EMresearch.ch

Liechti, R., Fourie, L., Stickel, M., Schrading, S., Link, B. C., Fischer, H., Lehnick, D., Babst, R., Metzger, J., and Beeres, F. J. P. “Routine Follow-Up Imaging Has Limited Advantage In The Non-Operative Management Of Blunt Splenic Injury In Adult Patients”. Injury 51, no. 4: 863-870. doi:10.1016/j.injury.2020.02.089.

Abstract: BACKGROUND: To date, limited evidence exists regarding follow-up imaging during the non-operative management (NOM) of blunt splenic injury (BSI), especially concerning ultrasound as first-line imaging modality. The aim of this study was to investigate the incidence and time to failure of NOM as well as to evaluate the relevance of follow-up imaging. METHODS: All adult patients with BSI admitted to our level I trauma center, including two associated hospitals, between 01/01/2010 and 31/12/2017 were retrospectively analyzed. Demographic data, comorbidities, injury pattern, trauma mechanism, Injury Severity Score, splenic injury grade and free intra-abdominal fluid were reviewed. Additional analysis of indication, frequency, modality, results and consequences of follow-up imaging was performed. Risk factors for failure of NOM were evaluated using fisher's exact test. RESULTS: A total of 122 patients with a mean age of 43.8 +/- 20.7 years (16-84 years) met inclusion criteria. Twenty patients (16.4%) underwent immediate intervention. One-hundred-and-two patients (83.6%) were treated by NOM. Failure of NOM occurred in 4 patients (3.9%). Failure was significantly associated with active bleeding (3 of 4 [75%] failures vs. 8 of 98 [8.2%] non-failures, OR 33.75, 95% CI 3.1, 363.2, p = 0.004), and liver cirrhosis (2 of 4 [50%] failures vs. 0 of 98 [0%] non-failures, OR 197, 95% CI 7.4, 5265.1, p = 0.001). Eighty patients (78.4%) in the NOM-Group received follow-up imaging by ultrasound (US, n = 51) or computed tomography (CT, n = 29). In 57 cases, routine imaging examinations were conducted (43 US and 14 CT scans) without prior clinical deterioration. Fifty-fife (96.4%) of these imaging results revealed no new significant findings. Every failure of NOM was detected following clinical deterioration in the first 48 h. CONCLUSION: To our knowledge this study includes the largest single centric patient cohort undergoing ultrasound as first-line follow-up imaging modality in the NOM setting of BSI in adult patients. The results indicate that a routine follow-up imaging, regardless of the modality, has limited therapeutic advantage. Indication for radiological follow-up should be based on clinical findings. If indicated, a CT scan should be used as preferred imaging modality.

Tags: Abdominal CT scan, Abdominal ultrasound, Adolescent, Adult, Aged, Aged, 80 and over, Blunt splenic injury, Delayed bleeding, Embolization, Therapeutic, Female, Follow-up imaging, Follow-Up Studies, Humans, Injury Severity Score, Male, Middle Aged, Non-operative management, Ongoing bleeding, Retrospective Studies, Risk, Spleen conserving surgery, Spleen/*diagnostic imaging/*injuries, Splenectomy, Splenic angio-embolization, Time Factors, Tomography, X-Ray Computed, Trauma Centers/*statistics & numerical data, Treatment Failure, Treatment Outcome, Ultrasonography, Wounds, Nonpenetrating/diagnosis/physiopathology/*therapy, Young Adult.

Gordon, L., Pasquier, M., Brugger, H., and Paal, P. “Autoresuscitation (Lazarus Phenomenon) After Termination Of Cardiopulmonary Resuscitation - A Scoping Review”. Scand J Trauma Resusc Emerg Med 28, no. 1: 14. doi:10.1186/s13049-019-0685-4.

Abstract: BACKGROUND: Autoresuscitation describes the return of spontaneous circulation after termination of resuscitation (TOR) following cardiac arrest (CA). We aimed to identify phenomena that may lead to autoresuscitation and to provide guidance to reduce the likelihood of it occurring. MATERIALS AND METHODS: We conducted a literature search (Google Scholar, MEDLINE, PubMed) and a scoping review according to PRISMA-ScR guidelines of autoresuscitation cases where patients undergoing CPR recovered circulation spontaneously after TOR with the following criteria: 1) CA from any cause; 2) CPR for any length of time; 3) A point was reached when it was felt that the patient had died; 4) Staff declared the patient dead and stood back. No further interventions took place; 5) Later, vital signs were observed. 6) Vital signs were sustained for more than a few seconds, such that staff had to resume active care. RESULTS: Sixty-five patients with ROSC after TOR were identified in 53 articles (1982-2018), 18 (28%) made a full recovery. CONCLUSIONS: Almost a third made a full recovery after autoresuscitation. The following reasons for and recommendations to avoid autoresuscitation can be proposed: 1) In asystole with no reversible causes, resuscitation efforts should be continued for at least 20 min; 2) CPR should not be abandoned immediately after unsuccessful defibrillation, as transient asystole can occur after defibrillation; 3) Excessive ventilation during CPR may cause hyperinflation and should be avoided; 4) In refractory CA, resuscitation should not be terminated in the presence of any potentially-treatable cardiac rhythm; 5) After TOR, the casualty should be observed continuously and ECG monitored for at least 10 min.

Tags: *Cardiopulmonary Resuscitation, *Respiration, Autoresuscitation, Cardiopulmonary resuscitation, Emergency medicine, Heart Arrest/*therapy, Humans, Hyperventilation, Lazarus phenomenon, Resuscitation, Resuscitation orders, Vital Signs.

Payot, C., Vuadens-Lehmann, A., Giraud, R., and Bendjelid, K. “Haemodynamic Monitoring During Therapeutic Hypothermia: Which Tool?”. Anaesth Crit Care Pain Med 39, no. 2: 243-244. doi:10.1016/j.accpm.2019.10.016.

Tags: *Hemodynamic Monitoring, *Hypothermia, Induced, *Hypothermia/therapy, Coma/therapy, Humans.

Mathis, A., Villiger, L., Reiner, M. F., Egloff, M., Schmid, H. R., Stivala, S., Limacher, A., et al. “Elevated Hba1C Is Not Associated With Recurrent Venous Thromboembolism In The Elderly, But With All-Cause Mortality- The Sweetco 65+ Study”. Sci Rep 10, no. 1: 2495. doi:10.1038/s41598-020-59173-2.

Abstract: The association of glycated hemoglobin (HbA1c) with venous thromboembolism (VTE) and death in the elderly is unknown. In the SWEETCO 65+ study we analyzed prospectively a Swiss Cohort of Elderly Patients with Venous Thromboembolism (SWITCO 65+). 888 patients were enrolled for the SWEETCO 65+ analysis. HbA1c was determined at baseline and divided into three categories (HbA1c < 5.7%, normal range; 5.7-6.49%, pre-diabetic range; and >6.5%, diabetic range). Median follow-up was 2.5 years. The primary endpoint was recurrent VTE. Secondary endpoints included all-cause mortality and major bleeds. The total prevalence of diabetes was 22.1%. The risk of recurrent VTE was similar in patients with HbA1c with pre-diabetes (adjusted subhazard ratio (aSHR) 1.07 [0.70 to 1.63]) and diabetes (aSHR 0.73 [0.39 to 1.37]) as compared to those with a HbA1c in the normal range. However, a HbA1c >/= 6.5% (median IQ range 7.0 [6.70;7.60]) was significantly associated with a higher risk of all-cause mortality (adjusted hazard ratio [aHR] 1.83 [1.21 to 2.75]). In summary we found no association between HbA1c and major bleeding. Elevated HbA1c levels are not associated with recurrent VTE but with increased all-cause mortality in an elderly population with acute VTE.

Tags: Aged, Aged, 80 and over, Biomarkers/blood, Female, Glycated Hemoglobin/*metabolism, Humans, Male, Mortality/*trends, Venous Thromboembolism/*blood/epidemiology.

Sauter, T. C., Ronz, K., Hirschi, T., Lehmann, B., Hutt, C., Exadaktylos, A. K., and Muller, M. “Intubation In Acute Alcohol Intoxications At The Emergency Department”. Scand J Trauma Resusc Emerg Med 28, no. 1: 11. doi:10.1186/s13049-020-0707-2.

Abstract: BACKGROUND: Guidelines recommend endotracheal intubation in trauma patients with a Glasgow coma scale (GCS) < 9 because of the loss of airway reflexes and consequential risk of airway obstruction. However, in patients with acute alcohol intoxication guidelines are not clear. Thus, we aimed to determine the proportional incidence of intubation in alcohol intoxication and compare the clinical characteristics of intubated and non-intubated patients, as well as reasons for intubation in all patients and in the subgroup of patients with reduced GCS (< 9) but without traumatic brain injury. METHODS: We performed a retrospective analysis of all consultations to an urban ED in Switzerland that presented with an acute alcohol intoxication between 1st June 2012 and 31th Mai 2017. Patient and emergency consultations' characteristics, related injuries, intubation and reason for intubations were extracted. As a subgroup analysis, we analysed the patients with a GCS < 9 without a traumatic brain injury. RESULTS: Of 3003 consultations included from 01.06.2012 to 31.05.2017, 68 were intubated, leading to a proportional incidence of 2.3% intubations in alcohol-intoxication. Intubated patients had a lower blood alcohol concentration (1.3 g/kg [IQR 1.0-2.2] vs. 1.6 g/kg [IQR1.1-2.2], p = 0.034) and less often suffered from chronic alcohol abuse (1183 [39.4%] patients vs. 14 [20.6%], p = 0.001) than non-intubated patients. Patients with trauma were intubated more often (33 patients [48.5%] vs. 742 [25.3%], p < 0.001). In subgroup analysis, 110/145 patients (74.3%) were not intubated; again, more intubated patients had a history of trauma (9 patients [25.7%] vs. 10 [9.1%], p = 0.011). CONCLUSIONS: Intubation in alcohol-intoxicated patients is rare and, among intoxicated patients with GCS < 9, more than two thirds were not intubated in our study - without severe complications. Trauma in general, independent of the history of a traumatic brain injury, and a missing history of chronic alcohol abuse are associated with intubation, but not with blood alcohol concentration. Special caution is required for intoxicated patients with trauma or other additional intoxications or diseases.

Tags: *Emergency Service, Hospital, Acute Disease, Adult, Airway management, Alcoholic intoxication, Alcoholic Intoxication/blood/*therapy, Blood Alcohol Content, Drug overdoses, Female, Glasgow Coma Scale, Humans, Intratracheal intubation, Intubation, Intratracheal/*methods, Male, Middle Aged, Retrospective Studies, Unconsciousness.

Leidi, A., Rouyer, F., Marti, C., Reny, J. L., and Grosgurin, O. “Point Of Care Ultrasonography From The Emergency Department To The Internal Medicine Ward: Current Trends And Perspectives”. Intern Emerg Med 15, no. 3: 395-408. doi:10.1007/s11739-020-02284-5.

Abstract: The advent of portable devices in the early 80s has brought ultrasonography to the patient's bedside. Currently referred to as 'point of care ultrasonography' (POCUS), it has become an essential tool for clinicians. Initially developed in the emergency and critical care settings, POCUS has gained increasing importance in internal medicine wards in the last decade, with both its growing diagnostic accuracy and portability making POCUS an optimal instrument for everyday clinical assessment and procedures. There is large body of evidence to confirm POCUS' superiority when compared to clinical examination and standard X-ray imaging in a variety of clinical situations. On the contrary, only few indications, such as procedural guidance, have a proven additional benefit for patients. Since POCUS is highly user-dependent, pre- and post-graduate curricula are needed and the range of use should be clearly defined. This review focuses on trends and perspectives of POCUS in the management of diseases frequently encountered in emergency and internal medicine. In addition, questions are raised regarding the teaching and supervision of POCUS needing to be addressed in the near future.

Tags: Emergency medicine, Emergency Service, Hospital/organization & administration/trends, History, 20th Century, History, 21st Century, Humans, Internal medicine, Internal Medicine/methods/*trends, Point of care, Point-of-Care Systems/history/*trends, Sensitivity and Specificity, Ultrasonography, Ultrasonography/history/*methods/trends, Ultrasound.

Hautz, W. E., Hautz, S. C., and Kammer, J. E. “Whether Two Heads Are Better Than One Is The Wrong Question (Though Sometimes They Are)”. Adv Health Sci Educ Theory Pract 25, no. 4: 905-911. doi:10.1007/s10459-020-09956-z.

Adam, A., Faouzi, M., McNeely, J., Yersin, B., Daeppen, J. B., and Bertholet, N. “Further Utilization Of Emergency Department And Inpatient Psychiatric Services Among Young Adults Admitted At The Emergency Department With Clinical Alcohol Intoxication”. J Addict Med 14, no. 1: 32-38. doi:10.1097/ADM.0000000000000529.

Abstract: OBJECTIVES: To assess in a cohort of young adults admitted with alcohol intoxication (AI) to the Emergency Department (ED): how many patients are readmitted to the ED or to a Psychiatric Department (PD) inpatient unit; and which characteristics are associated with further ED and PD inpatient admissions. METHODS: In 630 patients aged 18 to 30 years admitted for AI in 2006 to 2007 to the ED of a Swiss tertiary hospital, further ED and PD inpatient admissions through 2013 were assessed. Patient characteristics at the index (initial) ED visit were assessed using administrative and medical records. MEASUREMENTS: Proportion of subjects with at least 1 further ED admission, 1 further ED admission with AI, and any PD admission over the study period.Associations between patients' characteristics at index visit and readmissions were assessed using backward selection multivariate regression analyses. RESULTS: Mean age was 24, 66% were male, 60% had any ED/PD admissions during the study period, 17.9% a PD admission, and 13.8% were re-admitted to ED with AI. Disruptive behavior at the index visit was associated with further ED (odds ratio [OR] 1.69 [1.13; 2.54]) and PD admissions (OR 2.41 [1.44; 4.05]). Psychiatric diagnosis was associated with any further ED admission (OR 2.07 [1.41; 3.05]), with further ED admission with AI (OR 4.56 [2.36; 8.81]) and with PD admission (OR 3.92 [2.40; 6.41]). Female sex predicted any further ED admission (OR 1.65 [1.14; 2.39]). CONCLUSIONS: Young adults presenting with alcohol intoxication have high rates of subsequent inpatient emergency and psychiatric admissions. Being female, presenting with disruptive behavior, and having a psychiatric diagnosis at the ED visit were predictors of further admissions.

Tags: Adolescent, Adult, Alcoholic Intoxication/*epidemiology, Emergency Service, Hospital/*statistics & numerical data, Female, Humans, Logistic Models, Male, Mental Disorders/epidemiology, Multivariate Analysis, Patient Admission/*statistics & numerical data, Patient Readmission/*statistics & numerical data, Prognosis, Psychiatric Department, Hospital/*statistics & numerical data, Retrospective Studies, Sex Factors, Switzerland, Tertiary Care Centers, Young Adult.

Kottwitz, J., Bruno, K. A., Berg, J., Salomon, G. R., Fairweather, D., Elhassan, M., Baltensperger, N., et al. “Myoglobin For Detection Of High-Risk Patients With Acute Myocarditis”. J Cardiovasc Transl Res 13, no. 5: 853-863. doi:10.1007/s12265-020-09957-8.

Abstract: There is an unmet need for accurate and practical screening to detect myocarditis. We sought to test the hypothesis that the extent of acute myocarditis, measured by late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR), can be estimated based on routine blood markers. A total of 44 patients were diagnosed with acute myocarditis and included in this study. There was strong correlation between myoglobin and LGE (r(s) = 0.73 [95% CI 0.51; 0.87], p < 0.001), while correlation was weak between LGE and TnT-hs (r(s) = 0.37 [95% CI 0.09; 0.61], p = 0.01). Receiver operating curve (ROC) analysis determined myoglobin >/= 87 mug/L as cutoff to identify myocarditis (92% sensitivity, 80% specificity). The data were reproduced in an established model of coxsackievirus B3 myocarditis in mice (n = 26). These data suggest that myoglobin is an accurate marker of acute myocarditis. Graphical Abstract Receiver operating curve analysis determined myoglobin >/= 87 mug/L as cutoff to identify myocarditis and these data were reproduced in an established model of coxsackievirus B3 myocarditis in mice: CMRI, cardiac magnetic resonance imaging; Mb, myoglobin; LGE, late gadolinium enhancement; ROC, receiver operating curve analysis.

Tags: (Circulation. 2018, *Magnetic Resonance Imaging, Cine, 136[suppl, 138[suppl I]:A12867)., Acute Disease, Adult, Animals, Association in Chicago, IL, November 5, 2018, and published as an abstract, Biomarker, Biomarkers/blood, CA, November 14, 2017, and published as an abstract (Circulation.2017, Cardiac enzymes, Contrast Media/*administration & dosage, Coxsackievirus Infections/blood/diagnostic imaging/virology, Disease Models, Animal, Female, Humans, I]: A15156). Further data of this work were presented in part for the Paul Dudley, Late gadolinium enhancement, Magnetic resonance imaging, Male, Mice, Inbred BALB C, Middle Aged, Myocardial inflammation, Myocarditis, Myocarditis/*blood/*diagnostic imaging/virology, Myoglobin, Myoglobin/*blood, Predictive Value of Tests, presented in part at the meeting of the American Heart Association in Anaheim,, Reproducibility of Results, Retrospective Studies, Troponin, White International Scholar Award at the meeting of the American Heart.

Slankamenac, K., Rutsche, N., and Keller, D. I. “Availability Of Advance Directives In The Emergency Department”. Swiss Med Wkly 150: w20184. doi:10.4414/smw.2020.20184.

Abstract: BACKGROUND: Emergency departments (EDs) are crowded with critically ill patients, many of whom are no longer able to communicate with the emergency staff. Substitute decision makers are often unknown or not reachable in time. The availability of advance directives (ADs) among Swiss ED patients has not yet been evaluated. The purpose of this prospective survey was to investigate the prevalence of ADs among ED patients and to identify factors associated with the existence or absence of ADs. METHODS: In a prospective survey, we enrolled consecutive patients from 10–30 July 2017 who visited a tertiary care ED. Patients completed a written, standardised and self-administrated questionnaire during the waiting time. The primary endpoint was the prevalence of ADs in ED patients. Secondarily, we defined predictors associated with the existence or absence of ADs. Two months after the first survey, there was a written follow-up survey asking patients without ADs whether they had completed an AD in the meantime. RESULTS: Fifty-eight of 292 enrolled ED patients (19.9%) had a completed AD. Overall, 49.3% of the survey population was female. Patients having an AD were older (69.5 years, interquartile range [IQR] 57–81 vs 39 years, IQR 27–56) and had more comorbidities (67.2% vs 38.9%) compared with patients without ADs. The four leading reasons given for not having an AD were: 33.6% never considered completing one, 26% did not know about ADs, 14% preferred family to make decisions, 11.6% felt it was too early to make such a decision. Predictors for having an AD were older age (p <0.001), being in long-term medical treatment by a specialist (p = 0.050), being Swiss (p = 0.021) and living with nursing care (p = 0.043). Of the ED patients with ADs, 46.6% discussed their AD with the family and 31% with their general practitioner. Results of the follow-up survey showed that eight participants had completed an AD in the meantime. The prevalence of ADs increased from 19.9% to 22.6%. DISCUSSION: During the last 20 years, the percentage of patients having an AD has not changed. Even today, only every fifth ED patient has a completed AD. Nearly two thirds of ED patients never considered completing one or did not know about ADs. Therefore, there is an urgent need to better inform and sensitise the public, so that they will define in a timely manner legally valid and specifically defined decisions about future medical treatments and wishes by completing individual directives.

Tags: Adult, Advance Directives/*statistics & numerical data, Aged, Aged, 80 and over, Emergency Service, Hospital, Female, Humans, Male, Middle Aged, Prospective Studies, Surveys and Questionnaires, Switzerland, Tertiary Care Centers, Young Adult.

Nickel, C. H., Kellett, J., Nieves Ortega, R., Lyngholm, L., Hanson, S., Cooksley, T., Bingisser, R., and Brabrand, M. “A Simple Prognostic Score Predicts One-Year Mortality Of Alert And Calm Emergency Department Patients: A Prospective Two-Center Observational Study”. Int J Clin Pract 74, no. 5: e13481. doi:10.1111/ijcp.13481.

Abstract: STUDY OBJECTIVE: To derive and validate a prognostic score to predict 1-year mortality using vital signs, mobility and other variables that are readily available at the bedside at no additional cost. METHODS: Post hoc analysis of two independent prospective observational studies in two emergency departments, one in Denmark and the other in Switzerland. PARTICIPANTS: Alert and calm emergency department patients. MEASUREMENTS: The prediction of mortality from presentation to 365 days by vital signs, mobility and other variables that are readily available at the bedside at no additional cost. RESULTS: One thousand six hundred and eighteen alert and calm patients were in the Danish cohort and 1331 in the Swiss cohort. Logistic regression identified age >68 years, abnormal vital signs, impaired mobility and the decision to admit as significant predictors of 365-day mortality. A simple prognostic score awarded one point to each of these predictors. Less than two of these predictors were present in 45.6% of patients, and only 0.4% of these patients died within a year. If two or more of these predictors were present, 365-day mortality increased exponentially. CONCLUSION: Age >68 years, the decision for hospital admission, any vital sign abnormality at presentation and impaired mobility at presentation are equally powerful predictors of 1-year mortality in alert and calm emergency department patients. If validated by others these predictors could be used to discharge patients with confidence since nearly half of these patients had less than two predictors and none of them died within 30 days. However, when two or more predictors were present 365-day mortality increased exponentially.

Tags: *Emergency Service, Hospital, *Vital Signs, Aged, Cohort Studies, Denmark, Female, Hospital Mortality/*trends, Hospitalization/trends, Humans, Logistic Models, Male, Middle Aged, Patient Discharge/*trends, Prognosis, Prospective Studies, Switzerland.

Zante, B., Hautz, W. E., and Schefold, J. C. “Physiology Education For Intensive Care Medicine Residents: A 15-Minute Interactive Peer-Led Flipped Classroom Session”. Plos One 15, no. 1: e0228257. doi:10.1371/journal.pone.0228257.

Abstract: INTRODUCTION: In acute care medicine, knowledge of the underlying (patho)-physiology is of paramount importance. This may be especially relevant in intensive care medicine, where individual competence and proficiency greatly depend on knowledge and understanding of critical care physiology. In settings with time constraints such as intensive care units (ICUs), time allotted to education is often limited. We evaluated whether introduction of a short, interactive, peer-led flipped classroom session is feasible and can provide ICU residents with a better understanding of critical care physiology. MATERIALS AND METHODS: Using the flipped classroom concept, we developed a 15-minute peer-led interactive "physiology education" session to introduce a total of 44 residents to critical care physiology. Using a nine-item electronic survey with open questions and a five-point Likert scale, we analysed the overall concept with regard to feasibility, motivation, and subjective learning of critical care physiology. RESULTS: The overall rate of response to the survey was 70.5% (31/44). The residents reported that these sessions sparked their interest (p = 0.005, Chi square 10.52), and that discussion and interaction during these sessions had promoted their knowledge and understanding. Both novice and experienced residents reported that new knowledge was imparted (both p<0.0001, Chi-square 32.97 and 25.04, respectively). CONCLUSIONS: In an environment with time constraints such as the ICU, a 15-minute, interactive, peer-led flipped classroom teaching session was considered feasible and generally appeared useful for teaching critical care physiology to ICU residents. Responses to questions on questionnaires indicated that teaching sessions sparked interest and increased motivation. This approach may theoretically induce a modification in professional behaviour and promote self-directed learning. We therefore support the use of peer-led flipped classroom training sessions in the ICU. Whether these sessions result in improved ICU care should be addressed in subsequent studies.

Tags: *Critical Care, Educational Measurement, Humans, Intensive Care Units, Internship and Residency, Learning, Physiology/*education, Professional Competence, Surveys and Questionnaires, Tertiary Care Centers, Thinking.

Grimm, K., Twerenbold, R., Abaecherli, R., Boeddinghaus, J., Nestelberger, T., Koechlin, L., Troester, V., et al. “Diagnostic And Prognostic Value Of St-Segment Deviation Scores In Suspected Acute Myocardial Infarction”. Eur Heart J Acute Cardiovasc Care 9, no. 8: 857-868. doi:10.1177/2048872619853579.

Abstract: BACKGROUND: Recent advances in digital electrocardiography technology allow evaluating ST-segment deviations in all 12 leads as quantitative variables and calculating summed ST-segment deviation scores. The diagnostic and prognostic utility of summed ST-segment deviation scores is largely unknown. METHODS: We aimed to explore the diagnostic and prognostic utility of the conventional and the modified ST-segment deviation score (Better Analysis of ST-segment Elevations and Depressions in a 12- Lead-ECG-Score (BASEL-Score): sum of elevations in the augmented voltage right - lead (aVR) plus absolute, unsigned ST-segment depressions in the remaining leads) in patients presenting with suspected non-ST-segment elevation myocardial infarction. The diagnostic endpoint was non-ST-segment elevation myocardial infarction, adjudicated by two independent cardiologists. Prognostic endpoint was mortality during two-year follow up. RESULTS: Among 1330 patients, non-ST-segment elevation myocardial infarction was present in 200 (15%) patients. Diagnostic accuracy for non-ST-segment elevation myocardial infarction as quantified by the area under the receiver-operating-characteristics curve was significantly higher for the BASEL-Score (0.73; 95% confidence interval 0.69-0.77) as compared to the conventional ST-segment deviation score (0.53; 95% confidence interval 0.49-0.57, p<0.001). The BASEL-Score provided additional independent diagnostic value to dichotomous electrocardiogram variables (ST-segment depression, T-inversion, both p<0.001) and to high-sensitivity cardiac troponin (p<0.001) as well as clinical judgment at 90 min (p<0.001). Similarly, only the BASEL-Score proved to be an independent predictor of two year mortality. CONCLUSIONS: The modified ST-segment deviation score BASEL-Score focusing on ST-segment elevation in aVR and ST-segment depressions in the remaining leads provides incremental diagnostic and prognostic information.

Tags: *Electrocardiography, Acute coronary syndrome, Aged, Disease Progression, electrocardiogram, Female, Follow-Up Studies, Humans, Male, Middle Aged, Prognosis, Prospective Studies, ROC Curve, ST Elevation Myocardial Infarction/diagnosis/*physiopathology, ST-segment deviation.

Mamede, S., Hautz, W. E., Berendonk, C., Hautz, S. C., Sauter, T. C., Rotgans, J., Zwaan, L., and Schmidt, H. G. “Think Twice: Effects On Diagnostic Accuracy Of Returning To The Case To Reflect Upon The Initial Diagnosis”. Acad Med 95, no. 8: 1223-1229. doi:10.1097/ACM.0000000000003153.

Abstract: PURPOSE: Diagnostic errors have been attributed to failure to sufficiently reflect on initial diagnoses. However, evidence of the benefits of reflection is conflicting. This study examined whether reflection upon initial diagnoses on difficult cases improved diagnostic accuracy and whether reflection triggered by confrontation with case evidence was more beneficial than simply revising initial diagnoses. METHOD: Participants were physicians in Bern, Switzerland, registered for the 2018 Swiss internal medicine certification exam. They diagnosed written clinical cases, providing an initial diagnosis by following the same instructions and returning to the case to provide a final diagnosis. The latter required different types of reflection depending on the physician's experimental condition: return without instructions, identify confirmatory evidence, identify contradictory evidence, or identify both confirmatory and contradictory evidence. The authors examined diagnostic accuracy scores (range 0-1) as a function of diagnostic phase and reflection type. RESULTS: One hundred and sixty-seven physicians participated. Diagnostic accuracy scores did not significantly differ between the 4 groups of physicians in the initial (I) or the final (F) diagnostic phase (mean [95% CI]: return without instructions, I: 0.21 [0.17, 0.26], F: 0.23 [0.18, 0.28]; confirmatory evidence, I: 0.24 [0.19, 0.29], F: 0.31 [0.25, 0.37]; contradictory evidence, I: 0.22 [0.17, 0.26], F: 0.26 [0.22, 0.30]; confirmatory and contradictory evidence, I: 0.19 [0.15, 0.23], F: 0.25 [0.20, 0.31]). Regardless of type of reflection employed while revising the case, accuracy increased significantly between initial and final diagnosis, I: 0.22 (0.19, 0.24) vs F: 0.26 (0.24, 0.29); P < .001. CONCLUSIONS: Physicians' diagnostic accuracy improved after reflecting upon initial diagnoses provided for difficult cases, independently of the evidence searched for while reflecting. The findings support the importance attributed to reflection in clinical teaching. Future research should investigate whether revising the case can become more beneficial by triggering additional reflection.

Tags: *Clinical Competence, *Clinical Decision-Making, *Diagnostic Errors, Humans, Internal Medicine/*education, Random Allocation, Switzerland.

Chan, M., Fehlmann, C. A., Pasquier, M., Suppan, L., and Savoldelli, G. L. “Endotracheal Intubation Success Rate In An Urban, Supervised, Resident-Staffed Emergency Mobile System: An 11-Year Retrospective Cohort Study”. J Clin Med 9, no. 1. doi:10.3390/jcm9010238.

Abstract: OBJECTIVES: In the prehospital setting, endotracheal intubation (ETI) is sometimes required to secure a patient's airways. Emergency ETI in the field can be particularly challenging, and success rates differ widely depending on the provider's training, background, and experience. Our aim was to evaluate the ETI success rate in a resident-staffed and specialist-physician-supervised emergency prehospital system. METHODS: This retrospective study was conducted on data extracted from the Geneva University Hospitals' institutional database. In this city, the prehospital emergency response system has three levels of expertise: the first is an advanced life-support ambulance staffed by two paramedics, the second is a mobile unit staffed by an advanced paramedic and a resident physician, and the third is a senior emergency physician acting as a supervisor, who can be dispatched either as backup for the resident physician or when a regular Mobile Emergency and Resuscitation unit (Service Mobile d'Urgence et de Reanimation, SMUR) is not available. For this study, records of all adult patients taken care of by a second- and/or third-level prehospital medical team between 2008 and 2018 were screened for intubation attempts. The primary outcome was the success rate of the ETI attempts. The secondary outcomes were the number of ETI attempts, the rate of ETI success at the first attempt, and the rate of ETIs performed by a supervisor. RESULTS: A total of 3275 patients were included in the study, 55.1% of whom were in cardiac arrest. The overall ETI success rate was 96.8%, with 74.4% success at the first attempt. Supervisors oversaw 1167 ETI procedures onsite (35.6%) and performed the ETI themselves in only 488 cases (14.9%). CONCLUSION: A resident-staffed and specialist-physician-supervised urban emergency prehospital system can reach ETI success rates similar to those reported for a specialist-staffed system.

Tags: airway management, emergency medical services, endotracheal intubation, prehospital emergency care.

Richard-Lepouriel, H., Bajwa, N., de Grasset, J., Audetat, M. C., Dominice Dao, M., Jastrow, N., Nendaz, M., and Junod Perron, N. “Medical Students As Feedback Assessors In A Faculty Development Program: Implications For The Future”. Med Teach 42, no. 5: 536-542. doi:10.1080/0142159X.2019.1708875.

Abstract: Background: Little is known about simulated students' ability in assessing feedback received in Objective Structured Teaching Encounters (OSTEs). We aimed to assess to which extent students' perceptions matched objective analysis regarding quality of received feedback, to explore what elements of feedback they emphasized and what they learned about feedback.Methods: In this mixed-method study, 43 medical students participated as simulated residents in five OSTEs at Geneva University Hospitals. They assessed quality of feedback from faculty using a 15-item questionnaire and gave written/oral comments. Videotaped feedbacks were assessed using an 18-item feedback scale. During four focus groups, 25 students were asked about what they learned as feedback assessors.Results: 453 students' questionnaires and feedback scale were compared. Correlations were moderate for stimulating self-assessment (0.48), giving a balanced feedback (0.44), checking understanding (0.47) or planning (0.43). Students' feedback emphasized elements such as faculty's empathy or ability to give concrete advice. They reported that being a feedback assessor helped them to realize importance of making the learner active and that giving effective feedback required structure and skills.Conclusion: Medical students may identify quality of feedback. Involving them in OSTEs could be interesting to train them to become valid raters of supervisors' teaching skills.

Tags: *Students, Medical, Clinical Competence, collaborative/peer-to-peer, Faculty, Medical, Feedback, Humans, Learning, medical education research, Videotape Recording.

Dami, F., Darioli, V., and Pasquier, M. “Association Between The Naca Score And Clinical Outcomes”. Am J Emerg Med 38, no. 8: 1692-1693. doi:10.1016/j.ajem.2020.01.021.

Tags: *Air Ambulances, *Emergency Medical Services, Arrhythmias, Cardiac, Emergency medical services, Humans, Mortality, National Advisory Committee for Aeronautics score, Outcome, Retrospective Studies, Severity score.

Potasso, L., Sailer, C. O., Blum, C. A., Cesana-Nigro, N., Schuetz, P., Mueller, B., and Christ-Crain, M. “Mild To Moderate Hyponatremia At Discharge Is Associated With Increased Risk Of Recurrence In Patients With Community-Acquired Pneumonia”. Eur J Intern Med 75: 44-49. doi:10.1016/j.ejim.2019.12.009.

Abstract: BACKGROUND: Hyponatremia is the most common electrolyte disorder in hospitalized patients with pneumonia. Different studies have shown an association of hyponatremia on admission and worse patient's outcome. Yet, the impact of hyponatremia at discharge or of hyponatremia correction on patient's prognosis is unknown. METHODS: This is a preplanned secondary data analysis from a double-blind, randomized, placebo-controlled trial of hospitalized patients with community-acquired pneumonia and prednisone treatment. The primary outcome was the impact of hyponatremia on admission and at discharge on patient relevant outcomes (i.e. mortality, rehospitalization and recurrence rate) within 180 days. RESULTS: Of the 708 included patients, 185 (26.1%) were hyponatremic on admission. Of these, 28 (15.1%) were still hyponatremic at discharge. 34 (4.8%) patients developed hyponatremia during hospitalization despite being normonatremic on admission. Patients with hyponatremia at discharge had a higher rate of pneumonia recurrence as compared to normonatremic patients (OR 2.68; 95%-CI 1.09-6.95; p = 0.037). Among patients with hyponatremia at discharge, patients who were already hyponatremic on admission showed the strongest association with increased recurrence rate (OR 4.01; 95%-CI 1.08-12.64; p = 0.022). In contrast, recurrence rate was not affected in patients who were hyponatremic on admission but had normalized serum sodium levels at discharge (p = 0.73). CONCLUSION: Mild to moderate hyponatremia at discharge is associated with an increased risk of recurrence in hospitalized patients with pneumonia. This association is particularly strong for patients who are hyponatremic both on admission and at discharge, emphasizing the importance of hyponatremia correction during hospitalization.

Tags: *Hyponatremia/complications/epidemiology, *Pneumonia/complications/epidemiology, Hospitalization, Humans, Patient Discharge, Patient relevant outcomes, Retrospective Studies, Sodium, Water-electrolyte imbalance.

Talisuna, A. O., Okiro, E. A., Yahaya, A. A., Stephen, M., Bonkoungou, B., Musa, E. O., Minkoulou, E. M., et al. “Spatial And Temporal Distribution Of Infectious Disease Epidemics, Disasters And Other Potential Public Health Emergencies In The World Health Organisation Africa Region, 2016-2018”. Global Health 16, no. 1: 9. doi:10.1186/s12992-019-0540-4.

Abstract: BACKGROUND: Emerging and re-emerging diseases with pandemic potential continue to challenge fragile health systems in Africa, creating enormous human and economic toll. To provide evidence for the investment case for public health emergency preparedness, we analysed the spatial and temporal distribution of epidemics, disasters and other potential public health emergencies in the WHO African region between 2016 and 2018. METHODS: We abstracted data from several sources, including: the WHO African Region's weekly bulletins on epidemics and emergencies, the WHO-Disease Outbreak News (DON) and the Emergency Events Database (EM-DAT) of the Centre for Research on the Epidemiology of Disasters (CRED). Other sources were: the Program for Monitoring Emerging Diseases (ProMED) and the Global Infectious Disease and Epidemiology Network (GIDEON). We included information on the time and location of the event, the number of cases and deaths and counter-checked the different data sources. DATA ANALYSIS: We used bubble plots for temporal analysis and generated graphs and maps showing the frequency and distribution of each event. Based on the frequency of events, we categorised countries into three: Tier 1, 10 or more events, Tier 2, 5-9 events, and Tier 3, less than 5 or no event. Finally, we compared the event frequencies to a summary International Health Regulations (IHR) index generated from the IHR technical area scores of the 2018 annual reports. RESULTS: Over 260 events were identified between 2016 and 2018. Forty-one countries (87%) had at least one epidemic between 2016 and 2018, and 21 of them (45%) had at least one epidemic annually. Twenty-two countries (47%) had disasters/humanitarian crises. Seven countries (the epicentres) experienced over 10 events and all of them had limited or developing IHR capacities. The top five causes of epidemics were: Cholera, Measles, Viral Haemorrhagic Diseases, Malaria and Meningitis. CONCLUSIONS: The frequent and widespread occurrence of epidemics and disasters in Africa is a clarion call for investing in preparedness. While strengthening preparedness should be guided by global frameworks, it is the responsibility of each government to finance country specific needs. We call upon all African countries to establish governance and predictable financing mechanisms for IHR implementation and to build resilient health systems everywhere.

Tags: Africa/epidemiology, African region, Communicable Diseases/*epidemiology, Disaster, Disasters/*statistics & numerical data, Emergencies, Epidemic, Epidemics/*statistics & numerical data, Event, Humans, International health regulations, Public health emergency, Public health emergency of international concern, Public Health/*statistics & numerical data, Spatio-Temporal Analysis, World Health Organisation, World Health Organization.

Alligier, M., Barres, R., Blaak, E. E., Boirie, Y., Bouwman, J., Brunault, P., Campbell, K., et al. “Obedis Core Variables Project: European Expert Guidelines On A Minimal Core Set Of Variables To Include In Randomized, Controlled Clinical Trials Of Obesity Interventions”. Obes Facts 13, no. 1: 1-28. doi:10.1159/000505342.

Abstract: Heterogeneity of interindividual and intraindividual responses to interventions is often observed in randomized, controlled trials for obesity. To address the global epidemic of obesity and move toward more personalized treatment regimens, the global research community must come together to identify factors that may drive these heterogeneous responses to interventions. This project, called OBEDIS (OBEsity Diverse Interventions Sharing - focusing on dietary and other interventions), provides a set of European guidelines for a minimal set of variables to include in future clinical trials on obesity, regardless of the specific endpoints. Broad adoption of these guidelines will enable researchers to harmonize and merge data from multiple intervention studies, allowing stratification of patients according to precise phenotyping criteria which are measured using standardized methods. In this way, studies across Europe may be pooled for better prediction of individuals' responses to an intervention for obesity - ultimately leading to better patient care and improved obesity outcomes.

Tags: *Biological Variation, Population/physiology, *Expert Testimony, Choice Behavior, Diet, Europe, from Itrim and Ethicon Johnson & Johnson. L. Tappy received a research grant from, Humans, Interventions, Medical History Taking/*standards, Obesity, Obesity/diagnosis/*therapy, Precision medicine, Prognosis, Randomized Controlled Trials as Topic/*standards, Research Design/standards, Soremartec Italy srl and speaker's fees from Soremartec Italy srl and Nestle AG,, Stratification, Switzerland. No other authors have conflicts of interest to declare., unassociated with the present study. M. Neovius has received advisory board fees, Variables.

Gauss, T., Bouzat, P., and Ageron, F. X. “Problems With Clinical Application Of Low-Dose Vasopressin For Traumatic Hemorrhagic Shock”. Jama Surg 155, no. 4: 363. doi:10.1001/jamasurg.2019.5433.

Tags: *Shock, Hemorrhagic/drug therapy/etiology, Arginine Vasopressin, Dietary Supplements, Humans, Vasopressins.

Woitok, B. K., Funk, G. C., Walter, P., Schwarz, C., Ravioli, S., and Lindner, G. “Dysnatremias In Emergency Patients With Acute Kidney Injury: A Cross-Sectional Analysis”. Am J Emerg Med 38, no. 12: 2602-2606. doi:10.1016/j.ajem.2020.01.009.

Abstract: PURPOSE: We aimed to investigate the prevalence, risk factors and outcome of hypo- and hypernatremia in emergency patients with acute kidney injury (AKI). METHODS: In this cross-sectional analysis all emergency patients between January 1st 2017 and December 31st 2018 with measurements of creatinine and sodium were included. Baseline characteristics, medication and laboratory data were gathered. Chart reviews were performed to identify patients with a diagnosis of chronic kidney disease (CKD) and to extract baseline creatinine. For all other patients the ADQI backformula was used to calculate baseline creatinine. AKI was graduated using creatinine criteria of the acute kidney injury network. Binary logistic regression analysis was used to identify risk factors for appearance of dysnatremias and outcome. RESULTS: AKI was found in 8% of patients. 392 patients (23.16%) had hyponatremia, 24 (1.4%) had hypernatremia. Use of potassium sparing diuretics, a medical cause for emergency referral, use of thiazide diuretics and AKI stage were the strongest risk factors for hyponatremia. Loop diuretics, a medical cause for emergency referral and AKI stage were risk factors for hypernatremia. In patients with all classes of hyponatremia, length of hospital stay was significantly longer compared to patients with a normal serum sodium. In the binary logistic regression analysis with death as outcome, hyponatremia as well as severe hypernatremia were independent risk factors for mortality. CONCLUSIONS: Dysnatremias are common in emergency patients with AKI. Diuretic medication is a major risk factor for hypo- and hypernatremia. Both hyponatremia and severe hypernatremia were independent risk factors for adverse outcome.

Tags: Acute kidney injury, Acute Kidney Injury/*epidemiology, Adult, Aged, Aged, 80 and over, Cross-Sectional Studies, Diuretics, Potassium Sparing/therapeutic use, Emergency, Emergency Service, Hospital, Female, Humans, Hypernatremia, Hypernatremia/*epidemiology, Hyponatremia, Hyponatremia/*epidemiology, Length of Stay, Logistic Models, Male, Middle Aged, Mortality, Prevalence, Renal Insufficiency, Chronic/epidemiology, Risk Factors, Severity of Illness Index, Sodium, Sodium Chloride Symporter Inhibitors/therapeutic use, Sodium Potassium Chloride Symporter Inhibitors/therapeutic use, to declare..

Ruhle, A., Oehme, F., Link, B. C., Metzger, J., Fischer, H., Stickel, M., Delagrammaticas, D. E., Babst, R., and Beeres, F. J. P. “Swiss Chocolate And Free Beverages To Increase The Motivation For Scientific Work Amongst Residents: A Prospective Interventional Study In A Non-Academic Teaching Hospital In Switzerland”. Trials 21, no. 1: 74. doi:10.1186/s13063-019-3956-5.

Abstract: BACKGROUND: The success of a clinical trial depends on its recruitment of eligible patients; therefore, the recruitment period requires special attention. We hypothesized that with a new approach focused on continuous information and gratification, resident motivation to participate in scientific work will increase and recruitment rates will improve. METHODS: Our new recruitment approach was applied to the recruitment phase of two prospective randomized trials (registered at the German Clinical Trials Register). Randomization of these trials was performed first using blinded envelopes; later a soft drink machine was used as the delivery tool of randomization as a lighthearted motivation to join scientific work and to reward the resident with free soft drinks for each recruitment. Residents were informed about the trial via a lecture and by mail. To increase interest everyone received Swiss chocolate. With a multiple choice survey we investigated the success of our actions at 6 and 12 months. Recruitment rates of the trials were evaluated and associated with the motivational approaches. RESULTS: Our residents rated their awareness of the trials with median 9 (IQR 7;9) during the first and 8 (IQR 5;9) during the second survey and their interest in scientific work with median 7 (IQR 4;8) and 6 (IQR 5;8). The percentage of residents feeling highly motivated improved from 58% to 70%. The recruitment rates stayed stably high over time with 73% and 72% in trial 1 and 90% and 85% in trial 2; 24% of residents stated their motivation could be increased by gratifications. CONCLUSIONS: After implementation of our new recruitment approach we found positively motivated residents and high recruitment rates in the corresponding trials. We propose this procedure may help to ensure the successful initiation of clinical trials. Larger studies testing this approach are warranted.

Tags: *Attitude of Health Personnel, *Beverages, *Chocolate, *Hospitals, Teaching, *Internship and Residency, *Motivation, *Patient Selection, *Randomized Controlled Trials as Topic, *Token Economy, Food Dispensers, Automatic, Humans, Improving inclusion rates, Increasing motivation, Motivation for research, Prospective Studies, Sample Size, Switzerland.

Lindner, G., and Woitok, B. K. “Emergency Department Overcrowding : Analysis And Strategies To Manage An International Phenomenon”. Wien Klin Wochenschr 133, no. 5-6: 229-233. doi:10.1007/s00508-019-01596-7.

Abstract: Overcrowding in emergency departments is a common and worldwide phenomenon, which is widely reported even in the lay press. Strategies to address this incriminating situation for patients, nurses, physicians and hospital administrators are urgently needed. The current review presents an analysis of the overcrowding problem as well as strategies to answer overcrowding situations.

Tags: *Crowding, *Emergency Service, Hospital, Fast-Track, Humans, Patient-Flow, Team-Triage, Triage, Waiting time.

Wachelder, J., Stassen, P. M., Fourmanov, R. S., Nickel, C. H., and Haak, H. R. “Higher In-Hospital Mortality In Patients With Nonspecific Complaints Presenting To The Emergency Department”. Acute Med 18, no. 4: 232-238. https://www.ncbi.nlm.nih.gov/pubmed/31912054.

Abstract: BACKGROUND: Nonspecific complaints (NSC) at the Emergency Department (ED) are not well researched yet. OBJECTIVE: To investigate the number of patients who could be classified as having NSC early after arrival in the ED using an algorithm. METHOD: Retrospective cohort study was conducted among all hemodynamically stable non-trauma adult patients with MTS category orange/yellow visiting the ED. Patients who had no specific complaints/signs, predefined on a list, were categorized as NSC. RESULTS: In total, 2419 patients, of whom 102 (4.2%) presented with NSC. Hospitalization was more prevalent (85.3% vs. 69.0%, p<0.001) and in-hospital mortality was higher in the NSC-group (11.8% vs. 3.5%, adjusted OR 2.0, 95% CI 1.0-3.9, p=0.04). CONCLUSION: Using an algorithm it is possible to identify NSC patients who have (worse) outcomes than those classified as SC.

Tags: *Emergency Service, Hospital/statistics & numerical data, *Hospital Mortality, *Hospitalization, Adult, Humans, Prospective Studies, Retrospective Studies.

Lampart, A., Arnold, I., Mader, N., Niedermeier, S., Escher, A., Stahl, R., Trumm, C., et al. “Prevalence Of Fractures And Diagnostic Accuracy Of Emergency X-Ray In Older Adults Sustaining A Low-Energy Fall: A Retrospective Study”. J Clin Med 9, no. 1. doi:10.3390/jcm9010097.

Abstract: BACKGROUND: Plain radiography (XR) series are standard of care for detection of fall-related fractures in older patients with low-energy falls (LEF) in the emergency department (ED). We have investigated the prevalence of fractures and diagnostic accuracy of XR imaging in the ED. METHODS: 2839 patients with LEF, who were presented to two urban level I trauma centers in 2016 and received XR and computed tomography (CT), were consecutively included in this retrospective cohort study. The primary endpoint was the prevalence of fractures of the vertebral column, rib cage, pelvic ring, and proximal long bones. Secondary endpoints were diagnostic accuracy of XR for fracture detection with CT as reference standard and cumulative radiation doses applied. RESULTS: Median age was 82 years (range 65-105) with 64.1% female patients. Results revealed that 585/2839 (20.6%) patients sustained fractures and 452/2839 (15.9%) patients received subsequent XR and CT examinations of single body regions. Cross-tabulation analysis revealed sensitivity of XR of 49.7%, a positive likelihood ratio of 27.6, and negative likelihood ratio of 0.5. CONCLUSIONS: XR is of moderate diagnostic accuracy for ruling-out fractures of the spine, pelvic ring, and rib cage in older patients with LEF. Prospective validations are required to investigate the overall risk-benefit of direct CT imaging strategies, considering the trade-off between diagnostic safety, health care costs, and radiation exposure.

Tags: computed tomography, fracture, low-energy fall, older adult, X-ray.

Kuehne, A., Keating, P., Polonsky, J., Haskew, C., Schenkel, K., Le Polain de Waroux, O., and Ratnayake, R. “Event-Based Surveillance At Health Facility And Community Level In Low-Income And Middle-Income Countries: A Systematic Review”. Bmj Glob Health 4, no. 6: e001878. doi:10.1136/bmjgh-2019-001878.

Abstract: BACKGROUND: The International Health Regulations require member states to establish "capacity to detect, assess, notify and report events". Event-based surveillance (EBS) can contribute to rapid detection of acute public health events. This is particularly relevant in low-income and middle-income countries (LMICs) which may have poor public health infrastructure. To identify best practices, we reviewed the literature on the implementation of EBS in LMICs to describe EBS structures and to evaluate EBS systems. METHODS: We conducted a systematic literature search of six databases to identify articles that evaluated EBS in LMICs and additionally searched for grey literature. We used a framework approach to facilitate qualitative data synthesis and exploration of patterns across and within articles. RESULTS: We identified 778 records, of which we included 15 studies concerning 13 different EBS systems. The 13 EBS systems were set up as community-based surveillance, health facility-based surveillance or open surveillance (ie, notification by non-defined individuals and institutions). Four systems were set up in outbreak settings and nine outside outbreaks. All EBS systems were integrated into existing routine surveillance systems and pre-existing response structures to some extent. EBS was described as useful in detecting a large scope of events, reaching remote areas and guiding outbreak response. CONCLUSION: Health facility and community-based EBS provide valuable information that can strengthen the early warning function of national surveillance systems. Integration into existing early warning and response systems was described as key to generate data for action and to facilitate rapid verification and response. Priority in its implementation should be given to settings that would particularly benefit from EBS strengths. This includes areas most prone to outbreaks and where traditional 'routine' surveillance is suboptimal.

Tags: epidemiology, infections, diseases, disorders, injuries, public health, systematic review.

Kutz, A., Ebrahimi, F., Sailer, C. O., Wagner, U., Schuetz, P., Mueller, B., and Christ-Crain, M. “Seasonality Of Hypoosmolar Hyponatremia In Medical Inpatients - Data From A Nationwide Cohort Study”. J Clin Endocrinol Metab 105, no. 4: E947-E954. doi:10.1210/clinem/dgz320.

Abstract: CONTEXT: Hyponatremia is the most prevalent electrolyte disturbance in hospitalized patients. Previous studies have shown a seasonal variation of profound hyponatremia with higher prevalence during warmer months. OBJECTIVE: This study aimed at analyzing the seasonal prevalence and sex- and age-specific differences of hyponatremia in medical inpatients. DESIGN: Nationwide cohort study from January 2009 and December 2015 using prospective administrative data. SETTING: Medical inpatients. PATIENTS: Diagnosis of hypoosmolar hyponatremia. MAIN OUTCOME MEASURES: The primary outcome was the monthly alteration in hyponatremia prevalence. Secondary outcomes were the association of outdoor temperature with hyponatremia prevalence and differences among sex and age groups. RESULTS: Of 2 426 722 medical inpatients, 84 210 were diagnosed with hypoosmolar hyponatremia, of whom 61% (n = 51 262) were female. The highest overall prevalence of hyponatremia was observed in July (4.5%, n = 8976); the lowest in December (2.7%, n = 6530). The overall prevalence of hyponatremia in women compared with men was higher by 58% (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.56-1.60). The sex-specific difference was most pronounced in the warmest month of July (mean temperature 20.1 degrees C (OR, 1.76; 95% CI, 1.68-1.84). We observed the strongest association between seasonality and hyponatremia in elderly (>80 years) female inpatients admitted during the month of July (OR, 2.40; 95% CI, 2.20-2.62]). CONCLUSION: The prevalence of diagnosed hypoosmolar hyponatremia in medical inpatients increases during summer months with higher outdoor temperature. Elderly female inpatients were most susceptible to the seasonal rise in hyponatremia prevalence.

Tags: *Seasons, age differences, Aged, Aged, 80 and over, aging, Cross-Sectional Studies, Female, Follow-Up Studies, Hospitalization/*statistics & numerical data, hot weather, Humans, Hyponatremia/*epidemiology, Inpatients/*statistics & numerical data, Male, Middle Aged, Osmolar Concentration, outdoor temperature, Prevalence, Prognosis, Prospective Studies, sex differences, Switzerland/epidemiology.

Rauch, S., Wallner, B., Strohle, M., Dal Cappello, T., and Brodmann Maeder, M. “Climbing Accidents-Prospective Data Analysis From The International Alpine Trauma Registry And Systematic Review Of The Literature”. Int J Environ Res Public Health 17, no. 1. doi:10.3390/ijerph17010203.

Abstract: Climbing has become an increasingly popular sport, and the number of accidents is increasing in parallel. We aim at describing the characteristics of climbing accidents leading to severe (multisystem) trauma using data from the International Alpine Trauma Registry (IATR) and at reporting the results of a systematic review of the literature on the epidemiology, injury pattern, severity and prevention of climbing accidents. We found that climbing accidents are a rare event, since approximately 10% of all mountain accidents are climbing related. Climbing accidents mainly affect young men and mostly lead to minor injuries. Fall is the most common mechanism of injury. Extremities are the most frequently injured body part. However, in multisystem climbing-related trauma, the predominant portion of injuries are to head/neck, chest and abdomen. The fatality rate of climbing accidents reported in the literature varies widely. Data on climbing accidents in general are very heterogeneous as they include different subspecialties of this sport and report accidents from different regions. A number of risk factors are accounted for in the literature. Appropriate training, preparation and adherence to safety standards are key in reducing the incidence and severity of climbing accidents.

Tags: *Emergency Medical Services, *Registries, accident, Accidental Falls/*statistics & numerical data, climbing, Data Analysis, Humans, Injury Severity Score, International Alpine Trauma Registry, literature review, Mountaineering/*injuries, Prospective Studies, trauma.

Ratzenbck, Elisabeth, Khne, Michael, and Nestelberger, Thomas. “The Winter Gets Well(Ens) – A Rare Pattern Of Left Anterior Descending Artery Occlusion”. Cardiovascular Medicine 23, no. 2. doi:10.4414/cvm.2020.02089.

Abstract: De Winter syndrome is a rare presentation in patients with acute left anterior descending artery occlusion, thus an equivalent of anterior ST elevation myocardial infarction (STEMI) requiring immediate coronary angiography. We present a case of de Winter syndrome, where, after successful revascularisation, the patient's ECG proceeded to Wellens syndrome while he complained of atypical chest pain. Follow-up coronary angiography showed good results, so possibly the Wellens ECG pattern here might indicate myocardial reperfusion. © EMH Schweizerischer Arzteverlag AG. All Rights Reserved.

Froidevaux, Laurent, Sarasin, Franois P., Hugli, Olivier, Sztajzel, Juan M., Schlpfer, Jrg, Varcher-Herrera, Monica, Graz, Johan, Berchier, Christophe, Mischler, Corinne, and Pruvot, Etienne. “Patients With Syncope Remaining Unexplained After A Structured Work-Up Share The Characteristics Of Patients With Neurally Mediated Syncope”. Cardiovascular Medicine 23, no. 2. doi:10.4414/cvm.2020.02098.

Abstract: Syncope is a common symptom in emergency department visits and, despite extensive evaluation, still remains unexplained in a significant number of cases. Our study compared the clinical characteristics of patients with syncope of unexplained aetiology (SUA) with those of patients with other causes of syncope after the application of a standardised work-up. Recurrence and death rates were also evaluated at one year. We found that patients with SUA shared most of the clinical and paraclinical characteristics of patients with neurally mediated syncope. During followup, recurrences occurred essentially in the SUA group. These findings support the concept that patients with SUA suffer from some form of neurally mediated syncope. © EMH Schweizerischer Arzteverlag AG. All Rights Reserved.

Falk, M., Brugger, H., Bouzat, P., Pasquier, M., Mair, P., Fieler, J., Darocha, T., et al. “Data And Methods To Calculate Cut-Off Values For Serum Potassium And Core Temperature At Hospital Admission For Extracorporeal Rewarming Of Avalanche Victims In Cardiac Arrest”. Data Brief 28: 104913. doi:10.1016/j.dib.2019.104913.

Abstract: The data and estimation methods presented in this article are associated with the research article, "Cut-off values of serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest: a retrospective multi-centre study" [1]. In this article we estimate recommended cut-off values for in-hospital triage with respect to extracorporeal rewarming. With only 6 survivors of 103 patients collected over a period of 20 years the ability to estimate reliable threshold values is limited. In addition, because the number of avalanche victims is also limited, a significantly larger dataset is unlikely to be obtained. We have therefore adapted two non-parametric estimation methods (bootstrapping and exact binomial distribution) to our specific needs and performed a simulations to confirm validity and reliability.

Tags: Accidental hypothermia, Avalanche, Core temperature, Cut-off value, Extracorporeal life support, Serum potassium, Triage.

Clase, C. M., Carrero, J. J., Ellison, D. H., Grams, M. E., Hemmelgarn, B. R., Jardine, M. J., Kovesdy, C. P., et al. “Potassium Homeostasis And Management Of Dyskalemia In Kidney Diseases: Conclusions From A Kidney Disease: Improving Global Outcomes (Kdigo) Controversies Conference”. In, 97:42-61, 2020. doi:10.1016/j.kint.2019.09.018.

Abstract: Potassium disorders are common in patients with kidney disease, particularly in patients with tubular disorders and low glomerular filtration rate. A multidisciplinary group of researchers and clinicians met in October 2018 to identify evidence and address controversies in potassium management. The issues discussed encompassed our latest understanding of the regulation of tubular potassium excretion in health and disease; the relationship of potassium intake to cardiovascular and kidney outcomes, with increasing evidence showing beneficial associations with plant-based diet and data to suggest a paradigm shift from the idea of dietary restriction toward fostering patterns of eating that are associated with better outcomes; the paucity of data on the effect of dietary modification in restoring abnormal serum potassium to the normal range; a novel diagnostic algorithm for hypokalemia that takes into account the ascendency of the clinical context in determining cause, aligning the educational strategy with a practical approach to diagnosis; and therapeutic approaches in managing hyperkalemia when chronic and in the emergency or hospital ward. In sum, we provide here our conference deliberations on potassium homeostasis in health and disease, guidance for evaluation and management of dyskalemias in the context of kidney diseases, and research priorities in each of the above areas. © 2019 International Society of Nephrology

Christian, M., Corinna, S., Monika, B. M., and Jörg, M. T. “Sports-Psychiatry And Psychotherapy For Alpine Sports”. Sports &Amp; Exercise Medicine Switzerland 68, no. 3. doi:10.34045/sems/2020/24.

Abstract: Our group focusses on (A) prevention and therapy of acute stress reaction and PTSD after incidents in an alpine environment (B) education/prevention of PTSD in professional organisations covering alpine activities (C) prevention and treatment of eating disorders in professional and amateur sports and alpine climbers and (D) evaluation and thus prevention of suicides in alpine environment and counselling of alpine rescue services. © 2020 Sport and Exercise Medicine Switzerland Journal.

Swiss Emergency Research collection

2020

2019