Failure rate of D-dimer testing in patients with high clinical probability of pulmonary embolism: Ancillary analysis of three European studies.
Bannelier H, Kapfer T, Roussel M, Freund Y, Alame K, Catoire P, Vromant A. | Acad Emerg Med. 2024 Nov 1
DOI: https://doi.org/10.1111/acem.15032  | Télécharger l'article au format  
Keywords: Bayesian analysis; D‐dimer; Wells; computed tomography pulmonary angiography; emergency department; emergency medicine; probability scores; pulmonary embolism; revised Geneva.

Original article

Introduction : In patients with a high clinical probability of pulmonary embolism (PE), the high prevalence can lower the D-dimer negative predictive value and increase the risk of diagnostic failure. It is therefore recommended that these high-risk patients should undergo chest imaging without D-dimer testing although no evidence supports this recommendation.

Méthode : The objective was to evaluate the safety of ruling out PE based on D-dimer testing among patients with a high clinical probability of PE.
Methods: This was a post hoc analysis of three European studies (PROPER, MODIGLIANI, and TRYSPEED). Patients were included if they presented a high clinical probability of PE (according to either the Wells or the revised Geneva score) and underwent D-dimer testing. The D-dimer-based strategy ruled out PE if the D-dimer level was below the age-adjusted threshold (i.e., <500 ng/mL in patients aged less than 50 and age × 10 ng/mL in patients older than 50). The primary endpoint was a thromboembolic event in patients with negative D-dimer either at index visit or at 3-month follow-up. A Bayesian approach estimated the probability that the failure rate of the D-dimer-based strategy was below 2% given observed data.

Résultats : Among the 12,300 patients included in the PROPER, MODIGLIANI, and TRYSPEED studies, 651 patients (median age 68 years, 60% female) had D-dimer testing and a high clinical probability of PE and were included in the study. PE prevalence was 31.3%. Seventy patients had D-dimer levels under the age-adjusted threshold, and none of them had a PE after follow-up (failure rate 0.0% [95% CI 0.0%-6.5%]). Bayesian analysis reported a credible interval of 0.0%-4.1%, with a 76.2% posterior probability of a failure rate below 2%.

Conclusion : In this study, ruling out PE in high-risk patients based on D-dimer below the age-adjusted threshold was safe, with no missed PE. However, the large CI of the primary endpoint precludes a definitive conclusion.

Conclusion (proposition de traduction) : Dans cette étude, l'exclusion de l'embolie pulmonaire chez les patients à haut risque sur la base du taux de D-dimères inférieurs au seuil ajusté à l'âge s'est avérée sûre, aucune embolie pulmonaire n'ayant été manquée. Cependant, l'important intervalle de confiance du critère d'évaluation principal ne permet pas de tirer une conclusion définitive.

The Impact of Point-of-Care Ultrasound-Guided Resuscitation on Clinical Outcomes in Patients With Shock: A Systematic Review and Meta-Analysis.
Basmaji J, Arntfield R, Desai K, Lau VI, Lewis K, Rochwerg B, Fiorini K, Honarmand K, Slessarev M, Leligdowicz A, Park B, Prager R, Wong MYS, Jones PM, Ball IM, Orozco N, Meade M, Thabane L, Guyatt G. | Crit Care Med. 2024 Nov 1;52(11):1661-1673
DOI: https://doi.org/10.1097/ccm.0000000000006399  | Télécharger l'article au format  
Keywords: Aucun

FEATURE ARTICLE

Introduction : To determine the impact of point-of-care ultrasound (POCUS)-guided resuscitation on clinical outcomes in adult patients with shock.

Méthode : We searched MEDLINE, Embase, and unpublished sources from inception to December 2023.
Study selection: We included randomized controlled trials (RCTs) that examined the use of POCUS to guide resuscitation in patients with shock.
Data extraction: We collected data regarding study and patient characteristics, POCUS protocol, control group interventions, and outcomes

Résultats : We identified 18 eligible RCTs. POCUS slightly influences physicians' plans for IV fluid (IVF) and vasoactive medication prescription (moderate certainty), but results in little to no changes in the administration of IVF (low to high certainty) or inotropes (high certainty). POCUS may result in no change in the number of CT scans performed (low certainty) but probably reduces the number of diagnostic echocardiograms performed (moderate certainty). POCUS-guided resuscitation probably reduces 28-day mortality (relative risk [RR] 0.88; 95% CI, 0.78-0.99), the duration of vasoactive medication (mean difference -0.73 d; 95% CI, -1.16 to -0.30), and the need for renal replacement therapy (RRT) (RR 0.80; 95% CI, 0.63-1.02) (low to moderate certainty evidence), and lactate clearance (high certainty evidence). POCUS-guided resuscitation may results in little to no difference in ICU or hospital admissions, ICU and hospital length of stay, and the need for mechanical ventilation (MV) (low to moderate certainty evidence). There is an uncertain effect on the risk of acute kidney injury and the duration of MV or RRT (very low certainty evidence).

Conclusion : POCUS-guided resuscitation in shock may yield important patient and health system benefits. Due to lack of sufficient evidence, we were unable to explore how the thresholds of operator competency, frequency, and timing of POCUS scans impact patient outcomes.

Conclusion (proposition de traduction) : La réanimation échoguidée au point d'intervention en cas d'état de choc peut apporter d'importants bénéfices aux patients et au système de santé. Faute de preuves suffisantes, nous n'avons pas été en mesure d'étudier l'impact des seuils de compétence de l'opérateur, de la fréquence et du moment des échographies au point d'intervention sur le devenir des patients.

New strategies for the treatment of hyperkalemia.
Masi S, Dalpiaz H, Piludu S, Piani F, Fiorini G, Borghi C. | Eur J Intern Med. 2024 Nov 2:S0953-6205(24)00434-5
DOI: https://doi.org/10.1016/j.ejim.2024.10.016  | Télécharger l'article au format  
Keywords: Finerenone; Heart failure; Hyperkalaemia; Hypertension; Potassium binders; Sodium-glucose co-transporter-2 inhibitors.

Review Article

Editorial : Renin-angiotensin-aldosterone system inhibitors (RAASi) and mineralocorticoid receptor antagonists (MRAs) are key drugs in the management of patients with cardiovascular diseases (CVD), particularly those with hypertension, diabetes, chronic kidney disease and heart failure (HF), given their demonstrated effectiveness in reducing the risk of both surrogate and hard endpoints. Despite their positive impact on the outcome, patients with RAASi and MRAs are particularly vulnerable to hyperkalaemia, with approximately 50 % of these individuals experiencing two or more recurrences annually. The common practice of reducing the dose or discontinuing the treatment with RAASi and MRAs in conditions of hyperkalaemia results in suboptimal management of these patients, with a potential impact on their mortality and morbidity risk. Recent guidelines from cardiovascular and renal international societies increasingly recognize the need for alternative strategies to manage the risk of hyperkalaemia, allowing the continuation of RAASi and MRA therapies. In this review, we summarise the new potential options available to manage hyperkalaemia in patients with CVD and the recommendations of the most recent guidelines on the topic.

Conclusion : Hyperkalemia is a common finding along the cardiovascular disease continuum and is associated with adverse health outcomes, increased morbidity and mortality. Early diagnosis and understanding of the underlying causes are crucial for appropriate patient management. Given the diverse mechanisms contributing to hyperkalemia, a multidisciplinary approach is necessary to optimize the patient’s management and reduce the risk associated with this condition. Several effective and safe therapeutic options exist for treating hyperkalemia across different patient groups. However, there are still gaps in our knowledge related to the long-term capacity of novel potassium binder treatments to effectively reduce the mortality and morbidity risk across the cardiovascular disease continuum, by enabling optimization of the medical therapy, making ongoing research essential to enhance our understanding of their potential impact on the patient outcome.

Conclusion (proposition de traduction) : L'hyperkaliémie est un phénomène courant dans le continuum des maladies cardiovasculaires et est associée à des effets indésirables sur la santé, à une augmentation de la morbidité et de la mortalité. Un diagnostic précoce et la compréhension des causes sous-jacentes sont essentiels pour une prise en charge appropriée des patients. Compte tenu des divers mécanismes contribuant à l'hyperkaliémie, une approche multidisciplinaire est nécessaire pour optimiser la prise en charge du patient et réduire le risque associé à cette pathologie. Il existe plusieurs options thérapeutiques efficaces et sûres pour traiter l'hyperkaliémie dans différents groupes de patients. Cependant, nos connaissances sont encore lacunaires en ce qui concerne la capacité à long terme des nouveaux traitements à base de chélateurs du potassium à réduire efficacement le risque de mortalité et de morbidité dans le continuum des maladies cardiovasculaires, en permettant l'optimisation du traitement médicale, ce qui rend la recherche continue essentielle pour améliorer notre compréhension de leur impact potentiel sur le résultat du patient.

Acute Aortic Syndrome Revisited: JACC State-of-the-Art Review.
Vilacosta I, San Román JA, di Bartolomeo R, Eagle K, Estrera AL, Ferrera C, Kaji S, Nienaber CA, Riambau V, Schäfers HJ, Serrano FJ, Song JK, Maroto L. | J Am Coll Cardiol. 2021 Nov 23;78(21):2106-2125
DOI: https://doi.org/10.1016/j.jacc.2021.09.022  | Télécharger l'article au format  
Keywords: acute aortic syndrome; aortic diseases; management.

JACC STATE-OF-THE-ART REVIEW

Editorial : The purpose of this paper is to describe all available evidence on the distinctive features of a group of 4 life-threatening acute aortic pathologies gathered under the name of acute aortic syndrome (AAS). The epidemiology, diagnostic strategy, and management of these patients has been updated. The authors propose a new and simple diagnostic algorithm to support clinical decision making in cases of suspected AAS, thereby minimizing diagnostic delays, misdiagnoses, and unnecessary advanced imaging. AAS-related entities are reviewed, and a guideline to avoid imaging misinterpretation is provided. Centralization of patients with AAS in high-volume centers with high-volume surgeons is key to improving clinical outcomes. Thus, the role of multidisciplinary teams, an "aorta code" (streamlined emergent care pathway), and aortic centers in the management of these patients is boosted. A tailored patient treatment approach for each of these acute aortic entities is needed, and as such has been summarized. Finally, a set of prevention measures against AAS is discussed.

Conclusion : The past 20 years of progress in recognizing and treating patients with AAS have provided us with basic insights in the management of acute aortic pathology, but have also revealed many gaps in knowledge. We look ahead to emerging technologies to further enhance our knowledge on aortic wall architecture and functional properties. Specific AAS biomarkers are desperately needed to detect the disease at its earliest stage. Centers for aortic surgery and aorta codes should be promoted. Additional studies are necessary to outline the course and treatment of patients with the less common variants of AAS. Prospective multicenter clinical trials and more realistically compulsory registries are necessary to test the efficacy of preventive interventions in the setting of aortic conditions.

Conclusion (proposition de traduction) : Les 20 dernières années de progrès dans la reconnaissance et le traitement des patients présentant un syndrome aortique aigu nous ont permis d'acquérir des connaissances fondamentales dans la gestion de la pathologie aortique aiguë, mais ont également révélé de nombreuses lacunes dans les connaissances. Nous attendons des technologies nouvelles qu'elles améliorent encore nos connaissances sur l'architecture et les propriétés fonctionnelles de la paroi aortique. Des biomarqueurs spécifiques du syndrome aortique aigu sont désespérément nécessaires pour détecter la maladie à son stade le plus précoce. Il convient de promouvoir les centres de chirurgie aortique et les centres de traitement de l'aorte. Des études supplémentaires sont nécessaires pour définir l'évolution et le traitement des patients présentant les variantes les moins courantes du syndrome aortique aigu. Des essais cliniques multicentriques prospectifs et des registres plus réalistes et obligatoires sont nécessaires pour tester l'efficacité des interventions préventives dans le cadre des affections aortiques.

Treatment of acute urticaria: A systematic review.
Badloe FMS, Grosber M, Ring J, Kortekaas Krohn I, Gutermuth J. | J Eur Acad Dermatol Venereol. 2024 Nov;38(11):2082-2092
DOI: https://doi.org/10.1111/jdv.19904
Keywords: Aucun

SYSTEMATIC REVIEW

Editorial : There are only a few clinical trials which address the treatment of acute urticaria (AU). Especially, the added value of systemic corticosteroids to antihistamines is unclear in treatment of severe AU. To review the existing evidence-based approaches for AU treatment. A systematic electronic search was done in PubMed and Web of Science to retrieve all studies on the treatment of patients with AU. A descriptive synthesis was conducted based on the PRISMA statement. Quality assessment was independently performed by both reviewers ('Cochrane risk-of-bias tool' for RCTs). Ten randomized controlled trials (RCTs) (n = 857 participants) were included. Four studies assessed corticosteroid effectiveness added to antihistamines and six studies compared the efficacy of H1 and/ or H2-antihistamines. The addition of corticosteroid (prednisone) to an antihistamine (levo)cetirizine did not improve symptoms of AU compared to antihistamine alone in two out of three RCTs. The combination of diphenhydramine (50 mg, IV) and ranitidine (50 mg, IV) or cimetidine (300 mg, IV) was most efficient for relief of urticaria in two out of five studies. Most frequent adverse effects were sedation and drowsiness. Recent guidelines on urticaria treatment mainly focus on chronic urticaria rather than on AU. Moreover, only few, small RCTs provide evidence for the management of AU. Thus, the state-of-the-art management of this frequent condition remains unclear. The addition of corticosteroids to an antihistamine as treatment for AU needs to be further investigated. Well-designed, high-quality interventional trials are needed to establish evidence-based treatment guidelines for AU.

Conclusion : As the results of the published studies are inconsistent, the addition of corticosteroids to an antihistamine as a treatment for AU option needs to be further investigated. None of the included studies analysed the progression from AU to CSU. A longer follow-up of more than 6 weeks is needed to evaluate whether corticoid steroid use in addition to antihistamine has a protective impact on the development of CSU. The latest guidelines on the treatment of AU are based on a limited number of trials (RCTs and non-RCT). Finally, AU recommendations are often extrapolated from CSU. The currently available data does not allow us to answer the question of whether the addition of corticosteroids to antihistamine indeed have a beneficial effect. Sufficiently powered trials are needed to address the optimal approach, using up-to-date read-outs.

Conclusion (proposition de traduction) : Les résultats des études publiées n'étant pas concluants, l'ajout de corticoïdes à un antihistaminique dans le traitement de l'urticaire aiguë doit faire l'objet d'un complément d'étude. Aucune des études incluses n'a analysé la progression de l'urticaire aiguë vers l'urticaire chronique spontanée. Un suivi plus long, de plus de 6 semaines, est nécessaire pour évaluer si l'utilisation de corticoïdes en plus d'un antihistaminique a un effet protecteur sur le développement de l'urticaire chronique spontanée. Les dernières lignes directrices sur le traitement de l'urticaire aiguë sont basées sur un nombre limité d'essais (essais contrôlés randomisés et essais contrôlés non randomisés). Enfin, les recommandations relatives à l'urticaire aiguë sont souvent extrapolées à partir de l'urticaire chronique spontanée. Les données actuellement disponibles ne nous permettent pas de répondre à la question de savoir si l'ajout de corticoïdes aux antihistaminiques a effectivement un effet bénéfique. Des essais suffisamment puissants sont nécessaires pour déterminer l'approche optimale, en utilisant des résultats actualisés.

High risk and low incidence diseases: Massive hemoptysis.
Pirotte M, Pirotte A, Koyfman A, Long B. | Am J Emerg Med. Am J Emerg Med. 2024 Sep 10;85:179-185
DOI: https://doi.org/10.1016/j.ajem.2024.09.013
Keywords: Airway; Asphyxia; Bleeding; Bronchial; Hemoptysis; Hemorrhage; Massive hemoptysis; Pulmonary; Pulmonology; Respiratory; Severe hemoptysis.

Article

Introduction : Massive hemoptysis (MH) is a serious condition that carries with it a high rate of morbidity and mortality.

Méthode : This review highlights the pearls and pitfalls of massive hemoptysis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

Discussion : MH is a rare but deadly condition. It is defined clinically as any bleeding from the tracheobronchial tree that compromises respiratory or circulatory function. The bronchial artery system is the primary source in the majority of cases of MH. The most common cause is tuberculosis worldwide, but bronchiectasis, bronchogenic carcinoma, and mycetoma are more common causes in the U.S. Patients with MH require rapid assessment and management, as decompensation can be rapid. Patients with altered mental status, inability to clear their sections, respiratory distress, or hemodynamic compromise require emergent airway intervention. The imaging modality of choice is computed tomography angiography with pulmonary arterial phase contrast. A reasonable order or sequence of management includes initial stabilization; assessment for the need for airway intervention; reversal of any coagulopathy; advanced imaging; and emergent consultation of pulmonary, cardiothoracic surgery, and interventional radiology. Ongoing resuscitation including blood products may be required in some patients with MH until definitive hemostasis is achieved.

Conclusion : An understanding of MH can assist emergency clinicians in diagnosing and managing this dangerous disease. Providing a prompt evaluation, obtaining intravenous access, pursuing advanced imaging, providing reversal of coagulopathy, supporting hemodynamics, and appropriate consultation are key interventions in MH.

Conclusion (proposition de traduction) : Une bonne compréhension de l'hémoptysie massive peut aider les médecins urgentistes à diagnostiquer et à prendre en charge cette maladie dangereuse. Une évaluation rapide, l'obtention d'un accès intraveineux, la réalisation d'une imagerie spécialisée, la réversion de la coagulopathie, le support de l'hémodynamique et une consultation appropriée sont des interventions clés dans l'hémoptysie massive.

Commentaire :  Algorithme hémoptysie massive