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Swiss Emergency Research collection

2019

  • Errecaborde, K. M., Macy, K. W., Pekol, A., Perez, S., O'Brien, M. K., Allen, I., Contadini, F., et al. “Factors That Enable Effective One Health Collaborations - A Scoping Review Of The Literature”. Plos One 14, no. 12: e0224660. doi:10.1371/journal.pone.0224660.
    Abstract: Advocates for a One Health approach recognize that global health challenges require multidisciplinary collaborative efforts. While past publications have looked at interdisciplinary competency training for collaboration, few have identified the factors and conditions that enable operational One Health. Through a scoping review of the literature, a multidisciplinary team of researchers analyzed peer-reviewed publications describing multisectoral collaborations around infectious disease-related health events. The review identified 12 factors that support successful One Health collaborations and a coordinated response to health events across three levels: two individual factors (education & training and prior experience & existing relationships), four organizational factors (organizational structures, culture, human resources and, communication), and six network factors (network structures, relationships, leadership, management, available & accessible resources, political environment). The researchers also identified the stage of collaboration during which these factors were most critical, further organizing into starting condition or process-based factors. The research found that publications on multisectoral collaboration for health events do not uniformly report on successes or challenges of collaboration and rarely identify outputs or outcomes of the collaborative process. This paper proposes a common language and framework to enable more uniform reporting, implementation, and evaluation of future One Health collaborations.
    Tags: *Communication, *Cooperative Behavior, *Leadership, *Organizations, *Public Health, Humans, One Health/*standards, Research Personnel, Social Behavior.
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  • Boillat, T., Siebert, J. N., Alduaij, N., and Ehrler, F. “Goflow: Smartwatch App To Deliver Laboratory Results In Emergency Departments - A Feasibility Study”. Int J Med Inform 134: 104034. doi:10.1016/j.ijmedinf.2019.104034.
    Abstract: PURPOSE: Information Technology (IT) plays a critical role in supporting emergency physicians' (EPs) routines. Pagers, personal computers, and smartphones offer fast access to patient data, such as laboratory results. However, due to the inherent features of specimen processing and laboratory instruments, the turnaround time from test ordering to availability of results can be long. Lack of follow-up of abnormal results can lead to missed information that could impact patient care and safety. Despite the increasing use of ubiquitous technologies, a third of physicians remains devoid of reliable methods for ensuring that results have been received. In this feasibility study, we report the potential of using a smartwatch to deliver laboratory results to EPs at the point-of-care and to support efficiency in emergency care. Unlike mobile devices that are increasingly used by EPs, smartwatches are always accessible, even during hands-on procedures. METHOD: Two EPs and four experts in human-computer interaction designed the smartwatch application following the Design Science Research Methodology (DSRM). The application was then evaluated in a pediatric emergency department through semi-simulated scenarios by eleven EPs. The primary outcome was to measure both the app perceived usability and satisfaction scores by the aim of the System Usability Scale (SUS), and the perceived usefulness and intention of its use by the aim of the Unified Theory of Acceptance and Use of Technology (UTAUT) scale. Secondary outcomes were to assess the application's efficiency by measuring the delay between the reception of the notification and 1) the access to its details and 2) the visit to the patient. Finally, open questions about the positive and negative aspects of the prototype as well as potential improvements were asked and evaluated qualitatively. RESULTS: The prototype obtained a score of 81.4 out of 100 (good) on the SUS and a score of 5.96 out of 7 on the UTAUT scale. EPs using the smartwatch visited patients within 30 seconds receiving the laboratory results. CONCLUSIONS: This study demonstrates the capacity of smartwatches to speed up the point-of-care delivery of laboratory results in the ED.
    Tags: Adult, Delivery of Health Care/*standards, Emergency department, Emergency Service, Hospital/*statistics & numerical data, Feasibility Studies, Female, Humans, Laboratories/*supply & distribution, Laboratory result delivery, Male, Physicians/psychology/*statistics & numerical data, Point-of-Care Systems/*standards, Smartphone/*statistics & numerical data, Smartwatch, Usability, Young Adult.
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  • Berlin, C., Techel, F., Moor, B. K., Zwahlen, M., Hasler, R. M., and Swiss National Cohort study, group. “Snow Avalanche Deaths In Switzerland From 1995 To 2014-Results Of A Nation-Wide Linkage Study”. Plos One 14, no. 12: e0225735. doi:10.1371/journal.pone.0225735.
    Abstract: OBJECTIVES: More than 20 people die each year in snow avalanches in Switzerland. Previous studies have primarily described these victims, but were not population based. We investigated sociodemographic factors for avalanche mortality between 1995 and 2014 in the entire Swiss resident population. DESIGN AND METHODS: Within the Swiss National Cohort we ascertained avalanche deaths by anonymous data linkage with the avalanche accident database at the Swiss WSL Institute of Snow and Avalanche Research SLF. We calculated incidence rates, by dividing the number of deaths from avalanches by the number of person-years, and hazard ratios (HRs) for sociodemographic and economic characteristics using Cox proportional hazard models. RESULTS: The data linkage yielded 250 deaths from avalanche within the SNC population for the 20 years 1995 to 2014. The median distance between the place of residence and the place of the event (avalanche) was 61.1 km. Male gender, younger age (15-45 years), Swiss nationality, living in the Alpine regions, higher education, living in the highest socioeconomic quintile of neighbourhoods, being single, and living in a household with one or more children were associated with higher avalanche mortality rates. Furthermore, for younger persons (<40 years) the hazard of dying in an avalanche between 2005 and 2014 was significantly lower than in the years 1995 to 2004 (HR = 0.56, 95%-CI: 0.36-0.85). CONCLUSION: Over a 20-year period in Switzerland, higher rates of dying in an avalanche were observed in men, in younger age groups, and persons with tertiary education, living in the highest socioeconomic quintile of neighbourhoods, and living in an Alpine region. For younger persons (<40 years), the hazard declined during the study period.
    Tags: *Avalanches, *Death, *Snow, Adolescent, Adult, Cohort Studies, Female, Geography, Humans, Male, Proportional Hazards Models, Switzerland/epidemiology, Young Adult.
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  • Ringwald, M., Crich, A., and Beysard, N. “Smart Watch Recording Of Ventricular Tachycardia: Case Study”. Am J Emerg Med 38, no. 4: 849 e3-849 e5. doi:10.1016/j.ajem.2019.10.040.
    Abstract: Smartphones and connected devices allow patients to monitor their health in a variety of ways. We report the case of a patient presenting to the emergency department complaining of palpitations and syncope. Standard investigations were unremarkable. However, an electrocardiogram recorded through his Apple Watch(R) indicated ventricular tachycardia. This case highlights the importance of proactively requesting such information from patients, though normal recordings may not preclude cardiac arrhythmia. Controlled clinical studies are needed to validate such practices.
    Tags: *Emergency Service, Hospital, *Smartphone, Cardiac arrhythmia, Electrocardiography, Humans, Male, Middle Aged, Monitoring, Ambulatory/instrumentation/methods, Smart watch, Syncope, Tachycardia, Ventricular/*diagnosis, Ventricular tachycardia.
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  • Doulberis, M., Papaefthymiou, A., Kountouras, J., Polyzos, S. A., Srivastava, S., Klokowska-Roetzler, J., Perrig, M., Papoutsi, S., Exadaktylos, AKappa, and Srivastava, D. S. “Vitamin D Deficiency And Unclear Abdominal Pain In Patients From Low- And Middle-Income Countries”. Int J Environ Res Public Health 16, no. 23. doi:10.3390/ijerph16234607.
    Abstract: Background: Abdominal pain is one of the commonest symptoms in emergency departments (EDs). Diagnosis demands full attention and critical thinking, since many diseases manifest atypically and the consequences of overlooking the symptoms may be disastrous. Despite intensive diagnostic procedures, some cases remain elusive and unclear abdominal pain (UAP) is not infrequent. Emerging evidence supports the hypothesis that functional pain might be attributed to vitamin D deficiency (VDD). People with darker or covered skin are predisposed to developing VDD. Patients in Switzerland stemming from low- and middle-income countries (LMIC) are such a population. Aim: To identify cases with UAP in LMIC patients and to compare vitamin D status with a control group. Methods: A retrospective single-center case-control study was carried out from 1 January 2013 to 31 August 2016 in all adult patients (more than 16 years old) stemming from LMIC and presenting at the university ED of Bern with abdominal pain. Vitamin D status was retrieved from these cases when available. The control group consisted of patients without abdominal pain or metabolic diseases and was matched (1:1) to the cases for age, gender, body mass index, geographic distribution, and season of vitamin D estimation. Results: A total of 10,308 cases from LMIC were reported to the ED. In total, 223 cases were identified with UAP. The status of vitamin D was available for 27 patients; 27 matched individuals were subsequently retrieved for the control group. Women made up 56.7% of the UAP group and 43.3% of the control group. The most common origin of the LMIC subjects was southern Europe (20.4%), followed by southern Asia (16.7%) and Eastern Europe (13%). Fourteen UAP patients exhibited severe VDD (< 25 nmol/L) versus one in the control group (p = 0.001). The difference remained significant if the patients were identified as having VDD (<50 nmol/L) or not (p = 0.024). Comparison of the means indicated that the UAP group had lower vitamin D levels than the control group (41.3 vs. 53.7 nmol/L, respectively), but this difference was marginal (p = 0.060) and not statistically significant. After adjustment for potential confounders, including gender, mean vitamin D levels remained non-significantly different between groups. In the sub-group analysis, vitamin D levels were lower in women than in men (p = 0.037), compared to the respective controls. Conclusion: This study showed for the first time that patients from LMIC who presented to ED with UAP displayed VDD. Validation from larger studies is warranted to evaluate the linkage of VDD with UAP.
    Tags: *Developing Countries, abdominal pain, Abdominal Pain/*etiology, Adolescent, Adult, Aged, Aged, 80 and over, Asia/epidemiology, Case-Control Studies, emergency department, Europe/epidemiology, Female, Global Health, Humans, irritable bowel syndrome (IBS)1. Introduction, low income, Male, Middle Aged, middle income, migrants, Retrospective Studies, vitamin D, Vitamin D Deficiency/*complications/diagnosis/epidemiology, Young Adult.
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  • Correia, J. C., Lachat, S., Lagger, G., Chappuis, F., Golay, A., Beran, D., and Project, Cohesion. “Interventions Targeting Hypertension And Diabetes Mellitus At Community And Primary Healthcare Level In Low- And Middle-Income Countries:a Scoping Review”. Bmc Public Health 19, no. 1: 1542. doi:10.1186/s12889-019-7842-6.
    Abstract: BACKGROUND: Hypertension (HTN) and diabetes mellitus (DM) are highly prevalent in low- and middle-income countries (LMIC) and a leading cause of morbidity and mortality. Recent evidence on effectiveness of primary care interventions has attracted renewed calls for their implementation. This review aims to synthesize evidence pertaining to primary care interventions on these two diseases, evaluated and tested in LMICs. METHODS: Two reviewers conducted an electronic search of three databases (Pubmed, EMBASE and Web of Science) and screened for eligible articles. Interventions covering health promotion, prevention, treatment, or rehabilitation activities at the PHC or community level were included. Studies published in English, French, Portuguese and Spanish, from January 2007 to January 2017, were included. Key extraction variables included the 12 criteria identified by the Template for Intervention Description and Replication (TIDieR) checklist and guide. The Innovative Care for Chronic Conditions Framework (ICCCF) was used to guide analysis and reporting of results. RESULTS: 198 articles were analyzed. The strategies focused on healthcare service organization (76.5%), community level (9.7 %), creating a positive policy environment (3.6%) and strategies covering multiple domains (10.2%). Studies included related to the following topics: description or testing of interventions (n=81; 41.3%), implementation or evaluation projects (n=42; 21.4%), quality improvement initiatives (n=15; 7.7%), screening and prevention efforts (n=26; 13.2%), management of HTN or DM (n=13; 6.6%), integrated health services (n=10; 5.1%), knowledge and attitude surveys (n=5; 2.5%), cost-effective lab tests (n=2; 1%) and policy making efforts (n=2; 1%). Most studies reported interventions by non-specialists (n=86; 43.4%) and multidisciplinary teams (n=49; 25.5%). CONCLUSION: Only 198 articles were found over a 10 year period which demonstrates the limited published research on highly prevalent diseases in LMIC. This review shows the variety and complexity of approaches that have been tested to address HTN and DM in LMICs and highlights the elements of interventions needed to be addressed in order to strengthen delivery of care. Most studies reported little information regarding implementation processes to allow replication. Given the need for multi-component complex interventions, study designs and evaluation techniques will need to be adapted by including process evaluations versus simply effectiveness or outcome evaluations.
    Tags: Community Health Services/*statistics & numerical data, Developing Countries/*statistics & numerical data, diabetes, Diabetes Mellitus/*prevention & control, Humans, hypertension, Hypertension/*prevention & control, low- and middle-income countries, non-communicable diseases, primary health care, Primary Health Care/*statistics & numerical data, Randomized Controlled Trials as Topic.
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  • Schmid, Y., Scholz, I., Mueller, L., Exadaktylos, A. K., Ceschi, A., Liechti, M. E., and Liakoni, E. “Emergency Department Presentations Related To Acute Toxicity Following Recreational Use Of Cannabis Products In Switzerland”. Drug Alcohol Depend 206: 107726. doi:10.1016/j.drugalcdep.2019.107726.
    Abstract: BACKGROUND: Concomitant use of cannabis and other psychoactive substances is common and it is often difficult to differentiate its acute effects from those of other substances. This study aimed to characterize the acute toxicity of cannabis with and without co-use of other substances. METHODS: Retrospective analysis of cases presenting at the emergency departments of three large hospitals in Switzerland due to acute toxicity related to cannabis recreational use. RESULTS: Among 717 attendances related to acute cannabis toxicity, 186 (26 %) were due to use of cannabis alone. The median patient age was 26 years (range 14-68), and 73 % were male. Commonly reported symptoms/signs in lone-cannabis cases included nausea/vomiting (26 %), palpitations (25 %), anxiety (23 %), and chest pain (15 %); there were no fatalities and most intoxications were of minor severity (61 %). Most patients (83 %) using cannabis alone were discharged from the emergency department, 8 % were referred to psychiatric, and two (1 %) to the intensive care; severe complications included psychosis (7 %), coma (6 %), and seizures (5 %) and one patient (<1 %) required intubation. Lone-cannabis patients presented more often with palpitations, anxiety, panic attacks, and chest pain than patients in the co-use group, whereas the latter presented more often with impaired consciousness, agitation, respiratory depression and hallucinations, and were more often admitted to psychiatric or intensive care. CONCLUSION: Intoxication with cannabis alone was mostly associated with minor toxicity. Nevertheless, severe complications and cases requiring admission to intensive or psychiatric care were also reported, which indicates that intoxication with cannabis alone does not exclude considerable health risks.
    Tags: Acute toxicity, Adolescent, Adult, Aged, Cannabis, Cannabis/*toxicity, Emergency department, Emergency Service, Hospital/*statistics & numerical data, Female, Hospitalization/*statistics & numerical data, Humans, Male, Marijuana Use/*adverse effects/epidemiology, Middle Aged, Recreational use, Retrospective Studies, Switzerland/epidemiology, Thc, Young Adult.
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  • Rotzinger, D. C., Dunet, V., Ilic, V., Hugli, O. W., Meuli, R. A., and Schmidt, S. “Pulmonary Embolism During Pregnancy: A 17-Year Single-Center Retrospective Mdct Pulmonary Angiography Study”. Eur Radiol 30, no. 3: 1780-1789. doi:10.1007/s00330-019-06501-4.
    Abstract: OBJECTIVES: To determine the prevalence of pulmonary embolism (PE) and alternative diagnoses detected by computed tomography pulmonary angiography (CTPA) in pregnant women; and to assess changes over time regarding radiation dose, technical quality, and examination frequency. MATERIALS AND METHODS: This retrospective study included all pregnant women referred for CTPA due to clinically suspected PE over 17 years. Two blinded radiologists reviewed the CTPAs in consensus with regard to PE, alternative diagnoses, and technical quality. We retrieved patient data regarding radiation dose metrics and associated clinical and laboratory parameters. Subgroup comparisons were performed (Wilcoxon and Kruskal-Wallis tests). RESULTS: Of the 237 identified patients, 8 (3.3%) were excluded due to inadequate technical CTPA quality, and 229 patients were analyzed (mean age, 31.7 years; mean gestational age, 28 +/- 7 weeks). The four different CT systems used over the study period had similar technical quality (p = 0.28). Of 229 patients 16 (7%) patients had PE, 144 (62.9%) had no abnormal findings, and 69 (30.1%) had an alternative diagnosis (consolidation, other pulmonary opacities, pleural effusion, and basal atelectasis). Gestational age, symptoms, and D-dimer levels were not significantly different between patients with or without PE (p > 0.05). Over time, radiation dose exposure decreased by 30% (p < 0.001), while the number of annual examinations increased by > 4-folds. CONCLUSIONS: In pregnant women, CTPA rarely indicates PE and more often shows alternative diagnoses. Over 17 years, the use of CTPA in pregnancy has notably increased, while the radiation dose exposure has decreased by one third. KEY POINTS: * The use of CTPA in pregnancy has steadily risen over the last 17 years * In pregnant women, CTPA rarely reveals PE and more often shows alternative diagnoses * Recent technical improvements have substantially decreased the radiation dose exposure inherent in CTPA without reducing diagnostic image quality.
    Tags: Adolescent, Adult, Computed tomography angiography, Computed Tomography Angiography/*methods, Female, Hematologic pregnancy complications, Humans, Middle Aged, Multidetector computed tomography, Multidetector Computed Tomography/*methods, Pregnancy, Pregnancy Complications, Cardiovascular/*diagnosis, products or services may be related to the subject matter of the article., Pulmonary Artery/*diagnostic imaging, Pulmonary embolism, Pulmonary Embolism/*diagnosis, Radiation Exposure, Retrospective Studies, Young Adult.
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  • Harjola, P., Miro, O., Martin-Sanchez, F. J., Escalada, X., Freund, Y., Penaloza, A., Christ, M., et al. “Pre-Hospital Management Protocols And Perceived Difficulty In Diagnosing Acute Heart Failure”. Esc Heart Fail 7, no. 1: 289-296. doi:10.1002/ehf2.12524.
    Abstract: AIM: To illustrate the pre-hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre-hospital conditions. METHODS AND RESULTS: A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre-hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated. Ultrasound devices and point-of-care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST-elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12-lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point-of-care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non-invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST-elevation myocardial infarction, asthma, and stroke. CONCLUSIONS: The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre-hospital conditions.
    Tags: Acute Disease, Acute heart failure, Dispatching centre, Electrocardiography, Emergency care, Emergency medical services, Emergency Medical Services/*methods, Europe/epidemiology, Follow-Up Studies, Heart Failure/diagnosis/mortality/*therapy, Hospital Mortality/trends, Humans, Pre-hospital, Retrospective Studies, Risk Assessment/*methods, Risk Factors, Surveys and Questionnaires, Survival Rate/trends.
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  • Schwitzguebel, A. J., Jeckelmann, C., Gavinio, R., Levallois, C., Benaim, C., and Spechbach, H. “Differential Diagnosis Assessment In Ambulatory Care With An Automated Medical History-Taking Device: Pilot Randomized Controlled Trial”. Jmir Med Inform 7, no. 4: e14044. doi:10.2196/14044.
    Abstract: BACKGROUND: Automated medical history-taking devices (AMHTDs) are emerging tools with the potential to increase the quality of medical consultations by providing physicians with an exhaustive, high-quality, standardized anamnesis and differential diagnosis. OBJECTIVE: This study aimed to assess the effectiveness of an AMHTD to obtain an accurate differential diagnosis in an outpatient service. METHODS: We conducted a pilot randomized controlled trial involving 59 patients presenting to an emergency outpatient unit and suffering from various conditions affecting the limbs, the back, and the chest wall. Resident physicians were randomized into 2 groups, one assisted by the AMHTD and one without access to the device. For each patient, physicians were asked to establish an exhaustive differential diagnosis based on the anamnesis and clinical examination. In the intervention group, residents read the AMHTD report before performing the anamnesis. In both the groups, a senior physician had to establish a differential diagnosis, considered as the gold standard, independent of the resident's opinion and AMHTD report. RESULTS: A total of 29 patients were included in the intervention group and 30 in the control group. Differential diagnosis accuracy was higher in the intervention group (mean 75%, SD 26%) than in the control group (mean 59%, SD 31%; P=.01). Subgroup analysis showed a between-group difference of 3% (83% [17/21]-80% [14/17]) for low complexity cases (1-2 differential diagnoses possible) in favor of the AMHTD (P=.76), 31% (87% [13/15]-56% [18/33]) for intermediate complexity (3 differential diagnoses; P=.02), and 24% (63% [34/54]-39% [14/35]) for high complexity (4-5 differential diagnoses; P=.08). Physicians in the intervention group (mean 4.3, SD 2) had more years of clinical practice compared with the control group (mean 5.5, SD 2; P=.03). Differential diagnosis accuracy was negatively correlated to case complexity (r=0.41; P=.001) and the residents' years of practice (r=0.04; P=.72). The AMHTD was able to determine 73% (SD 30%) of correct differential diagnoses. Patient satisfaction was good (4.3/5), and 26 of 29 patients (90%) considered that they were able to accurately describe their symptomatology. In 8 of 29 cases (28%), residents considered that the AMHTD helped to establish the differential diagnosis. CONCLUSIONS: The AMHTD allowed physicians to make more accurate differential diagnoses, particularly in complex cases. This could be explained not only by the ability of the AMHTD to make the right diagnoses, but also by the exhaustive anamnesis provided.
    Tags: analyses were the responsibility of CL and CB, with the support of Angele, clinical applications software, computer-assisted, decision making, differential diagnosis, Gayet-Ageron., general practitioners, hospital outpatient clinics, interest as much as possible, the choice of the study design and the statistical, liability company that owns the DIAANA AMHTD. To decrease any conflicts of, patient engagement.
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  • Eschler, C. M., Woitok, B. K., Funk, G. C., Walter, P., Maier, V., Exadaktylos, A. K., and Lindner, G. “Oral Anticoagulation In Patients In The Emergency Department: High Rates Of Off-Label Doses, No Difference In Bleeding Rates”. Am J Med 133, no. 5: 599-604. doi:10.1016/j.amjmed.2019.09.026.
    Abstract: BACKGROUND: Empirically, a significant proportion of patients using direct oral anticoagulation (DOAC) take off-label reduced doses. We aimed to investigate the prevalence, indications, dosages, and bleeding complications of oral anticoagulants on admission to the emergency department. METHODS: In this retrospective analysis, patients presenting to our emergency department between January 1 and December 31, 2018, with therapeutic oral anticoagulation were included (ie, vitamin-K antagonists, rivaroxaban, apixaban, edoxaban, and dabigatran). A detailed chart review was performed for each case concerning characteristics, indication, and bleeding complications. RESULTS: A total of 19,662 consecutive cases in the emergency department were reported: 1721 (9%) had therapeutic oral anticoagulation. Vitamin-K antagonists (41%), rivaroxaban (36%), and apixaban (19%) were the most common. Stroke prophylaxis in patients with atrial fibrillation (63.2%) and venous thromboembolism (24.1%) were the most common indications. In 27 cases (1.6%), no indication could be identified; further, 32% of patients were classified to have either off-label doses of DOACs or an international normalized ratio (INR) out of range (in vitamin-K antagonists), whereas 20% were classified as off-label underdosed and 12% as overdosed. No difference in the likelihood of bleeding on admission could be found between the respective drugs. Only concomitant use of aspirin was significantly associated with presence and higher severity of bleeding. CONCLUSIONS: Vitamin-K antagonists are still the most widely used drug followed by rivaroxaban. A significant proportion of patients are being prescribed off label-doses. While no difference was found for the respective anticoagulants with respect to bleeding, concomitant aspirin use was a significant predictor for bleeding in our collective.
    Tags: Administration, Oral, Aged, Anticoagulants/administration & dosage/*adverse effects/therapeutic use, Anticoagulation, Atrial Fibrillation/drug therapy, Bleeding, Dabigatran/administration & dosage/adverse effects, Dosage, Emergency, Emergency Service, Hospital/*statistics & numerical data, Female, Hemorrhage/*chemically induced/epidemiology, Humans, Male, Off-Label Use/*statistics & numerical data, Pyrazoles/administration & dosage/adverse effects, Pyridines/administration & dosage/adverse effects, Pyridones/administration & dosage/adverse effects, Retrospective Studies, Rivaroxaban/administration & dosage/adverse effects, Stroke/prevention & control, Thiazoles/administration & dosage/adverse effects, Vitamin K/antagonists & inhibitors.
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  • Bajwa, N. M., Nendaz, M. R., Galetto-Lacour, A., Posfay-Barbe, K., Yudkowsky, R., and Park, Y. S. “Can Professionalism Mini-Evaluation Exercise Scores Predict Medical Residency Performance? Validity Evidence Across Five Longitudinal Cohorts”. In, 94:S57-S63, 2019. doi:10.1097/ACM.0000000000002895.
    Abstract: Purpose The residency admissions process is a high-stakes assessment system with the purpose of identifying applicants who best meet standards of the residency program and the medical specialty. Prior studies have found that professionalism issues contribute significantly to residents in difficulty during training. This study examines the reliability (internal structure) and predictive (relations to other variables) validity evidence for a standardized patient (SP)-based Professionalism Mini-Evaluation Exercise (P-MEX) using longitudinal data from pediatrics candidates from admission to the end of the first year of postgraduate training. Method Data from 5 cohorts from 2012 to 2016 (195 invited applicants) were analyzed from the University of Geneva (Switzerland) Pediatrics Residency Program. Generalizability theory was used to examine the reliability and variance components of the P-MEX scores, gathered across 3 cases. Correlations and mixed-effects regression analyses were used to examine the predictive utility of SP-based P-MEX scores (gathered as part of the admissions process) with rotation evaluation scores (obtained during the first year of residency). Results Generalizability was moderate (G coefficient = 0.52). Regression analyses predicting P-MEX scores to first-year rotation evaluations indicated significant standardized effect sizes for attitude and personality (β = 0.36, P = .02), global evaluation (β = 0.27, P = .048), and total evaluation scores (β = 0.34, P = .04). Conclusions Validity evidence supports the use of P-MEX scores as part of the admissions process to assess professionalism. P-MEX scores provide a snapshot of an applicant’s level of professionalism and may predict performance during the first year of residency. Copyright © 2019 by the Association of American Medical Colleges.
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  • Van Der Linden, B. W. A., Sieber, S., Cheval, B., Orsholits, D., Guessous, I., Gabriel, R., Von Arx, M., et al. “Life-Course Circumstances And Frailty In Old Age Within Different European Welfare Regimes: A Longitudinal Study With Share”. J Gerontol B Psychol Sci Soc Sci 75, no. 6: 1326-1335. doi:10.1093/geronb/gbz140.
    Abstract: OBJECTIVES: This study aimed to assess whether cumulative disadvantage in childhood misfortune and adult-life socioeconomic conditions influence the risk of frailty in old age and whether welfare regimes influence these associations. METHOD: Data from 23,358 participants aged 50 years and older included in the longitudinal SHARE survey were used. Frailty was operationalized according to Fried's phenotype as presenting either weakness, shrinking, exhaustion, slowness, or low activity. Confounder-adjusted mixed-effects logistic regression models were used to analyze associations of childhood misfortune and life-course socioeconomic conditions with frailty. RESULTS: Childhood misfortune and poor adult-life socioeconomic conditions increased the odds of (pre-)frailty at older age. With aging, differences narrowed between categories of adverse childhood experiences (driven by Scandinavian welfare regime) and adverse childhood health experiences (driven by Eastern European welfare regime), but increased between categories of occupational position (driven by Bismarckian welfare regime). DISCUSSION: These findings suggest that childhood misfortune is linked to frailty in old age. Such a disadvantaged start in life does not seem to be compensated by a person's life-course socioeconomic trajectory, though certain types of welfare regimes affected this relationship. Apart from main occupational position, our findings do not support the cumulative dis/advantage theory, but rather show narrowing differences.
    Tags: *Adverse Childhood Experiences/economics/psychology/statistics & numerical data, *Frailty/diagnosis/epidemiology, *Quality of Life, *Social Welfare/classification/statistics & numerical data, Aged, Child Health, Childhood disadvantage, Employment, Europe/epidemiology, Female, Health outcomes, Health Status Disparities, Humans, Life Change Events, Longitudinal Studies, Male, Socioeconomic Factors, Socioeconomic status, Successful aging.
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  • Meyer Sauteur, P. M., Krautter, S., Ambroggio, L., Seiler, M., Paioni, P., Relly, C., Capaul, R., et al. “Improved Diagnostics Help To Identify Clinical Features And Biomarkers That Predict Mycoplasma Pneumoniae Community-Acquired Pneumonia In Children”. Clin Infect Dis 71, no. 7: 1645-1654. doi:10.1093/cid/ciz1059.
    Abstract: BACKGROUND: There are no reliable signs or symptoms that differentiate Mycoplasma pneumoniae (Mp) infection in community-acquired pneumonia (CAP) from other etiologies. Additionally, current diagnostic tests do not reliably distinguish between Mp infection and carriage. We previously determined that the measurement of Mp-specific immunoglobulin M antibody-secreting cells (ASCs) by enzyme-linked immunospot assay allowed for differentiation between infection and carriage. Using this new diagnostic test, we aimed to identify clinical and laboratory features associated with Mp infection. METHODS: This is a prospective cohort study of children, 3-18 years of age, with CAP from 2016 to 2017. Clinical features and biomarkers were compared between Mp-positive and -negative groups by Mann-Whitney U test or Fisher exact test, as appropriate. Area under the receiver operating characteristic curve (AUC) differences and optimal thresholds were determined by using the DeLong test and Youden J statistic, respectively. RESULTS: Of 63 CAP patients, 29 were Mp-positive (46%). Mp positivity was statistically associated with older age (median, 8.6 vs 4.7 years), no underlying disease, family with respiratory symptoms, prior antibiotic treatment, prolonged prodromal respiratory symptoms and fever, and extrapulmonary (skin) manifestations. Lower levels of C-reactive protein, white blood cell count, absolute neutrophil count, and procalcitonin (PCT), specifically PCT <0.25 mug/L, were statistically associated with Mp infection. A combination of age >5 years (AUC = 0.77), prodromal fever and respiratory symptoms >6 days (AUC = 0.79), and PCT <0.25 mug/L (AUC = 0.81) improved diagnostic performance (AUC = 0.90) (P = .05). CONCLUSIONS: A combination of clinical features and biomarkers may aid physicians in identifying patients at high risk for Mp CAP.
    Tags: *Community-Acquired Infections/diagnosis, *Pneumonia, Mycoplasma/diagnosis, Aged, antibiotics, Biomarkers, C-reactive protein, Child, Child, Preschool, diagnosis, Diagnostic Tests, Routine, Humans, Mycoplasma pneumoniae, procalcitonin, Prospective Studies, treatment.
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  • Peters, D. H., Hanssen, O., Gutierrez, J., Abrahams, J., and Nyenswah, T. “Financing Common Goods For Health: Core Government Functions In Health Emergency And Disaster Risk Management”. Health Syst Reform 5, no. 4: 307-321. doi:10.1080/23288604.2019.1660104.
    Abstract: In the absence of good data on the costs and comparative benefits from investing in health emergency and disaster risk management (EDRM), governments have been reluctant to invest adequately in systems to reduce the risks and consequences of emergencies and disasters. Yet they spend heavily on their response. We describe a set of key functional areas for investment and action in health EDRM, and calculate the costs needed to establish and operate basic health EDRM services in low- and middle-income countries, focusing on management of epidemics and disasters from natural hazards.We find that health EDRM costs are affordable for most governments. They range from an additional 4.33 USD capital and 4.16 USD annual recurrent costs per capita in low-income countries to 1.35 USD capital to 1.41 USD recurrent costs in upper middle-income countries. These costs pale in comparison to the costs of not acting-the direct and indirect costs of epidemics and other emergencies from natural hazards are more than 20-fold higher.We also examine options for the institutional arrangements needed to design and implement health EDRM. We discuss the need for creating adaptive institutions, strengthening capacities of countries, communities and health systems for managing risks of emergencies, using "all-of-society" and "all-of-state institutions" approaches, and applying lessons about rules and regulations, behavioral norms, and organizational structures to better implement health EDRM. The economic and social value, and the feasibility of institutional options for implementing health EDRM systems should compel governments to invest in these common goods for health that strengthen national health security.
    Tags: Civil Defense/*economics/methods, common goods for health, costing, emergency and disaster risk management, epidemic, Government Programs/economics/*standards/trends, Health Care Costs, health financing, Humans, institutional analysis, natural disaster, Risk Management/*economics/methods.
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  • Bingisser, R., and Nickel, C. H. “The Last Decade Of Symptom-Oriented Research In Emergency Medicine: Triage, Work-Up, And Disposition”. Swiss Med Wkly 149, no. 41-42: w20141. doi:10.4414/smw.2019.20141.
    Abstract: As a result of the ever-increasing use of imaging and clinical chemistry, symptom-oriented research has lost ground in many areas of clinical medicine. In emergency medicine, the importance of symptom-oriented research is obvious, as the three major tasks (triage, work-up and disposition) are still under-investigated. Scientific progress is closely linked to the analysis of readily available information, such as the patients&rsquo; symptoms. A decade ago, there were more questions than answers. Therefore, we describe the state of the evidence and the importance of symptoms for decisions at triage, during work-up and for disposition. Recent advances in each field focusing on symptoms as predictors of outcome and/or diagnosis are shown. Finally, future directions of research regarding novel triage tools, efficient work-up and evidence-based disposition are discussed. Symptom-oriented research has been a driver for medical progress for centuries, and re-focusing on patient-centred clinical research will strengthen this field in the future in order to support smarter medicine.
    Tags: *Emergency Medicine, *Symptom Assessment, *Triage, Emergency Service, Hospital, Evidence-Based Emergency Medicine, Humans, Research.
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  • van der Weide, L., Popal, Z., Terra, M., Schwarte, L. A., Ket, J. C. F., Kooij, F. O., Exadaktylos, A. K., Zuidema, W. P., and Giannakopoulos, G. F. “Prehospital Ultrasound In The Management Of Trauma Patients: Systematic Review Of The Literature”. Injury 50, no. 12: 2167-2175. doi:10.1016/j.injury.2019.09.034.
    Abstract: INTRODUCTION: Emergency ultrasound methods such as Focused Assessment with Sonography in Trauma (FAST) are a widely used imaging method. This examination can be performed to examine the presence of several life-threatening injuries. Early diagnosis may lead to better outcome, but the effect of timely diagnosis in the prehospital setting is not yet clear. Therefore, the aim is to determine the diagnostic accuracy and the effect of prehospital ultrasound performed in (poly)trauma patients. METHODS: A literature search was performed in PubMed, Embase and Cochrane's Library. Articles were included if prehospital ultrasound was performed as a diagnostic intervention in patients with trauma. The main outcome measures included diagnostic accuracy, changes in prehospital diagnosis/treatment, changes in destination hospital and in-hospital response. Case reports and case series were excluded. RESULTS: After screening 3343 articles, nine studies met the inclusion criteria. These included three retrospective and six prospective observational studies, with a total number of 2,889 patients. Five studies report at least one change in polytrauma management, ranging from 6% to 48,9% of the cases. The diagnostic accuracy of prehospital ultrasound was adequate in eight (out of nine) articles. High sensitivity and high specificity were found on several endpoints (pneumothorax, free abdominal fluid, haemoperitoneum, both on site and during transport). CONCLUSION: Prehospital ultrasound led to a change in polytrauma management in all studies that included this as an outcome measure. The diagnostic accuracy was described in eight studies, high sensitivity and specificity were found. Overall, the studies seem to suggest a positive influence of performing ultrasound. However, additional research with homogenous accuracy endpoints and uniformly trained prehospital care providers is recommended.
    Tags: Early Diagnosis, Emergency Medical Services/*methods, Focused assessment with sonography in trauma (FAST), Humans, Multiple Trauma/*diagnosis, Prehospital, Sensitivity and Specificity, Time-to-Treatment, Trauma patients, Ultrasonography/*methods, Ultrasound.
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  • Samer, C. F., Gloor, Y., Rollason, V., Guessous, I., Doffey-Lazeyras, F., Saurat, J. H., Sorg, O., Desmeules, J., and Daali, Y. “Cytochrome P450 1A2 Activity And Incidence Of Thyroid Disease And Cancer After Chronic Or Acute Exposure To Dioxins”. Basic Clin Pharmacol Toxicol 126, no. 3: 296-303. doi:10.1111/bcpt.13339.
    Abstract: BACKGROUND: Dioxin (2,3,7,8-tetrachlorodibenzo-p-dioxin; TCDD) is the most toxic congener of a family of structurally and mechanistically related persistent organic pollutants whose effects are mediated through the aryl hydrocarbon receptor (AhR). Induction of CYP1A1/2 by TCDD through the AhR depends on the magnitude and the duration of exposure. We aimed to assess CYP1A2 activity after acute and chronic exposure to TCDD. The Maincy cohort is a sample population from Melun in the Val-de-Seine region in France that lived for at least 5 years close to a waste incinerator emitting polluted vapours (1974-2002) with high concentrations of dioxins (up to 2000 times the maximal recommended values). Acute exposure to TCDD (Viktor Yushchenko) has been described elsewhere by Sorg et al (Toxicol. Sci. 2012; 125:310-317). Both are rare cases of well-identified source of chronic and acute exposure to TCDD. METHODS: All subjects underwent a full medical history and physical examination and had a cutaneous examination, and a retro-auricular skin biopsy was taken. A questionnaire was designed and used regarding demographic, personal, environmental and occupational characteristics. CYP1A2 activity was assessed 2 hours after the ingestion of a drink containing caffeine through measurement of the metabolic ratio of paraxanthine (17X) over caffeine (137X) by LC-MS/MS or LC-UV. CYP1A1 expression in skin biopsies was determined by immunohistochemical analysis. RESULTS: Forty-seven exposed subjects (age 11-78) and 31 controls were included in the study. Eleven exposed subjects had a history of thyroid disease (23.4%), and 7 (14.8%) had a cancer vs none and 1, respectively, in controls. Nodular skin lesions were found in 13 exposed subjects (27.7%) vs none in controls. Mean CYP1A2 activity of the exposed population was modestly elevated as compared to controls (17X/137X metabolic ratio of 0.475 vs 0.374, P = .051). CYP1A2 was, however, induced (17X/137X, metabolic ratio >0.5) in 27.6% of the exposed cases vs 6.4% of the controls. In contrast, acute dioxin exposure was associated with a strong induction (mean 17X/137X, metabolic ratio of 1.9) still present 29 months after the acute exposure. CYP1A1 was expressed in 59.6% of the skin biopsies (highly expressed in 31.9%) of the Maincy cohort. No correlation between CYP1A2 activity, CYP1A1 expression and clinical manifestations (thyroid disease, cancer, skin lesions) could be demonstrated. CONCLUSION: Higher frequencies of dysthyroidism and cancer were detected in the population exposed chronically to dioxins from a waste incinerator. CYP1A2 was induced in 27.6% of the exposed population, while the magnitude of induction was fourfold higher after acute exposure in the case of Yushchenko.
    Tags: Adolescent, Adult, Aged, cancer, Child, Cohort Studies, Cytochrome P-450 CYP1A1/metabolism, Cytochrome P-450 CYP1A2/*metabolism, cytochrome P450, dioxin, endocrine disruptor, Environmental Exposure/adverse effects, Environmental Pollutants/administration & dosage/toxicity, Female, France/epidemiology, Humans, Incidence, Male, Middle Aged, Neoplasms/*epidemiology, phenotyping, Polychlorinated Dibenzodioxins/administration & dosage/*toxicity, Surveys and Questionnaires, thyroid, Thyroid Diseases/*epidemiology, Young Adult.
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  • Stoto, M. A., Nelson, C., Piltch-Loeb, R., Mayigane, L. N., Copper, F., and Chungong, S. “Getting The Most From After Action Reviews To Improve Global Health Security”. Global Health 15, no. 1: 58. doi:10.1186/s12992-019-0500-z.
    Abstract: BACKGROUND: After Action Reviews (AARs) provide a means to observe how well preparedness systems perform in real world conditions and can help to identify - and address - gaps in national and global public health emergency preparedness (PHEP) systems. WHO has recently published guidance for voluntary AARs. This analysis builds on this guidance by reviewing evidence on the effectiveness of AARs as tools for system improvement and by summarizing some key lessons about ensuring that AARs result in meaningful learning from experience. RESULTS: Empirical evidence from a variety of fields suggests that AARs hold considerable promise as tools of system improvement for PHEP. Our review of the literature and practical experience demonstrates that AARs are most likely to result in meaningful learning if they focus on incidents that are selected for their learning value, involve an appropriately broad range of perspectives, are conducted with appropriate time for reflection, employ systems frameworks and rigorous tools such as facilitated lookbacks and root cause analysis, and strike a balance between attention to incident specifics vs. generalizable capacities and capabilities. CONCLUSIONS: Employing these practices requires a PHEP system that facilitates the preparation of insightful AARs, and more generally rewards learning. The barriers to AARs fall into two categories: concerns about the cultural sensitivity and context, liability, the political response, and national security; and constraints on staff time and the lack of experience and the requisite analytical skills. Ensuring that AARs fulfill their promise as tools of system improvement will require ongoing investment and a change in mindset. The first step should be to clarify that the goal of AARs is organizational learning, not placing blame or punishing poor performance. Based on experience in other fields, the buy-in of agency and political leadership is critical in this regard. National public health systems also need support in the form of toolkits, guides, and training, as well as research on AAR methods. An AAR registry could support organizational improvement through careful post-event analysis of systems' own events, facilitate identification and sharing of best practices across jurisdictions, and enable cross-case analyses.
    Tags: *Global Health, *Public Health, After action reports (AARs), After action reviews (AARs), Critical incident reviews, Disaster Planning/*organization & administration, Disease Outbreaks/*prevention & control, Humans, Public health emergencies, Public health preparedness, Systems improvement.
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  • Lollgen, R. M. “Visible Injuries, Unrecognized Truth - The Reality Of Intimate Partner Violence”. N Engl J Med 381, no. 15: 1408-1409. doi:10.1056/NEJMp1904164.
    Tags: *Denial, Psychological, Diagnosis, Education, Medical, Female, Humans, Intimate Partner Violence/*psychology.
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  • Ebrahimi, F., Widmer, A., Wagner, U., Mueller, B., Schuetz, P., Christ-Crain, M., and Kutz, A. “Association Of Adrenal Insufficiency With Patient-Oriented Health-Care Outcomes In Adult Medical Inpatients”. Eur J Endocrinol 181, no. 6: 701-709. doi:10.1530/EJE-19-0469.
    Abstract: OBJECTIVE: Adrenal insufficiency in the outpatient setting is associated with excess morbidity, mortality, and impaired quality of life. Evidence on its health-care burden in medical inpatients is scarce. The aim of this study was to assess the health-care burden of primary adrenal insufficiency (PAI) and secondary adrenal insufficiency (SAI) among hospitalized inpatients. DESIGN AND METHODS: In this nationwide cohort study, adult medical patients with either PAI or SAI hospitalized between 2011 and 2015 were compared with propensity-matched (1:1) medical controls, respectively. The primary outcome was 30-day all-cause in-hospital mortality. Main secondary outcomes included ICU admission rate, length-of-hospital stay, 30-day and 1-year all-cause readmission rates. RESULTS: In total, 594 hospitalized cases with PAI and 4880 cases with SAI were included. Compared with matched controls, in-hospital mortality was not increased among PAI or SAI patients, respectively. Patients with adrenal insufficiency were more likely to be admitted to ICU (PAI: OR 1.9 (95% CI, 1.27 to 2.72) and SAI: OR 1.5 (95% CI, 1.35 to 1.75)). Length of hospital stay was prolonged by 1.0 days in PAI patients (8.9 vs 7.9 days (95% CI, 0.06 to 1.93)), and by 3.3 days in SAI patients (12.1 vs 8.8 days (95% CI, 2.82 to 3.71)), when compared with matched controls. Patients with SAI were found to have higher 30-day and 1-year readmission rates (14.1 vs 12.1% and 50.0 vs 40.7%; P < 0.001) than matched controls. CONCLUSIONS: While no difference in in-hospital mortality was found, adrenal insufficiency was associated with prolonged length of hospital stay, and substantially higher rates of ICU admission and hospital readmission.
    Tags: Addison Disease/physiopathology, Adrenal Insufficiency/*physiopathology, Aged, Aged, 80 and over, Cohort Studies, Female, Hospital Mortality, Humans, Inpatients/statistics & numerical data, Intensive Care Units/statistics & numerical data, Length of Stay/statistics & numerical data, Male, Middle Aged, Patient Readmission/statistics & numerical data, Quality of Life.
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  • Nestelberger, T., Boeddinghaus, J., Greenslade, J., Parsonage, W. A., Than, M., Wussler, D., Lopez-Ayala, P., et al. “Two-Hour Algorithm For Rapid Triage Of Suspected Acute Myocardial Infarction Using A High-Sensitivity Cardiac Troponin I Assay”. Clin Chem 65, no. 11: 1437-1447. doi:10.1373/clinchem.2019.305193.
    Abstract: BACKGROUND: We aimed to derive and externally validate a 0/2-h algorithm using the high-sensitivity cardiac troponin I (hs-cTnI)-Access assay. METHODS: We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI) in 2 prospective diagnostic studies using central adjudication. Two independent cardiologists adjudicated the final diagnosis, including all available medical information including cardiac imaging. hs-cTnI-Access concentrations were measured at presentation and after 2 h in a blinded fashion. RESULTS: AMI was the adjudicated final diagnosis in 164 of 1131 (14.5%) patients in the derivation cohort. Rule-out by the hs-cTnI-Access 0/2-h algorithm was defined as 0-h hs-cTnI-Access concentration <4 ng/L in patients with an onset of chest pain >3 h (direct rule-out) or a 0-h hs-cTnI-Access concentration <5 ng/L and an absolute change within 2 h <5 ng/L in all other patients. Derived thresholds for rule-in were a 0-h hs-cTnI-Access concentration >/=50 ng/L (direct rule-in) or an absolute change within 2 h >/=20 ng/L. In the derivation cohort, these cutoffs ruled out 55% of patients with a negative predictive value (NPV) of 99.8% (95% CI, 99.3-100) and sensitivity of 99.4% (95% CI, 96.5-99.9), and ruled in 30% of patients with a positive predictive value (PPV) of 73% (95% CI, 66.1-79). In the validation cohort, AMI was the adjudicated final diagnosis in 88 of 1280 (6.9%) patients. These cutoffs ruled out 77.9% of patients with an NPV of 99.8% (95% CI, 99.3-100) and sensitivity of 97.7% (95% CI, 92.0-99.7), and ruled in 5.8% of patients with a PPV of 77% (95% CI, 65.8-86) in the validation cohort. CONCLUSIONS: Safety and efficacy of the l hs-cTnI-Access 0/2-h algorithm for triage toward rule-out or rule-in of AMI are very high. TRIAL REGISTRATION: APACE, NCT00470587; ADAPT, ACTRN1261100106994; IMPACT, ACTRN12611000206921.
    Tags: *Algorithms, *Triage, Acute Disease, Adult, Aged, Biological Assay/methods, Biomarkers/blood, Cohort Studies, Emergency Service, Hospital, Female, Humans, Male, Middle Aged, Myocardial Infarction/blood/*diagnosis, Predictive Value of Tests, Prospective Studies, Time Factors, Troponin I/*blood.
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  • Boeddinghaus, J., Twerenbold, R., Nestelberger, T., Koechlin, L., Wussler, D., Meier, M., Troester, V., et al. “Clinical Use Of A New High-Sensitivity Cardiac Troponin I Assay In Patients With Suspected Myocardial Infarction”. Clin Chem 65, no. 11: 1426-1436. doi:10.1373/clinchem.2019.304725.
    Abstract: BACKGROUND: We aimed to validate the clinical performance of the high-sensitivity cardiac troponin I [VITROS((R)) Immunodiagnostic Products hs Troponin I (hs-cTnI-VITROS)] assay. METHODS: We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI). Final diagnoses were centrally adjudicated by 2 independent cardiologists considering all clinical information, including cardiac imaging: first, using serial hs-cTnT-Elecsys (primary analysis) and, second, using hs-cTnI-Architect (secondary analysis) measurements in addition to the clinically used (hs)-cTn. hs-cTnI-VITROS was measured at presentation and at 1 h in a blinded fashion. The primary objective was direct comparison of diagnostic accuracy as quantified by the area under the ROC curve (AUC) of hs-cTnI-VITROS vs hs-cTnT-Elecsys and hs-cTnI-Architect, and in a subgroup also hs-cTnI-Centaur and hs-cTnI-Access. Secondary objectives included the derivation and validation of an hs-cTnI-VITROS-0/1-h algorithm. RESULTS: AMI was the adjudicated final diagnosis in 158 of 1231 (13%) patients. At presentation, the AUC for hs-cTnI-VITROS was 0.95 (95% CI, 0.93-0.96); for hs-cTnT-Elecsys, 0.94 (95% CI, 0.92-0.95); and for hs-cTnI-Architect, 0.92 (95% CI, 0.90-0.94). AUCs for hs-cTnI-Centaur and hs-cTnI-Access were 0.95 (95% CI, 0.94-0.97). Applying the derived hs-cTnI-VITROS-0/1-h algorithm (derivation cohort n = 519) to the validation cohort (n = 520), 53% of patients were ruled out [sensitivity, 100% (95% CI, 94.1-100)] and 14% of patients were ruled in [specificity, 95.6% (95% CI, 93.4-97.2)]. Patients ruled out by the 0/1-h algorithm had a survival rate of 99.8% at 30 days. Findings were confirmed in the secondary analyses using the adjudication including serial measurements of hs-cTnI-Architect. CONCLUSIONS: The hs-cTnI-VITROS assay has at least comparable diagnostic accuracy with the currently best validated hs-cTnT and hs-cTnI assays. CLINICALTRIALSGOV IDENTIFIER: NCT00470587.
    Tags: Aged, Aged, 80 and over, Area Under Curve, Biological Assay/*methods, Biomarkers/blood, Female, Humans, Limit of Detection, Male, Middle Aged, Myocardial Infarction/blood/*diagnosis, Prospective Studies, ROC Curve, Troponin I/*blood.
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  • Klenk, L., von Rutte, C., Henssler, J. F., Sauter, T. C., Hautz, W. E., Exadaktylos, A. K., and Muller, M. “Resource Consumption Of Multi-Substance Users In The Emergency Room: A Neglected Patient Group”. Plos One 14, no. 9: e0223118. doi:10.1371/journal.pone.0223118.
    Abstract: BACKGROUND: Multi-substance use is accompanied by increased morbidity and mortality and responsible for a large number of emergency department (ED) consultations. To improve the treatment for this vulnerable group of patients, it is important to quantify and break down in detail the ED resources used during the ED treatment of multi-substance users. METHODS: This retrospective single centre case-control study included all ED consultations of multi-substance users over a three-year study period at a university hospital in Switzerland. Resource consumption of these patients was compared to an age-matched control group of non-multi-substance users. RESULTS: The analysis includes 867 ED consultations of multi-substance users compared to 4,335 age-matched controls (5:1). Multi-substance users needed more total resources (median tax points [medical currency] (IQR): 762 (459-1226) vs. 462 (196-833), p<0.001), especially physician, radiology, and laboratory resources. This difference persisted in multivariable analysis (geometric mean ratio (GMR) 1.2, 95% CI: 1.1-1.3, p = 0.001) adjusted for sociodemographic parameters, consultation characteristics, and patient comorbidity; the GMR was highest in ED laboratory and radiology resource consumption. Among multi-substance user, indirect and non-drug-related consultations had higher ED resource consumption compared to drug-related consultations. Furthermore, leading discipline as well as urgency were predictors of ED resource consumption. Moreover, multi-substance users had more revisits (55.2% vs. 24.9%, p<0.001) as well as longer ED and in-hospital stays (both: GMR 1.2, 95% CI: 1.1-1.3, p<0.001). CONCLUSION: ED consultations of multi-substance users are expensive and resource intensive. Multi-substance users visited the ED more often and stayed longer at the ED and in-hospital. The findings of our study underline the importance of this patient group. Additional efforts should be made to improve their ED care. Special interventions should target this patient group in order to decrease the high frequency and costs of emergency consultations caused by multi-substance users.
    Tags: Adult, Drug Users/statistics & numerical data, Emergency Medical Services, Emergency Service, Hospital/economics/*statistics & numerical data, Female, Health Resources/*statistics & numerical data, Humans, Length of Stay/economics/statistics & numerical data, Male, Middle Aged, Patient Acceptance of Health Care/statistics & numerical data, Referral and Consultation/economics/*statistics & numerical data, Retrospective Studies, Substance-Related Disorders/*economics/therapy, Switzerland, Vulnerable Populations/*statistics & numerical data.
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  • Minotti, B., Batali, A. I., and Sieber, R. “Woman With Painful Bowel Movements”. Ann Emerg Med 74, no. 4: e77-e78. doi:10.1016/j.annemergmed.2019.03.039.
    Tags: Abdominal Pain/diagnostic imaging/*etiology, Anal Canal, Buttocks, Defecation/*physiology, Female, Humans, Middle Aged, Multimodal Imaging, Tarlov Cysts/complications/*diagnostic imaging, Tomography, X-Ray Computed, Ultrasonography.
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  • Goeldlin, M., Gaschen, J., Kammer, C., Comolli, L., Bernasconi, C. A., Spiegel, R., Bassetti, C. L., et al. “Frequency, Aetiology, And Impact Of Vestibular Symptoms In The Emergency Department: A Neglected Red Flag”. J Neurol 266, no. 12: 3076-3086. doi:10.1007/s00415-019-09525-4.
    Abstract: OBJECTIVE: We aimed to determine the incidence of all vestibular symptoms in a large interdisciplinary tertiary emergency department (ED) and to assess stroke prevalence, and frequency of other life-threatening aetiologies. METHODS: In this 1-year retrospective study, we manually screened all medical records of 23,608 ED visits for descriptions of vestibular symptoms. Symptoms were classified according to the International Classification of Vestibular Disorders of the Barany Society. We evaluated all patients older than 16 years in whom vestibular symptoms were the main or accompanying complaint. We extracted clinical, radiological, and laboratory findings as well as aetiologies from medical records. RESULTS: We identified a total of 2596 visits by 2464 patients (11% of ED visits) who reported at least one vestibular symptom. In 1677/2596 visits (64.6%), vestibular symptoms were the main reason for the ED consultation. Vestibular symptoms were classified as dizziness (43.8%), vertigo (33.9%), postural symptoms (6.5%), or more than one symptom (15.8%). In 324/2596 visits (12.5%), cerebrovascular events were the aetiology of vestibular symptoms, and in 355/2596 visits (13.7%), no diagnosis could be established. In 23.8% of visits with vestibular symptoms as the main complaint, the underlying condition was life-threatening. CONCLUSION: Frequency and impact of vestibular symptoms in patients visiting the ED were higher than previously reported, and life-threatening aetiologies such as strokes are common. Therefore, awareness among physicians regarding the importance of vestibular symptoms has to be improved.
    Tags: Adult, Aetiology, Aged, Cerebrovascular Disorders/*complications/*epidemiology, Dizziness/*epidemiology/*etiology, Emergency department, Emergency Service, Hospital/*statistics & numerical data, Female, Frequency, Humans, Impact, Incidence, Male, Middle Aged, Prevalence, Retrospective Studies, Stroke, Stroke/complications/epidemiology, Vertigo/epidemiology/etiology, Vestibular Diseases/*epidemiology/*etiology, Vestibular symptoms.
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  • Backer, H. C., Busko, M., Krause, F. G., Exadaktylos, A. K., Klukowska-Roetzler, J., and Deml, M. C. “Exertional Rhabdomyolysis And Causes Of Elevation Of Creatine Kinase”. Phys Sportsmed 48, no. 2: 179-185. doi:10.1080/00913847.2019.1669410.
    Abstract: Background: Rhabdomyolysis is a potentially fatal condition that can be triggered by a variety of inciting events, including excessive muscular exertion.The purpose of this study was to investigate the causes of creatine kinase elevation (CK>/=1000U/L) to determine what percentage result from exRML, the etiology, and kinetics of CK levels, as well as the complications of exRML and comorbidities that may predispose an individual to this condition.Methods: We performed a cross-sectional analysis of the emergency department database for patients with CK>/=1000U/L between 2012 and 2017. In total, there were 1957 cases of rhabdomyolysis diagnosed based on laboratory data and documentation. Trauma was the most common cause for rhabdomyolysis (n = 726/1957; 37.1%, respectively).Results: ExRML was identified in 2.1% (n = 42/1957) of the total cases. Patients with ExRML were significantly younger (30.1 +/- 10.6 years) with a significantly higher maximal level of CK compared to the non-exertional causes of rhabdomyolysis, (CK = 16,884.4 +/- 41,645.6U/L; both p < 0.005). The far majority of cases were sport or exercise related (n = 35/42; 83.3%), with strength training at the gym making up the largest group of athletes (n = 16/42; 38.1%). The main complication amongst the ExRML group was acute kidney insufficiency, which was observed in 42.9% of patients. The CK levels of the patients in the ExRML cohort steadily decreased after initiation of aggressive hydration.Conclusion: ExRML may be more prevalent than the current literature predicts, which is important to recognize as it has the potential to cause kidney failure, irregular heart rhythm, and death. Therefore, physicians and active individuals should be sensitized to the signs and symptoms that may lead to earlier recognition and proper treatment in exercising individuals.
    Tags: Acute Kidney Injury/etiology, Adult, Aged, Ck, Creatine, Creatine Kinase/*blood, Cross-Sectional Studies, exertional, Female, Fluid Therapy, Humans, insufficiency, kidney, kinase, Male, Middle Aged, Physical Exertion, Resistance Training/*adverse effects, rhabdomyolysis, Rhabdomyolysis/*blood/*etiology/therapy, Rml, Wounds and Injuries/blood/complications, Young Adult.
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  • Malik, M. R., Abubakar, A., Kholy, A. E., Buliva, E., Khan, W. M., Lamichhane, J., Moen, A., McCarron, M., Zureick, K., and Obtel, M. “Improved Capacity For Influenza Surveillance In The Who Eastern Mediterranean Region: Progress In A Challenging Setting”. J Infect Public Health 13, no. 3: 391-401. doi:10.1016/j.jiph.2019.07.018.
    Abstract: BACKGROUND: The World Health Organization Regional Office for Eastern Mediterranean has partnered with the United States Centers for Disease Control and Prevention (CDC) to strengthen pandemic influenza preparedness and response in the Region since 2006. This partnership focuses on pandemic preparedness planning, establishing and enhancing influenza surveillance systems, improving laboratory capacity for detection of influenza viruses, estimating the influenza disease burden, and providing evidence to support policies for the introduction and increased use of seasonal influenza vaccines. METHODS: Various published and unpublished data from public and WHO sources, programme indicators of the CDC cooperative agreement and Pandemic Influenza Preparedness Framework were reviewed and analysed. Analyses and review of the programme indicators and published articles enabled us to generate information that was unavailable from only WHO sources. RESULTS: Most (19/22) countries of the Region have established influenza surveillance system; 16 countries in the Region have designated National Influenza Centres. The Region has seen considerable improvement in geographic coverage of influenza surveillance and influenza detection. Virus sharing has improved and almost all of the participating laboratories have achieved a 100% efficiency score in the WHO external quality assessment programme. At least seven countries have estimated their influenza disease burden using surveillance data and at least 17 are now using seasonal influenza vaccines as a control strategy for influenza illness. CONCLUSION: The Region has achieved substantial progress in surveillance and response to seasonal influenza, despite the adverse effects to the health systems of many countries due to acute and protracted emergencies and other significant challenges.
    Tags: Centers for Disease Control and Prevention, U.S., Communicable Disease Control/methods, Eastern Mediterranean Region, Health Policy, Humans, Influenza, Influenza Vaccines/*therapeutic use, Influenza, Human/*epidemiology/prevention & control, Laboratories, Mediterranean Region/epidemiology, Middle East/epidemiology, Pandemics/*prevention & control, Public Health Surveillance, Respiratory Tract Infections/epidemiology, Sari, United States, World Health Organization.
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  • Brandenberger, J., Sontag, K., Duchene-Lacroix, C., Jaeger, F. N., Peterhans, B., and Ritz, N. “Perspective Of Asylum-Seeking Caregivers On The Quality Of Care Provided By A Swiss Paediatric Hospital: A Qualitative Study”. Bmj Open 9, no. 9: e029385. doi:10.1136/bmjopen-2019-029385.
    Abstract: OBJECTIVES: This study investigated the perspective of asylum-seeking caregivers on the quality of healthcare delivered to their children in a qualitative in-depth interview study. The health of asylum-seeking children is of key interest for healthcare providers, yet knowledge of the perspective of asylum-seeking caregivers when accessing healthcare is limited. SETTING: The study took place in a paediatric tertiary care hospital in Basel, Switzerland. PARTICIPANTS: Interviews were done with 13 asylum-seeking caregivers who had presented with their children at the paediatric tertiary care hospital. Nine female and four male caregivers from Tibet, Eritrea, Afghanistan, Syria, Iraq, Albania and Macedonia were included. A diverse sample was chosen regarding cultural and social background, years of residence in Switzerland and reasons for seeking care. A previously developed and pilot-tested interview guide was used for semistructured in-depth interviews between 36 and 92 min in duration. Data analysis and reporting was done according to Consolidated Criteria for Reporting Qualitative Research. The number of interviews was determined by saturation of data. RESULTS: The interviewees described a mismatch of personal competencies and external challenges. Communication barriers and unfamiliarity with new health concepts were reported as challenges. These were aggravated by isolation and concerns about their child's health. The following factors were reported to strongly contribute to satisfaction of healthcare delivery: a respectful and trusting caregiver-provider relationship, the presence of interpreters and immediate availability of treatment. CONCLUSIONS: A mismatch of personal competencies and external challenges importantly influences the caregiver-provider relationship. To overcome this mismatch establishment of confidence was identified as a key factor. This can be achieved by availability of interpreter services, sufficient consultation time and transcultural trainings for healthcare workers. Coordination between the family, the government's asylum system and the medical system is required to facilitate this process.
    Tags: *Quality of Health Care, Adult, Caregivers/*psychology, Child, Communication Barriers, Female, health services, healthcare delivery, Hospitals, Pediatric/*standards, Humans, Interviews as Topic, Male, migrant, migrant health, Qualitative Research, quality of care, refugee health, Refugees/*psychology, Switzerland.
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  • Frei, N., and Bless, N. “Acute Longus Colli Calcific Tendinitis: A Rare Cause Of Neck Pain”. Eur J Case Rep Intern Med 6, no. 8: 001126. doi:10.12890/2019_001126.
    Abstract: A 48-year-old man presented to our emergency department with neck pain without sensorimotor deficit and with a sore throat without signs of infection. Magnetic resonance imaging was performed because the patient had not responded to regular treatment and a blood test had showed inflammation. The images revealed cervical prevertebral fluid collection and calcification, compatible with acute calcific tendinitis of the longus colli muscle. Prednisolone 50 mg with pantoprazol 40 mg was administered for 5 days with rapid resolution of symptoms. Acute calcific tendinitis of the longus colli muscle is a rare and possibly underdiagnosed cause of atypical neck pain and sore throat. LEARNING POINTS: The signs and symptoms of acute calcific tendinitis of the longus colli muscle can easily be mistaken for serious disease such as spondylodiscitis or retropharyngeal abscess.Imaging with easily available modalities such as computed tomography can be used for diagnosis.Anti-inflammatory medication led to quick resolution of symptoms despite elevated signs of inflammation and delayed diagnosis in our patient.
    Tags: inflammatory neck pain, prevertebral fluid collection, Retropharyngeal swelling.
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  • Nieves Ortega, R., Rosin, C., Bingisser, R., and Nickel, C. H. “Clinical Scores And Formal Triage For Screening Of Sepsis And Adverse Outcomes On Arrival In An Emergency Department All-Comer Cohort”. J Emerg Med 57, no. 4: 453-460 e2. doi:10.1016/j.jemermed.2019.06.036.
    Abstract: BACKGROUND: Early recognition of sepsis remains a major challenge. The clinical utility of the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score is still undefined. Several studies have tested its prognostic value. However, its ability to diagnose sepsis is still unknown. OBJECTIVE: Our aim was to compare the performance of qSOFA, systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score (NEWS), and formal triage with the Emergency Severity Index (ESI) algorithm to identify patients with sepsis and predict adverse outcomes on arrival in an emergency department (ED) all-comer cohort. METHODS: We included all patients presenting consecutively to the ED during a 3-week period. We used vital signs recorded at triage to calculate the study scores. Two independent assessors retrospectively assigned the primary outcome of sepsis according to Third International Consensus Definitions for Sepsis and Septic Shock criteria in a chart review process. RESULTS: There were 2523 cases included in the analysis and 39 (1.6%) had the primary outcome of sepsis. The area under the curve for sepsis was 0.79 (95% confidence interval [CI] 0.71-0.86) for qSOFA, 0.81 (95% CI 0.73-0.87) for SIRS, 0.85 (95% CI 0.77-0.92) for NEWS, and 0.77 (95% CI 0.70-0.83) for ESI. CONCLUSIONS: qSOFA offered high specificity for the prediction of sepsis and adverse outcomes. However, its low sensitivity does not support widespread use as a screening tool for sepsis. NEWS outperformed qSOFA for prediction of adverse outcomes and screening for sepsis.
    Tags: Adolescent, Adult, Aged, Aged, 80 and over, Area Under Curve, Child, Cohort Studies, Emergency Service, Hospital/organization & administration/standards/statistics &, Esi, Female, Hospital Mortality, Hospitalization/statistics & numerical data, Humans, Male, Mass Screening/methods/*standards/statistics & numerical data, Middle Aged, News, numerical data, Organ Dysfunction Scores, Prognosis, qSOFA, Retrospective Studies, ROC Curve, screening, sepsis, Sepsis/*classification/diagnosis, Sirs, Sofa, Treatment Outcome, Triage.
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  • Lyngholm, L., Nickel, C. H., Kellett, J., Chang, S., Cooksley, T., and Brabrand, M. “Normal Gait, Albumin And D-Dimer Levels Identify Low Risk Emergency Department Patients: A Prospective Observational Cohort Study With 365-Day 100% Follow-Up”. Qjm 113, no. 2: 86-92. doi:10.1093/qjmed/hcz226.
    Abstract: BACKGROUND: If survival could be reliably predicted many patients could be safely managed outside of hospital in an ambulatory care setting. AIM: Comparison of common laboratory findings, co-morbidities, mobility and vital signs as predictors of mortality of acutely ill emergency department (ED) attendees. DESIGN: Prospective observational study. METHODS: Secondary analysis of 1334 consenting acutely ill patients attending a Danish ED. RESULTS: 67 (5%) out of 1334 patients died within 100 days. After logistic regression seven predictors of 100 days mortality remained significant: an albumin level </=34 gm/l, D-dimer level >0.51 mg/l, an Asadollahi score (based on admission laboratory data and age) >/=12, a platelet count <159 X 1000/ml, impaired mobility on presentation, a respiratory rate >/=30 bpm and a Charlson co-morbidity index >/=3. Only 5 of the 442 without any of these variables died within 365 days. Only one of the 517 patients with a stable independent gait and normal d-dimer and albumin levels died within 100 days, none died within 30 days of assessment and 12 died within 365 days. Of the remaining 817 patients 66 (8%) died within 100 days. CONCLUSION: These findings suggest that normal gait, albumin and d-dimer levels are the most parsimonious way of identifying low risk ED patients.
    Tags: *Gait, Adult, Aged, Aged, 80 and over, Cause of Death, Critical Illness/*mortality, Denmark, Emergency Service, Hospital/*statistics & numerical data, Female, Fibrin Fibrinogen Degradation Products/*analysis, Humans, Logistic Models, Male, Middle Aged, Predictive Value of Tests, Prognosis, Prospective Studies, Risk Assessment, Serum Albumin, Human/*analysis, Time Factors.
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  • Keitel, K., Kilowoko, M., Kyungu, E., Genton, B., and D'Acremont, V. “Performance Of Prediction Rules And Guidelines In Detecting Serious Bacterial Infections Among Tanzanian Febrile Children”. Bmc Infect Dis 19, no. 1: 769. doi:10.1186/s12879-019-4371-y.
    Abstract: BACKGROUND: Health-workers in developing countries rely on clinical algorithms, such as the Integrated Management of Childhood Illnesses (IMCI), for the management of patients, including diagnosis of serious bacterial infections (SBI). The diagnostic accuracy of IMCI in detecting children with SBI is unknown. Prediction rules and guidelines for SBI from well-resourced countries at outpatient level may help to improve current guidelines; however, their diagnostic performance has not been evaluated in resource-limited countries, where clinical conditions, access to care, and diagnostic capacity differ. The aim of this study was to estimate the diagnostic accuracy of existing prediction rules and clinical guidelines in identifying children with SBI in a cohort of febrile children attending outpatient health facilities in Tanzania. METHODS: Structured literature review to identify available prediction rules and guidelines aimed at detecting SBI and retrospective, external validation on a dataset containing 1005 febrile Tanzanian children with acute infections. The reference standard, SBI, was established based on rigorous clinical and microbiological criteria. RESULTS: Four prediction rules and five guidelines, including IMCI, could be validated. All examined rules and guidelines had insufficient diagnostic accuracy for ruling-in or ruling-out SBI with positive and negative likelihood ratios ranging from 1.04-1.87 to 0.47-0.92, respectively. IMCI had a sensitivity of 36.7% (95% CI 29.4-44.6%) at a specificity of 70.3% (67.1-73.4%). Rules that use a combination of clinical and laboratory testing had better performance compared to rules and guidelines using only clinical and or laboratory elements. CONCLUSIONS: Currently applied guidelines for managing children with febrile illness have insufficient diagnostic accuracy in detecting children with SBI. Revised clinical algorithms including simple point-of-care tests with improved accuracy for detecting SBI targeting in tropical resource-poor settings are needed. They should undergo careful external validation against clinical outcome before implementation, given the inherent limitations of gold standards for SBI.
    Tags: *Practice Guidelines as Topic/standards, Age of Onset, Algorithms, Bacterial Infections/*diagnosis/epidemiology/microbiology, Child, Child, Preschool, Childhood infections, Clinical prediction rules, Diagnostic accuracy, External validation, Female, Fever/*diagnosis/microbiology, Humans, Imci, Infant, Male, Microbiological Techniques/methods/*standards/statistics & numerical data, Point-of-Care Testing/*standards/statistics & numerical data, Predictive Value of Tests, Prognosis, Reproducibility of Results, Retrospective Studies, Sensitivity and Specificity, Serious bacterial infections, Tanzania/epidemiology.
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  • Wirth, C., Nickel, C. H., Stickel, A., Mueller, J., Fuchs, S., and Bingisser, R. “Outpatient Management Of Individuals Transporting Drugs By Body Packing Is Feasible”. Swiss Med Wkly 149, no. 35-36: w20113. doi:10.4414/smw.2019.20113.
    Abstract: INTRODUCTION: Drug traffickers are increasingly making use of the human body for illegal drug transport. Three ways of intracorporeal drug transport are practiced, namely "body packing", "body stuffing" and "body pushing". Since police and border guards cannot accurately detect intracorporeal drug transport, authorities require medical professionals for examination and radiological imaging. The aim of this retrospective study was to assess outcomes in all presentations of suspected intracorporeal drug transport referred to the Emergency Department (ED) of the University Hospital of Basel. METHODS: We screened the electronic health records (EHRs) of all presentations to the ED between 1 January 2008 and 31 December 2017 for combinations of keywords "body", "pack", "stuff" and "push" in the diagnosis and history of presenting complaints. All presentations with suspicion of intracorporeal drug transport were included. Patient characteristics, imaging modality and the results of imaging were assessed. Outcomes were length of stay, hospitalisation, admission to the intensive care unit, surgical intervention and mortality. The main outcome was the rate of surgical interventions during follow-up in hospital and in prison. RESULTS: We included 363 presentations in 347 patients. The median age was 35 years and 46 (12.7%) were female. Positive results of imaging were found in 81 of 353 (22.9%) presentations assessed by imaging. In four presentations (1.1%), the result of imaging was indeterminate; in 10 presentations, no imaging was obtained owing to lack of consent or pregnancy. We observed 36 instances of body packing, 10 of body stuffing and 15 of body pushing, and 20 mixed or indeterminate presentations. The number of suspected presentations has risen over the last decade, and the relative number of positive results has almost remained stable over the last six years. No severe or life-threatening complications, interventions, or deaths were observed. Among the presentations with positive imaging results, ten (12.3%) were observed in hospital, as compared with four (1.5%) of those with negative results. CONCLUSIONS: Presentations have increased over the last decade while no severe complications or deaths were observed. The consistently low complication rate supports outpatient observation. Considering the ongoing discussion in media and politics, we suggest validation of medical, legal, and ethical guidelines.
    Tags: *Drug Trafficking/statistics & numerical data, Adult, Body Packing/*statistics & numerical data, Emergency Service, Hospital/*statistics & numerical data, Female, Humans, Male, Middle Aged, Outpatients, Physical Examination/*methods, Retrospective Studies, Switzerland.
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  • Bertrand, J., Fehlmann, C., Grosgurin, O., Sarasin, F., and Kherad, O. “Inappropriateness Of Repeated Laboratory And Radiological Tests For Transferred Emergency Department Patients”. J Clin Med 8, no. 9. doi:10.3390/jcm8091342.
    Abstract: BACKGROUND: Laboratory and radiographic tests are often repeated during inter-hospital transfers from secondary to tertiary emergency departments (ED), despite available data from the sending structure. The aim of this study was to identify the proportion of repeated tests in patients transferred to a tertiary care ED, and to estimate their inappropriateness and their costs. METHODS: A retrospective chart review of all adult patients transferred from one secondary care ED to a tertiary care ED during the year 2016 was carried out. The primary outcome was the redundancy (proportion of procedure repeated in the 8 h following the transfer, despite the availability of the previous results). Factors predicting the repetition of procedures were identified through a logistic regression analysis. Two authors independently assessed inappropriateness. RESULTS: In 2016, 432 patients were transferred from the secondary to the tertiary ED, and 251 procedures were repeated: 179 patients (77.2%) had a repeated laboratory test, 34 (14.7%) a repeated radiological procedure and 19 (8.2%) both. Repeated procedures were judged as inappropriate for 197 (99.5%) laboratory tests and for 39 (73.6%) radiological procedures. CONCLUSION: Over half of the patients transferred from another emergency department had a repeated procedure. In most cases, these repeated procedures were considered inappropriate.
    Tags: choosing wisely, emergency medicine, laboratory test, less-is-more, quality, radiological procedure, redundant.
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  • Hufner, K., Brugger, H., Caramazza, F., Stawinoga, A. E., Brodmann-Maeder, M., Gatterer, H., Turner, R., Tomazin, I., Fusar-Poli, P., and Sperner-Unterweger, B. “Development Of A Self-Administered Questionnaire To Detect Psychosis At High Altitude: The Hapsy Questionnaire”. High Alt Med Biol 20, no. 4: 352-360. doi:10.1089/ham.2019.0009.
    Abstract: Aims: Psychotic symptoms during exposure to high altitude (HA) have been linked to accidents or near accidents on the mountains. It is thus of great importance to directly identify psychotic symptoms in individuals who are exposed to HA quickly and reliably on the mountain, even in the absence of experienced medical personnel. Psychotic features at HA frequently include positive psychotic symptoms such as hallucinations, delusions, or disorganized thinking/speech. The aim of the current study was to develop the first self-administered questionnaire (High Altitude Psychosis [HAPSY] Questionnaire), which individuals may use in the future to self-assess altitude-related psychotic symptoms on the mountain. Methods: We utilized two existing self-rating questionnaires for psychotic symptoms (the Psychotomimetic States Inventory, PSI and the Cardiff Anomalous Perception Scale, CAPS) as the basis for a two-round Delphi process. As part of this process, additional statements were suggested by the 40 Delphi participants. Results: Eleven self-administered statements-all of them related to positive psychotic symptoms-were identified to be most useful for the self-detection of HA-related psychotic symptoms on the mountain. Conclusion: This is the first self-administered questionnaire that allows the identification of HA-related psychotic symptoms on the mountain. A subsequent validation study is needed to address the psychometric properties of this questionnaire. Clinical validation will have to be performed in a field study.
    Tags: Adult, Altitude, Altitude Sickness/*psychology, Delphi process, Environmental Exposure/adverse effects, Female, Hace, high altitude, Humans, Male, Mountaineering/*psychology, positive symptoms of psychosis, Psychiatric Status Rating Scales, psychosis, Psychotic Disorders/*diagnosis/etiology, Reproducibility of Results, self-rating questionnaire, Surveys and Questionnaires/*standards.
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  • Nestelberger, T., Boeddinghaus, J., Wussler, D., Twerenbold, R., Badertscher, P., Wildi, K., Miro, O., et al. “Predicting Major Adverse Events In Patients With Acute Myocardial Infarction”. J Am Coll Cardiol 74, no. 7: 842-854. doi:10.1016/j.jacc.2019.06.025.
    Abstract: BACKGROUND: Early and accurate detection of short-term major adverse cardiac events (MACE) in patients with suspected acute myocardial infarction (AMI) is an unmet clinical need. OBJECTIVES: The goal of this study was to test the hypothesis that adding clinical judgment and electrocardiogram findings to the European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) measurement at presentation and after 1 h (ESC hs-cTn 0/1 h algorithm) would further improve its performance to predict MACE. METHODS: Patients presenting to an emergency department with suspected AMI were enrolled in a prospective, multicenter diagnostic study. The primary endpoint was MACE, including all-cause death, cardiac arrest, AMI, cardiogenic shock, sustained ventricular arrhythmia, and high-grade atrioventricular block within 30 days including index events. The secondary endpoint was MACE + unstable angina (UA) receiving early (</=24 h) revascularization. RESULTS: Among 3,123 patients, the ESC hs-cTnT 0/1 h algorithm triaged significantly more patients toward rule-out compared with the extended algorithm (60%; 95% CI: 59% to 62% vs. 45%; 95% CI: 43% to 46%; p < 0.001), while maintaining similar 30-day MACE rates (0.6%; 95% CI: 0.3% to 1.1% vs. 0.4%; 95% CI: 0.1% to 0.9%; p = 0.429), resulting in a similar negative predictive value (99.4%; 95% CI: 98.9% to 99.6% vs. 99.6%; 95% CI: 99.2% to 99.8%; p = 0.097). The ESC hs-cTnT 0/1 h algorithm ruled-in fewer patients (16%; 95% CI: 14.9% to 17.5% vs. 26%; 95% CI: 24.2% to 27.2%; p < 0.001) compared with the extended algorithm, albeit with a higher positive predictive value (76.6%; 95% CI: 72.8% to 80.1% vs. 59%; 95% CI: 55.5% to 62.3%; p < 0.001). For 30-day MACE + UA, the ESC hs-cTnT 0/1 h algorithm had a higher positive predictive value for rule-in, whereas the extended algorithm had a higher negative predictive value for the rule-out. Similar findings emerged when using hs-cTnI. CONCLUSIONS: The ESC hs-cTn 0/1 h algorithm better balanced efficacy and safety in the prediction of MACE, whereas the extended algorithm is the preferred option for the rule-out of 30-day MACE + UA. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587).
    Tags: *Algorithms, acute myocardial infarction, Aged, Angina, Unstable/diagnosis/epidemiology, Arrhythmias, Cardiac/diagnosis/epidemiology, Atrioventricular Block/diagnosis/epidemiology, Biomarkers/blood, clinical assessment, Electrocardiography, Emergency Service, Hospital, Female, Heart Arrest/diagnosis/epidemiology, high-sensitivity cardiac troponin, Humans, major adverse cardiac events, Male, Middle Aged, Myocardial Infarction/blood/diagnosis/*epidemiology, Myocardial Revascularization, Predictive Value of Tests, Prospective Studies, Sensitivity and Specificity, Shock, Cardiogenic/diagnosis/epidemiology, Troponin/*blood.
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  • Brandt, L., Henssler, J., Muller, M., Wall, S., Gabel, D., and Heinz, A. “Risk Of Psychosis Among Refugees: A Systematic Review And Meta-Analysis”. Jama Psychiatry 76, no. 11: 1133-1140. doi:10.1001/jamapsychiatry.2019.1937.
    Abstract: IMPORTANCE: This systematic review and meta-analysis is, to date, the first and most comprehensive to focus on the incidence of nonaffective psychoses among refugees. OBJECTIVE: To assess the relative risk (RR) of incidence of nonaffective psychosis in refugees compared with the RR in the native population and nonrefugee migrants. DATA SOURCES: PubMed, PsycINFO, and Embase databases were searched for studies from January 1, 1977, to March 8, 2018, with no language restrictions (PROSPERO registration No. CRD42018106740). STUDY SELECTION: Studies conducted in Denmark, Sweden, Norway, and Canada were selected by multiple independent reviewers. Inclusion criteria were (1) observation of refugee history in participants, (2) assessment of effect size and spread, (3) adjustment for sex, (4) definition of nonaffective psychosis according to standardized operationalized criteria, and (5) comparators were either nonrefugee migrants or the native population. Studies observing ethnic background only, with no explicit definition of refugee status, were excluded. DATA EXTRACTION AND SYNTHESIS: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed for extracting data and assessing data quality and validity as well as risk of bias of included studies. A random-effects model was created to pool the effect sizes of included studies. MAIN OUTCOMES AND MEASURES: The primary outcome, formulated before data collection, was the pooled RR in refugees compared with the nonrefugee population. RESULTS: Of the 4358 screened articles, 9 studies (0.2%) involving 540 000 refugees in Denmark, Sweden, Norway, and Canada were included in the analyses. The RR for nonaffective psychoses in refugees was 1.43 (95% CI, 1.00-2.05; I2 = 96.3%) compared with nonrefugee migrants. Analyses that were restricted to studies with low risk of bias had an RR of 1.39 (95% CI, 1.23-1.58; I2 = 0.0%) for refugees compared with nonrefugee migrants, 2.41 (95% CI, 1.51-3.85; I2 = 96.3%) for refugees compared with the native population, and 1.92 (95% CI, 1.02-3.62; I2 = 97.0%) for nonrefugee migrants compared with the native group. Exclusion of studies that defined refugee status not individually but only by country of origin resulted in an RR of 2.24 (95% CI, 1.12-4.49; I2 = 96.8%) for refugees compared with nonrefugee migrants and an RR of 3.26 (95% CI, 1.87-5.70; I2 = 97.6%) for refugees compared with the native group. In general, the RR of nonaffective psychosis was increased in refugees and nonrefugee migrants compared with the native population. CONCLUSIONS AND RELEVANCE: Refugee experience appeared to be an independent risk factor in developing nonaffective psychosis among refugees in Denmark, Sweden, Norway, and Canada. These findings suggest that applying the conclusions to non-Scandinavian countries should include a consideration of the characteristics of the native society and its specific interaction with the refugee population.
    Tags: *Mental Health, Canada/epidemiology, Denmark/epidemiology, Humans, Incidence, Norway/epidemiology, Psychotic Disorders/*epidemiology/psychology, Refugees/*psychology, Risk, Sweden/epidemiology.
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  • Spechbach, H., Rochat, J., Gaspoz, J. M., Lovis, C., and Ehrler, F. “Patients' Time Perception In The Waiting Room Of An Ambulatory Emergency Unit: A Cross-Sectional Study”. Bmc Emerg Med 19, no. 1: 41. doi:10.1186/s12873-019-0254-1.
    Abstract: BACKGROUND: Patient satisfaction has become an increasingly important element in a service-oriented healthcare market. Although satisfaction is influenced by many factors, the waiting time to be seen by medical staff has been shown to be one of the key criteria. However, waiting is not an objective experience and several factors can influence its perception. METHODS: We conducted a questionnaire-based, cross-sectional study among patients attending the emergency unit of a Swiss university hospital in order to explore the key factors influencing wait perception. RESULTS: A total of 509 patients participated in the study. Appropriate assessment of emergency level by caregivers, the feeling of being forgotten, respect of privacy, and lack of information on the exact waiting time were identified as significant variables for wait perception. CONCLUSIONS: Our study confirmed the existence of a 'golden hour' when the patient is willing to wait until the medical encounter. In case the wait cannot be limited, an appropriate assessment of the emergency level by caregivers and avoiding the patients of feeling being forgotten are very important factors to avoid a negative perception of the waiting time before seeing a doctor. TRIAL REGISTRATION: (ID REQ-2016-00555).
    Tags: *Emergency Service, Hospital, *Patient Satisfaction, *Professional-Patient Relations, *Time Perception, Adult, Aged, Ambulatory Care Facilities, Cross-Sectional Studies, Emergency department, Female, Hospitals, University, Humans, Logistic Models, Male, Middle Aged, Outpatients/*psychology, Patient satisfaction, Perceived waiting time, Service-oriented health care, Surveys and Questionnaires, Switzerland, Waiting Lists, Waiting time.
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  • Reber, E., Gomes, F., Bally, L., Schuetz, P., and Stanga, Z. “Nutritional Management Of Medical Inpatients”. J Clin Med 8, no. 8. doi:10.3390/jcm8081130.
    Abstract: Malnutrition is a common condition in hospitalized patients that is often underdiagnosed and undertreated. Hospital malnutrition has multifactorial causes and is associated with negative clinical and economic outcomes. There is now growing evidence from clinical trials for the efficiency and efficacy of nutritional support in the medical inpatient population. Since many medical inpatients at nutritional risk or malnourished are polymorbid (i.e., suffer from multiple comorbidities), this makes the provision of adequate nutritional support a challenging task, given that most of the clinical nutrition guidelines are dedicated to single diseases. This review summarizes the current level of evidence for nutritional support in not critically ill polymorbid medical inpatients.
    Tags: design of the study, in, in the collection, analyses, or interpretation of data, malnutrition, nutritional management, nutritional therapy, the writing of the manuscript, or in the decision to publish the results..
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  • Lavoie, P. M., Popescu, C. R., Molyneux, E. M., Wynn, J. L., Chiume, M., Keitel, K., Lufesi, N., Levine, G. A., Ansermino, J. M., and Kissoon, N. “Rethinking Management Of Neonates At Risk Of Sepsis”. Lancet 394, no. 10195: 279-281. doi:10.1016/S0140-6736(19)31627-7.
    Tags: Anti-Bacterial Agents/pharmacology/*therapeutic use, Humans, Infant, Newborn, Microbiota/drug effects, Practice Guidelines as Topic, Risk Assessment, Sepsis/*prevention & control.
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  • Kellett, J., Nickel, C. H., Skyttberg, N., and Brabrand, M. “Is It Possible To Quickly Identify Acutely Unwell Patients Who Can Be Safely Managed As Outpatients? The Need For A "Universal Safe To Discharge Score"”. Eur J Intern Med 67: e13-e15. doi:10.1016/j.ejim.2019.07.018.
    Abstract: If scores or algorithms were developed that quickly identified patients who are bound to have 100% survival, if even only for a few days, more patients could be safely discharged from emergency department, this eliminating the risks of hospitalization for many patients. This hypothesis proposes that it is possible to develop a "Universal Safe to Discharge Score", and suggests how it might be developed and validated.
    Tags: *Patient Selection, Acute Disease/*therapy, Ambulatory Care/*standards, Humans, Needs Assessment, Patient Discharge/*standards, Patient outcomes, Prediction of outcomes, Predictive scores, Survival analysis, Time Factors.
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  • Twerenbold, R., Costabel, J. P., Nestelberger, T., Campos, R., Wussler, D., Arbucci, R., Cortes, M., et al. “Outcome Of Applying The Esc 0/1-Hour Algorithm In Patients With Suspected Myocardial Infarction”. J Am Coll Cardiol 74, no. 4: 483-494. doi:10.1016/j.jacc.2019.05.046.
    Abstract: BACKGROUND: The European Society of Cardiology (ESC) recommends the 0/1-h algorithm for rapid triage of patients with suspected non-ST-segment elevation myocardial infarction (MI). However, its impact on patient management and safety when routinely applied is unknown. OBJECTIVES: This study sought to determine these important real-world outcome data. METHODS: In a prospective international study enrolling patients presenting with acute chest discomfort to the emergency department (ED), the authors assessed the real-world performance of the ESC 0/1-h algorithm using high-sensitivity cardiac troponin T embedded in routine clinical care and its associated 30-day rates of major adverse cardiac events (MACE) (the composite of cardiovascular death and MI). RESULTS: Among 2,296 patients, non-ST-segment elevation MI prevalence was 9.8%. In median, 1-h blood samples were collected 65 min after the 0-h blood draw. Overall, 94% of patients were managed without protocol violations, and 98% of patients triaged toward rule-out did not require additional cardiac investigations including high-sensitivity cardiac troponin T measurements at later time points or coronary computed tomography angiography in the ED. Median ED stay was 2 h and 30 min. The ESC 0/1-h algorithm triaged 62% of patients toward rule-out, and 71% of all patients underwent outpatient management. Proportion of patients with 30-day MACE were 0.2% (95% confidence interval: 03% to 0.5%) in the rule-out group and 0.1% (95% confidence interval: 0% to 0.2%) in outpatients. Very low MACE rates were confirmed in multiple subgroups, including early presenters. CONCLUSIONS: These real-world data document the excellent applicability, short time to ED discharge, and low rate of 30-day MACE associated with the routine clinical use of the ESC 0/1-h algorithm for the management of patients presenting with acute chest discomfort to the ED.
    Tags: *Algorithms, *Guideline Adherence, 0/1-h algorithm, acute myocardial infarction, Adult, Aged, Aged, 80 and over, Female, high-sensitivity cardiac troponin, Humans, Male, Middle Aged, Non-ST Elevated Myocardial Infarction/*diagnosis, outcome, Outcome Assessment, Health Care, Prospective Studies, rule-out, safety, Time Factors, Triage/standards.
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  • Scholz, I., Schmid, Y., Exadaktylos, A. K., Haschke, M., Liechti, M. E., and Liakoni, E. “Emergency Department Presentations Related To Abuse Of Prescription And Over-The-Counter Drugs In Switzerland: Time Trends, Sex And Age Distribution”. Swiss Med Wkly 149, no. 29-30: w20056. doi:10.4414/smw.2019.20056.
    Abstract: AIMS OF THE STUDY: To analyse emergency department (ED) presentations related to acute medical problems after recreational use of prescription/over-the-counter (OTC) drugs in two major Swiss hospitals in order to identify the prevalence of specific drugs, vulnerable groups, time trends and local differences which could have major public health implications. METHODS: Retrospective analysis of cases presenting with signs/symptoms consistent with acute toxicity due to recreational use of prescription/OTC drugs from May 2012 to August 2017 at the ED of the University Hospital of Bern and from October 2013 to July 2017 at the ED of the University Hospital Basel. We investigated time trends, sex differences, patient characteristics and consumption patterns within three age groups (&ge;16 to &lt;36 years; &ge;36 to &lt;56 years; &ge;56 years). RESULTS: During the study period, 344 cases were included out of 1715 ED attendances due to acute drug toxicity and a total of 412,557 ED presentations. The use of prescription drugs in conjunction with illegal drugs was reported in nearly half the cases. The most frequently reported prescription drugs were benzodiazepines (64%, n = 220) and methadone (13%, n = 45). Forty-eight percent (n = 166) of all presentations occurred within the youngest age group. The analysis of time trends showed a significant increase in presentations in the youngest and the oldest groups in Basel (both p &lt;0.05), while the trend remained stable over time in Bern for all age groups. While the number of presentations remained constant over time for men and women in Bern, a significant increase was found for the female cohort in Basel (p &lt;0.05). Patients in all age groups presented with toxicities of predominantly minor severity. CONCLUSION: The prescription/OTC drugs most frequently leading to ED presentations after recreational use were sedative substances. A large proportion of the patients belonged to the youngest age group. A significant increase in presentations was seen in the youngest and oldest age groups and within women in Basel. This information can be used to inform health care providers so that they can adapt their prevention and treatment strategies in their communities.
    Tags: *Emergency Service, Hospital, Adolescent, Adult, Age Distribution, Aged, Alcohol Drinking/epidemiology, Antidepressive Agents/adverse effects, Benzodiazepines/adverse effects, Central Nervous System Stimulants/adverse effects, Female, Humans, Illicit Drugs/adverse effects, Male, Methadone/adverse effects, Methylphenidate/adverse effects, Middle Aged, Nonprescription Drugs/*adverse effects, Retrospective Studies, Substance-Related Disorders/*epidemiology, Switzerland/epidemiology, Young Adult.
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  • Reber, E., Gomes, F., Vasiloglou, M. F., Schuetz, P., and Stanga, Z. “Nutritional Risk Screening And Assessment”. J Clin Med 8, no. 7. doi:10.3390/jcm8071065.
    Abstract: Malnutrition is an independent risk factor that negatively influences patients' clinical outcomes, quality of life, body function, and autonomy. Early identification of patients at risk of malnutrition or who are malnourished is crucial in order to start a timely and adequate nutritional support. Nutritional risk screening, a simple and rapid first-line tool to detect patients at risk of malnutrition, should be performed systematically in patients at hospital admission. Patients with nutritional risk should subsequently undergo a more detailed nutritional assessment to identify and quantify specific nutritional problems. Such an assessment includes subjective and objective parameters such as medical history, current and past dietary intake (including energy and protein balance), physical examination and anthropometric measurements, functional and mental assessment, quality of life, medications, and laboratory values. Nutritional care plans should be developed in a multidisciplinary approach, and implemented to maintain and improve patients' nutritional condition. Standardized nutritional management including systematic risk screening and assessment may also contribute to reduced healthcare costs. Adequate and timely implementation of nutritional support has been linked with favorable outcomes such as a decrease in length of hospital stay, reduced mortality, and reductions in the rate of severe complications, as well as improvements in quality of life and functional status. The aim of this review article is to provide a comprehensive overview of nutritional screening and assessment methods that can contribute to an effective and well-structured nutritional management (process cascade) of hospitalized patients.
    Tags: malnutrition, nutritional assessment, nutritional risk screening.
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  • Popovic, M., Cesana-Nigro, N., Winzeler, B., Thomann, R., Schutz, P., Muller, B., Christ-Crain, M., and Blum, C. A. “Estimation Of Treatment Allocation In A Randomised, Double-Blinded, Placebo-Controlled Trial”. Swiss Med Wkly 149, no. 29-30: w20114. doi:10.4414/smw.2019.20114.
    Abstract: &nbsp; AIM OF THE STUDY: The internal validity of double blinding in randomised placebo-controlled trials (RCTs) has become a target of criticism. The goal of this study was to investigate (a) how accurately the patients and their treating physicians were able to guess their assigned treatment, and (b) predictors for an accurate guess. METHODS: Data on treatment estimation from patients (n = 382) and their physicians (n = 358 guesses) in an RCT investigating the role of adjunct prednisone for community-acquired pneumonia in a tertiary care setting were analysed. At discharge, patients and their physicians had to guess whether they had been assigned to the prednisone or to the placebo group. The alternative possibility was &ldquo;uncertain&rdquo;. Percentages and confidence intervals (CIs) were calculated for the proportion of patients guessing correctly. Chance finding was defined as having 50% or less correct guesses. To test for predictors for prednisone treatment guess, a mixed effects logistic regression model was performed. RESULTS: In the prednisone group, 28.9% (55/190; 95% CI 22.6&ndash;36.0%) of the patients made a correct guess and the majority (61.6%, 117/190) was uncertain. In the placebo group, 13.0% (25/192; 95% CI 8.8&ndash;18.8%) guessed correctly, with the majority being uncertain (69.8%, 134/192). Physicians guessed correctly in 48.3% (87/180, 95% CI 40.8&ndash;55.9%) of cases in the prednisone group and in 66.3% (118/178, 95% CI 58.8&ndash;73.2%) of cases in the placebo group, which was above chance for the placebo group. The physicians were uncertain in 21.7% (39/180) of cases in the prednisone group, and in 15.2% (27/178) of cases in the placebo group. Significant predictors for guessing prednisone were the occurrence of hyperglycaemia (odds ratio [OR] 3.77, 95% CI 2.39&ndash;5.95; p&lt;0.001) and a shorter time to clinical stability (OR 0.95, 95% CI 0.91&ndash;0.99; p = 0.02). CONCLUSIONS: We confirmed that patient blinding was achieved in this study. Physicians made correct guesses more often than patients. Treatment estimation by both patients and physicians was led not only by the expectations of treatment effects of the study drug but also by known side effects of prednisone. Trial registration no.: NCT00973154 &nbsp.
    Tags: *Double-Blind Method, Anti-Inflammatory Agents/therapeutic use, Humans, Physicians/*psychology, Placebos, Pneumonia/drug therapy, Prednisone/therapeutic use, Randomized Controlled Trials as Topic/*psychology, Research Subjects/*psychology, Switzerland.
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  • de Mestral, C., Chatelan, A., Marques-Vidal, P., Stringhini, S., and Bochud, M. “The Contribution Of Diet Quality To Socioeconomic Inequalities In Obesity: A Population-Based Study Of Swiss Adults”. Nutrients 11, no. 7. doi:10.3390/nu11071573.
    Abstract: Socioeconomically disadvantaged people are disproportionally more likely to develop obesity and obesity-related diseases. However, it remains unclear to what extent diet quality contributes to socioeconomic inequalities in obesity. We aimed to assess the role of diet quality in the association between socioeconomic status (SES) and obesity. Data originated from the national nutrition survey, a cross-sectional sample of the adult Swiss population (N = 1860). We used education and income as proxies for SES; calculated the Alternate Healthy Eating Index (AHEI) as a measure of diet quality; and used body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) as obesity markers. We applied counterfactual mediation modelling to generate odds ratios, 95% confidence intervals, and the proportion mediated by diet quality. Individuals with less than a tertiary education were two to three times more likely to be obese, regardless of the marker (OR (95% CI): 3.36 (2.01, 5.66) using BMI; 2.44 (1.58, 3.75) using WC; 2.48 (1.63, 3.78) using WHR; and 2.04 (1.43, 2.96) using WHtR). The proportion of the association between educational level and obesity that was mediated by diet quality was 22.1% using BMI, 26.6% using WC, 31.4% using WHtR, and 35.8% using WHR. Similar findings were observed for income. Our findings suggest that diet quality substantially contributes to socioeconomic inequalities in obesity while it does not fully explain them. Focusing efforts on improving the diet quality of disadvantaged groups could help reduce social inequalities in obesity.
    Tags: *Nutrition Surveys, *Social Class, 24 h dietary recall, Adult, Body Mass Index, Cross-Sectional Studies, diet quality, Diet/*standards, education, Female, Humans, income, inequalities, Male, Middle Aged, obesity, Obesity/*epidemiology/*etiology, socioeconomic status, Switzerland/epidemiology, Waist Circumference, Waist-Height Ratio, Waist-Hip Ratio.
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  • Sun, Q., Jankovic, M. V., and Mougiakakou, S. G. “Reinforcement Learning-Based Adaptive Insulin Advisor For Individuals With Type 1 Diabetes Patients Under Multiple Daily Injections Therapy∗”. In, 3609-3612, 2019. doi:10.1109/EMBC.2019.8857178.
    Abstract: The existing adaptive basal-bolus advisor (ABBA) was further developed to benefit patients under insulin therapy with multiple daily injections (MDI). Three different in silico experiments were conducted with the DMMS.R simulator to validate the approach of combined use of self-monitoring of blood glucose (SMBG) and insulin injection devices, e.g. insulin pen, as are used by the majority of type 1 diabetes patients under insulin therapy. The proposed approach outperforms the conventional method, as it increases the time spent within the target range and simultaneously reduces the risks of hyperglycaemic and hypoglycaemic events. © 2019 IEEE.
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  • Sun, Q., Jankovic, M. V., and Mougiakakou, S. G. “Impact Of Errors In Carbohydrate Estimation On Control Of Blood Glucose In Type 1 Diabetes”. In, 2019. doi:10.1109/NEUREL.2018.8586983.
    Abstract: This article investigates the impact of carbohydrate (CHO) estimation error on three different algorithms for insulin treatment optimisation. The experiments were conducted using the educational version of the UVa/Padova simulator on 11 virtual adult subjects. Under different CHO estimation error levels, two ways of CHO amount announcements were investigated: numerical value and categorical value (Small, Medium, and Large). Results of experiments suggest that by low CHO estimation error, the way of CHO level announcement has low impact on algorithm quality. As the error increases more intelligent algorithmic approaches need to be investigated. © 2018 IEEE.
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  • Sun, Q., Jankovic, M. V., Bally, L., and Mougiakakou, S. G. “Predicting Blood Glucose With An Lstm And Bi-Lstm Based Deep Neural Network”. In, 2019. doi:10.1109/NEUREL.2018.8586990.
    Abstract: A deep learning network was used to predict future blood glucose levels, as this can permit diabetes patients to take action before imminent hyperglycaemia and hypoglycaemia. A sequential model with one long-short-term memory (LSTM) layer, one bidirectional LSTM layer and several fully connected layers was used to predict blood glucose levels for different prediction horizons. The method was trained and tested on 26 retrospectively analysed datasets from 20 real patients. The proposed network outperforms the baseline methods in terms of all evaluation criteria. © 2018 IEEE.
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