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Swiss Emergency Research collection

2019

  • Bajwa, N. M., Bochatay, N., Muller-Juge, V., Cullati, S., Blondon, K. S., Junod Perron, N., Maitre, F., et al. “Intra Versus Interprofessional Conflicts: Implications For Conflict Management Training”. J Interprof Care 34, no. 2: 259-268. doi:10.1080/13561820.2019.1639645.
    Abstract: Interprofessional collaboration and conflict management training are necessary in health sciences curricula. Characteristics of conflicts occurring within intraprofessional or between interprofessional teams can vary and are poorly understood. We sought to compare and contrast characteristics of intra- versus interprofessional conflicts to inform future training programs. An exploratory study was conducted through semi-structured interviews with 82 healthcare professionals working in a tertiary hospital. Interviews focused on sources, consequences, and responses to conflicts. Conflict situations were analyzed with conventional content analysis. Participants shared more intra- than interprofessional situations. Intraprofessional conflicts were caused by poor relationships, whereas interprofessional conflicts were associated with patient-related tasks and social representations. Avoiding and forcing were the most commonly mentioned responses to intraprofessional conflicts. The theme of power impacted all aspects of conflict both intra- and interprofessional. Intraprofessional conflicts were found to be as important as interprofessional conflicts. Differences in the sources of conflict and similarities regarding consequences of and responses to conflicts support integration of authentic clinical situations in interprofessional training. Understanding similarities and differences between intra- and interprofessional conflicts may help educators develop conflict management training that addresses the sources, consequences, and responses to conflicts in clinical settings.
    Tags: *Communication, *Cooperative Behavior, *Interprofessional Relations, Adult, conflict, Cross-Sectional Studies, Female, Group Processes, Humans, interprofessional, interprofessional collaboration, Interviews as Topic, Intraprofessional, Male, Middle Aged, Negotiating/*methods, Patient Care Team/*organization & administration, post-graduate training, power, Qualitative Research, Social Behavior.
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  • Jimenez, N., Tran, N. T., Poletti, P. A., Platon, A., Meach, F., Juillerat, A., Getaz, L., and Wolff, H. “Case Report: Don't Chew The Fufu: A Case Report Of Suspected Drug Body Stuffing”. F1000Res 8: 1156. doi:10.12688/f1000research.19966.2.
    Abstract: Background: Intrabody concealment of illicit substances is a common practice in the trafficking chain. Body packing is a technique used in drug trafficking that consists of deliberately ingesting many drug pellets. Body stuffing consists of precipitously swallowing packets of substances, which are smaller and more fragile than body-packing pellets, for concealment from law-enforcement officers in anticipation of impending search or arrest. Therefore, body stuffing is particularly dangerous due to the rupture risk of the loosely wrapped drug packets, which could lead to substance intoxication or even death. Case presentation: This article reports the case of a young man who was taken by law enforcement authorities to our Emergency Department for investigation of suspected body stuffing. Although the patient denied the facts, the initial reading of the computed tomography (CT) scan confirmed the presence of multiple images compatible with drug pellets, which were mostly in the stomach. The pellet findings were more consistent with body packing than body stuffing as initially suspected by the police. However, upon admission to our secured inpatient ward for clinical surveillance of pellet evacuation, the patient denied again having ingested such pellets, and declared that he only ate 'fufu'. Fufu is a traditional food of central and western Africa consisting of a starchy preparation compacted by hand into small balls. Fufu balls are usually swallowed without chewing to allow a sensation of stomach fullness throughout the day. Considering the fufu intake history, a careful reassessment of the imaging confirmed the presence of food content. Conclusions: This case study offers an example of suspected intrabody concealment of illicit substances, which turned out to be false positive due to fufu. It illustrates the importance of a history of food intake that could bias the interpretation of CT scan images.
    Tags: bodypacking, Bodystuffing, fufu/foofoo/foufou, prison, radiology pitfalls.
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  • Bigdon, S. F., Gewiess, J., Hoppe, S., Exadaktylos, A. K., Benneker, L. M., Fairhurst, P. G., and Albers, C. E. “Spinal Injury In Alpine Winter Sports: A Review”. Scand J Trauma Resusc Emerg Med 27, no. 1: 69. doi:10.1186/s13049-019-0645-z.
    Abstract: INTRODUCTION: Alpine winter sports have become increasingly popular over recent decades, with a similar increase in accident incidence. This review provides an overview of the most recent literature concerning spinal injury epidemiology, mechanisms, patterns and prevention strategies in the context of alpine winter sports. MATERIAL AND METHODS: The PubMed, Cochrane Library, and EMBASE databases were searched using the keywords spine injury, alpine injury, spine fracture, skiing injuries, snowboard injuries. 64 published studies in English and German met a priori inclusion criteria and were reviewed in detail by the authors. RESULTS: There are various mechanisms of injury in alpine winter sports (high speed falls in skiing, jumping failure in snowboarding) whilst regionality and injury severity are broadly similar. The thoracolumbar spine is the most common region for spinal injury. Spinal cord injury is relatively rare, usually accompanying distraction and rotation type fractures and is most commonly localised to the cervical spine. Disc injuries seem to occur more commonly in alpine winter sport athletes than in the general population. DISCUSSION: Despite awareness of increasing rates and risks of spinal injuries in alpine winter sports, there has been little success in injury prevention.
    Tags: *Seasons, Alpine injuries, Athletic Injuries/*epidemiology, Global Health, Humans, Incidence, Male, Review, Spinal Injuries/epidemiology/*etiology, Spine injuries, Trauma.
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  • Malinovska, A., Pitasch, L., Geigy, N., Nickel, C. H., and Bingisser, R. “Modification Of The Emergency Severity Index Improves Mortality Prediction In Older Patients”. West J Emerg Med 20, no. 4: 633-640. doi:10.5811/westjem.2019.4.40031.
    Abstract: INTRODUCTION: Older patients frequently present to the emergency department (ED) with nonspecific complaints (NSC), such as generalized weakness. They are at risk of adverse outcomes, and early risk stratification is crucial. Triage using Emergency Severity Index (ESI) is reliable and valid, but older patients are prone to undertriage, most often at decision point D. The aim of this study was to assess the predictive power of additional clinical parameters in NSC patients. METHODS: Baseline demographics, vital signs, and deterioration of activity of daily living (ADL) in patients with NSC were prospectively assessed at four EDs. Physicians scored the coherence of history and their first impression. For prediction of 30-day mortality, we combined vital signs at decision point D (heart rate, respiratory rate, oxygen saturation) as "ESI vital," and added "ADL deterioration," "incoherence of history," or "first impression," using logistic regression models. RESULTS: We included 948 patients with a median age of 81 years, 62% of whom were female. The baseline parameters at decision point D (ESI vital) showed an area under the curve (AUC) of 0.64 for predicting 30-day mortality in NSC patients. AUCs increased to 0.67 by adding ADL deterioration to 0.66 by adding incoherence of history, and to 0.71 by adding first impression. Maximal AUC was 0.73, combining all parameters. CONCLUSION: Adding the physicians' first impressions to vital signs at decision point D increases predictive power of 30-day mortality significantly. Therefore, a modified ESI could improve predictive power of triage in older patients presenting with NSCs.
    Tags: *Emergency Service, Hospital, *Mortality, *Severity of Illness Index, *Triage, Aged, Aged, 80 and over, Female, Humans, Male, Prospective Studies, Respiratory Rate, Sex Factors, Vital Signs.
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  • Fehlmann, C., Louis Simonet, M., Reny, J. L., Stirnemann, J., and Blondon, K. “Associations Between Early Handoffs, Length Of Stay And Complications In Internal Medicine Wards: A Retrospective Study”. Eur J Intern Med 67: 77-83. doi:10.1016/j.ejim.2019.07.003.
    Abstract: BACKGROUND: In US healthcare system, handoffs are associated with an increase in medical error and in hospital length of stay. In non-US healthcare systems, this phenomenon has not been well studied. We studied the association between early handoffs (EH) in a non-US internal medicine ward with length of stay (LOS), use of resources, major complication (MC) and discharge to post-acute care (PAC) facility. METHODS: We conducted a retrospective cohort study on patients admitted to the general internal medicine division. Patients with EH (defined as a transfer of responsibility between primary teams within the first 72 h) were compared with patients without EH. The primary outcome was LOS in the general internal medicine division. Secondary outcomes were the use of resources, the incidence of MC (transfer to intensive care, to intermediate care or death) and discharge to a PAC facility. RESULTS: We included 11,869 patients, 38% of whom were in the EH group. Patients were 67.7+/-16.6 years old and 53% were males. EH was independently associated with an increase of LOS (+6.4% [95% CI, 3.5%-9.5%], P < .001) and with an increased rate of MC (OR 1.3 [95% CI, 1.1-1.7], P = .012). In our subgroup analysis, the association between early handoff and LOS and MC rate were not statistically significant when the admission occurred on public holidays and weekends. CONCLUSIONS: Among patients admitted in our general internal medicine division, early handoffs were associated with significantly higher length of stay and major complication rate, but not in patients admitted during week-ends.
    Tags: Aged, Aged, 80 and over, Cohort Studies, Female, Hospital Departments, Humans, Internal Medicine, Length of stay, Length of Stay/*statistics & numerical data, Male, Medical Errors/*statistics & numerical data, Middle Aged, Patient handoff, Patient Handoff/*statistics & numerical data, Patient safety, Quality of healthcare, Retrospective Studies, Time Factors.
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  • Saeed, K., Wilson, D. C., Bloos, F., Schuetz, P., van der Does, Y., Melander, O., Hausfater, P., et al. “Correction To: The Early Identification Of Disease Progression In Patients With Suspected Infection Presenting To The Emergency Department: A Multi-Centre Derivation And Validation Study”. Crit Care 23, no. 1: 255. doi:10.1186/s13054-019-2536-0.
    Abstract: In the publication of this article [1], there are two errors in contributing author affiliations. This has now been included in this correction article.
    Tags: erratum.
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  • Bernardi, M. H., Haider, D. G., Domenig, C. M., Ristl, R., Hagmann, M., Haisjackl, M., Hiesmayr, M. J., and Lassnigg, A. “Does The Choice Of Intraoperative Fluid Modify Abdominal Aneurysm Repair Outcomes?: A Cohort Analysis”. Medicine (Baltimore) 98, no. 28: e16387. doi:10.1097/MD.0000000000016387.
    Abstract: Intraoperatively administered hydroxyethyl starch could be a risk indicator for postoperative acute kidney injury (AKI) in vascular surgical patients.In a single-center retrospective cohort analysis, we assessed the impact of hydroxyethyl starch and other risk indicators on AKI and mortality in 1095 patients undergoing elective open abdominal aneurysm repair (AAA-OR) or endovascular aortic repair (EVAR). We established logistic regression models to determine the effect of various risk indicators, including hydroxyethyl starch, on AKI, as well as Cox proportional hazard models to assess the effect on mortality.The use of intravenous hydroxyethyl starch was not associated with an increased risk of AKI or mortality. Patients undergoing EVAR were less likely to develop AKI (4% vs 18%). Multivariate risk indicators associated for AKI included suprarenal or pararenal aortic cross-clamp [odds ratio (OR), 4.44; 95% confidence interval (95% CI), 2.538-7.784; P < .001] and procedure length (OR, 1.005; 95% CI, 1.003-1.007; P < .001), and favored EVAR (OR, 0.351; 95% CI, 0.118-0.654; P < .01). Main multivariate risk indicators associated with mortality included patients needing an urgent procedure [hazard ratio (HR), 2.294; 95% CI, 1.541-3.413; P < .001], those with suprarenal or pararenal aortic cross-clamp (HR, 1.756; 95% CI, 1.247-2.472; P < .01), and patients undergoing EVAR (HR, 1.654; 95% CI, 1.292-2.118; P < .001).We found neither a benefit nor a negative effect of hydroxyethyl starch on the risk of AKI or mortality. Instead, other variables and comorbidities were found to be relevant for the development of postoperative AKI and survival. Nevertheless, clinicians should be aware of the high risk of postoperative AKI, particularly among those undergoing AAA-OR procedures.
    Tags: *Perioperative Care/methods, Acute Kidney Injury/epidemiology, Administration, Intravenous, Aged, Aortic Aneurysm, Abdominal/epidemiology/*surgery, Cohort Studies, Endovascular Procedures, Female, Humans, Male, Middle Aged, Postoperative Complications/epidemiology, Risk Factors, Starch/*therapeutic use, Treatment Outcome.
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  • Reber, E., Norman, K., Endrich, O., Schuetz, P., Frei, A., and Stanga, Z. “Economic Challenges In Nutritional Management”. J Clin Med 8, no. 7. doi:10.3390/jcm8071005.
    Abstract: Disease-related malnutrition (DRM) is a highly prevalent independent risk and cost factor with significant influence on mortality, morbidity, length of hospital stay (LOS), functional impairment and quality of life. The aim of our research was to estimate the economic impact of the introduction of routinely performed nutritional screening (NS) in a tertiary hospital, with subsequent nutritional interventions (NI) in patients with potential or manifest DRM. Economic impact analysis of natural detection of inpatients at risk and estimation of the change in economic activity after the implementation of a systematic NS were performed. The reference population for natural detection of DRM is about 20,000 inpatients per year. Based on current data, DRM prevalence is estimated at 20%, so 4000 patients with potential and manifest DRM should be detected. The NI costs were estimated at CHF 0.693 million, with savings of CHF 1.582 million (LOS reduction) and CHF 0.806 million in additional revenue (SwissDRG system). Thus, the introduction of routine NS generates additional costs of CHF 1.181 million that are compensated by additional savings of CHF 2.043 million and an excess in additional revenue of CHF 2.071 million. NS with subsequent adequate nutritional intervention shows an economic potential for hospitals.
    Tags: economic challenges, malnutrition, nutritional management.
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  • von Arx, M., Cheval, B., Sieber, S., Orsholits, D., Widmer, E., Kliegel, M., Guessous, I., et al. “The Role Of Adult Socioeconomic And Relational Reserves Regarding The Effect Of Childhood Misfortune On Late-Life Depressive Symptoms”. Ssm Popul Health 8: 100434. doi:10.1016/j.ssmph.2019.100434.
    Abstract: BACKGROUND: Childhood misfortune is associated with late-life depressive symptoms, but it remains an open question whether adult socioeconomic and relational reserves could reduce the association between childhood misfortune and late-life depressive symptoms. METHODS: Using the Survey of Health, Ageing and Retirement in Europe (SHARE), data from 8'357 individuals (35'260 observations) aged 50-96 years and living in 11 European countries were used to examine associations between three indicators of childhood misfortune (adverse childhood events, poor childhood health, and childhood socioeconomic circumstances) and late-life depressive symptoms. Subsequently, we tested whether these associations were mediated by education, occupational position, the ability to make ends meet, and potential or perceived relational reserves; that is family members or significant others who can provide help in case of need, respectively. Analyses were stratified by gender and adjusted for confounding and control variables. RESULTS: Adult socioeconomic reserves partly mediated the associations between adverse childhood events, poor childhood health and late-life depressive symptoms. The associations with the third indicator of childhood misfortune (childhood socioeconomic circumstances) were fully mediated by adult socioeconomic reserves in men, and partly mediated in women. None of the associations were mediated by relational reserves. However, perceived relational reserves were associated with fewer late-life depressive symptoms. CONCLUSION: Childhood socioeconomic disadvantage can be mitigated more easily over the life course than adverse childhood events and poor childhood health, especially in men. Perceived relational reserves work primarily as a protective force against late-life depressive symptoms and may be particularly important in the context of the cumulative effect of childhood adversities.
    Tags: Childhood misfortune, Europe, Late-life depression, Life course, Reserves.
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  • Gartner, B. A., Fehlmann, C., Suppan, L., Niquille, M., Rutschmann, O. T., and Sarasin, F. “Effect Of Noninvasive Ventilation On Intubation Risk In Prehospital Patients With Acute Cardiogenic Pulmonary Edema: A Retrospective Study”. Eur J Emerg Med 27, no. 1: 54-58. doi:10.1097/MEJ.0000000000000616.
    Abstract: OBJECTIVE: The aim of this study was to assess the effect of prehospital noninvasive ventilation for acute cardiogenic pulmonary edema on endotracheal intubation rate and on ICU admission rate. METHODS: We carried out a retrospective study on patients' prehospital files between 2007 and 2010 (control period), and between 2013 and 2016 (intervention period). Adult patients were included if a diagnosis of acute cardiogenic pulmonary edema was made by the prehospital physician. Exclusion criteria were a Glasgow coma scale score less than 9 or any other respiratory diagnosis. We analyzed the association between noninvasive ventilation implementation and endotracheal intubation or ICU admission with univariable and multivariable regression models. The primary outcome was prehospital endotracheal intubation rate. Secondary outcomes were admission to an ICU, prehospital intervention length, and 30-day mortality. RESULTS: A total of 1491 patients were included. Noninvasive ventilation availability was associated with a significant decrease in endotracheal intubation rate (2.6% in the control versus 0.7% in the intervention period), with an adjusted odds ratio (OR) of 0.3 [95% confidence interval (CI), 0.1-0.7]. There was a decrease in ICU admissions (18.6% in the control versus 13.0% in the intervention period) with an adjusted OR of 0.6 (95% CI, 0.5-0.9). There was no significant change in 30-day mortality (11.2% in the control versus 11.0% in the intervention period, P = 0.901). CONCLUSION: In our physician-staffed prehospital system, use of noninvasive ventilation for acute cardiogenic pulmonary edema decreased both endotracheal intubation and ICU admission rates.
    Tags: Aged, Aged, 80 and over, Emergency Medical Services/*methods/statistics & numerical data, Female, Humans, Intensive Care Units/statistics & numerical data, Intubation, Intratracheal/*statistics & numerical data, Male, Noninvasive Ventilation, Pulmonary Edema/*therapy, Retrospective Studies, Risk Factors.
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  • Bolliger, R., Neeser, O., Merker, M., Vukajlovic, T., Felder, L., Fiumefreddo, R., Haubitz, S., et al. “Validation Of A Prediction Rule For Legionella Pneumonia In Emergency Department Patients”. Open Forum Infect Dis 6, no. 7: ofz268. doi:10.1093/ofid/ofz268.
    Abstract: We validated a clinical prediction rule for Legionella based on clinical parameters (dry cough, fever) and laboratory findings (C-reactive protein, lactate dehydrogenase, sodium, platelet counts) in 713 consecutive patients with community-acquired pneumonia. The Legionella Score performed well in estimating the likelihood for Legionella infection and thus may help to direct diagnostic and therapeutic decisions.
    Tags: community-acquired pneumonia, Legionella, Legionella Score.
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  • Birnie, E., Virk, H. S., Savelkoel, J., Spijker, R., Bertherat, E., Dance, D. A. B., Limmathurotsakul, D., Devleesschauwer, B., Haagsma, J. A., and Wiersinga, W. J. “Global Burden Of Melioidosis In 2015: A Systematic Review And Data Synthesis”. Lancet Infect Dis 19, no. 8: 892-902. doi:10.1016/S1473-3099(19)30157-4.
    Abstract: BACKGROUND: Melioidosis is an infectious disease caused by the environmental bacterium Burkholderia pseudomallei. It is often fatal, with a high prevalence in tropical areas. Clinical presentation can vary from abscess formation to pneumonia and sepsis. We assessed the global burden of melioidosis, expressed in disability-adjusted life-years (DALYs), for 2015. METHODS: We did a systematic review of the peer-reviewed literature for human melioidosis cases between Jan 1, 1990, and Dec 31, 2015. Quantitative data for cases of melioidosis were extracted, including mortality, age, sex, infectious and post-infectious sequelae, antibiotic treatment, and symptom duration. These data were combined with established disability weights and expert panel discussions to construct an incidence-based disease model. The disease model was integrated with established global incidence and mortality estimates to calculate global melioidosis DALYs. The study is registered with PROSPERO, number CRD42018106372. FINDINGS: 2888 articles were screened, of which 475 eligible studies containing quantitative data were retained. Pneumonia, intra-abdominal abscess, and sepsis were the most common outcomes, with pneumonia occurring in 3633 (35.7%, 95% uncertainty interval [UI] 34.8-36.6) of 10 175 patients, intra-abdominal abscess in 1619 (18.3%, 17.5-19.1) of 8830 patients, and sepsis in 1526 (18.0%, 17.2-18.8) of 8469 patients. We estimate that in 2015, the global burden of melioidosis was 4.6 million DALYs (UI 3.2-6.6) or 84.3 per 100 000 people (57.5-120.0). Years of life lost accounted for 98.9% (UI 97.7-99.5) of the total DALYs, and years lived with disability accounted for 1.1% (0.5-2.3). INTERPRETATION: Melioidosis causes a larger disease burden than many other tropical diseases that are recognised as neglected, and so it should be reconsidered as a major neglected tropical disease. FUNDING: European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Research Grant 2018, AMC PhD Scholarship, The Netherlands Organisation for Scientific Research (NWO), H2020 Marie Sklodowska-Curie Innovative Training Network European Sepsis Academy.
    Tags: *Quality-Adjusted Life Years, Burkholderia pseudomallei/isolation & purification, Global Burden of Disease/*statistics & numerical data, Humans, Incidence, Melioidosis/*epidemiology/mortality, Neglected Diseases.
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  • Burkhard, J. P. M., Pitteloud, C., Klukowska-Rotzler, J., Exadaktylos, A. K., Iizuka, T., and Schaller, B. “Changing Trends In Epidemiology And Management Of Facial Trauma In A Swiss Geriatric Population”. Gerodontology 36, no. 4: 358-364. doi:10.1111/ger.12410.
    Abstract: OBJECTIVE: To assess the prevalence and surgical treatment of facial fractures in a Swiss population aged 65 and over. BACKGROUND: The knowledge of the characteristics of geriatric trauma may help to prevent injuries and better allocate clinical resources for the management of multimorbid patients. MATERIAL AND METHODS: This study retrospectively evaluated a cohort of 181 patients who presented at the Bern University Hospital in Switzerland from May 2012 to September 2016. Data on age, gender, aetiology and type of trauma, treatment and complications, co-morbidities and associated injuries were obtained. RESULTS: Women were most frequently affected (55.2%). Mean age was 80 years. Zygomatic complex fractures were the most frequent type of fractures (37%), followed by isolated orbital fractures (27.6%). Falls were the most common cause of trauma (76.1%). Thirty-five per cent of all patients were taking anticoagulation or platelet aggregation medication. Hospitalisation was required in 88.4%, whereby 92.3% of the patients underwent surgical treatment. Surgery had to be performed immediately in three cases to treat compression of the optic nerve. Median hospital length of stay was 4 days, with 68% of patients returning to a domestic environment and 32% being transferred to another institution for further treatment. CONCLUSION: The most common cause of facial injuries is a fall while standing in a domestic environment. Midface fractures were the most common type of fractures.
    Tags: *Facial Injuries, *Skull Fractures, *Zygomatic Fractures, Accidental Falls, Aged, Aged, 80 and over, epidemiology, facial trauma, Female, geriatric, Humans, Retrospective Studies, trauma.
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  • Meyer Sauteur, P. M., Stahli, N., Theiler, M., Hurlimann, R., and Berger, C. “Mycoplasma Pneumoniae-Induced Non-Sexually Acquired Genital Ulceration (Lipschutz Ulcers)”. Arch Dis Child 105, no. 5: 517-518. doi:10.1136/archdischild-2019-317676.
    Tags: *Mycoplasma Infections/diagnosis, *Mycoplasma pneumoniae, Child, Female, Humans, mucositis, pneumonia, respiratory, sexual abuse, sexually transmitted infection, Ulcer/diagnosis/*microbiology, Vulvar Diseases/diagnosis/*microbiology.
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  • Pasquier, M., Taffe, P., Hugli, O., Borens, O., Kirkham, K. R., and Albrecht, E. “Fascia Iliaca Block In The Emergency Department For Hip Fracture: A Randomized, Controlled, Double-Blind Trial”. Bmc Geriatr 19, no. 1: 180. doi:10.1186/s12877-019-1193-0.
    Abstract: BACKGROUND: Hip fracture causes moderate to severe pain and while fascia iliaca block has been reported to provide analgesic benefit, most previous trials were unblinded, with subsequent high risks of performance, selection and detection biases. In this randomized, control double-blind trial, we tested the hypothesis that a fascia iliaca block provides effective analgesia for patients suffering from hip fracture. METHODS: Thirty ASA I-III hip fracture patients over 70 years old, who received prehospital morphine, were randomized to receive either a fascia iliaca block using 30 ml of bupivacaine 0.5% with epinephrine 1:200,000 or a sham injection with normal saline. The fascia iliaca block was administered by emergency medicine physicians trained to perform an anatomic landmark-based technique. The primary outcome was the comparison between groups of the longitudinal pain score profiles at rest over the first 45 min following the procedure (numeric rating scale, 0-10). Secondary outcomes included the longitudinal pain score profiles on movement and the comparison over 4 h, 8 h, 12 h, and 24 h after the procedure, along with cumulative intravenous morphine consumption at 24 h. RESULTS: At baseline, the fascia iliaca group had a lower mean pain score than the sham injection group, both at rest (difference = - 0.9, 95%CI [- 2.4, 0.5]) and on movement (difference = - 0.9, 95%CI [- 2.7; 0.9]). These differences remained 45 min after the procedure and the two longitudinal pain score profiles were parallel both for patients at rest and on movement (test of parallelism for patients at rest p = 0.53 and on movement p = 0.45). The same parallel change in pain scores over time was observed over 24 h of follow-up (test of parallelism for patients at rest p = 0.82 and on movement p = 0.12). These results were confirmed after adjustment for gender, ASA score, and cumulative sums of intravenous morphine received pre-procedure and during-follow-up. In addition, there was no difference between the two groups in total cumulative intravenous morphine consumption at 24 h. CONCLUSION: Fascia iliaca block following anatomic landmarks may not provide supplementary analgesia for patients suffering from hip fracture, when low pain scores are reported after prehospital morphine. Additional larger trials will help reach definitive conclusion. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov - NCT02433548 . The study was registered retrospectively.
    Tags: *Emergency Service, Hospital, Aged, Aged, 80 and over, Analgesia, Analgesia/methods, and from B. Braun (Melsungen AG) to support his clinical research. EA has also, Autonomic Nerve Block/*methods, by the other authors., Double-Blind Method, Female, Hip fractures, Hip Fractures/*diagnosis/*drug therapy, Humans, Longitudinal Studies, Lumbosacral plexus, Male, no grant numbers attributed), Pain Management/*methods, Pain Measurement/drug effects/*methods, received an honorarium from B. Braun Medical (Melsungen AG). No interest declared, Research (SACAR), Lausanne, Switzerland (50,000 CHF, Retrospective Studies.
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  • Hasemann, W., Grossmann, F. F., Bingisser, R., Hafner, M., Breil, D., Kressig, R. W., and Nickel, C. H. “Optimizing The Month Of The Year Backwards Test For Delirium Screening Of Older Patients In The Emergency Department”. Am J Emerg Med 37, no. 9: 1754-1757. doi:10.1016/j.ajem.2019.06.035.
    Abstract: INTRODUCTION: Different scoring methods exist for the Month of the Year Backward Test (MBT), which is designed to detect inattention, the core feature of delirium. When used as a part of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED), each error in the MBT scores one point. Because this scoring procedure is complex, we aimed to simplify the scoring method of the MBT. METHODS: This is a secondary analysis of a single center prospective validation study of the mCAM-ED comprising a sample of Emergency Department (ED) patients aged 65 or older presenting to our ED. DATA COLLECTION: Research assistants (RAs) who were trained nurses conducted the MBT. Geriatricians conducted the reference standard delirium assessment within 1 h of the RA. RESULTS: For the scoring method "number of errors", optimal performance according the Youden index was achieved when 8 or more errors were reached resulting in an overall sensitivity of 0.95 and overall specificity of 0.94. The scoring method "number of errors in combination with time needed" resulted in a comparable result with minimally lower positive likelihood ratios. For the scoring method "last month in correct order", optimal performance according the Youden index was achieved with the month of September resulting in an overall sensitivity of 0.90 and an overall specificity of 0.89. DISCUSSION: We suggest omitting the factor time and using a more practical scoring method with good performance: "last month in correct order" with the requirement to reach September to rule out delirium.
    Tags: Aged, Aged, 80 and over, Delirium, Delirium/*diagnosis, Diagnostic testing, Emergency medicine, Emergency nursing, Emergency Service, Hospital, Female, Geriatric Assessment/*methods, Humans, Male, Mass Screening/*methods, Mental Status and Dementia Tests/standards, Neuropsychological tests, Psychometrics, Retrospective Studies, Symptom assessment.
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  • Quaegebeur, A., Brunard, L., Javaudin, F., Vibet, M. A., Bemer, P., Le Bastard, Q., Batard, E., Montassier, E., and Euro, U. T. I. Study Group. “Trends And Prediction Of Antimicrobial Susceptibility In Urinary Bacteria Isolated In European Emergency Departments: The Eurouti 2010-2016 Study”. J Antimicrob Chemother 74, no. 10: 3069-3076. doi:10.1093/jac/dkz274.
    Abstract: OBJECTIVES: To assess recent trends in susceptibility to antibiotics among urinary isolates isolated in European emergency departments (EDs) and to identify isolates with a high (90% or more) predicted probability of susceptibility to fluoroquinolones or third-generation cephalosporins (3GCs). METHODS: In this cross-sectional study, we included urine cultures obtained from adult patients between 2010 and 2016 in 24 European EDs. Temporal trends were assessed using time-series analysis and multivariate logistic models. Multivariate logistic models were also used to predict susceptibility to fluoroquinolones or 3GCs from patient age and sex, year, month and ED. RESULTS: We included 88242 isolates. Time-series analysis found a significant increase in susceptibility to fluoroquinolones and no significant trend for susceptibility to 3GCs. Adjusting for patient age and sex, ED and organism, multivariate models showed that susceptibility to 3GCs decreased from 2014 to 2016, while susceptibility to fluoroquinolones increased in 2015 and 2016. Among isolates from 2016, multivariate models predicted high probability of susceptibility to fluoroquinolones in 11% of isolates (positive predictive value 91%) and a high probability of susceptibility to 3GCs in 35% of isolates (positive predictive value 94%). CONCLUSIONS: Susceptibility of ED urinary isolates to fluoroquinolones increased from 2014, while susceptibility to 3GCs decreased from 2015. Predictive models identified isolates with a high probability of susceptibility to fluoroquinolones or 3GCs. The ability of such models to guide the empirical treatment of pyelonephritis in the ED remains to be determined.
    Tags: Aged, Aged, 80 and over, Anti-Bacterial Agents/*therapeutic use, Anti-Infective Agents/therapeutic use, Bacteria/*drug effects, Cephalosporins/therapeutic use, Cross-Sectional Studies, Drug Resistance, Bacterial/drug effects, Emergency Service, Hospital, Europe, Female, Fluoroquinolones/therapeutic use, Humans, Male, Microbial Sensitivity Tests/methods, Middle Aged, Retrospective Studies.
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  • Podsiadlo, P., Kosinski, S., Darocha, T., Hugli, O., and Pasquier, M. “Hypothermic Cardiac Arrest Patients' Selection Criteria For Extracorporeal Life Support Rewarming In Extreme Cases”. Ann Emerg Med 74, no. 1: 166-167. doi:10.1016/j.annemergmed.2019.02.006.
    Tags: *Extracorporeal Membrane Oxygenation, *Heart Arrest, *Hypothermia, Humans, Patient Selection, Rewarming.
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  • Klingenberg, R., Schlager, O., Limacher, A., Mean, M., Vuilleumier, N., Beer, J. H., Staub, D., et al. “Risk Stratification Of Elderly Patients With Acute Pulmonary Embolism”. Eur J Clin Invest 49, no. 9: e13154. doi:10.1111/eci.13154.
    Abstract: BACKGROUND: Combining high-sensitivity cardiac Troponin T (hs-cTnT), NT-pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hs-CRP) may improve risk stratification of patients with pulmonary embolism (PE) beyond the PESI risk score. METHODS: In the prospective multicentre SWITCO65+ study, we analysed 214 patients >/= 65 years with a new submassive PE. Biomarkers and clinical information for the PESI risk score were ascertained within 1 day after diagnosis. Associations of hs-TnT, NT-proBNP, hs-CRP and the PESI risk score with the primary endpoint defined as 6-month mortality were assessed. The discriminative power of the PESI risk score and its combination with hs-cTnT, NT-proBNP and hs-CRP for 6-month mortality was compared using integrated discrimination improvement (IDI) index and net reclassification improvement (NRI). RESULTS: Compared with the lowest quartile, patients in the highest quartile had a higher risk of death during the first 6 months for hs-cTnT (adjusted HR 10.22; 95% CI 1.79-58.34; P = 0.009) and a trend for NT-proBNP (adjusted HR 4.3; 95% CI 0.9-20.41; P = 0.067) unlike hs-CRP (adjusted HR 1.97; 95% CI 0.48-8.05; P = 0.344). The PESI risk score (c-statistic 0.77 (95% CI 0.69-0.84) had the highest prognostic accuracy for 6-month mortality, outperforming hs-cTnT, NT-proBNP and hs-CRP (c-statistics of 0.72, 0.72, and 0.54), respectively. Combining all three biomarkers had no clinically relevant impact on risk stratification when added to the PESI risk score (IDI = 0.067; 95% CI 0.012-0.123; P = 0.018; NRI = 0.101 95% CI -0.099-0.302; P = 0.321). CONCLUSIONS: In elderly patients with PE, 6-month mortality can adequately be predicted by the PESI risk score alone.
    Tags: *Mortality, Acute Disease, Aged, Aged, 80 and over, biomarkers, C-Reactive Protein/*metabolism, Cohort Studies, elderly, Female, Humans, Male, mortality, Natriuretic Peptide, Brain/*metabolism, Peptide Fragments/*metabolism, Predictive Value of Tests, Prognosis, Proportional Hazards Models, Prospective Studies, pulmonary embolism, Pulmonary Embolism/*metabolism, Risk Assessment, risk stratification, Troponin T/*metabolism.
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  • Pasquier, M., Rousson, V., Darocha, T., and Hugli, O. “Reply To: The Integration Of Prehospital Standard Operating Procedures And In-Hospital Hope Score For Management Of Hypothermic Patients In Cardiac Arrest”. Resuscitation 141: 214-215. doi:10.1016/j.resuscitation.2019.06.275.
    Tags: *Emergency Medical Services, *Extracorporeal Membrane Oxygenation, *Hypothermia, *Out-of-Hospital Cardiac Arrest, Humans.
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  • Lecuyer Giguere, F., Frasnelli, A., De Guise, E., and Frasnelli, J. “Olfactory, Cognitive And Affective Dysfunction Assessed 24 Hours And One Year After A Mild Traumatic Brain Injury (Mtbi)”. Brain Inj 33, no. 9: 1184-1193. doi:10.1080/02699052.2019.1631486.
    Abstract: Objective: This cross-sectional study aimed to evaluate olfaction 24 h (baseline) and 1 year (follow-up) after a mild traumatic brain injury (TBI). We further evaluated the influence of the cognition and affective state on olfactory function. Method: At baseline, olfactory function, neuropsychological, and affective states were assessed in 42 patients (20 mild TBI; 22 orthopedic injury). At follow-up, 12 patients with mild TBI and 7 controls could be included, and we assessed olfactory function, affective states, and post-concussion symptoms. Results: At baseline, patients with mild TBI demonstrated significantly reduced olfactory function, compared to controls, with more than 55% of the patients presenting signs of hyposmia. One year later, no significant differences in olfactory scores between cases and controls were observed. However, patients with mild TBI who had exhibited hyposmia at baseline exhibited significantly higher anxiety levels and more post-concussion symptoms than patients with mild TBI with normal olfactory function at baseline. Conclusions: In the acute phase of mild TBI a majority of patients has impaired olfactory function. Further patients with olfactory dysfunction are more likely to exhibit post-concussion and anxious symptoms at follow-up. Olfactory testing in the acute phase may therefore serve as a screening tool for long-term outcome.
    Tags: *Psychomotor Performance, Adolescent, Adult, Affect, Affective Symptoms/etiology/*psychology, anxiety, Anxiety/etiology/psychology, Brain Concussion/*psychology, cognition, Cognition Disorders/etiology/*psychology, cross-sectional, Cross-Sectional Studies, Executive Function, Female, Follow-Up Studies, Humans, Male, Middle Aged, Mild traumatic brain injury, Neuropsychological Tests, olfaction, Olfaction Disorders/etiology/*psychology, Post-Concussion Syndrome, Smell, Young Adult.
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  • Ribeiro, A. I., Fraga, S., Kelly-Irving, M., Delpierre, C., Stringhini, S., Kivimaki, M., Joost, S., et al. “Neighbourhood Socioeconomic Deprivation And Allostatic Load: A Multi-Cohort Study”. Sci Rep 9, no. 1: 8790. doi:10.1038/s41598-019-45432-4.
    Abstract: Living in deprived neighbourhoods may have biological consequences, but few studies have assessed this empirically. We examined the association between neighbourhood deprivation and allostatic load, a biological marker of wear and tear, taking into account individual's socioeconomic position. We analysed data from three cohort studies (CoLaus-Switzerland; EPIPorto-Portugal; Whitehall II-UK) comprising 16,364 participants. We defined allostatic load using ten biomarkers of dysregulated metabolic, cardiovascular, and inflammatory systems (body mass index; waist circumference; total, high and low density lipoprotein cholesterol; triglycerides; glucose; systolic and diastolic blood pressure; C-reactive protein). Mixed Poisson regression models were fitted to examine associations with neighbourhood deprivation (in quintiles, Q1-least deprived as reference). After adjustment for confounding variables, participants living in the most deprived quintile had 1.13 times higher allostatic load than those living in the least deprived quintile (Relative Risk, RR, for Q2 RR = 1.06, 95% CI 1.03-1.09; Q3 = 1.06, 1.03-1.10; Q4 = 1.09, 1.06-1.12; Q5 = 1.13, 1.09-1.16). This association was partially modified by individual's socioeconomic position, such that the relative risk was higher in participants with low socioeconomic position (Q5 vs Q1 1.16, 1.11-1.22) than those with high socioeconomic position (Q5 vs Q1 1.07, 1.01-1.13). Neighbourhood deprivation is associated with biological wear and tear, suggesting that neighbourhood-level interventions may yield health gains.
    Tags: *Allostasis, *Psychosocial Deprivation, *Residence Characteristics, *Socioeconomic Factors, Cohort Studies, Female, Humans, Male, Middle Aged, Portugal, Switzerland, United Kingdom.
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  • Mongelli, F., Fischer, H., Stickel, M., Patella, M., Heeren, N., Christ, M., and Gass, M. “Surgical Residents' Proficiency And Turnover May Affect The Overall Efficiency In An Emergency Department”. World J Surg 43, no. 10: 2365-2370. doi:10.1007/s00268-019-05062-3.
    Abstract: BACKGROUND: Within Emergency Department (ED), problem responsiveness and organizational capacity are extremely important for providing acute care. The "July effect" has been described as the period when junior doctors start new turnovers, possibly reflecting on hospital and ED efficiency. The objective of this study was to investigate the impact of residents' turnover on ED efficiency at a Swiss teaching hospital. METHODS: We retrospectively evaluated patients presenting with surgical needs to ED from June 2014 to January 2019. Data regarding gender, age, length of stay (LOS), resident doctors and level of urgency were collected and analyzed. RESULTS: We identified 27,767 surgical admissions treated by 92 residents. The LOS analysis within residents' period in the ED showed a progressive reduction over time, with 80% of proficiency achieved after 98 patients. The mean LOS was 257.3 and 237.6 min during and after the learning curve (p < 0.0001), although no difference was noted in triage level 1 patients (p = 0.813). By replacing 40-70% of residents (January and July), the LOS raised from 243.1 to 259.7 min (absolute difference 16.6 min, p < 0.001), but if only 10-20% of residents newly started, no difference was detected (p = 0.071). CONCLUSIONS: Our study demonstrates that surgical residents' turnover within the ED could affect the overall efficiency. The training period for new resident physicians was a caseload of 98 patients, respectively, 3 weeks of work. The impact of trainees' turnover was only relevant if more than 40% of the resident team is replaced at one time and only less urgent cases were affected.
    Tags: *Internship and Residency, *Personnel Turnover, Adult, Efficiency, Emergency Service, Hospital/*organization & administration, Female, General Surgery/*education, Humans, Length of Stay, Male, Retrospective Studies.
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  • Barras, P., Siclari, F., Hugli, O., Rossetti, A. O., Lamy, O., and Novy, J. “A Potential Role Of Hypophosphatemia For Diagnosing Convulsive Seizures: A Case-Control Study”. Epilepsia 60, no. 8: 1580-1585. doi:10.1111/epi.16090.
    Abstract: OBJECTIVE: Transient loss of consciousness (TLOC) is a common presentation in the emergency room, where patient history can usually differentiate syncope from generalized tonic-clonic (GTC) seizures. Several serum markers, such as creatine kinase and lactate, can be helpful, especially when history is unreliable. Here, we explore a potential supporting role of electrolyte plasma levels in a case-control study. METHODS: In our electroencephalographic database, we retrospectively identified consecutive episodes of loss of consciousness in adults seen over 3 years in our hospital emergency department for a case-control study. We investigated plasma levels of several electrolytes (sodium, potassium, phosphate, calcium, magnesium) at the emergency visit, as well as demographics, diagnosis, blood-sample delay time, and history of alcohol abuse. RESULTS: Of the 126 patients identified, 75 had GTC seizures and 46 had other TLOC causes. Among electrolyte levels, only hypophosphatemia was associated with GTC seizures (median = 0.79 mmol.L(-1) , range = 0.34-1.37 in GTC seizures vs 0.93 mmol.L(-1) , range = 0.52-1.56, P = 0.001 in TLOC). After adjusting for blood sampling delay, alcohol abuse, and other electrolyte levels, only hypophosphatemia was associated with GTC seizures, occurring in 37 (51%) of GTC seizures and 12 (22%) of other TLOC (odds ratio = 3.5, 95% confidence interval = 1.5-8.3, P = 0.003). Hypophosphatemia < 0.6 mmol.L(-1) was 93% specific and 20% sensitive for GTC seizure occurrence. In follow-ups, hypophosphatemia was transitory. SIGNIFICANCE: Transient hypophosphatemia is common after GTC seizures and could represent an additional biological marker to help differentiate GTC seizures from other TLOC, especially when history is unclear. This hypothesis needs to be tested prospectively.
    Tags: Adolescent, Adult, Aged, Aged, 80 and over, biomarker, Biomarkers/blood, Calcium/blood, Case-Control Studies, diagnosis, Female, Humans, Hypophosphatemia/*blood/complications/diagnosis, Magnesium/blood, Male, Middle Aged, Phosphates/blood, Potassium/blood, Retrospective Studies, Seizures/blood/complications/*diagnosis, sensitivity, Sodium/blood, specificity, syncope, Young Adult.
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  • Muller, M., Bosshard, F., Nagler, M., Roth, B., Exadaktylos, A. K., and Sauter, T. C. “Shorter Hospital Stay And Fewer Hospitalizations In Patients With Visible Hematuria On Direct Oral Anticoagulants Compared To On Vitamin K Antagonists”. Urology 132: 101-108. doi:10.1016/j.urology.2019.06.004.
    Abstract: OBJECTIVE: To investigate the influence of type of anticoagulation - direct oral anticoagulants (DOAC) vs vitamin K antagonists (VKA) - on length of hospital stay (LOS) and hospitalization rates in patients with visible hematuria, as visible hematuria in anticoagulated patients can be distressing, difficult to control and even life-threatening. METHODS: This retrospective cohort study was conducted at the emergency department (ED) of a tertiary university hospital in Switzerland. All patients admitted with visible hematuria from January 1, 2013 to December 31, 2016 were included. We compared the primary clinical outcome parameters (hospitalization rate and LOS) as well as secondary outcomes (ICU admission, ED LOS, and in-hospital mortality) in patients with visible hematuria on either DOAC therapy, VKA therapy or no anticoagulants. RESULTS: We included 811 (100%) patients with visible hematuria; 53 (6.5%) patients were on DOAC, compared to 85 (10.5%) on VKA and 673 (83.0%) patients without any anticoagulation. In confounder-adjusted multivariable testing, there were fewer hospitalizations (odds ratio: 2.2, 95% confidence interval [CI]: 1.1-4.9, P = .028) and shorter LOS (geometric mean ratio: 2.2, 95% CI: 1.3-4.0, P = .006) on DOAC than on VKA. The secondary outcomes were not significantly associated with the anticoagulation groups. No differences were found between the DOAC and no-anticoagulant groups for any outcome. CONCLUSION: Visible hematuria in patients on DOAC therapy is associated with shorter hospital stays and fewer hospitalizations compared to VKA.
    Tags: Administration, Oral, Adult, Aged, Aged, 80 and over, Anticoagulants/administration & dosage/*adverse effects, Cohort Studies, Female, Hematuria/*chemically induced/*therapy, Hospitalization/*statistics & numerical data, Humans, Length of Stay/statistics & numerical data, Male, Middle Aged, Retrospective Studies, Vitamin K/*antagonists & inhibitors.
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  • Brandenberger, J., Tylleskar, T., Sontag, K., Peterhans, B., and Ritz, N. “A Systematic Literature Review Of Reported Challenges In Health Care Delivery To Migrants And Refugees In High-Income Countries - The 3C Model”. Bmc Public Health 19, no. 1: 755. doi:10.1186/s12889-019-7049-x.
    Abstract: BACKGROUND: Migrants and refugees have important health needs and face inequalities in their health status. Health care delivery to this patient group has become a challenging public health focus in high income countries. This paper summarizes current knowledge on health care delivery to migrants and refugees in high-income countries from multiple perspectives. METHODS: We performed a systematic literature review including primary source qualitative and quantitative studies between 2000 and 2017. Articles were excluded if the study setting was in low- or middle-income countries or focused on skilled migration. Quality assessment was done for qualitative and quantitative studies separately. Predefined variables were extracted in a standardized form. Authors were approached to provide missing information. RESULTS: Of 185 identified articles, 35 were included in the final analysis. We identified three main topics of challenges in health care delivery: communication, continuity of care and confidence. All but one study included at least one of the three main topics and in 21/35 (60%) all three topics were mentioned. We further developed the 3C model and elaborated the interrelatedness of the three topics. Additional topics identified showed that the specific regional context with legal, financial, geographical and cultural aspects is important and further influences the 3C model. CONCLUSIONS: The 3C model gives a simple and comprehensive, patient-centered summary of key challenges in health care delivery for refugees and migrants. This concept is relevant to support clinicians in their day to day practice and in guiding stakeholders in priority setting for refugee and migrant health policies.
    Tags: *Developed Countries, *Refugees, *Transients and Migrants, Asylum, Communication, Confidence, Continuity of care, Delivery of Health Care/*organization & administration, Humans, Immigrant, Interpreter, Models, Organizational, perspectives of the institutions with which they are affiliated., Quality of care, Refugee, Translator, Trust, views summarized in this article and they do not necessarily represent.
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  • Lyngholm, L. E., Nickel, C. H., Kellett, J., Chang, S., Cooksley, T., and Brabrand, M. “A Negative D-Dimer Identifies Patients At Low Risk Of Death Within 30 Days: A Prospective Observational Emergency Department Cohort Study”. Qjm 112, no. 9: 675-680. doi:10.1093/qjmed/hcz140.
    Abstract: OBJECTIVE: To determine the ability of a normal D-dimer level (<0.5 mg/l) to identify emergency department (ED) patients at low risk of 30-day all-cause mortality. DESIGN: In this prospective observational study, D-dimer levels of adult medical patients were assessed at arrival to the ED. Data on 30-day survival status were extracted from the Danish Civil Registration System with complete follow-up. SETTING: The Hospital of South West Jutland. PATIENTS: All patients aged 18 years or older who required any blood sample on a clinical indication on arrival to the ED. Participants were required to give written informed consent before enrollment. MAIN RESULTS: The study population of 1 518 patients with median age 66 years of which 49.4% were female. Of the 791 (52.1%) patients with normal D-dimer levels, 3 (0.4%) died within 30 days; one death resulted from an unrelated traumatic accident. Of the 727 (47.9%) patients with abnormal D-dimer levels (>/=0.50 mg/l), 32 (4.4%) died within 30 days. Patients with normal D-dimer levels had a significantly lower 30-day mortality compared to patients with abnormal D-dimer levels (odds ratio 0.08, 95% CI 0.02-0.28): of the 35 patients who died within 30 days, 19 (54.3%) had normal or near normal vital signs when first assessed. CONCLUSION: Normal D-dimer levels identified patients at low risk of 30-day mortality. Since most patients who died within 30 days presented with normal or near normal vital signs, D-dimer levels appear to provide additional prognostic information.
    Tags: *Hospital Mortality, Adolescent, Adult, Aged, Aged, 80 and over, Cause of Death, Critical Illness/*mortality, Denmark, Emergency Service, Hospital/*statistics & numerical data, Female, Fibrin Fibrinogen Degradation Products/*analysis, Humans, Male, Middle Aged, Predictive Value of Tests, Prognosis, Prospective Studies, Risk Assessment, Time Factors, Young Adult.
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  • Becker, C., Lecheler, L., Hochstrasser, S., Metzger, K. A., Widmer, M., Thommen, E. B., Nienhaus, K., et al. “Association Of Communication Interventions To Discuss Code Status With Patient Decisions For Do-Not-Resuscitate Orders: A Systematic Review And Meta-Analysis”. Jama Netw Open 2, no. 6: e195033. doi:10.1001/jamanetworkopen.2019.5033.
    Abstract: IMPORTANCE: Whether specific communication interventions to discuss code status alter patient decisions regarding do-not-resuscitate code status and knowledge about cardiopulmonary resuscitation (CPR) remains unclear. OBJECTIVE: To conduct a systematic review and meta-analysis regarding the association of communication interventions with patient decisions and knowledge about CPR. DATA SOURCES: PubMed, Embase, PsycINFO, and CINAHL were systematically searched from the inception of each database to November 19, 2018. STUDY SELECTION: Randomized clinical trials focusing on interventions to facilitate code status discussions. Two independent reviewers performed the data extraction and assessed risk of bias using the Cochrane Risk of Bias Tool. Data were pooled using a fixed-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported. DATA EXTRACTION AND SYNTHESIS: The study was performed according to the PRISMA guidelines. MAIN OUTCOMES AND MEASURES: The primary outcome was patient preference for CPR, and the key secondary outcome was patient knowledge regarding life-sustaining treatment. RESULTS: Fifteen randomized clinical trials (2405 patients) were included in the qualitative synthesis, 11 trials (1463 patients) were included for the quantitative synthesis of the primary end point, and 5 trials (652 patients) were included for the secondary end point. Communication interventions were significantly associated with a lower preference for CPR (390 of 727 [53.6%] vs 284 of 736 [38.6%]; RR, 0.70; 95% CI, 0.63-0.78). In a preplanned subgroup analysis, studies using resuscitation videos as decision aids compared with other interventions showed a stronger decrease in preference for life-sustaining treatment (RR, 0.56; 95% CI, 0.48-0.64 vs 1.03; 95% CI, 0.87-1.22; between-group heterogeneity P < .001). Also, a significant association was found between communication interventions and better patient knowledge (standardized mean difference, 0.55; 95% CI, 0.39-0.71). CONCLUSIONS AND RELEVANCE: Communication interventions are associated with patient decisions regarding do-not-resuscitate code status and better patient knowledge and may thus improve code status discussions.
    Tags: *Communication, *Decision Making, *Patient Preference, Advance Directives, Cardiopulmonary Resuscitation/psychology, Health Knowledge, Attitudes, Practice, Humans, Resuscitation Orders/*psychology.
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  • Pasquier, M., Carron, P. N., Rodrigues, A., Dami, F., Frochaux, V., Sartori, C., Deslarzes, T., and Rousson, V. “An Evaluation Of The Swiss Staging Model For Hypothermia Using Hospital Cases And Case Reports From The Literature”. Scand J Trauma Resusc Emerg Med 27, no. 1: 60. doi:10.1186/s13049-019-0636-0.
    Abstract: BACKGROUND: The Swiss staging model for hypothermia uses clinical indicators to stage hypothermia and guide the management of hypothermic patients. The proposed temperature range for clinical stage 1 is < 35-32 degrees C, for stage 2 is < 32-28 degrees C, for stage 3 is < 28-24 degrees C, and for stage 4 is below 24 degrees C. Our previous study using 183 case reports from the literature showed that the measured temperature only corresponded to the clinical stage in the Swiss staging model in approximately 50% of cases. This study, however, included few patients with moderate hypothermia. We aimed to expand this database by adding cases of hypothermic patients admitted to hospital to perform a more comprehensive evaluation of the staging model. METHODS: We retrospectively included patients aged >/=18 y admitted to hospital between 1.1.1994 and 15.7.2016 with a core temperature below 35 degrees C. We added the cases identified through our previously published literature review to estimate the percentage of those patients who were correctly classified and compare the theoretical with the observed temperature ranges for each clinical stage. RESULTS: We included 305 cases (122 patients from the hospital sampling and the 183 previously published). Using the theoretically derived temperature ranges for clinical stages resulted in 185/305 (61%) patients being assigned to the correct temperature range. Temperature was overestimated using the clinical stage in 55/305 cases (18%) and underestimated in 65/305 cases (21%); important overlaps in temperature existed among the four stage groups. The optimal temperature thresholds for discriminating between the four stages (32.1 degrees C, 27.5 degrees C, and 24.1 degrees C) were close to those proposed historically (32 degrees C, 28 degrees C, and 24 degrees C). CONCLUSIONS: Our results provide further evidence of the relationship between the clinical state of patients and their temperature. The historical proposed temperature thresholds were almost optimal for discriminating between the different stages. Adding overlapping temperature ranges for each clinical stage might help clinicians to make appropriate decisions when using clinical signs to infer temperature. An update of the Swiss staging model for hypothermia including our methodology and findings could positively impact clinical care and future research.
    Tags: Adolescent, Adult, Aged, Blood Alcohol Content, Blood Pressure, Body Temperature/*physiology, Cardiac arrest, Core temperature, Emergency medicine, Emergency Service, Hospital, Female, Glasgow Coma Scale, Hospitalization, Humans, Hypothermia, Hypothermia, Induced/nursing/*standards, Male, Middle Aged, Retrospective Studies, Rewarming/methods, Swiss staging, Young Adult.
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  • Pasquier, M., Beysard, N., Feiner, A. S., Moix, P. A., and Carron, P. N. “An Unusual Cause Of Pseudo-Pulseless Electrical Activity”. Europace 21, no. 11: 1685. doi:10.1093/europace/euz158.
    Tags: *Electrocardiography, Aged, Cardiopulmonary Resuscitation/*methods, Fatal Outcome, Heart Arrest/*etiology/physiopathology/therapy, Heart Rate/*physiology, Humans, Male, Ventricular Fibrillation/*complications/physiopathology.
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  • Fiechter, S., Geissbuhler, E., Bahler, A., Obmann, V., Meierhans, S., Exadaktylos, A. K., Christe, A., Thalmann, G. N., and Roth, B. “Identification Of Ureteral Stones At Reduced Radiation Exposure: A Pilot Study Comparing Conventional Versus Digital Low-Dosage Linear Slot Scanning (Lodox((R))) Radiography”. World J Urol 38, no. 4: 1065-1071. doi:10.1007/s00345-019-02803-w.
    Abstract: PURPOSE: Digital low-dosage, linear slot scanning radiography (Lodox((R))) is an imaging modality that can emit down to one-tenth the radiation of conventional X-ray systems. We prospectively evaluated Lodox((R)) as a diagnostic imaging modality in patients with ureterolithiasis. METHODS: Conventional kidney-ureter-bladder (KUB) X-ray and Lodox((R)) were performed in 41 patients presenting with acute flank pain due to unilateral ureteral stone confirmed by computed tomography. KUB X-ray and Lodox((R)) images were then reviewed by four blinded readers (urology expert/resident, radiology expert/resident). Identification rates were compared using Pearson's Chi square test. The impact of different parameters on stone identification by Lodox((R)) was evaluated using logistic regression and generalized linear mixed models. Inter-reader agreement was tested using Cohen's kappa coefficient. RESULTS: Median stone size was 5 mm (range 2-12), median stone density was 800 HU (range 200-1500). The identification rates of the urology expert were 68% for KUB X-ray and 90% for Lodox((R)) (p = 0.014), and for all four readers 61% for KUB X-ray and 62% for Lodox((R)) (p = 0.8). Radiation exposure for KUB X-ray and Lodox((R)) was 0.45 mSv (SD +/- 0.64) and 0.027 mSv (SD +/- 0.038), respectively. Multivariable analyses showed an association between stone identification by Lodox((R)) and stone size (p < 0.001), stone density (p = 0.005), lower body mass index (p = 0.005), and reader (p < 0.001). CONCLUSIONS: The high identification rates and low radiation doses of Lodox((R)) make it a promising imaging modality for the diagnosis of ureteral stones. Further validation in larger cohorts, including performance evaluation for renal stones, is warranted. TRIAL REGISTRATION: http://www.controlled-trails.com/ISRCTN12915426.
    Tags: Adult, Aged, Aged, 80 and over, Female, Humans, Imaging, Lodox(R), Male, Middle Aged, Pilot Projects, Radiation Dosage, Radiation exposure, Radiation Exposure/*prevention & control, Radiography/methods, Ureteral Calculi/*diagnostic imaging, Urolithiasis.
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  • Henssler, J., Brandt, L., Muller, M., Liu, S., Montag, C., Sterzer, P., and Heinz, A. “Migration And Schizophrenia: Meta-Analysis And Explanatory Framework”. Eur Arch Psychiatry Clin Neurosci 270, no. 3: 325-335. doi:10.1007/s00406-019-01028-7.
    Abstract: Systematic reviews and meta-analyses suggest that there are increased rates of schizophrenia and related psychoses in first- and second-generation migrants and refugees. Here, we present a meta-analysis on the incidence of non-affective psychotic disorders among first- and second-generation migrants. We found substantial evidence for an increased relative risk of incidence among first- and second-generation migrants compared to the native population. As heterogeneity of included studies was high, effect estimates should be interpreted with caution and as guiding values rather than exact risk estimates. We interpret our findings in the context of social exclusion and isolation stress, and provide an explanatory framework that links cultural differences in verbal communication and experienced discrimination with the emergence of psychotic experiences and their neurobiological correlates. In this context, we discuss studies observing stress-dependent alterations of dopamine neurotransmission in studies among migrants versus non-migrants as well as in subjects with psychotic disorders. We suggest that social stress effects can impair contextualization of the meaning of verbal messages, which can be accounted for in Bayesian terms by a reduced precision of prior beliefs relative to sensory data, causing increased prediction errors and resulting in a shift towards the literal or "concrete" meaning of words. Compensatory alterations in higher-level beliefs, e.g., in the form of generalized interpretations of ambiguous interactions as hostile behavior, may contribute to psychotic experiences in migrants. We thus suggest that experienced discrimination and social exclusion is at the core of increased rates of psychotic experiences in subjects with a migration background.
    Tags: Bayesian inference, Dopamine, Emigrants and Immigrants/*statistics & numerical data, Humans, Meta-analysis, Migration, Psychosis, Psychotic Disorders/*epidemiology, Refugees/*statistics & numerical data, Schizophrenia/*epidemiology, Stress.
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  • Pasquier, M., Debaty, G., Carron, P. N., and Darocha, T. “Reply To: The Importance Of Pre-Hospital Interventions For Prevention And Management Of Witnessed Hypothermic Cardiac Arrest'”. Resuscitation 140: 219-220. doi:10.1016/j.resuscitation.2019.05.030.
    Tags: *Heart Arrest, *Hypothermia, Hospitals, Humans.
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  • Garcia-Nicolas, O., Lewandowska, M., Ricklin, M. E., and Summerfield, A. “Corrigendum: Monocyte-Derived Dendritic Cells As Model To Evaluate Species Tropism Of Mosquito-Borne Flaviviruses”. Front Cell Infect Microbiol 9, no. MAY: 163. doi:10.3389/fcimb.2019.00163.
    Abstract: [This corrects the article DOI: 10.3389/fcimb.2019.00005.].
    Tags: Flavivirus, in vitro model, infection, innate immune response, monocyte-derived dendritic cells, tropism.
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  • Muller, M., and Exadaktylos, A. K. “Injuries After Oldtimer Accidents: Eighteen Years Experience In The Emergency Department Of A Swiss University Hospital”. J Acute Med 9, no. 2: 73-76. doi:10.6705/j.jacme.201906_9(2).0006.
    Abstract: In recent decades, morbidity in road traffi c accidents has declined in Western Europe, mainly due to the enforcement of road safety policies and innovations in car engineering. In classic cars-so called "oldtimers" in Switzerland-these innovations in car engineering and often even seat belts are lacking, leading to a greater risk of morbidity after accidents. Thus, we reviewed our own series of victims of accidents with oldtimers who were admitted to our Level 1 Trauma Centre in Switzerland over the last 18 years. Within the 18-year study period and a total of 500,000 consultations, six documented oldtimer accidents were included in this case series. In three of the six oldtimer accidents and in all high-speed accidents, the car was overturned. In one case, the reason for this was unknown, in another a tire had suddenly burst and in a third this was triggered by evading an obstacle. Four reports contained information about a missing airbag and/or seat belt. Injuries included blunt abdominal injuries (laceration, mesenteric vessel injury), chest trauma (pneumothorax, rip fracture, scapula fracture), brain injury, and contusions. None of the patients died. In conclusion, oldtimer accidents are rare. However, pre-clinicians and clinicians treating patients after oldtimer car accidents should be aware of the specific risks-such as steering wheel injuries and consequences of trauma, i.e., extensive injuries to the head, chest and abdomen.
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  • Nestelberger, T., Cullen, L., Lindahl, B., Reichlin, T., Greenslade, J. H., Giannitsis, E., Christ, M., et al. “Diagnosis Of Acute Myocardial Infarction In The Presence Of Left Bundle Branch Block”. Heart 105, no. 20: 1559-1567. doi:10.1136/heartjnl-2018-314673.
    Abstract: OBJECTIVE: Patients with suspected acute myocardial infarction (AMI) in the setting of left bundle branch block (LBBB) present an important diagnostic and therapeutic challenge to the clinician. METHODS: We prospectively evaluated the incidence of AMI and diagnostic performance of specific ECG and high-sensitivity cardiac troponin (hs-cTn) criteria in patients presenting with chest discomfort to 26 emergency departments in three international, prospective, diagnostic studies. The final diagnosis of AMI was centrally adjudicated by two independent cardiologists according to the universal definition of myocardial infarction. RESULTS: Among 8830 patients, LBBB was present in 247 (2.8%). AMI was the final diagnosis in 30% of patients with LBBB, with similar incidence in those with known LBBB versus those with presumably new LBBB (29% vs 35%, p=0.42). ECG criteria had low sensitivity (1%-12%) but high specificity (95%-100%) for AMI. The diagnostic accuracy as quantified by the receiver operating characteristics (ROC) curve of hs-cTnT and hs-cTnI concentrations at presentation (area under the ROC curve (AUC) 0.91, 95% CI 0.85 to 0.96 and AUC 0.89, 95% CI 0.83 to 0.95), as well as that of their 0/1-hour and 0/2-hour changes, was very high. A diagnostic algorithm combining ECG criteria with hs-cTnT/I concentrations and their absolute changes at 1 hour or 2 hours derived in cohort 1 (45 of 45(100%) patients with AMI correctly identified) showed high efficacy and accuracy when externally validated in cohorts 2 and 3 (28 of 29 patients, 97%). CONCLUSION: Most patients presenting with suspected AMI and LBBB will be found to have diagnoses other than AMI. Combining ECG criteria with hs-cTnT/I testing at 0/1 hour or 0/2 hours allows early and accurate diagnosis of AMI in LBBB. TRIAL REGISTRATION NUMBER: APACE: NCT00470587; ADAPT: ACTRN12611001069943; TRAPID-AMI: RD001107;Results.
    Tags: *Algorithms, *Bundle-Branch Block/diagnosis/epidemiology, *Myocardial Infarction/blood/diagnosis/epidemiology/therapy, Abbott Diagnostics, grants from Siemens, grants from Radiometer, personal fees, Abbott, during the conduct of the study, and grants from Roche, grants and, acute coronary syndromes, acute myocardial infarction, Area Under Curve, Beckman Coulter, bioMerieux, BRAHMS, Critical Diagnostics, Nanosphere, Roche,, Biomarkers/analysis, BMS, Boehringer Ingelheim, BRAHMS, Cardiorentis, Daiichi Sankyo, Novartis, Roche,, BRAHMS and Roche. EG has received honoraria for lectures from Roche Diagnostics,, BRAHMS, Thermo Fisher and Mitsubishi Chemical Europe. MC has received research, Canterbury District Health. All other authors declare that they have no conflict, Cardiovascular Research Foundation Basel, 8sense, Abbott, Alere, AstraZeneca,, Clinical Decision Rules, consulting honoraria from Abbott, Alere, AstraZeneca, BG Medicine, bioMerieux,, Diagnostic Errors/*prevention & control, Diagnostics, Radiometer Medical, bioMerieux Clinical Diagnostics, Philips, during the conduct of the study, grants from Roche, grants and personal fees from, ECG/electrocardiogram, Electrocardiography/*methods, Emergency Service, Hospital/statistics & numerical data, employee of Roche Diagnostics. JWP is supported by a Senior Research Fellowship, Female, from AstraZeneca, and grants from Alere, outside the submitted work. BL has, from the Canterbury Medical Research Foundation, Emergency Care Foundation and, has received speaking honoraria from Abbott and a research grant from the Swiss, Healthcare and Fiomi Diagnostics. TR has received research grants from the Swiss, Heart Foundation. JB has received speaking honoria from Siemens. GB is an, Humans, Internal Medicine, University Hospital Basel, as well as speaker's honoraria from, Male, Middle Aged, National Science Foundation (PASMP3-136995), the Swiss Heart Foundation, the, of interest with this study., personal fees from Abbott Diagnostics, grants from Siemens, grants from, personal fees from Hospira and grants from Alere, outside the submitted work. MRG, Prospective Studies, Radiometer, personal fees from AstraZeneca, non-financial support from Bayer,, Sanofi, Singulex and Siemens. LC reports grants from Roche and from Abbott,, Science Foundation and the Swiss Heart Foundation, the European Union, the, served as a consultant for Roche Diagnostics, Beckman Coulter, Siemens Healthcare, Siemens, Singulex and the University Hospital Basel, as well as speaker or, speaker honoraria from BRAHMS and Roche. WP reports grants from Roche and from, support and speaking honoraria from Roche, Thermo Fisher and Novartis. RT reports, Time-to-Treatment, Troponin I/*analysis, University of Basel, the Professor Max Cloetta Foundation, and the Department of.
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  • Neeser, O. L., Vukajlovic, T., Felder, L., Haubitz, S., Hammerer-Lercher, A., Ottiger, C., Mueller, B., Schuetz, P., and Fux, C. A. “A High C-Reactive Protein/Procalcitonin Ratio Predicts Mycoplasma Pneumoniae Infection”. Clin Chem Lab Med 57, no. 10: 1638-1646. doi:10.1515/cclm-2019-0194.
    Abstract: Background Discriminating Mycoplasma pneumoniae (MP) from Streptococcus pneumoniae (SP) and viral etiologies of community-acquired pneumonia (CAP) is challenging but has important implications regarding empiric antibiotic therapy. We investigated patient parameters upon hospital admission to predict MP infection. Methods All patients hospitalized in a tertiary care hospital between 2013 and 2017 for CAP with a confirmed etiology were analyzed using logistic regression analyses and area under the receiver operator characteristics (ROC) curves (AUC) for associations between demographic, clinical and laboratory features and the causative pathogen. Results We analyzed 568 patients with CAP, including 47 (8%) with MP; 152 (27%) with SP and 369 (65%) with influenza or other viruses. Comparing MP and SP by multivariate logistic regression analysis, younger age (odds ration [OR] 0.56 per 10 years, 95% CI 0.42-0.73), a lower neutrophil/lymphocyte ratio (OR 0.9, 0.82-0.99) and an elevated C-reactive protein/procalcitonin (CRP/PCT) ratio (OR 15.04 [5.23-43.26] for a 400 mg/mug cut-off) independently predicted MP. With a ROC curve AUC of 0.91 (0.80 for the >400 mg/mug cutoff), the CRP/PCT ratio was the strongest predictor of MP vs. SP. The discriminatory value resulted from significantly lower PCT values (p < 0.001) for MP, while CRP was high in both groups (p = 0.057). Comparing MP and viral infections showed similar results with again the CRP/PCT ratio providing the best information (AUC 0.83; OR 5.55 for the >400 mg/mug cutoff, 2.26-13.64). Conclusions In patients hospitalized with CAP, a high admission CRP/PCT ratio predicts M. pneumoniae infection and may improve empiric management.
    Tags: Adult, Aged, biomarker, Biomarkers, C-Reactive Protein/*analysis, Calcitonin Gene-Related Peptide/analysis, Calcitonin/analysis, community acquired pneumonia, Community-Acquired Infections, Female, Hospitalization, Humans, Lymphocytes, M. pneumoniae, Male, Middle Aged, Mycoplasma pneumoniae/metabolism/pathogenicity, Neutrophils, Pneumonia, Mycoplasma/blood/*diagnosis/metabolism, procalcitonin, Procalcitonin/*analysis/blood, Prognosis, Protein Precursors, respiratory infections, ROC Curve, Streptococcus pneumoniae/pathogenicity.
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  • Junod Perron, N., Le Breton, J., Perrier-Gros-Claude, O., Schussele Filliettaz, S., Hudelson, P., and Pautex, S. “Written Interprofessional Communication In The Context Of Home Healthcare: A Qualitative Exploration Of Swiss Perceptions And Practices”. Home Health Care Serv Q 38, no. 3: 224-240. doi:10.1080/01621424.2019.1616025.
    Abstract: The aim of this study was to explore the practices and perceptions of Swiss home care professionals with regards to written interprofessional communication. We analyzed 11 home care notebooks and conducted six focus groups with home health-care professionals in 2015-2016. Interprofessional written communication was rarely explicit. Health professionals reported a lack of clarity about what to document and for whom. They felt unsure how to reconcile the need for confidential information-sharing among health professionals and the desire for patient/families' active involvement. An ideal (electronic) tool should allow patients to formulate goals and use the platform while allowing health professionals to communicate confidentially among themselves in order to avoid information retention.
    Tags: *Communication, *Cooperative Behavior, *Interprofessional Relations, *Narration, Adult, Aged, Aged, 80 and over, elderly patients, Female, Focus Groups, Health Personnel/*psychology/*statistics & numerical data, home care, Humans, Interprofessional collaboration, Male, Middle Aged, older patients, Patient Care Team/*statistics & numerical data, Qualitative Research, Switzerland, written communication.
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  • Saporito, A., Aguirre, J., Borgeat, A., Perren, A., Anselmi, L., Poggi, R., Minotti, B., Cafarotti, S., La Regina, D., and Ceruti, S. “Persistent Postdischarge Pain And Chronic Postoperative Pain After Breast Cancer Surgery Under General Anesthesia And Single-Shot Paravertebral Block: Incidence, Characteristics And Impact On Quality Of Life And Healthcare Costs”. J Pain Res 12: 1193-1199. doi:10.2147/JPR.S195702.
    Abstract: Introduction: Breast surgery is associated with persistent postsurgical pain; usually related to poorly treated acute pain. Paravertebral block has been successfully employed in analgesic protocols for breast surgery; its impact on postdischarge pain (PDP) has not been investigated. The aim of this study was to assess characteristics of PDP after breast surgery, the development of chronic postoperative pain (CPP) and its impact on health care costs. Methods: We conducted a retrospective, observational study on a continuous cohort of adult female patients undergoing local breast cancer surgery under combined anesthesia. All patients were interviewed 6 months after hospital discharge. The survey was specifically conceived to assess incidence, features and duration of PDP. The overall cost of additional healthcare resources consumed with a specific relationship to persistent PDP was estimated. Results: A database of 244 patients was preliminarily analyzed. Of these, 188 were included in the following statistical analysis; 123 patients (65.2%) reported significant PDP, with a median intensity on NRS of 6 (IQR=2), more frequently described as burning and associated with paresthesia and/or hyperalgesia (87 patients, 46%). One hundred and six patients (56.5%) reported this pain as interfering with their normal daily activities, work and sleep. In 26.8% of cases (50 patients) symptoms lasted more than 1 month and in 28 patients (15.0%) pain became chronic. The majority of patients self-treated their pain with non-steroideal anti-inflammatory drugs, but in 50 patients (26.8%) this therapy was reported as ineffective. This additional consumption of healthcare resources led to a significant economical impact. Conclusion: PDP and CPP seem to be common complications after breast cancer surgery, even if a combined anesthesia technique with a thoracic paravertebral block is performed, leading to severe consequences on patients' quality of life and increasing consumption of healthcare resources after discharge. Trial number: NCT03618459 (www.clinicaltrials.gov).
    Tags: breast surgery, paravertebral block, postoperative pain, regional anesthesia.
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  • Polonsky, J. A., Baidjoe, A., Kamvar, Z. N., Cori, A., Durski, K., Edmunds, W. J., Eggo, R. M., et al. “Outbreak Analytics: A Developing Data Science For Informing The Response To Emerging Pathogens”. Philos Trans R Soc Lond B Biol Sci 374, no. 1776: 20180276. doi:10.1098/rstb.2018.0276.
    Abstract: Despite continued efforts to improve health systems worldwide, emerging pathogen epidemics remain a major public health concern. Effective response to such outbreaks relies on timely intervention, ideally informed by all available sources of data. The collection, visualization and analysis of outbreak data are becoming increasingly complex, owing to the diversity in types of data, questions and available methods to address them. Recent advances have led to the rise of outbreak analytics, an emerging data science focused on the technological and methodological aspects of the outbreak data pipeline, from collection to analysis, modelling and reporting to inform outbreak response. In this article, we assess the current state of the field. After laying out the context of outbreak response, we critically review the most common analytics components, their inter-dependencies, data requirements and the type of information they can provide to inform operations in real time. We discuss some challenges and opportunities and conclude on the potential role of outbreak analytics for improving our understanding of, and response to outbreaks of emerging pathogens. This article is part of the theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: epidemic forecasting and control'. This theme issue is linked with the earlier issue 'Modelling infectious disease outbreaks in humans, animals and plants: approaches and important themes'.
    Tags: *Data Science, *Models, Biological, Communicable Diseases, Emerging/*prevention & control, Disease Outbreaks/*prevention & control, epidemics, Humans, infectious, methods, pipeline, software, tools.
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  • Morgan, O. “How Decision Makers Can Use Quantitative Approaches To Guide Outbreak Responses”. Philos Trans R Soc Lond B Biol Sci 374, no. 1776: 20180365. doi:10.1098/rstb.2018.0365.
    Abstract: Decision makers are responsible for directing staffing, logistics, selecting public health interventions, communicating to professionals and the public, planning future response needs, and establishing strategic and tactical priorities along with their funding requirements. Decision makers need to rapidly synthesize data from different experts across multiple disciplines, bridge data gaps and translate epidemiological analysis into an operational set of decisions for disease control. Analytic approaches can be defined for specific response phases: investigation, scale-up and control. These approaches include: improved applications of quantitative methods to generate insightful epidemiological descriptions of outbreaks; robust investigations of causal agents and risk factors; tools to assess response needs; identifying and monitoring optimal interventions or combinations of interventions; and forecasting for response planning. Data science and quantitative approaches can improve decision-making in outbreak response. To realize these benefits, we need to develop a structured approach that will improve the quality and timeliness of data collected during outbreaks, establish analytic teams within the response structure and define a research agenda for data analytics in outbreak response. This article is part of the theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: epidemic forecasting and control'. This theme issue is linked with the earlier issue 'Modelling infectious disease outbreaks in humans, animals and plants: approaches and important themes'.
    Tags: *Decision Making, *Models, Biological, Data Science, decision-making, Disease Outbreaks/*prevention & control, Humans, infectious diseases, modelling, outbreaks, Public Health/*methods.
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  • Meyer Sauteur, P. M., Burkhard, A., Moehrlen, U., Relly, C., Kellenberger, C., Ruoss, K., and Berger, C. “Pleural Tap-Guided Antimicrobial Treatment For Pneumonia With Parapneumonic Effusion Or Pleural Empyema In Children: A Single-Center Cohort Study”. J Clin Med 8, no. 5. doi:10.3390/jcm8050698.
    Abstract: Parapneumonic effusion or pleural empyema (PPE/PE) is a frequent complication of community-acquired pneumonia (CAP) in children. Different management approaches exist for this condition. We evaluated a 14-day treatment with amoxicillin (AMX) with/without clavulanic acid (AMC) confirmed or modified by microbiological findings from pleural tap. Children </=16 years of age with radiologically diagnosed PPE/PE and initial diagnostic pleural tap were included at University Children's Hospital Zurich from 2001-2015. AMX/AMC was given for 14 days and rationalized according to microbiological pleural tap results. Clinical and radiological follow-up was scheduled until six months or full recovery. In 114 of 147 (78%) children with PPE/PE a pathogen was identified by culture, polymerase chain reaction (PCR), and/or antigen testing. Streptococcus pneumoniae was detected in 90 (79%), S. pyogenes in 13 (11%), and Staphylococcus aureus in seven cases (6%), all but two cultured pathogens (96%) were sensitive to AMX/AMC. One-hundred two of 147 (69%) patients received treatment with AMX/AMC for 14 days. They recovered more rapidly than patients with a different management (p = 0.026). Of 139 children with follow-up, 134 (96%) patients fully recovered. In conclusion, 14-day AMX/AMC treatment confirmed and rarely modified by microbiological findings from pleural tap resulted in full recovery in >95% of children with PPE/PE.
    Tags: antibiotics, chest tube, community-acquired pneumonia, drainage, fibrinolysis, parapneumonic effusion, pleural draining catheter, pleural tap, Streptococcus pneumoniae, thoracocentesis, thoracotomy, video-assisted thoracic surgery.
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  • Brown, A. D., Muller, M., Hirschi, T., Henssler, J. F., Ronz, K., Exadaktylos, A. K., and Srivastava, D. “Acute And Mixed Alcohol Intoxications In Asylum Seekers Presenting To An Urban Emergency Department In Switzerland”. Bmc Public Health 19, no. 1: 536. doi:10.1186/s12889-019-6910-2.
    Abstract: BACKGROUND: Previous studies have reported an increase in alcohol-and-mixed intoxication (AAMI)-related emergency department (ED) admissions, but less is known about the incidence and characteristics of AAMI admissions to EDs among asylum-seeking patients. Asylum seeking patients may be at higher risk for AAMI due stressors associated with forced migration. The aim of this study was to determine the proportional incidence, population characteristics, and predictors of ED admissions due to AAMI among patients with a residency status of asylum seeker as compared to those with a residency status of Swiss-national. METHODS: This retrospective analysis included all medical consultations from a large, adult ED in Switzerland between January 1, 2013 to December 31, 2016. The residency status of consultations was established if possible, and AAMI was determined utilizing a two-step screening procedure, blinded for residency status. A multivariable logistic regression was performed to determine the odds of AAMI in asylum-seeking patient consultations compared to consultations for Swiss-national patients. In addition, patient characteristics among asylum seekers admitted for AAMI were compared to patients with Swiss-national residency status for AAMI. RESULTS: In total, 117,716 eligible consultations (Swiss-national patient consultations: n = 115,226 and asylum-seeker consultations: n = 2490) were included in this study. The proportional incidence of AAMI among asylum seekers was 3.7% (n = 92) compared to 1.6% (n = 1841) among the Swiss-national patients. AAMI in asylum seekers was associated with higher levels of trauma (37.0% vs. 23.5%, p = 0.003), and hospital admission (35.4% vs. 14.1%, p < 0.001), but a smaller proportion of chronic alcohol consumption (13.0% vs. 43.5%, p < 0.001), and psychiatric referrals (26.1% vs. 49.0%, p < 0.001). Multivariable analysis controlling for age, sex, triage category, weekend admission, year of admission, and multiple visits showed a 1.6 times higher odds (95% CI: 1.3, 2.0; p < 0.001) for an AAMI-related ED consultation in asylum seeking patients. CONCLUSIONS: These findings show that individuals seeking asylum in a high-income country may be at greater risk for AAMI-related admission than the local population. Given the observed association between AAMI-related ED admissions and trauma, suicidality, and psychiatric referrals among this subpopulation, the data also suggests that co-morbid mental health disorders associated with forced displacement may contribute to hazardous alcohol use.
    Tags: Acute Disease/epidemiology, Adult, Alcohol disorders, Alcoholic Intoxication/*epidemiology/therapy, Applicable. COMPETING INTERESTS: The authors declare that they have no competing, Asylum-seeking, Early intervention, Emergency department, Emergency Service, Hospital/*statistics & numerical data, Emigrants and Immigrants/*statistics & numerical data, Ethikkommission Bern, Ref. No. KEK-BE: 010/2016). The Ethics Committee approved, Female, Hazardous drinking, Humans, interests. PUBLISHER'S NOTE: Springer Nature remains neutral with regard to, jurisdictional claims in published maps and institutional affiliations., Logistic Models, Male, Middle Aged, Mixed intoxication, Public health, Refugees, Refugees/psychology/*statistics & numerical data, Retrospective Studies, Swiss law. The Ethics Committee, within the Canton of Bern (Kantonale, Switzerland/epidemiology, the waiver of consent to analyse these records. CONSENT FOR PUBLICATION: Not, Young Adult.
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  • Hautz, W. E., Kammer, J. E., Hautz, S. C., Sauter, T. C., Zwaan, L., Exadaktylos, A. K., Birrenbach, T., Maier, V., Muller, M., and Schauber, S. K. “Diagnostic Error Increases Mortality And Length Of Hospital Stay In Patients Presenting Through The Emergency Room”. Scand J Trauma Resusc Emerg Med 27, no. 1: 54. doi:10.1186/s13049-019-0629-z.
    Abstract: BACKGROUND: Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies' consequences, and factors predicting them. METHODS: Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients' hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. RESULTS: 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen's d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician's assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33-6.96; P = 0.009). CONCLUSIONS: Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context. TRIAL REGISTRATION: https://bmjopen.bmj.com/content/6/5/e011585.
    Tags: Aged, Diagnostic Errors/*mortality, Emergency Service, Hospital/*statistics & numerical data, Female, Follow-Up Studies, Hospital Mortality/trends, Humans, Length of Stay/*trends, Male, Middle Aged, Patient Discharge/trends, Prospective Studies, Switzerland/epidemiology.
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  • Pfortmueller, C. A., Faeh, L., Muller, M., Eberle, B., Jenni, H., Zante, B., Prazak, J., Englberger, L., Takala, J., and Jakob, S. M. “Fluid Management In Patients Undergoing Cardiac Surgery: Effects Of An Acetate- Versus Lactate-Buffered Balanced Infusion Solution On Hemodynamic Stability (Hemacetat)”. Crit Care 23, no. 1: 159. doi:10.1186/s13054-019-2423-8.
    Abstract: BACKGROUND: Recent evidence suggests that acetate-buffered infusions result in better hemodynamic stabilization than 0.9% saline in patients undergoing major surgery. The choice of buffer in balanced crystalloid solutions may modify their hemodynamic effects. We therefore compared the inopressor requirements of Ringer's acetate and lactate for perioperative fluid management in patients undergoing cardiac surgery. METHODS: Using a randomized controlled double-blind design, we compared Ringer's acetate (RA) to Ringer's lactate (RL) with respect to the average rate of inopressor administered until postoperative hemodynamic stabilization was achieved. Secondary outcomes were the cumulative dose of inopressors, the duration of inopressor administration, the total fluid volume administered, and the changes in acid-base homeostasis. Patients undergoing elective valvular cardiac surgery were included. Patients with severe cardiac, renal, or liver disease were excluded from the study. RESULTS: Seventy-five patients were randomly allocated to the RA arm, 73 to the RL. The hemodynamic profiles were comparable between the groups. The groups did not differ with respect to the average rate of inopressors (RA 2.1 mcg/kg/h, IQR 0.5-8.1 vs. RL 1.7 mcg/kg/h, IQR 0.7-8.2, p = 0.989). Cumulative doses of inopressors and time on individual and combined inopressors did not differ between the groups. No differences were found in acid-base parameters and their evolution over time. CONCLUSION: In this study, hemodynamic profiles of patients receiving Ringer's lactate and Ringer's acetate were comparable, and the evolution of acid-base parameters was similar. These study findings should be evaluated in larger, multi-center studies. TRIAL REGISTRATION: Clinicaltrials.gov NCT02895659 . Registered 16 September 2016.
    Tags: Aged, Blood Gas Analysis, Buffers, Cardiac surgical procedures, Cardiac Surgical Procedures/methods/standards, committee of the Canton of Berne. CONSENT FOR PUBLICATION: All authors give their, consent for publication. COMPETING INTERESTS: The authors declare that they have, Crystalloid solutions, Double-Blind Method, Female, Fluid therapy, Fluid Therapy/methods/*standards, Hemodynamics, Hemodynamics/*drug effects, Humans, Isotonic Solutions/adverse effects/*pharmacology/therapeutic use, Linear Models, Male, Middle Aged, Monitoring, Physiologic/methods/statistics & numerical data, no competing interests. PUBLISHER'S NOTE: Springer Nature remains neutral with, Perioperative period, Randomized controlled trial, regard to jurisdictional claims in published maps and institutional affiliations., Ringer's Lactate/adverse effects/*pharmacology/therapeutic use, Time Factors, Vasoconstrictor agents.
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  • Hillinger, P., Strebel, I., Abacherli, R., Twerenbold, R., Wildi, K., Bernhard, D., Nestelberger, T., et al. “Prospective Validation Of Current Quantitative Electrocardiographic Criteria For St-Elevation Myocardial Infarction”. Int J Cardiol 292: 1-12. doi:10.1016/j.ijcard.2019.04.041.
    Abstract: BACKGROUND: Rapid and reliable diagnosis of ST-elevation myocardial infarction (STEMI) as a surrogate for acute coronary occlusion is critical for early reperfusion therapy. OBJECTIVES: We aimed to examine the diagnostic performance of current guideline-recommended Electrocardiogram (ECG) STEMI criteria. METHODS: In a prospective diagnostic multicenter study, we objectively quantified the extent of ST-segment elevation in all ECG leads using an automated software-based analysis of the digital 12-lead-ECG in adult patients presenting to the emergency department (ED) with suspected myocardial infarction (MI). Classification according to current guideline-recommended ECG criteria for STEMI at ED presentation was compared against a final diagnosis adjudicated by two independent cardiologists after reviewing all available medical records including serial ECGs, cardiac imaging and coronary angiograms. RESULTS: Among 2486 patients, 52 (2%) were found to have significant ST-segment elevation on ECG at ED presentation according to current guideline-recommended ECG criteria for STEMI. Eighty-one (3%) patients received a final adjudicated diagnosis of STEMI. Only 35% (28 of 81) of all patients with a final diagnosis of STEMI were correctly identified (PPV 54% (95% CI 41-66%), sensitivity 35% (95% Cl 24-46%), NPV 97.8% (95% CI 97.5-98.1%). Four reasons for missing STEMIs emerged: timing (significant STE at an earlier/later time point) in 25%, incorrect measurement points in 30%, non or borderline-significant STE in 36% and inferoposterior MI localisation in 9%. CONCLUSIONS: A computerized analysis of current guideline-recommended ECG criteria for STEMI showed suboptimal diagnostic performance when applied to a single 12‑lead ECG performed at ED presentation. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00470587.
    Tags: *Electrocardiography, Aged, Aged, 80 and over, Diagnostic accuracy, ECG criteria, Female, Humans, Male, Middle Aged, Prospective Studies, Software-based measurement, ST Elevation Myocardial Infarction/*diagnosis, Stemi.
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  • Huber, J. L., Berger, S., and Lollgen, R. M. “Balanced Electrolyte Solutions Or Normal Saline? Resuscitative Fluid Administration Practice In Swiss Pediatric Acute Care: A Cross-Sectional Study”. Pediatr Emerg Care 37, no. 12: e812-e816. doi:10.1097/PEC.0000000000001813.
    Abstract: INTRODUCTION: The ideal asanguineous intravenous fluid for volume resuscitation in children is controversially debated and clinical practice guidelines are scarce. Administration of large amounts of normal saline has been associated with complications including hyperchloremic acidosis, dysnatremia, neurologic damage, and fatality. AIM: We examined the current practice of intravenous fluid and blood product administration in acutely ill and injured children among pediatric acute care physicians in Switzerland. METHODS: For this descriptive, cross-sectional study, pediatric emergency departments, pediatric and neonatal intensive care units were surveyed by means of an online questionnaire. RESULTS: Sixty of 66 departments and 47 of 87 participants returned the survey. Normal saline (NS) was most commonly administered (n = 42/46, 91.3%) and twice as many times as balanced electrolyte solutions (n = 20/46, 43.5%). The mean fluid volumes ranged from 7.9 to 19.1 mL/kg. Hypertonic saline/NS were selected most often for shock with severe head injury. Half of participants administered colloids (48.9%). Packed red blood cells (97.7%) and fresh frozen plasma (88.4%) were most frequently given blood products. CONCLUSION: There is a distinct practice variation in intravenous fluid and blood product administration in children in Switzerland. Although NS is most frequently given, we observed a trend toward the use of balanced electrolyte solutions. Prospective studies are warranted to compare NS with balanced electrolyte solution (BES) in the pediatric acute care setting. We suggest that pediatric fluid administration guidelines and mass transfusion protocols are implemented to standardize this frequent intervention and minimize complications.
    Tags: *Fluid Therapy, *Saline Solution, Child, Cross-Sectional Studies, Electrolytes, Humans, Isotonic Solutions, Switzerland.
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  • Backer, H. C., Wu, C. H., Vosseller, J. T., Exadaktylos, A. K., Benneker, L., Krause, F., Hoppe, S., and Albers, C. E. “Spinopelvic Dissociation In Patients Suffering Injuries From Airborne Sports”. Eur Spine J 29, no. 10: 2513-2520. doi:10.1007/s00586-019-05983-6.
    Abstract: BACKGROUND: Spinopelvic dissociation which is also called U-type or referred to H-type sacral fractures with a transverse fracture line is an infrequent injury that results mainly from high-energy accidents. This results in an osseous dissociation of the upper central segment of the sacrum and the entire spine from the lower sacral segments. The purpose was to investigate the incidence of spinopelvic fracture in general among airborne injuries. PATIENTS AND METHODS: Using our electronic patient records, we retrospectively investigated all sacral fractures related to airborne sports between 2010 and 2017. All injuries were classified according to the Roy-Camille, Denis, AOSpine and the Tile classification system. RESULTS: During the period of interest, 44 patients (18.7%) were admitted with sacral fractures after accidents obtained from airborne sports, including 16 spinopelvic dissociations (36.4%). The majority of these injuries were obtained from paragliding (75.0%), followed by BASE jumping (21.4%) and parachuting (4%). The mean injury severity score (ISS) in the spinopelvic dissociation group was significantly higher compared with other sacral fracture group (38.1 vs. 20.0; p < 0.001). Six lambda-type, four T-type, four H-type and two U-type injuries were identified. In total, four patients (25%) were found to have neurological impairment. For treatment, 87.5% of patients underwent subsequent surgical stabilization. CONCLUSION: Airborne sports have high potential for serious, life-threatening injuries with a high incidence of spinopelvic dissociation. In the literature, the prevalence of spinopelvic dissociation in sacral fractures is described to be between 3 and 5%. In our series, the prevalence is 36.4%. It is important to identify the potential injuries promptly for the further treatment. These slides can be retrieved under Electronic Supplementary Material.
    Tags: *Fractures, Bone, *Spinal Fractures/diagnostic imaging/epidemiology, Fracture Fixation, Internal, Highly traumatic injuries, Humans, Injury Severity Score, Lumbopelvic, Paragliding, Retrospective Studies, Sacral fractures, Sacrum/diagnostic imaging/injuries, Spinopelvic, Trauma.
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  • Schuetz, P., Fehr, R., Baechli, V., Geiser, M., Deiss, M., Gomes, F., Kutz, A., et al. “Individualised Nutritional Support In Medical Inpatients At Nutritional Risk: A Randomised Clinical Trial”. Lancet 393, no. 10188: 2312-2321. doi:10.1016/S0140-6736(18)32776-4.
    Abstract: BACKGROUND: Guidelines recommend the use of nutritional support during hospital stays for medical patients (patients not critically ill and not undergoing surgical procedures) at risk of malnutrition. However, the supporting evidence for this recommendation is insufficient, and there is growing concern about the possible negative effects of nutritional therapy during acute illness on recovery and clinical outcomes. Our aim was thus to test the hypothesis that protocol-guided individualised nutritional support to reach protein and caloric goals reduces the risk of adverse clinical outcomes in medical inpatients at nutritional risk. METHODS: The Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) is a pragmatic, investigator-initiated, open-label, multicentre study. We recruited medical patients at nutritional risk (nutritional risk screening 2002 [NRS 2002] score >/=3 points) and with an expected length of hospital stay of more than 4 days from eight Swiss hospitals. These participants were randomly assigned (1:1) to receive either protocol-guided individualised nutritional support to reach protein and caloric goals (intervention group) or standard hospital food (control group). Randomisation was done with variable block sizes and stratification according to study site and severity of malnutrition using an interactive web-response system. In the intervention group, individualised nutritional support goals were defined by specialist dietitians and nutritional support was initiated no later than 48 h after admission. Patients in the control group received no dietary consultation. The composite primary endpoint was any adverse clinical outcome defined as all-cause mortality, admission to intensive care, non-elective hospital readmission, major complications, and decline in functional status at 30 days, and it was measured in all randomised patients who completed the trial. This trial is registered with ClinicalTrials.gov, number NCT02517476. FINDINGS: 5015 patients were screened, and 2088 were recruited and monitored between April 1, 2014, and Feb 28, 2018. 1050 patients were assigned to the intervention group and 1038 to the control group. 60 patients withdrew consent during the course of the trial (35 in the intervention group and 25 in the control group). During the hospital stay, caloric goals were reached in 800 (79%) and protein goals in 770 (76%) of 1015 patients in the intervention group. By 30 days, 232 (23%) patients in the intervention group experienced an adverse clinical outcome, compared with 272 (27%) of 1013 patients in the control group (adjusted odds ratio [OR] 0.79 [95% CI 0.64-0.97], p=0.023). By day 30, 73 [7%] patients had died in the intervention group compared with 100 [10%] patients in the control group (adjusted OR 0.65 [0.47-0.91], p=0.011). There was no difference in the proportion of patients who experienced side-effects from nutritional support between the intervention and the control group (162 [16%] vs 145 [14%], adjusted OR 1.16 [0.90-1.51], p=0.26). INTERPRETATION: In medical inpatients at nutritional risk, the use of individualised nutritional support during the hospital stay improved important clinical outcomes, including survival, compared with standard hospital food. These findings strongly support the concept of systematically screening medical inpatients on hospital admission regarding nutritional risk, independent of their medical condition, followed by a nutritional assessment and introduction of individualised nutritional support in patients at risk. FUNDING: The Swiss National Science Foundation and the Research Council of the Kantonsspital Aarau, Switzerland.
    Tags: Acute Disease/epidemiology, Aged, Aged, 80 and over, Chronic Disease/epidemiology, Comorbidity, Energy Intake, Female, Hospitalization/statistics & numerical data, Humans, Male, Malnutrition/*prevention & control, Middle Aged, Nutritional Support/*methods, Outcome Assessment, Health Care/*statistics & numerical data, Patient-Centered Care/*methods, Practice Guidelines as Topic, Risk Assessment.
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  • Minotti, B., Pulver, C., Schaub, P., Sieber, R., von Ow, D., and Leskow, P. “Pneumothorax, Chest Drain, And Commercial Air Travel”. Ann Emerg Med 73, no. 5: 551-552. doi:10.1016/j.annemergmed.2019.01.010.
    Tags: Accidents, Traffic, Conservative Treatment, Drainage, Hemopneumothorax/*therapy, Humans, Middle Aged, Rib Fractures/*therapy.
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