Добірка наукової літератури з теми "Nocturnal medical emergencies"

AbstractIntroductionMedical problems are frequently encountered during electronic dance music (EDM) events.ProblemThere are uncertainties about the frequencies and severity of intoxications with different types of recreational drugs: ethanol, “classical” illicit party drugs, and new psychoactive substances (NPS).MethodsStatistical data on the medical problems encountered during two editions of an indoor electronic dance event with around 30,000 attendants were retrieved from the Belgian Red Cross (Mechelen, Belgium) database. Data on drug use were prospectively collected from the patient (or a bystander), the clinical presentation, and/or toxicological screening.ResultsIn the on-site medical station, 487 patients were treated (265 in 2013 and 222 in 2014). The most frequent reasons were trauma (n=171), headache (n=36), gastro-intestinal problems (n=44), and intoxication (n=160). Sixty-nine patients were transferred to a hospital, including 53 with severe drug-related symptoms. Analysis of blood samples from 106 intoxicated patients detected ethanol in 91.5%, 3,4-methylenedioxymethamphetamine (MDMA) in 34.0%, cannabis in 30.2%, cocaine in 7.5%, amphetamine in 2.8%, and gamma-hydroxybutyric acid (GHB) in 0.9% of patients (alone or in combination). In only six of the MDMA-positive cases, MDMA was the sole substance found. In 2014, the neuroleptic drug clozapine was found in three cases and ketamine in one. Additional analyses for NPS were performed in 20 cases. Only in one agitated patient, the psychedelic phenethylamines 25B-NBOMe and 25C-NBOMe were found.ConclusionsAt this particular event, recreational drug abuse necessitated on-site medical treatment in one out of 350 attendants and a hospital transfer in one out of 1,000. Ethanol remains the most frequently abused (legal) drug, yet classical illicit recreational drugs are also frequently (co-) ingested. The most worrying observation was high-risk poly-drug use, especially among MDMA users. Regarding NPS, the number of cases was low and the clinical presentations were rather mild. It should be stressed that these observations only apply to this particular event and cannot be generalized to other EDM events.CalleP, SundahlN, MaudensK, WilleSMR, Van SassenbroeckD, De GraeveK, GogaertS, De PaepeP, DevrieseD, ArnoG, BlanckaertP. Medical emergencies related to ethanol and illicit drugs at an annual, nocturnal, indoor, electronic dance music event. Prehosp Disaster Med. 2018;33(1):71–76.

Abstract Abstract 5134 Aim: PNH is a rare disease with prevalence between 7.3 and 15.9 cases/million. PNH is a life-threatening disease that affects mostly young adults with median age at diagnosis being 33 years. Diagnosis is difficult and often delayed because of the clinical polymorphism of the disease. ECLIPSE is a French study which aimed to evaluate the delay between the onset of PNH symptoms and the date of diagnosis, to identify the clinical signs leading to diagnosis and to determine which medical specialists are seen first by PNH patients (pts). Patients and Methods: 4920 physicians were asked to participate in the study: 992 haematologists, 1638 internists, 1155 gastroenterologists, 697 nephrologists, 438 neurovascular physicians. Physicians were divided into 3 groups: (a) physicians having diagnosed PNH at least once, (b) having suspected a PNH without having confirmed the diagnosis, (c) neither having suspected nor diagnosed a PNH. The response rate was analysed by medical speciality and was defined by the number of physicians responding divided by the number of physicians invited to participate. Results: 528 physicians accepted to participate in the study (overall response rate: 10.7%). In total, 507 answers were analysed. Among the 507 physicians, 108 (21 %) had diagnosed PNH at least once (group a), 213 (42 %) had suspected PNH without confirming the diagnosis (group b) and 186 (37 %, CI95% [32.49 % - 41.05 %]) neither had suspected nor diagnosed PNH (group c). In group (a), the clinical signs and symptoms which led to diagnosis were: pancytopenia 44%, anaemia 37%, haemolysis 23%, peripheral venous thrombosis 18%, hepatic vein thrombosis 14% and hemoglobinuria 14%. The physicians of group (a) were also asked to describe the clinical situations which raised the suspicion for PNH diagnosis: unexplained thrombosis (86%), hemoglobinuria (84%), aplastic anaemia (83%), Coombs negative anaemia (80%), cytopenias (71%) were the most frequent symptoms triggering the test for PNH. Physicians of group (a) were also asked to describe the circumstances of their latest PNH diagnosis. The patient was referred to the physician most frequently by the Emergencies (23%), a haematologist (22%) or by an internist (21%). The most frequent functional symptoms of their latest diagnosed pts were: fatigue (39%), anaemia (24%), abdominal pain (20%) and thrombosis (14%). Seven percent of PNH pts did not report any functional symptom before diagnosis. PNH diagnosis was confirmed in a mean time of 9.32±11.46 months after the onset of symptoms, and a maximum delay between first symptoms and diagnosis being 60 months. Biological signs which raised the suspicion for a PNH were: anaemia (80%), increase of LDH (60%), increase of biluribin (44%), thrombocytopenia (41%) and/or neutropenia (28%). Confirmation of PNH diagnosis was made by flow cytometry in 87% of the cases. Two hundred and thirteen physicians belong to group (b), having at least once suspected PNH without confirming diagnosis. Half of them (50%) had suspected at least 5 times a PNH diagnosis, without confirmation. Clinical and biological signs which prompted physicians of group (b) to suspect PNH were: Coombs negative anaemia (48%), pancytopenia (42%) and/or aplastic anaemia (38.5%), myelodysplastic syndrome (18%), hemoglobinuria (15.5%), increase level of LDH associated with venous or arterial thrombosis (15%), abdominal pain (14%), dark urine (12%) or jaundice (11%). Finally, 186 physicians declared having neither suspected nor diagnosed any PNH pts. Furthermore, 6.5% of physicians have never heard about PNH. Conclusions: PNH diagnosis is usually difficult and delayed as its signs and symptoms are diverse and non-specific. The ECLIPSE study aimed to better understand the diagnostic procedures for PNH, to evaluate the delay between onset of symptoms and diagnosis and to determine the medical specialists involved in the diagnosis and management of PNH pts. PNH is mainly diagnosed by hematologists. Frequent symptoms leading to diagnosis were unexplained thrombosis, hemoglobinuria, Coombs negative anaemia, but also aplastic anaemia, unexplained cytopenias and myelodysplastic syndrome. Flow cytometry, the gold standard for PNH testing, was only used in 87% of cases. Diagnosis was usually delayed with a maximum of 5 years between onset of PNH symptoms and diagnosis. Fatigue and abdominal pain were commonly reported symptoms and should therefore be more routinely assessed. Disclosures: No relevant conflicts of interest to declare.

Orthostatic hypotension (OH) is a common non-motor feature of Parkinson’s disease that may cause unexplained falls, syncope, lightheadedness, cognitive impairment, dyspnea, fatigue, blurred vision, shoulder, neck, or low-back pain upon standing. Blood pressure (BP) measurements supine and after 3 minutes upon standing screen for OH at bedside. The medical history and cardiovascular autonomic function tests ultimately distinguish neurogenic OH, which is due to impaired sympathetic nerve activity, from non-neurogenic causes of OH, such as hypovolemia and BP lowering drugs. The correction of non-neurogenic causes and exacerbating factors, lifestyle changes and non-pharmacological measures are the cornerstone of OH treatment. If these measures fail, pharmacological interventions (sympathomimetic agents and/or fludrocortisone) should be introduced stepwise depending on the severity of symptoms. About 50% of patients with neurogenic OH also suffer from supine and nocturnal hypertension, which should be monitored for with in-office, home and 24 h-ambulatory BP measurements. Behavioral measures help prevent supine hypertension, which is eventually treated with non-pharmacological measures and bedtime administration of short-acting anti-hypertensive drugs in severe cases. If left untreated, OH impacts on activity of daily living and increases the risk of syncope and falls. Supine hypertension is asymptomatic, but often limits an effective treatment of OH, increases the risk of hypertensive emergencies and, combined with OH, facilitates end-organ damage. A timely management of both OH and supine hypertension ameliorates quality of life and prevents short and long-term complications in patients with Parkinson’s disease.

Nocturnal human sleep is composed of cycles between rapid eye movement (REM) sleep and non-REM (NREM) sleep. In adults, the structure of ultradian cycles between NREM and REM sleep is well characterized; however, less is known about the developmental trajectories of ultradian sleep cycles across early childhood. Cross-sectional studies indicate that the rapid ultradian cycling of active-quiet sleep in infancy shifts to a more adult-like pattern of NREM-REM sleep cycling by the school-age years, yet longitudinal studies elucidating the details of this transition are scarce. To address this gap, we examined ultradian cycling during nocturnal sleep following 13 h of prior wakefulness in 8 healthy children at 3 longitudinal points: 2Y (2.5-3.0 years of age), 3Y (3.5-4.0 years of age), and 5Y (5.5-6.0 years of age). We found that the length of ultradian cycles increased with age as a result of increased NREM sleep episode duration. In addition, we observed a significant decrease in the number of NREM sleep episodes as well as a nonsignificant trend for a decrease in the number of cycles with increasing age. Together, these findings suggest a concurrent change in which cycle duration increases and the number of cycles decreases across development. We also found that, consistent with data from adolescents and adults, the duration of NREM sleep episodes decreased with time since lights-off whereas the duration of REM sleep episodes increased over this time period. These results indicate the presence of circadian modulation of nocturnal sleep in preschool children. In addition to characterizing changes in ultradian cycling in healthy children ages 2 to 5 years, this work describes a developmental model that may provide insights into the emergence of normal adult REM sleep regulatory circuitry as well as potential trajectories of dysregulated ultradian cycles such as those associated with affective disorders.

Abstract Our ability to interrogate a broad array of genetic alterations in myeloid neoplasm has increased significantly with the advance in next-generation sequencing (NGS). In addition to morphologic examination, flow cytometry and cytogenetics, NGS-based testing can add additional useful information to the diagnostic workup. With improved turnaround time, decreasing costs and an expanding knowledge of the therapeutic and prognostic significance of the detected variants, NGS-based panel testing has increasingly played a major role in the management of patients with myeloid neoplasm. Rapid Heme Panel (RHP) is a custom, 95-gene, amplicon-based NGS panel (PMID: 27339098) that was launched at the Center for Advanced Molecular Diagnostics (CAMD), Brigham and Women's Hospital and Dana-Farber Cancer Institute in August of 2014. RHP covers a total territory of ~200 KB, including hotspots of oncogenes and whole coding exons of tumor suppressor genes that are frequently mutated in myeloid and lymphoid malignancies. Single nucleotide variants, insertions/deletions up to 52-bp, and copy number variations are detected. In the two years following its launch, over 5,000 RHP was performed and reported with an average turnaround time of 7.2 days from time of receipt into the lab. The specimen failed rate is <0.5% and sample repeat rate is <0.2%. Over half of the specimens came from patients with a known myeloid disease: 25% with acute leukemia, 15% with a myelodysplastic syndrome (MDS), 10% with a myeloproliferative neoplasm (MPN) and a minor fraction each with a variety of other myeloid neoplasms such as paroxysmal nocturnal hemoglobinuria (PNH), aplastic anemia, systemic mastocytosis or chronic myeloid leukemia (CML). Twenty percent of the specimens came from patients with known lymphoid malignancies such as hairy cell leukemia, chronic lymphocytic leukemia, lymphoplasmacytic lymphoma, or splenic marginal zone lymphoma. The remainder 25-30% of the specimens came from patients with abnormal blood count (CBC) such as anemia, neutropenia, thrombocytopenia, leukocytosis, thrombocytosis and/or abnormal serum protein electrophoresis (SPEP) where a myeloid or a lymphoid neoplasm was suspected. Greater than 98% of the time, the test was ordered by a hematologist/oncologist. Among patients with a prior diagnosis, >80% of them had at least one pathogenic alterations identified by RHP while about 30% of the patients with abnormal CBC or abnormal SPEP had positive findings. RHP results have been used to (1) provide eligibility for enrollment into clinical trials of targeted therapies; (2) monitor effect of therapy by quantifying variant allele fraction; (3) identify disease progression with detection of emergence of new variants; (4) evaluate post-transplant status by following allele fractions of pre-transplant pathogenic variants; (5) shorten the time and cost to diagnosis by establishing clonality and identification of disease-defining alterations. Disclosures No relevant conflicts of interest to declare.

BackgroundThe sudden emergence of SARS-CoV-2 onto the world stage has accelerated a major change in the management of patients with chronic rheumatic diseases and has catalyzed the rapid emergence of telemedicine.ObjectivesOur aim was to describe which parameters were used by rheumatologists to monitor patients with rheumatoid arthritis (RA) in teleconsultation during the first wave of the pandemic and identify the most relevant for decision making.MethodsRetrospective monocentric routine care cross-sectional study including RA patients seen in teleconsultation between March and September 2020. Available parameters assessing disease status were collected in teleconsultation files. Clinician intervention was defined by treatment escalation and/or the need for a rapid face-to-face consultation or day hospitalization.Results143 RA patients were included (117 females, mean age of 58±16 years, mean disease duration of 14±11 years). The presence or absence of patient self-reported RA flares was mentioned in all medical files, followed by the presence and/or the number of tender joints (76%), the duration of morning stiffness (66%), the number of pain-related nocturnal awakenings (66%) and the CRP value (54%).Patient self-reported RA flares concerned 43/143 patients (30%). The presence of self-reported RA flares was associated with a more detailed evaluation of patient in teleconsultation: The presence (or number) of tender joints and swollen joints were more significantly reported in patients who presented a flare (39/43, 91% vs. 70/100, 70%, p=0.008 and 25/43, 58% vs. 23/100, 23%, p<0.001, respectively).Teleconsultation led to a clinician intervention in 22/143 patients (14%), representing 51% of patients with self-reported flares (22/43 patients). Therapeutic escalation was necessary in 13 patients: introduction or dose increase of corticosteroids in 8 patients, introduction or dose increase of methotrexate in 4 patients and introduction of hydroxychloroquine in 1 patient. Face-to-face consultation or day hospitalization were organized for 10 patients. Active disease was confirmed during this next face-to-face visit in 9 patients, with DAS28 ranging from 3.35 to 5.62, leading to therapeutic modification. The 133 other patients were seen in face-to-face consultation 6±2 months after the teleconsultation. No DMARD modification was recorded during this next face-to-face consultation.The following variables were associated with clinician intervention during the teleconsultation in univariate analysis: patient self-reported RA flares since the last visit (p<0.001), CRP >10 mg/mL (p=0.012) and a morning stiffness > 30 minutes (p<0.001). Multivariate analysis confirmed RA flares (Odds Ratio, OR: 15.6 95% CI 3.37-68.28) and CRP values >10 mg/L (OR: 3.32, 95% CI % 1.12-13.27) as the variables independently associated with clinician intervention.ConclusionOur study identified patient reported RA flares and increased CRP values as 2 red flags in teleconsultation, independently associated with therapeutic modification and/or the need for a rapid face-to-face consultation. These indicators may help clinician’s decision making in teleconsultation.Disclosure of InterestsJerôme Avouac Speakers bureau: Bristol Myers Squibb, SANOFI, galapagos, Lilly, Abbvie, Pfizer, Novartis, Biogen, Fresenius Kabi, Janssen, MSD, Roche-Chugai, Medac, Consultant of: galapagos, Abbvie, Pfizer, Bristol Myers Squibb, SANOFI, Nordic-Pharma, Grant/research support from: Bristol-Myers Squibb, Pfizer (Passerelle), Novartis (Dreamer), Fresenius Kabi, Anna Moltó: None declared, CAMELIA FRANTZ: None declared, Sarah Wanono: None declared, Elise Descamps: None declared, Olivier Fogel: None declared, Alice Combier: None declared, Lucile Poiroux: None declared, Corinne Miceli Richard: None declared, Yannick Allanore: None declared

Robson Cristiano Zandomenighi1, Eleine Aparecida Penha Martins2RESUMOObjetivo: analisar as características epidemiológicas das vítimas e ocorrências de parada cardiorrespiratória em ambiente pré-hospitalar e seus desfechos. Método: estudo quantitativo, epidemiológico e transversal, com as vítimas atendidas pelas unidades de suporte avançado de vida, submetidas à reanimação cardiopulmonar. Coletados os dados no relatório de atendimento do socorrista e realizada análise estatística a partir do Microsoft Office Excel e do Software SPSS 20.0. Resultados: houve 163 atendimentos, mediana de idade de 65 anos, predominando o sexo masculino, com hipertensão arterial e diabetes mellitus. A causa clínica e a assistolia foram mais prevalentes, havendo mais ocorrências na região central, durante o outono, no período noturno. O tempo-resposta da ambulância foi menor na região central. A duração do atendimento demonstrou associação com o desfecho, sendo maior entre os sobreviventes. O principal destino dos sobreviventes foram hospitais terciários. A taxa de sobrevida imediata foi de 25,1%. Conclusão: idosos com comorbidades foram as principais vítimas, havendo elevada taxa de mortalidade. Verificou-se a importância de uma resposta rápida e eficaz do serviço de emergência. Descritores: Parada Cardíaca Extra-Hospitalar; Reanimação Cardiopulmonar; Epidemiologia; Serviços Médicos de Emergência; Ambulâncias. ABSTRACT Objective: to analyze the epidemiological characteristics of victims and occurrences of cardiorespiratory arrest cases in a prehospital environment and their outcomes. Method: this is a quantitative, epidemiological and cross-sectional study with victims assisted in advanced life support units and submitted to cardiopulmonary resuscitation. Data were collected from the report of the rescue team. The the Microsoft Office Excel and SPSS 20.0 software were used for statistical analyses. Results: there were 163 cases, the median age of the victims was 65 years, they were predominantly male, and presented hypertension and diabetes mellitus. Clinical cause and asystole were more prevalent, with more occurrences in the central region, during the fall, at night. The ambulance response time was lower in the central region. The duration of care was associated with the outcome, being higher among survivors. The main destination of survivors was tertiary hospitals. The immediate survival rate was 25.1%. Conclusion: elderly patients with comorbidities were the main victims, with a high mortality rate. It was verified the importance of a rapid and effective response from the emergency service. Descriptors: Extra-Hospital Cardiac Arrest; Cardiopulmonary resuscitation; Epidemiology; Emergency Medical Services; Ambulances.RESUMEN Objetivo: analizar las características epidemiológicas de las víctimas y ocurrencias de parada cardiorrespiratoria en ambiente pre-hospitalario y sus desenlaces. Método: estudio cuantitativo, epidemiológico y transversal, con las víctimas atendidas por las unidades de soporte avanzado de vida, sometidas a la reanimación cardiopulmonar. Los datos fueron recogidos en el informe de atención del socorrista y fue realizado el análisis estadístico a partir del Microsoft Office Excel y del Software SPSS 20.0. Resultados: hubo 163 atendimientos, mediana de edad de 65 años, predominando el sexo masculino, con hipertensión arterial y diabetes mellitus. La causa clínica y la asistolia fueron más prevalentes, habiendo más ocurrencias en la región central, durante el otoño, en el período nocturno. El tiempo-respuesta de la ambulancia fue menor en la región central. La duración del atendimiento demostró asociación con el desenlace, siendo mayor entre los sobrevivientes. El principal destino de los sobrevivientes fueron hospitales terciarios. La tasa de sobrevida inmediata fue de 25,1%. Conclusión: ancianos con comorbilidades fueron las principales víctimas, habiendo elevada tasa de mortalidad. Se verifico la importancia de una respuesta rápida y eficaz del servicio de emergencia. Descriptores: Paro Cardíaco Extra-Hospitalario; Reanimación Cardiopulmonar; Epidemiología; Servicios Médicos de Urgencia; Ambulancias.

We focus our research on how the core-shell organization controls behavior of the suprachiasmatic nucleus (SCN), how the core and shell are synchronized to the environment, what impact they have on the behavior of the SCN under different lighting conditions, and what mechanisms disrupt synchronization. To this end, we use a reduced Kuramoto model, with parameters inferred from experimental observations and calibrated for mice, and perform a detailed comparison between the model and experimental data under light-dark (LD), dark-dark (DD), and light-light (LL) conditions. The operating limits of free-running and entrained SCN activity under symmetric LD cycles are analyzed, with particular focus on the phenomena of anticipation and dissociation. Results reveal that the core-shell organization of the SCN enables anticipation of future events over circadian cycles. The model predicts the emergence of a second (dissociated) rhythm for large and small LD periods. Our results are in good qualitative and quantitative agreement with experimental observations of circadian dissociation. We further describe SCN activity under LL conditions and show that our model satisfies Aschoff’s first rule, according to which the endogenous free-running circadian period observed under complete darkness will shorten in diurnal animals and lengthen in nocturnal animals under constant light. Our results strongly suggest that the Kuramoto model captures essential features of synchronization and entrainment in the SCN. Moreover, our approach is easily extendible to an arbitrary number of groups, with dynamics described by explicit equations for the group phase and synchronization index. Viewed together, the reduced Kuramoto model presents itself as a useful tool for exploring open problems in the study of circadian rhythms, one that can account for evolving views of the circadian system’s organization, including peripheral clocks and inter-hemispheric interaction, and can be translated to other nocturnal and diurnal animals, including humans.

Purpose This paper aims to explore the misuse of prescription opioids, associated consumption cultures and the emergence of “informal governing images” among young men in Nigeria. Design/methodology/approach Using a qualitative research approach involving purposive sampling: six in-depth interviews, one focus group discussion and key informant interviews with two health-care professionals using the transgressive theory approach, this paper explores consumption cultures, motivations and the resultant “informal governing images” associated with the misuse of prescription opioids among young local street high-risk users in Nigeria. Findings Findings show complex expressions of diverse consumption practices, such as grinding, sniffing and concoction of tramadol (TM)with other opioids. The “puff-puff pass” practice serves as induction for new users of opioids commonly accessed through street drug dealers and pharmacists sold via backdoors. Codeine mixtures with different brands of soft drinks for dilution are used to achieve a “lower high” while a concoction of different opioids, with alcohol, and spirits obtains a “higher high”. Manufacturers’ indelible colouring and bottling discourage the non-medical use of opioids. Desiring to be awake for nocturnal activities, mostly “yahoo-yahoo” (internet fraud), sexual enhancement and dosage competitions, are motivations for the non-medical use of prescription opioids. These consumption cultures create “misuse circuits”, leading to the emergence of “informal governing images” triggered by threats from formal controls. Practical implications This paper, therefore, concludes that pharmaceutical industries should also add colourings to TM and codeine just like they did in rophinol to discourage the non-medical use of prescription opioids among young people in Nigeria. Social implications This paper concludes that rather than branding and packaging in such a way that concealability is difficult for high-risk users as the best way to discourage the non-medical consumption of prescription opioids in Nigeria, the focus should be on addressing youth poverty and unemployment and improving access to treatment for drug use disorders, instead of calling for more enforcement-based measures. Originality/value This is an original research.

Objetivo: Identificar o conhecimento dos dos trabalhadores de Enfermagem do pronto socorro de um hospital universitário acerca dos riscos laborais a que estão submetidos. Método: Estudo exploratório sob a abordagem quantitativa, onde aplicou-se um questionário para 137 profissionais de Enfermagem (48 enfermeiros, 37 técnicos de enfermagem e 52 auxiliares de enfermagem) do Pronto Socorro de um Hospital Universitário. Resultados: Os sujeitos do estudo são predominantemente do sexo feminino (70,8%), na faixa etária de 26 a 35 anos (43,1%), com até cinco anos de trabalho no pronto socorro (81,6%) e atuando no turno noturno (41,6%). Dos riscos, os mais apontados foram os biológicos como bactérias, vírus, sangue, e secreções, pelas três categorias profissionais. Seguiram-se os riscos físicos com material perfuro cortante, manutenção precária e ruídos; os químicos medicamentos, poeira e desinfetantes; e os ergonômicos levantar e sustentar pacientes e andar muito pelo setor. Conclusão: Os profissionais reconhecem o principal risco envolvido em sua prática assistencial como sendo biológico. Esses resultados são importantes para nortear ações na gestão que visem ações preventivas.Descritores: Riscos Ocupacionais; Serviço Hospitalar de Engenharia e Manutenção; Serviços Médicos de Emergência; Hospitais Universitários.EVALUATION OF HEALTH RISKS FOR NURSING WORKERS IN THE EMERGENCY DEPARTMENT OF A UNIVERSITY HOSPITALObjective: To identify the health risks of nursing workers in the emergency department of a university hospital. Method: Exploratory study with quantitative approach, using a questionnaire applied in 137 nursing workers (48 nurses, 37 nursing technicians and 52 nursing assistants) from the Emergency Room of an university hospital center. Results: The sample consisted of predominantly female (70.8%), ages 26 to 35 years old (43.1%), with up to five years of work in the emergency room (81.6%) and working in the night shift (41.6%). The main risk cited by all professionals was Biological, exemplified by bacteria, viruses, blood, and secretions. Others risks were also remembered, such as the Physical ones: use of sharp-perforating material, poor maintenance of the environment and noise; Chemical risks described as contact with medical drugs, dust and disinfectants; and the Ergonomic ones, like to raise and to support patients and walk around the sector a lot. Conclusion: Nursing Professionals recognize the main risk involved in their daily practice as being biological. These results are important to guide further preventive actions.Descriptors: Occupational Risks; Maintenance and Engineering, Hospital; Emergency Medical Services; Hospitals, University.EVALUACIÓN DE RIESGOS DE SALUD DE TRABAJADORES DE ENFERMERÍA EN UN HOSPITAL UNIVERSITARIOObjetivo: identificar los riesgos para la salud de los trabajadores de enfermería en el departamento de emergencias de un hospital universitario. Método: estudio exploratório con enfoque cuantitativo, desarrollado a partir de un cuestionario para 137 profesionales de enfermería (48 enfermeras, 37 técnicas de enfermería y 52 auxiliares de enfermería) de la sala de emergencias de uno hospital universitario. Resultados: Los sujetos del estudio son predominantemente mujeres (70.8%), de 26 a 35 años (43.1%), con hasta cinco años de trabajo en la sala de emergencias (81.6%) y trabajando en el turno nocturno (41,6%). De los riesgos, los más destacados fueron los Biologicos, como bacterias, virus, sangre y secreciones, por las tres categorías profesionales. A seguir fueran los riesgos Fisicos con lo material perforante, mala conservación del área física y ruido; los Quimicos con las drogas químicas, polvo y desinfectantes; y los Ergonómicos com la movilizacion y apoyo a los pacientes y se muever mucho por el sector. Conclusión: Los profesionales reconocen que el principal riesgo involucrado en su práctica de cuidado es biológico. Estos resultados son importantes para guiar las acciones de gestión dirigidas a acciones preventivasDescriptores: Riesgos Laborales; Servicio de Mantenimiento e Ingeniería en Hospital; Servicios Médicos de Urgencia; Hospitales Universitarios.

Cette thèse étudie comment des infirmier.es de nuit prennent la décision de recourir ou non à l'hôpital en cas d'urgence gériatrique en EHPAD. Le raisonnement clinique et la prise de décision chez des infirmiers sont rarement documentés. L'expérimentation « IDE de nuit » des projets paerpa offrait l'occasion de les étudier au prisme de l'âge et de l'incertitude dans un contexte d'urgence. Elle a aussi permis d'étudier l'épreuve organisationnelle que constitue une telle innovation. En mobilisant une approche interactionniste et sociocognitive et en nous fondant sur une enquête ethnographique trois années durant, nous avons saisi in situ le raisonnement et le jugement infirmiers à l'épreuve de l'urgence et du contexte expérimental. Cette recherche éclaire plusieurs aspects : comment le care est mobilisé au service du cure ; comment l'urgence constitue une construction, qui est influencée par le rôle joué par le patient âgé et ses aides-soignantes ; comment les compétences qui font l'innovation s'élaborent à l'épreuve de l'irréversibilité des actions et des résultats ; comment et quand commence et se termine une innovation organisationnelle dans un contexte expérimental ; enfin, comment tous ces éléments participent à définir l'économie morale qui s'est mise en place autour des personnes âgées vivant en EHPAD, cibles de cette innovation.Mot clés : urgence gériatrique, prise de décision, innovation organisationnelle, IDE de nuit, expérimentation, paerpa, le 15, recours à l'hôpital, aides-soignantes, EHPAD
This thesis studies how night-shift nurses decide whether or not to resort to the hospital to deal with geriatric emergency cases in a nursing home. Clinical reasoning and decision-making among nurses are rarely documented. The “IDE de nuit” experimentation of Paerpa's projects offered the opportunity to study them through the prism of age and uncertainty in the context of an emergency. It also made it possible to study the organizational test that such an innovation constitutes. Through an interactionist and socio-cognitive approach and based on an ethnographic investigation lasting three years, we captured in situ nurses' reasoning and judgment while dealing with emergency cases in an experimental context. This research sheds light on several aspects: how care is mobilized in the service of the cure; how the emergency constitutes a social construction, which is influenced by the role played by the elderly patient and his caregivers; how the skills that drive innovation are developed and conditioned by the irreversibility of the actions and their results; how and when an organizational innovation begins and ends in an experimental context; finally, how all these elements contribute to defining the moral economy that has been made up and created around elderly people living in EHPADs, targets of this innovation.Keywords: geriatric emergency, decision-making, organizational innovation, IDE de nuit, experimentation, paerpa, le 15, SAMU, hospital, nursing assistants, EHPAD

Parasomnias are defined as undesirable physical and/or experiential phenomena accompanying sleep that involve skeletal muscle activity (movements, behaviours), autonomic nervous system changes, and/or emotional-perceptual events. Parasomnias can emerge during entry into sleep, within sleep, or during arousals from any stage of sleep; therefore, all of sleep carries a vulnerability for parasomnias. Parasomnias can be objectively diagnosed by means of polysomnography (i.e. the physiologic monitoring of sleep—figures 4.14.4.1, 4.14.4.2), and can be successfully treated in the majority of cases. Understanding of the parasomnias, based on polysomnographic documentation, has expanded greatly over the past two decades, as new disorders have been identified, and as known disorders have been recognized to occur more frequently, across a broader age group, and with more serious consequences than previously understood. Parasomnias demonstrate how our instinctual behaviours, such as locomotion, feeding, sex, and aggression, can be released during sleep, itself a basic instinct. There are at least eight reasons why parasomnias should be of interest and importance to psychiatrists: 1 Parasomnias can be misdiagnosed and inappropriately treated as a psychiatric disorder. 2 Parasomnias can be a direct manifestation of a psychiatric disorder, e.g. dissociative disorder, nocturnal bulimia nervosa. 3 The emergence and/or recurrence of a parasomnia can be triggered by stress. 4 Psychotropic medications can induce the initial emergence of a parasomnia, or aggravate a preexisting parasomnia. 5 Parasomnias can cause psychological distress or can induce or reactivate a psychiatric disorder in the patient or bed partner on account of repeated loss of self-control during sleep and sleep-related injuries. 6 Familiarity with the parasomnias will allow psychiatrists to be more fully aware of the various medical and neuro-logical disorders, and their therapies, that can be associated with disturbed (sleep-related) behaviour and disturbed dreaming. 7 Parasomnias present a special opportunity for interlinking animal basic science research (including parasomnia animal models) with human (sleep) behavioural disorders. 8 Parasomnias carry forensic implications, as exemplified by the newly-recognized entity of ‘Parasomnia Pseudo-suicide.’ Also, psychiatrists are often asked to render an expert opinion in medicolegal cases pertaining to sleep-related violence.