EMresearch.ch

Fuller, G., Hasler, R. M., Mealing, N., Lawrence, T., Woodford, M., Juni, P., and Lecky, F. “The Association Between Admission Systolic Blood Pressure And Mortality In Significant Traumatic Brain Injury: A Multi-Centre Cohort Study”. Injury 45, no. 3: 612-7. doi:10.1016/j.injury.2013.09.008.

Abstract: INTRODUCTION: Low systolic blood pressure (SBP) is an important secondary insult following traumatic brain injury (TBI), but its exact relationship with outcome is not well characterised. Although a SBP of <90 mmHg represents the threshold for hypotension in consensus TBI treatment guidelines, recent studies suggest redefining hypotension at higher levels. This study therefore aimed to fully characterise the association between admission SBP and mortality to further inform resuscitation endpoints. METHODS: We conducted a multicentre cohort study using data from the largest European trauma registry. Consecutive adult patients with AIS head scores >2 admitted directly to specialist neuroscience centres between 2005 and July 2012 were studied. Multilevel logistic regression models were developed to examine the association between admission SBP and 30 day inpatient mortality. Models were adjusted for confounders including age, severity of injury, and to account for differential quality of hospital care. RESULTS: 5057 patients were included in complete case analyses. Admission SBP demonstrated a smooth u-shaped association with outcome in a bivariate analysis, with increasing mortality at both lower and higher values, and no evidence of any threshold effect. Adjusting for confounding slightly attenuated the association between mortality and SBP at levels <120 mmHg, and abolished the relationship for higher SBP values. Case-mix adjusted odds of death were 1.5 times greater at <120 mmHg, doubled at <100 mmHg, tripled at <90 mmHg, and six times greater at SBP<70 mmHg, p<0.01. CONCLUSIONS: These findings indicate that TBI studies should model SBP as a continuous variable and may suggest that current TBI treatment guidelines, using a cut-off for hypotension at SBP<90 mmHg, should be reconsidered.

Tags: *Blood Pressure, *Hospital Mortality, *Trauma Centers, Adult, Aged, Blood Pressure Determination/methods, Brain Injuries/*mortality/physiopathology, Cohort Studies, Craniocerebral trauma, Europe/epidemiology, Female, Glasgow Outcome Scale, Humans, Hypertension/*mortality/physiopathology, Hypotension, Hypotension/*mortality/physiopathology, Injury Severity Score, Male, Middle Aged, Odds Ratio, Practice Guidelines as Topic, Prognosis, Prospective Studies, Registries, Resuscitation, Survival Analysis, Systolic blood pressure, Triage.

Pfortmueller, C. A., Efeoglou, A., Furrer, H., and Exadaktylos, A. K. “Dog Bite Injuries: Primary And Secondary Emergency Department Presentations--A Retrospective Cohort Study”. Scientificworldjournal 2013: 393176. doi:10.1155/2013/393176.

Abstract: Dog bites in humans are a complex problem, embracing both public health and animal welfare. The primary aim of this study is to examine primary and secondary presentations related to dog bite injuries in adults. METHODS: We retrospectively assessed all adult patients admitted with a dog bite injury to the Emergency Department of Bern University Hospital. RESULTS: A total of 431 patients were eligible for the study. Forty-nine (11.4%) of all patients were admitted with secondary presentations. Bites to the hands were most common (177, 41.1%). All patients (47, 100%) with secondary presentations were admitted because of signs of infection. The median time since the dog bite was 3.8 days (SD 3.9, range 1-21). Thirty-one patients had already been treated with antibiotic; coamoxicillin was the most common primary antibiotic therapy (27/47 patients, 57.4%). Patients with injuries to the hand were at increased risk of secondary presentations (OR 2.08, 95% CI 1.21-3.55, P < 0.006). CONCLUSION: Dog bite injuries to the hands are a major problem. They often lead to infectious complications. Immediate antibiotic therapy should carefully be evaluated for each patient.

Tags: *Dogs, Adult, Animals, Anti-Bacterial Agents/therapeutic use, Bites and Stings/drug therapy/*epidemiology/*pathology, Cohort Studies, Emergency Service, Hospital/*statistics & numerical data, Humans, Odds Ratio, Retrospective Studies, Switzerland/epidemiology.

Favrod-Coune, T., Baroudi, M., Casillas, A., Rieder, J. P., Getaz, L., Barro, J., Gaspoz, J. M., Broers, B., and Wolff, H. “Opioid Substitution Treatment In Pretrial Prison Detention: A Case Study From Geneva, Switzerland”. Swiss Med Wkly 143: w13898. doi:10.4414/smw.2013.13898.

Abstract: BACKGROUND: Opioid substitution treatment (OST) is not uniformly provided in all prisons as recommended by international guidelines. The Swiss prison of Champ-Dollon in Geneva is an exception, where OST has been available for the last 20 years. The aims of this study were to describe the OST programme in this pretrial prison setting, and the patients involved. METHODS: We reviewed health records of 2566 detainees entering Switzerland's largest pretrial prison in 2007. Sociodemographic characteristics, substance use diagnosis and history, OST history and prison course, medical complications, and evidence of OST side effects were assessed by questionnaire. RESULTS: The mean age was 29.6 years (SD 7.1) and 95.4% of prisoners were male. Among 233 opioid users (9.1%) at baseline, 221 (94.8%) used other substances, and 39.9% had used drugs intravenously. Opioid dependence was confirmed in 71.2% of opioid users. OST was offered to all dependent users, and all patients accepted treatment. Methadone was the treatment of preference, with a prescribed mean dose of 41.7 mg (standard deviation 29.1) upon departure. No serious side effects or death by overdose occurred. There was postrelease OST continuity-of-care for 49.7% of OST patients. CONCLUSIONS: Prescription of OST for opioid dependent detainees by trained physicians is feasible and safe in a pretrial setting. The methadone dose was lower when compared with general OST treatment recommendations. Nevertheless, treatment was available in accordance with national and international guidelines. In-prison OST offers access to a much needed and safe healthcare service for this vulnerable population.

Tags: *Prisoners, *Prisons, Adult, Analgesics, Opioid/*therapeutic use, Buprenorphine/*therapeutic use, Continuity of Patient Care, Female, Health Services Accessibility, Humans, Male, Methadone/*therapeutic use, Opiate Substitution Treatment/*methods, Opioid-Related Disorders/*rehabilitation, Retrospective Studies, Substance Abuse, Intravenous/*rehabilitation, Switzerland, Vulnerable Populations, Young Adult.

Hudelson, P., Dao, M. D., Perron, N. J., and Bischoff, A. “Interpreter-Mediated Diabetes Consultations: A Qualitative Analysis Of Physician Communication Practices”. Bmc Fam Pract 14: 163. doi:10.1186/1471-2296-14-163.

Abstract: BACKGROUND: Patient-provider communication, in particular physicians' ability to listen to their patients, and support them in making difficult lifestyle changes, is an essential component of effective diabetes care. Clinical communication around diabetes can be especially challenging when language barriers are present, and may contribute to poor diabetes management and outcomes. Clinicians need to be aware of and address potential communication difficulties associated with interpreter-mediated consultations. The purpose of our study was to explore how physicians communicate in interpreter-mediated consultations with diabetic patients, and how their communication behaviors may impact diabetes communication and care. METHOD: We analyzed transcripts from 8 audio recorded, outpatient consultations at the Basel University Hospital general medicine outpatient clinic involving Turkish-speaking patients, German-speaking physicians, and Turkish-German interpreters (both community interpreters and family members). RESULTS: Clinicians used closed questions when asking about symptoms and glucose control. When providing information and explanation, they spoke in long and complex speech turns. They often directed their speech to interpreters or became sidetracked by family members' questions or requests for information. Patients' participation in the consultation was minimal, and limited to brief answers to clinicians' questions. CONCLUSIONS: Clinicians need to be aware of common pitfalls that diminish patient-centeredness during interpreter-mediated consultations, and learn strategies to avoid them. Attention to established guidelines on triadic communication is recommended, as is hands-on training with interpreters.

Tags: *Communication Barriers, *Language, *Physician-Patient Relations, *Translating, Adult, Aged, Communication, Diabetes Mellitus/*therapy, Disease Management, Family, Female, Humans, Male, Middle Aged, Professional-Patient Relations, Qualitative Research.

Kebaili, R., Harrabi, I., Maatoug, J., Ghammam, R., Slim, S., and Ghannem, H. “School-Based Intervention To Promote Healthy Nutrition In Sousse, Tunisia”. Int J Adolesc Med Health 26, no. 2: 253-8. doi:10.1515/ijamh-2013-0306.

Abstract: INTRODUCTION: Obesity among children is a major risk factor for chronic diseases. School interventions programs can represent a mean to implement healthy nutrition attitudes at early ages. Our objective was to evaluate the effects of a school intervention program to promote healthy nutrition among adolescents, in terms of knowledge, behaviors and intention. METHODS: Quasi experimental study among urban students in Sousse, Tunisia with 2 groups, intervention and control. The intervention group had an interactive program integrated with school courses that promoted healthy nutrition habits. Both groups had a pre post evaluation. RESULTS: 2200 students aged from 12 to 16 participated to the pre post evaluation. In the intervention group, there were significant changes form pre to post test in knowledge, intentions, and behaviors. In the control group, almost no significant changes were observed. CONCLUSION: School intervention programs can represent an interesting approach to promote healthy nutrition habits among adolescents.

Tags: *Feeding Behavior, Adolescent, Child, Female, Health Promotion/*methods, Humans, Male, Obesity/*prevention & control, Pilot Projects, Program Evaluation, School Health Services/*organization & administration, Tunisia, Urban Population.

Pfortmueller, C. A., Funk, G. C., Marti, G., Leichtle, A. B., Fiedler, G. M., Schwarz, C., Exadaktylos, A. K., and Lindner, G. “Diagnostic Performance Of High-Sensitive Troponin T In Patients With Renal Insufficiency”. Am J Cardiol 112, no. 12: 1968-72. doi:10.1016/j.amjcard.2013.08.028.

Abstract: In the present study, we wanted to (1) evaluate whether high-sensitive troponin T levels correlate with the grade of renal insufficiency and (2) test the accuracy of high-sensitive troponin T determination in patients with renal insufficiency for diagnosis of acute myocardial infarction (AMI). In this cross-sectional analysis, all patients who received serial measurements of high-sensitive troponin T from August 1, 2010, to October 31, 2012, at the Department of Emergency Medicine were included. We analyzed data on baseline characteristics, reason for referral, medication, cardiovascular risk factors, and outcome in terms of presence of AMI along with laboratory data (high-sensitive troponin T, creatinine). A total of 1,514 patients (67% male, aged 65 +/- 16 years) were included, of which 382 patients (25%) had moderate to severe renal insufficiency and significantly higher levels of high-sensitive troponin T on admission (0.028 vs 0.009, p <0.0001). In patients without AMI, high-sensitive troponin T correlated inversely with the estimated glomerular filtration rate (R = -0.12, p <0.0001). Overall, sensitivity of an elevated high-sensitive troponin for diagnosis of AMI was 0.64 (0.56 to 0.71) and the specificity was 0.48 (0.45 to 0.51). The area under the curve of the receiver operating characteristic for all patients was 0.613 (standard error [SE] 0.023), whereas it was 0.741 (SE 0.029) for patients with a Modification of Diet in Renal Disease estimated glomerular filtration rate >60 ml/min presenting with acute chest pain or dyspnea and 0.535 (SE 0.056) for patients with moderate to severe renal insufficiency presenting with acute chest pain or dyspnea. In conclusion, the diagnostic accuracy for presence of AMI of a baseline measurement of high-sensitive troponin in patients with renal insufficiency was poor and resembles tossing a coin.

Tags: Aged, Cardiovascular Diseases/epidemiology, Creatinine/blood, Cross-Sectional Studies, Female, Glomerular Filtration Rate, Humans, Male, Middle Aged, Renal Insufficiency/*diagnosis, ROC Curve, Sensitivity and Specificity, Troponin T/*blood.

Cottet, P., d'Hollander, A., Cahana, A., Van Gessel, E., and Tassaux, D. “A New Process-Centered Description Tool To Initiate Meta-Reporting Methodology In Healthcare - 7Carecat. Feasibility Study In A Post-Anesthesia Care Unit”. Ann Fr Anesth Reanim 32, no. 10: e129-34. doi:10.1016/j.annfar.2013.06.015.

Abstract: BACKGROUND: In the healthcare domain, different analytic tools focused on accidents appeared to be poorly adapted to sub-accidental issues. Improving local management and intra-institutional communication with simpler methods, allowing rapid and uncomplicated meta-reporting, could be an attractive alternative. METHODS: A process-centered structure derived from the industrial domain - DEPOSE(E) - was selected and modified for its use in the healthcare domain. The seven exclusive meta-categories defined - Patient, Equipment, Process, Actor, Supplies, work Room and Organization- constitute 7CARECAT. A collection of 536 "improvement" reports from a tertiary hospital Post anesthesia care unit (PACU) was used and four meta-categorization rules edited prior to the analysis. Both the relevance of the metacategories and of the rules were tested to build a meta-reporting methodology. The distribution of these categories was analyzed with a chi 2 test. RESULTS: Five hundred and ninety independent facts were collected out of the 536 reports. The frequencies of the categories are: Organization 44%, Actor 37%, Patient 11%, Process 3%, work Room 3%, Equipment 1% and Supplies 1%, with a p-value <0.005 (chi 2). During the analysis, three more rules were edited. The reproducibility, tested randomly on 200 reports, showed a <2% error rate. CONCLUSION: This meta-reporting methodology, developed with the 7CARECAT structure and using a reduced number of operational rules, has successfully produced a stable and consistent classification of sub-accidental events voluntarily reported. This model represents a relevant tool to exchange meta-informations important for local and transversal communication in healthcare institutions. It could be used as a promising tool to improve quality and risk management.

Tags: Accident, Accidentologie, Accidentology, Adverse events, Anesthesia Department, Hospital/*organization & administration, Anesthesie, Anesthesiology, Categorisation, Categorization, Data Interpretation, Statistical, Effets indesirables, Equipment and Supplies, Hospital/statistics & numerical data, Feasibility Studies, Gestion du risque, Humans, Incident, Meta-categorisation, Meta-categorization, Models, Organizational, Near-miss, Patients, Postoperative recovery room, Quality Improvement, Recovery Room/*organization & administration, Reproducibility of Results, Risk management, Risk Management/*methods, Salle de surveillance post-interventionnelle (SSPI).

Reilly, J. R., Pasquier, M., Yersin, B., Schoettker, P., and Carron, P. N. “Blaming The Balloon: The Risk Of Post-Intubation Tracheobronchial Rupture”. Intern Emerg Med 8, no. 8: 753-6. doi:10.1007/s11739-013-0994-y.

Tags: Aged, 80 and over, Bronchi/*injuries, Fatal Outcome, Female, Humans, Intubation, Intratracheal/*adverse effects/instrumentation, Risk Factors, Rupture, Trachea/*injuries.

Pfortmueller, Carmen A., Graf, Fabienne, Tabbara, Malek, Lindner, Gregor, Zimmermann, Heinz, and Exadaktylos, Aristomenis K. “Erratum To: Acute Health Problems In African Refugees”. Wiener Klinische Wochenschrift 125, no. 17-18: 575-575. doi:10.1007/s00508-013-0410-7.

Tags: erratum, error.

Albers, C. E., von Allmen, M., Evangelopoulos, D. S., Zisakis, A. K., Zimmermann, H., and Exadaktylos, A. K. “What Is The Incidence Of Intracranial Bleeding In Patients With Mild Traumatic Brain Injury? A Retrospective Study In 3088 Canadian Ct Head Rule Patients”. Biomed Res Int 2013: 453978. doi:10.1155/2013/453978.

Abstract: OBJECTIVE: Only limited data exists in terms of the incidence of intracranial bleeding (ICB) in patients with mild traumatic brain injury (MTBI). METHODS: We retrospectively identified 3088 patients (mean age 41 range (7-99) years) presenting with isolated MTBI and GCS 14-15 at our Emergency Department who had undergone cranial CT (CCT) between 2002 and 2011. Indication for CCT was according to the "Canadian CT head rules." Patients with ICB were either submitted for neurosurgical treatment or kept under surveillance for at least 24 hours. Pearson's correlation coefficient was used to correlate the incidence of ICB with age, gender, or intake of coumarins, platelet aggregation inhibitors, or heparins. RESULTS: 149 patients (4.8%) had ICB on CCT. No patient with ICB died or deteriorated neurologically. The incidence of ICB increased with age and intake of anticoagulants without clinically relevant correlation (R = 0.11; P < 0.001; R = -0.06; P < 0.001). CONCLUSION: Our data show an incidence of 4.8% for ICB after MTBI. However, neurological deterioration after MTBI seems to be rare, and the need for neurosurgical intervention is only required in selected cases. The general need for CCT in patients after MTBI is therefore questionable, and clinical surveillance may be sufficient when CCT is not available.

Tags: *Tomography, X-Ray Computed, Adolescent, Adult, Aged, Aged, 80 and over, Brain Injuries/complications/*diagnostic imaging/*epidemiology/pathology, Canada, Female, Humans, Intracranial Hemorrhages/complications/diagnostic imaging/*pathology, Male, Middle Aged, Retrospective Studies, Young Adult.

Dami, F., Pasquier, M., and Carron, P. N. “Use Of Lights And Siren: Is There Room For Improvement?”. Eur J Emerg Med 21, no. 1: 52-6. doi:10.1097/MEJ.0b013e328364b607.

Abstract: OBJECTIVE: The objective of this study was to analyse the use of lights and siren (L&S) during transport to the hospital by the prehospital severity status of the patient and the time saved by the time of day of the mission. METHODS: We searched the Public Health Services data of a Swiss state from 1 January 2010 to 31 December 2010. All primary patient transports within the state were included (24 718). The data collected were on the use of L&S, patient demographics, the time and duration of transport, the type of mission (trauma vs. nontrauma) and the severity of the condition according to the National Advisory Committee for Aeronautics (NACA) score assigned by the paramedics and/or emergency physician. We excluded 212 transports because of missing data. RESULTS: A total of 24 506 ambulance transports met the inclusion criteria. L&S were used 4066 times, or in 16.6% of all missions. Of these, 40% were graded NACA less than 4. Overall, the mean total transport time to return to the hospital was 11.09 min (confidence interval 10.84-11.34) with L&S and 12.84 min (confidence interval 12.72-12.96) without. The difference was 1.75 min (105 s; P<0.001). For night-time runs alone, the mean time saved using L&S was 0.17 min (10.2 s; P=0.27). CONCLUSION: At present, the use of L&S seems questionable given the severity status or NACA score of transported patients. Our results should prompt the implementation of more specific regulations for L&S use during transport to the hospital, taking into consideration certain physiological criteria of the victim as well as time of day of transport.

Tags: *Ambulances, *Lighting, *Severity of Illness Index, Female, Humans, Male, Noise.

Nouira, A., Maatoug, J., Harrabi, I., Hmad, S., Belkacem, M., Slama, S., Al'absi, M., Lando, H., and Ghannem, H. “Clustering Of Risk Factors In The Smoking Habits Of Schoolchildren In Sousse, Tunisia”. Int J Adolesc Med Health 26, no. 2: 267-73. doi:10.1515/ijamh-2013-0511.

Abstract: BACKGROUND: In Tunisia, little is known about the association between tobacco use and other chronic disease risk factors. This is the case for both adults and children. It is important to know the characteristics of young smokers to facilitate the creation and implementation of future programs for tobacco prevention. AIM: The aim of this study was to determine the association between tobacco use and other lifestyle factors among schoolchildren in Tunisia. METHODS: We conducted a 2009/2010 cross-sectional questionnaire survey of 4003 randomly selected school children aged 13 years old (7th and 9th grades) to evaluate their knowledge, attitudes towards, and beliefs about the three risk factors for chronic disease (unhealthy diet, physical inactivity, and tobacco use). Written informed consent was obtained from each child's parents who allowed their child to participate. RESULTS: The mean age of our sample was 13.36 +/- 1.28 years. The proportions of daily smokers were 2.2% and 0.1% among boys and girls, respectively. The proportions of irregular smokers were 9.1% and 1.5% among boys and girls, respectively. In our population, 19.1% (n=767) had ever experimented to smoke, with 29.8% among boys and 9% among girls (p<0.001). The proportions of schoolchildren who reported daily participation in physical activity were different between smokers and nonsmokers with 17.7% and 11.5%, respectively (p=0.03). Concerning eating habits, there was no significant difference in the consumption of fruits and vegetables; however, smokers frequently ate more high fat foods and in fast food restaurants. Similar results were found while comparing regular smoking children with those who experimented but who never became hooked on smoking. CONCLUSION: This study and previous research suggest the importance of early intervention in adolescents on smoking and combing these efforts with interventions focusing on physical activity and dietary habits.

Tags: *Health Knowledge, Attitudes, Practice, Adolescent, Cross-Sectional Studies, Exercise, Feeding Behavior, Female, Humans, Male, Prevalence, Risk Factors, Smoking/*epidemiology, Tunisia/epidemiology.

Nickel, C. H., Messmer, A. S., Geigy, N., Misch, F., Mueller, B., Dusemund, F., Hertel, S., Hartmann, O., Giersdorf, S., and Bingisser, R. “Stress Markers Predict Mortality In Patients With Nonspecific Complaints Presenting To The Emergency Department And May Be A Useful Risk Stratification Tool To Support Disposition Planning”. Acad Emerg Med 20, no. 7: 670-9. doi:10.1111/acem.12172.

Abstract: OBJECTIVES: To the authors' knowledge, no prospectively validated, biomarker-based risk stratification tools exist for elderly patients presenting to the emergency department (ED) with nonspecific complaints (NSCs), such as generalized weakness, despite the fact that an acute serious disease often underlies nonspecific disease presentation. The primary purpose for this study was to validate the retrospectively derived model for outcome prediction using copeptin and peroxiredoxin 4 (Prx4), in a different group of patients, in a prospective fashion, in a multicenter setting. The secondary goals were to evaluate the potential contribution of the midregional portion of the precursor of adrenomedullin (MR-proADM) for outcome prediction and to investigate whether disposition decisions show promise for potential improvement by using biomarker levels in addition to a clinical assessment. METHODS: The Basel Nonspecific Complaints (BANC) study is a delayed-type cross-sectional diagnostic study, carried out in three EDs in Switzerland, with a prospective 30-day follow-up. Patients presenting to the ED with NSCs, as defined previously, were included if their vital signs were within predefined limits. Measurement of biomarkers was performed in serum samples with sandwich immunoluminometric assays. To examine the disposition process, the final disposition was compared with a combination of the first clinical disposition decision and the risk assessment, which included the biomarker MR-proADM in a retrospective simulation. Patients were divided into three groups according to MR-proADM concentration, defining three risk classes with three disposition possibilities (admission to tertiary care, transfer to geriatric hospital, discharge). RESULTS: Thirty-three 30-day nonsurvivors were observed from among 504 study patients with NSCs. Biomarker levels were significantly greater in nonsurvivors than survivors (p < 0.0001 for all three biomarkers). Univariate Cox models reveal a C-index of 0.732 for MR-proADM, 0.719 for Prx4, and 0.723 for copeptin. The incremental added value for chi-square obtained via multivariate modeling showed that models inclusive of MR-proADM, copeptin, or Prx4 are superior to and independent of models limited to sex and age. The incrementally added chi-square for MR-proADM, beyond the chi-square of a base model consisting of age and sex, was 29.79 (p < 0.00001). In a multimarker approach, only Prx4 provided additional information to MR-proADM alone (C-index = 0.77). Applying an algorithm combining physicians' first clinical assessment plus biomarker information to derive a modified risk assessment, reassignment would lead to a potential decrease of 48 admissions to acute care, seven additional transfers to geriatric care, and 41 additional discharges (negative likelihood ratio [-LR] = 0.13). Analysis of 30-day mortality reveals that our algorithm is not inferior in terms of safety. CONCLUSIONS: In this study the authors confirm that these new stress biomarkers permit reliable prognostication of adverse outcomes in a heterogeneous group of patients with NSCs. A simulation showed that this prognostic information could be useful to enhance the appropriateness of disposition decisions of ED patients with NSC. The use of biomarkers for risk stratification in this patient group should be evaluated with prospective intervention studies.

Tags: *Hospital Mortality, Acute Disease, Adrenomedullin/*blood, Aged, Aged, 80 and over, Algorithms, Analysis of Variance, Biomarkers/blood, Cause of Death, Chi-Square Distribution, Chronic Disease, Cross-Sectional Studies, Emergency Service, Hospital/*statistics & numerical data, Fatigue/diagnosis/mortality, Female, Geriatric Assessment, Glycopeptides/*blood, Hospitals, University, Humans, Length of Stay, Male, Multivariate Analysis, Peroxiredoxins/*blood, Predictive Value of Tests, Proportional Hazards Models, Risk Assessment, Sensitivity and Specificity, Stress, Psychological, Survival Analysis, Switzerland.

Sanchez, B., Hirzel, A. H., Bingisser, R., Ciurea, A., Exadaktylos, A., Lehmann, B., Matter, H., et al. “State Of Emergency Medicine In Switzerland: A National Profile Of Emergency Departments In 2006”. Int J Emerg Med 6, no. 1: 23. doi:10.1186/1865-1380-6-23.

Abstract: BACKGROUND: Emergency departments (EDs) are an essential component of any developed health care system. There is, however, no national description of EDs in Switzerland. Our objective was to establish the number and location of EDs, patient visits and flow, medical staff and organization, and capabilities in 2006, as a benchmark before emergency medicine became a subspecialty in Switzerland. METHODS: In 2007, we started to create an inventory of all hospital-based EDs with a preliminary list from the Swiss Society of Emergency and Rescue Medicine that was improved with input from ED physicians nationwide. EDs were eligible if they offered acute care 24 h per day, 7 days per week. Our goal was to have 2006 data from at least 80% of all EDs. The survey was initiated in 2007 and the 80% threshold reached in 2012. RESULTS: In 2006, Switzerland had a total of 138 hospital-based EDs. The number of ED visits was 1.475 million visits or 20 visits per 100 inhabitants. The median number of visits was 8,806 per year; 25% of EDs admitted 5,000 patients or less, 31% 5,001-10,000 patients, 26% 10,001-20,000 patients, and 17% >20,000 patients per year. Crowding was reported by 84% of EDs with >20,000 visits/year. Residents with limited experience provided care for 77% of visits. Imaging was not immediately available for all patients: standard X-ray within 15 min (70%), non-contrast head CT scan within 15 min (38%), and focused sonography for trauma (70%); 67% of EDs had an intensive care unit within the hospital, and 87% had an operating room always available. CONCLUSIONS: Swiss EDs were significant providers of health care in 2006. Crowding, physicians with limited experience, and the heterogeneity of emergency care capabilities were likely threats to the ubiquitous and consistent delivery of quality emergency care, particularly for time-sensitive conditions. Our survey establishes a benchmark to better understand future improvements in Swiss emergency care.

Marti, G., Schwarz, C., Leichtle, A. B., Fiedler, G. M., Arampatzis, S., Exadaktylos, A. K., and Lindner, G. “Etiology And Symptoms Of Severe Hypokalemia In Emergency Department Patients”. Eur J Emerg Med 21, no. 1: 46-51. doi:10.1097/MEJ.0b013e3283643801.

Abstract: OBJECTIVES: To investigate the prevalence, etiology, and symptoms of severe hypokalemia in patients presenting to the emergency department. METHODS: In this retrospective, cross-sectional analysis, we included all patients who received measurement of serum potassium between April 2008 and 31 March 2011 at the emergency department to calculate the prevalence rate for hypokalemia. Of all patients with a serum potassium below 2.6 mmol/l (severe hypokalemia), we performed a detailed review of the patients' charts from the emergency department and the chart of the subsequent hospitalization. We identified ECG changes attributable to hypokalemia from the ECGs performed in the emergency department. RESULTS: During the study period, measurements of serum potassium for a total of 43 805 patients were performed. Of these patients, 4826 (11%) had hypokalemia (potassium <3.5 mmol/l) at presentation. Fifty-three (1%) patients with severe hypokalemia could be identified. Twenty-six (49%) patients were symptomatic, with weakness and muscle pain being the most common symptoms. Twenty (69%) patients had ECG changes with the presence of a U wave, followed by ST segment depression and ventricular extrasystoles. Malnutrition and use of diuretics were the main causes of severe hypokalemia. CONCLUSION: Hypokalemia is common in the emergency department. Severe hypokalemia is often symptomatic and more than two-thirds of patients show ECG changes.

Tags: Adult, Aged, Cross-Sectional Studies, Electrocardiography, Emergency Service, Hospital/*statistics & numerical data, Female, Humans, Hypokalemia/*diagnosis/*epidemiology/etiology, Male, Middle Aged, Prevalence, Retrospective Studies, Switzerland/epidemiology.

Lindner, G., Pfortmueller, C. A., Funk, G. C., Leichtle, A. B., Fiedler, G. M., and Exadaktylos, A. K. “High-Sensitive Troponin Measurement In Emergency Department Patients Presenting With Syncope: A Retrospective Analysis”. Plos One 8, no. 6: e66470. doi:10.1371/journal.pone.0066470.

Abstract: OBJECTIVE: To study the relevance of high-sensitive troponin measurements in the acute workup in patients admitted to the emergency department of a large university hospital due to syncope. METHODS: In this retrospective study all patients admitted to the emergency department because of syncope of the Inselspital, University Hospital Bern between 01 August 2010 and 31 October 2012, with serial determination of high-sensitive troponin (baseline and three hours control) were included. Of all identified patients we obtained data on demographics, laboratory data, ECG as well as on outcome. A change in high-sensitive troponin in the three hours control of +/-30% compared to baseline was considered significant. RESULTS: A total of 121 patients with a mean age of 67 years (SD 16) were included in the study. 79 patients (65%) were male and 42 (35%) were female. There was no significant difference in the median high sensitive-troponin level at baseline and in the three hours control (0.01 mcg/L [0.003 to 0.022] versus 0.011 mcg/L [0.003 to 0.022], p = 0.47). Median percent change in high-sensitive troponin level between baseline and control was 0% (-9.1 to 5). 51 patients (42%) had elevated high-sensitive troponin levels at baseline with 7 patients (6%) showing a dynamic of +/-30% change from the baseline measurement in the 3 hours control. 3 of these patients received coronary angiography due to the dynamic in high-sensitive troponin, none of whom needed intervention for coronary revascularization. CONCLUSIONS: On basis of the current study, where no single patient took benefit from determination of high-sensitive troponin, measurement of cardiac troponins should be reserved for patients with syncope presenting with symptoms suggestive for the presence of an acute cardiac syndrome.

Tags: *Emergency Service, Hospital, Aged, Female, Humans, Male, Middle Aged, Retrospective Studies, Sensitivity and Specificity, Syncope/*diagnosis, Troponin/*blood.

Bodmer, M., Jick, S. S., and Meier, C. R. “Comment On: Suissa And Azoulay. Metformin And The Risk Of Cancer: Time-Related Biases In Observational Studies. Diabetes Care 2012;35:2665-2673”. Diabetes Care 36, no. 6: e85. doi:10.2337/dc12-2693.

Tags: Animals, Humans, Hypoglycemic Agents/*therapeutic use, Metformin/*therapeutic use.

Hudelson, P., Dominice Dao, M., and Durieux-Paillard, S. “Quality In Practice: Integrating Routine Collection Of Patient Language Data Into Hospital Practice”. Int J Qual Health Care 25, no. 4: 437-42. doi:10.1093/intqhc/mzt035.

Abstract: QUALITY PROBLEM: Timely identification of patients' language needs can facilitate the provision of language-appropriate services and contribute to quality of care, clinical outcomes and patient satisfaction. INITIAL ASSESSMENT: At the University Hospitals of Geneva, Switzerland, timely organization of interpreter services was hindered by the lack of systematic patient language data collection. CHOICE OF SOLUTION: We explored the feasibility and acceptability of a procedure for collecting patient language data at the first point of contact, prior to its hospital-wide implementation. IMPLEMENTATION: During a one-week period, receptionists and triage nurses in eight clinical services tested a new procedure for collecting patient language data. Patients were asked to identify their primary language and other languages they would be comfortable speaking with their doctor. Staff noted patients' answers on a paper form and provided informal feedback on their experience with the procedure. EVALUATION: Registration staff encountered few difficulties collecting patient language data and thought that the two questions could easily be incorporated into existing administrative routines. Following the pilot test, two language fields with scroll-down language menus were added to the electronic patient file, and the subsequent filling-in of these fields has been rapid and hospital wide. LESSONS LEARNED: Our experience suggests that routine collection of patient language data at first point of contact is both feasible and acceptable and that involving staff in a pilot project may facilitate hospital-wide implementation. Future efforts should focus on exploring the sensitivity and specificity of the proposed questions, as well as the impact of data collection on interpreter use.

Tags: *Language, Communication Barriers, Data Collection/*methods, Hospital Administration/*methods, Humans, language barriers, patient language data, patient-provider communication, Pilot Projects, quality of care, Quality of Health Care/*organization & administration, Translating.

Lindner, G., and Exadaktylos, A. K. “The Reply”. Am J Med 126, no. 6: e15. doi:10.1016/j.amjmed.2012.12.008.

Tags: Female, Humans, Hypernatremia/*blood, Hyponatremia/*blood, Male, Sodium/*blood.

Lindner, G., and Funk, G. C. “Hypernatremic Alkalosis Or Chloride Depletion Alkalosis? Reply To Vasconcelos Et Al”. Intensive Care Med 39, no. 7: 1332. doi:10.1007/s00134-013-2929-5.

Tags: Alkalosis/*blood/*etiology, Female, Humans, Hypernatremia/*complications, Male, Sodium/*blood.

Schminke, L. H., Jeger, V., Evangelopoulos, D. S., Zimmerman, H., and Exadaktylos, A. K. “Riding The Escalator: How Dangerous Is It Really?”. West J Emerg Med 14, no. 2: 141-5. doi:10.5811/westjem.2012.12.13346.

Abstract: INTRODUCTION: About 10,000 escalator-related injuries per year result in emergency department treatment in the United States. Since the 1990s, a steady increase has been reported, but few statistics on escalator-related injuries have been published worldwide. We have therefore analyzed escalator accident statistics in admissions to our hospital in Switzerland since 2000. METHODS: Using retrospective electronic patient chart analysis, we included in our study patients >16 years treated over an 11-year period. We categorized patients in terms of gender, age and associated risk factors, and classified accidents according to day, time, location and cause. Resulting trauma was categorized according to type and location. We divided post-admission treatment into surgical and conservative, and into treatment as an outpatient, in a short-stay unit, or as a hospital admission. Women and men were compared using Fisher's exact test. RESULTS: We identified 173 patients with 285 discrete injuries. Of these, 87 patients (50%) were women. Fifty-three (61%) of the women and 38 (44%) of the men were >60 years old (P = 0.033). Fifty percent of the men (43/86) of the men, but only 7% (6/87) of the women showed signs of alcohol intoxication (P < 0.0001). Accidents in women occurred predominantly on Tuesdays (19/87; 22%) between 12pm and 6pm (35/87; 40%), and in men on Saturdays (16/86; 19%) between 6pm and 12am (29/86; 34%; P = 0.0097). Sixty-two percent (44/71) of the accidents were in public transport facilities and 30% (21/71) in shopping centers. The majority of injuries in women were to the lower extremities (49/87; 56%), while most accidents in men were to the head and neck (51/86; 59%; P = 0.0052). About half (90; 52%) of the patients were treated conservatively. Almost half of all patients (76, 44%) required hospital admission. Of those, 45% left the hospital within 24 hours of admission (short stay unit) and 55% stayed longer than 24 hours. CONCLUSION: Escalator accidents can result in severe trauma. Significant gender differences in escalator accidents have been observed. Alcohol intoxication and age are significant risk factors in escalator-related accidents and might be possible targets for preventive measures.

Junod Perron, N., Dao, M. D., Righini, N. C., Humair, J. P., Broers, B., Narring, F., Haller, D. M., and Gaspoz, J. M. “Text-Messaging Versus Telephone Reminders To Reduce Missed Appointments In An Academic Primary Care Clinic: A Randomized Controlled Trial”. Bmc Health Serv Res 13, no. 1: 125. doi:10.1186/1472-6963-13-125.

Abstract: BACKGROUND: Telephone or text-message reminders have been shown to significantly reduce the rate of missed appointments in different medical settings. Since text-messaging is less resource-demanding, we tested the hypothesis that text-message reminders would be as effective as telephone reminders in an academic primary care clinic. METHODS: A randomized controlled non-inferiority trial was conducted in the academic primary care division of the Geneva University Hospitals between November 2010 and April 2011. Patients registered for an appointment at the clinic, and for whom a cell phone number was available, were randomly selected to receive a text-message or a telephone call reminder 24 hours before the planned appointment. Patients were included each time they had an appointment. The main outcome was the rate of unexplained missed appointments. Appointments were not missed if they were cancelled or re-scheduled before or independently from the intervention. We defined non-inferiority as a difference below 2% in the rate of missed appointments and powered the study accordingly. A satisfaction survey was conducted among a random sample of 900 patients (response rate 41%). RESULTS: 6450 patients were included, 3285 in the text-message group and 3165 in the telephone group. The rate of missed appointments was similar in the text-message group (11.7%, 95% CI: 10.6-12.8) and in the telephone group (10.2%, 95% CI: 9.2-11.3 p = 0.07). However, only text message reminders were cost-effective. No patient reported any disturbance by any type of reminder in the satisfaction survey. Three quarters of surveyed patients recommended its regular implementation in the clinic. CONCLUSIONS: Text-message reminders are equivalent to telephone reminders in reducing the proportion of missed appointments in an academic primary care clinic and are more cost-effective. Both types of reminders are well accepted by patients.

Tags: *Academic Medical Centers, *Appointments and Schedules, *Outpatient Clinics, Hospital, *Patient Compliance, *Primary Health Care, *Telephone, *Text Messaging, Adult, Female, Humans, Male, Middle Aged, Patient Satisfaction, Reminder Systems/*instrumentation, Surveys and Questionnaires, Switzerland.

Arampatzis, S., Funk, G. C., Leichtle, A. B., Fiedler, G. M., Schwarz, C., Zimmermann, H., Exadaktylos, A. K., and Lindner, G. “Impact Of Diuretic Therapy-Associated Electrolyte Disorders Present On Admission To The Emergency Department: A Cross-Sectional Analysis”. Bmc Med 11, no. 1: 83. doi:10.1186/1741-7015-11-83.

Abstract: BACKGROUND: Diuretics are among the most commonly prescribed medications and, due to their mechanisms of action, electrolyte disorders are common side effects of their use. In the present work we investigated the associations between diuretics being taken and the prevalence of electrolyte disorders on admission as well as the impact of electrolyte disorders on patient outcome. METHODS: In this cross sectional analysis, all patients presenting between 1 January 2010 and 31 December 2011 to the emergency room (ER) of the Inselspital, University Hospital Bern, Switzerland were included. Data on diuretic medication, baseline characteristics and laboratory data including electrolytes and renal function parameters were obtained from all patients. A multivariable logistic regression model was performed to assess the impact of factors on electrolyte disorders and patient outcome. RESULTS: A total of 8.5% of patients presenting to the ER used one diuretic, 2.5% two, and 0.4% three or four. In all, 4% had hyponatremia on admission and 12% hypernatremia. Hypokalemia was present in 11% and hyperkalemia in 4%. All forms of dysnatremia and dyskalemia were more common in patients taking diuretics. Loop diuretics were an independent risk factor for hypernatremia and hypokalemia, while thiazide diuretics were associated with the presence of hyponatremia and hypokalemia. In the Cox regression model, all forms of dysnatremia and dyskalemia were independent risk factors for in hospital mortality. CONCLUSIONS: Existing diuretic treatment on admission to the ER was associated with an increased prevalence of electrolyte disorders. Diuretic therapy itself and disorders of serum sodium and potassium were risk factors for an adverse outcome.

Tags: Adult, Aged, Cross-Sectional Studies, Diuretics/*administration & dosage/*adverse effects, Emergency Medicine/*statistics & numerical data, Female, Humans, Male, Middle Aged, Prevalence, Switzerland/epidemiology, Water-Electrolyte Imbalance/*chemically induced/*epidemiology.

Pfortmuller, C. A., Leichtle, A. B., Fiedler, G. M., Exadaktylos, A. K., and Lindner, G. “Hyperkalemia In The Emergency Department: Etiology, Symptoms And Outcome Of A Life Threatening Electrolyte Disorder”. Eur J Intern Med 24, no. 5: e59-60. doi:10.1016/j.ejim.2013.02.010.

Tags: Acute Disease, Aged, Aged, 80 and over, Emergency Service, Hospital, Female, Humans, Hyperkalemia/*diagnosis/*etiology/mortality, Male, Middle Aged, Renal Insufficiency/*complications/mortality, Retrospective Studies, Water-Electrolyte Imbalance/diagnosis/etiology/mortality.

Nickel, C. H., Ruedinger, J. M., Messmer, A. S., Maile, S., Peng, A., Bodmer, M., Kressig, R. W., Kraehenbuehl, S., and Bingisser, R. “Drug-Related Emergency Department Visits By Elderly Patients Presenting With Non-Specific Complaints”. Scand J Trauma Resusc Emerg Med 21, no. 1: 15. doi:10.1186/1757-7241-21-15.

Abstract: BACKGROUND: Since drug-related emergency department (ED) visits are common among older adults, the objectives of our study were to identify the frequency of drug-related problems (DRPs) among patients presenting to the ED with non-specific complaints (NSC), such as generalized weakness and to evaluate responsible drug classes. METHODS: Delayed type cross-sectional diagnostic study with a prospective 30 day follow-up in the ED of the University Hospital Basel, Switzerland. From May 2007 until April 2009, all non-trauma patients presenting to the ED with an Emergency Severity Index (ESI) of 2 or 3 were screened and included, if they presented with non-specific complaints. After having obtained complete 30-day follow-up, two outcome assessors reviewed all available information, judged whether the initial presentation was a DRP and compared their judgment with the initial ED diagnosis. Acute morbidity ("serious condition") was allocated to individual cases according to predefined criteria. RESULTS: The study population consisted of 633 patients with NSC. Median age was 81 years (IQR 72/87), and the mean Charlson comorbidity index was 2.5 (IQR 1/4). DRPs were identified in 77 of the 633 cases (12.2%). At the initial assessment, only 40% of the DRPs were correctly identified. 64 of the 77 identified DRPs (83%) fulfilled the criteria "serious condition". Polypharmacy and certain drug classes (thiazides, antidepressants, benzodiazepines, anticonvulsants) were associated with DRPs. CONCLUSION: Elderly patients with non-specific complaints need to be screened systematically for drug-related problems. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00920491.

Tags: Aged, Aged, 80 and over, Cross-Sectional Studies, Drug-Related Side Effects and Adverse Reactions/diagnosis/*epidemiology, Emergency Service, Hospital/*statistics & numerical data, Female, Humans, Male, Prescription Drugs/*adverse effects, Prospective Studies, Switzerland/epidemiology.

Schulte, D., Habernig, S., Zuzak, T., Staubli, G., Altermatt, S., Horst, M., and Garcia, D. “Forearm Fractures In Children: Split Opinions About Splitting The Cast”. Eur J Pediatr Surg 24, no. 2: 163-7. doi:10.1055/s-0033-1341412.

Abstract: BACKGROUND: Fractures of the forearm are the most common fractures in children. Various methods of cast immobilization have been recommended. Currently, there is still controversy regarding the optimal method of treatment, especially regarding the need for cast splitting. METHODS: We conducted a single-center randomized and controlled trial between June 2008 and September 2009. Children younger than 16 years presenting to the emergency department with a closed fracture of the forearm needing reduction were eligible for random assignment to immobilization in a closed or split circumferential semirigid cast. The primary outcome was the incidence of cast-related soft-tissue problems such as compartment syndrome, neurovascular compromise, saw burns, or skin breakdown. The secondary outcome was fracture stability. RESULTS: During this period, 100 patients were randomly assigned to one of the two procedures and analyzed. Follow-up was completed in 99 patients. No compartment syndrome was observed in either group. Moderate skin breakdown (< 2 cm(2)) occurred in two patients, one in the closed cast and one in the split cast group. Secondary splitting was necessary in one patient because of a reversible lymphedema. Significant secondary displacement of the fracture was slightly more common in the split group (5 of 50 patients [10%] vs. 4 of 49 patients [8%] in the closed cast group) without reaching statistical significance. CONCLUSIONS: No significant difference in the incidence of cast-related problems was observed between the groups. Fracture stability was comparable in both groups. We suggest that closed circumferential semirigid casts are a safe and effective immobilization technique for fractures of the forearm in children and splitting can be omitted.

Tags: *Casts, Surgical/adverse effects, Adolescent, Child, Child, Preschool, Compartment Syndromes/etiology, Female, Humans, Infant, Infant, Newborn, Male, Pressure, Prospective Studies, Radius Fractures/*therapy, Skin/blood supply/injuries/innervation, Treatment Outcome, Ulna Fractures/*therapy.

Lindner, G., and Exadaktylos, A. K. “Are We In The Midst Of A Copernican Revolution In Infusion Therapy?”. Am J Emerg Med 31, no. 2: 435. doi:10.1016/j.ajem.2012.10.037.

Tags: Fluid Therapy/adverse effects/*methods, Humans, Infusions, Intravenous, Isotonic Solutions/chemistry/*therapeutic use.

Jackson, Y., Chatelain, E., Mauris, A., Holst, M., Miao, Q., Chappuis, F., and Ndao, M. “Serological And Parasitological Response In Chronic Chagas Patients 3 Years After Nifurtimox Treatment”. Bmc Infect Dis 13, no. 1: 85. doi:10.1186/1471-2334-13-85.

Abstract: BACKGROUND: With declining vectorial transmission, Chagas disease predominantly affects adults nowadays. The efficacy of nifurtimox in the chronic phase in adult patients is poorly known, particularly in regions where there is no risk of reinfection. Recommendations for treatment outcome assessment rely on serological follow-up. We evaluated the serological and parasitological response to nifurtimox in a cohort of adult patients three years post-treatment in Switzerland. METHODS: Patients treated with nifurtimox in 2008 during a cross-sectional study in Geneva, Switzerland, were contacted for follow-up in 2011. Two ELISAs and a rapid immunochromatographic test were used to test 2008 and 2011 serum samples simultaneously. In addition, conventional and real-time PCR were performed on 2011 samples. RESULTS: Thirty-seven (84.1%) of 44 eligible patients, predominantly female, middle-aged, Bolivians at the indeterminate stage, were enrolled. All 2011 ELISA and immunochromatographic tests were positive. Twenty-eight (75.7%) patients presented a lower optical density (OD) in 2011 compared to 2008. This OD difference was significant in both commercial (P < 0.001) and in-house (P = 0.002) ELISAs. Agreement between the two ELISAs was low (Kappa = 0.469). All patients had negative conventional PCR results but one (2.7%) was positive with real-time PCR. CONCLUSION: Our results highlight the inadequacy of serology for assessing response in adults, three years after treatment. In our cohort, 97.3% had results that could either indicate treatment failure or persistant humoral response despite treatment. The lack of accurate early post-treatment tests of cure prevents appropriate patients information and councelling. New follow-up tests are needed to assess treatments efficacy given the large adult population in need of antiparasitic therapy.

Tags: *Trypanosoma cruzi/genetics/immunology, Adult, Chagas Disease/*drug therapy/*parasitology, Chronic Disease, Cross-Sectional Studies, Enzyme-Linked Immunosorbent Assay, Female, Follow-Up Studies, Humans, Male, Middle Aged, Nifurtimox/*therapeutic use, Real-Time Polymerase Chain Reaction, Treatment Outcome, Trypanocidal Agents/*therapeutic use.

Lindner, G. “Hypernatremia In The Intensive Care Unit--An Iatrogenic Complication?”. J Crit Care 28, no. 2: 214-5. doi:10.1016/j.jcrc.2012.11.017.

Tags: *Critical Illness, *Intensive Care Units, Humans, Hypernatremia/*complications/*physiopathology.

Simion, N. I., Muntean, V., and Fabian, O. “Current State Of Knowledge On Neuroendocrine Small Bowel Tumours: Non-Systematic Review Of The Literature Based On One Case”. Bmj Case Rep 2013. doi:10.1136/bcr-2012-007217.

Abstract: More than 60% of neuroendocrine tumours, also called carcinoids, are localised within the gastrointestinal tract. Small bowel neuroendocrine tumours have been diagnosed with increasing frequency over the past 35 years, being the second most frequent tumours of the small intestine. Ileal neuroendocrine tumours diagnosis is late because patients have non-specific symptoms. We have proposed to illustrate as an example the case of a patient, and on its basis, to make a brief review of the literature on small bowel neuroendocrine tumours, resuming several recent changes in the field, concerning classification criteria of these tumours and new recommendations and current advances in diagnosis and treatment. This patient came to our emergency department with a complete bowel obstruction, along with a 2-year history of peristaltic abdominal pain, vomits and diarrhoea episodes. During emergency laparotomy, an ileal stricture was observed, that showed to be a neuroendocrine tumour of the small bowel.

Tags: *Intestine, Small, Diagnosis, Differential, Humans, Intestinal Neoplasms/complications/*diagnosis/surgery, Intestinal Obstruction/diagnosis/*etiology/surgery, Laparoscopy, Neuroendocrine Tumors/complications/*diagnosis/surgery, Tomography, X-Ray Computed.

Alcoba, G., Kerac, M., Breysse, S., Salpeteur, C., Galetto-Lacour, A., Briend, A., and Gervaix, A. “Do Children With Uncomplicated Severe Acute Malnutrition Need Antibiotics? A Systematic Review And Meta-Analysis”. Plos One 8, no. 1: e53184. doi:10.1371/journal.pone.0053184.

Abstract: BACKGROUND: Current (1999) World Health Organization guidelines recommend giving routine antibiotics (AB) for all children with severe acute malnutrition (SAM), even if they have uncomplicated disease with no clinically obvious infections. We examined the evidence behind this recommendation. METHODS AND FINDINGS: OVID-MEDLINE, EMBASE, COCHRANE, GLOBAL-HEALTH, CINAHL, POPLINE, AFRICA-WIDE-NiPAD, and LILACS were searched for AB efficacy, bacterial resistance, and infection rates in SAM. Following PRISMA guidelines, a systematic review and meta-analysis were performed. Three randomised controlled trials (RCT), five Cochrane reviews, and 37 observational studies were identified. One cohort-study showed no increase in nutritional-cure and mortality in uncomplicated SAM where no AB were used. (p>0.05). However, an unpublished RCT in this setting did show mortality benefits. Another RCT did not show superiority of ceftriaxone over amoxicilllin for these same outcomes, but adressed SAM children with and without complications (p = 0.27). Another RCT showed no difference between amoxicillin and cotrimoxazole efficacies for pneumonia in underweight, but not SAM. Our meta-analysis of 12 pooled susceptibility-studies for all types of bacterial isolates, including 2767 stricly SAM children, favoured amoxicillin over cotrimoxazole for susceptibility medians: 42% (IQR 27-55%) vs 22% (IQR 17-23%) and population-weighted-means 52.9% (range 23-57%) vs 35.4% (range 6.7-42%). Susceptibilities to second-line AB were better, above 80%. Prevalence of serious infections in SAM, pooled from 24 studies, ranged from 17% to 35.2%. No study infered any association of infection prevalence with AB regimens in SAM. CONCLUSIONS: The evidence underlying current antibiotic recommendations for uncomplicated SAM is weak. Susceptibility-studies favour amoxicillin over cotrimoxazole. However, given that these antibiotics have side-effects, costs, and risks as well as benefits, their routine use needs urgent testing. With reliable monitoring, we believe that there is sufficient equipoise for placebo controlled RCTs, the only robust way to demonstrate true efficacy.

Tags: Acute Disease, Amoxicillin/therapeutic use, Anti-Bacterial Agents/*therapeutic use, Bacteria/*drug effects, Bacterial Infections/complications/*drug therapy/microbiology, Ceftriaxone/therapeutic use, Child, Child Nutrition Disorders/complications/*drug therapy/pathology, Child, Preschool, Humans, Practice Guidelines as Topic.

Hertwig, R., Meier, N., Nickel, C., Zimmermann, P. C., Ackermann, S., Woike, J. K., and Bingisser, R. “Correlates Of Diagnostic Accuracy In Patients With Nonspecific Complaints”. Med Decis Making 33, no. 4: 533-43. doi:10.1177/0272989X12470975.

Abstract: OBJECTIVE: To investigate diagnostic accuracy in patient histories involving nonspecific complaints and the extent to which characteristics of physicians and structural properties of patient histories are associated with accuracy. METHODS: Six histories of patients presenting to the emergency department (ED) with nonspecific complaints were provided to 112 physicians: 36 ED physicians, 50 internists, and 26 family practitioners. Physicians listed the 3 most likely diagnoses for each history and indicated which cue(s) they considered crucial. Four weeks later, a subset of 20 physicians diagnosed the same 6 histories again. For each history, experts had previously determined the correct diagnoses and the diagnostic cues. RESULTS: Accuracy ranged from 14% to 64% correct diagnoses (correct diagnosis listed as the most likely) and from 29% to 87% correct differential diagnoses (correct diagnosis listed in the differential). Acute care physicians (ED physicians and internists) included the correct diagnosis in the differential in, on average, 3.4 histories, relative to 2.6 for the family practitioners (P = 0.001, d = .75). Diagnostic performance was fairly reliable (r = .61, P < 0.001). Clinical experience was negatively correlated with diagnostic accuracy (r = -.25, P = 0.008). Two structural properties of patient histories-cue consensus and cue substitutability-were significantly associated with diagnostic accuracy, whereas case difficulty was not. Finally, prevalence of diagnosis also proved significantly correlated with accuracy. CONCLUSIONS: Average diagnostic accuracy in cases with nonspecific complaints far exceeds chance performance, and accuracy varies with medical specialty. Analyzing cue properties in patient histories can help shed light on determinants of diagnostic performance and thus suggest ways to enhance physicians' ability to accurately diagnose cases with nonspecific complaints.

Tags: *Diagnosis, Differential, Attitude of Health Personnel, Clinical Competence, diagnostic decision making, emergency department physicians, Emergency Service, Hospital/*statistics & numerical data, experience, family practitioners., Humans, internists, Medical History Taking, Medical Staff, Hospital/psychology, nonspecific complaints, Probability, Switzerland, Workforce.

Van Der Wilden, G. M., Albers, C. E., Haefeli, P. C., Zimmermann, H., Exadaktylos, A., Levy, P., Birkhan, O., et al. “A Population-Based Analysis Of The Clinical Course Of 10,304 Patients With Acute Cholecystitis Discharged Without Cholecystectomy”. Journal Of Trauma And Acute Care Surgery 74, no. 1: 348-349. doi:10.1097/TA.0b013e31827e4ca5.

Tags: erratum, error, priority journal.

Rieder, J. P., Casillas, A., Mary, G., Secretan, A. D., Gaspoz, J. M., and Wolff, H. “Health Care In Small Prisons: Incorporating High-Quality Standards”. Int J Prison Health 9, no. 1: 20-30. doi:10.1108/17449201311310779.

Abstract: PURPOSE: In the past, health management in Geneva's six post-trial prisons had been variable and inconsistent. In 2008, the unit of penitentiary medicine of the Geneva University Hospitals was mandated to re-organize and provide health care at all six prison facilities. The specific aim of this paper is to outline the example as a practical solution to some of the common challenges in unifying the structure and process of health services across multiple small facilities, while meeting European prison health and local quality standards. DESIGN/METHODOLOGY/APPROACH: Geneva's post-trial prisons are small and close to one another in geographical proximity - ideal conditions for the construction of a health mobile team (HMT). This multidisciplinary mobile team operated like a community ambulatory care model; it was progressively launched in all prison facilities in Geneva. The authors incorporated an implementation strategy where health providers partnered with prison and community stakeholders in the health delivery model's development and adaption process. FINDINGS: The model's strategic initiatives are described along the following areas, in light of other international prison health activity and prior care models: access to a health care professional, equivalence of care, patient consent, confidentiality, humanitarian interventions, and professional competence and independence. ORIGINALITY/VALUE: From the perspective of the HMT members, the authors provide the "lessons learned" through this experience, especially to providers who are working on prison health services reform and coordination improvement. The paper particularly stresses the importance of partnering with community health stakeholders and prison staff, a key component to the approach.

Tags: *Prisons, Access, Community health network, Delivery of Health Care/*organization & administration, Evaluation, Health care quality, Health care team, Health services, Humans, Interdisciplinary Communication, Interdisciplinary health team, Mobile health unit, Mobile Health Units, Prisons, Switzerland.

Dobrila-Dintinjana, R., Redžović, A., Valković, T., Ilijić, V., and Vanis, N. “Emergiencies In Oncology And Haematology”. Medicina Fluminensis 49, no. 4: 405-413. https://www.scopus.com/inward/record.uri?eid=2-s2.0-84891455735&partnerID=40&md5=e7cdbc29c7d039c1a6e9e041d73a98a1.

Abstract: With the increasing incidence of cancer in the general population and improved survival, emergencies in oncology and hematology are more frequently encountered. Oncologic emergencies represent a wide variety of conditions that can occur at any time during the course of a malignancy, from an initial presenting manifestations in patients with an undiagnosed cancer, to end-stage incurable metastatic disease. Oncologic emergencies include conditions caused by the cancer itself or side effects of antitumor therapy but they can also be independent from malignant disease. Oncologic emergencies can be metabolic (tumor lysis syndrome), hematologic (intravascular coagulation), inflammatory (neutropenic fever) and mechanic (brain edema) as emergencies in palliative care (pain). Prompt interventions can be lifesaving and may spare patients considerable morbidity and mortality. Implementation of palliative care is increasing patients Quality of Life and decreasing intensity of symptoms and it's crucial in preparation for the natural completion diseases, departures and mourning.

Derungs, A., Schwaninger, A. E., Mansella, G., Bingisser, R., Kraemer, T., and Liechti, M. E. “Symptoms, Toxicities, And Analytical Results For A Patient After Smoking Herbs Containing The Novel Synthetic Cannabinoid Mam-2201”. In, 31:164-171, 2013. doi:10.1007/s11419-012-0166-1.

Abstract: We report a case of intoxication by the synthetic cannabinoid MAM-2201 ([1-(5-fluoropentyl)-1H-indol-3-yl](4-methyl-1-naphthalenyl)-methanone). A 31-year-old man smoked about 300 mg of a herbal blend. He experienced an acute transient psychotic state with agitation, aggression, anxiety, and vomiting associated with a sympathomimetic syndrome. MAM-2201 was detected and quantified in a plasma sample using liquid chromatography-tandem mass spectrometry (LC-MS-MS). The level was 49 ng/ml 1 h after smoking. The use of other drugs was analytically excluded. The presence of MAM-2201 was confirmed in the herbal blend using gas chromatography-mass spectrometry (GC-MS) and LC-high resolution MS. This is the first description of an analytically confirmed intoxication and of the determination of MAM-2201 in human blood plasma. © 2012 Japanese Association of Forensic Toxicology and Springer Japan.

Swiss Emergency Research collection

2013

2012