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Swiss Emergency Research collection

2023

  • Schmutz, T., Le Terrier, C., Ribordy, V., and Guechi, Y. “No Waiting Lying In A Corridor: A Quality Improvement Initiative In An Emergency Department”. Bmj Open Qual 12, no. 3. doi:10.1136/bmjoq-2023-002431.
    Abstract: BACKGROUND: Overcrowding in the emergency department (ED) is a global problem and a source of morbidity and mortality and exhaustion for the teams. Despite multiple strategies proposed to overcome overcrowding, the accumulation of patients lying in bed awaiting treatment or hospitalisation is often inevitable and a major obstacle to quality of care. We initiated a quality improvement project with the objective of zero patients lying in bed awaiting care/referral outside a care area. METHODS: Several plan-do-study-act (PDSA) cycles were tested and implemented to achieve and especially maintain the goal of having zero patients waiting for care outside the ED care area. The project team introduced and adapted five rules during these cycles: (1) no patients lying down outside of a care unit; (2) forward movement; (3) examination room always available; (4) team huddle and (5) an organisation overcrowding plan. RESULTS: Adaptation of ED organisation in the form of PDSA cycles allowed to obtain a collective team dimension to patient flow management. Since December 2021, despite an increase in activity, no patient is placed in a lying-in waiting area outside a care zone, irrespective of their care level. Vital distress and fragile patients who need to be kept in a supine position are treated immediately. In 2022, waiting time before medical contact was <2 hours for 90% of all patients combined. CONCLUSIONS: The PDSA strategy based on these five measures allowed to remove in-house obstacles to the internal flow of patients and to fight against their installation outside the care area. These measures are easily replicable by other management teams. Quality indicators of EDs are often heterogeneous, but we propose that the absence of patients lying on a stretcher outside a care area could be part of these indicators, and thus contribute to the improvement and safety of care provided to all patients.
    Tags: *Emergency Medical Services, *Quality Improvement, Emergency department, Emergency Service, Hospital, Health Facilities, Healthcare quality improvement, Hospitalization, Human factors, Humans.
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  • Christ, M. “Pulmonary Embolism: "Keep On Adding, Keep On Walking, Keep On Progressing"”. Am J Cardiol 208: 197-198. doi:10.1016/j.amjcard.2023.08.021.
  • Beynon, F., Guerin, F., Lampariello, R., Schmitz, T., Tan, R., Ratanaprayul, N., Tamrat, T., et al. “Digitalizing Clinical Guidelines: Experiences In The Development Of Clinical Decision Support Algorithms For Management Of Childhood Illness In Resource-Constrained Settings”. Glob Health Sci Pract 11, no. 4. doi:10.9745/GHSP-D-22-00439.
    Abstract: Clinical decision support systems (CDSSs) can strengthen the quality of integrated management of childhood illness (IMCI) in resource-constrained settings. Several IMCI-related CDSSs have been developed and implemented in recent years. Yet, despite having a shared starting point, the IMCI-related CDSSs are markedly varied due to the need for interpretation when translating narrative guidelines into decision logic combined with considerations of context and design choices. Between October 2019 and April 2021, we conducted a comparative analysis of 4 IMCI-related CDSSs. The extent of adaptations to IMCI varied, but common themes emerged. Scope was extended to cover a broader range of conditions. Content was added or modified to enhance precision, align with new evidence, and support rational resource use. Structure was modified to increase efficiency, improve usability, and prioritize care for severely ill children. The multistakeholder development processes involved syntheses of recommendations from existing guidelines and literature; creation and validation of clinical algorithms; and iterative development, implementation, and evaluation. The common themes surrounding adaptations of IMCI guidance highlight the complexities of digitalizing evidence-based recommendations and reinforce the rationale for leveraging standards for CDSS development, such as the World Health Organization's SMART Guidelines. Implementation through multistakeholder dialogue is critical to ensure CDSSs can effectively and equitably improve quality of care for children in resource-constrained settings.
    Tags: *Decision Support Systems, Clinical, *Ichthyosiform Erythroderma, Congenital, *Lipid Metabolism, Inborn Errors, Algorithms, Child, Humans.
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  • Seelandt, J. C., Boos, M., Kolbe, M., and Kammer, J. E. “How To Enrich Team Research In Healthcare By Considering Five Theoretical Perspectives”. Front Psychol 14: 1232331. doi:10.3389/fpsyg.2023.1232331.
    Abstract: The aim of this paper is to inspire team research to apply diverse and unconventional perspectives to study team dynamics and performance in healthcare settings. To illustrate that using multiple perspectives can yield valuable insights, we examine a segment of a team interaction during a heart-surgery, using five distinct interdisciplinary perspectives known from small group research: the psychodynamic, functional, conflict-power-status, temporal, and social identity perspectives. We briefly describe each theoretical perspective, discuss its application to study healthcare teams, and present possible research questions for the segment at hand using the respective perspective. We also highlight the benefits and challenges associated with employing these diverse approaches and explore how they can be integrated to analyze team processes in health care. Finally, we offer our own insights and opinions on the integration of these approaches, as well as the types of data required to conduct such analyses. We also point to further research avenues and highlight the benefits associated with employing these diverse approaches. Finally, we offer our own insights and opinions on the integration of these approaches, as well as the types of data required to conduct such analyses.
    Tags: commercial or financial relationships that could be construed as a potential, conflict of interest., group dynamics, healthcare teams, interaction analysis, small group research, theoretical perspectives.
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  • Hall, N., Metrailler-Mermoud, J., Cools, E., Fehlmann, C., Carron, P. N., Rousson, V., Grabherr, S., et al. “Hypothermic Cardiac Arrest Patients Admitted To Hospital Who Were Not Rewarmed With Extracorporeal Life Support: A Retrospective Study”. Resusc Plus 15: 100443. doi:10.1016/j.resplu.2023.100443.
    Abstract: AIMS: Our goal was to study hypothermic cardiac arrest (CA) patients who were not rewarmed by Extracorporeal Life Support (ECLS) but were admitted to a hospital equipped for it. The focus was on whether the decisions of non-rewarming, meaning termination of resuscitation, were compliant with international guidelines based on serum potassium at hospital admission. METHODS: We retrospectively included all hypothermic CA who were not rewarmed, from three Swiss centers between 1st January 2000 and 2nd May 2021. Data were extracted from medical charts and assembled into two groups for analysis according to serum potassium. We identified the criteria used to terminate resuscitation. We also retrospectively calculated the HOPE score, a multivariable tool predicting the survival probability in hypothermic CA undergoing ECLS rewarming. RESULTS: Thirty-eight victims were included in the study. The decision of non-rewarming was compliant with international guidelines for 12 (33%) patients. Among the 36 patients for whom the serum potassium was measured at hospital admission, 24 (67%) had a value that - alone - would have indicated ECLS. For 13 of these 24 (54%) patients, the HOPE score was <10%, meaning that ECLS was not indicated. The HOPE estimation of the survival probabilities, when used with a 10% threshold, supported 23 (68%) of the non-rewarming decisions made by the clinicians. CONCLUSIONS: This study showed a low adherence to international guidelines for hypothermic CA patients. In contrast, most of these non-rewarming decisions made by clinicians would have been compliant with current guidelines based on the HOPE score.
    Tags: Accidental hypothermia, Cardiac arrest, Ecls, HOPE score, personal relationships that could have appeared to influence the work reported in, Potassium, Resuscitation, this paper..
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  • Herren, A., Palmer, C. S., Landolt, M. A., Lehner, M., Neuhaus, T. J., and Simma, L. “Pediatric Trauma And Trauma Team Activation In A Swiss Pediatric Emergency Department: An Observational Cohort Study”. Children (Basel) 10, no. 8. doi:10.3390/children10081377.
    Abstract: BACKGROUND: Trauma is one of the most common causes of death in childhood, but data on severely injured Swiss children are absent from existing national registries. Our aim was to analyze trauma activations and the profiles of critically injured children at a tertiary, non-academic Swiss pediatric emergency department (PED). In the absence of a national pediatric trauma database, this information may help to guide the design of infrastructure, processes within organizations, training, and policies. METHODS: A retrospective analysis of pediatric trauma patients in a prospective resuscitation database over a 2-year period. Critically injured trauma patients under the age of 16 years were included. Patients were described with established triage and injury severity scales. Statistical evaluation included logistic regression analysis. RESULTS: A total of 82 patients matched one or more of the study inclusion criteria. The most frequent age group was 12-15 years, and 27% were female. Trauma team activation (TTA) occurred with 49 patients (59.8%). Falls were the most frequent mechanism of injury, both overall and for major trauma. Road-traffic-related injuries had the highest relative risk of major trauma. In the multivariate analysis, patients receiving medicalized transport were more likely to trigger a TTA, but there was no association between TTA and age, gender, or Injury Severity Score (ISS). Nineteen patients (23.2%) sustained major trauma with an ISS > 15. Injuries of Abbreviated Injury Scale severity 3 or greater were most frequent to the head, followed by abdomen, chest, and extremities. The overall mortality rate in the cohort was 2.4%. Conclusions: Major trauma presentations only comprise a small proportion of the total patient load in the PED, and trauma team activation does not correlate with injury severity. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED. Our findings indicate that high priority should be given to training in the management of severely injured children in the PED. The leading major trauma mechanisms were preventable, which should prompt further efforts in injury prevention.
    Tags: adolescent, child, data, emergency department, in the collection, analyses, or interpretation of, in the design of the study, in the writing of the manuscript, major trauma, or the decision to publish the results., pediatric, pediatric emergency medicine, trauma, trauma center, trauma team activation.
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  • Barco, S., Virdone, S., Gotschi, A., Ageno, W., Arcelus, J. I., Bingisser, R., Colucci, G., et al. “Enoxaparin For Symptomatic Covid-19 Managed In The Ambulatory Setting: An Individual Patient Level Analysis Of The Ovid And Ethic Trials”. Thromb Res 230: 27-32. doi:10.1016/j.thromres.2023.08.009.
    Abstract: BACKGROUND: Antithrombotic treatment may improve the disease course in non-critically ill, symptomatic COVID-19 outpatients. METHODS: We performed an individual patient-level analysis of the OVID and ETHIC randomized controlled trials, which compared enoxaparin thromboprophylaxis for either 14 (OVID) or 21 days (ETHIC) vs. no thromboprophylaxis for outpatients with symptomatic COVID-19 and at least one additional risk factor. The primary efficacy outcome included all-cause hospitalization and all-cause death within 30 days from randomization. Both studies were prematurely stopped for futility. Secondary efficacy outcomes were major symptomatic venous thromboembolic events, arterial cardiovascular events, or their composite occurring within 30 days from randomization. The same outcomes were assessed over a 90-day follow-up. The primary safety outcome was major bleeding (ISTH criteria). RESULTS: A total of 691 patients were randomized: 339 to receive enoxaparin and 352 to the control group. Over 30-day follow-up, the primary efficacy outcome occurred in 6.0 % of patients in the enoxaparin group vs. 5.8 % of controls for a risk ratio (RR) of 1.05 (95%CI 0.57-1.92). The incidence of major symptomatic venous thromboembolic events and arterial cardiovascular events was 0.9 % vs. 1.8 %, respectively (RR 0.52; 95%CI 0.13-2.06). Most cardiovascular thromboembolic events were represented by symptomatic venous thromboembolic events, occurring in 0.6 % vs. 1.5 % of patients, respectively. A similar distribution of outcomes between the treatment groups was observed over 90 days. No major bleeding occurred in the enoxaparin group vs. one (0.3 %) in the control group. CONCLUSIONS: We found no evidence for the clinical benefit of early administration of enoxaparin thromboprophylaxis in outpatients with symptomatic COVID-19. These results should be interpreted taking into consideration the relatively low occurrence of events.
    Tags: advisory, Amgen, Bristol-Myers Squibb, GlaxoSmithKline, Medtronic, Pfizer, Sanofi-Aventis, and speakers' honoraria from Bayer, Daiichi Sankyo, Boston Scientific, Boehringer, and support for attending meetings and/or travel from Bayer and Sanofi., Anticoagulation, Arcelus declares speaker fees from Sanofi and Rovi. H.G reports personal fees, boards for Bayer, Leo Pharma, Norgine, Sanofi, Techdow, Viatris. Juan Ignacio, Boston Scientific, conflicts of interest. Renato D Lopes reports research grants or contracts from, conflicts of interest. Walter Ageno reports research grants from Bayer, consulting fees from, Covid-19, Death, education programme from Axonlab, and Thermo Fisher Scientific, from Pfizer, Bayer, Boehringer Ingelheim. Peter MacCallum reports no conflicts of, funding for an accredited continuing medical education, funding for an accredited continuing medical education programme from Alnylam,, funding for educational activities or lectures from Pfizer, Bristol-Myers Squibb,, Haas reports honoraria from Bayer, BMS, Daiichi-Sankyo, Pfizer and Sanofi. Lukas, Hobohm received lecture/consultant fees from Johnson&Johnson, INARI, MSD and, INARI, Ingelheim, and BMS/Pfizer. Tim Sebastian reports no conflicts of interest. Sylvia, Ingelheim, Bristol-Myers Squibb, Novo Nordisk, AstraZeneca., interest. Daniel Duerschmied has received consulting fees from Boston Scientific, interests/personal relationships which may be considered as potential competing, interests: Stefano Barco reports grants or contracts from Bayer, INARI, Boston, Medical, Novo Nordisk, AstraZeneca, and unding for consulting from Bayer, Boehringer, outside the submitted work. The other authors report no, payment or honoraria from INARI, Boston Scientific, Penumbra and Concept, personal fees and, Pfizer, and Sanofi, programme from Bayer, Bristol Myers Squibb, Daiichi-Sankyo, Takeda, Octapharma,, reports employment by Sanofi-Aventis Switzerland. Thomas Rosemann reports no, reports non-financial support and funding for an accredited continuing medical, research grants to the institution from Edwards Lifesciences, Medtronic, Abbott, Roland Bingisser reports no conflicts of interest. Stefan Stortecky has received, Scientific, Medtronic, Bard, Sanofi, and Concept Medical, Scientific. Giuseppe Colucci reports no conflicts of interest. Bernhard Gerber, SOBI, Janssen, Novo Nordisk, Mitsubishi Pfizer, Tanabe Pharma, outside the, submitted work. Jelle C L Himmelreich reports no conflicts of interest. DS, Trial, Vascular, Boston Scientific and Guerbet AG and speaker fees from Boston, Venous thromboembolism.
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  • Corradi-Dell'Acqua, C., Hofstetter, C., Sharvit, G., Hugli, O., and Vuilleumier, P. “Healthcare Experience Affects Pain-Specific Responses To Others' Suffering In The Anterior Insula”. Hum Brain Mapp 44, no. 17: 5655-5671. doi:10.1002/hbm.26468.
    Abstract: Medical students and professional healthcare providers often underestimate patients' pain, together with decreased neural responses to pain information in the anterior insula (AI), a brain region implicated in self-pain processing and negative affect. However, the functional significance and specificity of these neural changes remains debated. Across two experiments, we recruited university medical students and emergency nurses to test the role of healthcare experience on the brain reactivity to other's pain, emotions, and beliefs, using both pictorial and verbal cues. Brain responses to self-pain was also assessed and compared with those to observed pain. Our results confirmed that healthcare experience decreased the activity in AI in response to others' suffering. This effect was independent from stimulus modality (pictures or texts), but specific for pain, as it did not generalize to inferences about other mental or affective states. Furthermore, representational similarity and multivariate pattern analysis revealed that healthcare experience impacted specifically a component of the neural representation of others' pain that is shared with that of first-hand nociception, and related more to AI than to other pain-responsive regions. Taken together, our study suggests a decreased propensity to appraise others' suffering as one's own, associated with a reduced recruitment of pain-specific information in AI. These findings provide new insights into neural mechanisms leading to pain underestimation by caregivers in clinical settings.
    Tags: *Emotions/physiology, *Empathy, affect, Brain Mapping, Brain/physiology, empathy, fMRI, Humans, Magnetic Resonance Imaging, medical students, Mvpa, nurses, Pain/psychology, representation similarity.
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  • Anti-fibrinolytics Trialists Collaborators - Obstetric Trialists, Group, Ker, K., Shakur-Still, H., Sentilhes, L., Pacheco, L. D., Saade, G., Deneux-Tharaux, C., et al. “Tranexamic Acid For The Prevention Of Postpartum Bleeding: Protocol For A Systematic Review And Individual Patient Data Meta-Analysis”. Gates Open Res 7: 3. doi:10.12688/gatesopenres.13747.2.
    Abstract: Tranexamic acid (TXA) reduces the risk of death and is recommended as a treatment for women with severe postpartum bleeding. There is hope that giving TXA shortly before or immediately after birth could prevent postpartum bleeding. Extending the use of TXA to prevent harmful postpartum bleeding could improve outcomes for millions of women; however we must carefully consider the balance of benefits and potential harms. This article describes the protocol for a systematic review and individual patient data (IPD) meta-analysis to assess the effectiveness and safety of TXA for preventing postpartum bleeding in all women giving birth, and to explore how the effects vary by underlying risk and other patient characteristics. Methods: We will search for prospectively registered, randomised controlled trials involving 500 patients or more assessing the effects of TXA in women giving birth. Two authors will extract data and assess risk of bias. IPD data will be sought from eligible trials. Primary outcomes will be life-threatening bleeding and thromboembolic events. We will use a one-stage model to analyse the data. Subgroup analyses will be conducted to explore whether the effectiveness and safety of TXA varies by underlying risk, type birth, maternal haemoglobin (Hb), and timing of TXA. This protocol is registered on PROSPERO (CRD42022345775). Conclusions: This systematic review and IPD meta-analysis will address important clinical questions about the effectiveness and safety of the use of TXA for the prevention of postpartum bleeding that cannot be answered reliably using aggregate data and will inform the decision of who to treat. PROSPERO registration: CRD42022345775 Keywords Anti-fibrinolytics; Tranexamic acid; childbirth; postpartum haemorrhage; meta-analysis.
    Tags: Anti-fibrinolytics, childbirth, Ferring. No competing interests were disclosed for any other author., meta-analysis, postpartum haemorrhage, Tranexamic acid.
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  • Simma, L., Pocepcova, V., and Fontana, S. “A Boy With Ten Days Of Fever”. Ann Emerg Med 82, no. 3: 271-361. doi:10.1016/j.annemergmed.2023.04.006.
  • Deschamps, J., Choffat, D., Limacher, A., Righini, M., Beer, J. H., Baumgartner, C., Hugli, O., Aujesky, D., and Mean, M. “Quality Of Life In Elderly Patients With Venous Thromboembolism Assessed Using Patient-Reported Outcome Measures”. J Thromb Haemost 21, no. 11: 3193-3202. doi:10.1016/j.jtha.2023.07.022.
    Abstract: BACKGROUND: We aimed to evaluate the quality of life (QoL), using patient-reported outcome measures (PROMs), in elderly patients with venous thromboembolism (VTE) and to explore whether VTE complications (recurrence, bleeding, or postthrombotic syndrome) had an impact on later QoL. METHODS: We used data from the SWIss venous Thromboembolism COhort of older patients(SWITCO65+), a prospective multicenter cohort of patients aged >/=65 years with acute, symptomatic VTE. Primary outcome was changes in QoL up to 24 months, assessed using generic (36-Item Short-Form Health Survey), with physical (PCS) and mental component score (MCS), and disease-specific (Venous Insufficiency Epidemiological and Economic Study [VEINES]-QoL, [VEINES-Sym], and Pulmonary Embolism QoL) PROMs. PROM scores ranged from 0 to 100 points, higher scores indicating a better QoL. Longitudinal latent class analysis was used to group patients with similar PCS trajectories. Repeated-measures linear regression analyses were used to assess effects of VTE complications on changes in QoL scores. RESULTS: In 923 patients (median age, 75; male, 54%), 140 (15%) patients died, 97 (11%) experienced recurrent VTE, and 106 (12%) major bleeding during follow-up. Compared with patients with higher PCS trajectories, patients with lower PCS trajectories were more likely to be older, female, sicker, and less physically active. On average, generic and disease-specific QoL scores improved over time (+11% in PCS, +3% in MCS, +6% in VEINES QoL, and +16% in Pulmonary Embolism QoL at 3 months). VTE complications were always associated with significantly lower QoL scores (for VTE recurrence: PCS adjusted difference -2.57, 95% CI, -4.47 to -0.67). CONCLUSION: Although QoL following VTE tended to improve over time, patients with VTE-related complications had lower QoL than patients without complications.
    Tags: *Pulmonary Embolism/diagnosis, *Venous Insufficiency, *Venous Thromboembolism/diagnosis, Aged, elderly patients, Female, Hemorrhage, Humans, major bleeding, Male, Patient Reported Outcome Measures, patient-reported outcome measures, Prospective Studies, Quality of Life, venous thromboembolism.
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  • Wozniak, H., Le Terrier, C., Primmaz, S., Suh, N., Lenglet, S., Thomas, A., Vuilleumier, N., et al. “Association Of Trace Element Levels With Outcomes In Critically Ill Covid-19 Patients”. Nutrients 15, no. 15. doi:10.3390/nu15153308.
    Abstract: The primary objective of this study was to compare the plasma levels of copper, selenium, and zinc between critically ill COVID-19 patients and less severe COVID-19 patients. The secondary objective was to investigate the association of these trace element levels with adverse outcomes, including the duration of mechanical ventilation, occurrence of septic shock, and mortality in critically ill COVID-19 patients. All COVID-19 patients admitted to the ICU of the Geneva University Hospitals between 9 March 2020 and 19 May 2020 were included in the study. Plasma levels of copper, selenium and zinc were measured on admission to the ICU and compared with levels measured in COVID-19 patients hospitalized on the ward and in non-hospitalized COVID-19 patients. To analyze the association of trace elements with clinical outcomes, multivariate linear and logistic regressions were performed. Patients in the ICU had significantly lower levels of selenium and zinc and higher levels of copper compared to COVID-19 patients hospitalized on the ward and in non-hospitalized COVID-19 patients. In ICU patients, lower zinc levels tended to be associated with more septic shock and increased mortality compared to those with higher zinc levels (p = 0.07 for both). Having lower copper or selenium levels was associated with a longer time under mechanical ventilation (p = 0.01 and 0.04, respectively). These associations remained significant in multivariate analyses (p = 0.03 for copper and p = 0.04 for selenium). These data support the need for interventional studies to assess the potential benefit of zinc, copper and selenium supplementation in severe COVID-19 patients.
    Tags: *covid-19, *Selenium, *Shock, Septic, *Trace Elements, Copper, Covid-19, Critical Illness, Humans, intensive care unit, mortality, selenium, trace elements, Zinc.
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  • Mueller, J., Beck, K., Loretz, N., Becker, C., Gross, S., Blatter, R., Urben, T., Amacher, S. A., Schaefert, R., and Hunziker, S. “The Disclosure Of Bad News Over The Phone Vs. In Person And Its Association With Psychological Distress: A Systematic Review And Meta-Analysis”. J Gen Intern Med 38, no. 16: 3589-3603. doi:10.1007/s11606-023-08323-z.
    Abstract: BACKGROUND: Communicating bad news such as a new cancer diagnosis to patients may have a major impact on their well-being. We investigated differences in patients' psychological distress due to the disclosure of bad news by telephone compared to in person in a systematic review and meta-analysis. METHODS: We included all studies that investigated anxiety, depressive or post-traumatic stress disorder (PTSD) symptoms in adult patients in whom bad news by telephone compared to in person were disclosed. We systematically searched PubMed, Embase, PsycINFO and CINAHL from the inception of each database to October 18, 2022. We included randomized and non-randomized trials. RESULTS: We screened 5944 studies and included 11 studies in the qualitative analysis and 9 in the meta-analyses, including four randomized controlled trials. Overall, the quality of studies was moderate to good. There was no difference regarding psychological distress when bad news was disclosed by telephone compared to in person with similar symptom levels of anxiety (3 studies, 285 participants; standardized mean difference [SMD] 0.10 [95% CI -0.15 to 0.35]), depression (3 studies, 284 participants; SMD 0.10 [95% CI -0.30 to 0.49]), and PTSD (2 studies, 171 participants; SMD -0.01 [95% CI -0.48 to 0.36]). Results were similar for satisfaction with care. DISCUSSION: This meta-analysis found no difference regarding psychological distress regardless if bad news were disclosed by telephone or in person, but there were overall only few and heterogeneous studies with a small number of eligible patients. The findings suggest that the modality of disclosure might play a secondary role and the way in which the bad news are communicated might be more important.
    Tags: *Disclosure, *Stress Disorders, Post-Traumatic/diagnosis/psychology, Adult, anxiety, Anxiety Disorders, Anxiety/diagnosis, breaking bad news, disclosure, Humans, phone, satisfaction, Telephone.
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  • Jakob, D. A., Muller, M., Jud, S., Albrecht, R., Hautz, W., and Pietsch, U. “The Forgotten Cohort-Lessons Learned From Prehospital Trauma Death: A Retrospective Cohort Study”. Scand J Trauma Resusc Emerg Med 31, no. 1: 37. doi:10.1186/s13049-023-01107-8.
    Abstract: BACKGROUND: Trauma related deaths remain a relevant public health problem, in particular in the younger male population. A significant number of these deaths occur prehospitally without transfer to a hospital. These patients, sometimes termed "the forgotten cohort", are usually not included in clinical registries, resulting in a lack of information about prehospitally trauma deaths. The aim of the present study was to compare patients who died prehospital with those who sustained life-threatening injuries in order to analyze and potentially improve prehospital strategies. METHODS: This cohort study included all primary operations carried out by Switzerland's largest helicopter emergency medical service (HEMS) between January 1, 2011, and December 31, 2021. We included all adult trauma patients with life-threatening or fatal conditions. The outcome of this study is the vital status of the patient at the end of mission, i.e. fatal or life-threatening. Injury, rescue characteristics, and interventions of the forgotten trauma cohort, defined as patients with a fatal injury (NACA score of VII), were compared with life-threatening injuries (NACA score V and VI). RESULTS: Of 110,331 HEMS missions, 5534 primary operations were finally analyzed, including 5191 (93.8%) life-threatening and 343 (6.2%) fatal injuries. More than two-thirds of patients (n = 3772, 68.2%) had a traumatic brain injury without a significant difference between the two groups (p > 0.05). Thoracic trauma (44.6% vs. 28.7%, p < 0.001) and abdominal trauma (22.2% vs. 16.1%, p = 0.004) were more frequent in fatal missions whereas pelvic trauma was similar between the two groups (13.4% vs. 12.9%, p = 0.788). Pneumothorax decompression rate (17.2% vs. 3.7%, p < 0.001) was higher in the forgotten cohort group and measures for bleeding control (15.2% vs. 42.7%, p < 0.001) and pelvic belt application (2.9% vs. 13.1% p < 0.001) were more common in the life-threating injury group. CONCLUSION: Chest decompression rates and measures for early hemorrhage control are areas for potential improvement in prehospital care.
    Tags: *Air Ambulances, *Emergency Medical Services/methods, Adult, Aircraft, Chest decompression, Cohort Studies, Helicopter emergency medical services, Hemorrhage control, Humans, Male, Prehospital management, Retrospective Studies, Traumatic cardiac arrest.
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  • Jermini-Gianinazzi, I., Blum, M., Trachsel, M., Trippolini, M. A., Tochtermann, N., Rimensberger, C., Liechti, F. D., and Wertli, M. M. “Management Of Acute Non-Specific Low Back Pain In The Emergency Department: Do Emergency Physicians Follow The Guidelines? Results Of A Cross-Sectional Survey”. Bmj Open 13, no. 8: e071893. doi:10.1136/bmjopen-2023-071893.
    Abstract: OBJECTIVES: Clinical guidelines for acute non-specific low back pain (LBP) recommend avoiding imaging studies or invasive treatments and to advise patients to stay active. The aim of this study was to evaluate the management of acute non-specific LBP in the emergency departments (ED). SETTING: We invited all department chiefs of Swiss EDs and their physician staff to participate in a web-based survey using two clinical case vignettes of patients with acute non-specific LBP presenting to an ED. In both cases, no neurological deficits or red flags were present. Guideline adherence and low-value care was defined based on current guideline recommendations. RESULTS: In total, 263 ED physicians completed at least one vignette, while 212 completed both vignettes (43% residents, 32% senior/attending physicians and 24% chief physicians). MRI was considered in 31% in vignette 1 and 65% in vignette 2. For pain management, non-steroidal anti-inflammatory drugs, paracetamol and metamizole were mostly used. A substantial proportion of ED physicians considered treatments with questionable benefit and/or increased risk for adverse events such as oral steroids (vignette 1, 12% and vignette 2, 19%), muscle relaxants (33% and 38%), long-acting strong opioids (25% and 33%) and spinal injections (22% and 43%). Although guidelines recommend staying active, 72% and 67% of ED physicians recommended activity restrictions. CONCLUSION: Management of acute non-specific LBP in the ED was not in agreement with current guideline recommendations in a substantial proportion of ED physicians. Overuse of imaging studies, the use of long-acting opioids and muscle relaxants, as well as recommendations for activity and work restrictions were prevalent and may potentially be harmful.
    Tags: *Acute Pain/diagnosis/therapy, *Low Back Pain/therapy, *Physicians, accident & emergency medicine, Analgesics, Opioid, Cross-Sectional Studies, education & training (see medical education & training), Emergency Service, Hospital, Humans, Magnetic Resonance Imaging, pain management.
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  • Ungericht, M., Groaz, V., Messner, M., Schuetz, T., Brunelli, L., Zaruba, M. M., Lener, D., et al. “Correlation Of 99Mtc-Dpd Bone Scintigraphy With Histological Amyloid Load In Patients With Attr Cardiac Amyloidosis”. Amyloid 31, no. 1: 22-31. doi:10.1080/13506129.2023.2239986.
    Abstract: BACKGROUND: The significance of measuring 99mTc-labelled-3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) in transthyretin (ATTR) cardiac amyloidosis has not been adequately studied. This single-centre observational study evaluated the correlation between 99mTc-DPD scintigraphy and histological amyloid load in endomyocardial biopsy (EMB). METHODS: Twenty-eight patients with biopsy-proven ATTR amyloidosis and concomitantly available 99mTc-DPD scintigraphy were included. Visual Perugini scoring, and (semi-)quantitative analysis of cardiac 99mTc-DPD uptake by planar whole-body imaging and single photon emission computed tomography (SPECT/CT) using regions of interest (ROI) were performed. From this, heart-to-whole-body ratio (H/WB) and heart-to-contralateral-chest ratio (H/CL) were calculated. The histological amyloid load was quantified using two different staining methods. RESULTS: Increased cardiac tracer uptake was documented in all patients (planar: ROImean 129 +/- 37 cps; SPECT/CT: ROImean 369 +/- 142 cps). Histological amyloid load (19 +/- 13%) significantly correlated with Perugini score (r = 0.69, p < .001) as well as with cardiac 99mTc-DPD uptake (planar: r = 0.64, p < .001; H/WB: r = 0.50, p = .014; SPECT/CT: r = 0.53, p = .008; H/CL: r = 0.43, p = .037) (results are shown for correlations with Congo Red-staining). CONCLUSION: In ATTR, cardiac 99mTc-DPD uptake significantly correlated with histological amyloid load in EMB. Further studies are needed to implement thresholds in cardiac 99mTc-DPD uptake measurements for risk stratification and guidance of therapy.
    Tags: *Amyloid Neuropathies, Familial/diagnostic imaging, *Amyloidosis/diagnostic imaging, *Cardiomyopathies/diagnostic imaging, 99mTc-DPD, Amyloid, Amyloidogenic Proteins, Attr, cardiac amyloidosis, endomyocardial biopsy, Humans, Organotechnetium Compounds, Prealbumin, Radionuclide Imaging, Spect/ct, Tomography, X-Ray Computed.
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  • Wu, L., Chen, X., Khalemsky, A., Li, D., Zoubeidi, T., Lauque, D., Alsabri, M., et al. “The Association Between Emergency Department Length Of Stay And In-Hospital Mortality In Older Patients Using Machine Learning: An Observational Cohort Study”. J Clin Med 12, no. 14. doi:10.3390/jcm12144750.
    Abstract: The association between emergency department (ED) length of stay (EDLOS) with in-hospital mortality (IHM) in older patients remains unclear. This retrospective study aims to delineate the relationship between EDLOS and IHM in elderly patients. From the ED patients (n = 383,586) who visited an urban academic tertiary care medical center from January 2010 to December 2016, 78,478 older patients (age >/=60 years) were identified and stratified into three age subgroups: 60-74 (early elderly), 75-89 (late elderly), and >/=90 years (longevous elderly). We applied multiple machine learning approaches to identify the risk correlation trends between EDLOS and IHM, as well as boarding time (BT) and IHM. The incidence of IHM increased with age: 60-74 (2.7%), 75-89 (4.5%), and >/=90 years (6.3%). The best area under the receiver operating characteristic curve was obtained by Light Gradient Boosting Machine model for age groups 60-74, 75-89, and >/=90 years, which were 0.892 (95% CI, 0.870-0.916), 0.886 (95% CI, 0.861-0.911), and 0.838 (95% CI, 0.782-0.887), respectively. Our study showed that EDLOS and BT were statistically correlated with IHM (p < 0.001), and a significantly higher risk of IHM was found in low EDLOS and high BT. The flagged rate of quality assurance issues was higher in lower EDLOS </=1 h (9.96%) vs. higher EDLOS 7 h <t</= 8 h (1.84%). Special attention should be given to patients admitted after a short stay in the ED and a long BT, and new concepts of ED care processes including specific areas and teams dedicated to older patients care could be proposed to policymakers.
    Tags: boarding time, emergency department, in-hospital mortality, length of stay, machine learning, older adults.
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  • Gaume, J., Blanc, S., Magill, M., McCambridge, J., Bertholet, N., Hugli, O., and Daeppen, J. B. “Who Benefits From Brief Motivational Intervention Among Young Adults Presenting To The Emergency Department With Alcohol Intoxication: A Latent-Class Moderation Analysis”. Alcohol Clin Exp Res (Hoboken) 47, no. 8: 1614-1623. doi:10.1111/acer.15128.
    Abstract: BACKGROUND: Research has not identified which patients optimally benefit from brief Motivational Interviewing (bMI) for heavy drinking when delivered to young adults in the Emergency Department (ED). METHODS: We conducted secondary analyses of data from a randomized controlled trial in which 344 young adults (18-35 years) presenting to the ED with alcohol intoxication received either bMI or Brief Advice (BA, control group). We used Latent Class Analysis to derive participants' profiles from baseline characteristics (i.e., sex, age, severity of alcohol use disorder, attribution of ED admission to alcohol use, importance, and confidence to change, cognitive discrepancy, anxiety, depression, and trait reactance). We then conducted a moderation analysis to assess the number of heavy drinking days at short-term (1-month) and long-term (12-month) follow-up using negative binomial regressions with interactions between the intervention and derived classes. RESULTS: Fit statistics indicated that a 4-class solution best fit the data. Class 3 (high severity, importance and discrepancy, and low confidence and anxiety) benefitted more from bMI than BA at short- and long-term follow-up than Class 1 (younger; lowest severity, importance, discrepancy, reactance, anxiety and depression, and highest confidence). Class 2 (older; highest severity, importance, discrepancy, reactance, anxiety and depression, and lowest confidence) also benefitted more from bMI than BA than did Class 1 at short-term follow-up. In these significant contrasts, Class 1 benefitted more from BA than bMI. There were no significant interactions involving Class 4 (more likely to be women; low severity; high levels of anxiety, depression, and reactance). CONCLUSIONS: This study identified the patient profiles that benefitted more from bMI than BA among nontreatment-seeking young adults who present intoxicated to the ED. The findings have implications for intervention design and argue for the importance of research aimed at developing intervention content tailored to patient profiles.
    Tags: alcohol intoxication, brief motivational interviewing, emergency department, latent class analysis, moderation analysis.
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  • Henao, J. A. G., Depotter, A., Bower, D. V., Bajercius, H., Todorova, P. T., Saint-James, H., de Mortanges, A. P., et al. “A Multiclass Radiomics Method-Based Who Severity Scale For Improving Covid-19 Patient Assessment And Disease Characterization From Ct Scans”. Invest Radiol 58, no. 12: 882-893. doi:10.1097/RLI.0000000000001005.
    Abstract: OBJECTIVES: The aim of this study was to evaluate the severity of COVID-19 patients' disease by comparing a multiclass lung lesion model to a single-class lung lesion model and radiologists' assessments in chest computed tomography scans. MATERIALS AND METHODS: The proposed method, AssessNet-19, was developed in 2 stages in this retrospective study. Four COVID-19-induced tissue lesions were manually segmented to train a 2D-U-Net network for a multiclass segmentation task followed by extensive extraction of radiomic features from the lung lesions. LASSO regression was used to reduce the feature set, and the XGBoost algorithm was trained to classify disease severity based on the World Health Organization Clinical Progression Scale. The model was evaluated using 2 multicenter cohorts: a development cohort of 145 COVID-19-positive patients from 3 centers to train and test the severity prediction model using manually segmented lung lesions. In addition, an evaluation set of 90 COVID-19-positive patients was collected from 2 centers to evaluate AssessNet-19 in a fully automated fashion. RESULTS: AssessNet-19 achieved an F1-score of 0.76 +/- 0.02 for severity classification in the evaluation set, which was superior to the 3 expert thoracic radiologists (F1 = 0.63 +/- 0.02) and the single-class lesion segmentation model (F1 = 0.64 +/- 0.02). In addition, AssessNet-19 automated multiclass lesion segmentation obtained a mean Dice score of 0.70 for ground-glass opacity, 0.68 for consolidation, 0.65 for pleural effusion, and 0.30 for band-like structures compared with ground truth. Moreover, it achieved a high agreement with radiologists for quantifying disease extent with Cohen kappa of 0.94, 0.92, and 0.95. CONCLUSIONS: A novel artificial intelligence multiclass radiomics model including 4 lung lesions to assess disease severity based on the World Health Organization Clinical Progression Scale more accurately determines the severity of COVID-19 patients than a single-class model and radiologists' assessment.
    Tags: *covid-19, Artificial Intelligence, Disease Progression, Humans, Lung/diagnostic imaging, Retrospective Studies, Tomography, X-Ray Computed/methods.
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  • Brandenberger, J., Duchen, R., Lu, H., Wanigaratne, S., Cohen, E., To, T., Piche-Renaud, P. P., and Guttmann, A. “Covid-19 Vaccine Uptake In Immigrant, Refugee, And Nonimmigrant Children And Adolescents In Ontario, Canada”. Jama Netw Open 6, no. 7: e2325636. doi:10.1001/jamanetworkopen.2023.25636.
    Abstract: IMPORTANCE: COVID-19 vaccinations are recommended for minors. Surveys indicate lower vaccine acceptance by some immigrant and refugee groups. OBJECTIVE: To identify characteristics in immigrant, refugee, and nonimmigrant minors associated with vaccination. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used linked, population-based demographic and health care data from Ontario, Canada, including all children aged 4 to 17 years registered for universal health insurance on January 1, 2021, across 2 distinct campaigns: for adolescents (ages 12-17 years), starting May 23, 2021, and for children (ages 5-11 years), starting November 25, 2021, through April 24, 2022. Data were analyzed from May 9 to August 2, 2022. EXPOSURES: Immigrant or refugee status and immigration characteristics (recency, category, region of origin, and generation). MAIN OUTCOMES AND MEASURES: Outcomes of interest were crude rates of COVID-19 vaccination (defined as >/=1 vaccination for children and >/=2 vaccinations for adolescents) and adjusted odds ratios (aORs) with 95% CIs for vaccination, adjusted for clinical, sociodemographic, and health system factors. RESULTS: The total cohort included 2.2 million children and adolescents, with 1 098 749 children (mean [SD] age, 7.06 [2.00] years; 563 388 [51.3%] males) and 1 142 429 adolescents (mean [SD] age, 14.00 [1.99] years; 586 617 [51.3%] males). Among children, 53 090 (4.8%) were first-generation and 256 886 (23.4%) were second-generation immigrants or refugees; among adolescents, 104 975 (9.2%) were first-generation and 221 981 (19.4%) were second-generation immigrants or refugees, most being economic or family-class immigrants. Immigrants, particularly refugees, were more likely to live in neighborhoods with highest material deprivation (first-generation immigrants: 18.6% of children and 20.2% of adolescents; first-generation refugees: 46.4% of children and 46.3% of adolescents; nonimmigrants: 18.5% of children and 17.2% of adolescents) and COVID-19 risk (first-generation immigrants; 20.0% of children and 20.5% of adolescents; first-generation refugees: 9.4% of children and 12.6% of adolescents; nonimmigrants: 6.9% of children and 6.8% of adolescents). Vaccination rates (53.1% in children and 79.2% in adolescents) were negatively associated with material deprivation. In both age groups, odds for vaccination were higher in immigrants (children: aOR, 1.30; 95% CI, 1.27-1.33; adolescents: aOR, 1.10; 95% CI, 1.08-1.12) but lower in refugees (children: aOR, 0.34; 95% CI, 0.33-0.36; adolescents: aOR, 0.88; 95% CI, 0.84-0.91) compared with nonimmigrants. In immigrant- and refugee-only models stratified by generation, region of origin was associated with uptake, compared with the overall rate, with the lowest odds observed in immigrants and refugees from Eastern Europe (children: aOR, 0.40; 95% CI, 0.35-0.46; adolescents: aOR, 0.41; 95% CI, 0.38-0.43) and Central Africa (children: aOR, 0.24; 95% CI, 0.16-0.35; adolescents: aOR, 0.51,CI: 0.45-0.59) and the highest odds observed in immigrants and refugees from Southeast Asia (children: aOR, 2.68; 95% CI, 2.47-2.92; adolescents aOR, 4.42; 95% CI, 4.10-4.77). Adjusted odds of vaccination among immigrants and refugees from regions with lowest vaccine coverage were similar across generations. CONCLUSIONS AND RELEVANCE: In this cohort study using a population-based sample in Canada, nonrefugee immigrants had higher vaccine coverage than nonimmigrants. Substantial heterogeneity by region of origin and lower vaccination coverage in refugees persisted across generations. These findings suggest that vaccine campaigns need precision public health approaches targeting specific barriers in identified, undervaccinated subgroups.
    Tags: *COVID-19/epidemiology/prevention & control, *Emigrants and Immigrants, *Refugees, *Vaccines, Adolescent, Child, Cohort Studies, COVID-19 Vaccines, Female, Humans, Male, Ontario/epidemiology, Retrospective Studies.
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  • Marcin, T., Luthi, A., Graf, R. R., Krummrey, G., Schauber, S. K., Breakey, N., Hautz, W. E., and Hautz, S. C. “Is Language An Issue? Accuracy Of The German Computerized Diagnostic Decision Support System Isabel And Cross-Validation With The English Counterpart”. Diagnosis (Berl) 10, no. 4: 398-405. doi:10.1515/dx-2023-0047.
    Abstract: OBJECTIVES: Existing computerized diagnostic decision support tools (CDDS) accurately return possible differential diagnoses (DDx) based on the clinical information provided. The German versions of the CDDS tools for clinicians (Isabel Pro) and patients (Isabel Symptom Checker) from ISABEL Healthcare have not been validated yet. METHODS: We entered clinical features of 50 patient vignettes taken from an emergency medical text book and 50 real cases with a confirmed diagnosis derived from the electronic health record (EHR) of a large academic Swiss emergency room into the German versions of Isabel Pro and Isabel Symptom Checker. We analysed the proportion of DDx lists that included the correct diagnosis. RESULTS: Isabel Pro and Symptom Checker provided the correct diagnosis in 82 and 71 % of the cases, respectively. Overall, the correct diagnosis was ranked in 71 , 61 and 37 % of the cases within the top 20, 10 and 3 of the provided DDx when using Isabel Pro. In general, accuracy was higher with vignettes than ED cases, i.e. listed the correct diagnosis more often (non-significant) and ranked the diagnosis significantly more often within the top 20, 10 and 3. On average, 38 +/- 4.5 DDx were provided by Isabel Pro and Symptom Checker. CONCLUSIONS: The German versions of Isabel achieved a somewhat lower accuracy compared to previous studies of the English version. The accuracy decreases substantially when the position in the suggested DDx list is taken into account. Whether Isabel Pro is accurate enough to improve diagnostic quality in clinical ED routine needs further investigation.
    Tags: *Dichlorodiphenyl Dichloroethylene, *Research Design, clinical decision support, Diagnosis, Differential, diagnostic accuracy, diagnostic decision support, diagnostic error, differential diagnosis generator, Electronic Health Records, emergency medicine, Humans, Language.
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  • Polymeris, A. A., Karwacki, G. M., Siepen, B. M., Schaedelin, S., Tsakiris, D. A., Stippich, C., Guzman, R., et al. “Tranexamic Acid For Intracerebral Hemorrhage In Patients On Non-Vitamin K Antagonist Oral Anticoagulants (Tich-Noac): A Multicenter, Randomized, Placebo-Controlled, Phase 2 Trial”. Stroke 54, no. 9: 2223-2234. doi:10.1161/STROKEAHA.123.042866.
    Abstract: BACKGROUND: Evidence-based hemostatic treatment for intracerebral hemorrhage (ICH) associated with non-vitamin K antagonist oral anticoagulants (NOACs) is lacking. Tranexamic acid (TXA) is an antifibrinolytic drug potentially limiting hematoma expansion. We aimed to assess the efficacy and safety of TXA in NOAC-ICH. METHODS: We performed a double-blind, randomized, placebo-controlled trial at 6 Swiss stroke centers. Patients with NOAC-ICH within 12 hours of symptom onset and 48 hours of last NOAC intake were randomized (1:1) to receive either intravenous TXA (1 g over 10 minutes followed by 1 g over 8 hours) or matching placebo in addition to standard medical care via a centralized Web-based procedure with minimization on key prognostic factors. All participants and investigators were masked to treatment allocation. Primary outcome was hematoma expansion, defined as >/=33% relative or >/=6 mL absolute volume increase at 24 hours and analyzed using logistic regression adjusted for baseline hematoma volume on an intention-to-treat basis. RESULTS: Between December 12, 2016, and September 30, 2021, we randomized 63 patients (median age, 82 years [interquartile range, 76-86]; 40% women; median hematoma volume, 11.5 [4.8-27.4] mL) of the 109 intended sample size before premature trial discontinuation due to exhausted funding. The primary outcome did not differ between TXA (n=32) and placebo (n=31) arms (12 [38%] versus 14 [45%]; adjusted odds ratio, 0.63 [95% CI, 0.22-1.82]; P=0.40). There was a signal for interaction with onset-to-treatment time (P(interaction)=0.024), favoring TXA when administered within 6 hours of symptom onset. Between the TXA and placebo arms, the proportion of participants who died (15 [47%] versus 13 [42%]; adjusted odds ratio, 1.07 [0.37-3.04]; P=0.91) or had major thromboembolic complications within 90 days (4 [13%] versus 2 [6%]; odds ratio, 1.86 [0.37-9.50]; P=0.45) did not differ. All thromboembolic events occurred at least 2 weeks after study treatment, exclusively in participants not restarted on oral anticoagulation. CONCLUSIONS: In a smaller-than-intended NOAC-ICH patient sample, we found no evidence that TXA prevents hematoma expansion, but there were no major safety concerns. Larger trials on hemostatic treatments targeting an early treatment window are needed for NOAC-ICH. REGISTRATION: URL: https://clinicaltrials.gov; Unique identifier: NCT02866838.
    Tags: (Alexion) Advisory board (fees paid to the institution), (https://clinicaltrials.gov, (SAMS)/Bangerter-Rhyner-Foundation, Swiss Heart Foundation (SHF). Dr Siepen:, (SNSF), Prof Dr med Karl und Rena Theiler-Haag Stiftung. Dr Traenka: research, (Wissenschaftsfonds) University Hospital Basel, University of Basel,, (Wissenschaftspool) of the University Hospital Basel, *Antifibrinolytic Agents/adverse effects, *Hemostatics/therapeutic use, *Thromboembolism/drug therapy, *Tranexamic Acid/adverse effects, Administration, Oral, advisory board honoraria from Daiichi, advisory boards and consultancy for, advisory boards for Boehringer Ingelheim, Bayer, Recordati SA, Daiichi Sankyo, Aged, 80 and over, and, and Boehringer Ingelheim for expert witness services and consulting fees from, anticoagulants, Anticoagulants/adverse effects, AstraZeneca, authors report no conflicts., Bangerter-Rhyner Foundation, and University of Basel, Bangerter-Rhyner-Stiftung, Basel, Bayer, Bayer Foundation, Bayer, Novartis, biological and medical research, Freiwillige Akademische Gesellschaft Basel,, BMS/Pfizer, boards for Bayer, Boehringer Ingelheim, BMS/Pfizer, MindMaze, cerebral hemorrhage, Cerebral Hemorrhage/drug therapy/complications, compensation from, compensation from Amgen for consultant services, compensation from AstraZeneca for consultant services, compensation from Bayer for consultant services, compensation from Biogen, compensation from Biogen for other services, compensation from Boehringer, compensation from Claret Medical, Inc, for data and safety monitoring services., compensation from Medtronic, Novo, compensation from Pfizer, Boehringer Ingelheim for consultant services. The other, conference fees from BMS/Pfizer. Dr Engelter: funding for travel or speaker, consultancy fee from Bayer, Novartis. Dr Baumgartner:, consultant honoraria from, consultant services, Data Safety Monitoring Board for the IN EXTREMIS trial, TITAN trial, DeQuervain, Dr Fischer: financial support for the SWIFT DIRECT trial from Medtronic, Dr Gensicke: research support from SNSF, editorial board of, factor Xa inhibitors, Felix Platter, Freiwillige Akademische Gesellschaft Basel, SHF, SNSF. Dr Seiffge:, Female, Fondazione Dr. Ettore Balli, for Daiichi Sankyo, AstraZeneca, OM Pharma, from SNSF (Nr.32003B_200573 and Nr.PBBEP3_139388), fund of the University Hospital Basel. Dr Bonati: compensation from BMS for, funding by the Doc.Mobility instrument of the Swiss National Science Foundation, funding for travel and, funding for travel from BMS/Pfizer, and AbbVie. Dr De Marchis: support, funding from SAMS/Bangerter-Rhyner-Foundation. Dr Tsakiris: unrestricted research, grants and lecture honoraria from Bayer Schweiz AG, Pfizer, Daiichi Sankyo,, grants from, grants from Medtronic BEYOND SWIFT registry, SNSF, SHF, grants from Phenox, Inc,, grants from SHF, grants from SNSF, grants from Stiftung zur Forderung der gastroenterologischen und allgemeinen, grants from University of Basel, Hematoma/drug therapy, honoraria from Bayer, Boehringer Ingelheim, Daiichi Sankyo, Humans, Industry payments made to the research, Ingelheim, AstraZeneca, Novo Nordisk for other services. Dr Lyrer: research, klinischen Forschung sowie der medizinischen Bildauswertung, Male, Medtronic, Stryker, CSL Behring (fees paid to the institution), member of the Steering Committee of PACIFIC Stroke, membership of a, Nachwuchsforderung Klinische Forschung, University of Basel, NCT04304508), Nordisk, Vifor Pharma for expert witness services, Novartis grant, personal research scholarships from the Novartis Foundation for, Phenox, Inc, for end point review committee services, Portola, Portola/Alexion/AstraZeneca, Bayer, VarmX. Dr Peters: research support from SHF,, ProPatient Foundation, Rapid Medical, Penumbra, Research, Sankyo, Science Funds, SHF, SNSF, SNSF, Swiss Society of Neurology, Bangerter-Rhyner-Foundation, Daiichi Sankyo,, Spezialprogramm, Springer, Teva Pharma, Stago (compensation for educational efforts), Stago (compensation for educational efforts), Daiichi Sankyo, Science Funds, Stroke, Swiss Neurological Society, Swisslife Jubilaumsstiftung for Medical, Takeda. Dr Sprigg: grants from the National Institute of Health Research. Dr, Thermo Fisher GmbH, Thilemann: travel grants from Bristol Myers Squibb (BMS)/Pfizer. Dr Wagner:, Vice Presidency of the Swiss Neurological Society. Dr, Wegener: research funds by SNSF, UZH Clinical Research Priority Program stroke,, Wissenschaftsfonds Rehabilitation University Department for Geriatric Medicine, Zurich Neuroscience Center, Baugarten Foundation.
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  • Trottet, C., Vogels, T., Keitel, K., Kulinkina, A. V., Tan, R., Cobuccio, L., Jaggi, M., and Hartley, M. A. “Modular Clinical Decision Support Networks (Modn)-Updatable, Interpretable, And Portable Predictions For Evolving Clinical Environments”. Plos Digit Health 2, no. 7: e0000108. doi:10.1371/journal.pdig.0000108.
    Abstract: Clinical Decision Support Systems (CDSS) have the potential to improve and standardise care with probabilistic guidance. However, many CDSS deploy static, generic rule-based logic, resulting in inequitably distributed accuracy and inconsistent performance in evolving clinical environments. Data-driven models could resolve this issue by updating predictions according to the data collected. However, the size of data required necessitates collaborative learning from analogous CDSS's, which are often imperfectly interoperable (IIO) or unshareable. We propose Modular Clinical Decision Support Networks (MoDN) which allow flexible, privacy-preserving learning across IIO datasets, as well as being robust to the systematic missingness common to CDSS-derived data, while providing interpretable, continuous predictive feedback to the clinician. MoDN is a novel decision tree composed of feature-specific neural network modules that can be combined in any number or combination to make any number or combination of diagnostic predictions, updatable at each step of a consultation. The model is validated on a real-world CDSS-derived dataset, comprising 3,192 paediatric outpatients in Tanzania. MoDN significantly outperforms 'monolithic' baseline models (which take all features at once at the end of a consultation) with a mean macro F1 score across all diagnoses of 0.749 vs 0.651 for logistic regression and 0.620 for multilayer perceptron (p < 0.001). To test collaborative learning between IIO datasets, we create subsets with various percentages of feature overlap and port a MoDN model trained on one subset to another. Even with only 60% common features, fine-tuning a MoDN model on the new dataset or just making a composite model with MoDN modules matched the ideal scenario of sharing data in a perfectly interoperable setting. MoDN integrates into consultation logic by providing interpretable continuous feedback on the predictive potential of each question in a CDSS questionnaire. The modular design allows it to compartmentalise training updates to specific features and collaboratively learn between IIO datasets without sharing any data.
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  • Dahmke, H., Fiumefreddo, R., Schuetz, P., De Iaco, R., and Zaugg, C. “Tackling Alert Fatigue With A Semi-Automated Clinical Decision Support System: Quantitative Evaluation And End-User Survey”. Swiss Med Wkly 153, no. 7: 40082. doi:10.57187/smw.2023.40082.
    Abstract: STUDY AIMS: Clinical decision support systems (CDSS) embedded in hospital electronic health records efficiently reduce medication errors, but there is a risk of low physician adherence due to alert fatigue. At the Cantonal Hospital Aarau, a CDSS is being developed that allows the highly accurate detection and correction of medication errors. The semi-automated CDSS sends its alerts either directly to the physician or to a clinical pharmacist for review first. Our aim was to evaluate the performance of the recently implemented CDSS in terms of acceptance rate and alert burden, as well as physicians' satisfaction with the CDSS. METHODS: All alerts generated by the clinical decision support systems between January and December 2021 were included in a retrospective quantitative evaluation. A team of clinical pharmacists performed a follow-up to determine whether the recommendation made by the CDSS was implemented by the physician. The acceptance rate was calculated including all alerts for which it was possible to determine an outcome. A web-based survey was conducted amongst physicians to assess their attitude towards the CDSS. The survey questions included overall satisfaction, helpfulness of individual algorithms, and perceived alert burden. RESULTS: In 2021, a total of 10,556 alerts were generated, of which 619 triggered a direct notification to the physician and 2,231 notifications were send to the physician after evaluation by a clinical pharmacist. The acceptance rates were 89.8% and 68.4%, respectively, which translates as an overall acceptance rate of 72.4%. On average, clinical pharmacists received 17.2 alerts per day, while all of the hospital physicians together received 7.8 notifications per day. In the survey, 94.5% of physicians reported being satisfied or very satisfied with the CDSS. Algorithms addressing potential medication errors concerning anticoagulants received the highest usefulness ratings. CONCLUSION: The development of this semi-automated clinical decision support system with context-based algorithms resulted in alerts with a high acceptance rate. Involving clinical pharmacists proved a promising approach to limit the alert burden of physicians and thus tackle alert fatigue. The CDSS is well accepted by our physicians.
    Tags: *Decision Support Systems, Clinical, *Medical Order Entry Systems, Hospitals, Humans, Medication Errors/prevention & control, Retrospective Studies.
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  • Meier, M., Boeddinghaus, J., Nestelberger, T., Koechlin, L., Lopez-Ayala, P., Wussler, D., Walter, J. E., et al. “Comparing The Utility Of Clinical Risk Scores And Integrated Clinical Judgement In Patients With Suspected Acute Coronary Syndrome”. Eur Heart J Acute Cardiovasc Care 12, no. 10: 693-702. doi:10.1093/ehjacc/zuad081.
    Abstract: AIMS: The utility of clinical risk scores regarding the prediction of major adverse cardiac events (MACE) is uncertain. We aimed to directly compare the prognostic performance of five established clinical risk scores as well as an unstructured integrated clinical judgement (ICJ) of the treating emergency department (ED) physician. METHODS AND RESULTS: Thirty-day MACE including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (including the index event), and unstable angina requiring urgent coronary revascularization were centrally adjudicated by two independent cardiologists in patients presenting to the ED with acute chest discomfort in an international multicentre study. We compared the prognostic performance of the HEART score, GRACE score, T-MACS, TIMI score, and EDACS, as well as the unstructured ICJ of the treating ED physician (visual analogue scale to estimate the probability of acute coronary syndrome, ranging from 0 to 100). Among 4551 eligible patients, 1110/4551 patients (24.4%) had at least one MACE within 30 days. Prognostic accuracy was high and comparable for the HEART score, GRACE score, T-MACS, and ICJ [area under the receiver operating characteristic curve (AUC) 0.85-0.87] but significantly lower and only moderate for the TIMI score (AUC 0.79, P < 0.001) and EDACS (AUC 0.74, P < 0.001), resulting in sensitivities for the rule-out of 30-day MACE of 93-96, 87 (P < 0.001), and 72% (P < 0.001), respectively. CONCLUSION: The HEART score, GRACE score, T-MACS, and unstructured ICJ of the treating physician, not the TIMI score or EDACS, performed well for the prediction of 30-day MACE and may be considered for routine clinical use. TRIAL REGISTRATION: ClinicalTrials.gov number NCT00470587.
    Tags: (P300PB_167803), the Swiss Heart Foundation, the Swiss Society of Cardiology, the, *Acute Coronary Syndrome/diagnosis/complications, Abbott, Amgen, Brahms, Roche, Singulex, and Siemens. C.M. has received research, access to all of the data in the study and take responsibility for the integrity, Akademische Gesellschaft Basel'. M.R.G. received research grants from the Swiss, Akademische Gesellschaft') and from the University of Basel. K.W. received a, approved the manuscript. The sponsors had no role in designing or conducting the, authors declare that they have no conflict of interest with this study. The, B.Braun, Siemens, Beckman Coulter, Bayer, Ortho Clinical Diagnostics, Edwards, Basel and the Division of Internal Medicine, the Swiss Academy of Medical, being considered for publication elsewhere in whole or in part in any language,, BMS, Idorsia, Novartis, Osler, Roche, Sanofi, Siemens, and Singulex. All other, Chest Pain/etiology, Clinical Diagnostics, Quidel, Roche, and Siemens. D.M.G. reports grants from the, Clinical judgement, Clinical Reasoning, Coulter, Brahms, Idorsia, Novartis, Ortho Clinical Diagnostics, Quidel, Roche,, data, vouch for the data and analysis, wrote the paper, and decided to submit it, Diagnosis of ACS, Diagnostics, and Quidel Corporation. T.N. received research support from the, Emergency Service, Hospital, for publication. J.B., T.N., R.T., L.K., P.B., M.R.G., K.W., and C.M. had full, Foundation and a PhD scholarship from the University of Queensland. C.P. received, Foundation, as well as the 'Freiwillige Akademische Gesellschaft Basel'. J.E.W., Foundation, the Margarete und Walter Lichtenstein-Stiftung (3MS1038), and the, Gottfried and Julia Bangerter-Rhyner Foundation as well as research grants from, Gottfried and Julia Bangerter-Rhyner Foundation, and the Prince Charles Hospital, Herzschrittmacher und Elektrophysiologie' and the FAG Basel ('Freiwillige, honoraria from Amgen, Astra Zeneca, Bayer, Beckman Coulter, Boehringer Ingelheim,, honoraria/consulting honoraria from Siemens, Roche Diagnostics, Ortho Clinical, hs-cTn assays investigated were donated by the manufacturers, who had no role in, Humans, including publicly accessible websites or e-print servers. We disclose that J.B., Lifesciences, and Orion Pharma, outside the submitted work. L.K. received a, manuscript, or the decision to submit the manuscript for publication., National Science Foundation (P400PM_180828), the Swiss Heart Foundation, and the, of the data and the accuracy of the data analysis. All authors have read and, Paulo, Brazil) and personal fees from Roche, outside the submitted work. R.T., Prospective Studies, received a research grant from the Swiss Academy of Medical Sciences and the, received research grants from the University of Basel, the University Hospital of, received research support from the Swiss National Science Foundation, Research Foundation Basel as well as speaker honoraria/consulting honoraria from, research grant from the 'Freiwillige Akademische Gesellschaft Basel', the, research grant from the Swiss Heart Foundation, the University of Basel, the, research support from the Swiss Heart Foundation and Roche Diagnostics, outside, Risk Assessment/methods, Risk Factors, Risk scores, Sciences, and the Gottfried and Julia Bangerter-Rhyner-Foundation and speaker, Siemens, Singulex, and Sphingotec as well as speaker honoraria/consulting, study and no role in gathering or analysing the data or writing the manuscript., support from the Swiss National Science Foundation, the Swiss Heart Foundation,, Swiss Academy of Medical Sciences, and the Gottfried and Julia Bangerter-Rhyner, Swiss Heart Foundation and FAPESP (Fundacao de Amparo a Pesquisa do Estado de Sao, Swiss National Science Foundation (P400PM_191037/1), the Prof. Dr. Max Cloetta, the current study. T.Z. received research support from the 'Freiwillige, the design of the study, the analysis of the data, the preparation of the, the KTI, the University of Basel, the University Hospital Basel, Abbott, Beckman, The manuscript and its content have not been published previously and are not, the Swiss Heart Foundation. P.B. received research funding from the 'Stiftung fur, University Hospital Basel as well as speaker honoraria/consulting honoraria from, University Hospital of Basel, the University of Basel, and the Cardiovascular, Women and Heart Foundation and speaker/consulting honoraria from Abbott, Ortho.
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  • Boesiger, F., Poggioli, A., Netzhammer, C., Bretscher, C., Kaegi-Braun, N., Tribolet, P., Wunderle, C., et al. “Changes In Serum Albumin Concentrations Over 7 Days In Medical Inpatients With And Without Nutritional Support. A Secondary Post-Hoc Analysis Of A Randomized Clinical Trial”. Eur J Clin Nutr 77, no. 10: 989-997. doi:10.1038/s41430-023-01303-w.
    Abstract: BACKGROUND: Serum albumin concentrations are frequently used to monitor nutritional therapy in the hospital setting but supporting studies are largely lacking. Within this secondary analysis of a randomized nutritional trial (EFFORT), we assessed whether nutritional support affects short-term changes in serum albumin concentrations and whether an increase in albumin concentration has prognostic implications regarding clinical outcome and response to treatment. METHODS: We analyzed patients with available serum albumin concentrations at baseline and day 7 included in EFFORT, a Swiss-wide multicenter randomized clinical trial that compared individualized nutritional therapy with usual hospital food (control group). RESULTS: Albumin concentrations increased in 320 of 763 (41.9%) included patients (mean age 73.3 years (SD +/- 12.9), 53.6% males) with no difference between patients receiving nutritional support and controls. Compared with patients that showed a decrease in albumin concentrations over 7 days, those with an increase had a lower 180-day mortality [74/320 (23.1%) vs. 158/443 (35.7%); adjusted odds ratio 0.63, 95% CI 0.44 to 0.90; p = 0.012] and a shorter length of hospital stay [11.2 +/- 7.3 vs. 8.8 +/- 5.6 days, adjusted difference -2.2 days (95%CI -3.1 to -1.2)]. Patients with and without a decrease over 7 days had a similar response to nutritional support. CONCLUSION: Results from this secondary analysis indicate that nutritional support did not increase short-term concentrations of albumin over 7 days, and changes in albumin did not correlate with response to nutritional interventions. However, an increase in albumin concentrations possibly mirroring resolution of inflammation was associated with better clinical outcomes. Repeated in-hospital albumin measurements in the short-term is, thus, not indicated for monitoring of patients receiving nutritional support but provides prognostic information. TRAIL REGISTRATION: ClinicalTrials.gov Identifier: NCT02517476.
    Tags: *Inpatients, *Nutrition Therapy, Aged, Aged, 80 and over, Female, Humans, Length of Stay, Male, Middle Aged, Nutritional Support/adverse effects, Serum Albumin.
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  • Ehrhard, S., Keller, M., Morgenstern, L., Muller, M., Ricklin, M. E., Klukowska-Rotzler, J., Exadaktylos, A. K., and Jakob, D. A. “Presentation And Treatment Of Animal And Human Bite Injuries At A Swiss Tertiary Emergency Department: A Cross-Sectional Study”. Swiss Med Wkly 153, no. 6: 40093. doi:10.57187/smw.2023.40093.
    Abstract: BACKGROUND: Animal and human bite injuries are a relevant health problem worldwide. With the increasing number of pets, bite injuries are becoming more frequent. Previous studies on animal and human bite injuries in Switzerland were completed several years ago. The aim of the present study was to provide a detailed overview of patients with bite injuries admitted to a tertiary emergency department in Switzerland in terms of demographics, injury patterns and treatment strategies. METHODS: A 9-year cross-sectional analysis of patients presenting to the emergency department of Bern University Hospital in the period January 2013 to December 2021 following an animal or human bite injury. RESULTS: A total of 829 patients with bite injuries were identified, including 70 for postexposure prophylaxis only. Their median age was 39 (IQR 27-54) years and 53.6% were female. Most patients were bitten by a dog (44.3%), followed by cats (31.5%) and humans (15.2%). Most bite injuries were mild (80.2%); severe injuries were mainly found in dog bites (28.3%). Most patients were treated within six hours after human (80.9%) or dog (61.6%) bites; after cat bites, patients often presented with a delay (74.5%) and signs of infection (73.6%). Human bite wounds were superficial in the majority of cases (95.7%), rarely showed signs of infection (5.2%) at the time of presentation and hospitalisation was never required. CONCLUSIONS: Our study provides a detailed overview of patients admitted to an emergency department of a tertiary Swiss University Hospital after an animal or human bite. In summary, bite injuries are common among patients who present to the emergency department. Therefore, primary and emergency care clinicians should be familiar with these injuries and their treatment strategies. The high risk of infection, particularly in cat bites, may warrant surgical debridement in the initial treatment of these patients. Prophylactic antibiotic therapy and close follow-up examinations are recommended in most cases.
    Tags: *Bites and Stings/epidemiology/therapy, *Bites, Human, Adult, Animals, Cats, Cross-Sectional Studies, Dogs, Emergency Service, Hospital, Female, Humans, Male, Middle Aged, Retrospective Studies, Switzerland/epidemiology.
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  • Christ, M. “Invasive Treatment In Patients With Acute Myocardial Infarction And End-Stage Renal Disease: Does One Size Fits For All?”. Am J Cardiol 201: 364-366. doi:10.1016/j.amjcard.2023.06.035.
    Tags: *Kidney Failure, Chronic/complications/epidemiology/therapy, *Myocardial Infarction/complications/therapy, declare., Humans, Treatment Outcome.
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  • Berchtold, M. B., Wuthrich, C., Garcia, D., Berger, S., and Lollgen, R. M. “Nurses' And Physicians' Reported Difficulties And Enablers To Recognising And Reporting Child Abuse In Swiss Paediatric Emergency And Paediatric Surgery Departments - An Observational Study”. Swiss Med Wkly 153, no. 6: 40017. doi:10.57187/smw.2023.40017.
    Abstract: BACKGROUND: Under-detection and under-reporting of child abuse remains a considerable challenge in paediatric care, with a high number of cases missed each year in Switzerland and abroad. Published data regarding the obstacles and facilitators of detecting and reporting child maltreatment among paediatric nursing and medical staff in the paediatric emergency department (PED) are scarce. Despite the existence of international guidelines, the measures taken to counteract the incomplete detection of harm done to children in paediatric care are insufficient. AIM: We sought to examine up-to-date obstacles and enablers for detecting and reporting child abuse among nursing and medical staff in PED and paediatric surgery departments in Switzerland. METHODS: We surveyed 421 nurses and physicians working in PEDs and on paediatric surgical wards in six large Swiss paediatric hospitals using an online questionnaire between February 1, 2017, and August 31, 2017. RESULTS: The survey was returned by 261/421 (62.0%) respondents (complete n = 200, 76.6%; incomplete n = 61, 23.3%) with a preponderance of nurses (n = 150/261; 57.5%), 106/261 (40.6%) physicians, and 1/261 (0.4%) psychologists (n = 4/261; 1.5% missing profession). The stated obstacles to reporting child abuse were uncertainty about the diagnosis (n = 58/80; 72.5%), feeling unaccountable for notification (n = 28/80; 35%), uncertainty of whether reporting has any consequences (n = 5/80; 6.25%), lack of time (n = 4/80; 5%), forgetting to report (n = 2/80; 2.5%), and parental protection (n = 2/80; 2.5%) (unspecific answer, n = 4/80; 5%, multiple answers were possible, therefore items don not sum up to 100%). Even though most (n = 249/261 95.4%) respondents had previously been confronted with child abuse at/outside work, only 185/245 (75.5%) reported cases; significantly fewer nursing (n = 100/143, 69.9%) than medical staff (n = 83/99, 83.8%) (p = 0.013). Furthermore, significantly more nursing (n = 27/33; 81.8%) than medical staff (n = 6/33; 18.2%) (p = 0.005) reported a discrepancy between the number of suspected and reported cases (total 33/245 (13.5%). An overwhelming amount of participants were strongly interested in mandatory child abuse training (n= 226/242, 93.4%) and in the availability of standardised patient questionnaires and documentation forms (n = 185/243, 76.1%). CONCLUSION: In line with previous studies, insufficient knowledge about and lack of confidence in detecting the signs and symptoms of child abuse were the principal obstacles to reporting maltreatment. To finally address this unacceptable gap in child abuse detection, we recommend the implementation of mandatory child protection education in all countries where no such education has been implemented in addition to the introduction of cognitive aid tools and validated screening tools to increase child abuse detection rates and ultimately prevent further harm to children.
    Tags: *Child Abuse/diagnosis/prevention & control, *Nurses, *Physicians, Child, Emergency Service, Hospital, Humans, Mandatory Reporting, Surveys and Questionnaires, Switzerland.
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  • Skrifvars, M. B., Luethi, N., Bailey, M., French, C., Nichol, A., Trapani, T., McArthur, C., et al. “The Effect Of Recombinant Erythropoietin On Long-Term Outcome After Moderate-To-Severe Traumatic Brain Injury”. Intensive Care Med 49, no. 7: 831-839. doi:10.1007/s00134-023-07141-5.
    Abstract: PURPOSE: Recombinant erythropoietin (EPO) administered for traumatic brain injury (TBI) may increase short-term survival, but the long-term effect is unknown. METHODS: We conducted a pre-planned long-term follow-up of patients in the multicentre erythropoietin in TBI trial (2010-2015). We invited survivors to follow-up and evaluated survival and functional outcome with the Glasgow Outcome Scale-Extended (GOSE) (categories 5-8 = good outcome), and secondly, with good outcome determined relative to baseline function (sliding scale). We used survival analysis to assess time to death and absolute risk differences (ARD) to assess favorable outcomes. We categorized TBI severity with the International Mission for Prognosis and Analysis of Clinical Trials in TBI model. Heterogeneity of treatment effects were assessed with interaction p-values based on the following a priori defined subgroups, the severity of TBI, and the presence of an intracranial mass lesion and multi-trauma in addition to TBI. RESULTS: Of 603 patients in the original trial, 487 patients had survival data; 356 were included in the follow-up at a median of 6 years from injury. There was no difference between treatment groups for patient survival [EPO vs placebo hazard ratio (HR) (95% confidence interval (CI) 0.73 (0.47-1.14) p = 0.17]. Good outcome rates were 110/175 (63%) in the EPO group vs 100/181 (55%) in the placebo group (ARD 8%, 95% CI [Formula: see text] 3 to 18%, p = 0.14). When good outcome was determined relative to baseline risk, the EPO groups had better GOSE (sliding scale ARD 12%, 95% CI 2-22%, p = 0.02). When considering long-term patient survival, there was no evidence for heterogeneity of treatment effect (HTE) according to severity of TBI (p = 0.85), presence of an intracranial mass lesion (p = 0.48), or whether the patient had multi-trauma in addition to TBI (p = 0.08). Similarly, no evidence of treatment heterogeneity was seen for the effect of EPO on functional outcome. CONCLUSION: EPO neither decreased overall long-term mortality nor improved functional outcome in moderate or severe TBI patients treated in the intensive care unit (ICU). The limited sample size makes it difficult to make final conclusions about the use of EPO in TBI.
    Tags: *Brain Injuries, Traumatic/drug therapy, *Erythropoietin/therapeutic use, *Multiple Trauma, Erythropoietin, Humans, Neurological outcome, Survival Analysis, that they have no relevant conflicts of interest., Traumatic brain injury, Treatment Outcome.
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  • Potin, M., Carron, P. N., and Genton, B. “Injuries And Medical Emergencies Among International Travellers”. J Travel Med 31, no. 1. doi:10.1093/jtm/taad088.
    Abstract: BACKGROUND: Tropical infectious diseases and vaccine-preventable emergencies are the mainstay of pre-travel consultations. However, non-communicable diseases, injuries and accidents that occur during travel are not emphasized enough in these settings. METHODS: We performed a narrative review based on a literature search of PubMed, Google Scholar, UpToDate, DynaMed and LiSSa and on reference textbooks and medical journals dedicated to travel, emergency and wilderness medicine. Relevant secondary references were extracted. We also aimed to discuss newer or neglected issues, such as medical tourism, Coronavirus Disease 2019, exacerbations of co-morbidities associated with international travel, insurance coverage, health care seeking abroad, medical evacuation or repatriation and tips for different types of travellers' emergency medical kits (personal, group, physician handled). RESULTS: All sources reviewed led to the selection of >170 references. Among epidemiological data on morbidity and deaths while abroad, only retrospective data are available. Deaths are estimated to occur in 1 in 100 000 travellers, with 40% caused by trauma and 60% by diseases, and <3% linked to infectious diseases. Trauma and other injuries acquired during travel, such as traffic accidents and drowning, can be reduced by up to 85% with simple preventive recommendations such as avoiding simultaneous alcohol intake. In-flight emergencies occur on 1 in 604 flights on average. Thrombosis risk is two to three times greater for travellers than for non-travellers. Fever during or after travel can occur in 2-4% of travellers, but in up to 25-30% in tertiary centres. Traveller's diarrhoea, although rarely severe, is the most common disease associated with travel. Autochthonous emergencies (acute appendicitis, ectopic pregnancy, dental abscess) can also occur. CONCLUSIONS: Pre-travel medicine encounters must include the topic of injuries and medical emergencies, such as the risk-taking behaviours and foster better planning in a comprehensive approach along with vaccines and infectious diseases advices.
    Tags: *Communicable Diseases, *Vaccines, Emergencies, health care abroad, Humans, insurance coverage, medical evacuation, medical repatriation, non-communicable diseases, Retrospective Studies, Travel, travel medical kit, Unintentional injuries.
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  • Fuchs, A., Franzmeier, L., Cheseaux-Carrupt, M., Kaempfer, M., Disma, N., Pietsch, U., Huber, M., Riva, T., and Greif, R. “Characteristics And Neurological Survival Following Intraoperative Cardiac Arrest In A Swiss University Hospital: A 7-Year Retrospective Observational Cohort Study”. Front Med (Lausanne) 10: 1198078. doi:10.3389/fmed.2023.1198078.
    Abstract: INTRODUCTION: Little is known about intraoperative cardiac arrest during anesthesia care. In particular, data on characteristics of cardiac arrest and neurological survival are scarce. METHODS: We conducted a single-center retrospective observational study evaluating anesthetic procedures from January 2015 until December 2021. We included patients with an intraoperative cardiac arrest and excluded cardiac arrest outside of the operating room. The primary outcome was the return of spontaneous circulation (ROSC). Secondary outcomes were sustained ROSC over 20 min, 30-day survival, and favorable neurological outcome according to Clinical Performance Category (CPC) 1 and 2. RESULTS: We screened 228,712 anesthetic procedures, 195 of which met inclusion criteria and were analyzed. The incidence of intraoperative cardiac arrest was 90 (CI 95% 78-103) in 100,000 procedures. The median age was 70.5 [60.0; 79.4] years, and two-thirds of patients (n = 135; 69.2%) were male. Most of these patients with cardiac arrest had ASA physical status IV (n = 83; 42.6%) or V (n = 47; 24.1%). Cardiac arrest occurred more frequently (n = 104; 53.1%) during emergency procedures than elective ones (n = 92; 46.9%). Initial rhythm was pre-dominantly non-shockable with pulseless electrical activity mostly. Most patients (n = 163/195, 83.6%; CI 95 77.6-88.5%) had at least one instance of ROSC. Sustained ROSC over 20 min was achieved in most patients with ROSC (n = 147/163; 90.2%). Of the 163 patients with ROSC, 111 (68.1%, CI 95 60.4-75.2%) remained alive after 30 days, and most (n = 90/111; 84.9%) had favorable neurological survival (CPC 1 and 2). CONCLUSION: Intraoperative cardiac arrest is rare but is more likely in older patients, patients with ASA physical status >/=IV, cardiac and vascular surgery, and emergency procedures. Patients often present with pulseless electrical activity as the initial rhythm. ROSC can be achieved in most patients. Over half of the patients are alive after 30 days, most with favorable neurological outcomes, if treated immediately.
    Tags: anesthesia, cardiac arrest, cardiopulonary resuscitation, commercial or financial relationships that could be construed as a potential, conflict of interest., functional outcomes, health-related quality of life, ILCOR, and the ILCOR Education, Implementation and Team Task Force Chair. The, perioperative care (intraoperative care), remaining authors declare that the research was conducted in the absence of any, ROSC (return of spontaneous circulation).
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  • Busch, J. M., Arnold, I., Karakoumis, J., Winkel, D. J., Segeroth, M., Nickel, C. H., and Bingisser, R. “Emergency Presentations For Dizziness-Radiological Findings, Final Diagnoses, And Mortality”. Int J Clin Pract 2023: 7450009. doi:10.1155/2023/7450009.
    Abstract: BACKGROUND: Dizziness is a frequent presentation in patients presenting to emergency departments (EDs), often triggering extensive work-up, including neuroimaging. Therefore, gathering knowledge on final diagnoses and outcomes is important. We aimed to describe the incidence of dizziness as primary or secondary complaint, to list final diagnoses, and to determine the use and yield of neuroimaging and outcomes in these patients. METHODS: Secondary analysis of two observational cohort studies, including all patients presenting to the ED of the University Hospital of Basel from 30th January 2017-19th February 2017 and from 18th March 2019-20th May 2019. Baseline demographics, Emergency Severity Index (ESI), hospitalization, admission to Intensive Care Units (ICUs), and mortality were extracted from the electronic health record database. At presentation, patients underwent a structured interview about their symptoms, defining their primary and secondary complaints. Neuroimaging results were obtained from the picture archiving and communication system (PACS). Patients were categorized into three non-overlapping groups: dizziness as primary complaint, dizziness as secondary complaint, and absence of dizziness. RESULTS: Of 10076 presentations, 232 (2.3%) indicated dizziness as their primary and 984 (9.8%) as their secondary complaint. In dizziness as primary complaint, the three (out of 73 main conditions defined) main diagnoses were nonspecific dizziness (47, 20.3%), dysfunction of the peripheral vestibular system (37, 15.9%), as well as somatization, depression, and anxiety (20, 8.6%). 104 of 232 patients (44.8%) underwent neuroimaging, with relevant findings in 5 (4.8%). In dizziness as primary complaint 30-day mortality was 0%. CONCLUSION: Work-up for dizziness in emergency presentations has to consider a broad differential diagnosis, but due to the low yield, it should include neuroimaging only in few and selected cases, particularly with additional neurological abnormalities. Presentation with primary dizziness carries a generally favorable prognosis lacking short-term mortality. .
    Tags: *Anxiety, *Dizziness, Anxiety Disorders, Databases, Factual, Diagnosis, Differential, Humans.
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  • Suttels, V., Guedes Da Costa, S., Garcia, E., Brahier, T., Hartley, M. A., Agodokpessi, G., Wachinou, P., Fasseur, F., and Boillat-Blanco, N. “Barriers And Facilitators To Implementation Of Point-Of-Care Lung Ultrasonography In A Tertiary Centre In Benin: A Qualitative Study Among General Physicians And Pneumologists”. Bmj Open 13, no. 6: e070765. doi:10.1136/bmjopen-2022-070765.
    Abstract: OBJECTIVES: Owing to its ease-of-use and excellent diagnostic performance for the assessment of respiratory symptoms, point-of-care lung ultrasound (POC-LUS) has emerged as an attractive skill in resource-low settings, where limited access to specialist care and inconsistent radiology services erode health equity.To narrow down the research to practice gap, this study aims to gain in-depth insights in the perceptions on POC-LUS and computer-assisted POC-LUS for the diagnosis of lower respiratory tract infections (LRTIs) in a low-income and middle-income country (LMIC) of sub-Saharan Africa. DESIGN AND SETTING: Qualitative study using face-to-face semi-structured interviews with three pneumologists and five general physicians in a tertiary centre for pneumology and tuberculosis in Benin, West Africa. The center hosts a prospective cohort study on the diagnostic performance of POC-LUS for LRTI. In this context, all participants started a POC-LUS training programme 6 months before the current study. Transcripts were coded by the interviewer, checked for intercoder reliability by an independent psychologist, compared and thematically summarised according to grounded theory methods. RESULTS: Various barriers- and facilitators+ to POC-LUS implementation were identified related to four principal categories: (1) hospital setting (eg, lack of resources for device renewal or maintenance-, need for POC tests+), (2) physician's perceptions (eg, lack of opportunity to practice-, willingness to appropriate the technique+), (3) tool characteristics (eg, unclear lifespan-, expedited diagnosis+) and (4) patient's experience (no analogous image to keep-, reduction in costs+). Furthermore, all interviewees had positive attitudes towards computer-assisted POC-LUS. CONCLUSIONS: There is a clear need for POC affordable lung imaging techniques in LMIC and physicians are willing to implement POC-LUS to optimise the diagnostic approach of LRTI with an affordable tool. Successful integration of POC-LUS into clinical routine will require adequate responses to local challenges related to the lack of available maintenance resources and limited opportunity to supervised practice for physicians.
    Tags: *General Practitioners, *Respiratory Tract Infections, Benin, Humans, Lung, Point-of-Care Systems, Prospective Studies, Qualitative Research, Reproducibility of Results, Tropical medicine, Ultrasonography/methods, Ultrasound.
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  • Suppan, L., Jampen, L., Siebert, J. N., Zund, S., Stuby, L., and Ozainne, F. “Correction: Suppan Et Al. Impact Of Two Resuscitation Sequences On Alveolar Ventilation During The First Minute Of Simulated Pediatric Cardiac Arrest: Randomized Cross-Over Trial. Healthcare 2022, 10, 2451”. Healthcare (Basel) 11, no. 12. doi:10.3390/healthcare11121799.
    Abstract: There was an error in the original publication [...].
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  • Burger, A., Studt, J. D., Mendez, A., Alberio, L., Fontana, P., Wuillemin, W. A., Schmidt, A., et al. “Determination Of Anti-Xa Inhibitor Plasma Concentrations Using A Universal Edoxaban Calibrator”. Diagnostics (Basel) 13, no. 12. doi:10.3390/diagnostics13122128.
    Abstract: A universal calibrator for the determination of all anti-Xa inhibitors would support laboratory processes. We aimed to test the clinical performance of an anti-Xa assay utilizing a universal edoxaban calibrator to determine clinically relevant concentrations of all anti-Xa inhibitors. Following a pilot study, we enrolled 553 consecutive patients taking rivaroxaban, edoxaban, or apixaban from nine study centers in a prospective cross-sectional study. The Technochrom((R)) anti-Xa assay was conducted using the Technoview((R)) edoxaban calibrator. Using ultra-high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS), anti-Xa inhibitor drug concentrations were determined. Sensitivities and specificities to detect three clinically relevant drug concentrations (30 microgL(-1), 50 microgL(-1), 100 microgL(-1)) were determined. Overall, 300 patients treated with rivaroxaban, 221 with apixaban, and 32 with edoxaban were included. The overall correlation coefficient (r(s)) was 0.95 (95% CI 0.94, 0.96). An area under the receiver operating characteristic curve of 0.96 for 30 microgL(-1), 0.98 for 50 microgL(-1), and 0.99 for 100 microgL(-1) was found. The sensitivities were 92.3% (95% CI 89.2, 94.6), 92.7% (89.4, 95.1), and 94.8% (91.1, 97.0), respectively (specificities 82.2%, 93.7%, and 94.4%). In conclusion, the clinical performance of a universal, edoxaban-calibrated anti-Xa assay was solid and most drug concentrations were predicted correctly.
    Tags: accredited continuing medical education program from Axonlab, and from Thermo, an accredited continuing medical education program from Alnylam, and Sanofi, and honoraria for participating in scientific advisory boards from, anti-Xa assay, anticoagulants introduction, apixaban, Bayer, Pfizer, and from Alexion Pharma GmbH, all outside the submitted work. JDS, Bristol Myers Squibb, Daiichi-Sankyo, Takeda, Octapharma, SOBI, Janssen, Novo, diagnostic accuracy, edoxaban, employee and stakeholder of Technoclone., fees and funding for accredited continuing medical education program from Pfizer, Fisher Scientific, during the conduct of the study, funding for an accredited continuing medical education program from Bayer,, grants from Bayer, CSL-Behring, Novartis, Novo Nordisk, Roche, Sobi, and Takeda., grants, personal, laboratory monitoring, lecture honoraria from Bayer Healthcare, and Daiichi Sankyo. LA reports research, Nordisk, and Mitsubishi Tanabe Pharma, outside the submitted work. NBB is an, personal fees and funding for, reports lecture fees and advisory honoraria from Bayer Healthcare, Pfizer,, rivaroxaban, Takeda, Siemens, and Sanofi. TCS holds an endowed professorship supported by the, Touring Club Switzerland. BG reports non-financial support and funding for an, WAW reports research grants from Bayer Healthcare, BMS-Pfizer, Daiichi Sankyo,.
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  • Darioli, V., and Ageron, F. X. “Identifying Traumatic Significant Haemorrhage Is Challenging For Patient With Low And Intermediate Risk, Not When Bleeding Is Obvious”. Scand J Trauma Resusc Emerg Med 31, no. 1: 32. doi:10.1186/s13049-023-01096-8.
    Tags: *Hemorrhage/diagnosis/etiology, Humans.
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  • Weber, D. M., Kraus, R., Wirth-Welle, R., Andreisek, G., Gnannt, R., Guero, S., Neeser, H. R., and Seiler, M. “Paediatric Fractures Of Carpal Bones Other Than The Scaphoid”. Hand Surg Rehabil 42, no. 5: 406-412. doi:10.1016/j.hansur.2023.06.009.
    Abstract: OBJECTIVES: Fractures of carpal bones other than the scaphoid are rare in children. The aim of this study was to analyze results and identify risk factors for an unfavorable outcome. MATERIAL AND METHODS: Children and adolescents up to the age of 16 years who sustained a carpal fracture other than in the scaphoid between 2004 and 2021 were reviewed in this single-center retrospective study. RESULTS: In a series of 209 children and adolescents with carpal fractures, 22 had fractures other than the scaphoid. Mean age was 13 years (range 8-16) years, with a total of 41 fractures, with highest incidences for the capitate (10), trapezium (6), triquetrum (4) and pisiform (4). Twenty-nine of these 41 fractures were missed on initial X-ray. Non-displaced fractures were treated with a short arm spica cast including the thumb. Four patients were operated on for displacement fracture or carpometacarpal subluxation. All fractures united, and patients returned to full activities. At the final consultation at a median 14 months (range 6-89) post-injury, all patients with non-displaced fractures were free of symptoms, with excellent Mayo Wrist Scores (MWS). However, three patients with operated trapezium fractures developed early radiological signs of osteoarthritis, two of them with residual pain and MWS rated only good. CONCLUSION: Non-displaced pediatric carpal fractures treated by forearm cast have excellent prognosis. Fractures of the trapezium with displacement or first carpometacarpal subluxation incur a risk of osteoarthritis despite anatomical reduction and internal fixation.
    Tags: *Fractures, Bone/diagnostic imaging/surgery, *Hand Injuries, *Joint Dislocations/surgery, *Osteoarthritis, *Scaphoid Bone/diagnostic imaging/surgery/injuries, *Wrist Injuries/diagnosis, Adolescent, Capitate, Capitatum, Carpal bone fracture, Child, Children, Comminuted fracture, Enfants, Fracture comminutive, Fracture du carpe, Humans, Retrospective Studies, Trapezium, Triquetrum, Wrist.
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  • Schonenberger, K. A., Reber, E., Schlappi, K., Baumgartner, A., Stanga, Z., and Kollar, A. “Determinants Of Treatment Toxicity In Patients With Soft Tissue Sarcomas”. Nutr Cancer 75, no. 8: 1638-1645. doi:10.1080/01635581.2023.2227405.
    Abstract: Soft tissue sarcomas are rare malignant tumors. Traditionally, treatment is guided by patient and tumor characteristics. Data on the influence of patient characteristics, particularly nutritional status, on clinical outcomes are scarce. Body composition and its changes during treatment play an essential role in predicting toxicity, clinical outcomes, and mortality. This analysis aimed to investigate the relationship between treatment toxicity and body composition. Patients diagnosed with sarcoma who underwent first-line palliative chemotherapy between October 2017 and January 2020 were included. Baseline and follow-up computed tomographic scans at the third lumbar vertebra, available from diagnostic purposes, were analyzed using SliceOmatic software. Treatment toxicity was defined as a composite score of the Common Terminology Criteria for Adverse Events. Nutritional Risk Screening (NRS) 2002 score, psoas muscle thickness to height ratio, and comorbidity showed a significant association with overall toxicity, while skeletal muscle index and age showed a strong trend. In summary, the NRS 2002 tool must be routinely implemented in inpatient and outpatient settings for cancer patients, and nutritional therapy needs to become a fixed component of multimodal cancer treatment. Furthermore, validated standardized procedures for the quantification of muscle mass are needed to individualize and optimize cancer treatment.
    Tags: *Sarcoma/drug therapy, *Soft Tissue Neoplasms/drug therapy, Humans, Muscle, Skeletal/pathology, Nutritional Status, Risk Factors.
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  • Rickenbacher-Frey, S., Adam, S., Exadaktylos, A. K., Muller, M., Sauter, T. C., and Birrenbach, T. “Development And Evaluation Of A Virtual Reality Training For Emergency Treatment Of Shortness Of Breath Based On Frameworks For Serious Games”. Gms J Med Educ 40, no. 2: Doc16. doi:10.3205/zma001598.
    Abstract: BACKGROUND: Virtual reality (VR) can offer an innovative approach to providing training in emergency situations, especially in times of COVID-19. There is no risk of infection, and the procedure is scalable and resource-efficient. Nevertheless, the challenges and problems that can arise in the development of VR training are often unclear or underestimated. As an example, we present the evaluation of the feasibility of development of a VR training session for the treatment of dyspnoea. This is based on frameworks for serious games, and provides lessons learned. We evaluate the VR training session with respect to usability, satisfaction, as well as perceived effectiveness and workload of participants. METHODS: The VR training was developed using the established framework (Steps 1-4) for serious games of Verschueren et al. and Nicholson's RECIPE elements for meaningful gamification. Primary validation (Step 4) was performed at the University of Bern, Switzerland, in a pilot study without control group, with a convenience sample of medical students (n=16) and established measurement tools. RESULTS: The theoretical frameworks permitted guided development of the VR training session. Validation gave a median System Usability Scale of 80 (IQR 77.5-85); for the User Satisfaction Evaluation Questionnaire, the median score was 27 (IQR 26-28). After the VR training, there was a significant gain in the participants' confidence in treating a dyspnoeic patient (median pre-training 2 (IQR 2-3) vs. post-training 3 (IQR 3-3), p=0.016).Lessons learned include the need for involving medical experts, medical educators and technical experts at an equivalent level during the entire development process. Peer-teaching guidance for VR training was feasible. CONCLUSION: The proposed frameworks can be valuable tools to guide the development and validation of scientifically founded VR training. The new VR training session is easy and satisfying to use and is effective - and is almost without motion sickness.
    Tags: *COVID-19/epidemiology, *Virtual Reality, Bern supported by the Touring Club Switzerland. The sponsor has no influence on, Covid-19, Dyspnea/therapy, emergency medicine, Emergency Treatment, have no competing interests., Humans, medical education, Pilot Projects, serious game, shortness of breath, the research conducted or the decision to publish. The authors declare that they, virtual reality.
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  • Scherr, B. F., Reiner, M. F., Baumann, F., Hohne, K., Muller, T., Ayata, K., Muller-Quernheim, J., Idzko, M., and Zissel, G. “Prevention Of M2 Polarization And Temporal Limitation Of Differentiation In Monocytes By Extracellular Atp”. Bmc Immunol 24, no. 1: 11. doi:10.1186/s12865-023-00546-3.
    Abstract: BACKGROUND: Elevated levels of extracellular adenosine triphosphate (ATP) modulate immunologic pathways and are considered to be a danger signal in inflammation, lung fibrosis and cancer. Macrophages can be classified into two main types: M1 macrophages are classically activated, pro-inflammatory macrophages, whereas M2 macrophages are alternatively activated, pro-fibrotic macrophages. In this study, we examined the effect of ATP on differentiation of native human monocytes into these macrophage subtypes. We characterized M1 and M2 like macrophages by their release of Interleukin-1beta (IL-1beta) and Chemokine (C-C motif) ligand 18 (CCL18), respectively. RESULTS: Monocytes were stimulated with ATP or the P2X7 receptor agonist Benzoylbenzoyl-ATP (Bz-ATP), and the production of various cytokines was analyzed, with a particular focus on CCL18 and IL-1beta, along with the expression of different purinergic receptors. Over a 72 h period of cell culture, monocytes spontaneously differentiated to M2 like macrophages, as indicated by an increased release of CCL18. Immediate stimulation of monocytes with ATP resulted in a dose-dependent reduction in CCL18 release, but had no effect on the concentration of IL-1beta. In contrast, delayed stimulation with ATP had no effect on either CCL18 or IL-1beta release. Similar results were observed in a model of inflammation using lipopolysaccharide-stimulated human monocytes. Stimulation with the P2X7 receptor agonist Bz-ATP mimicked the effect of ATP on M2-macrophage differentiation, indicating that P2X7 is involved in ATP-induced inhibition of CCL18 release. Indeed, P2X7 was downregulated during spontaneous M2 differentiation, which may partially explain the ineffectiveness of late ATP stimulation of monocytes. However, pre-incubation of monocytes with PPADS, Suramin (unselective P2X- and P2Y-receptor blockers) and KN62 (P2X7-antagonist) failed to reverse the reduction of CCL18 by ATP. CONCLUSIONS: ATP prevents spontaneous differentiation of monocytes into M2-like macrophages in a dose- and time-dependent manner. These effects were not mediated by P2X and P2Y receptors.
    Tags: *Monocytes, *Receptors, Purinergic P2X7, Adenosine Triphosphate, Atp, Ccl18, Cell Differentiation, Cells, Cultured, Differentiation, Humans, Inflammation, M2 macrophage, Macrophages, Monocyte.
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  • Ziaka, M., and Exadaktylos, A. “Insights Into Sars-Cov-2-Associated Subacute Thyroiditis: From Infection To Vaccine”. Virol J 20, no. 1: 132. doi:10.1186/s12985-023-02103-1.
    Abstract: Since the COVID-19 emergence as a global pandemic in March 2020, more than 5 million SARS-CoV-2-related deaths have been globally documented. As the pandemic progressed, it became clear that, although the infection is mainly characterized as a respiratory disease, it also affects other organs and systems, including the thyroid gland. Indeed, emerging evidence suggests that SARS-CoV-2 can act as a trigger for various thyroid disorders, for example, subacute thyroiditis (SAT), Grave's disease, and non-thyroidal illness syndrome. The entry of SARS-CoV-2 into the host cells is mainly mediated by the ACE2-receptor, making organs and systems with high expression of this receptor, such as the thyroid gland, highly vulnerable to COVID-19. Accumulating data propose that SAT may be an underestimated manifestation of COVID-19 infection. Importantly, if SAT remains unrecognized, it may trigger or aggravate potential other complications of the disease, for example, respiratory insufficiency and cardiovascular complications, and thus negatively influence prognosis. Moreover, recent case reports, case series, and systematic reviews highlight SAT as a potential side effect of the vaccination against SARS-CoV-2. The present review aims to raise awareness of SARS-CoV-2-associated- and post-vaccination subacute thyroiditis, to discuss recent evidence regarding its pathophysiology, and to present useful information for this special form of SAT related to daily clinical practice.
    Tags: *COVID-19/prevention & control, *Thyroiditis, Subacute, *Vaccines, Humans, SARS-CoV-2, Vaccination.
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  • Heimer, J., Arneberg, L., Blunier, S., Klukowska-Rotzler, J., Gonzenbach, A. G., Exadaktylos, A., Ruder, T., and Wagner, F. “Under-Reporting Of Forensic Findings: Craniocervical Emergency Imaging In Cases Of Survived Hanging”. Forensic Sci Med Pathol 20, no. 2: 434-442. doi:10.1007/s12024-023-00665-8.
    Abstract: To determine the diagnostic bias between clinical and forensic radiology in cases of nonfatal hanging and determine and describe typical underreported imaging findings. In a retrospective, single-center study, all patients admitted for attempted suicide with near-hanging or fatal hanging between January 2008 and December 2020 who received CT or MRI of head and neck were reviewed and missed findings in the original report were documented. A binary regression with disagreement as dependent variable was fitted for the imaging modality, fatality, age, and sex. A total of 123 hanging incidents were retrospectively analyzed. The vast majority (n = 108; 87.8%) had attempted suicide with a nonfatal outcome. Fatal outcome occurred in 15 (12.0%). The extra- and intracranial injuries documented on CT and MRI scans were laryngeal (n = 8; 6.5%), soft tissue (n = 42; 34.1%), and vascular injuries (n = 1; 0.8%). Intracranial pathology was evident on 18 (14.6%) scans. Disagreement occurred in 36 (29.3%) cases and represented 52 (69.2%) of all cases with a radiological finding. Disagreement was strongly associated with fatality (OR: 2.7-44.9.4, p = 0.0012). In most cases, nonfatal hangings cause no or only minor injuries. Fatal cases are associated with a greater probability of missed minor imaging findings. This suggests that findings deemed clinically irrelevant are probably not reported in such severe emergency cases. This association indicates that minor abnormalities are underreported when major pathologies are evident on imaging in victims of strangulation.
    Tags: *Asphyxia/diagnostic imaging/pathology, *Magnetic Resonance Imaging, *Neck Injuries/diagnostic imaging/mortality/pathology, *Suicide, Attempted, *Tomography, X-Ray Computed, Adolescent, Adult, Aged, Clinical radiology, Female, Forensic radiology, Humans, Imaging findings, Larynx/diagnostic imaging/pathology/injuries, Male, Middle Aged, Nonfatal hanging, Retrospective Studies, Suicide, Completed, Underreported, Young Adult.
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  • Schmutz, T., Le Terrier, C., Ribordy, V., Iglesias, K., and Guechi, Y. “The Effect Of Positive Therapeutic Communication On Pain (Popain) And Anxiety During Arterial Blood Gas Standardized Procedures In The Emergency Department Compared To Traditional Communication: Protocol For A Monocentric Randomized Controlled Trial”. Jmir Res Protoc 12: e42043. doi:10.2196/42043.
    Abstract: BACKGROUND: In the emergency department (ED), medical procedures, such as arterial blood gas (ABG) testing, can cause pain and high stress levels. However, ABG testing is a routine procedure assessing the severity of the patient's condition. To reduce the pain of ABG, several methods have been investigated without significant difference in pain perception. Communication, a key element of care, has shown a significant effect on pain perception. A positive communication strategy, including positive, kind, or reassuring words, can reduce pain perception, while negative words can raise this perception, causing discomfort, known as the "nocebo effect." Although some studies have compared the impact of verbal attitudes, particularly in anesthesia and mainly with staff already trained in hypnosis, to the best of our knowledge, none have investigated the effect of communication in the emergency setting, where patients may be more suggestible to the words used. OBJECTIVE: In this study, we will investigate the effect of positive therapeutic communication on pain, anxiety, discomfort, and global satisfaction in patients requiring ABG compared to nocebo and neutral communication. METHODS: A single-center, double-blind randomized controlled trial (RCT) with 3 parallel arms will be conducted with 249 patients requiring ABG during their ED visit. Patients will be randomly assigned to 1 of 3 groups before receiving ABG: positive communication group, negative communication (nocebo) group, or neutral communication (neutral) group. The communication and the words used by the physicians during hygiene preparation, artery location, and puncture will be imposed in each group. The study will be proposed to each patient corresponding to the inclusion criteria. The physicians will not be trained in hypnosis or in positive therapeutic communication. The procedure will be recorded with audio recorders to test its quality. Intention-to-treat analysis will be performed. The primary endpoint is the onset of pain. The secondary outcomes are patient comfort, patient anxiety, and global satisfaction of the patient with the communication strategy used. RESULTS: On average, 2000 ABG procedures are performed each year in the EDs of hospitals. In this study, 249 patients are expected to be included. With a projected positive response rate of 80%, we intend to include 25 (10%) patients per month. The inclusion period began in April 2023 and will run until July 2024. We hope to publish the results of the study during the fall of 2024. CONCLUSIONS: To the best of our knowledge, this study is the first RCT assessing the use of positive communication on pain and anxiety in patients undergoing the ABG procedure in the ED. A reduction in pain, discomfort, and anxiety is expected when using positive communication. If the results are positive, this could be useful to the medical community and encourage clinicians to monitor their communication during care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05434169; https://clinicaltrials.gov/ct2/show/NCT05434169. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/42043.
    Tags: anxiety, arterial blood gas, emergency department, nocebo, pain, positive therapeutic communication, therapeutic communication.
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  • Jakob, D. A., Muller, M., Lewis, M., Wong, M. D., Exadaktylos, A. K., and Demetriades, D. “Risk Factors For Thromboembolic Complications In Isolated Severe Head Injury”. Eur J Trauma Emerg Surg 50, no. 1: 185-195. doi:10.1007/s00068-023-02292-y.
    Abstract: PURPOSE: Patients with traumatic brain injury (TBI) are at high risk for venous thromboembolism (VTE). The aim of the present study is to identify factors independently associated with VTE events. Specifically, we hypothesized that the mechanism of penetrating head trauma might be an independent factor associated with increased VTE events when compared with blunt head trauma. METHODS: The ACS-TQIP database (2013-2019) was queried for all patients with isolated severe head injuries (AIS 3-5) who received VTE prophylaxis with either unfractionated heparin or low-molecular-weight heparin. Transfers, patients who died within 72 h and those with a hospital length of stay < 48 h were excluded. Multivariable analysis was used as the primary analysis to identify independent risk factors for VTE in isolated severe TBI. RESULTS: A total of 75,570 patients were included in the study, 71,593 (94.7%) with blunt and 3977 (5.3%) with penetrating isolated TBI. Penetrating trauma mechanism (OR 1.49, CI 95% 1.26-1.77), increasing age (age 16-45: reference; age > 45-65: OR 1.65, CI 95% 1.48-1.85; age > 65-75: OR 1.71, CI 95% 1.45-2.02; age > 75: OR 1.73, CI 95% 1.44-2.07), male gender (OR 1.53, CI 95% 1.36-1.72), obesity (OR 1.35, CI 95% 1.22-1.51), tachycardia (OR 1.31, CI 95% 1.13-1.51), increasing head AIS (AIS 3: reference; AIS 4: OR 1.52, CI 95% 1.35-1.72; AIS 5: OR 1.76, CI 95% 1.54-2.01), associated moderate injuries (AIS = 2) of the abdomen (OR 1.31, CI 95% 1.04-1.66), spine (OR 1.35, CI 95% 1.19-1.53), upper extremity (OR 1.16, CI 95% 1.02-1.31), lower extremity (OR 1.46, CI 95% 1.26-1.68), craniectomy/craniotomy or ICP monitoring (OR 2.96, CI 95% 2.65-3.31) and pre-existing hypertension (OR 1.18, CI 95% 1.05-1.32) were identified as independent risk factors for VTE complications in isolated severe head injury. Increasing GCS (OR 0.93, CI 95% 0.92-0.94), early VTE prophylaxis (OR 0.48, CI 95% 0.39-0.60) and LMWH compared to heparin (OR 0.74, CI 95% 0.68-0.82) were identified as protective factors for VTE complications. CONCLUSION: The identified factors independently associated with VTE events in isolated severe TBI need to be considered in VTE prevention measures. In penetrating TBI, an even more aggressive VTE prophylaxis management may be justified as compared to that in blunt.
    Tags: *Brain Injuries, Traumatic, *Head Injuries, Closed/complications, *Venous Thromboembolism/epidemiology/etiology/prevention & control, Adolescent, Adult, Anticoagulants/therapeutic use, Deep vein thrombosis, Head trauma, Heparin, Low-Molecular-Weight/therapeutic use, Heparin/therapeutic use, Humans, Male, Mechanism of injury, Middle Aged, Pulmonary embolism, Risk Factors, Young Adult.
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  • Heitmann, J., Glangetas, A., Doenz, J., Dervaux, J., Shama, D. M., Garcia, D. H., Benissa, M. R., et al. “Deepbreath-Automated Detection Of Respiratory Pathology From Lung Auscultation In 572 Pediatric Outpatients Across 5 Countries”. Npj Digit Med 6, no. 1: 104. doi:10.1038/s41746-023-00838-3.
    Abstract: The interpretation of lung auscultation is highly subjective and relies on non-specific nomenclature. Computer-aided analysis has the potential to better standardize and automate evaluation. We used 35.9 hours of auscultation audio from 572 pediatric outpatients to develop DeepBreath : a deep learning model identifying the audible signatures of acute respiratory illness in children. It comprises a convolutional neural network followed by a logistic regression classifier, aggregating estimates on recordings from eight thoracic sites into a single prediction at the patient-level. Patients were either healthy controls (29%) or had one of three acute respiratory illnesses (71%) including pneumonia, wheezing disorders (bronchitis/asthma), and bronchiolitis). To ensure objective estimates on model generalisability, DeepBreath is trained on patients from two countries (Switzerland, Brazil), and results are reported on an internal 5-fold cross-validation as well as externally validated (extval) on three other countries (Senegal, Cameroon, Morocco). DeepBreath differentiated healthy and pathological breathing with an Area Under the Receiver-Operator Characteristic (AUROC) of 0.93 (standard deviation [SD] +/- 0.01 on internal validation). Similarly promising results were obtained for pneumonia (AUROC 0.75 +/- 0.10), wheezing disorders (AUROC 0.91 +/- 0.03), and bronchiolitis (AUROC 0.94 +/- 0.02). Extval AUROCs were 0.89, 0.74, 0.74 and 0.87 respectively. All either matched or were significant improvements on a clinical baseline model using age and respiratory rate. Temporal attention showed clear alignment between model prediction and independently annotated respiratory cycles, providing evidence that DeepBreath extracts physiologically meaningful representations. DeepBreath provides a framework for interpretable deep learning to identify the objective audio signatures of respiratory pathology.
    Tags: Acute respiratory illness, age, Article, asthma, Automated detection, automation, Biological organs, Brazil, breathing pattern, breathing rate, Bronchiolitis, bronchitis, Cameroon, child, classifier, cohort analysis, Computer aided analysis, Computer-aided analysis, controlled study, Convolutional neural network, Convolutional neural networks, cross validation, Deep learning, diagnostic test accuracy study, Diseases, external validity, female, Healthy controls, human, Learning models, Learning systems, logistic regression analysis, Logistic regression classifier, lung auscultation, major clinical study, male, model, Morocco, observational study, outpatient, Pathology, Pediatrics, Physiological models, pneumonia, prediction, receiver operating characteristic, Receiver operator characteristics, Respiratory pathology, respiratory tract disease, Senegal, Switzerland, wheezing.
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  • Siebert, J. N., Hartley, M. A., Courvoisier, D. S., Salamin, M., Robotham, L., Doenz, J., Barazzone-Argiroffo, C., Gervaix, A., and Bridevaux, P. O. “Deep Learning Diagnostic And Severity-Stratification For Interstitial Lung Diseases And Chronic Obstructive Pulmonary Disease In Digital Lung Auscultations And Ultrasonography: Clinical Protocol For An Observational Case-Control Study”. Bmc Pulm Med 23, no. 1: 191. doi:10.1186/s12890-022-02255-w.
    Abstract: BACKGROUND: Interstitial lung diseases (ILD), such as idiopathic pulmonary fibrosis (IPF) and non-specific interstitial pneumonia (NSIP), and chronic obstructive pulmonary disease (COPD) are severe, progressive pulmonary disorders with a poor prognosis. Prompt and accurate diagnosis is important to enable patients to receive appropriate care at the earliest possible stage to delay disease progression and prolong survival. Artificial intelligence-assisted lung auscultation and ultrasound (LUS) could constitute an alternative to conventional, subjective, operator-related methods for the accurate and earlier diagnosis of these diseases. This protocol describes the standardised collection of digitally-acquired lung sounds and LUS images of adult outpatients with IPF, NSIP or COPD and a deep learning diagnostic and severity-stratification approach. METHODS: A total of 120 consecutive patients (>/= 18 years) meeting international criteria for IPF, NSIP or COPD and 40 age-matched controls will be recruited in a Swiss pulmonology outpatient clinic, starting from August 2022. At inclusion, demographic and clinical data will be collected. Lung auscultation will be recorded with a digital stethoscope at 10 thoracic sites in each patient and LUS images using a standard point-of-care device will be acquired at the same sites. A deep learning algorithm (DeepBreath) using convolutional neural networks, long short-term memory models, and transformer architectures will be trained on these audio recordings and LUS images to derive an automated diagnostic tool. The primary outcome is the diagnosis of ILD versus control subjects or COPD. Secondary outcomes are the clinical, functional and radiological characteristics of IPF, NSIP and COPD diagnosis. Quality of life will be measured with dedicated questionnaires. Based on previous work to distinguish normal and pathological lung sounds, we estimate to achieve convergence with an area under the receiver operating characteristic curve of > 80% using 40 patients in each category, yielding a sample size calculation of 80 ILD (40 IPF, 40 NSIP), 40 COPD, and 40 controls. DISCUSSION: This approach has a broad potential to better guide care management by exploring the synergistic value of several point-of-care-tests for the automated detection and differential diagnosis of ILD and COPD and to estimate severity. Trial registration Registration: August 8, 2022. CLINICALTRIALS: gov Identifier: NCT05318599.
    Tags: *Deep Learning, *Idiopathic Interstitial Pneumonias/diagnosis, *Idiopathic Pulmonary Fibrosis/diagnostic imaging, *Lung Diseases, Interstitial/diagnostic imaging/pathology, *Pulmonary Disease, Chronic Obstructive/diagnostic imaging/complications, Adult, All other authors declare that they have no competing interests., Artificial Intelligence, Auscultation, Case-Control Studies, Clinical Protocols, Deep learning, Humans, Idiopathic interstitial pneumonias, Idiopathic pulmonary fibrosis, Lung, Lung diseases, Interstitial, Observational Studies as Topic, Pulmonary disease, Chronic obstructive, Quality of Life, Respiratory Sounds, Ultrasonography.
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  • Libersa, M., Marxer, L., Zafren, K., Oggier, S., Pucci, L., and Pasquier, M. “Takotsubo Cardiomyopathy Following Complete Avalanche Burial: A Case Report”. High Alt Med Biol 24, no. 2: 149-151. doi:10.1089/ham.2023.0026.
    Abstract: Libersa, Marie, Louis Marxer, Ken Zafren, Stephane Oggier, Lorenzo Pucci, and Mathieu Pasquier. Takotsubo cardiomyopathy following complete avalanche burial: a case report. High Alt Med Biol. 24:149-151, 2023.-Takotsubo cardiomyopathy is a transient left ventricular dyskinesia triggered by a stressful physical or emotional event. We report a case of mid-ventricular Takotsubo stress cardiomyopathy in an avalanche victim. The patient was a 41-year-old woman who was completely buried under 1.2 m of snow for 30 minutes. On arrival at the hospital, she was conscious and hypothermic (core temperature 33.7 degrees C). Her ECG showed rapid atrial fibrillation (142 beats/min) that converted to sinus rhythm after rewarming and administration of crystalloids. Echocardiography showed akinesia of the left mid-ventricle with a left ventricular ejection fraction of 41%. At 48-hour follow-up, echocardiography showed an almost complete recovery. During her hospital stay the patient was diagnosed with an acute stress disorder with symptoms of dissociation. She was discharged home after 5 days. At 2-week follow-up echocardiography was normal. Psychological follow-up was normal at 7 months. The physical and psychological stress of the avalanche, as well as hypothermia, were all possible triggers of Takotsubo cardiomyopathy.
    Tags: *Avalanches, *Hypothermia/complications, *Takotsubo Cardiomyopathy/diagnosis/etiology, accidental hypothermia, Adult, avalanche, Echocardiography/adverse effects, emergency medical services, Female, Humans, Stroke Volume, Takotsubo cardiomyopathy, Ventricular Function, Left.
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  • Zagalioti, S. C., Fyntanidou, B., Exadaktylos, A., Lallas, K., and Ziaka, M. “The First Positive Evidence That Training Improves Triage Decisions In Greece: Evidence From Emergency Nurses At An Academic Tertiary Care Emergency Department”. Bmc Emerg Med 23, no. 1: 60. doi:10.1186/s12873-023-00827-5.
    Abstract: BACKGROUND: Triage refers to the process of patient prioritisation in the emergency department (ED). This is based on the severity of the patient's illness and is performed by emergency nurses (ENs). This has a pivotal role in ensuring patient safety and in ensuring that the ED operates smoothly - so continuous and accurate training are essential. As Emergency Nursing has been formally established in Greece since 2019, it is of the uppermost importance that all Greek ENs should be trained in the use of a standardised triage system. The present study aimed to evaluate the effect of triage training of ENs in the use of the Swiss Triage System (STS) after an intervention of one week. METHODS: The effect of triage training was studied experimentally by comparing performance before and one week after training. A sample of thirty-six ENs from the University Department of Emergency Medicine at AHEPA University Hospital took part. The role of training in triage by the STS was assessed by completing the same self-administered questionnaire before and after a 45-minute e-learning program (presentation video of STS but with simulation scenarios) which was available during the period of a week. The post-training test was taken 2 weeks later, after the training process. RESULTS: The most promising finding was that there was a significant improvement in the number of correct answers after the training in triage (p<0.001). A significant improvement was also detected (p<0.001) in the questions that tested vigilance in providing safe health services by ENs, whereas there was no significant association between the number of correct answers and years of emergency experience or level of education, - either before or after the intervention. CONCLUSIONS: Triage training seems to successfully improve effective and efficient triage. To the best of our knowledge, this is the first study that has demonstrated that triage training has a significant positive impact on triage performance by ENs in Greece. It is planned to support these findings by real time studies in an ED.
    Tags: *Emergency Service, Hospital, *Triage, Clinical Competence, Decision-making, Emergency nurses, Greece, Humans, Tertiary Healthcare, Triage, Triage training.
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  • Morand, O., Safin, S., Larribau, R., and Rizza, C. “Using Photography As A Trace Of Activity To Facilitate The Retention Of Emergency Response Actions”. In, 2023-text:773-783, 2023. https://www.scopus.com/inward/record.uri?eid=2-s2.0-85171783629&partnerID=40&md5=983c649374c0d57b88a9265f50cf6407.
    Abstract: The chances of survival of a victim of cardiac arrest or stroke decrease considerably without rapid intervention. Bystanders, the first people able to intervene, are however few to act. This ignorance of the seriousness signs of the pathologies, and of the importance of acting, combined with a feeling of incapacity to perform emergency gestures, are the main reasons for this low level of action. The absence of knowledge originates both from a lack of training and from forgetting training courses. To overcome this problem, some trainings propose high fidelity simulation devices associated with a debriefing to create a strong emotional impact leading to a stronger memory impact. To assess the impact of this type of simulation, we set up a Living Lab including a high fidelity simulation of emergency situations (with citizens, dispatchers, first responders and paramedics), a debriefing and a method to create a "trace of activity", still aiming at generating a higher memory impact. To measure the effects of the Living Lab, we analyzed the emotional impacts evoked by the participants, categorized the learning and finally studied the creation of the activity trace. The results show that the Living-Lab elicits emotions (for the cardiac arrest scenario) and projections (for the stroke scenario) and can therefore potentially improve the retention. The learnings were of several natures: individual and practical learnings on emergency management, learnings on collaboration within the chain of survival and theoretical learnings. Analysis of the retained learning after 2 to 8 months is in progress, therefore no results are available yet. © 2023 Information Systems for Crisis Response and Management, ISCRAM. All rights reserved.
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