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Potassium disturbances are associated with adverse prognosis in patients with chronic conditions. Its prognostic implications in stable patients attending the emergency department (ED) is poorly described. This study aimed to assess the prevalence of dyskalemia, describe its predisposing factors and prognostic associations in a population presenting the ED without unstable medical illness. Post-hoc analysis of a prospective, cross-sectional, multicenter study in the ED of 11 French academic hospitals over a period of 8 weeks. All adults presenting to the ED during this period were included, except instances of self-drug poisoning, inability to complete self-medication questionnaire, presence of an unstable medical illness and decline to participate in the study. All-cause hospitalization or deaths were assessed. A total of 1242 patients were included. The mean age was 57.2±22.3 years, 51% were female. The distribution according to potassium concentrations was: hypokalemia5mmol/L(n = 73, 0,6%). The proportion of patients with a kalemia<3.5mmol/L was 8% (n = 101). Renal insufficiency (OR [95% CI] = 3.56[1.94-6.52], p-value <0.001) and hemoglobin <12g/dl (OR [95% CI] = 2.62[1.50-4.60], p-value = 0.001) were associated with hyperkalemia. Female sex (OR [95% CI] = 1.31[1.03-1.66], p-value = 0.029), age <45years (OR [95% CI] = 1.69 [1.20-2.37], p-value = 0.002) and the use of thiazide diuretics (OR [95% CI] = 2.04 [1.28-3.32], p-value = 0.003), were associated with hypokalemia<4mmol/l. Two patients died in the ED and 629 (52.7%) were hospitalized. Hypokalemia <3.5mmol/L was independently associated with increased odds of hospitalization or death (OR [95% CI] = 1.47 [1.00-2.15], p-value = 0.048). Hypokalemia is frequently found in the ED and was associated with worse outcomes in a low-risk ED population.

Abstract Background In the management of infective endocarditis (IE), the presence of extracardiac complications has an influence on both diagnosis and treatment. Current guidelines suggest that systematic thoracoabdominal-pelvic computed tomography (TAP-CT) may be helpful. Our objective was to describe how systematic TAP-CT affects the diagnosis and the management of IE. Methods In this multicenter cohort study, between January 2013 and July 2016 we included consecutive patients who had definite or possible IE according to the Duke modified criteria, validated by endocarditis teams. We analyzed whether the Duke classification and therapeutic management were modified regarding the presence or the absence of IE-related lesion on CT and investigated the tolerance of this examination. Results Of the 522 patients included in this study, 217 (41.6%) had 1 or more IE-related lesions. On the basis of CT results in asymptomatic patients, diagnostic classification was upgraded from possible endocarditis to definite endocarditis for only 4 cases (0.8%). The presence of IE-related lesions on CT did not modify the duration of antibiotic treatment (P = .55), nor the decision of surgical treatment (P = .39). Specific treatment of the lesion was necessary in 42 patients (8.0%), but only 9 of these lesions (1.9%) were asymptomatic and diagnosed only on the TAP-CT. Acute kidney injury (AKI) within 5 days of CT was observed in 78 patients (14.9%). Conclusions The TAP-CT findings slightly affected diagnosis and treatment of IE in a very small proportion of asymptomatic patients. Furthermore, contrast media should be used with caution because of the high risk of AKI. Thoracoabdominal-pelvic computed tomography (CT) frequently leads to the finding of embolic event or metastatic foci. However, when patients are asymptomatic, scans rarely change the diagnosis or therapeutic management. Moreover, the risk of acute kidney injury after contrast CT is significant.

Background Little is known about the relation of adverse drug reactions (ADRs) to self-use of medications. Objective The aim of this study was to determine the frequency and severity of ADRs related to self-medication (ADR-SM) among emergency department (ED) patients and to describe their main characteristics. Methods A prospective, cross-sectional, observational study was conducted over a period of 8 weeks (1 March to 20 April 2010), in the ED of 11 French academic hospitals. Adult patients presenting to the ED during randomization periods were included, with the exception of cases of self-drug poisoning, inability to complete self-medication questionnaire, or refusal. Clinical outcomes were assessed as well as history of self-medication behaviours and all drugs taken. All doubtful files and those related to ADR-SM were systematically reviewed by an expert committee. Results A total of 3,027 of 4,661 patients presenting to the ED met the inclusion criteria. Of these, 84.4 % declared a self-medication behaviour, 63.7 % took at least one non-prescribed drug during the previous 2 weeks and 59.9 % took a prescribed medication. A total of 296 patients experienced an ADR (9.78 %), of which 52 (1.72 %) were related to self-medication. Those ADRs related to self-medication included prescribed drugs ( n  = 19), non-prescribed drugs ( n  = 17), treatment discontinuation ( n  = 14), and interactions between non-prescribed and prescribed drugs ( n  = 2). The ADRs attributed to non-prescribed drugs represented 1 % of all patients taking non-prescribed drugs ( n  = 1,927). ADR severity was significantly lower for those related to self-medication ( p  = .032). Conclusion Self-medication is frequent; its potential toxicity should not be neglected, taking into account the rate of adverse drug reactions in about 1 % of ED patient.

Purpose Data on encephalitis in elderly patients are scarce. We aimed to describe the characteristics, aetiologies, management, and outcome of encephalitis in patients older than 65 years. Methods We performed an ancillary study of ENCEIF, a prospective cohort that enrolled all cases of encephalitis managed in 46 clinical sites in France during years 2016–2019. Cases were categorized in three age groups: (1) 18–64; (2) 65–79; (3) ≥ 80 years. Results Of the 494 adults with encephalitis enrolled, 258 (52%) were ≥ 65 years, including 74 (15%) ≥ 80 years. Patients ≥ 65 years were more likely to present with coma, impaired consciousness, confusion, aphasia, and rash, but less likely to present with fever, and headache ( P  < 0.05 for each). Median cerebrospinal fluid (CSF) white cells count was 61/mm 3 [13–220] in 65–79 years, 62 [17–180] in ≥ 80 years, vs. 114 [34–302] in < 65 years ( P  = 0.01). The proportion of cases due to Listeria monocytogenes and VZV increased after 65 years ( P  < 0.001), while the proportion of tick-borne encephalitis and Mycobacterium tuberculosis decreased with age ( P  < 0.05 for each). In-hospital mortality was 6/234 (3%) in < 65 years, 18/183 (10%) in 65–79 years, and 13/73 (18%) in ≥ 80 years ( P  < 0.001). Age ≥ 80 years, coma on admission, CSF protein ≥ 0.8 g/L and viral encephalitis were independently predictive of 6 month mortality. Conclusion Elderly patients represent > 50% of adults with encephalitis in France, with higher proportion of L. monocytogenes and VZV encephalitis, increased risk of death, and sequels. The empirical treatment currently recommended, aciclovir and amoxicillin, is appropriate for this age group.

Abstract Background As the epidemiology of encephalitis varies from one country to another, international travel may be an important clue for the diagnostic workout of this puzzling disease. Methods We performed an ancillary study using the ENCEIF prospective cohort conducted in 62 clinical sites in France from 2016 to 2019. All cases of encephalitis in adults that fulfilled a case definition derived from the International Encephalitis Consortium were included. Travellers were defined as patients who spent at least one night in a foreign country within the last six months. Results Of the 494 encephalitis patients enrolled, 69 (14%) were travellers. As compared to non-travellers, they were younger (median age, 48 years [interquartile range, 36–69] vs 66 [49–76], P < 0.001), less likely to be immunocompromised: 2/69 (3%) vs 56/425 (13%), P = 0.02, and reported more arthralgia: 7/69 (10%) vs 11/425 (3%), P = 0.007. The risk of poor outcome at hospital discharge (Glasgow outcome scale ≤3), was similar for travellers and for non-travellers after adjustment (aOR 0.80 [0.36–1.80], P = 0.594). Arboviruses were the main causes of encephalitis in travellers: 15/69 (22%) vs 20/425 (5%) in non-travellers, P < 0.001, and Herpes simplex virus (HSV) was the second (9/69, 13%). Of note, in 19% (13/69) of cases, the risk of encephalitis in travellers may have been decreased with a vaccine. Conclusion The two primary causes of encephalitis in travellers are arboviruses and HSV. Empirical treatment of encephalitis in travellers must include acyclovir. Pre-travel advice and vaccination may decrease the risk of encephalitis in travellers.

Purpose To highlight cervical spondylodiscitis as an infrequent complication following an invasive procedure on the neopharynx in patients previously treated with circumferential pharyngolaryngectomy with pectoralis major myocutaneous flap reconstruction. Methods Patients diagnosed with cervical spondylodiscitis after circumferential pharyngolaryngectomy between 2001 and 2013 were retrospectively studied using a questionnaire sent to the French head and neck tumour study group. Medical history; tumour management; clinical symptoms; biological, microbiological and imaging results; and management of the infection were collected for each patient. Results Six men aged 51–66 years were diagnosed with spondylodiscitis on average 5.6 years after circumferential pharyngolaryngectomy, and a mean 2 months following an invasive procedure on the neopharynx (oesophageal dilatation, phonatory prosthesis insertion). The patients presented with cervical pain and increased CRP level. MRI showed epidural abscess and communication between the pharynx and vertebral bodies in most cases. Microbiological samples yielded bacteria from the pharynx flora. Infection was managed using antibiotics adjusted according to the culture results and spinal immobilisation for duration of 6–12 weeks. No surgical treatment was required. During follow-up, no patient experienced recurrence or residual disability. Conclusions Cervical spondylodiscitis is a rare but potentially severe complication following an invasive procedure on the neopharynx after circumferential pharyngolaryngectomy. Therefore, the onset of nonspecific symptoms should not be overlooked, and MRI must be performed if infection is suspected. Microbiological confirmation is critical in optimising treatment, which should be aggressive, even if overall prognosis seems to be good.

Overview of clinical pharmacy practice around the world shows that pharmaceutical services in emergency departments (EDs) are far less common in Europe than in North America. Reported experiences have shown the impact of a clinical pharmacy service on drug utilisation and safety issues. This commentary presents the implementation of a pharmacy presence in the ED of a French tertiary care hospital. Our experience helps to define the role of the clinical pharmacist in the ED, including patient interviewing, providing medication reconciliation, promoting drug safety, and supporting specific interventions to improve quality of care and patient safety. The role of ED pharmacists in the improvement of quality of care is not necessarily limited to drug therapy, e.g. by helping outpatients to access care and treatment facilities as best suits their needs. Challenges of implementing ED pharmacy services have been identified well, but still require developing strategies to be overcome.