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Swiss Emergency Research collection

2006

  • Rutschmann, O. T., Kossovsky, M., Geissbuhler, A., Perneger, T. V., Vermeulen, B., Simon, J., and Sarasin, F. P. “Interactive Triage Simulator Revealed Important Variability In Both Process And Outcome Of Emergency Triage”. J Clin Epidemiol 59, no. 6: 615-21. doi:10.1016/j.jclinepi.2005.11.003.
    Abstract: BACKGROUND AND OBJECTIVES: (1) to evaluate the performance of emergency department triage; (2) to explore the variability of the triage process; and (3) to examine the reliability of a four-level triage scale, using an interactive triage simulator. METHODS: We developed 22 interactive computerized vignettes describing patients presenting at the Emergency Department. Each vignette displayed the presenting complaint and offered the possibility to ask questions and obtain vital signs before deciding on the triage severity rating. The vignettes were rated twice by 45 nurses and 8 physicians. RESULTS: (1) The concordance between the observed triage decision and an expert-attributed emergency level was perfect in 58% of the situations. Triage acuity was overestimated in 11%, and underestimated in 31%. (2) There was a wide variability in the triage process across observers and vignettes. The mean number of questions varied from 1.77 to 18.95 across individuals, and from 3.96 to 11.60 across vignettes. (3) Finally, the test-retest reliability of our instrument was good (weighted kappa = 0.82) but the interrater reliability was moderate (weighted kappa = 0.41). CONCLUSIONS: The computerized triage simulator is an innovative tool to evaluate the process and the performance of triage and to evaluate the reliability of a triage instrument.
    Tags: *Emergency Service, Hospital, *Triage, Adult, Aged, Computer Simulation, Emergencies, Female, Humans, Male, Middle Aged, Outcome and Process Assessment, Health Care/*methods, Prospective Studies, Quality of Health Care, Reproducibility of Results, Severity of Illness Index.
  • Tomaske, M., Gerber, A. C., and Weiss, M. “Anesthesia And Periinterventional Morbidity Of Rigid Bronchoscopy For Tracheobronchial Foreign Body Diagnosis And Removal”. Paediatr Anaesth 16, no. 2: 123-9. doi:10.1111/j.1460-9592.2005.01714.x.
    Abstract: BACKGROUND: Undiagnosed tracheobronchial foreign body aspiration (FBA) or delayed extraction can lead to serious morbidity. The aim of this study was to evaluate anesthetic and periinterventional morbidity of a straightforward regime using rigid bronchoscopy to rule out or remove a tracheobronchial foreign body in children with suspicion of FBA. METHODS: We retrospectively analyzed rigid bronchoscopy charts of children with suspicion of acute (< or = 24 h) and subacute (>24 h-2 weeks) tracheobronchial FBA (1990-2003). Patient characteristics, duration of fasting, technique/course of anesthesia induction, and duration/course of rigid bronchoscopy were taken. Anesthetic, periinterventional complications and length of hospital stay were noted. Data are given in median (range [interquartile range]). RESULTS: A total of 287 children were included in this study. Median age was 1.7 years (0.2-14.2 [1.2-2.5]); in 72.1% a tracheobronchial foreign body was found and removed. Fasting time before induction of anesthesia was 5 h (1-14 [4.0-7.0]). Anesthesia adverse events were seen in 0.7%, whereas periinterventional complication from rigid bronchoscopy was observed in 7.6%. Hospital discharge within 4 h after bronchoscopy was possible in 65.2%. Complications of delayed diagnosis (>24 h) were prolonged duration of rigid bronchoscopy because of severe mucosal changes or difficulties in foreign body extraction. CONCLUSIONS: General anesthesia for rigid bronchoscopy to rule out a tracheobronchial foreign body in children carries low morbidity. Most of the complications originated from the foreign body itself especially in patients with late diagnosis. The risk for serious complications caused by retained foreign bodies outweighs the low morbidity of explorative rigid bronchoscopy in children with suspected FBA or children with prolonged cough or pulmonary infection unresponsive to medical treatment.
    Tags: Anesthesia, General/*adverse effects, Bronchi/*surgery, Bronchoscopes, Bronchoscopy/*adverse effects, Child, Child, Preschool, Fasting/physiology, Female, Foreign Bodies/complications/*diagnosis/*surgery, Humans, Infant, Length of Stay, Male, Retrospective Studies, Time Factors, Trachea/*surgery, Treatment Outcome.
  • Exadaktylos, A. K., Buggy, D. J., Sclabas, G., and Zimmermann, H. “Six Month Outcome Of Extremely Old (≫ Or = 95 Years) Trauma Patients”. Age Ageing 35, no. 2: 204-5. doi:10.1093/ageing/afj022.
    Tags: Aged, 80 and over, Cardiovascular Diseases/complications, Cohort Studies, Female, Follow-Up Studies, Humans, Length of Stay, Male, Retrospective Studies, Treatment Outcome, Wounds and Injuries/complications/*therapy.

2005

  • Dieterle, T., Schuurmans, M. M., Strobel, W., Battegay, E. J., and Martina, B. “Moderate-To-Severe Blood Pressure Elevation At Ed Entry: Hypertension Or Normotension?”. Am J Emerg Med 23, no. 4: 474-9. doi:10.1016/j.ajem.2005.02.046.
    Abstract: PURPOSE: It is controversial whether arterial hypertension (AHT) can be diagnosed in the emergency department (ED). We sought to prospectively investigate the natural time course of blood pressure (BP) to define an optimal period for AHT screening in ED patients with an elevated initial BP. PROCEDURES: Patients with a BP greater than 160/100 mm Hg upon ED admission underwent repeated BP measurements every 5 minutes for 2 hours using an automated device. Arterial hypertension was confirmed using 12-hour ambulatory BP measurement or repeated office BP measurement according to the Joint National Committee VII guidelines by the primary care physician after discharge from the hospital. MAIN FINDINGS: Systolic BP decreased significantly during the first 10 to 20 minutes of ED stay in hypertensive and normotensive patients without further significant changes thereafter. Diastolic BP remained stable in both hypertensive and normotensive patients. Discrimination between hypertensive and normotensive patients was best between minutes 60 and 80 after ED admission. An average BP of 165/105 mm Hg or higher during this period strongly suggests AHT whereas a BP of less than 130/80 mm Hg excludes AHT with high sensitivity. CONCLUSIONS: Screening for AHT in the ED is possible with high specificity and sensitivity. Blood pressure measurements between minutes 60 and 80 after entry into the ED yield the highest diagnostic value.
    Tags: Blood Pressure Determination/*methods, Emergency Medicine/*methods, Female, Humans, Hypertension/*diagnosis, Male, Middle Aged, Prospective Studies, Reference Values, Sensitivity and Specificity.
  • Katz, E., Metzger, J. T., Schlaepfer, J., Fromer, M., Fishman, D., Mayer, L., Niquille, M., and Kappenberger, L. “Increase Of Out-Of-Hospital Cardiac Arrests In The Male Population Of The French Speaking Provinces Of Switzerland During The 1998 Fifa World Cup”. Heart 91, no. 8: 1096-7. doi:10.1136/hrt.2004.045195.
    Tags: *Soccer, Emergency Medical Services/statistics & numerical data, Female, France/ethnology, Heart Arrest/*mortality/psychology, Humans, Male, Retrospective Studies, Sex Distribution, Stress, Psychological/epidemiology/mortality, Switzerland/epidemiology.
  • Guyot, E., and Dormond, O. “Images In Emergency Medicine. Giant Pulmonary Bulla”. Ann Emerg Med 45, no. 6: 586, 591. doi:10.1016/j.annemergmed.2004.08.053.
    Tags: Adult, Blister/complications/*diagnostic imaging/surgery, Chest Pain/etiology, Cough/etiology, Dyspnea/etiology, Humans, Lung Diseases/complications/*diagnostic imaging/surgery, Lung/diagnostic imaging, Male, Thoracoscopy, Tomography, X-Ray Computed.

2004

  • Exadaktylos, A. K., Eggensperger, N. M., Eggli, S., Smolka, K. M., Zimmermann, H., and Iizuka, T. “Sports Related Maxillofacial Injuries: The First Maxillofacial Trauma Database In Switzerland”. Br J Sports Med 38, no. 6: 750-3. doi:10.1136/bjsm.2003.008581.
    Abstract: BACKGROUND: With the increase in the amount of medical data handled by emergency units, advances in computerisation have become necessary. New computer technology should have a major influence on accident analysis and prevention and the quality of research in the future. OBJECTIVES: To investigate the occurrence of sports related maxillofacial injuries using a newly installed relational database. To establish the first sports trauma database in Switzerland. METHODS: The Qualicare databank was used to prospectively review 57 248 case histories of patients treated in the Department of Emergency Medicine between January 2000 and December 2002. Pre-defined key words were used to collect data on sports related maxillofacial injuries. RESULTS: A total of 750 patients with maxillofacial injuries were identified. Ninety (12%) were sports related maxillofacial fractures. Most (27%) were sustained during skiing and snowboarding, 22% during team sports such as soccer or ice hockey, and 21% were from cycling accidents. Sixty eight per cent of the cyclists, 50% of the ice hockey players and soccer players, and 48% of the skiers and snowboarders had isolated fractures of the midface. Fractures of the mandible were noted predominantly in contact sports. CONCLUSIONS: Computerisation of trauma and emergency units and the introduction of customised software can significantly reduce the workload of researchers and doctors. The effective use of new computer technology should have a considerable influence on research and the quality of future prospective and retrospective studies.
    Tags: Athletic Injuries/*epidemiology, Databases, Factual, Facial Bones/injuries, Humans, Maxillofacial Injuries/*epidemiology/etiology, Prospective Studies, Quality Control, Skull Fractures/epidemiology/etiology, Switzerland/epidemiology.
  • Rutschmann, O. T., Janssens, J. P., Vermeulen, B., and Sarasin, F. P. “Knowledge Of Guidelines For The Management Of Copd: A Survey Of Primary Care Physicians”. Respir Med 98, no. 10: 932-7. doi:10.1016/j.rmed.2004.03.018.
    Abstract: OBJECTIVES: To evaluate primary care physicians' knowledge of guidelines for the management of COPD. METHOD: Survey to 455 primary care physicians in private practice in the state of Geneva, Switzerland, and to 243 physicians practicing in Geneva University Hospital. RESULTS: Although 75% of respondents identified that the prevalence of COPD was increasing and 33% recognized it as a major public health issue, only 55% of physicians used spirometric criteria to define COPD, and one-third knew the correct GOLD criteria. Fifty-two percent felt uncomfortable with smoking cessation counselling. Sixty-two percent administered influenza vaccination annually and 29% had immunized their patients against Pneumococcus. Beta2-agonists were the first-line treatment for 89% of physicians, but 10% overestimated their clinical benefit. Twenty-five percent of respondents used systematically inhaled corticosteroids, but 46% ignored their indications. Oral corticosteroids were used by 42% of physicians outside of acute exacerbations. Seventy-nine percent thought that oral steroids had a beneficial effect on stable COPD. Finally, pulmonary rehabilitation was underused by 72% of physicians. CONCLUSIONS: This study shows major gaps in the knowledge of all core elements of guidelines for the management of COPD and identifies targets for future educational programs.
    Tags: *Clinical Competence, *Practice Guidelines as Topic, *Primary Health Care, Adolescent, Adult, Child, Child, Preschool, Cross-Sectional Studies, Female, Humans, Infant, Infant, Newborn, Male, Middle Aged, Prospective Studies, Pulmonary Disease, Chronic Obstructive/*therapy, Risk Factors, Surveys and Questionnaires.
  • Osterwalder, J. J. “Insufficient Quality Of Research On Prehospital Medical Emergency Care - Where Are The Major Problems And Solutions?”. In, 134:389-394, 2004. https://www.scopus.com/inward/record.uri?eid=2-s2.0-4043093413&partnerID=40&md5=5a101a59056c43b724e77755c3e22e0b.
    Abstract: It is still unclear today whether a few minutes more or less spent in prehospital medical emergency care have a positive effect on a range of outcome variables. Modern emergency medical services (EMS) systems are expensive and have been introduced all over the industrialized world. Yet their effectiveness and efficiency are supported by scant scientific evidence. This is why research into EMS systems is urgently needed. There are significant differences between the approach to EMS research and traditional clinical research. New methodological approaches, such as system-orientated research and risk-adjustment measurements, must be further developed. The implementation of randomized controlled trials (RCTs) in the prehospital setting is often very difficult and not always possible or suitable. Valid alternatives to RCTs exist and should be further developed. Epidemiologists would be of assistance here. Agreement on clear definitions, standard data elements and validated severity scoring for trauma and non-trauma conditions, as well as their validation and routine use throughout the world are urgently needed. Clarifying many questions with regard to EMS systems cannot be left to chance. An internationally recognized research agenda with prioritisation and adaptation to regional requirements would be of great assistance here. Finally, reliable research in Switzerland into EMS enabling relevant decisions will hardly be possible without financial support from the Swiss National Fund and other institutions. Furthermore, it would be inappropriate to decrease the current standard of prehospital care we offer in the short term in order to save money as long as we have no reliable results that indicate that we should. This would also render impossible the very research into this sector that is urgently needed.
  • Bucheli, B., and Martina, B. “Reduced Length Of Stay In Medical Emergency Department Patients: A Prospective Controlled Study On Emergency Physician Staffing”. Eur J Emerg Med 11, no. 1: 29-34. doi:10.1097/00063110-200402000-00006.
    Abstract: OBJECTIVE: Patients, emergency department staff and hospital managers are often confronted with a prolonged length of stay of emergency department patients, with resulting overcrowding in the emergency department. We hypothesized that additional medical personnel would reduce the length of stay. METHODS: We prospectively studied consecutive patients managed in a medical emergency department by internal medicine residents during the evening shift. Data were collected on patients managed before (n=200) and after (n=160) the addition of a second physician on the shift. RESULTS: The addition of a physician in the busy evening shift decreased the length of stay from 176+/-137 to 141+/-86 min (mean+/-SD, P=0.012) for outpatients discharged after evaluation and management in the emergency department. The length of stay for emergency department inpatients admitted for hospitalization was not significantly reduced. CONCLUSION: An additional physician significantly reduced the length of stay of medical emergency department outpatients.
    Tags: *Emergency Medicine, Adult, Emergency Service, Hospital/*statistics & numerical data, Female, Humans, Length of Stay/*statistics & numerical data, Male, Outcome and Process Assessment, Health Care, Personnel Staffing and Scheduling/*statistics & numerical data, Prospective Studies, Switzerland, Time Factors, Waiting Lists, Workforce.
  • Righini, M., De Moerloose, P., Reber, G., Bounameaux, H., and Perrier, A. “Potential Role Of D-Dimer To Rule In Pulmonary Embolism: A Rebuttal”. J Thromb Haemost 2, no. 2: 367-8; author reply 369-70. doi:10.1111/j.1538-7836.2004.0584n.x.
    Tags: Fibrin Fibrinogen Degradation Products/*analysis, Humans, Predictive Value of Tests, Pulmonary Embolism/*diagnosis, Research Design, Sample Size, Sensitivity and Specificity.

2003

  • Osterwalder, J. J. “Mortality Of Blunt Polytrauma: A Comparison Between Emergency Physicians And Emergency Medical Technicians--Prospective Cohort Study At A Level I Hospital In Eastern Switzerland”. J Trauma 55, no. 2: 355-61. doi:10.1097/01.TA.0000034231.94460.1F.
    Abstract: BACKGROUND: The role of prehospital basic life support as opposed to prehospital advanced life support and the best qualifications for emergency personnel are controversial. Our objective was to establish whether the prehospital deployment of emergency physicians (EPs) rather than emergency medical technicians (EMTs) decreased mortality in blunt polytrauma patients. METHODS: In a prospective, observational cohort study conducted between 1990 and 1996, we used the A Severity Characterization of Trauma score to compare the actual mortality with the predicted mortality in 71 blunt polytrauma patients, 63 treated by EMTs alone and 8 treated also by anesthetic nurses. The same comparison was conducted in 196 blunt polytrauma patients treated by EPs together with EMTs or paramedics. Multivariate logistic regression analysis was conducted to test for any confounding factors and bias, and for the identification of factors associated with mortality. Inclusion criteria were blunt trauma at a minimum of two body sites, an Injury Severity Score of 8 or more, and direct admission to our trauma center. RESULTS: The mortality in patients treated by EPs was 11.2% (22 of 196) and was statistically not significantly lower than the 14.1% calculated for the patients treated without EP involvement (10 of 71). In the group treated by EPs, there were 1.3 (95% confidence interval [CI], -5.9-8.5), or 6%, fewer deaths than would have been expected on the basis of the results of the Major Trauma Outcome Study (p = 0.734). In contrast, in the group treated without EP involvement, there were 3.4 (95% CI, -0.2-7), or 34%, more deaths than predicted (p = 0.066). This trend was confirmed by multivariate logistic regression, which showed a significant mortality odds ratio of 37 (95% CI, 2-749) for the EMT group as compared with the EP group. CONCLUSION: In contrast with the deployment of EPs, care of blunt polytrauma patients by EMTs showed a statistical trend to a higher mortality than predicted and also a significantly higher risk of mortality. It is likely that the consistent deployment of EPs for moderate to severe blunt polytrauma in our catchment area might prevent between 0% and 23% of all deaths from blunt polytrauma or, in absolute terms, up to 1 death per year or 0 to 9.9 per 100 patients treated by an EP instead of an EMT.
    Tags: *Emergency Medical Services, *Emergency Medical Technicians, *Physicians, Adult, Clinical Competence, Cohort Studies, Female, Humans, Injury Severity Score, Male, Multiple Trauma/*mortality/*therapy, Prospective Studies, Switzerland, Wounds, Nonpenetrating/*mortality/*therapy.
  • Kucher, N., Kohler, H. P., Dornhofer, T., Wallmann, D., and Lammle, B. “Accuracy Of D-Dimer/Fibrinogen Ratio To Predict Pulmonary Embolism: A Prospective Diagnostic Study”. J Thromb Haemost 1, no. 4: 708-13. doi:10.1046/j.1538-7836.2003.00145.x.
    Abstract: D-Dimer and fibrinogen are elevated in many diseases presenting signs and symptoms similar to those seen in patients with pulmonary embolism (PE). We tested the hypothesis that patients with PE have lower fibrinogen and higher d-dimer values than patients in whom the diagnosis is suspected but safely excluded. One hundred and ninety-one consecutive patients with suspected acute PE (85 positive, 106 negative) were investigated with a diagnostic strategy including d-dimer, pretest probability, and helical computed tomography as first-line tests. In 38 of 40 patients with suspected PE and d-dimer <500 microg L(-1), PE was excluded without further testing. During a 3-month follow-up, there was no clinical PE among these 38 and the 68 patients with a negative helical CT. In 151 patients with d-dimer >500 microg L(-1), d-dimer, fibrinogen, and d-dimer/fibrinogen ratio (D/F ratio) were different in PE-positive compared with PE-negative patients [medians (and ranges) for d-dimer: 3793 (780 - 42 195) vs. 992 (621-6957) microg L(-1), fibrinogen: 3.8 (0.4-6.2) vs. 4.7 (2.2-8.4) g L(-1), and D/F ratio: 1.22 (0.15-85.45) 103 vs. 0.25 (0.09-1.03) x 103; P < 0.0001, respectively). The true positive rate was almost twice as high using D/F ratio >1.04 x 103 (49 of 85 patients; 57.6%) compared with d-dimer >7000 micro g L(-1) (25 of 85 patients; 29.4%). Patients with acute PE have lower fibrinogen values than patients with suspected but excluded PE. D/F ratio >103 is highly specific for the presence of acute PE, and causes a doubling of the diagnostic rate compared with d-dimer testing alone.
    Tags: Adult, Aged, Algorithms, Diagnosis, Differential, Enzyme-Linked Immunosorbent Assay/standards, Female, Fibrin Fibrinogen Degradation Products/*analysis, Fibrinogen/*analysis, Humans, Male, Middle Aged, Predictive Value of Tests, Probability, Prospective Studies, Pulmonary Embolism/blood/*diagnosis, Tomography, Spiral Computed.
  • Exadaktylos, A. K., Sclabas, G., Eggli, S., Schonfeld, H., Gygax, E., and Zimmermann, H. “Paragliding Accidents--The Spine Is At Risk. A Study From A Swiss Trauma Centre”. Eur J Emerg Med 10, no. 1: 27-9. doi:10.1097/00063110-200303000-00008.
    Abstract: In recent decades, paragliding-like other fashionable activities-has become a part of lifestyle and outdoor activities. The introduction of protective devices has helped to reduce the risk of severe injuries. However, it seems that the spine remains the paraglider's 'Achilles heel'. Better education, training, and the introduction of innovative back protectors are required to reduce the frequency and severity of paragliding injuries.
    Tags: *Accidents, Aviation/prevention & control, Accidental Falls, Adult, Aged, Athletic Injuries/classification/*epidemiology/prevention & control, Female, Humans, Lumbar Vertebrae/*injuries, Male, Middle Aged, Prospective Studies, Spinal Injuries/epidemiology/prevention & control, Switzerland/epidemiology, Thoracic Vertebrae/*injuries, Trauma Centers/statistics & numerical data.
  • Wilcock, M. “Change In General Practitioner Prescribing”. Age Ageing 32, no. 2: 231. doi:10.1093/ageing/32.2.231.
    Tags: *Drug Prescriptions, *Family Practice, Aged, Antipsychotic Agents/administration & dosage, Humans, United Kingdom.
  • Savolainen, Hannu, Vogt, Andreas, Nohl, Felix, Dinkel, Hans-Peter, Berdat, Pascal, and Kipfer, Beat. “Rectus Sheath Hematoma Complicated By Deep Vein Thrombosis”. International Journal Of Angiology 12, no. 02: 129-131. doi:10.1007/s00547-003-1003-5.
    Abstract: A 63-year-old previously healthy female on no medications was admitted in the emergency department due to pain in the left flank. Initially, she was hemodynamically stable. During the initial examination she became unstable. An ultrasound examination showed a large retroperitoneal hematoma, and a computerized tomography showed a hematoma of the rectus sheath as well. The patient was admitted in the Intensive Care Unit. Due to signs of elevated intra-abdominal pressure and deep vein thrombosis of the left lower extremity, a surgical evacuation of the hematoma was performed the day after. It had to be repeated due to continued bleeding 24 hours later. The management and possible sequelae of rectus sheath hematoma are discussed.

2002

  • Osterwalder, J. J. “Can The "Golden Hour Of Shock" Safely Be Extended In Blunt Polytrauma Patients? Prospective Cohort Study At A Level I Hospital In Eastern Switzerland”. Prehosp Disaster Med 17, no. 2: 75-80. doi:10.1017/s1049023x00000212.
    Abstract: BACKGROUND: The objective was to test, in this trauma system, the North American hypothesis that exceeding the 60-minute limit for the entire prehospital time ("golden hour of shock") increases mortality of blunt polytrauma patients. METHODS: In a prospective, observational, cohort study conducted between 1990 and 1996, a severity characterization of trauma (ASCOT) score was used to compare the actual mortality with the predicted mortality in 107 blunt polytrauma patients (Group 1) with prehospital rescue periods < or = 60 minutes (time from accident until arrival at the emergency department). The same comparison was performed for 147 blunt polytrauma patients (Group 2) with rescue periods > 60 minutes. Inclusion criteria were blunt trauma of at least two body sites, an Injury Severity Score (ISS) of > or = 8, and direct admission to the trauma centre. Multivariate regression analysis was performed to test for bias and confounding, and to identify factors that might influence mortality. Odd ratio (OR) and 95% confidence interval (CI) were calculated. RESULTS: The mortality in Group 1 was 14%, and was not statistically significantly higher than the 10.2% observed for Group 2. 4.8 patients, or 47% more than predicted, died in Group 1 (p = 0.057). The corresponding figures in Group 2 were 4.2 patients or 22% fewer than predicted (p = 0.19). Multivariate logistic regression confirmed this trend with a significant mortality odds ratio of 8 (95% CI 1.7 to 38.5) for Group 1 compared to Group 2. Significantly more patients in Group 2 were treated by emergency physicians. CONCLUSIONS: It appears in this trauma system, in which emergency physicians often are deployed, that the 'golden hour of shock' can be extended safely in many blunt polytrauma patients, since this was associated with better survival figures than in those patients for whom the time was < 1 hour.
    Tags: *Time Factors, Adult, Cohort Studies, Efficiency, Organizational, Emergency Medical Services/*standards, Emergency Service, Hospital/*standards, Female, Health Services Research, Humans, Injury Severity Score, Male, Multiple Trauma/complications/mortality/therapy, Outcome Assessment, Health Care, Practice Guidelines as Topic, Prospective Studies, Shock, Traumatic/etiology/*mortality/therapy, Survival Rate, Switzerland/epidemiology, Wounds, Nonpenetrating/classification/complications/*mortality/therapy.
  • Osterwalder, J. J. “The P Value As The Guardian Of Medical Truth -- Illusion Or Reality?”. Eur J Emerg Med 9, no. 3: 283-6. doi:10.1097/00063110-200209000-00017.
    Abstract: Most medical procedures are based on scientific investigations. Such investigations hinge on the demonstration of causal relationships and therefore the principle of causality. This paper shows that neither philosophy nor the much praised value is in a position to prove that causal relationships exist. The value is able to define the precision of measurements by quantifying the random error and to demonstrate statistical relationships. For the purposes of everyday practice, conclusions can only be drawn on statistical tests based on the value with the help of intuition, deductive and inductive reasoning, belief and social consensus.
    Tags: *Ethics, Research, *Philosophy, Medical, Causality, Humans, Probability.
  • Loretti, A., Leus, X., and Van Holsteijn, B. “Relevant In Times Of Turmoil: Who And Public Health In Unstable Situations”. Prehosp Disaster Med 16, no. 4: 184-91. doi:10.1017/s1049023x00043296.
    Abstract: For millions of people world-wide, surviving the pressure of extreme events is the predominant objective in daily existence. The distinction between natural and human-induced disasters is becoming more and more blurred. Some countries have known only armed conflict for the last 25 years, and their number is increasing. Recently, humanitarian sources reported 24 ongoing emergencies, each of them involving at least 300,000 people "requiring international assistance to avoid malnutrition or death". All together, including the countries still only at risk and those emerging from armed conflicts, 73 countries, i.e., almost 1.8 trillion people, were undergoing differing degrees of instability. Instability must be envisioned as a spectrum extending between "Utopia" and "Chaos". As emergencies bring forward extreme challenges to human life, medical and public health ethics make it imperative for the World Health Organisation (WHO) to be involved. As such, WHO must enhance its presence and effectiveness in its capacity as a universally accepted advocate for public health. Furthermore, as crises become more enmeshed with the legitimacy of the State, and armed conflicts become more directed against countries' social capital, they impinge more on WHO's work, and WHO must reconcile its unique responsibility in the health sector, the humanitarian imperative and the mandate to assist its primary constituents. Health can be viewed as a bridge to peace. The Organization specifically has recognised that disasters can and do affect the achievement of health and health system objectives. Within WHO, the Department of Emergency and Humanitarian Action (EHA) is the instrument for intervention in such situations. The scope of EHA is defined in terms of humanitarian action, emergency preparedness, national capacity building, and advocacy for humanitarian principles. The WHO's role is changing from ensuring a two-way flow of information on new scientific developments in public health in the ideal all-stable, all-equitable, well-resourced state, to dealing with sheer survival when the state is shattered or is part of the problem. The WHO poses itself the explicit goals to reduce avoidable loss of life, burden of disease and disability in emergencies and post-crisis transitions, and to ensure that the Humanitarian Health Assistance is in-line with international standards and local priorities and does not compromise future health development. A planning tree is presented. The World Health Organization must improve its own performance. This requires three key pre-conditions: 1) presence; 2) surge capacity; and 3) institutional support, knowledge, and competencies. Thus, in order to be effective, WHO's presence and surge capacity in emergencies must integrate the institutional knowledge, the competencies, and the managerial set-up of the Organization.
    Tags: *Disaster Planning, *Relief Work, *World Health Organization/organization & administration, Altruism, Humans, Public Health.
  • Griekspoor, A., and Sondorp, E. “Enhancing The Quality Of Humanitarian Assistance: Taking Stock And Future Initiatives”. Prehosp Disaster Med 16, no. 4: 209-15. doi:10.1017/s1049023x00043326.
    Abstract: During the last five years, the debate on the performance of humanitarian assistance has intensified. The motivation to "do better" has come both from within the humanitarian agencies as well as from pressure exerted by the donors and the media. Paradoxically, until now, the voice of those who are to benefit from this assistance has not been heard. This paper is an overview of the most important initiatives to increase the quality of humanitarian assistance. The introduction of the logical framework and the increasing body of knowledge made available through guidelines have improved project management by measuring process and outcomes. Increasingly, evaluations are used to give account and to learn from experiences. But, current evaluation practice must develop in a wider variety of approaches more appropriate to create change of the operations in the field. Some agencies oppose new developments like the Sphere and the Humanitarian Accountability Projects, arguing that standards and regulation would undermine necessary flexibility to adjust responses to the local context, or be a threat to their independence. Nonetheless, standards are considered to be a prerequisite as reference to assess performance. Furthermore, it is hoped that a new breakthrough will be achieved by improved accountability towards beneficiaries. An option to address some of the gaps in the current quality assessment tools was to widen the perspective on performance from projects to the organisations behind them. Quality management models may provide the required framework, and they also can be used to embed current initiatives by organisations. Humanitarian organisations may want to develop forms of self-regulation rather than waiting for accreditation by donors. Another area in which progress is needed is a system-wide approach to performance. At this level, the influence of political actors, donors, national governments, and other representatives of the parties in a conflict also should be assessed. It is their legal obligation to protect the basic right to assistance of persons affected by disasters, as enshrined in international law.
    Tags: *International Cooperation, Altruism, Humans, Quality Control, Relief Work/*organization & administration/standards.
  • Osterwalder, J. J. “Could A Regional Trauma System In Eastern Switzerland Decrease The Mortality Of Blunt Polytrauma Patients? A Prospective Cohort Study”. J Trauma 52, no. 6: 1030-6. doi:10.1097/00005373-200206000-00003.
    Abstract: BACKGROUND: In Europe and Switzerland, hardly any studies have been performed on regional trauma systems. We therefore decided to conduct a prospective study in our region to establish whether an organized trauma system derived from the American model would have a beneficial effect on the survival of blunt polytrauma patients. METHODS: In a prospective observational cohort study conducted between 1990 and 1996, we compared the actual mortality in 280 blunt polytrauma patients admitted directly to our trauma center with the predicted mortality using the A Severity Characterization of Trauma score. The same comparison was made for 190 transferred polytrauma admissions from regional hospitals. Our hypothesis was that for the transferred admissions, the actual mortality would be significantly higher than predicted, but that there would be no difference for the directly admitted patients. Inclusion criteria were blunt trauma of at least two body sites and an Injury Severity Score of 8 or more. RESULTS: Mortality in the patients admitted directly to the trauma center was 11.8% (33 of 280), which was not significantly lower than that for the transferred admissions at 14.2% (27 of 190). There were 10% (3 of 30) more deaths than predicted among the direct admissions (i.e., 3 more deaths; 95% confidence interval, -5.2-11.1; p = NS). Among the transferred admissions, there were 46% (8.6 of 18.4) more deaths than predicted (i.e., 8.6 more deaths; 95% confidence interval, 2.5-14.7; p < 0.05). CONCLUSION: It is likely that a regional trauma system in eastern Switzerland for polytrauma patients with an ISS of 8 or more would have a moderately positive effect on mortality. During the period of observation, transferred admissions from regional hospitals to our trauma center had a 46% higher mortality than predicted. In absolute terms, therefore, with a regional trauma system, it might have been possible to avoid between one death every 2 to 3 years and two to three deaths every year.
    Tags: *Hospital Mortality, Adolescent, Adult, Aged, Aged, 80 and over, Child, Child, Preschool, Female, Humans, Injury Severity Score, Male, Middle Aged, Multiple Trauma/etiology/*mortality, Patient Transfer, Predictive Value of Tests, Prospective Studies, Regional Medical Programs/*statistics & numerical data, Switzerland, Wounds, Nonpenetrating/etiology/*mortality.
  • Exadaktylos, A. K., Hauser, S., Luterbacher, J., Marti, U., Zimmermann, H., and Studer, U. E. “The Moon And The Stones. Can The Moon's Attractive Forces Cause Renal Colic?”. J Emerg Med 22, no. 3: 303-5. doi:10.1016/s0736-4679(01)00496-6.
    Tags: *Moon, Colic/*etiology, Emergencies, Gravitation, Humans, Urinary Calculi/*complications/diagnosis.
  • Leus, X., Wallace, J., and Loretti, A. “Internally Displaced Persons”. Prehosp Disaster Med 16, no. 3: 116-23. doi:10.1017/s1049023x00025851.
    Abstract: There were estimated to be over 20 million internally displaced persons (IDPs) at the end of 1999, a number that surpasses global estimates of refugees. Displacement exposes IDPs to new hazards and accrued vulnerability. These dynamics result in greater risk for the development of illness and death. Often, access of IDPs to health care and humanitarian assistance is excluded deliberately by conflicting parties. Furthermore, the arrival of IDPs into another community or region strains local health systems, and the host population ends up sharing the sufferings of the internally displaced. Health outcomes are dismaying. From a health perspective, the best option is to avoid human displacement. WHO contributes to the prevention of displacement by working for sustainable development. Placing health high on the political agenda helps maintain stability, and thereby, reduce the likelihood for displacement. Primary responsibility for assisting IDPs, irrespective of the cause, rests with the national government. However, where the government is unwilling or unable to provide the necessary aid, the international humanitarian community must step in, with WHO playing a major role in the health sector. There is consensus among the partners of the World Health Organization (WHO) that, in emergencies, the WHO must: 1) take the lead in rapid health assessment, epidemiological and nutritional surveillance, epidemic preparedness, essential drugs management, control of communicable diseases, and physical and psychosocial rehabilitation; and 2) provide guidelines and advice on nutritional requirements and rehabilitation, immunisation, medical relief items, and reproductive health. If the vital health needs of IDPs--security, food, water, shelter, sanitation and household items--are not satisfied, the provision of health services alone cannot save lives. Community participation is essential, and community participation implies bolstering the assets and capacities of the beneficiaries.
    Tags: *Health Services Needs and Demand, *Public Health, Adult, Child, Communicable Disease Control/organization & administration, Emergency Medical Services/*organization & administration, Female, Humans, Hunger, International Cooperation, Male, Mortality/trends, Refugees/*statistics & numerical data, Relief Work/*organization & administration, Risk Assessment, Warfare, World Health Organization.

2001

  • Katz, B. Z. “Refugees”. Lancet 358, no. 9284: 845. doi:10.1016/S0140-6736(01)05994-3.
    Tags: *Arabs, *Refugees, Humans, Israel.
  • Exadaktylos, A., Eggli, S., and Zimmermann, H. “The Kick With The Stick”. Br J Sports Med 35, no. 4: 276-7. doi:10.1136/bjsm.35.4.276.
    Abstract: OBJECTIVE: To investigate the incidence and type of severe microscooter related injuries in adults. METHOD: Data were collected between January and September 2000 from the University Hospital Berne, the only referral centre for major trauma in that city, using the software package Qualicare, which connects clinical data with categorised keywords, allowing the immediate localisation of patient groups with defined diagnosis or other clinical information. RESULTS: Only 0.2% of the patients treated had suffered a microscooter accident. There were five head injuries: three facial lacerations, one fractured mandible, and one cerebral concussion. One patient showed clinical signs of a cervical whiplash injury without radiological findings. There were also two cases of finger laceration and two of muscular contusions of the lower extremities. CONCLUSIONS: Although only a small proportion of the trauma cases were the result of riding microscooters, a system of injury surveillance should be started. Furthermore, protective gear should be worn particularly when microscooters are ridden in the street.
    Tags: Adolescent, Adult, Athletic Injuries/*classification/*epidemiology/prevention & control, Contusions/epidemiology, Craniocerebral Trauma/epidemiology, Female, Finger Injuries/epidemiology, Humans, Male, Skating/injuries/statistics & numerical data, Switzerland/epidemiology, Whiplash Injuries/epidemiology.
  • Exadaktylos, A. K., Sclabas, G., Siegenthaler, A., Eggli, S., Kohler, H. P., and Luterbacher, J. “Friday The 13Th And Full-Moon: The "Worst Case Scenario" Or Only Superstition?”. Am J Emerg Med 19, no. 4: 319-20. doi:10.1053/ajem.2001.24488.
    Tags: *Periodicity, *Superstitions, Emergency Service, Hospital/*statistics & numerical data, Humans, Switzerland.

2000

  • Wagner, Patrick, Bucher, Heiner C., Bucheli, Bruno, Battegay, Edouard, and Martina, Benedict. “Predictors Of Hospitalization In Emergency Department Patients With Syncope”. European Journal Of Internal Medicine 11, no. 1: 39-44. doi:10.1016/s0953-6205(99)00070-9.
    Abstract: Background: Up to 67% of emergency department (ED) patients with syncope are hospitalized. Methods: To identify predictors of hospitalization in ED patients with syncope we studied all 95 patients admitted to our medical ED with syncope during a 3-month period. Complete records and triage decisions were analyzed. A 2-year follow-up was performed to evaluate the quality of the decision. Results: The mean age of 43 outpatients was 53±24 years compared to 73±16 years for 52 inpatients (P<0.002). All patients with cardiac syncope (n=7) had in-hospital care. In addition to cardiac etiology of syncope (OR 1.16, 95% confidence interval (CI) 1.04-1.29) and age (OR 1.05, 95% CI 1.02-1.08), predictors of hospitalization in age-adjusted analysis were unexplained etiology of syncope (OR 10.6, 95% CI 1.23-14.29, P=0.03) and the need for assistance with everyday activities (OR 3.48, 95% CI 0.95-107.7, P=0.05). Follow-up data were obtained in 84% of outpatients and in 98% of inpatients 27 months (range 24-34 months) after their ED stay. Conclusion: Predictors of in-hospital care include age, cardiac syncope, and factors unrelated to the prognosis, such as unexplained etiology of syncope and the need for assistance with everyday activities. © 2000 Elsevier Science B.V.
  • Leus, X. R. “The Road Ahead”. In, 15:10-17, 2000. doi:10.1017/S1049023X00025231.

1999

  • Vermeulen, B., Morabia, A., Unger, P. F., Goehring, C., Grangier, C., Skljarov, I., and Terrier, F. “Acute Appendicitis: Influence Of Early Pain Relief On The Accuracy Of Clinical And Us Findings In The Decision To Operate--A Randomized Trial”. Radiology 210, no. 3: 639-43. doi:10.1148/radiology.210.3.r99fe54639.
    Abstract: PURPOSE: To determine the influence of early pain relief on the diagnostic performance of ultrasonography (US) and on the appropriateness of the surgical decision. MATERIALS AND METHODS: A prospective randomized, double-blind placebo-controlled trial with morphine was conducted. A visual analog scale was used to evaluate pain in 340 patients aged 16 years or older. US was performed with a standardized protocol. Diagnosis was confirmed at histologic analysis or, in the patients released without surgery, at follow-up. RESULTS: One hundred seventy-five patients were injected with morphine, and 165 were injected with the placebo. Pain relief was stronger in the morphine group. In the morphine group, US had lower (71.1%) sensitivity (difference, -9.5%; 95% CI, -18.5%, -0.5%) and higher (65.2%) specificity (difference, 11.4%; 95% CI, 1.0%, 21.8%). This group had also a higher positive predictive value (64.6%) and a lower negative predictive value (71.4%), but the differences between this group and the placebo group were not statistically significant. Among female patients, the decision to operate was appropriate more often in the morphine group (75.8%), but the difference between this group and the placebo group was not statistically significant (5.1%; 95% CI, -7.4%, 17.6%). In male patients and overall, opiate analgesia did not influence the appropriateness of the decision. The appropriateness to discharge patients without surgery was 100% in all groups. CONCLUSION: Morphine does not improve US-based diagnosis of appendicitis.
    Tags: *Appendectomy, *Decision Making, Abdominal Pain/*drug therapy, Acute Disease, Adolescent, Adult, Analgesics, Opioid/administration & dosage/therapeutic use, Appendicitis/*diagnostic imaging/surgery, Confidence Intervals, Double-Blind Method, Female, Follow-Up Studies, Humans, Injections, Intravenous, Male, Morphine/administration & dosage/therapeutic use, Pain Measurement, Patient Discharge, Placebos, Predictive Value of Tests, Prospective Studies, Sensitivity and Specificity, Sex Factors, Ultrasonography.

1998

  • Osterwalder, J. J. “Emergency Medicine In Switzerland”. Ann Emerg Med 32, no. 2: 243-7. doi:10.1016/s0196-0644(98)70144-1.
    Abstract: Situated in the heart of Europe, Switzerland's 7 million inhabitants, including 1 million foreigners, live in an area of 41,000 km2. German, French, Italian, and Rhaeto-Romanic are the official languages. The Swiss health service stands out because of the high quality and efficiency of its ambulatory and hospitalized health care management.
    Tags: *Emergency Medicine/education/organization & administration, Ambulatory Care, Education, Medical, Continuing, Efficiency, Organizational, Emergency Medical Services, Emergency Service, Hospital, Health Resources, Health Services Administration/economics, Health Services/economics, Hospital Administration, Humans, Language, Quality of Health Care, Switzerland.
  • Osterwalder, J. J., and Schuhwerk, W. “Effectiveness Of Mask Ventilation In A Training Mannikin. A Comparison Between The Oxylator Em100 And The Bag-Valve Device”. Resuscitation 36, no. 1: 23-7. doi:10.1016/s0300-9572(97)00091-9.
    Abstract: The demands for an optimal ventilation apparatus are that it can be easily handled, achieves a sufficiently high ventilation volume, and minimizes gastric inflation. Our aim was therefore to carry out a study in a training mannikin to find out whether the Oxylator EM100, compared with the bag, obtains improved ventilation and a decrease in gastric inflation. In a randomized crossover study, 72 subjects were selected (24 physicians, 44 nurses and 4 auxiliary nurses), chosen from the operating theatre, emergency department and intensive care unit of two hospitals. We used the Ambu-Bag Mark III with mask No. 4, the Oxylator EM100 with a pressure setting of 35 cm H2O run in the manual setting, the Ambu-Man C mannikin as well as the Ambu-CPR computer program. The resuscitation cycles of the standard two-rescuer's adult procedure lasted 3 min each, with a 3-min pause between the crossover procedure. The participants could improve their ventilatory volume with the Oxylator EM100 by 635 ml (95% confidence interval 578-692 ml) compared with the bag ventilation. The number of subjects who could attain a mean ventilatory volume of 800 ml or more increased from 15% to 98.6% (P < 0.001). Compared with the bag, the increase of adequate respirations (> or = 800 ml) obtained by the Oxylator EM100 for the individual participants amounted to a median of 91% (P < 0.001). Moreover, conventional ventilation caused in 42% one or several instances of gastric inflation, whereas no such reactions occurred with the Oxylator EM100. The Oxylator EM100 showed significantly better results in the mannikin than the bag. Of most importance is a significant lowering of gastric inflation and less so a marked increase in ventilatory volume. Our trial procedure with a relatively high lung compliance and a high oesophageal sphincter opening simulated favorable conditions. Owing to a large in vivo variability of these magnitudes, a direct testing in real patients with circulatory arrest is indicated.
    Tags: *Masks, Adult, Cardiopulmonary Resuscitation/education/*instrumentation, Cross-Over Studies, Female, Humans, Male, Manikins, Respiration, Artificial/*instrumentation.

1997

1996

  • Osterwalder, J. J. “Naloxone-For Intoxications With Intravenous Heroin And Heroin Mixtures-Harmless Or Hazardous? A Prospective Clinical Study”. In, 34:409-416, 1996. doi:10.3109/15563659609013811.
    Abstract: Background: Naloxone is standard medication for the treatment of heroin intoxications. No large-scale studies have yet been carried out to determine its toxicity in heroin intoxications. Methods: We have undertaken an investigation as to the frequency, type and degree of severity of complications attributable to naloxone administration. Subjects treated between 1991 and 1993 with naloxone for intravenous drug intoxications were prospectively evaluated. Main Outcome Measurements: Development of ventricular tachycardia or fibrillation; atrial fibrillation; asystole; pulmonary edema; convulsions; vomiting; and violent behavior within ten minutes after parenteral administration of naloxone. Results: Six of 453 intoxicated subjects (1.3%;95% confidence interval 0.4%-3%) suffered severe adverse effects within ten minutes after naloxone administration (one asystole; three generalized convulsions; one pulmonary edema; and one violent behavior). After the ten minute period, no further complications were observed. Conclusions: The short time between naloxone administration and the occurrence of complications, as well as the type of complications, are strong evidence of a causal link. In 1000 clinically diagnosed intoxications with heroin or heroin mixtures, from 4 to 30 serious complications can be expected. Such a high incidence of complications is unacceptable and could theoretically be reduced by artificial respiration with a bag valve device (hyperventilation) as well as by administering naloxone in minimal divided doses, injected slowly. © 1996 Informa UK Ltd All rights reserved.

1995

  • Vernazza, P. L., Gresser, S., Koller, C., and Osterwalder, J. J. “Condom Semen Samples For Unlinked Anonymous Hiv Testing”. Lancet 346, no. 8980: 962-3. doi:10.1016/S0140-6736(95)91581-8.
    Tags: *Condoms, Feasibility Studies, Female, HIV Antibodies/*analysis, HIV Seropositivity, Humans, Male, Semen/*immunology, Sex Work.
  • Osterwalder, J. J. “Patients Intoxicated With Heroin Or Heroin Mixtures: How Long Should They Be Monitored?”. Eur J Emerg Med 2, no. 2: 97-101. doi:10.1097/00063110-199506000-00009.
    Abstract: Our investigation was carried out in subjects intoxicated with heroin or heroin mixtures to find out the time interval during which delayed life-threatening complications become manifest, such as pulmonary oedema or relapse into respiratory depression or coma after naloxone treatment. We studied prospectively all drug intoxications between 1991 and 1992. Of the 538 intoxications, we assessed in detail 160 outpatients who lived within the catchment area of our hospital. The outcome variables studied were (1) rehospitalization for pulmonary oedema, (2) relapse into coma, and/or (3) death and cause within 24 h after release from hospital. Deaths occurring outside our hospital have to be reported, as decreed by law, to the Institute for Forensic Medicine. The results of our investigation showed no rehospitalization owing to pulmonary oedema or coma, but one death, outside the hospital, owing to delayed pulmonary oedema. This delayed complication had an incidence of 0.6% (95% confidence interval 0-3.8%). A reintoxication could be excluded in this patient. Based on reliable report, the pulmonary oedema occurred between approximately 2 1/4 and 8 1/4 hours after intoxication. In the literature, only two cases of delayed pulmonary oedema have been reported with reliable time statements (4 and 6 h after hospitalization). We therefore conclude that surveillance for at least 8 h is essential after successful treatment to exclude delayed pulmonary oedema in patients intoxicated with heroin or heroin mixtures.
    Tags: Adolescent, Adult, Benzodiazepines/poisoning, Cannabis/poisoning, Drug Interactions, Drug Overdose/diagnosis/mortality/therapy, Emergency Service, Hospital, Emergency Treatment/*methods, Ethanol/poisoning, Female, Glasgow Coma Scale, Heroin Dependence/mortality/therapy, Heroin/*poisoning, Humans, Male, Monitoring, Physiologic/*methods, Narcotics/*poisoning, Prospective Studies, Survival Rate, Switzerland/epidemiology, Time Factors.
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