Comorbidities and Treatment-Limiting Decisions in Older Adults Dying in the Emergency Department: Is There an Association?

International audienc

Evaluation de la prise en charge des traumatismes du rachis cervical au service d accueil des urgences chirurgicales du CHU d Angers

Les traumatismes du rachis cervical sont un motif fréquent de consultation au service d accueil des urgences. L enjeu principal est de ne pas méconnaître une lésion instable à risque médullaire. Deux études récentes (NEXUS et CCR) ont développées des outils décisionnels pour aider le clinicien dans la prescription des radiographies. Nous avons évalué la prise en charge des patients chez lesquels est suspectée une lésion du rachis cervical. Pour cela nous avons réalisé une étude prospective dans le service des urgences du CHU d'Angers. L'évaluation s'est faite par rapport à un protocole de prise en charge établi en concertation avec les services d'urgence, d'orthopédie et de radiologie. Le traitement proposé n'a pas été étudié.L'effectif est de 210 dossiers. La population concernée est jeune, 87,1% ont moins de 65 ans. Les AVP sont en cause dans 58,1% des cas. Un diagnostic cervical est retenu dans 42,9% des cas: contusion 57,8%; entorses bénignes 37%; fractures 5,6%. Des radiographies standard ont été prescrites dans 58,6% des cas. Dans 41,7% des cas elles n'étaient pas recommandées. Au total 57,1% des dossiers sont en adéquation dans l'utilisation de l'imagerie. Des clichés dynamiques sont prescrits dans 26,3%.Les patients de moins de 65 ans semblent moins bien pris en charge, le risque de lésion du rachis cervical apparaissant sous évalué. Les radiographies standards sont largement utilisées mais de façon inadéquate dans la moitié des cas. Par ailleurs trop souvent la charnière cervico-thoracique n'est pas visible. Les clichés dynamiques sont prescrits à bon escient, en moyenne à 10 jours du traumatisme. Ils n'ont jamais mis en évidence d'instabilité ligamentaire.ANGERS-BU Médecine-Pharmacie (490072105) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Prise en charge de la prévention du tétanos à l'accueil chirurgical adulte du CHU d'Angers (Intérêt de l'utilisation du "Tétanos Quick Stick")

ANGERS-BU Médecine-Pharmacie (490072105) / SudocSudocFranceF

quelle prise en charge de la douleur aux urgences du CHU d'Angers en 2011?

ANGERS-BU Médecine-Pharmacie (490072105) / SudocSudocFranceF

Ungulate predation and ecological roles of wolves and coyotes in eastern North America

Understanding the ecological roles of species that influence ecosystem processes is a central goal of ecology and conservation biology. Eastern coyotes (Canis latrans) have ascended to the role of apex predator across much of eastern North America since the extirpation of wolves (Canis spp.) and there has been considerable confusion regarding their ability to prey on ungulates and their ecological niche relative to wolves. Eastern wolves (C. lycaon) are thought to have been the historical top predator in eastern deciduous forests and have previously been characterized as deer specialists that are inefficient predators of moose because of their smaller size relative to gray wolves (C. lupus). We investigated intrinsic and extrinsic influences on per capita kill rates of white-tailed deer (Odocoileus virginianus) and moose (Alces alces) during winter by sympatric packs of eastern coyotes, eastern wolves, and admixed canids in Ontario, Canada to clarify the predatory ability and ecological roles of the different canid top predators of eastern North America. Eastern coyote ancestry within packs negatively influenced per capita total ungulate (deer and moose combined) and moose kill rates. Furthermore, canids in packs dominated by eastern coyote ancestry consumed significantly less ungulate biomass and more anthropogenic food than packs dominated by wolf ancestry. Similar to gray wolves in previous studies, eastern wolves preyed on deer where they were available. However, in areas were deer were scarce, eastern wolves killed moose at rates similar to those previously documented for gray wolves at comparable moose densities across North America. Eastern coyotes are effective deer predators, but their dietary flexibility and low kill rates on moose suggest they have not replaced the ecological role of wolves in eastern North America

Oral rivaroxaban for the treatment of symptomatic pulmonary embolism.

BACKGROUND: A fixed-dose regimen of rivaroxaban, an oral factor Xa inhibitor, has been shown to be as effective as standard anticoagulant therapy for the treatment of deep-vein thrombosis, without the need for laboratory monitoring. This approach may also simplify the treatment of pulmonary embolism. METHODS: In a randomized, open-label, event-driven, noninferiority trial involving 4832 patients who had acute symptomatic pulmonary embolism with or without deep-vein thrombosis, we compared rivaroxaban (15 mg twice daily for 3 weeks, followed by 20 mg once daily) with standard therapy with enoxaparin followed by an adjusted-dose vitamin K antagonist for 3, 6, or 12 months. The primary efficacy outcome was symptomatic recurrent venous thromboembolism. The principal safety outcome was major or clinically relevant nonmajor bleeding. RESULTS: Rivaroxaban was noninferior to standard therapy (noninferiority margin, 2.0; P=0.003) for the primary efficacy outcome, with 50 events in the rivaroxaban group (2.1%) versus 44 events in the standard-therapy group (1.8%) (hazard ratio, 1.12; 95% confidence interval [CI], 0.75 to 1.68). The principal safety outcome occurred in 10.3% of patients in the rivaroxaban group and 11.4% of those in the standard-therapy group (hazard ratio, 0.90; 95% CI, 0.76 to 1.07; P=0.23). Major bleeding was observed in 26 patients (1.1%) in the rivaroxaban group and 52 patients (2.2%) in the standard-therapy group (hazard ratio, 0.49; 95% CI, 0.31 to 0.79; P=0.003). Rates of other adverse events were similar in the two groups. CONCLUSIONS: A fixed-dose regimen of rivaroxaban alone was noninferior to standard therapy for the initial and long-term treatment of pulmonary embolism and had a potentially improved benefit-risk profile. (Funded by Bayer HealthCare and Janssen Pharmaceuticals; EINSTEIN-PE ClinicalTrials.gov number, NCT00439777.)