 125 rue de Stalingrad, 93009 Bobigny Cedex, France; Université Paris 13, Sorbonne Paris Cité, EA 3509 Bobigny, France.

Background: The optimal therapeutic strategy for patients with high-risk acute coronary syndrome without ST-segment elevation (NSTE-ACS) remains unclear.

Objective: Our aim was to compare the effectiveness of an early invasive strategy and a delayed invasive strategy in the management of high-risk NSTE-ACS patients.

Methods: This randomized clinical trial in a primarily pre-hospital setting enrolled patients with chest pain, electrocardiographic criteria for an NSTE-ACS, and at least one criterion of severity (ESC criterion or TIMI score >5). Patients were randomized to either an early invasive strategy (tirofiban infusion and coronary angiography within 6h) or delayed invasive strategy (as per guidelines and physician discretion; coronary angiography within 6h was not advised). The primary endpoint was the cumulative incidence of deaths, myocardial infarctions, or urgent revascularizations at 30days of follow-up. Secondary endpoints were failure of delayed management, length of hospital stay and long-term mortality.

Results: Between January 2007 and February 2010, 170 patients were enrolled. The cumulative incidence of adverse outcomes was significantly lower for early invasive than delayed management (2% [95% CI 0-9] vs. 24% [95% CI 16-35], p<10(-4)). Delayed management failed in 24% of cases. The length of hospital stay was significantly shorter in patients undergoing angioplasty or treated with tirofiban within 6h (p=0.0003). Long-term mortality was 16% in both arms after a median follow-up of 4.1years.

Conclusion: An early invasive strategy reduced major adverse cardiac events in patients with high-risk NSTE-ACS. Early angiography or tirofiban (GP IIb/IIIa inhibitor) infusion proved necessary in a quarter of patients assigned to delayed management.
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http://dx.doi.org/10.1016/j.ijcard.2014.12.089DOI Listing
March 2015

[Acquired angioedema].

Presse Med 2015 Jan 18;44(1):48-51. Epub 2014 Dec 18.

AP-HP, université Paris 7, urgences, hôpital Louis-Mounier, 92700 Colombes, France.

Acquired angioedema are rare. They are associated with monoclonal gammapathies of uncertain significance (MGUS) or lymphomas. They give the same symptoms as the hereditary form and the same laryngeal risk. They are characterized by a low level of C4, C1Inh and C1q. They are linked to the consumption of C1Inh by the lymphoid cells or to the presence of anti-C1Inh autoantibodies. They must be treated by symptomatic treatment when attack occur (C1Inh concentrate and icatibant). The use of rituximab needs to prove its efficiency.
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http://dx.doi.org/10.1016/j.lpm.2014.09.010DOI Listing
January 2015

[Emergency management of bradykinin-mediated angioedema].

Presse Med 2015 Jan 13;44(1):70-7. Epub 2014 Dec 13.

Hospices civils de Lyon, hôpital Édouard-Herriot, centre de référence multisites des angiœdèmes bradykiniques, département d'anesthésie-réanimation, 69437 Lyon, France.

In the emergency setting, the diagnosis of bradykinin-mediated angioedema is based exclusively on history and physical examination. Severe attacks must be identified because the evolution is unpredictable with a risk of life-threatening airway obstruction. Underestimate the severity of the attack is a management pitfall to avoid. All attack under the shoulders should be considered as severe and must benefit from early specific treatment.
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http://dx.doi.org/10.1016/j.lpm.2014.09.012DOI Listing
January 2015

[Drug induced angioedema (ACE-inhibitors and other)].

Presse Med 2015 Jan 12;44(1):43-7. Epub 2014 Dec 12.

AP-HP, université Paris 7, urgences, hôpital Louis-Mounier, 92700 Colombes, France.

Angiotensin Converting Enzyme inhibitors (ACE-I) use is a frequent cause of AE and must be suspected systematically in all patients with AE. The risk of AE is increased in: black people, transplanted patients, those who take gliptins or immunosuppressants (mTOR i). Angiotensin converting enzyme inhibitors induced angioedema (ACE-I AE) can occur a few days to several years after the beginning of this treatment and persist a few months after stopping it. ACE-I AE affect mainly the face and particularly the tongue but also the abdomen. ACE-I AE can be life threatening, due to the involvement of the tongue and the larynx. ACE-I AE must be treated as in the hereditary form when life threatening signs are present, with icatibant or C1 inhibitor concentrate. AE can occur in 10% of angiotensin receptor blockers (ARBs) treated patients who had developed ACE-I AE.
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http://dx.doi.org/10.1016/j.lpm.2014.07.019DOI Listing
January 2015

Relative adrenal insufficiency in critically ill patient after rapid sequence intubation: KETASED ancillary study.

J Crit Care 2014 Jun 3;29(3):386-9. Epub 2014 Jan 3.

Urgences-Samu 93, hôpital Avicenne, APHP, 93000 Bobigny, France.

Purpose: Relative adrenal insufficiency (RAI) has been reported as a predictor of mortality in septic patient; however, its effects on mortality and outcomes for critically ill patients remain debatable. The objective of this study was to assess the effect of RAI on prognostic outcomes in patients after out-of-hospital rapid sequence intubation (RSI) and factors associated with the onset of RAI.

Patients And Methods: A prespecified ancillary study of KETASED, a randomized prospective multicenter trial, was conducted. Three hundred ten patients who underwent RSI in an out-of-hospital setting had baseline cortisol and adrenocorticotropic hormone response test measurements within 24 hours of intensive care unit admission and were included.

Results: The mean (SD) age was 55 (19) years, with a mean (SD) Sequential Organ Failure Assessment score of 9 (4). Two hundred forty-seven (69%) patients presented with RAI. Baseline characteristics were similar between patients with and without RAI, except for the use of etomidate as a sedative agent (63% of patients with RAI vs 21%, P<.001), and history of chronic kidney disease. There was no difference in terms of 28-day mortality between the 2 groups (21% vs 19%, P=.65) and in terms of other 28-day prognosis end points.

Conclusion: In critically ill patients who require RSI, RAI is common and is not associated with worsened outcomes in our cohort.
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http://dx.doi.org/10.1016/j.jcrc.2013.12.018DOI Listing
June 2014