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Swiss Emergency Research collection

2016

  • Yildirgan, K., Zahir, E., Sharafi, S., Ahmad, S., Schaller, B., Ricklin, M. E., and Exadaktylos, A. K. “Mandibular Fractures Admitted To The Emergency Department: Data Analysis From A Swiss Level One Trauma Centre”. Emerg Med Int 2016: 3502902. doi:10.1155/2016/3502902.
    Abstract: Mandibular fracture is a common occurrence in emergency medicine and belongs to the most frequent facial fractures. Historically road traffic injuries (RTIs) have played a prominent role as a cause for mandibular fractures. We extracted data from all patients between August 2012 and February 2015 with "lower jaw fracture" or "mandibular fracture" from the routine database from the emergency department. We conducted a descriptive analysis at a Swiss level one trauma centre. 144 patients were admitted with suspected mandibular fractures. The majority underwent CT diagnostic (83%). In 7% suspected mandibular fracture was not confirmed. More than half of all patients suffered two or more fractures. The fractures were median or paramedian in 77/144 patients (53%) and in other parts (corpus, mandibular angle, ramus mandibularis, collum, and temporomandibular joint) in 100/144 (69%). Male to female ratio was 3 : 1 up to 59 years of age; 69% were younger than 40 years. 72% of all patients presented during daytime, 69% had to be hospitalized, and 31% could be discharged from the ED after treatment. Most fractures were due to fall (44%), followed by interpersonal violence (25%) and sport activities (12%). Falls were a dominant cause of fracture in all age groups while violence and sport activities were common only in younger patients. Comparisons to other studies were difficult due to lack of standardization of causes contributing to the injuries. In the observed time period and setting RTIs have played a minor role compared to falls, interpersonal violence, and sports. In the future, standardized documentation as well as categorization of causes for analytic purposes is urgently needed to facilitate international comparison of studies.
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  • Schnegg, B., Pasquier, M., Carron, P. N., Yersin, B., and Dami, F. “Prehospital Emergency Medical Services Departure Interval: Does Patient Age Matter?”. Prehosp Disaster Med 31, no. 6: 608-613. doi:10.1017/S1049023X16000947.
    Abstract: Introduction The concept of response time with minimal interval is intimately related to the practice of emergency medicine. The factors influencing this time interval are poorly understood. Problem In a process of improvement of response time, the impact of the patient's age on ambulance departure intervals was investigated. METHOD: This was a 3-year observational study. Departure intervals of ambulances, according to age of patients, were analyzed and a multivariate analysis, according to time of day and suspected medical problem, was performed. RESULTS: A total of 44,113 missions were included, 2,417 (5.5%) in the pediatric group. Mean departure delay for the adult group was 152.9 seconds, whereas it was 149.3 seconds for the pediatric group (P =.018). CONCLUSION: A statistically significant departure interval difference between missions for children and adults was found. The difference, however, probably was not significant from a clinical point of view (four seconds). Schnegg B , Pasquier M , Carron PN , Yersin B , Dami F . Prehospital Emergency Medical Services departure interval: does patient age matter? Prehosp Disaster Med. 2016;31(6):608-613.
    Tags: *Ambulances, Adolescent, Adult, Age Factors, Aged, Aged, 80 and over, Child, Child, Preschool, DC dispatch center, departure interval, EMD emergency medical dispatcher, Emergency Medical Services/*statistics & numerical data, Ems, EMS Emergency Medical Services, Humans, Infant, Infant, Newborn, Middle Aged, Multivariate Analysis, pediatrics, Retrospective Studies, Switzerland, Time Factors, Transportation of Patients/*trends, Young Adult.
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  • Paal, P., Gordon, L., Strapazzon, G., Brodmann Maeder, M., Putzer, G., Walpoth, B., Wanscher, M., et al. “Accidental Hypothermia-An Update : The Content Of This Review Is Endorsed By The International Commission For Mountain Emergency Medicine (Icar Medcom)”. Scand J Trauma Resusc Emerg Med 24, no. 1: 111. doi:10.1186/s13049-016-0303-7.
    Abstract: BACKGROUND: This paper provides an up-to-date review of the management and outcome of accidental hypothermia patients with and without cardiac arrest. METHODS: The authors reviewed the relevant literature in their specialist field. Summaries were merged, discussed and approved to produce this narrative review. RESULTS: The hospital use of minimally-invasive rewarming for non-arrested, otherwise healthy, patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionised the management of hypothermic cardiac arrest, with survival rates approaching 100 % in some cases. Hypothermic patients with risk factors for imminent cardiac arrest (temperature <28 degrees C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS-centre. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanical CPR can be helpful. Delayed or intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern post-resuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimise pre-hospital triage, transport and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and post-resuscitation care. CONCLUSIONS: Based on new evidence, additional clinical experience and clearer management guidelines and documentation, the treatment of accidental hypothermia has been refined. ECLS has substantially improved survival and is the treatment of choice in the patient with unstable circulation or cardiac arrest.
    Tags: Cardiopulmonary bypass, Cardiopulmonary resuscitation, Cardiopulmonary Resuscitation/*methods, Emergency Medical Services/*methods, Emergency medicine, Extracorporeal membrane oxygenation, Heart Arrest/*therapy, Humans, Hypothermia, Hypothermia/*therapy, Resuscitation, Rewarming/*methods.
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  • Popovic, M., Blum, C. A., Nigro, N., Mueller, B., Schuetz, P., and Christ-Crain, M. “Benefit Of Adjunct Corticosteroids For Community-Acquired Pneumonia In Diabetic Patients”. Diabetologia 59, no. 12: 2552-2560. doi:10.1007/s00125-016-4091-4.
    Abstract: AIMS/HYPOTHESIS: We have recently shown that adjunct prednisone shortens the time taken to reach clinical stability (time to clinical stability, TTCS) in patients with community-acquired pneumonia (CAP). Considering the hyperglycaemic effects of prednisone, there are concerns about the efficacy and safety of this therapy for diabetic patients with CAP. Our objective was to evaluate whether diabetes and/or hyperglycaemia on admission to hospital has an influence on the effect of corticosteroids on outcome in a well-defined cohort of patients with CAP. METHODS: This is a preplanned subanalysis of a prospective randomised, double-blind placebo-controlled multicentre trial. Patients aged 18 years or older with CAP were eligible and were recruited from seven tertiary care hospitals in Switzerland within 24 h of presentation. Patients were randomised (1:1 ratio) to receive either 50 mg of prednisone daily for 7 days or placebo. Allocation was concealed with a prespecified computer-generated randomisation list. Patients, treating physicians, investigators and data assessors were masked to treatment allocation. The primary endpoint was TTCS; secondary endpoints were length of stay, mortality, duration of antibiotic treatment, CAP complications and new insulin requirement at day 30. Furthermore, we analysed whether these endpoints were influenced by a glycaemic dysregulation during the study time. RESULTS: Of 802 patients randomised (n = 402 in the prednisone, n = 400 in the placebo group), 726 patients were treated per protocol and included in this analysis (n = 362 in the prednisone, n = 364 in the placebo group). Nineteen per cent of 726 patients had diabetes mellitus (n = 66 in the prednisone group, n = 72 in the placebo group). Adjunct prednisone shortened TTCS in diabetic and non-diabetic patients (HR 1.65 [95% CI 1.16, 2.35], p = 0.007; 1.30 [95% CI 1.10, 1.53], p = 0.002) with no evidence for effect modification by diabetes in interaction analysis (p = 0.44). No difference was found in other clinically relevant endpoints. Although adjunct prednisone was associated with glycaemic dysregulation, this did not translate into worse clinical outcomes in either group, and there was no difference in secondary endpoints. CONCLUSIONS/INTERPRETATION: The benefit of adjunct prednisone in CAP patients is also valid for those with diabetes or hyperglycaemia on admission. Hyperglycaemia in diabetic patients or due to adjunct prednisone did not have a negative effect on outcome. TRIAL REGISTRATION: ClinicalTrials.gov NCT00973154 FUNDING : This study was supported by a grant from the Swiss National Foundation and by the Nora van Meeuwen Hafliger Stiftung and the Gottfried Julia Bangerter-Rhyner Stiftung.
    Tags: Aged, Aged, 80 and over, Anti-Inflammatory Agents/adverse effects/therapeutic use, Community-Acquired Infections, Community-acquired pneumonia, Corticosteroids, Diabetes mellitus, Diabetes Mellitus/*blood/*drug therapy, Double-Blind Method, Female, Humans, Hyperglycaemia, Hyperglycemia/*blood/*drug therapy, Male, Middle Aged, Pneumonia, Pneumonia/*blood/*drug therapy, Prednisone, Prednisone/*adverse effects/*therapeutic use, Time to clinical stability, Treatment Outcome.
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  • Liakoni, E., Walther, F., Nickel, C. H., and Liechti, M. E. “Presentations To An Urban Emergency Department In Switzerland Due To Acute Gamma-Hydroxybutyrate Toxicity”. Scand J Trauma Resusc Emerg Med 24, no. 1: 107. doi:10.1186/s13049-016-0299-z.
    Abstract: BACKGROUND: gamma-Hydroxybutyrate (GHB) is a drug of abuse with dose-dependent sedative effects. Systematic data on the acute toxicity of GHB from emergency department (ED) presentations over a long period of time are currently missing from the literature. The present study described the clinical features of GHB toxicity. METHODS: Retrospective case series of GHB intoxications seen in an urban ED. RESULTS: From January 2002 to September 2015, 78 GHB-related intoxication cases were recorded (71 % male patients). The mean +/- SD age was 29 +/- 8 years. The co-use of alcohol and/or other illicit drugs was reported in 65 % of the cases. Neurological symptoms other than central nervous system depression included agitation (40 %) and clonus (21 %). The most frequent reasons for admission were coma (64 %) and agitation (23 %). The median time to regain consciousness was 90 min (range, 3-400 min). Sudden recovery was reported in 25 cases (32 %). Coma was not significantly associated with polyintoxication. Coma occurred in 77 % of the alcohol co-users and in 62 % ofthe non-alcohol users (p=0.052). The mean recovery time in comatose patients was 142 min in patients with co-use of alcohol compared with 89 min in patients without alcohol co-use (p=0.07). Alcohol co-use was not significantly associated with nausea/vomiting (p=0.07). The co-use of stimulants was not significantly associated with non-responsive coma (Glasgow Coma Scale = 3) or mean recovery time. Analytical confirmation of GHB was available in 37 cases (47 %), with additional quantitative analysis in 20 cases. The median GHB concentration was 240 mg/L (range, 8.3-373 mg/L). Intoxication was severe in 72 % of the cases. No fatalities occurred, and 72 % of the patients were discharged directly home from the ED. DISCUSSION: There were trend associations between alcohol co-use and frequency and length of coma and nausea/vomiting which did not reach the significance level (all p=0.05-0.07) but may nevertheless be clinically relevant. As the exact time of use is not always known, and co-use of other substances can affect the severity of poisoning, no definitive conclusions can be drawn regarding the association between GHB concentration and severity. CONCLUSION: Impaired consciousness and agitation were typical findings of GHB intoxication. The co-use of alcohol and/or other illicit substances is common but was not significantly associated with the severity of the intoxications in our study.
    Tags: *Hospitals, Urban, Acute toxicity, Adolescent, Adult, Diagnosis, Differential, Drug Overdose/diagnosis/*epidemiology, Female, Follow-Up Studies, Gamma-hydroxybutyrate, Ghb, Humans, Incidence, Male, Middle Aged, Retrospective Studies, Sodium Oxybate/*poisoning, Switzerland/epidemiology, Young Adult.
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  • Tavares, V., Carron, P. N., Yersin, B., Taffe, P., Burnand, B., and Pittet, V. “The Probability Of Having Advanced Medical Interventions Is Associated With Age In Out-Of-Hospital Life-Threatening Situations”. Scand J Trauma Resusc Emerg Med 24, no. 1: 103. doi:10.1186/s13049-016-0294-4.
    Abstract: BACKGROUND: The use of out-of-hospital emergency medical services by old and very old individuals is increasing. These patients frequently require complex evaluation and decision-making processes to determine a strategy of care, therapeutic choices or withdrawal of care in life-threatening situations. During out-of-hospital missions, thorough decision-making is difficult because of the limited amount of time and lack of direct access to medical charts or to pre-existing advance directives. In this setting, age may be used as a proxy to determine strategy of care, therapeutic choices or withdrawal of care, particularly in relation to advanced medical interventions. We aimed to determine how an emergency physician's initiation of out-of-hospital advanced medical interventions varies with the patient's age. METHODS: We performed a retrospective analysis of the missions conducted by the emergency physicians-staffed emergency medical services in a Swiss region. We used logistic regression analysis to determine whether the probability of receiving an advanced medical intervention was associated with the patient's age. RESULTS: Among 21,922 out-of-hospital emergency adult missions requiring an emergency physician, the probability of receiving an advanced medical intervention decreased with age. It was highest among those aged 18 - 58 years and significantly lower among those aged >/= 89 years (OR = 0.66; 95 % CI: 0.53 - 0.82). The probability of cardiopulmonary resuscitation attempts progressively decreased with age and was significantly lower for the three oldest age deciles (80 - 83, 84 - 88 and >/= 89 years). CONCLUSION: The number of out-of-hospital advanced medical interventions significantly decreased for patients aged >/= 89 years. It is unknown whether this lower rate of interventions was related only to age or to other medical characteristics of these patients, such as the number or severity of comorbidities. Thus, further studies are needed to confirm whether this observation corresponds to underuse of advanced medical interventions in very old patients.
    Tags: *Decision Making, *Emergency Medical Services, Adolescent, Adult, Age Factors, Aged, Aged, 80 and over, Ageing, Cardiopulmonary resuscitation, Critical care medicine, Critical Care/*methods, Databases, Factual, Decision-making, Female, Humans, Logistic Models, Male, Middle Aged, Out-of-hospital emergency medical services, Retrospective Studies, Switzerland, Young Adult.
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  • Schuetz, P., Daniels, L. B., Kulkarni, P., Anker, S. D., and Mueller, B. “Procalcitonin: A New Biomarker For The Cardiologist”. Int J Cardiol 223: 390-397. doi:10.1016/j.ijcard.2016.08.204.
    Abstract: Due to its high accuracy for the diagnosis of bacterial infections, the inflammatory biomarker procalcitonin (PCT) is increasingly being used in patients with suspected infection. In patients with infections of the respiratory tract, it allows rapid rule out of bacterial etiology and facilitates decisions pertaining to antibiotic management. A growing body of evidence also supports PCT testing in patients with cardiovascular disorders including, but not limited to, those with shortness of breath, possible heart failure, suspected endocarditis, and acute coronary syndromes. In these clinical situations, PCT may provide diagnostic information on the likelihood of an infectious cause in cardiovascular patients presenting with acute symptoms such as dyspnea. It may also have a prognostic value that correlates with clinical outcome and can potentially guide drug therapy. This narrative review summarizes current concepts and evidence from the published literature on the strengths and limitations of PCT as a biomarker, with a focus on patients with a variety of cardiovascular disorders.
    Tags: *Cardiologists, Acute Disease, Biomarker, Biomarkers/blood, Calcitonin/*blood, Cardiovascular Diseases/blood/*diagnosis, Dyspnea, Humans, Procalcitonin.
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  • Carr, Z., Weiss, W., Roebbel, N., and Abrahams, J. “Protecting Public Health In Nuclear Emergencies-The Need To Broaden The Process”. Radiat Prot Dosimetry 171, no. 1: 163-7. doi:10.1093/rpd/ncw233.
    Abstract: It is necessary for the radiation protection system to broaden beyond radioactive dose, the view on impact of nuclear accidents, taking in consideration the psychological, social and economic determinants impacting the vulnerability of the exposed population, as well as the impacts of emergency countermeasures. It is strongly recommended to pursue strategies, approaches and services that will address these aspects within the general health protection system and will be applied before, during and after an emergency. The paper raises awareness and proposes a three-step development process for an integrated framework based on the social determinants of health approach.
    Tags: Disaster Planning/methods, Emergencies, Environmental Exposure/*prevention & control, Europe, Humans, Public Health, Radiation Injuries/*prevention & control, Radiation Monitoring, Radiation Protection/*methods, Radioactive Hazard Release/*prevention & control, Risk Assessment, Risk Management/methods.
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  • Hofmann, E., Limacher, A., Mean, M., Kucher, N., Righini, M., Frauchiger, B., Beer, J. H., et al. “Echocardiography Does Not Predict Mortality In Hemodynamically Stable Elderly Patients With Acute Pulmonary Embolism”. Thromb Res 145: 67-71. doi:10.1016/j.thromres.2016.07.014.
    Abstract: BACKGROUND: The evidence on the prognostic value of transthoracic echocardiography (TTE) in elderly, hemodynamically stable patients with Pulmonary Embolism (PE) is limited. OBJECTIVES: To evaluate the prevalence of common echocardiographic signs of right ventricular (RV) dysfunction and their prognostic impact in hemodynamically stable patients aged >/=65years with acute PE in a prospective multicenter cohort. METHODS: TTE was performed by cardiologists. We defined RV dysfunction as a RV/left ventricular ratio >0.9 or RV hypokinesis (primary definition) or the presence of >/=1 or >/=2 of 6 predefined echocardiographic signs (secondary definitions). Outcomes were overall mortality and mortality/non-fatal recurrent venous thromboembolism (VTE) at 30days, adjusting for the Pulmonary Embolism Severity Index risk score and highly sensitive troponin T values. RESULTS: Of 400 patients, 36% had RV dysfunction based on our primary definition, and 81% (>/=1 sign) and 53% (>/=2 signs) based on our secondary definitions, respectively. Using our primary definition, there was no association between RV dysfunction and mortality (adjusted HR 0.90, 95% CI 0.31-2.58) and mortality/non-fatal VTE (adjusted HR 1.09, 95% CI 0.40-2.98). Similarly, there was no statistically significant association between the presence of >/=1 or >/=2 echocardiographic signs (secondary definitions) and clinical outcomes. CONCLUSION: The prevalence of echocardiographic RV dysfunction varied widely depending upon the definition used. There was no association between RV dysfunction and clinical outcomes. Thus, TTE may not be suitable as a stand-alone risk assessment tool in elderly patients with acute PE. CLINICAL TRIAL REGISTRATION: http://clinicaltrials.gov. Identifier: NCT00973596.
    Tags: Aged, Aged, 80 and over, Cohort Studies, Echocardiography, Echocardiography/*methods, Female, Humans, Male, Mortality, Prospective Studies, Pulmonary embolism, Pulmonary Embolism/*diagnostic imaging/mortality, Treatment Outcome.
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  • Webb, M. J., Kauer, S. D., Ozer, E. M., Haller, D. M., and Sanci, L. A. “Does Screening For And Intervening With Multiple Health Compromising Behaviours And Mental Health Disorders Amongst Young People Attending Primary Care Improve Health Outcomes? A Systematic Review”. Bmc Fam Pract 17, no. 1: 104. doi:10.1186/s12875-016-0504-1.
    Abstract: BACKGROUND: Adolescence and young adulthood are important developmental periods. Screening for health compromising behaviours and mental health disorders during routine primary care visits has the potential to assist clinicians to identify areas of concern and provide appropriate interventions. The objective of this systematic review is to investigate whether screening and subsequent interventions for multiple health compromising behaviours and mental health disorders in primary care settings improves the health outcomes of young people. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, literature searches were conducted in Medline, PsycINFO, Scopus and Cochrane Library databases (Prospero registration number CRD42013005828) using search terms representing four thematic concepts: primary care, young people, screening, and mental health and health compromising behaviour. To be eligible for inclusion, studies had to: include a measure of health outcome; include at least 75 % of participants aged under 25 years; use a screening tool that assessed more than one health domain; and be conducted within a primary care setting. Risk of bias was assessed using the Quality Rating Scale. RESULTS: From 5051 articles identified, nine studies fulfilled the inclusion criteria and were reviewed: two randomised controlled trials (RCTs), one pilot RCT, two clustered RCTs, one randomised study with multiple intervention groups and no control group, one cluster RCT with two active arms, one longitudinal study and one pre-post study. Seven studies, including two RCTs and one clustered RCT, found positive changes in substance use, diet, sexual health or risky sexual behaviour, alcohol-related risky behaviour, social stress, stress management, helmet use, sleep and exercise. Of only two studies reporting on harms, one reported a negative health outcome of increased alcohol use. CONCLUSIONS: There is some evidence that the use of screening and intervention with young people for mental health disorder or health compromising behaviours in clinical settings improves health outcomes. Along with other evidence that young people value discussions of health risks with their providers, these discussions should be part of the routine primary care of young people. Further quality studies are needed to strengthen this evidence.
    Tags: *Health Behavior, *Mass Screening, *Primary Health Care, Adolescent, Diet, Exercise, Head Protective Devices, Health compromising behaviour, Humans, Mental health, Prevention, Primary care, Screening, Sleep, Smoking/*therapy, Stress, Psychological/diagnosis/therapy, Substance-Related Disorders/*diagnosis/therapy, Treatment Outcome, Unsafe Sex/prevention & control, Young Adult.
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  • Sauter, T. C., Hautz, W. E., Hostettler, S., Brodmann-Maeder, M., Martinolli, L., Lehmann, B., Exadaktylos, A. K., and Haider, D. G. “Interprofessional And Interdisciplinary Simulation-Based Training Leads To Safe Sedation Procedures In The Emergency Department”. Scand J Trauma Resusc Emerg Med 24, no. 1: 97. doi:10.1186/s13049-016-0291-7.
    Abstract: BACKGROUND: Sedation is a procedure required for many interventions in the Emergency department (ED) such as reductions, surgical procedures or cardioversions. However, especially under emergency conditions with high risk patients and rapidly changing interdisciplinary and interprofessional teams, the procedure caries important risks. It is thus vital but difficult to implement a standard operating procedure for sedation procedures in any ED. Reports on both, implementation strategies as well as their success are currently lacking. This study describes the development, implementation and clinical evaluation of an interprofessional and interdisciplinary simulation-based sedation training concept. METHODS: All physicians and nurses with specialised training in emergency medicine at the Berne University Department of Emergency Medicine participated in a mandatory interdisciplinary and interprofessional simulation-based sedation training. The curriculum consisted of an individual self-learning module, an airway skill training course, three simulation-based team training cases, and a final practical learning course in the operating theatre. Before and after each training session, self-efficacy, awareness of emergency procedures, knowledge of sedation medication and crisis resource management were assessed with a questionnaire. Changes in these measures were compared via paired tests, separately for groups formed based on experience and profession. To assess the clinical effect of training, we collected patient and team satisfaction as well as duration and complications for all sedations in the ED within the year after implementation. We further compared time to beginning of procedure, time for duration of procedure and time until discharge after implementation with the one year period before the implementation. Cohen's d was calculated as effect size for all statistically significant tests. RESULTS: Fifty staff members (26 nurses and 24 physicians) participated in the training. In all subgroups, there is a significant increase in self-efficacy and knowledge with high effect size (d z = 1.8). The learning is independent of profession and experience level. In the clinical evaluation after implementation, we found no major complications among the sedations performed. Time to procedure significantly improved after the introduction of the training (d = 0.88). DISCUSSION: Learning is independent of previous working experience and equally effective in raising the self-efficacy and knowledge in all professional groups. Clinical outcome evaluation confirms the concepts safety and feasibility. CONCLUSION: An interprofessional and interdisciplinary simulation-based sedation training is an efficient way to implement a conscious sedation concept in an ED.
    Tags: *Attitude of Health Personnel, *Curriculum, *Self Efficacy, Adult, Clinical Competence, Conscious sedation, Education, Medical/*standards, Emergency department, Emergency Medicine/*education, Female, Humans, Interprofessional education, Male, Middle Aged, Nurses/*standards, Physicians/*standards, Retrospective Studies, Young Adult.
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  • Rigamonti, F., Gencer, B., Rey, F., Chaara, J., Tessitore, E., Bunwaree, S., Meier, P., et al. “Pre-Hospital Alarm Activation For Stemi Patients Undergoing Primary Percutaneous Coronary Intervention In The Era Of Transradial Procedures”. Eur J Intern Med 35: 83-88. doi:10.1016/j.ejim.2016.07.002.
    Abstract: BACKGROUND: Transradial access (TRA) improves outcome compared with trans-femoral access for the management of patients with acute coronary syndromes. In this setting, it is unknown whether the activation of a pre-hospital alarm system (PHAS) confers additional benefit for the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). MATERIALS AND METHODS: We retrospectively analyzed a cohort of patients with a first STEMI who underwent a primary percutaneous coronary intervention (PPCI) at a single center within a prospective cohort of acute coronary syndrome patients (SPUM-ACS). TRA was used in 85% of patients. We assessed how PHAS (n=165) vs. no-PHAS (n=166) activation was associated with the composite outcome of all-cause mortality and recurrence of myocardial infarction (MI) at 1-year follow-up. As secondary outcomes, the individual clinical endpoints were separately assessed for association. RESULTS: Compared with no-PHAS patients, patients in the PHAS group were predominantly women, and presented more frequently with dyslipidemia and cardiac arrest. A significant reduction in the composite outcome of all-cause mortality and recurrent MI at 1-year was observed in the PHAS group, compared with no-PHAS (3.6% vs. 8.5%, p=0.027). When adjusted for age, sex and resuscitation status, PHAS activation remained associated with decreased all-cause mortality and recurrent MI (HR: 0.36 [95% CI: 0.13-0.95]; p=0.040). CONCLUSIONS: This study suggests that the benefit of PHAS activation in STEMI patients undergoing PPCI persists also in the era of TRA.
    Tags: *Percutaneous Coronary Intervention, Acute Coronary Syndrome/*complications, Aged, Anti-Inflammatory Agents, Non-Steroidal/therapeutic use, Emergency Medical Services/*methods, Female, Humans, Immunosuppressive Agents/therapeutic use, Male, Middle Aged, Multivariate Analysis, Pre-hospital alarm system, Primary PCI, Prognosis, Radial Artery/surgery, Retrospective Studies, ST Elevation Myocardial Infarction/mortality/*therapy, Stemi, Switzerland, Transradial access, Treatment Outcome.
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  • Hillinger, P., Twerenbold, R., Wildi, K., Rubini Gimenez, M., Jaeger, C., Boeddinghaus, J., Nestelberger, T., et al. “Gender-Specific Uncertainties In The Diagnosis Of Acute Coronary Syndrome”. Clin Res Cardiol 106, no. 1: 28-37. doi:10.1007/s00392-016-1020-y.
    Abstract: BACKGROUND: It is unknown whether higher rates of delayed diagnosis and misdiagnosis of acute coronary syndrome (ACS) in women might have contributed to the poorer outcome of women. METHODS: In a prospective diagnostic multicenter study, we recruited patients presenting to the emergency department (ED) with any kind of chest discomfort/chest pain with onset or peak within the last 12 h. We quantified early diagnostic uncertainty for the presence of ACS among treating physicians at the ED after 90 min, possibly responsible for delayed diagnosis, using a visual analogue scale. Late diagnostic uncertainty, possibly responsible for misdiagnosis, was defined as disagreement among two independent cardiologists' adjudication of the final diagnosis after complete work-up. RESULTS: Among 2795 patients (897 women and 1898 men), ACS was the adjudicated final diagnosis in 24 % of women and 35 % of men. Early diagnostic accuracy of clinical judgment of the ED physician for ACS as quantified by the area under the receiver-operating characteristics curve was 0.89 (95 % CI 0.87-0.92) in women and 0.86 (95 % CI 0.85-0.88) in men (p = 0.046). Late diagnostic uncertainty regarding the diagnosis of ACS was 5 % in women and 7 % in men (p = 0.069). CONCLUSION: Diagnostic uncertainty for the presence of ACS in women is not more common as compared to men and does, therefore, not explain the poorer outcome observed in women with ACS. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov . Unique identifier: NCT00470587.
    Tags: *Health Status Disparities, *Healthcare Disparities, *Uncertainty, Acute coronary syndrome, Acute Coronary Syndrome/complications/*diagnosis/therapy, Aged, Area Under Curve, Delayed Diagnosis, Diagnostic Errors, Diagnostic uncertainty, Emergency Service, Hospital, Europe, Female, Gender, Humans, Male, Middle Aged, Observer Variation, Predictive Value of Tests, Prognosis, Prospective Studies, Reproducibility of Results, ROC Curve, Sex Factors.
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  • Sauter, T. C., Ziegenhorn, S., Ahmad, S. S., Hautz, W. E., Ricklin, M. E., Leichtle, A. B., Fiedler, G. M., Haider, D. G., and Exadaktylos, A. K. “Age Is Not Associated With Intracranial Haemorrhage In Patients With Mild Traumatic Brain Injury And Oral Anticoagulation”. J Negat Results Biomed 15, no. 1: 12. doi:10.1186/s12952-016-0055-y.
    Abstract: BACKGROUND: Patients admitted to emergency departments with traumatic brain injury (TBI) are commonly being treated with oral anticoagulants. In contrast to patients without anticoagulant medication, no guidelines, scores or recommendations exist for the management of mild traumatic brain injury in these patients. We therefore tested whether age as one of the high risk factors of the Canadian head CT rule is applicable to a patient population on oral anticoagulants. METHODS: This cross-sectional analysis included all patients with mild TBI and concomitant oral anticoagulant therapy admitted to the Emergency Department, Inselspital Bern, Switzerland, from November 2009 to October 2014 (n = 200). Using a logistic regression model, two groups of patients with mild TBI on oral anticoagulant therapy were compared - those with and those without intracranial haemorrhage. RESULTS: There was no significant difference in age between the patient groups with (n = 86) and without (n = 114) intracranial haemorrhage (p = 0.078). In univariate logistic regression, GCS (OR = 0.419 (0.258; 0.680)) and thromboembolic event as reason for anticoagulant therapy (OR = 0.486 (0.257; 0.918)) were significantly associated with intracranial haemorrhage in patients with mild TBI and anticoagulation (all p < 0.05). However, there was no association with age (p = 0.078, OR = 1.024 (0.997; 1.051)), the type of accident or additional medication with acetylsalicylic acid or clopidogrel ((both p > 0.05; 0.552 (0.139; 2.202) and 0.256 (0.029; 2.237), respectively). CONCLUSION: Our study found no association between age and intracranial bleeding. Therefore, until further risk factors are identified, diagnostic imaging with CCT remains necessary for mild TBI patients on oral anticoagulation of all ages, especially those with therapeutic anticoagulation because of thromboembolic events.
    Tags: Administration, Oral, Age, Age Factors, Aged, Anticoagulants/*administration & dosage/*therapeutic use, Anticoagulation, Brain Injuries, Traumatic/*complications/*drug therapy, Female, Humans, Intracranial Hemorrhages/*complications/*drug therapy, Male, Mild traumatic brain injury, Risk factor.
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  • Bodenmann, P., Velonaki, V. S., Griffin, J. L., Baggio, S., Iglesias, K., Moschetti, K., Ruggeri, O., et al. “Case Management May Reduce Emergency Department Frequent Use In A Universal Health Coverage System: A Randomized Controlled Trial”. J Gen Intern Med 32, no. 5: 508-515. doi:10.1007/s11606-016-3789-9.
    Abstract: BACKGROUND: Frequent emergency department (ED) users account for a disproportionately high number of ED visits. Studies on case management (CM) interventions to reduce frequent ED use have shown mixed results, and few studies have been conducted within a universal health coverage system. OBJECTIVE: To determine whether a CM intervention-compared to standard emergency care-reduces ED attendance. DESIGN: Randomized controlled trial. PARTICIPANTS: Two hundred fifty frequent ED users (5 or more visits in the prior 12 months) who visited a public urban ED at the Lausanne University Hospital between May 2012 and July 2013 were allocated to either an intervention (n = 125) or control (n = 125) group, and monitored for 12 months. INTERVENTIONS: An individualized CM intervention consisting of concrete assistance in obtaining income entitlements, referral to primary or specialty medical care, access to mental health care or substance abuse treatment, and counseling on at-risk behaviors and health care utilization (in addition to standard care) at baseline and 1, 3, and 5 months. MAIN MEASURES: We used a generalized linear model for count data (negative binomial distribution) to compare the number of ED visits during the 12-month follow-up between CM and usual care, from an intention-to-treat perspective. KEY RESULTS: At 12 months, there were 2.71 (+/-0.23) ED visits in the intervention group versus 3.35 (+/-0.32) visits among controls (ratio = 0.81, 95 % CI = 0.63; 1.02). In the multivariate model, the effect of the CM intervention on the number of ED visits approached statistical significance (b = -0.219, p = 0.075). The presence of poor social determinants of health was a significant predictor of ED use in the multivariate model (b = 0.280, p = 0.048). CONCLUSIONS: CM may reduce ED use by frequent users through an improved orientation to the health care system. Poor social determinants of health significantly increase use of the ED by frequent users.
    Tags: *Patient Acceptance of Health Care, Adult, Aged, case management, Case Management/*trends, clinical trials, Emergency Service, Hospital/*statistics & numerical data/*trends, Female, Follow-Up Studies, Hospitals, University/trends, Humans, Male, Middle Aged, National Health Programs/*trends, Single-Blind Method, Switzerland/epidemiology, utilization, vulnerable populations.
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  • Drolz, A., Horvatits, T., Roedl, K., Rutter, K., Staufer, K., Haider, D. G., Zauner, C., et al. “Outcome And Features Of Acute Kidney Injury Complicating Hypoxic Hepatitis At The Medical Intensive Care Unit”. Ann Intensive Care 6, no. 1: 61. doi:10.1186/s13613-016-0162-4.
    Abstract: BACKGROUND: Hypoxic hepatitis (HH) is a frequent and potentially life-threatening event typically occurring in critically ill patients as a consequence of hemodynamic impairment. While acute kidney injury (AKI) has been well described in patients with acute liver failure, incidence and outcome of AKI accompanying HH are unclear. The aim of this study was to assess incidence, clinical implications and outcome of AKI and renal replacement therapy (RRT) in critically ill patients with HH. METHODS: A total of 1948 consecutive critically ill admissions were studied at the Medical University of Vienna. Laboratory and clinical parameters as well as the presence of HH and AKI were assessed on a daily basis. Outcome, renal recovery and length of stay were assessed and documented, and patients were followed for 1 year. RESULTS: A total of 295 admissions (15 %) developed HH. Main precipitators were cardiogenic (44 %) and septic shock (36 %). Occurrence of HH was significantly associated with AKI [OR 4.50 (95 % CI 3.30-6.12)] and necessity of renal replacement therapy [RRT; OR 3.36 (95 % CI 2.58-4.37)], p < 0.001 for both. Two hundred forty admissions with HH (81 %) developed AKI, 159 of whom (66 %) had AKI stage 3. Both HH and AKI were significantly linked to mortality. AKI stage 3, international normalized ratio (INR, during HH) and the presence of septic shock were identified as independent predictors of 28-day mortality in admissions with HH, whereas RRT was identified as an independent protective factor. There was a synergistic effect of HH and AKI on length of stay at the ICU. Of all HH survivors treated with RRT, 71 % showed renal recovery during follow-up. CONCLUSION: HH is frequently complicated by occurrence of AKI. Severity of HH, AKI stage and the presence of septic shock seem to contribute to poor outcome in these patients. Initiation of RRT in HH with AKI may enable renal recovery and should not be withheld in medical ICU patients.
    Tags: Acute kidney injury, Hypoxic hepatitis, Mortality, Renal replacement therapy.
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  • Dhayat, N. A., Ackermann, D., Pruijm, M., Ponte, B., Ehret, G., Guessous, I., Leichtle, A. B., et al. “Fibroblast Growth Factor 23 And Markers Of Mineral Metabolism In Individuals With Preserved Renal Function”. Kidney Int 90, no. 3: 648-57. doi:10.1016/j.kint.2016.04.024.
    Abstract: Fibroblast growth factor 23 (FGF23) is a bone-derived hormone that regulates phosphate homeostasis. Circulating FGF23 is elevated in chronic kidney disease (CKD) and independently associated with poor renal and cardiovascular outcomes and mortality. Because the study of FGF23 in individuals with normal renal function has received little attention, we examined in a large, population-based study of 1128 participants the associations of FGF23 with markers of mineral metabolism and renal function. The median estimated glomerular filtration rate (eGFR) of the cohort was 105 ml/min per 1.73 m(2), and the median plasma FGF23 was 78.5 RU/ml. FGF23 increased and plasma 1,25-dihydroxyvitamin D3 decreased significantly below an eGFR threshold of 102 and 99 ml/min per 1.73 m(2), respectively. In contrast, plasma parathyroid hormone increased continuously with decreasing eGFR and was first significantly elevated at an eGFR of 126 ml/min per 1.73 m(2). On multivariable analysis adjusting for sex, age, body mass index, and GFR, FGF23 was negatively associated with 1,25-dihydroxyvitamin D3, and urinary absolute and fractional calcium excretion but not with serum calcium or parathyroid hormone. We found a positive association of FGF23 with plasma phosphate, but no association with urinary absolute or fractional phosphate excretion and, unexpectedly, a positive association with tubular maximum phosphate reabsorption/GFR. Thus, in the absence of CKD, parathyroid hormone increases earlier than FGF23 when the eGFR decreases. The increase in FGF23 occurs at a higher eGFR threshold than previously reported and is closely associated with a decrease in 1,25-dihydroxyvitamin D3. We speculate that the main demonstrable effect of FGF23 in the setting of preserved renal function is suppression of 1,25-dihydroxyvitamin D3 rather than stimulation of renal phosphate excretion.
    Tags: Adult, Biomarkers/blood/urine, Calcitriol/*blood/metabolism, calcium, Calcium/blood/urine, Cross-Sectional Studies, Female, Fgf23, Fibroblast Growth Factor-23, Fibroblast Growth Factors/*blood/metabolism, Glomerular Filtration Rate/*physiology, Healthy Volunteers, Humans, Kidney/*physiology, Male, Middle Aged, Parathyroid Hormone/blood, phosphate, Phosphates/*blood/metabolism/urine, Pth, Renal Elimination/physiology, TmP/GFR.
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  • Adam, A., Faouzi, M., Yersin, B., Bodenmann, P., Daeppen, J. B., and Bertholet, N. “Women And Men Admitted For Alcohol Intoxication At An Emergency Department: Alcohol Use Disorders, Substance Use And Health And Social Status 7 Years Later”. Alcohol Alcohol 51, no. 5: 567-75. doi:10.1093/alcalc/agw035.
    Abstract: AIMS: To assess the prevalence of alcohol use disorder (AUD), substance use, mental health and social status 7 years following an Emergency Department (ED) admission for alcohol intoxication. To assess gender differences in these prevalences. METHODS: Cohort of 631 patients aged 18-30 years admitted for alcohol intoxication in 2006-2007 at a tertiary referral hospital in Switzerland, contacted for an interview in 2014. Assessment consisted of demography, Alcohol Use Disorders Identification Test-Consumption, Mini International Neuropsychiatric Interview for AUD, Patient Health Questionnaire (depression, anxiety) and lifetime/past year use of tobacco/illegal drugs. Gender differences were assessed with Chi-square tests, t-tests and Wilcoxon tests. RESULTS: In 2014, 318/631 (50.4%) completed the interview. Study completers were not different from non-completers on baseline characteristics (all P > 0.2). Of study completers, 36.8% were unemployed, 56.9% reported hazardous alcohol use, 15.1% alcohol dependence, 13.2% harmful use, 18.6% depression, 15.4% anxiety disorder. Prevalence of any use (lifetime/past year) was 93.4%/80.2% for tobacco, 86.6%/53.1% for cannabis, 54.7%/22.6% for cocaine, 25.6%/13.5% for sedatives, 40.9%/11.0% for stimulants, 21.7%/7.2% for opioids. Men reported significantly more binge drinking, AUD, cannabis use (past year) and more lifetime cannabis, cocaine and stimulants use (all P < 0.05). There was no gender difference in the prevalence of hazardous alcohol use and tobacco use. The prevalence of psychiatric disorders was significantly higher in women (P < 0.05). CONCLUSIONS: Seven years after being admitted for alcohol intoxication, young patients are likely to present substance misuse, mental health disorders and social problems, suggesting that they should be offered secondary prevention measures while in the ED. SHORT SUMMARY: We studied a cohort of patients aged 18-30 and admitted for alcohol intoxication in 2006-2007 at a tertiary hospital. Participants were interviewed in 2014. Seven years after an admission for alcohol intoxication, patients are likely to present AUDs, substance misuse, mental health disorders and social problems.
    Tags: *Emergency Service, Hospital/statistics & numerical data, *Social Class, Adolescent, Adult, Aftercare, Alcohol-Related Disorders/*epidemiology, Alcoholic Intoxication/*therapy, Female, Health Status, Hospitalization/statistics & numerical data, Humans, Male, Sex Factors, Substance-Related Disorders/*epidemiology, Surveys and Questionnaires, Switzerland/epidemiology, Young Adult.
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  • Nickel, C. H., Kellett, J., Cooksley, T., Bingisser, R., Henriksen, D. P., and Brabrand, M. “Combined Use Of The National Early Warning Score And D-Dimer Levels To Predict 30-Day And 365-Day Mortality In Medical Patients”. Resuscitation 106: 49-52. doi:10.1016/j.resuscitation.2016.06.012.
    Abstract: AIM: To investigate the combined use of NEWS and D-dimer levels to predict the 30-day and 365-day mortality rates of a cohort of Danish patients with complete follow-up. METHODS: Post-hoc retrospective observational study of acutely admitted medical patients aged 18 years or older who had D-dimer measured within 6h after arrival to two medical admission units in Denmark. RESULTS: The final study population consisted of 1201 patients with a median age of 65.0 years (range 18.0-107.0 years), and 44.7% were of male sex. Four patients (0.3%) died within 24h of admission, 69 (5.7%) within 30 days and 198 (16.5%) within 365 days. On admission, 576 (48%) patients had a NEWS>/=3 - of these 441 had a D-dimer>/=0.50mgL(-1): 55 (12.5%) of these patients died within 30 days, compared with 5 (3.7%) of the 135 patients with a D-dimer<0.50mgL(-1) (odds ratio 3.7, 95%CI 1.4-10.8). Nine of the 625 patients with a NEWS on admission <3 died within 30 days and all of these patients had a D-dimer>/=0.50mgL(-1). None of the 218 patients with a D-dimer<0.50mgL(-1) died within 30 days of admission. CONCLUSION: The combination of NEWS score<3 and D-dimer levels below 0.50mgL(-1) appears to identify patients of low risk of mortality within 30 days and, therefore, may prove to be a powerful risk assessment tool for acutely ill medical patients.
    Tags: *Hospital Mortality, *Predictive Value of Tests, Adolescent, Adult, Aged, Aged, 80 and over, Critical Illness/*mortality, D-dimer, Early warning scores, Emergency department, Female, Fibrin Fibrinogen Degradation Products/*analysis, Hospitalization/*statistics & numerical data, Humans, Male, Middle Aged, Mortality, predictive scores, Retrospective Studies, Risk Assessment, Risk stratification, Survival Analysis, Time Factors, Young Adult.
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  • Ackermann, S., Ghanim, L., Heierle, A., Hertwig, R., Langewitz, W., Mata, R., and Bingisser, R. “Information Structuring Improves Recall Of Emergency Discharge Information: A Randomized Clinical Trial”. Psychol Health Med 22, no. 6: 646-662. doi:10.1080/13548506.2016.1198816.
    Abstract: This article examines the extent to which structuring Emergency Department discharge information improves the ability to recall that information, and whether such benefits interact with relevant prior knowledge. Using three samples of students with different levels of prior medical knowledge, we investigated the amount of information recalled after structured vs. non-structured presentation of information. Across all student samples, the structured discharge information led to a relative increase in recalled items of 17% compared to non-structured discharge information (M = 9.70, SD = 4.96 vs. M = 8.31, SD = 4.93). In the sample with least medical knowledge, however, the structured discharge information resulted in a relative increase in recall by 42% (M = 8.12 vs. M = 5.71). These results suggest that structuring discharge information can be a useful tool to improve recall of information and is likely to be most beneficial for patient populations with lower levels of medical knowledge.
    Tags: *Health Knowledge, Attitudes, Practice, *Mental Recall, *Professional-Patient Relations, Adult, discharge communication, Emergency department, Emergency Service, Hospital/*standards, Female, Health Communication/*standards, Humans, information structuring, Male, Patient Discharge/*standards, physician-patient communication, recall, Young Adult.
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  • Garin, N., Felix, G., Chuard, C., Genne, D., Carballo, S., Hugli, O., Lamy, O., et al. “Predictors And Implications Of Early Clinical Stability In Patients Hospitalized For Moderately Severe Community-Acquired Pneumonia”. Plos One 11, no. 6: e0157350. doi:10.1371/journal.pone.0157350.
    Abstract: BACKGROUND: Assessment of early response to treatment is crucial for the management of community-acquired pneumonia (CAP). OBJECTIVE: To describe the predictors and the outcomes of early clinical stability. METHODS: We did a secondary analysis of a multicentre randomized controlled trial on CAP treatment in which 580 patients hospitalized for moderately severe CAP were included. The association between demographic, clinical and biological variables available at inclusion and early clinical stability (stabilization of vital signs within 72 hours with predetermined cut-offs) was assessed by multivariate logistic regression. The association between early clinical stability and mortality, severe adverse events, and length of stay was also tested. RESULTS: Younger age (OR 0.98, 95% CI 0.96-0.99), lower platelet count (OR per 10 G/L increment 0.96, 95% CI 0.94-0.98), lower respiratory rate (OR 0.94, 95% CI 0.90-0.97), absence of hypoxemia (OR 0.58, 95% CI 0.40-0.85), lower numbers of co-morbid conditions (OR 0.82, 95% CI 0.69-0.98) and signs or symptoms (OR 0.78, 95% CI 0.68-0.90) were significantly associated with early clinical stability. Patients with early clinical stability had lower 90-days mortality (3.4% vs. 11.9%, p<0.001), fewer admissions to the intensive care unit (2.7% vs. 8.0%, p = 0.005) and a shorter length of stay (6.0 days, IQR 4.0-10.0 vs. 10.0 days, IQR 7.0-15.0, p<0.001). CONCLUSIONS: Patients with younger age, less co-morbidity, fewer signs or symptoms, less respiratory compromise, and a lower platelet count are more likely to reach early clinical stability. Patients without early clinical stability have a worse prognosis and warrant close scrutiny.
    Tags: Adult, Age Factors, Aged, Community-Acquired Infections/*drug therapy/pathology, Female, Hospitalization/*statistics & numerical data, Humans, Length of Stay/*statistics & numerical data, Male, Middle Aged, Multicenter Studies as Topic, Multivariate Analysis, Outcome Assessment, Health Care/methods/statistics & numerical data, Pneumonia/*drug therapy/pathology, Prognosis, Randomized Controlled Trials as Topic, Severity of Illness Index, Time Factors, Young Adult.
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  • Wuest, A., Manser, H., Kuster, H., Lollgen, R. M., Arenz, T., Arenz, S., Nelle, M., and Gerull, R. “Comparison Of Treatment Strategies For Anaemia Of Prematurity In Extremely Low Birthweight Infants Between 1997 And 2011”. Arch Dis Child Fetal Neonatal Ed 101, no. 5: F480-1. doi:10.1136/archdischild-2016-310752.
    Tags: *Infant, Extremely Low Birth Weight, Anemia, Anemia, Neonatal/*therapy, Erythrocyte Transfusion, Erythropoietin/therapeutic use, Extremely low-birthweight infants, Humans, Infant, Premature, Preterm infants, Red blood cell, Transfusion.
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  • Persoz, M. O., Dami, F., Ciavatta, E., Vallotton, L., Albrecht, R., and Carron, P. N. “Hot Air Balloon: An Unusual Cause Of Multicasualty Trauma Incident”. Air Med J 35, no. 3: 176-9. doi:10.1016/j.amj.2015.12.014.
    Abstract: Hot air balloon incidents are few and far between compared with the total number of flights. Nevertheless, hot air balloon incidents may produce severe trauma involving several patients and are linked to significant mortality. The prehospital management of injured patients starts after having secured potential surrounding dangers, such as fire or explosion. In the context of a rescue by helicopter, close attention must be paid to potential obstacles, like trees or electrical wires, and the risk of aspiration of the balloon envelope into the rotor. Patients involved in such incidents are often split up in a closed perimeter around the crash point. The severity of the trauma depends essentially on the height of the fall. The most frequent traumatic lesions involve fractures of the lower limbs, the spine, and the pelvis as well as severe burns caused by the balloon fire. Because of the number of patients present, an initial triage is usually required at the site. The use of rescue helicopters can be helpful. They can perform aerial reconnaissance, provide on-site high-level resources, enable access to the patients even in hostile environments, and quickly transport them to trauma center hospitals.
    Tags: *Accidents, Aviation/prevention & control/statistics & numerical data, *Air Ambulances, Adult, Aged, Aircraft, Female, Humans, Male, Middle Aged, Multiple Trauma/etiology/therapy, Switzerland, Wounds and Injuries/*etiology/therapy, Young Adult.
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  • Garin, N., Hugli, O., Genne, D., and Greub, G. “Lack Of Chlamydia-Related Bacteria Among Patients With Community-Acquired Pneumonia”. New Microbes New Infect 8: 164-5. doi:10.1016/j.nmni.2015.10.002.
    Tags: Chlamydia psittaci, Chlamydia-related bacteria, community-acquired pneumonia, molecular diagnosis, Parachlamydia acanthamoebae.
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  • Braun, C. T., Ricklin, M. E., and Exadaktylos, A. K. “The Difficult Diagnosis Of Ischaemic Papillary Muscle Rupture: Case Report From An Urban Emergency Department”. Sultan Qaboos Univ Med J 16, no. 2: e234-7. doi:10.18295/squmj.2016.16.02.016.
    Abstract: We present a rare case of severe ischaemic papillary muscle rupture in a 67-year-old male patient who was admitted to the Emergency Department of the University Hospital Bern, Switzerland, in November 2013 with acute chest pain. On admission, the patient's blood pressure was 60/40 mm/Hg, his pulse was 110 beats per minute and his respiratory rate was 20 breaths per minute. An electrocardiogram was normal and focused assessment with sonography in trauma was negative. Transthoracic echocardiography showed possible thickening of the mitral valve leaflet with no indications of severe mitral insufficiency or wall motion abnormalities. Triple-rule-out computed tomography angiography revealed no pulmonary emboli or aortic dissection, although coronary atherosclerosis was present. Finally, severe insufficiency of the mitral valve with rupture of the papillary muscle, likely due to ischaemia, was observed via transoesophageal echocardiography. The patient underwent a successful surgical intervention and was discharged 10 days later in stable condition.
    Tags: Case Report, Echocardiography, Emergency Medicine, Heart Rupture, Myocardial Infarction, Papillary Muscles, Shock, Switzerland.
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  • Getaz, L., Casillas, A., Motamed, S., Gaspoz, J. M., Chappuis, F., and Wolff, H. “Hepatitis A Immunity And Region-Of-Origin In A Swiss Prison”. Int J Prison Health 12, no. 2: 98-105. doi:10.1108/IJPH-10-2015-0033.
    Abstract: Purpose - The environmental and demographic characteristics of closed institutions, particularly prisons, precipitate morbidity during hepatitis A virus (HAV) outbreaks. Given the high prevalence of chronic liver disease and other risk factors in the prison setting, the purpose of this paper is to examine HAV-immunity and its associated factors in this population. Design/methodology/approach - The cross-sectional study was conducted in 2009: a serology screening for HAV IgG was carried out among 116 inmates in Switzerland's largest pre-trial prison. Other participant characteristics were collected through a structured face-to-face questionnaire with a physician. Findings - In terms of significant demographics, Africa (53.5 percent) and the Balkans/Eastern Europe (36.2 percent) were the main regions of origin; a minority of inmates were from Western Europe (6.9 percent), Latin America (2.6 percent) or Asia (0.9 percent). The authors identified hepatitis A antibody-negative serology (lack of immunity) in five out of 116 prisoners (4.3 percent, 95 percent CI 1.4-9.7). Among participants of European origin alone, five out of 50 inmates were hepatitis A antibody-negative (10 percent, 95 percent CI 3.3-21.8), whereas the 66 inmates from other all continents were hepatitis A antibody-positive (immune) (p=0.026). Originality/value - In this prison population composed of mostly African migrants, hepatitis A immunity was high. This reaffirms that region of origin is highly associated with childhood immunity against HAV. HAV vaccination should take into account a patient's area of origin and his/her risk factors for systemic complications, if ever infected. This targeted strategy would offer herd immunity, and seek out the most vulnerable individuals who are potentially at risk of new exposure in this precarious setting.
    Tags: Adult, Black People/statistics & numerical data, Cross-Sectional Studies, Emigrants and Immigrants/statistics & numerical data, Harm reduction, Harm Reduction/drug effects, Health Status, Hepatitis A, Hepatitis A Antibodies/blood/immunology, Hepatitis A immunity, Hepatitis A Vaccines/*administration & dosage/immunology, Hepatitis A/blood/*ethnology/immunology, Humans, Immigrant health, Male, Middle Aged, Prevalence, Prisoners/*statistics & numerical data, Prisons, Seroepidemiologic Studies, Switzerland/epidemiology, Vaccination, Young Adult.
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  • Bauer, M., Giamarellos-Bourboulis, E. J., Kortgen, A., Moller, E., Felsmann, K., Cavaillon, J. M., Guntinas-Lichius, O., et al. “A Transcriptomic Biomarker To Quantify Systemic Inflammation In Sepsis - A Prospective Multicenter Phase Ii Diagnostic Study”. Ebiomedicine 6: 114-125. doi:10.1016/j.ebiom.2016.03.006.
    Abstract: Development of a dysregulated immune response discriminates sepsis from uncomplicated infection. Currently used biomarkers fail to describe simultaneously occurring pro- and anti-inflammatory responses potentially amenable to therapy. Marker candidates were screened by microarray and, after transfer to a platform allowing point-of-care testing, validated in a confirmation set of 246 medical and surgical patients. We identified up-regulated pathways reflecting innate effector mechanisms, while down-regulated pathways related to adaptive lymphocyte functions. A panel of markers composed of three up- (Toll-like receptor 5; Protectin; Clusterin) and 4 down-regulated transcripts (Fibrinogen-like 2; Interleukin-7 receptor; Major histocompatibility complex class II, DP alpha1; Carboxypeptidase, vitellogenic-like) described the magnitude of immune alterations. The created gene expression score was significantly greater in patients with definite as well as with possible/probable infection than with no infection (median (Q25/Q75): 80 (60/101)) and 81 (58/97 vs. 49 (27/66), AUC-ROC=0.812 (95%-CI 0.755-0.869), p<0.0001). Down-regulated lymphocyte markers were associated with prognosis with good sensitivity but limited specificity. Quantifying systemic inflammation by assessment of both pro- and anti-inflammatory innate and adaptive immune responses provides a novel option to identify patients-at-risk and may facilitate immune interventions in sepsis.
    Tags: Adaptive Immunity, Clinical utility, Gene Expression Profiling/*methods, Gene Expression Regulation, Genetic Markers/*immunology, Host response, Humans, Immunity, Innate, Oligonucleotide Array Sequence Analysis/*methods, Point-of-care, Point-of-Care Systems, Prognosis, Prospective Studies, RT-qPCR, Sensitivity and Specificity, Sepsis/*diagnosis/genetics/immunology, Transcriptomic profiling.
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  • Gosteli, G., Yersin, B., Mabire, C., Pasquier, M., Albrecht, R., and Carron, P. N. “Retrospective Analysis Of 616 Air-Rescue Trauma Cases Related To The Practice Of Extreme Sports”. Injury 47, no. 7: 1414-20. doi:10.1016/j.injury.2016.03.025.
    Abstract: INTRODUCTION: Extreme sports (ESs) are increasingly popular, and accidents due to ESs sometimes require helicopter emergency medical services (HEMSs). Little is known about their epidemiology, severity, specific injuries and required rescue operations. AIM: Our aims were to perform an epidemiological analysis, to identify specific injuries and to describe the characteristic of prehospital procedures in ES accidents requiring HEMSs. METHODS: This is a retrospective study, reviewing all rescue missions dedicated to ESs provided by HEMS REGA Lausanne, from 1 January 1998 to 31 December 2008. ES were classified into three categories of practice, according to the type of risk at the time of the fall. RESULTS: Among the 616 cases meeting inclusion criteria, 219 (36%) were clearly high-risk ES accidents; 69 (11%) and 328 (53%) were related to potential ES, but with respectively low or indeterminate risk at the time of the fall. In the high-risk ES group, the median age was 32 years and 80% were male. Mortality at 48h was 11%, almost ten times higher than in the other two groups. The proportion of potentially life-threatening injuries (the National Advisory Committee for Aeronautics (NACA) score>/=4) was 39% in the high-risk ES group and 13% in the other two groups. Thirty per cent of the cases in the high-risk ES group presented an Injury Severity Score (ISS) >15, compared with 7% in the other groups. Thoracolumbar vertebral fractures were the most common injuries with 32% of all cases having at least one, involving the T12-L2 junction in 56% of cases. The other most frequent injuries were traumatic brain injuries (16%), rib fractures (9%), pneumothorax (8%) and femoral (7%), cervical (7%), ankle (5%) and pelvic (5%) fractures. Median time on site for rescue teams was higher in the confirmed high-risk ES group, with 50% of prehospital missions including at least one environmental difficulty. CONCLUSIONS: High-risk ESs led to high-energy accidents, characterized by a large proportion of severe injuries and axial traumas (spine, thorax, pelvis and proximal femur). We identified a considerable percentage of thoracolumbar vertebral fractures, mainly in the T12-L2 junction. HEMSs dedicated to high-risk ESs implied longer and more complex interventions.
    Tags: Adult, Air Ambulances/*statistics & numerical data, Aircraft, Athletic Injuries/diagnosis/mortality/*therapy, Emergency medical services, Emergency Medical Services/*statistics & numerical data, Extreme sports, Fall, Female, Humans, Injury Severity Score, Male, Mountaineering, Multiple Trauma/diagnosis/mortality/*therapy, Prehospital, Rescue Work/*statistics & numerical data, Retrospective Studies, Risk Assessment, Switzerland/epidemiology, Trauma, Trauma Centers/*statistics & numerical data, Triage.
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  • Muller, M., Klingberg, K., Srivastava, D., and Exadaktylos, A. K. “Consultations By Asylum Seekers: Recent Trends In The Emergency Department Of A Swiss University Hospital”. Plos One 11, no. 5: e0155423. doi:10.1371/journal.pone.0155423.
    Abstract: BACKGROUND: Large-scale war-related migration to Switzerland and other European countries is currently challenging European health systems. Little is known about recent patterns and trends in Emergency Department (ED) consultations by Asylum Seekers (AS). METHODS: A retrospective single-centre analysis was performed of the data from all adult patients with the official status of "Asylum Seeker" or "Refugee" who consulted the ED of Bern University Hospital, Switzerland, between June 2012 and June 2015. Patient characteristics and clinical information, such as triage category, type of referral and discharge, violence-related injury and diagnostic group on discharge, were extracted from the computerised database or determined from the medical reports. Changes in categorical variables between the three studied years were described. RESULTS: A total of 1,653 eligible adult patients were identified in the 3-year period. Between the first (06/12-06/13) and third periods (06/14-06/15), the number of presentations per year increased by about 45%. The AS came from 62 different nations, the most common countries being Eritrea (13%), Somalia (13%) and Syria (11%). The mean age was 33.3 years (SD 12.3) and two thirds (65.7%) were male. The proportion of women increased over time. Moreover the relative proportions shifted from patients between 20 and 50 years to patients of under 20 or over 60 years. Nearly two thirds of the patients were walk-in emergencies and this proportion increased over time. The mean triage score was 2.9 (SD 0.7), with more than 90% presenting as "urgent consultation". About half of the patients were treated for trauma (17.2%), infections (16.8%) or psychiatric problems (14.2%). Trauma was seen in a higher proportion of male than female patients. About 25% of the patients were admitted for in-hospital treatment. CONCLUSIONS: The recent rise in AS in the population has lead to an increase in AS presenting to EDs. This changes the composition of ED patients and should raise awareness that changes in procedures may be needed. Infectious diseases and psychiatric problems remain a heavy burden for AS presenting in the ED. A trend towards an increasing proportion of walk-in patients to the ED could not be explained by this study. Further studies and surveillance are needed to investigate this trend.
    Tags: *Referral and Consultation, *Refugees, Adolescent, Adult, Aged, Emergency Service, Hospital/*statistics & numerical data, Female, Hospitalization, Hospitals, University/*statistics & numerical data, Humans, Male, Middle Aged, Public Health Surveillance, Retrospective Studies, Switzerland/epidemiology, Young Adult.
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  • Carron, P. N., Mabire, C., Yersin, B., and Bula, C. “Nursing Home Residents At The Emergency Department: A 6-Year Retrospective Analysis In A Swiss Academic Hospital”. Intern Emerg Med 12, no. 2: 229-237. doi:10.1007/s11739-016-1459-x.
    Abstract: The increasing number of elderly persons produces an increase in emergency department (ED) visits by these patients, including nursing home (NH) residents. This trend implies a major challenge for the ED. This study sought to investigate ED visits by NH residents in an academic hospital. A retrospective monocentric analysis of all ED visits by NH residents between 2005 and 2010 in a Swiss urban academic hospital. All NH residents aged 65 years and over were included. Socio-demographic data, mode of transfer to ED, triage severity rating, main reason for visit, ED and hospital length of stay, discharge dispositions, readmission at 30 and 90 day were collected. Annual ED visits by NH residents increased by 50 % (from 465 to 698) over the study period, accounting for 1.5 to 1.9 % of all ED visits from 2005 to 2010, respectively. Over the period, yearly rates of ED visits increased steadily from 18.8 to 27.5 per 100 NH residents. Main reasons for ED visits were trauma, respiratory, cardiovascular, digestive, and neurological problems. 52 % were for urgent situations. Less than 2 % of NH residents died during their ED stay and 60 % were admitted to hospital wards. ED use by NH residents disproportionately increased over the period, likely reflecting changes in residents and caregivers' expectations, NH staff care delivery, as well as possible correction of prior ED underuse. These results highlight the need to improve ED process of care for these patients and to identify interventions to prevent potentially unnecessary ED transfers.
    Tags: Aged, Aged, 80 and over, Ageing, Appropriateness, Emergencies/*epidemiology, Emergency department, Emergency Service, Hospital/*statistics & numerical data, Female, Frail Elderly/statistics & numerical data, Homes for the Aged/*statistics & numerical data, Humans, Male, Nursing home residents, Nursing Homes/*statistics & numerical data, Outcome Assessment, Health Care, Patient Admission/statistics & numerical data, Retrospective Studies, Switzerland.
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  • Kutz, A., Florin, J., Hausfater, P., Amin, D., Amin, A., Haubitz, S., Conca, A., et al. “Predictors For Delayed Emergency Department Care In Medical Patients With Acute Infections - An International Prospective Observational Study”. Plos One 11, no. 5: e0155363. doi:10.1371/journal.pone.0155363.
    Abstract: INTRODUCTION: In overcrowded emergency department (ED) care, short time to start effective antibiotic treatment has been evidenced to improve infection-related clinical outcomes. Our objective was to study factors associated with delays in initial ED care within an international prospective medical ED patient population presenting with acute infections. METHODS: We report data from an international prospective observational cohort study including patients with a main diagnosis of infection from three tertiary care hospitals in Switzerland, France and the United States (US). We studied predictors for delays in starting antibiotic treatment by using multivariate regression analyses. RESULTS: Overall, 544 medical ED patients with a main diagnosis of acute infection and antibiotic treatment were included, mainly pneumonia (n = 218; 40.1%), urinary tract (n = 141; 25.9%), and gastrointestinal infections (n = 58; 10.7%). The overall median time to start antibiotic therapy was 214 minutes (95% CI: 199, 228), with a median length of ED stay (ED LOS) of 322 minutes (95% CI: 308, 335). We found large variations of time to start antibiotic treatment depending on hospital centre and type of infection. The diagnosis of a gastrointestinal infection was the most significant predictor for delay in antibiotic treatment (+119 minutes compared to patients with pneumonia; 95% CI: 58, 181; p<0.001). CONCLUSIONS: We found high variations in hospital ED performance in regard to start antibiotic treatment. The implementation of measures to reduce treatment times has the potential to improve patient care.
    Tags: *Emergency Medical Services, *Emergency Service, Hospital, *Internationality, Acute Disease, Aged, Anti-Bacterial Agents/administration & dosage/therapeutic use, Communicable Diseases/*drug therapy, Female, Humans, Male, Prospective Studies, Time Factors.
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  • Hautz, S. C., Schuler, L., Kammer, J. E., Schauber, S. K., Ricklin, M. E., Sauter, T. C., Maier, V., Birrenbach, T., Exadaktylos, A., and Hautz, W. E. “Factors Predicting A Change In Diagnosis In Patients Hospitalised Through The Emergency Room: A Prospective Observational Study”. Bmj Open 6, no. 5: e011585. doi:10.1136/bmjopen-2016-011585.
    Abstract: INTRODUCTION: Emergency rooms (ERs) generally assign a preliminary diagnosis to patients, who are then hospitalised and may subsequently experience a change in their lead diagnosis (cDx). In ERs, the cDx rate varies from around 15% to more than 50%. Among the most frequent reasons for diagnostic errors are cognitive slips, which mostly result from faulty data synthesis. Furthermore, physicians have been repeatedly found to be poor self-assessors and to be overconfident in the quality of their diagnosis, which limits their ability to improve. Therefore, some of the clinically most relevant research questions concern how diagnostic decisions are made, what determines their quality and what can be done to improve them. Research that addresses these questions is, however, still rare. In particular, field studies that allow for generalising findings from controlled experimental settings are lacking. The ER, with its high throughput and its many simultaneous visits, is perfectly suited for the study of factors contributing to diagnostic error. With this study, we aim to identify factors that allow prediction of an ER's diagnostic performance. Knowledge of these factors as well as of their relative importance allows for the development of organisational, medical and educational strategies to improve the diagnostic performance of ERs. METHODS AND ANALYSIS: We will conduct a field study by collecting diagnostic decision data, physician confidence and a number of influencing factors in a real-world setting to model real-world diagnostic decisions and investigate the adequacy, validity and informativeness of physician confidence in these decisions. We will specifically collect data on patient, physician and encounter factors as predictors of the dependent variables. Statistical methods will include analysis of variance and a linear mixed-effects model. ETHICS AND DISSEMINATION: The Bern ethics committee approved the study under KEK Number 197/15. Results will be published in peer-reviewed scientific medical journals. Authorship will be determined according to ICMJE guidelines. TRIAL REGISTRATION NUMBER: The study protocol Version 1.0 from 17 May 2015 is registered in the Inselspital Research Database Information System (IRDIS) and with the IRB ('Kantonale Ethikkomission') Bern under KEK Number 197/15.
    Tags: *Clinical Decision-Making, *Diagnostic Errors, *Emergency Medicine, *Emergency Service, Hospital, Diagnostic decision making, diagnostic error, Humans, Patient Admission, patient safety, Prospective Studies, Research Design, Self Efficacy.
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  • Liu, S. W., Sri-On, J., Tirrell, G. P., Nickel, C., and Bingisser, R. “Serious Conditions For Ed Elderly Fall Patients: A Secondary Analysis Of The Basel Non-Specific Complaints Study”. Am J Emerg Med 34, no. 8: 1394-9. doi:10.1016/j.ajem.2016.04.007.
    Abstract: OBJECTIVE: Falls among older adults are a public health problem and are multifactorial. We sought to determine whether falls predict more serious conditions in older adult patients presenting to the emergency department (ED) with a "nonspecific complaint" (NSC). A secondary objective was to examine what factors predicted serious conditions among older adult patients with a fall. METHODS: This study was a secondary analysis of a prospective delayed-type cross-sectional diagnostic study that included a 30-day follow-up. We included patients 65 years and older who presented to the ED from May 2007 and July 2011 with a NSC and had an Emergency Severity Index score of 2 or 3. We then compared the serious conditions among older adults who presented to the ED with a fall with those who did not fall in a cohort of patients with NSC. RESULTS: We had 1111 patients enrolled in our study; 518 (47%) of them had fallen. We found that 310 (60%) of elderly fall patients vs 349 (59%) of nonfall patients had a 30-day serious condition (P=.74). In multiple logistic regression analysis, falls did not predict serious conditions or 30-day mortality among all NSC patients. Among fall patients, male sex, diuretic use, and generalized weakness predicted serious conditions. CONCLUSION: Fall patients share many features with nonfall NSC patient. However, falls did not increase the risk of serious conditions. Falls in the elderly could be considered under the broader entity of NSC.
    Tags: *Emergency Service, Hospital, *Geriatric Assessment, *Patient Compliance, Accidental Falls/*statistics & numerical data, Aged, Aged, 80 and over, Cross-Sectional Studies, Female, Follow-Up Studies, Humans, Incidence, Male, Muscle Weakness/*diagnosis/epidemiology, Prospective Studies, Risk Assessment/*methods, Risk Factors, Switzerland/epidemiology, Time Factors.
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  • Kaestli, L. Z., Noble, S., Combescure, C., Lacroix, L., Galetto, A., Gervaix, A., Fonzo-Christe, C., and Bonnabry, P. “Drug Information Leaflets Improve Parental Knowledge Of Their Child's Treatment At Paediatric Emergency Department Discharge”. Eur J Hosp Pharm 23, no. 3: 151-155. doi:10.1136/ejhpharm-2015-000776.
    Abstract: BACKGROUND: Hospital discharge is a complex multidisciplinary process that can lead to non-compliance and drugs-related problems. Crucial issue for children is parental knowledge of discharge treatments, especially in the time-limited and stressful environment of an emergency department (ED). OBJECTIVE: To compare parental correct knowledge of treatment with and without supply of customised drug information leaflets for the 10 most commonly prescribed drugs. METHOD: Inclusion criteria: paediatric patients (0-16 years) with French-speaking parents discharged from ED of the paediatric department of Geneva University Hospitals before (phase A) and after (phase B) intervention. INTERVENTION: Supply and brief comment of drug information leaflets focusing on specific information not available in official drugs information documents. Follow-up Semi-structured phone interview within 72 h after discharge to evaluate the percentage of parents with correct knowledge of dose, frequency, duration and indication of drugs. Multivariate analysis to identify factors associated with correct knowledge (phases A/B, drugs collection at usual pharmacy, drugs categories). RESULTS: 125 patients were included (phase A: 56; phase B: 69). Drug information leaflets were given to 63/69 ED patients (91%), covering 96/138 prescribed drugs (70%). Parental knowledge was significantly improved in phase B (dose: 62.3% to 89.1%; frequency: 57.9% to 85.5%; duration: 34.2% to 66.7%; indication: 70.2% to 94.9%; p<0.0001). Phase B and collection of drugs at usual pharmacy were significant factors associated with correct knowledge. CONCLUSIONS: Drug information leaflets significantly improved treatment knowledge of French-speaking parents after paediatric ED discharge. Leaflets are now available online for general population.
    Tags: Clinical pharmacy, Drug information, Emergency department, Hospital discharge, Paediatrics.
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  • Lauks, J., Mramor, B., Baumgartl, K., Maier, H., Nickel, C. H., and Bingisser, R. “Medical Team Evaluation: Effect On Emergency Department Waiting Time And Length Of Stay”. Plos One 11, no. 4: e0154372. doi:10.1371/journal.pone.0154372.
    Abstract: Emergency Departments (ED) are trying to alleviate crowding using various interventions. We assessed the effect of an alternative model of care, the Medical Team Evaluation (MTE) concept, encompassing team triage, quick registration, redesign of triage rooms and electronic medical records (EMR) on door-to-doctor (waiting) time and ED length of stay (LOS). We conducted an observational, before-and-after study at an urban academic tertiary care centre. On July 17th 2014, MTE was initiated from 9:00 a.m. to 10 p.m., 7 days a week. A registered triage nurse was teamed with an additional senior ED physician. Data of the 5-month pre-MTE and the 5-month MTE period were analysed. A matched comparison of waiting times and ED LOS of discharged and admitted patients pertaining to various Emergency Severity Index (ESI) triage categories was performed based on propensity scores. With MTE, the median waiting times improved from 41.2 (24.8-66.6) to 10.2 (5.7-18.1) minutes (min; P < 0.01). Though being beneficial for all strata, the improvement was somewhat greater for discharged, than for admitted patients. With a reduction from 54.3 (34.2-84.7) to 10.5 (5.9-18.4) min (P < 0.01), in terms of waiting times, MTE was most advantageous for ESI4 patients. The overall median ED LOS increased for about 15 min (P < 0.01), increasing from 3.4 (2.1-5.3) to 3.7 (2.3-5.6) hours. A significant increase was observed for all the strata, except for ESI5 patients. Their median ED LOS dropped by 73% from 1.2 (0.8-1.8) to 0.3 (0.2-0.5) hours (P < 0.01). In the same period the total orders for diagnostic radiology increased by 1,178 (11%) from 10,924 to 12,102 orders, with more imaging tests being ordered for ESI 2, 3 and 4 patients. Despite improved waiting times a decrease of ED LOS was only seen in ESI level 5 patients, whereas in all the other strata ED LOS increased. We speculate that this was brought about by the tendency of triage physicians to order more diagnostic radiology, anticipating that it may be better for the downstream physician to have more information rather than less.
    Tags: *Patient Selection, Adult, Aged, Attitude of Health Personnel, Critical Illness, Crowding, data, Emergency Service, Hospital/*organization & administration/statistics & numerical, Female, Hospitalization/*statistics & numerical data, Humans, Length of Stay/*statistics & numerical data, Male, Middle Aged, Patient Care Team/*organization & administration, Patient Discharge/statistics & numerical data, Retrospective Studies, Severity of Illness Index, Tertiary Care Centers, Time Factors, Triage/*organization & administration.
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  • Muller, M., Moser, E. M., Pfortmueller, C. A., Olariu, R., Lehmann, B., and Exadaktylos, A. K. “Aetiology Of Adult Burns Treated From 2000 To 2012 In A Swiss University Hospital”. Burns 42, no. 4: 919-25. doi:10.1016/j.burns.2016.03.005.
    Abstract: BACKGROUND: Burns in Switzerland are frequent and lead to high economic and social costs. However, little is known about the aetiology of burns suffered by patients seeking treatment in hospital emergency departments. This knowledge could be used to develop preventive measures. METHODS: This retrospective analysis included all patients (>/=16 years old) with acute thermal injuries of known cause admitted to the adult emergency department in Bern University Hospital (Switzerland, not a specialised burns unit) between 2000 and 2012. Clinical and sociodemographic data were extracted from medical records, i.e. the environment in which the burn occurred, as well as details of burn severity and aetiology. RESULTS: Seven hundred and one (701) patients with a mean age of 35.0+/-14.5 years (56% men) were included in the analysis. The winter season and the days around Christmas, turn of the year and Swiss National Day were identified as times with high risk of burns. Household (45%) and workplace (31%) were the most common locations/settings in which the burns occurred. Approximately every second burn was caused by scald, every fourth by flame and every seventh by hot objects. The analysis identified cooking, tar and electricity in workplace accidents, barbecues and the use of gasoline as aetiological factors in burns in leisure time, together with water in domestic thermal injuries. Burns occurred predominantly on non-protected skin on the hand and arms. The most severe burns were seen in electrical and flame burns. Men suffered more severe burns than women in all settings except psychopathology. CONCLUSIONS: The data suggest that the incidence and severity of burns in Switzerland could be reduced by preventive strategies and public campaigns, including education on fire protection systems, raising awareness about the times and locations where the risks of burns are greater, further improvement in workplace safety, particularly with cooking facilities and electrical equipment, and the development of innovative safety devices (i.e. machines, protective gloves). These findings have to be interpreted carefully, as this study includes only adult patients who presented in our ED and, in most cases, the burns covered less than 20% of the body surface.
    Tags: Accidents, Home/statistics & numerical data, Accidents, Occupational/statistics & numerical data, Adult, Aetiology, Burn Units/statistics & numerical data, Burns, Burns, Electric/epidemiology, Burns/epidemiology/*etiology, Causes, Emergency Service, Hospital/statistics & numerical data, Female, Fires/statistics & numerical data, Gender, Hospitals, University/statistics & numerical data, Humans, Incidence, Leisure Activities, Length of Stay, Location, Male, Middle Aged, Retrospective Studies, Switzerland, Switzerland/epidemiology, Young Adult.
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  • Nickel, C. H., Kuster, T., Keil, C., Messmer, A. S., Geigy, N., and Bingisser, R. “Risk Stratification Using D-Dimers In Patients Presenting To The Emergency Department With Nonspecific Complaints”. Eur J Intern Med 31: 20-4. doi:10.1016/j.ejim.2016.03.006.
    Abstract: BACKGROUND: Patients with nonspecific complaints (NSC) such as generalized weakness present frequently to acute care settings. These patients are at risk of adverse health outcomes. The aim of our study was to test the hypothesis whether D-dimers are predictive for 30-day mortality in patients with NSCs. METHODS: Delayed type cross-sectional diagnostic study with a 30-day follow-up period, registered with ClinicalTrials.gov (NCT00920491). This study took place in 2 EDs in Northwestern Switzerland. Patients were enrolled in the study if they were over 18years of age, gave informed consent, and if they presented with NSCs such as generalized weakness. D-dimer levels were determined at ED presentation. RESULTS: The final study population consisted of 524 patients. Median age was 82years (IQR=75 to 87years); 40.5% were men. There were 489 survivors and 35 non-survivors at 30-day follow-up. Twenty-one (60%) of the non-survivors were males. D-dimer levels were significantly higher in non-survivors than in survivors (p<0.001). Univariate Cox regression models for D-dimer resulted in a C-index of 0.77 for prediction of mortality. A model including sex, age, Katz ADL and D-dimer in a multivariate Cox regression lead to a C-Index of 0.80. CONCLUSION: D-dimer testing might be an effective risk stratification tool in patients with NSC by helping to identify patients at low risk of short-term mortality with a sensitivity of 0.97 and a negative likelihood ratio of 0.121. The use of D-dimers for risk stratification in patients with NSC should be confirmed with prospective studies.
    Tags: *Mortality, Aged, Aged, 80 and over, Biomarkers/analysis, Cohort Studies, Cross-Sectional Studies, D-dimer, Emergency Service, Hospital, Female, Fibrin Fibrinogen Degradation Products/*analysis, Geriatric, Humans, Kaplan-Meier Estimate, Male, Mortality, Multivariate Analysis, Muscle Weakness/*diagnosis/etiology, Nonspecific complaints, Predictive Value of Tests, Proportional Hazards Models, Risk Assessment/*methods, Severity of Illness Index, Switzerland/epidemiology, Triage, Triage/*methods.
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  • Hasler, S., Manka, R., Greutmann, M., Gamperli, O., Schmied, C., Tanner, F. C., Biaggi, P., Luscher, T. F., Keller, D. I., and Gruner, C. “Elevated High-Sensitivity Troponin T Levels Are Associated With Adverse Cardiac Remodelling And Myocardial Fibrosis In Hypertrophic Cardiomyopathy”. Swiss Med Wkly 146: w14285. doi:10.4414/smw.2016.14285.
    Abstract: INTRODUCTION: Clinical manifestations of hypertrophic cardiomyopathy (HCM) range from asymptomatic disease to early-onset heart failure and sudden cardiac death (SCD). Risk stratification for SCD remains imperfect and novel risk markers are needed. The aim of our study was to evaluate the association of elevated high-sensitivity cardiac troponin T levels (hs-cTnT) with the severity of disease expression and adverse events in patients with HCM. METHODS: All patients followed-up at a dedicated HCM clinic at a tertiary care centre between April 2012 and March 2014 were analysed. The clinical care track for these patients includes 12-lead ECG, blood work-up, echocardiography, Holter ECG, exercise stress testing and cardiovascular magnetic resonance imaging (CMR). Clinical data were obtained from medical records. RESULTS: Of 91 HCM patients (77% males, mean age at follow up 51 +/- 16 years), 46 (51%) had elevated hs-cTnT levels (>0.014 ng/ml). Patients with elevated hs-cTnT levels had greater maximum wall thickness (23 +/- 7 mm vs 19 +/- 3 mm, p = 0.001), more often had myocardial fibrosis (96% vs 54%, p <0.001), and lower exercise capacity (90% predicted vs 76% predicted, p = 0.002). There was a trend towards lower event-free survival estimates (Kaplan-Meier method, 15% vs 7%, p = 0.16). CONCLUSIONS: Elevated hs-cTnT levels in HCM patients are associated with disease severity and, potentially, with more adverse cardiac events. Future studies should test whether integration of hs-cTnT in clinical decision algorithms will improve risk stratification.
    Tags: Adolescent, Adult, Aged, Atrial Remodeling, Cardiomyopathy, Hypertrophic/*blood, Cohort Studies, Echocardiography, Electrocardiography, Exercise Test, Female, Fibrosis/blood, Humans, Magnetic Resonance Imaging, Male, Middle Aged, Myocardium/*pathology, Organ Size, Prognosis, Retrospective Studies, Risk Assessment, Severity of Illness Index, Tertiary Care Centers, Troponin T/*blood, Ventricular Remodeling, Young Adult.
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  • Klingberg, K., and Srivastava, D. “Restart The Heart”. Bmj Case Rep 2016. doi:10.1136/bcr-2016-214382.
    Abstract: Early bystander cardiopulmonary resuscitation and rapid defibrillation are the most important factors for favourable outcomes after out of hospital cardiac arrest (OHCA)-as the new American Heart Association/European Resuscitation Council (AHA/ERC) guidelines emphasise. The patient in our case was a healthy young man who had a witnessed cardiac arrest due to a chest collision with the goalkeeper during a football match. Basic life support was immediately provided by his teammates until an automated external defibrillator was brought to the scene. Blunt cardiac injury (BCI) may result in injured myocardium or arrhythmias. Ventricular fibrillation due to BCI in absence of structural cardiac disease is one of the main causes of OHCA in young healthy athletes with high mortality rates. We demonstrate important aspects of the recently released guidelines on cardiac arrest and the chain of survival by the leading societies.
    Tags: Cardiopulmonary Resuscitation/*methods, Heart, Humans, Male, Myocardial Contusions/*complications/mortality, Out-of-Hospital Cardiac Arrest/etiology/mortality/*therapy, Treatment Outcome, Ventricular Fibrillation/etiology/mortality, Young Adult.
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  • Chmiel, C., Wang, M., Sidler, P., Eichler, K., Rosemann, T., and Senn, O. “Implementation Of A Hospital-Integrated General Practice--A Successful Way To Reduce The Burden Of Inappropriate Emergency-Department Use”. Swiss Med Wkly 146: w14284. doi:10.4414/smw.2016.14284.
    Abstract: PRINCIPLES: Emergency departments (EDs) are overcrowded by lower acuity patients, which might be more efficiently treated by general practitioners (GPs). This study evaluated the impact of triaging lower acuity patients to a new hospital-integrated general practice (HGP) on ED case-load and the reasons for choosing the ED/HGP. METHODS AND RESULTS: Patients were consecutively assessed according to the emergency severity index (ESI) to triage lower acuity patients to the HGP. Consultation numbers at the emergency centre (ED and HGP) increased by 43% between 2007 (n = 16 974) and 2011 (n = 24 331) (implementation of HGP in 2009). Although self-referrals increased significantly at the emergency centre from 54% to 63% (p <0.001), the proportion of self-referrals at the ED was significantly reduced to 48% (p = 0.007). The HGP was able to reduce the burden of increasing total consultations by 36%; 4.6% were referred back to the ED after triaging to the HGP. Overall, 95% of HGP patients were self-referred, Swiss nationals (65%) and with a personal GP (82%) they attended regularly (69%). The most common reason for presenting at the emergency centre was not being able to reach the GP (60%). Diagnoses were injury- (29%) and infection- (23%) related problems affecting the musculoskeletal (27%) system and skin (21%). CONCLUSION: The HGP succeeded in reducing the burden of inappropriate ED use: the majority of low acuity self-referred patients were conclusively treated at the HGP. The HGP does not represent competition to the GP out-of-hours care service, since the main reason for presenting at the hospital was not lacking a relationship but the GPs' inaccessibility.
    Tags: *Outpatient Clinics, Hospital, *Referral and Consultation, Adult, Cohort Studies, Emergency Service, Hospital/*statistics & numerical data, Female, General Practice/*methods, Health Care Rationing/methods, Health Services Accessibility, Health Services Misuse/*prevention & control, Humans, Male, Middle Aged, Patient Acuity, Prospective Studies, Switzerland, Triage/methods, Young Adult.
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  • Frasnelli, A. “Successful Resuscitation After Splenic Artery Aneurysm Rupture”. J Emerg Trauma Shock 9, no. 1: 38-9. doi:10.4103/0974-2700.173863.
  • Anthimopoulos, M., Christodoulidis, S., Ebner, L., Christe, A., and Mougiakakou, S. “Lung Pattern Classification For Interstitial Lung Diseases Using A Deep Convolutional Neural Network”. Ieee Trans Med Imaging 35, no. 5: 1207-1216. doi:10.1109/TMI.2016.2535865.
    Abstract: Automated tissue characterization is one of the most crucial components of a computer aided diagnosis (CAD) system for interstitial lung diseases (ILDs). Although much research has been conducted in this field, the problem remains challenging. Deep learning techniques have recently achieved impressive results in a variety of computer vision problems, raising expectations that they might be applied in other domains, such as medical image analysis. In this paper, we propose and evaluate a convolutional neural network (CNN), designed for the classification of ILD patterns. The proposed network consists of 5 convolutional layers with 2 x 2 kernels and LeakyReLU activations, followed by average pooling with size equal to the size of the final feature maps and three dense layers. The last dense layer has 7 outputs, equivalent to the classes considered: healthy, ground glass opacity (GGO), micronodules, consolidation, reticulation, honeycombing and a combination of GGO/reticulation. To train and evaluate the CNN, we used a dataset of 14696 image patches, derived by 120 CT scans from different scanners and hospitals. To the best of our knowledge, this is the first deep CNN designed for the specific problem. A comparative analysis proved the effectiveness of the proposed CNN against previous methods in a challenging dataset. The classification performance ( ~ 85.5%) demonstrated the potential of CNNs in analyzing lung patterns. Future work includes, extending the CNN to three-dimensional data provided by CT volume scans and integrating the proposed method into a CAD system that aims to provide differential diagnosis for ILDs as a supportive tool for radiologists.
    Tags: *Neural Networks, Computer, Algorithms, Humans, Image Interpretation, Computer-Assisted/*methods, Lung Diseases, Interstitial/*diagnostic imaging, Lung/*diagnostic imaging, Tomography, X-Ray Computed.
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  • Soriano-Arandes, A., Angheben, A., Serre-Delcor, N., Trevino-Maruri, B., Gomez, I. Prat J., and Jackson, Y. “Control And Management Of Congenital Chagas Disease In Europe And Other Non-Endemic Countries: Current Policies And Practices”. Trop Med Int Health 21, no. 5: 590-6. doi:10.1111/tmi.12687.
    Abstract: OBJECTIVES: Identifying pregnant women infected with Trypanosoma cruzi is one of the major challenges for preventing and controlling Chagas disease (CD) in non-endemic countries. The aim of this paper was to perform a policy evaluation of the current practices of congenital Chagas disease (CCD) control in non-endemic countries and to propose specific targets for enhanced interventions to tackle this emerging health problem outside the endemic areas of Latin America. METHODS: We conducted a mixed method review of CCD policy strategies by searching the literature in the PubMed, Google Scholar and the World Health Organization (WHO) databases using the key terms 'CCD', 'paediatric Chagas disease' and 'non-endemic countries'; as free text and combined as one phrase to increase the search sensitivity. Reviews, recommendations, guidelines and control/surveillance programme reports were included. RESULTS: Of 427 CCD papers identified in non-endemic countries, 44 matched the inclusion. Although local programmes were launched in different countries with large numbers of Latin American immigrants, there were considerable disparities in terms of the programmes' distribution, delivery, integration and appropriated CCD control strategies. Moreover, Catalonia, Spain is the only region/country with an established systematic monitoring of CCD in pregnant women from Latin American countries. CONCLUSIONS: Given the worldwide dissemination of CD, the nature of its vertical transmission, and the gaps of the current strategies in non-endemic countries, there is an urgent need to standardise, expand and reinforce the control measures against CCD transmission.
    Tags: *Health Policy, *Public Health Practice, Chagas disease, Chagas Disease/congenital/diagnosis/epidemiology/*prevention & control, congenital infection, Diagnosis, Differential, Disease Management, Female, Global Health, Humans, immigrant population, Infant, Low Birth Weight, infection a Trypanosoma cruzi, infection congenitale, Infectious Disease Transmission, Vertical/*prevention & control/statistics &, maladie de Chagas, maladies tropicales negligees, neglected tropical diseases, numerical data, pauvrete, population immigrante, poverty, Pregnancy, Pregnancy Complications, Infectious/*diagnosis/epidemiology/prevention & control, Pregnancy Outcome/*epidemiology, Premature Birth/epidemiology, Prevalence, Stillbirth/epidemiology, Trypanosoma cruzi infection.
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  • Lollgen, R. M., Sabo, J., Mettler, A., Liniger, B., and Berger, S. “Unique Presentation Of Hematometrocolpos Mimicking Cauda Equina Syndrome: Severe Back Pain And Urinary Incontinence In An Adolescent Girl”. J Emerg Med 51, no. 2: e19-23. doi:10.1016/j.jemermed.2016.01.031.
    Abstract: BACKGROUND: Imperforate hymen with hematometrocolpos in adolescent females is a rare pediatric condition. Classical presentation includes abdominal pain or a pelvic mass in female patients with primary amenorrhea. Atypical complaints and reluctance among emergency physicians to perform genital examination in the emergency department or the pediatric emergency department (PED) may delay correct diagnosis. CASE REPORT: We report a unique, cauda equina syndrome-like presentation of hematometrocolpos secondary to imperforate hymen in a 13-year old, previously healthy girl with primary amenorrhea. In the PED, the unusual clinical presentation of severe back pain and urinary incontinence initially mimicked cauda equina syndrome and led to delayed correct diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The novelty of this case is a cauda equina-like presentation of imperforate hymen secondary to hematocolpos. This report illustrates the highly variable clinical presentation of this rare gynecological pediatric entity. It underlines the importance of considering this rare condition in the differential diagnosis of severe upper or lower back pain alongside voiding abnormalities including urinary retention and incontinence in adolescent females with primary amenorrhea. Above all, the importance of performing a thorough history and genital examination in this subgroup early in the investigation process in the PED emerges from this case. Essentially, excellent clinical judgment and genital examination by the emergency physician may minimize unnecessary radiological investigations and ultimately, accelerate correct diagnosis and expedite appropriate surgical treatment. However, not only pediatric and adult emergency physicians, but also pediatricians and general practitioners should be aware of this entity and its diverse clinical presentation.
    Tags: Adolescent, Back Pain/*etiology, cauda equina syndrome, Congenital Abnormalities, Diagnosis, Differential, Female, genital examination, Hematometra/*complications/diagnosis, hematometrocolpos, Humans, Hymen/abnormalities, Menstruation Disturbances/complications, pediatric emergency department, Polyradiculopathy/*etiology, Urinary Incontinence/*etiology.
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  • Insam, C., Mean, M., Limacher, A., Angelillo-Scherrer, A., Aschwanden, M., Banyai, M., Beer, J. H., et al. “Anticoagulation Management Practices And Outcomes In Elderly Patients With Acute Venous Thromboembolism: A Clinical Research Study”. Plos One 11, no. 2: e0148348. doi:10.1371/journal.pone.0148348.
    Abstract: Whether anticoagulation management practices are associated with improved outcomes in elderly patients with acute venous thromboembolism (VTE) is uncertain. Thus, we aimed to examine whether practices recommended by the American College of Chest Physicians guidelines are associated with outcomes in elderly patients with VTE. We studied 991 patients aged >/=65 years with acute VTE in a Swiss prospective multicenter cohort study and assessed the adherence to four management practices: parenteral anticoagulation >/=5 days, INR >/=2.0 for >/=24 hours before stopping parenteral anticoagulation, early start with vitamin K antagonists (VKA) </=24 hours of VTE diagnosis, and the use of low-molecular-weight heparin (LMWH) or fondaparinux. The outcomes were all-cause mortality, VTE recurrence, and major bleeding at 6 months, and the length of hospital stay (LOS). We used Cox regression and lognormal survival models, adjusting for patient characteristics. Overall, 9% of patients died, 3% had VTE recurrence, and 7% major bleeding. Early start with VKA was associated with a lower risk of major bleeding (adjusted hazard ratio 0.37, 95% CI 0.20-0.71). Early start with VKA (adjusted time ratio [TR] 0.77, 95% CI 0.69-0.86) and use of LMWH/fondaparinux (adjusted TR 0.87, 95% CI 0.78-0.97) were associated with a shorter LOS. An INR >/=2.0 for >/=24 hours before stopping parenteral anticoagulants was associated with a longer LOS (adjusted TR 1.2, 95% CI 1.08-1.33). In elderly patients with VTE, the adherence to recommended anticoagulation management practices showed mixed results. In conclusion, only early start with VKA and use of parenteral LMWH/fondaparinux were associated with better outcomes.
    Tags: Acute Disease, Aged, Anticoagulants/*therapeutic use, Assessment of Medication Adherence, Female, Humans, Length of Stay, Male, Treatment Outcome, Venous Thromboembolism/*drug therapy.
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  • Petrovic, D., Pivin, E., Ponte, B., Dhayat, N., Pruijm, M., Ehret, G., Ackermann, D., et al. “Sociodemographic, Behavioral And Genetic Determinants Of Allostatic Load In A Swiss Population-Based Study”. Psychoneuroendocrinology 67: 76-85. doi:10.1016/j.psyneuen.2016.02.003.
    Abstract: Allostatic load (AL) is a marker of physiological dysregulation which reflects exposure to chronic stress. High AL has been related to poorer health outcomes including mortality. We examine here the association of socioeconomic and lifestyle factors with AL. Additionally, we investigate the extent to which AL is genetically determined. We included 803 participants (52% women, mean age 48+/-16years) from a population and family-based Swiss study. We computed an AL index aggregating 14 markers from cardiovascular, metabolic, lipidic, oxidative, hypothalamus-pituitary-adrenal and inflammatory homeostatic axes. Education and occupational position were used as indicators of socioeconomic status. Marital status, stress, alcohol intake, smoking, dietary patterns and physical activity were considered as lifestyle factors. Heritability of AL was estimated by maximum likelihood. Women with a low occupational position had higher AL (low vs. high OR=3.99, 95%CI [1.22;13.05]), while the opposite was observed for men (middle vs. high OR=0.48, 95%CI [0.23;0.99]). Education tended to be inversely associated with AL in both sexes(low vs. high OR=3.54, 95%CI [1.69;7.4]/OR=1.59, 95%CI [0.88;2.90] in women/men). Heavy drinking men as well as women abstaining from alcohol had higher AL than moderate drinkers. Physical activity was protective against AL while high salt intake was related to increased AL risk. The heritability of AL was estimated to be 29.5% +/-7.9%. Our results suggest that generalized physiological dysregulation, as measured by AL, is determined by both environmental and genetic factors. The genetic contribution to AL remains modest when compared to the environmental component, which explains approximately 70% of the phenotypic variance.
    Tags: *Life Style, *Social Class, Allostasis/*genetics/*physiology, Allostatic load, Female, heritability, Humans, Male, Middle Aged, physiological dysregulation, population-based, socioeconomic status.
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  • Bryant-Lukosius, D., Spichiger, E., Martin, J., Stoll, H., Kellerhals, S. D., Fliedner, M., Grossmann, F., et al. “Framework For Evaluating The Impact Of Advanced Practice Nursing Roles”. J Nurs Scholarsh 48, no. 2: 201-9. doi:10.1111/jnu.12199.
    Abstract: PURPOSE: To address the gap in evidence-based information required to support the development of advanced practice nursing (APN) roles in Switzerland, stakeholders identified the need for guidance to generate strategic evaluation data. This article describes an evaluation framework developed to inform decisions about the effective utilization of APN roles across the country. APPROACH: A participatory approach was used by an international group of stakeholders. Published literature and an evidenced-based framework for introducing APN roles were analyzed and applied to define the purpose, target audiences, and essential elements of the evaluation framework. Through subsequent meetings and review by an expert panel, the framework was developed and refined. FINDINGS: A framework to evaluate different types of APN roles as they evolve to meet dynamic population health, practice setting, and health system needs was created. It includes a matrix of key concepts to guide evaluations across three stages of APN role development: introduction, implementation, and long-term sustainability. For each stage, evaluation objectives and questions examining APN role structures, processes, and outcomes from different perspectives (e.g., patients, providers, managers, policy-makers) were identified. CONCLUSIONS: A practical, robust framework based on well-established evaluation concepts and current understanding of APN roles can be used to conduct systematic evaluations. CLINICAL RELEVANCE: The evaluation framework is sufficiently generic to allow application in developed countries globally, both for evaluation as well as research purposes.
    Tags: *Advanced Practice Nursing, *Nurse's Role, Advanced practice nursing, evaluation, evaluation framework, Evidence-Based Nursing, human resources, Humans, models of care, Nursing Evaluation Research/*organization & administration, role development, Switzerland.
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  • Pfortmueller, C. A., Schwetlick, M., Mueller, T., Lehmann, B., and Exadaktylos, A. K. “Adult Asylum Seekers From The Middle East Including Syria In Central Europe: What Are Their Health Care Problems?”. Plos One 11, no. 2: e0148196. doi:10.1371/journal.pone.0148196.
    Abstract: BACKGROUND: Forced displacement related to persecution and violent conflict has reached a new peak in recent years. The primary aim of this study is to provide an initial overview of the acute and chronic health care problems of asylum seekers from the Middle East, with special emphasis on asylum seekers from Syria. METHODS: Our retrospective data analysis comprised adult patients presenting to our emergency department between 01.11.2011 and 30.06.2014 with the official resident status of an "asylum seeker" or "refugee" from the Middle East. RESULTS: In total, 880 patients were included in the study. Of these, 625 (71.0%) were male and 255 (29.0%) female. The median age was 34 (range 16-84). 222 (25.2%) of our patients were from Syria. The most common reason for presentation was surgical (381, 43.3%), followed by medical (321, 36.5%) and psychiatric (137, 15.6%). In patients with surgical presentations, trauma-related problems were most common (n = 196, 50.6%). Within the group of patients with medical presentation, acute infectious diseases were most common (n = 141, 43.9%), followed by neurological problems (n = 70, 21.8%) and gastrointestinal problems (n = 47, 14.6%). There were no differences between Syrian and non-Syrian refugees concerning surgical or medical admissions. The most common chronic disorder of unclear significance was chronic gastrointestinal problems (n = 132, 15%), followed by chronic musculoskeletal problems (n = 108, 12.3%) and chronic headaches (n = 78, 8.9%). Patients from Syria were significantly younger and more often suffered from a post-traumatic stress disorder than patients of other nationalities (p<0.0001, and p = 0.05, respectively). CONCLUSION: Overall a remarkable number of our very young group of patients suffered from psychiatric disorders and unspecified somatic symptoms. Asylum seekers should be carefully evaluated when presenting to a medical facility and physicians should be aware of the high incidence of unspecified somatic symptoms in this patient population.In general, there is no major difference between asylum seekers from Syria when compared to other nationalities of asylum seekers from the Middle East.
    Tags: *Refugees, Acute Disease, Adolescent, Adult, Aged, Aged, 80 and over, Communicable Diseases/*diagnosis/epidemiology/physiopathology, Female, Gastrointestinal Diseases/*diagnosis/epidemiology/physiopathology, Headache/*diagnosis/epidemiology/physiopathology, Health Status, Humans, Male, Middle Aged, Musculoskeletal Diseases/*diagnosis/epidemiology/physiopathology, Retrospective Studies, Stress Disorders, Post-Traumatic/*diagnosis/epidemiology/physiopathology, Switzerland/epidemiology, Syria/ethnology, Wounds and Injuries/*diagnosis/epidemiology/pathology.
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  • Cerutti, B., Blondon, K., and Galetto, A. “Long-Menu Questions In Computer-Based Assessments: A Retrospective Observational Study”. Bmc Med Educ 16, no. 1: 55. doi:10.1186/s12909-016-0578-4.
    Abstract: BACKGROUND: Computer based assessments of paediatrics in our institution use series of clinical cases, where information is progressively delivered to the students in a sequential order. Three types of formats are mainly used: Type A (single answer), Pick N, and Long-menu. Long-menu questions require a long, hidden list of possible answers: based on the student's initial free text response, the program narrows the list, allowing the student to select the answer. This study analyses the psychometric properties of Long-menu questions compared with the two other commonly used formats: Type A and Pick N. METHODS: We reviewed the difficulty level and discrimination index of the items in the paediatric exams from 2009 to 2015, and compared the Long-menu questions with the Type A and Pick N questions, using multiple-way analyses of variances. RESULTS: Our dataset included 13 exam sessions with 855 students and 558 items included in the analysis, 212 (38 %) Long-menu, 201 (36 %) Pick N, and 140 Type A (25 %) items. There was a significant format effect associated with both level of difficulty (p = .005) and discrimination index (p < .001). Long-menu questions were easier than Type A questions(+5.2 %; 95 % CI 1.1-9.4 %), and more discriminative than both Type A (+0.07; 95 % CI 0.01-0.14), and Pick N (+0.10; 95 % CI 0.05-0.16) questions. CONCLUSIONS: Long-menu questions show good psychometric properties when compared with more common formats such as Type A or Pick N, though confirmatory studies are needed. They provide more variety, reduce the cueing effect, and thus may more closely reflect real life practice than the other item formats inherited from paper-based examination that are used during computer-based assessments.
    Tags: *User-Computer Interface, administration/*standards, Choice Behavior, Education, Medical, Undergraduate/methods/organization &, Educational Measurement/*methods, Humans, Pediatrics/*education, Problem Solving, Psychometrics, Retrospective Studies, Students, Medical/*psychology.
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  • Moser, A., Mabire, C., Hugli, O., Dorribo, V., Zanetti, G., Lazor-Blanchet, C., and Carron, P. N. “Vaccination Against Seasonal Or Pandemic Influenza In Emergency Medical Services”. Prehosp Disaster Med 31, no. 2: 155-62. doi:10.1017/S1049023X16000121.
    Abstract: INTRODUCTION: Influenza is a major concern for Emergency Medical Services (EMS); EMS workers' (EMS-Ws) vaccination rates remain low despite promotion. Determinants of vaccination for seasonal influenza (SI) or pandemic influenza (PI) are unknown in this setting. HYPOTHESIS: The influence of the H1N1 pandemic on EMS-W vaccination rates, differences between SI and PI vaccination rates, and the vaccination determinants were investigated. METHODS: A survey was conducted in 2011 involving 65 Swiss EMS-Ws. Socio-professional data, self-declared SI/PI vaccination status, and motives for vaccine refusal or acceptation were collected. RESULTS: Response rate was 95%. The EMS-Ws were predominantly male (n=45; 73%), in good health (87%), with a mean age of 36 (SD=7.7) years. Seventy-four percent had more than six years of work experience. Self-declared vaccination rates were 40% for both SI and PI (PI+/SI+), 19% for PI only (PI+/SI-), 1.6% for SI only (PI-/SI+), and 39% were not vaccinated against either (PI-/SI-). Women's vaccination rates specifically were lower in all categories but the difference was not statistically significant. During the previous three years, 92% of PI+/SI+ EMS-Ws received at least one SI vaccination; it was 8.3% in the case of PI-/SI- (P=.001) and 25% for PI+/SI- (P=.001). During the pandemic, SI vaccination rate increased from 26% during the preceding year to 42% (P=.001). Thirty percent of the PI+/SI+ EMS-Ws declared that they would not get vaccination next year, while this proportion was null for the PI-/SI- and PI+/SI- groups. Altruism and discomfort induced by the surgical mask required were the main motivations to get vaccinated against PI. Factors limiting PI or SI vaccination included the option to wear a mask, avoidance of medication, fear of adverse effects, and concerns about safety and effectiveness. CONCLUSION: Average vaccination rate in this study's EMS-Ws was below recommended values, particularly for women. Previous vaccination status was a significant determinant of PI and future vaccinations. The new mask policy seemed to play a dual role, and its net impact is probably limited. This population could be divided in three groups: favorable to all vaccinations; against all, even in a pandemic context; and ambivalent with a "pandemic effect." These results suggest a consistent vaccination pattern, only altered by exceptional circumstances.
    Tags: *Attitude of Health Personnel, Adult, Emergency Medical Services, Emergency Medical Services/*statistics & numerical data, EMS Emergency Medical Service, EMS-W Emergency Medical Service workers, EMS-workers, Female, HCW health care workers, Humans, influenza, Influenza A Virus, H1N1 Subtype/*immunology, Influenza Vaccines/*administration & dosage, Influenza, Human/epidemiology/*prevention & control, Male, Middle Aged, Motivation, Pandemics/*prevention & control, PI pandemic influenza, PPE personal protective equipment, SI seasonal influenza, Surveys and Questionnaires, vaccination, Vaccination/*statistics & numerical data, Young Adult.
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