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Swiss Emergency Research collection

2014

  • Hudelson, P., Dominice Dao, M., Perneger, T., and Durieux-Paillard, S. “A "Migrant Friendly Hospital" Initiative In Geneva, Switzerland: Evaluation Of The Effects On Staff Knowledge And Practices”. Plos One 9, no. 9: e106758. doi:10.1371/journal.pone.0106758.
    Abstract: BACKGROUND: International migration poses important challenges to European health care systems. The development of "migrant friendly hospitals" has been identified as a priority in both Europe and Switzerland. METHODS: A multi-pronged initiative was developed at Geneva University Hospitals (HUG) to improve staff knowledge and use of existing "migrant friendly" resources. A self-administered questionnaire was sent pre and post-intervention to random samples of 4 major professional groups with direct patient contact at the HUG. The questionnaire assessed staff knowledge, attitudes and reported practices regarding the care of migrant patients. RESULTS: Overall response rate was 51% (N = 1460) in 2010 but only 19% (N = 761) in 2013 owing to an institutionally imposed change in survey method. Despite these difficulties, and after adjusting for sample differences, we found that respondents in 2013 were significantly more likely to have received training in how to organize an appointment with an interpreter, how to work with an interpreter and about health and social services available for migrant patients. Respondents were also significantly more likely to have used several Migrant Friendly structures at the HUG. Use of, preference for and perceived skill at working with professional interpreters all improved, and respondents were both more likely to be encouraged by their supervisors to use professional interpreters, and less likely to be encouraged to look for alternative solutions for communicating with non francophone patients. Finally, 2013 respondents encountered fewer difficulties caring for migrant patients, although lack of time and language barriers continued to be the most important sources of difficulty. CONCLUSION: Our results suggest that an institution-wide information campaign may contribute to increased awareness and use of migrant friendly resources by clinical staff. Hospital commitment and financing, along with inter-departmental participation in all activities were important in creating and maintaining project visibility, and in contributing to a migrant friendly institutional culture.
    Tags: *Emigrants and Immigrants, *Personnel, Hospital, Hospitals, University/organization & administration, Professional-Patient Relations, Switzerland.
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  • Ramser, M., Messmer, A. S., Zbinden, I., Von Holzen, U., and Nebiker, C. A. “Incarcerated Obturator Hernia-Laparoscopic Repair With Intraoperative View Of The Corona Mortis”. J Surg Case Rep 2014, no. 8. doi:10.1093/jscr/rju081.
    Abstract: Obturator hernias are a rare form of abdominal wall hernias. We present a case of a patient with an obturator hernia diagnosed by the classical signs of lower abdominal pain, a positive Howship-Romberg sign (painful internal rotation of the hip) and a computed tomography scan showing a herniated loop of small bowel. During the emergency laparoscopic hernia repair (transabdominal preperitoneal approach) a variant vessel, the corona mortis, was detected.
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  • Grossmann, F. F., Zumbrunn, T., Ciprian, S., Stephan, F. P., Woy, N., Bingisser, R., and Nickel, C. H. “Undertriage In Older Emergency Department Patients--Tilting Against Windmills?”. Plos One 9, no. 8: e106203. doi:10.1371/journal.pone.0106203.
    Abstract: OBJECTIVES: The aim of this study was to investigate the long-term effect of a teaching intervention designed to reduce undertriage rates in older ED patients. Further, to test the hypothesis that non-adherence to the Emergency Severity Index (ESI) triage algorithm is associated with undertriage. Additionally, to detect patient related risk factors for undertriage. METHODS: Pre-post-test design. The study sample consisted of all patients aged 65 years or older presenting to the ED of an urban tertiary and primary care center in the study periods. A teaching intervention designed to increase adherence to the triage algorithm. To assess, if the intervention resulted in an increase of factual knowledge, nurses took a test before and immediately after the teaching intervention. Undertriage rates were assessed one year after the intervention and compared to the pre-test period. RESULTS: In the pre-test group 519 patients were included, and 394 in the post-test-group. Factual knowledge among triage nurses was high already before the teaching intervention. Prevalence of undertriaged patients before (22.5%) and one year after the intervention (24.2%) was not significantly different (chi2 = 0.248, df = 1, p = 0.619). Sex, age, mode of arrival, and type of complaint were not identified as independent risk factors for undertriage. However, undertriage rates increased with advancing age. Adherence to the ESI algorithm is associated with correct triage decisions. CONCLUSIONS: Undertriage of older ED patients remained unchanged over time. Reasons for undertriage seem to be more complex than anticipated. Therefore, additional contributing factors should be addressed.
    Tags: Aged, Algorithms, Emergency Service, Hospital/*statistics & numerical data, Female, Humans, Male, Nurses, Patient Compliance/statistics & numerical data, Prevalence, Retrospective Studies, Risk Factors, Severity of Illness Index, Teaching/*statistics & numerical data, Triage/*statistics & numerical data.
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  • Carron, P. N., Heymann, E., and Hugli, O. “Adrenaline In Out-Of Hospital Cardiac Arrest”. Resuscitation 85, no. 11: e177. doi:10.1016/j.resuscitation.2014.05.042.
    Tags: Epinephrine/*therapeutic use, Humans, Resuscitation/*methods, Vasoconstrictor Agents/*therapeutic use, Vasopressins/*therapeutic use.
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  • Adam, M., Imboden, M., Boes, E., Schaffner, E., Kunzli, N., Phuleria, H. C., Kronenberg, F., Gaspoz, J. M., Carballo, D., and Probst-Hensch, N. “Modifying Effect Of A Common Polymorphism In The Interleukin-6 Promoter On The Relationship Between Long-Term Exposure To Traffic-Related Particulate Matter And Heart Rate Variability”. Plos One 9, no. 8: e104978. doi:10.1371/journal.pone.0104978.
    Abstract: BACKGROUND: Exposure to particulate matter (PM) has been associated with an increase in many inflammatory markers, including interleukin 6 (IL6). Air pollution exposure has also been suggested to induce an imbalance in the autonomic nervous system (ANS), such as a decrease in heart rate variability (HRV). In this study we aimed to investigate the modifying effect of polymorphisms in a major proinflammatory marker gene, interleukin 6 (IL6), on the relationship between long-term exposure to traffic-related PM10 (TPM10) and HRV. METHODS: For this cross-sectional study we analysed 1552 participants of the SAPALDIA cohort aged 50 years and older. Included were persons with valid genotype data, who underwent ambulatory 24-hr electrocardiogram monitoring, and reported on medical history and lifestyle. Main effects of annual average TPM10 and IL6 gene variants (rs1800795; rs2069827; rs2069840; rs10242595) on HRV indices and their interaction with average annual exposure to TPM10 were tested, applying a multivariable mixed linear model. RESULTS: No overall association of TPM10 on HRV was found. Carriers of two proinflammatory G-alleles of the functional IL6 -174 G/C (rs1800795) polymorphism exhibited lower HRV. An inverse association between a 1 microg/m3 increment in yearly averaged TPM10 and HRV was restricted to GG genotypes at this locus with a standard deviation of normal-to-normal intervals (SDNN) (GG-carriers: -1.8%; 95% confidence interval -3.5 to 0.01; pinteraction(additive) = 0.028); and low frequency power (LF) (GG-carriers: -5.7%; 95%CI: -10.4 to -0.8; pinteraction(dominant) = 0.049). CONCLUSIONS: Our results are consistent with the hypothesis that traffic-related air pollution decreases heart rate variability through inflammatory mechanisms.
    Tags: Aged, Autonomic Nervous System/drug effects/metabolism, Cross-Sectional Studies, Electrocardiography, Female, Genotype, Heart Rate/drug effects, Humans, Interleukin-6/*genetics, Male, Middle Aged, Particulate Matter/*toxicity, Polymorphism, Genetic/*genetics, Promoter Regions, Genetic/*genetics.
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  • Krahenmann-Muller, S., Virgini, V. S., Blum, M. R., da Costa, B. R., Collet, T. H., Martin, Y., Cornuz, J., et al. “Patient And Physician Gender Concordance In Preventive Care In University Primary Care Settings”. Prev Med 67: 242-7. doi:10.1016/j.ypmed.2014.08.004.
    Abstract: OBJECTIVE: To assess the quality of preventive care according to physician and patient gender in a country with universal health care coverage. METHODS: We assessed a retrospective cohort study of 1001 randomly selected patients aged 50-80 years followed over 2 years (2005-2006) in 4 Swiss university primary care settings (Basel, Geneva, Lausanne, Zurich). We used indicators derived from RAND's Quality Assessment Tools and examined percentages of recommended preventive care. Results were adjusted using hierarchical multivariate logistic regression models. RESULTS: 1001 patients (44% women) were followed by 189 physicians (52% women). Female patients received less preventive care than male patients (65.2% vs. 72.1%, p<0.001). Female physicians provided significantly more preventive care than male physicians (p=0.01) to both female (66.7% vs. 63.6%) and male patients (73.4% vs. 70.7%). After multivariate adjustment, differences according to physician (p=0.02) and patient gender (p<0.001) remained statistically significant. Female physicians provided more recommended cancer screening than male physicians (78.4 vs. 71.9%, p=0.01). CONCLUSIONS: In Swiss university primary care settings, female patients receive less preventive care than male patients, with female physicians providing more preventive care than male physicians. Greater attention should be paid to female patients in preventive care and to why female physicians tend to provide better preventive care.
    Tags: *Physician-Patient Relations, *Sex Factors, Adult, Aged, Female, Humans, Male, Middle Aged, Patient physician gender concordance, Practice Patterns, Physicians'/*standards, Preventive care, Preventive Health Services/*standards, Primary health care, Primary Health Care/*methods, Retrospective Studies, Switzerland, Women's health.
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  • Bertholet, N., Adam, A., Faouzi, M., Boulat, O., Yersin, B., Daeppen, J. B., and Clerc, D. “Admissions Of Patients With Alcohol Intoxication In The Emergency Department: A Growing Phenomenon”. Swiss Med Wkly 144: w13982. doi:10.4414/smw.2014.13982.
    Abstract: QUESTION UNDER STUDY: To investigate the change over time in the number of ED admissions with positive blood alcohol concentration (BAC) and to evaluate predictors of BAC level. METHODS: We conducted a single site retrospective study at the ED of a tertiary referral hospital (western part of Switzerland) and obtained all the BAC performed from 2002 to 2011. We determined the proportion of ED admissions with positive BAC (number of positive BAC/number of admissions). Regression models assessed trends in the proportion of admissions with positive BAC and the predictors of BAC level among patients with positive BAC. RESULTS: A total of 319,489 admissions were recorded and 20,021 BAC tests were performed, of which 14,359 were positive, divided 34.5% female and 65.5% male. The mean (SD) age was 41.7(16.8), and the mean BAC was 2.12(1.04) permille (g of ethanol/liter of blood). An increase in the number of positive BAC was observed, from 756 in 2002 to 1,819 in 2011. The total number of admissions also increased but less: 1.2 versus 2.4 times more admissions with positive BAC. Being male was independently associated with a higher (+0.19 permille) BAC, as was each passing year (+0.03). A significant quadratic association with age indicated a maximum BAC at age 53. CONCLUSION: We observed an increase in the percentage of admissions with positive BAC that was not limited to younger individuals. Given the potential consequences of alcohol intoxication, and the large burden imposed on ED teams, communities should be encouraged to take measures aimed at reducing alcohol intoxication.
    Tags: Adult, Age Factors, Alcoholic Intoxication/*blood, Emergency Service, Hospital/*trends, Ethanol/*blood, Female, Humans, Male, Middle Aged, Patient Admission/*trends, Retrospective Studies, Sex Factors, Tertiary Care Centers, Young Adult.
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  • Pfortmueller, C. A., Schankath, A. C., Mordasini, P., Koetter, J., Wiest, R., Exadaktylos, A. K., and Puig, S. “Radiological Findings Of Sexual Intercourse Related Emergency Department Admissions: A First Overview”. Plos One 9, no. 8: e104170. doi:10.1371/journal.pone.0104170.
    Abstract: OBJECTIVES: Sexuality is an essential aspect of human function, well-being and quality of life. Many people have sex without complications. However, there are some people who need to seek emergency medical help for related health problems. The aim of this study was to present a first overview of patients who received a radiological examination related to sexual intercourse based emergency department admission. METHODS: Our centralized electronic patient record database was reviewed for patients who had been admitted to our emergency department with an emergency after sexual intercourse between 2000 and 2011. The database was scanned for the standardized key words 'sexual intercourse' or 'coitus' retrospectively. For all patients identified in the electronic patient record database the radiological examinations were searched for manually in our Radiology Information System, and reviewed by three independent radiologists. RESULTS: One hundred and twenty nine out of 445 (29,0%) patients received a radiological examination after immediate emergency department admission related to sexual intercourse. Fifty two out of 129 (40.3%) patients had positive radiological findings while 77 (59.7%) did not. Eighty point seven percent (n = 42) of the radiological findings were a sexual intercourse-associated pathology and 19.2% (n = 10) were considered to be incidental findings. Age and male sex positively correlated with radiological imaging workup (p<0.001, respectively p<0.037). The most common sexual intercourse-associated pathology was headache attributed to cerebrovascular insult (n = 21, 40.3%) followed by epididymitis (n = 7, 16.6%) and obstructive uropathy (n = 5, 11.6%). Of the patients with headache attributed to non-traumatic intracranial hemorrhage, subarachnoid hemorrhage (n = 14, 66.6%) was the most common, followed by intracerebral bleeding (n = 4, 19.0%) and one subdural hemorrhage. CONCLUSIONS: Pathological findings are manifold. Cerebral imaging is the most common type of radiological imaging performed. Further prospective and standardized studies should be performed to better evaluate the significance of radiological imaging in this patient collective with the aim to gain better knowledge on what patients profit from what type of radiological imaging when presenting with a sexual intercourse related emergency. ADVANCES IN KNOWLEDGE: The present study provides a first overview on radiological findings of sexual intercourse related emergency department admissions.
    Tags: *Emergencies, *Emergency Service, Hospital, *Patient Admission, *Radiography/methods, *Sexual Behavior, Adolescent, Adult, Aged, Databases, Factual, Female, Humans, Male, Middle Aged, Retrospective Studies, Young Adult.
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  • Guessous, I., Eap, C. B., and Bochud, M. “Blood Pressure In Relation To Coffee And Caffeine Consumption”. Curr Hypertens Rep 16, no. 9: 468. doi:10.1007/s11906-014-0468-2.
    Abstract: The relationship between blood pressure (BP) and coffee is of major interest given its widespread consumption and the public health burden of high BP. Yet, there is no specific recommendation regarding coffee intake in existing hypertension guidelines. The lack of a definitive understanding of the BP-coffee relationship is partially attributable to issues that we discuss in this review, issues such as acute vs. chronic effects, genetic and smoking effect modifications, and coffee vs. caffeine effects. We also present evidence from meta-analyses of studies on the association of BP with coffee intake. The scope of this review is limited to the latest advances published with a specific focus on caffeine, acknowledging that caffeine is only one among numerous components in coffee that may influence BP. Finally, considering the state of the research, we propose a mechanism by which the CYP1A2 gene and enzyme influence BP via inhibition of the adenosine receptor differentially in smokers and non-smokers.
    Tags: *Coffee, *Hypertension/epidemiology/etiology/physiopathology, Blood Pressure/*drug effects, Caffeine/*pharmacology, Central Nervous System Stimulants/pharmacology, Global Health, Humans, Morbidity, Risk Factors.
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  • Haller, D. M., Narring, F., Chondros, P., Pejic, D., Sredic, A., Huseinagic, S., Perone, N., Sanci, L. A., and Meynard, A. “Development Of Youth Friendly Family Medicine Services In Bosnia And Herzegovina: Protocol For A Cluster Randomized Controlled Trial”. Springerplus 3, no. 1: 319. doi:10.1186/2193-1801-3-319.
    Abstract: BACKGROUND: Young people face many barriers in accessing health services that are responsive to their needs. The World Health Organization has led a call to develop services that address these barriers, i.e. youth-friendly health services. Addressing the needs of young people is one of the priorities of Foundation fami, an organisation working in collaboration with the Swiss Federal Department of Development and Cooperation and Geneva University Hospitals to develop quality family medicine services in Bosnia and Herzegovina. This paper describes the design of a trial to assess the effectiveness of a multifaceted intervention involving family medicine teams (primary care doctors and nurses) to improve the youth-friendliness of family medicine services in Bosnia and Herzegovina. METHODS/DESIGN: This is a stratified cluster randomised trial with a repeated cross-sectional design involving 59 health services in 10 municipalities of the canton of Zenica in Bosnia and Herzegovina. Municipalities were the unit of randomisation: five municipalities were randomised to the intervention arm and five to a wait-list control arm. Family medicine teams in the intervention arm were invited to participate in an interactive training program about youth-friendly service principles and change processes within their service. The primary outcome was the youth-friendliness of the primary care service measured using the YFHS-WHO + questionnaire, a validated tool which young people aged 15 to 24 years complete following a family medicine consultation. A total of 600 young people aged 15 to 24 years were invited to participate and complete the YFHS-WHO + questionnaire: 300 (30 per municipality) at baseline, and 300 at follow-up, three to five months after the training program. DISCUSSION: The results of this trial should provide much awaited evidence about the development of youth-friendly primary care services and inform their further development both in Bosnia and Herzegovina and worldwide. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry_ ACTRN12610000142033.
    Tags: Adolescent health services, Cluster randomised trial, Family practice, Quality of healthcare, Youth-friendly services.
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  • Guessous, I., McClellan, W., Kleinbaum, D., Vaccarino, V., Zoller, O., Theler, J. M., Paccaud, F., Burnier, M., Bochud, M., and Swiss Survey on Salt, Group. “Comparisons Of Serum Vitamin D Levels, Status, And Determinants In Populations With And Without Chronic Kidney Disease Not Requiring Renal Dialysis: A 24-Hour Urine Collection Population-Based Study”. J Ren Nutr 24, no. 5: 303-12. doi:10.1053/j.jrn.2014.04.005.
    Abstract: OBJECTIVE: Vitamin D deficiency is frequent in the general population and might be even more prevalent among populations with kidney failure. We compared serum vitamin D levels, vitamin D insufficiency/deficiency status, and vitamin D level determinants in populations without chronic kidney disease (CKD) and with CKD not requiring renal dialysis. DESIGN AND METHODS: This was a cross-sectional, multicenter, population-based study conducted from 2010 to 2011. Participants were from 10 centers that represent the geographical and cultural diversity of the Swiss adult population (>/=15 years old). INTERVENTION: CKD was defined using estimated glomerular filtration rate and 24-hour albuminuria. Serum vitamin D was measured by liquid chromatography-tandem mass spectrometry. Statistical procedures adapted for survey data were used. MAIN OUTCOME MEASURE: We compared 25-hydroxy-vitamin D (25(OH)D) levels and the prevalence of vitamin D insufficiency/deficiency (serum 25(OH)D < 30 ng/mL) in participants with and without CKD. We tested the interaction of CKD status with 6 a priori defined attributes (age, sex, body mass index, walking activity, serum albumin-corrected calcium, and altitude) on serum vitamin D level or insufficiency/deficiency status taking into account potential confounders. RESULTS: Overall, 11.8% (135 of 1,145) participants had CKD. The 25(OH)D adjusted means (95% confidence interval [CI]) were 23.1 (22.6-23.7) and 23.5 (21.7-25.3) ng/mL in participants without and with CKD, respectively (P = .70). Vitamin D insufficiency or deficiency was frequent among participants without and with CKD (75.3% [95% CI 69.3-81.5] and 69.1 [95% CI 53.9-86.1], P = .054). CKD status did not interact with major determinants of vitamin D, including age, sex, BMI, walking minutes, serum albumin-corrected calcium, or altitude for its effect on vitamin D status or levels. CONCLUSION: Vitamin D concentration and insufficiency/deficiency status are similar in people with or without CKD not requiring renal dialysis.
    Tags: *Nutritional Status, *Renal Dialysis, Adolescent, Adult, Albuminuria/urine, Body Mass Index, Calcium/blood, Chromatography, Liquid, Creatinine/blood, Cross-Sectional Studies, Female, Glomerular Filtration Rate, Humans, Logistic Models, Male, Middle Aged, Multivariate Analysis, Prevalence, Renal Insufficiency, Chronic/*blood/complications, Serum Albumin/metabolism, Sunlight, Switzerland, Tandem Mass Spectrometry, Urine Specimen Collection/*methods, Vitamin D Deficiency/blood/complications/*epidemiology, Vitamin D/administration & dosage/*blood, Young Adult.
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  • Carron, P. N., Yersin, B., Trueb, L., Gonin, P., and Hugli, O. “Missed Opportunities: Evolution Of Patients Leaving Without Being Seen Or Against Medical Advice During A Six-Year Period In A Swiss Tertiary Hospital Emergency Department”. Biomed Res Int 2014: 690368. doi:10.1155/2014/690368.
    Abstract: AIM: The study aimed at describing the evolution over a 6-year period of patients leaving the emergency department (ED) before being seen ("left without being seen" or LWBS) or against medical advice ("left against medical advice" or LAMA) and at describing their characteristics. METHODS: A retrospective database analysis of all adult patients who are admitted to the ED, between 2005 and 2010, and who left before being evaluated or against medical advice, in a tertiary university hospital. RESULTS: During the study period, among the 307,716 patients who were registered in the ED, 1,157 LWBS (0.4%) and 1,853 LAMA (0.9%) patients were identified. These proportions remained stable over the period. The patients had an average age of 38.5+/-15.9 years for LWBS and 41.9+/-17.4 years for LAMA. The median time spent in the ED before leaving was 102.4 minutes for the LWBS patients and 226 minutes for LAMA patients. The most frequent reason for LAMA was related to the excessive length of stay. CONCLUSION: The rates of LWBS and LAMA patients were low and remained stable. The patients shared similar characteristics and reasons for leaving were largely related to the length of stay or waiting time.
    Tags: *Patient Acceptance of Health Care, *Patients, *Tertiary Care Centers, Adolescent, Adult, Aged, Aged, 80 and over, Emergency Service, Hospital, Female, Humans, Male, Middle Aged, Switzerland.
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  • Stuck, A. K., Mean, M., Limacher, A., Righini, M., Jaeger, K., Beer, H. J., Osterwalder, J., et al. “The Adherence To Initial Processes Of Care In Elderly Patients With Acute Venous Thromboembolism”. Plos One 9, no. 7: e100164. doi:10.1371/journal.pone.0100164.
    Abstract: BACKGROUND: We aimed to assess whether elderly patients with acute venous thromboembolism (VTE) receive recommended initial processes of care and to identify predictors of process adherence. METHODS: We prospectively studied in- and outpatients aged >/=65 years with acute symptomatic VTE in a multicenter cohort study from nine Swiss university- and non-university hospitals between September 2009 and March 2011. We systematically assessed whether initial processes of care, which are recommended by the 2008 American College of Chest Physicians guidelines, were performed in each patient. We used multivariable logistic models to identify patient factors independently associated with process adherence. RESULTS: Our cohort comprised 950 patients (mean age 76 years). Of these, 86% (645/750) received parenteral anticoagulation for >/=5 days, 54% (405/750) had oral anticoagulation started on the first treatment day, and 37% (274/750) had an international normalized ratio (INR) >/=2 for >/=24 hours before parenteral anticoagulation was discontinued. Overall, 35% (53/153) of patients with cancer received low-molecular-weight heparin monotherapy and 72% (304/423) of patients with symptomatic deep vein thrombosis were prescribed compression stockings. In multivariate analyses, symptomatic pulmonary embolism, hospital-acquired VTE, and concomitant antiplatelet therapy were associated with a significantly lower anticoagulation-related process adherence. CONCLUSIONS: Adherence to several recommended processes of care was suboptimal in elderly patients with VTE. Quality of care interventions should particularly focus on processes with low adherence, such as the prescription of continued low-molecular-weight heparin therapy in patients with cancer and the achievement of an INR >/=2 for >/=24 hours before parenteral anticoagulants are stopped.
    Tags: *Guideline Adherence, Acute Disease, Age Factors, Aged, Aged, 80 and over, Anticoagulants/administration & dosage/*therapeutic use, Cohort Studies, Female, Humans, Inpatients, Male, Multivariate Analysis, Neoplasms/complications, Outpatients, Practice Guidelines as Topic, Risk Factors, Stockings, Compression, Time Factors, Venous Thromboembolism/complications/*drug therapy/therapy.
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  • Stallone, F., Twerenbold, R., Wildi, K., Reichlin, T., Rubini Gimenez, M., Haaf, P., Fuechslin, N., et al. “Prevalence, Characteristics And Outcome Of Non-Cardiac Chest Pain And Elevated Copeptin Levels”. Heart 100, no. 21: 1708-14. doi:10.1136/heartjnl-2014-305583.
    Abstract: OBJECTIVE: Copeptin, a quantitative marker of endogenous stress, seems to provide incremental value in addition to cardiac troponin in the early rule-out of acute myocardial infarction (AMI). Prevalence, characteristics and outcome of acute chest pain patients with causes other than AMI and elevated copeptin are poorly understood. METHODS: A total of 984 consecutive patients with non-cardiac chest pain were selected from a prospective multicentre study of acute chest pain patients presenting to the emergency department. Levels of copeptin were determined in a blinded fashion and considered elevated if above 13 pmol/L (the 97,5th centile of healthy individuals). The final diagnosis was adjudicated by two independent cardiologists. Median duration of follow-up was 756 days. RESULTS: Elevated copeptin levels were seen in 215 patients (22%). In comparison to patients with normal copeptin levels, patients with elevated levels were older, had more pre-existing cardiac and non-cardiac disorders, more silent cardiomyocyte injury and increased haemodynamic stress as quantified by levels of high-sensitivity cardiac troponin T (9.6 ng/L (3.6-18.3) vs 5.8 ng/L (2.9-9.4)) and B-type natriuretic peptide (75 ng/L (37-187) vs 35 ng/L (15-77)) (both p<0.001), more electrocardiographic abnormalities, more often an adjudicated diagnosis of gastroesophageal reflux or bronchitis/pneumonia and higher 2- year mortality (HR 2.9, 95% CI 1.5 to 5.7). The increased mortality rate seemed to be largely explained by age and comorbidities. CONCLUSIONS: Elevated levels of copeptin are present in about one in five patients with non-cardiac chest pain and are associated with aging, cardiac and non-cardiac comorbidities as well as mortality.
    Tags: Acute Pain/blood/diagnosis/*epidemiology, Adult, Aged, Biomarkers/blood, Chest Pain/blood/diagnosis/*epidemiology, Coronary artery disease, Diagnosis, Differential, Electrocardiography, Female, Follow-Up Studies, Germany/epidemiology, Glycopeptides/*blood, Heart Diseases/diagnosis, Humans, Male, Middle Aged, Natriuretic Peptide, Brain/blood, Predictive Value of Tests, Prevalence, Prospective Studies, Protein Precursors, Reproducibility of Results, Risk Assessment/*methods, ROC Curve, Spain/epidemiology, Survival Rate/trends, Switzerland/epidemiology, Time Factors, Troponin T/blood.
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  • Mueller, C., Blum, C. A., Trummler, M., Stolz, D., Bingisser, R., Mueller, C., Tamm, M., Mueller, B., Schuetz, P., and Christ-Crain, M. “Association Of Adrenal Function And Disease Severity In Community-Acquired Pneumonia”. Plos One 9, no. 6: e99518. doi:10.1371/journal.pone.0099518.
    Abstract: INTRODUCTION: Rapid and accurate risk stratification in patients with community-acquired pneumonia (CAP) is an unmet clinical need. Cortisol to dehydroepiandrosterone (DHEA) ratio was put forward as a prognostic marker in sepsis. We herein validated the prognostic value of the adrenal hormones DHEA, DHEA-Sulfate (DHEAS), cortisol/DHEA-, cortisol/DHEAS- and DHEA/DHEAS-ratios in patients with CAP. METHODS: We assessed severity of illness using the pneumonia severity index (PSI) and measured adrenal hormone concentrations in 179 serum samples of prospectively recruited patients hospitalized with CAP. We calculated spearman rank correlation, logistic regression analysis and Kaplan Meier curves to study associations of adrenal hormones and outcomes. RESULTS: There was a significant correlation between PSI score and total cortisol (r = 0.24, p = 0.001), DHEAS (r = -0.23, p = 0.002), cortisol/DHEA (r = 0.23, p = 0.003), cortisol/DHEAS (r = 0.32, p = <0.0001) and DHEA/DHEAS (r = 0.20, p = 0.009). In age and gender adjusted logistic regression analysis, cortisol (OR:2.8, 95% CI: 1.48-5.28) and DHEA (OR: 2.62,95% CI: 1.28-5.34), but not DHEAS and the different ratios were associated with all-cause mortality. The discriminatory accuracy of cortisol and DHEA in ROC analysis (area under the curve) was 0.74 and 0.61. In Kaplan Meier analysis, patients in the highest deciles of cortisol and DHEA (p = 0.005 and p = 0.015), and to a lesser extent of cortisol/DHEAS ratio (p = 0.081) had a higher risk of death. CONCLUSION: Cortisol, DHEAS and their ratios correlate with CAP severity, and cortisol and DHEA predict mortality. Adrenal function in severe pneumonia may be an important factor for CAP outcomes.
    Tags: Adrenal Glands/*metabolism, Aged, Aged, 80 and over, Community-Acquired Infections/blood/*diagnosis/*metabolism/mortality, Dehydroepiandrosterone Sulfate/blood/metabolism, Dehydroepiandrosterone/blood/metabolism, Female, Humans, Hydrocortisone/blood/metabolism, Male, Middle Aged, Mortality, Pneumonia/blood/*diagnosis/*metabolism/mortality, Prognosis, ROC Curve, Severity of Illness Index.
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  • Lindner, G., Funk, G. C., Leichtle, A. B., Fiedler, G. M., Schwarz, C., Eleftheriadis, T., Pasch, A., Mohaupt, M. G., Exadaktylos, A. K., and Arampatzis, S. “Impact Of Proton Pump Inhibitor Use On Magnesium Homoeostasis: A Cross-Sectional Study In A Tertiary Emergency Department”. Int J Clin Pract 68, no. 11: 1352-7. doi:10.1111/ijcp.12469.
    Abstract: BACKGROUND: To date, the use of proton pump inhibitors (PPIs) has been associated with a low risk of hypomagnesaemia and associated adverse outcomes. We hypothesised that a better risk estimate could be derived from a large cohort of outpatients admitted to a tertiary emergency department (ED). METHODS: A cross-sectional study was performed in 5118 patients who had measurements of serum magnesium taken on admission to a large tertiary care ED between January 2009 and December 2010. Hypomagnesaemia was defined as a serum magnesium concentration < 0.75 mmol/l. Demographical data, serum electrolyte values, data on medication, comorbidities and outcome with regard to length of hospital stay and mortality were analysed. RESULTS: Serum magnesium was normally distributed where upon 1246 patients (24%) were hypomagnesaemic. These patients had a higher prevalence of out-of-hospital PPI use and diuretic use when compared with patients with magnesium levels > 0.75 mmol/l (both p < 0.0001). In multivariable regression analyses adjusted for PPIs, diuretics, renal function and the Charlson comorbidity index score, the association between use of PPIs and risk for hypomagnesaemia remained significant (OR = 2.1; 95% CI: 1.54-2.85). While mortality was not directly related to low magnesium levels (p = 0.67), the length of hospitalisation was prolonged in these patients even after adjustment for underlying comorbid conditions (p < 0.0001). CONCLUSION: Use of PPIs predisposes patients to hypomagnesaemia and such to prolonged hospitalisation irrespective of the underlying morbidity, posing a critical concern.
    Tags: *Emergency Service, Hospital, Adult, Aged, Cohort Studies, Cross-Sectional Studies, Female, Homeostasis/*drug effects, Humans, Magnesium/*blood, Male, Middle Aged, Prevalence, Proton Pump Inhibitors/adverse effects/*therapeutic use.
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  • Carron, P. N., and Yersin, B. “Cardiopulmonary Resuscitation With Mechanical Chest Compressions And Simultaneous Defibrillation”. Jama 311, no. 21: 2234. doi:10.1001/jama.2014.2089.
    Tags: *Electric Countershock, Cardiopulmonary Resuscitation/*methods, Female, Humans, Male, Out-of-Hospital Cardiac Arrest/*therapy.
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  • Marti-Soler, H., Gubelmann, C., Aeschbacher, S., Alves, L., Bobak, M., Bongard, V., Clays, E., et al. “Seasonality Of Cardiovascular Risk Factors: An Analysis Including Over 230 000 Participants In 15 Countries”. Heart 100, no. 19: 1517-23. doi:10.1136/heartjnl-2014-305623.
    Abstract: OBJECTIVE: To assess the seasonality of cardiovascular risk factors (CVRF) in a large set of population-based studies. METHODS: Cross-sectional data from 24 population-based studies from 15 countries, with a total sample size of 237 979 subjects. CVRFs included Body Mass Index (BMI) and waist circumference; systolic (SBP) and diastolic (DBP) blood pressure; total, high (HDL) and low (LDL) density lipoprotein cholesterol; triglycerides and glucose levels. Within each study, all data were adjusted for age, gender and current smoking. For blood pressure, lipids and glucose levels, further adjustments on BMI and drug treatment were performed. RESULTS: In the Northern and Southern Hemispheres, CVRFs levels tended to be higher in winter and lower in summer months. These patterns were observed for most studies. In the Northern Hemisphere, the estimated seasonal variations were 0.26 kg/m(2) for BMI, 0.6 cm for waist circumference, 2.9 mm Hg for SBP, 1.4 mm Hg for DBP, 0.02 mmol/L for triglycerides, 0.10 mmol/L for total cholesterol, 0.01 mmol/L for HDL cholesterol, 0.11 mmol/L for LDL cholesterol, and 0.07 mmol/L for glycaemia. Similar results were obtained when the analysis was restricted to studies collecting fasting blood samples. Similar seasonal variations were found for most CVRFs in the Southern Hemisphere, with the exception of waist circumference, HDL, and LDL cholesterol. CONCLUSIONS: CVRFs show a seasonal pattern characterised by higher levels in winter, and lower levels in summer. This pattern could contribute to the seasonality of CV mortality.
    Tags: *Cardiovascular Diseases/blood/etiology/mortality/physiopathology, Adult, Aged, Aged, 80 and over, Blood Pressure, Body Mass Index, Cold Temperature/*adverse effects, Cross-Sectional Studies, Data Interpretation, Statistical, Europe/epidemiology, Female, Humans, Lipids/blood, Male, Middle Aged, Mortality, New Zealand/epidemiology, Risk Assessment, Risk Factors, Seasons, Triglycerides/blood.
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  • Misch, F., Messmer, A. S., Nickel, C. H., Gujan, M., Graber, A., Blume, K., and Bingisser, R. “Impact Of Observation On Disposition Of Elderly Patients Presenting To Emergency Departments With Non-Specific Complaints”. Plos One 9, no. 5: e98097. doi:10.1371/journal.pone.0098097.
    Abstract: BACKGROUND: Emergency Departments (EDs) have to cope with an increasing number of elderly patients, often presenting with non-specific complaints (NSC), such as generalized weakness. Acute morbidity requiring early intervention is present in the majority of patients with NSC. Therefore, an early and optimal disposition plan is crucial. The objective of this study was to prospectively study the disposition process of patients presenting to the ED with NSC. METHODS: For two years, all patients presenting with NSC presenting to an urban ED were screened and consecutively included. The initial disposition plan was compared to the effective transfer after observation. Optimal disposition was defined as a high accuracy regarding disposition of patients with acute morbidity to an internal medicine ward. RESULTS: The final study population consisted of 669 patients with NSC. Admission to internal medicine increased from 297 (44%) planned admissions to 388 (58%) effective admissions after observation. Conversely, transfers to geriatric community hospitals and discharges decreased from the initially planned 372 (56%) patients to 281 (42%) effectively transferred and discharged patients. The accuracy regarding disposition of patients with acute morbidity increased from 53% to 68% after observation. CONCLUSION: Disposition planning in patients with NSC improves after observation, if defined by the accuracy regarding hospitalization of patients with acute morbidity. Further research should focus on risk stratification tools for timely disposition planning in order to reduce high admission rates for patients without acute morbidity and high readmission rates for discharged patients with non-specific complaints.
    Tags: Aged, Emergency Service, Hospital/*statistics & numerical data, Fatigue/*diagnosis/epidemiology, Geriatric Assessment/*methods, Humans, Morbidity, Muscle Weakness/*diagnosis/epidemiology, Patient Admission/statistics & numerical data, Prospective Studies, Switzerland/epidemiology.
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  • Maeder, M. M., Basnyat, B., and Harris, N. S. “From Matterhorn To Mt Everest: Empowering Rescuers And Improving Medical Care In Nepal”. Wilderness Environ Med 25, no. 2: 177-81. doi:10.1016/j.wem.2013.12.029.
    Abstract: This article describes a private initiative in which professional Swiss rescuers, based at the foot of the Matterhorn, trained Nepalese colleagues in advanced high altitude helicopter rescue and medical care techniques. What started as a limited program focused on mountain safety has rapidly developed into a comprehensive project to improve rescue and medical care in the Mt Everest area for both foreign travelers and the local Nepalese people.
    Tags: Aircraft, Altitude, Emergency Medical Services/*organization & administration, emergency medicine, Emergency Medicine/*education, Hospitals, Humans, Mountaineering/statistics & numerical data, Nepal, public health, rescue work, Rescue Work/*methods, Wilderness Medicine.
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  • Lindner, G., Pfortmuller, C. A., Leichtle, A. B., Fiedler, G. M., and Exadaktylos, A. K. “Age-Related Variety In Electrolyte Levels And Prevalence Of Dysnatremias And Dyskalemias In Patients Presenting To The Emergency Department”. Gerontology 60, no. 5: 420-3. doi:10.1159/000360134.
    Abstract: BACKGROUND: It was found that age and female gender are predisposing factors for hyponatremia in patients taking thiazides. OBJECTIVE: To investigate whether a relationship exists between age and gender and serum sodium and potassium as well as the prevalence rates in a large population of patients presenting to the emergency department of a university hospital. METHODS: In this retrospective analysis we gathered data on age, gender and current diuretic medication of all patients admitted to the emergency department of a large university hospital with measurement of serum sodium and potassium between January 1, 2009 and December 31, 2010. Prevalence rates of and risk factors for electrolyte disorders were calculated on the basis of these data. RESULTS: A total of 20,667 patients were included in the analysis. Serum sodium levels declined significantly with increasing age while serum potassium rose, independent of diuretic medication at presentation. The prevalence rates of hyponatremia and hyperkalemia increased from 2.3% for hyponatremia in patients aged 16-21 years to 16.9% in patients aged >80 years and from 0.8% for hyperkalemia to 10.4%. In the regression analysis, age >60 years was a predictor for the presence of hyponatremia and hyperkalemia as was current use of diuretic medication. Male gender was associated with a decreased prevalence of hyponatremia and hypokalemia, while it was a predictor of hyperkalemia. CONCLUSIONS: Sodium levels were lower with increasing age, independent of diuretic intake, while potassium levels were higher. We found dramatically increasing prevalences of hyponatremia and hyperkalemia with increasing age, while no such effect could be found for hypernatremia and hypokalemia.
    Tags: Adult, Aged, Aged, 80 and over, Aging/*blood, Diuretics/adverse effects, Emergency Service, Hospital, Female, Humans, Hyperkalemia/blood/epidemiology/etiology, Hyponatremia/blood/epidemiology/etiology, Male, Middle Aged, Potassium/*blood, Prevalence, Retrospective Studies, Risk Factors, Sodium/*blood, Switzerland/epidemiology, Water-Electrolyte Imbalance/blood/*epidemiology/etiology, Young Adult.
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  • Muthuri, S. G., Venkatesan, S., Myles, P. R., Leonardi-Bee, J., Al Khuwaitir, T. S., Al Mamun, A., Anovadiya, A. P., et al. “Effectiveness Of Neuraminidase Inhibitors In Reducing Mortality In Patients Admitted To Hospital With Influenza A H1N1Pdm09 Virus Infection: A Meta-Analysis Of Individual Participant Data”. Lancet Respir Med 2, no. 5: 395-404. doi:10.1016/S2213-2600(14)70041-4.
    Abstract: BACKGROUND: Neuraminidase inhibitors were widely used during the 2009-10 influenza A H1N1 pandemic, but evidence for their effectiveness in reducing mortality is uncertain. We did a meta-analysis of individual participant data to investigate the association between use of neuraminidase inhibitors and mortality in patients admitted to hospital with pandemic influenza A H1N1pdm09 virus infection. METHODS: We assembled data for patients (all ages) admitted to hospital worldwide with laboratory confirmed or clinically diagnosed pandemic influenza A H1N1pdm09 virus infection. We identified potential data contributors from an earlier systematic review of reported studies addressing the same research question. In our systematic review, eligible studies were done between March 1, 2009 (Mexico), or April 1, 2009 (rest of the world), until the WHO declaration of the end of the pandemic (Aug 10, 2010); however, we continued to receive data up to March 14, 2011, from ongoing studies. We did a meta-analysis of individual participant data to assess the association between neuraminidase inhibitor treatment and mortality (primary outcome), adjusting for both treatment propensity and potential confounders, using generalised linear mixed modelling. We assessed the association with time to treatment using time-dependent Cox regression shared frailty modelling. FINDINGS: We included data for 29,234 patients from 78 studies of patients admitted to hospital between Jan 2, 2009, and March 14, 2011. Compared with no treatment, neuraminidase inhibitor treatment (irrespective of timing) was associated with a reduction in mortality risk (adjusted odds ratio [OR] 0.81; 95% CI 0.70-0.93; p=0.0024). Compared with later treatment, early treatment (within 2 days of symptom onset) was associated with a reduction in mortality risk (adjusted OR 0.48; 95% CI 0.41-0.56; p<0.0001). Early treatment versus no treatment was also associated with a reduction in mortality (adjusted OR 0.50; 95% CI 0.37-0.67; p<0.0001). These associations with reduced mortality risk were less pronounced and not significant in children. There was an increase in the mortality hazard rate with each day's delay in initiation of treatment up to day 5 as compared with treatment initiated within 2 days of symptom onset (adjusted hazard ratio [HR 1.23] [95% CI 1.18-1.28]; p<0.0001 for the increasing HR with each day's delay). INTERPRETATION: We advocate early instigation of neuraminidase inhibitor treatment in adults admitted to hospital with suspected or proven influenza infection. FUNDING: F Hoffmann-La Roche.
    Tags: *Influenza A Virus, H1N1 Subtype, *Pandemics, Adolescent, Adult, Antiviral Agents/*therapeutic use, Child, Enzyme Inhibitors/*therapeutic use, Female, Hospitalization, Humans, Influenza, Human/*drug therapy/mortality, Male, Middle Aged, Neuraminidase/*antagonists & inhibitors, Oseltamivir/*therapeutic use, Proportional Hazards Models, Treatment Outcome, Young Adult, Zanamivir/*therapeutic use.
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  • Kherad, O., Bridevaux, P. O., Kaiser, L., Janssens, J. P., and Rutschmann, O. T. “Is Acute Exacerbation Of Copd (Aecopd) Related To Viral Infection Associated With Subsequent Mortality Or Exacerbation Rate?”. Open Respir Med J 8, no. 1: 18-21. doi:10.2174/1874306401408010018.
    Abstract: BACKGROUND: There is a growing interest in better defining risk factors associated with increased susceptibility to exacerbation in patients with COPD. INTRODUCTION: The aim of the study was to determine whether identification of a respiratory virus during a severe acute exacerbation of COPD (AECOPD) increases the risk of subsequent exacerbations and mortality during a one-year followup. METHODS: Secondary analysis of 86 COPD patients admitted for AECOPD between June 2007 and December 2008 at Geneva's University Hospital who were followed up for 1 year. Fifty-one percent of index AECOPD were related to viral infection. Rate of AECOPD, time to next AECOPD, and all-cause mortality were compared between patients with vs without viral index AECOPD. RESULTS: Eighty-one cases were included in this secondary follow-up analysis. Mean exacerbation rate was 1.9 AECOPD per person-year for patients with viral index AECOPD vs 4.0 AECOPD per person year for those with non-viral index AECOPD. Incidence rate ratio (IRR) for subsequent AECOPD during one year follow up was lower for patients with viral index AECOPD (IRR 0.57; [CI 95% 0.39-0.84]), after controlling for previous exacerbations, and was strongly associated with the number of exacerbations in the year preceding the index AECOPD. During the one-year follow-up period, 16 patients (19%) died. In a Cox regression model, patients with a proven viral infection did not have a higher mortality (HR 0.56 [CI 95% 0.20 -1.58]). CONCLUSION: Viral AECOPD was not associated with a higher rate of subsequent exacerbations or mortality during the following year.
    Tags: Copd, exacerbation, phenotype, virus..
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  • Buttner, M., Schlittler, F. L., Michel, C., Exadaktylos, A. K., and Iizuka, T. “Is A Black Eye A Useful Sign Of Facial Fractures In Patients With Minor Head Injuries? A Retrospective Analysis In A Level I Trauma Centre Over 10 Years”. Br J Oral Maxillofac Surg 52, no. 6: 518-22. doi:10.1016/j.bjoms.2014.03.018.
    Abstract: Orbital blunt trauma is common, and the diagnosis of a fracture should be made by computed tomographic (CT) scan. However, this will expose patients to ionising radiation. Our objective was to identify clinical predictors of orbital fracture, in particular the presence of a black eye, to minimise unnecessary exposure to radiation. A 10-year retrospective study was made of the medical records of all patients with minor head trauma who presented with one or two black eyes to our emergency department between May 2000 and April 2010. Each of the patients had a CT scan, was over 16 years old, and had a Glasgow Coma Score (GCS) of 13-15. The primary outcome was whether the black eye was a valuable predictor of a fracture. Accompanying clinical signs were considered as a secondary outcome. A total of 1676 patients (mean (SD) age 51 (22) years) and minor head trauma with either one or two black eyes were included. In 1144 the CT scan showed a fracture of the maxillofacial skeleton, which gave an incidence of 68.3% in whom a black eye was the obvious symptom. Specificity for facial fractures was particularly high for other clinical signs, such as diminished skin sensation (specificity 96.4%), diplopia or occulomotility disorders (89.3%), fracture steps (99.8%), epistaxis (95.5%), subconjunctival haemorrhage (90.4%), and emphysema (99.6%). Sensitivity for the same signs ranged from 10.8% to 22.2%. The most striking fact was that 68.3% of all patients with a black eye had an underlying fracture. We therefore conclude that a CT scan should be recommended for every patient with minor head injury who presents with a black eye.
    Tags: Adolescent, Adult, Aged, Aged, 80 and over, Black eye, Clinical predictors, Computed tomography, Conjunctival Diseases/diagnosis, Diplopia/diagnosis, Emphysema/diagnosis, Epistaxis/diagnosis, Facial Bones/injuries, Forecasting, Glasgow Coma Scale, Hematoma/*diagnosis, Hemorrhage/diagnosis, Humans, Hypesthesia/diagnosis, Middle Aged, Ocular Motility Disorders/diagnosis, Orbital Diseases/*diagnosis, Orbital fractures, Orbital Fractures/*diagnosis, Retrospective Studies, Retrospective study, Sensitivity and Specificity, Skull Fractures/diagnosis, Tomography, X-Ray Computed/methods, Wounds, Nonpenetrating/*diagnosis, Young Adult.
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  • Muller-Juge, V., Cullati, S., Blondon, K. S., Hudelson, P., Maitre, F., Vu, N. V., Savoldelli, G. L., and Nendaz, M. R. “Interprofessional Collaboration Between Residents And Nurses In General Internal Medicine: A Qualitative Study On Behaviours Enhancing Teamwork Quality”. Plos One 9, no. 4: e96160. doi:10.1371/journal.pone.0096160.
    Abstract: BACKGROUND: Effective teamwork is necessary for optimal patient care. There is insufficient understanding of interactions between physicians and nurses on internal medicine wards. OBJECTIVE: To describe resident physicians' and nurses' actual behaviours contributing to teamwork quality in the setting of a simulated internal medicine ward. METHODS: A volunteer sample of 14 pairs of residents and nurses in internal medicine was asked to manage one non-urgent and one urgent clinical case in a simulated ward, using a high-fidelity manikin. After the simulation, participants attended a stimulated-recall session during which they viewed the videotape of the simulation and explained their actions and perceptions. All simulations were transcribed, coded, and analyzed, using a qualitative method (template analysis). Quality of teamwork was assessed, based on patient management efficiency and presence of shared management goals and of team spirit. RESULTS: Most resident-nurse pairs tended to interact in a traditional way, with residents taking the leadership and nurses executing medical prescriptions and assuming their own specific role. They also demonstrated different types of interactions involving shared responsibilities and decision making, constructive suggestions, active communication and listening, and manifestations of positive team building. The presence of a leader in the pair or a truly shared leadership between resident and nurse contributed to teamwork quality only if both members of the pair demonstrated sufficient autonomy. In case of a lack of autonomy of one member, the other member could compensate for it, if his/her own autonomy was sufficiently strong and if there were demonstrations of mutual listening, information sharing, and positive team building. CONCLUSIONS: Although they often relied on traditional types of interaction, residents and nurses also demonstrated readiness for increased sharing of responsibilities. Interprofessional education should insist on better redefinition of respective roles and reinforce behaviours shown to enhance teamwork quality.
    Tags: *Cooperative Behavior, *Internal Medicine, *Physician-Nurse Relations, Adult, Attitude of Health Personnel, Female, Humans, Leadership, Male, Nurses, Patient Care, Patient Care Team, Physicians, Qualitative Research, Quality of Health Care.
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  • Schoenenberger, A. W., Bieri, C., Ozguler, O., Moser, A., Haberkern, M., Zimmermann, H., Stuck, A. E., and Exadaktylos, A. “A Novel Multidimensional Geriatric Screening Tool In The Ed: Evaluation Of Feasibility And Clinical Relevance”. Am J Emerg Med 32, no. 6: 623-8. doi:10.1016/j.ajem.2014.03.024.
    Abstract: PURPOSES: Geriatric problems frequently go undetected in older patients in emergency departments (EDs), thus increasing their risk of adverse outcomes. We evaluated a novel emergency geriatric screening (EGS) tool designed to detect geriatric problems. BASIC PROCEDURES: The EGS tool consisted of short validated instruments used to screen 4 domains (cognition, falls, mobility, and activities of daily living). Emergency geriatric screening was introduced for ED patients 75 years or older throughout a 4-month period. We analyzed the prevalence of abnormal EGS and whether EGS increased the number of EGS-related diagnoses in the ED during the screening, as compared with a preceding control period. MAIN FINDINGS: Emergency geriatric screening was performed on 338 (42.5%) of 795 patients presenting during screening. Emergency geriatric screening was unfeasible in 175 patients (22.0%) because of life-threatening conditions and was not performed in 282 (35.5%) for logistical reasons. Emergency geriatric screening took less than 5 minutes to perform in most (85.8%) cases. Among screened patients, 285 (84.3%) had at least 1 abnormal EGS finding. In 270 of these patients, at least 1 abnormal EGS finding did not result in a diagnosis in the ED and was reported for further workup to subsequent care. During screening, 142 patients (42.0%) had at least 1 diagnosis listed within the 4 EGS domains, significantly more than the 29.3% in the control period (odds ratio 1.75; 95% confidence interval, 1.34-2.29; P<.001). Emergency geriatric screening predicted nursing home admission after the in-hospital stay (odds ratio for >/=3 vs <3 abnormal domains 12.13; 95% confidence interval, 2.79-52.72; P=.001). PRINCIPAL CONCLUSIONS: The novel EGS is feasible, identifies previously undetected geriatric problems, and predicts determinants of subsequent care.
    Tags: *Emergency Service, Hospital/statistics & numerical data, Accidental Falls, Activities of Daily Living, Aged, Aged, 80 and over, Cognition Disorders/diagnosis, Feasibility Studies, Female, Geriatric Assessment/*methods/statistics & numerical data, Humans, Male, Mobility Limitation, Prospective Studies, Reproducibility of Results.
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  • Junod Perron, N., Nendaz, M., Louis-Simonet, M., Sommer, J., Gut, A., Cerutti, B., van der Vleuten, C. P., and Dolmans, D. “Impact Of Postgraduate Training On Communication Skills Teaching: A Controlled Study”. Bmc Med Educ 14, no. 1: 80. doi:10.1186/1472-6920-14-80.
    Abstract: BACKGROUND: Observation of performance followed by feedback is the key to good teaching of communication skills in clinical practice. The fact that it occurs rarely is probably due to clinical supervisors' perceived lack of competence to identify communication skills and give effective feedback. We evaluated the impact of a faculty development programme on communication skills teaching on clinical supervisors' ability to identify residents' good and poor communication skills and to discuss them interactively during feedback. METHODS: We conducted a pre-post controlled study in which clinical supervisors took part to a faculty development program on teaching communication skills in clinical practice. Outcome measures were the number and type of residents' communication skills identified by supervisors in three videotaped simulated resident-patient encounters and the number and type of communication skills discussed interactively with residents during three feedback sessions. RESULTS: 48 clinical supervisors (28 intervention group; 20 control group) participated. After the intervention, the number and type of communication skills identified did not differ between both groups. There was substantial heterogeneity in the number and type of communication skills identified. However, trained participants engaged in interactive discussions with residents on a significantly higher number of communication items (effect sizes 0.53 to 1.77); communication skills items discussed interactively included both structural and patient-centered elements that were considered important to be observed by expert teachers. CONCLUSIONS: The faculty development programme did not increase the number of communication skills recognised by supervisors but was effective in increasing the number of communication issues discussed interactively in feedback sessions. Further research should explore the respective impact of accurate identification of communication skills and effective teaching skills on achieving more effective communication skills teaching in clinical practice.
    Tags: *Clinical Competence, *Communication, *Education, Medical, Graduate, Adult, Faculty, Medical/standards, Feedback, Female, Humans, Male, Middle Aged, Teaching/*methods, Video Recording.
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  • Rohacek, M., Edenhofer, H., Bircher, A., and Bingisser, R. “Biphasic Anaphylactic Reactions: Occurrence And Mortality”. Allergy 69, no. 6: 791-7. doi:10.1111/all.12404.
    Abstract: BACKGROUND: Monitoring after complete resolution of anaphylactic reactions is recommended. The aim of this study was to define the occurrence of biphasic - and clinically important biphasic - anaphylactic reactions, the number of transfers to intensive care units (ICU) because of anaphylaxis, and the number of deaths within 10 days of presentation to the emergency department (ED). METHODS: Clinical records of patients visiting the ED of a tertiary care hospital were analysed retrospectively. Hospital databases, direct contact with patients and caregivers, and the Internet were used to obtain mortality rates. RESULTS: Of 259 557 ED presentations from February 2001 through to August 2013, 1334 (0.51%) episodes of allergic reactions were detected, and 532 (0.20%) episodes in 495 patients fulfilled the definition of anaphylaxis. In 227 (44.8%) episodes, the length of hospital stay was >/=8 h (median 22 h, IQR 16-24). There were 507 uniphasic and 25 (4.5%) biphasic anaphylactic reactions. Twelve (2.3%) were clinically important, including 2 (0.36%) that occurred during hospital stay, one of whom (0.19%) was transferred to ICU for shock. No risk factors for biphasic reactions could be found. Eight patients were lost to follow-up. There were no deaths during the 10-day follow-up. CONCLUSION: Biphasic anaphylactic reactions, especially clinically important ones, occurred rarely, and no mortality was found, whether the monitoring was for >/=8 h or for <8 h. Our study could motivate physicians to consider discharging patients after complete resolution of an anaphylactic reaction and to dispense with prolonged monitoring.
    Tags: Adult, anaphylaxis, Anaphylaxis/*epidemiology/etiology/mortality, Databases, Factual, Disease Management, epidemiology, Female, Humans, Male, Middle Aged, Patient Outcome Assessment, Retrospective Studies, Risk Factors, Switzerland/epidemiology.
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  • Pfortmueller, C. A., Kunz, M., Lindner, G., Zisakis, A., Puig, S., and Exadaktylos, A. K. “Fall-Related Emergency Department Admission: Fall Environment And Settings And Related Injury Patterns In 6357 Patients With Special Emphasis On The Elderly”. Scientificworldjournal 2014: 256519. doi:10.1155/2014/256519.
    Abstract: PRINCIPALS: Throughout the world, falls are a major public health problem and a socioeconomic burden. Nevertheless there is little knowledge about how the injury types may be related to the aetiology and setting of the fall, especially in the elderly. We have therefore analysed all patients presenting with a fall to our Emergency Department (ED) over the past five years. METHODS: Our retrospective data analysis comprised adult patients admitted to our Emergency Department between January 1, 2006, and December 31, 2010, in relation to a fall. RESULTS: Of a total of 6357 patients 78% (n = 4957) patients were younger than 75 years. The main setting for falls was patients home (n = 2239, 35.3%). In contrast to the younger patients, the older population was predominantly female (56.3% versus 38.6%; P < 0.0001). Older patients were more likely to fall at home and suffer from medical conditions (all P < 0.0001). Injuries to the head (P < 0.0001) and to the lower extremity (P < 0.019) occurred predominantly in the older population. Age was the sole predictor for recurrent falls (OR 1.2, P < 0.0001). CONCLUSION: Falls at home are the main class of falls for all age groups, particularly in the elderly. Fall prevention strategies must therefore target activities of daily living. Even though falls related to sports mostly take place in the younger cohort, a significant percentage of elderly patients present with falls related to sporting activity. Falls due to medical conditions were most likely to result in mild traumatic brain injury.
    Tags: *Environment, Accidental Falls/*statistics & numerical data, Adolescent, Adult, Age Distribution, Aged, Aged, 80 and over, Child, Child, Preschool, Craniocerebral Trauma/*epidemiology, Emergency Service, Hospital/*statistics & numerical data, Female, Humans, Infant, Leg Injuries/*epidemiology, Male, Middle Aged, Multiple Trauma/*epidemiology, Patient Admission/*statistics & numerical data, Prevalence, Risk Assessment, Sex Distribution, Switzerland/epidemiology, Young Adult.
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  • Bodenmann, P., Favrat, B., Wolff, H., Guessous, I., Panese, F., Herzig, L., Bischoff, T., Casillas, A., Golano, T., and Vaucher, P. “Screening Primary-Care Patients Forgoing Health Care For Economic Reasons”. Plos One 9, no. 4: e94006. doi:10.1371/journal.pone.0094006.
    Abstract: BACKGROUND: Growing social inequities have made it important for general practitioners to verify if patients can afford treatment and procedures. Incorporating social conditions into clinical decision-making allows general practitioners to address mismatches between patients' health-care needs and financial resources. OBJECTIVES: Identify a screening question to, indirectly, rule out patients' social risk of forgoing health care for economic reasons, and estimate prevalence of forgoing health care and the influence of physicians' attitudes toward deprivation. DESIGN: Multicenter cross-sectional survey. PARTICIPANTS: Forty-seven general practitioners working in the French-speaking part of Switzerland enrolled a random sample of patients attending their private practices. MAIN MEASURES: Patients who had forgone health care were defined as those reporting a household member (including themselves) having forgone treatment for economic reasons during the previous 12 months, through a self-administered questionnaire. Patients were also asked about education and income levels, self-perceived social position, and deprivation levels. KEY RESULTS: Overall, 2,026 patients were included in the analysis; 10.7% (CI95% 9.4-12.1) reported a member of their household to have forgone health care during the 12 previous months. The question "Did you have difficulties paying your household bills during the last 12 months" performed better in identifying patients at risk of forgoing health care than a combination of four objective measures of socio-economic status (gender, age, education level, and income) (R(2) = 0.184 vs. 0.083). This question effectively ruled out that patients had forgone health care, with a negative predictive value of 96%. Furthermore, for physicians who felt powerless in the face of deprivation, we observed an increase in the odds of patients forgoing health care of 1.5 times. CONCLUSION: General practitioners should systematically evaluate the socio-economic status of their patients. Asking patients whether they experience any difficulties in paying their bills is an effective means of identifying patients who might forgo health care.
    Tags: Adolescent, Adult, Aged, Aged, 80 and over, Cross-Sectional Studies, Female, Humans, Male, Middle Aged, Primary Health Care/*economics, Socioeconomic Factors, Surveys and Questionnaires, Switzerland, Young Adult.
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  • Lindner, G. “Hyponatremia In The Critically Ill: Time For A Change”. Indian J Crit Care Med 18, no. 2: 55-6. doi:10.4103/0972-5229.126071.
  • Alwan, H., Pruijm, M., Ponte, B., Ackermann, D., Guessous, I., Ehret, G., Staessen, J. A., et al. “Epidemiology Of Masked And White-Coat Hypertension: The Family-Based Skipogh Study”. Plos One 9, no. 3: e92522. doi:10.1371/journal.pone.0092522.
    Abstract: OBJECTIVE: We investigated factors associated with masked and white-coat hypertension in a Swiss population-based sample. METHODS: The Swiss Kidney Project on Genes in Hypertension is a family-based cross-sectional study. Office and 24-hour ambulatory blood pressure were measured using validated devices. Masked hypertension was defined as office blood pressure<140/90 mmHg and daytime ambulatory blood pressure>/=135/85 mmHg. White-coat hypertension was defined as office blood pressure>/=140/90 mmHg and daytime ambulatory blood pressure<135/85 mmHg. Mixed-effect logistic regression was used to examine the relationship of masked and white-coat hypertension with associated factors, while taking familial correlations into account. High-normal office blood pressure was defined as systolic/diastolic blood pressure within the 130-139/85-89 mmHg range. RESULTS: Among the 652 participants included in this analysis, 51% were female. Mean age (+/-SD) was 48 (+/-18) years. The proportion of participants with masked and white coat hypertension was respectively 15.8% and 2.6%. Masked hypertension was associated with age (odds ratio (OR) = 1.02, p = 0.012), high-normal office blood pressure (OR = 6.68, p<0.001), and obesity (OR = 3.63, p = 0.001). White-coat hypertension was significantly associated with age (OR = 1.07, p<0.001) but not with education, family history of hypertension, or physical activity. CONCLUSIONS: Our findings suggest that physicians should consider ambulatory blood pressure monitoring for older individuals with high-normal office blood pressure and/or who are obese.
    Tags: *Family, Adult, Female, Humans, Male, Masked Hypertension/*epidemiology, Middle Aged, Switzerland/epidemiology, White Coat Hypertension/*epidemiology.
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  • Pfortmueller, C. A., Funk, G. C., Leichtle, A. B., Fiedler, G. M., Schwarz, C., Exadaktylos, A. K., and Lindner, G. “Electrolyte Disorders And In-Hospital Mortality During Prolonged Heat Periods: A Cross-Sectional Analysis”. Plos One 9, no. 3: e92150. doi:10.1371/journal.pone.0092150.
    Abstract: BACKGROUND: Heat periods during recent years were associated with excess hospitalization and mortality rates, especially in the elderly. We intended to study whether prolonged warmth/heat periods are associated with an increased prevalence of disorders of serum sodium and potassium and an increased hospital mortality. METHODS: In this cross-sectional analysis all patients admitted to the Department of Emergency Medicine of a large tertiary care facility between January 2009 and December 2010 with measurements of serum sodium were included. Demographic data along with detailed data on diuretic medication, length of hospital stay and hospital mortality were obtained for all patients. Data on daily temperatures (maximum, mean, minimum) and humidity were retrieved by Meteo Swiss. RESULTS: A total of 22.239 patients were included in the study. 5 periods with a temperature exceeding 25 degrees C for 3 to 5 days were noticed and 2 periods with temperatures exceeding 25 degrees C for more than 5 days were noted. Additionally, 2 periods with 3 to 5 days with daily temperatures exceeding 30 degrees C were noted during the study period. We found a significantly increased prevalence of hyponatremia during heat periods. However, in the Cox regression analysis, prolonged heat was not associated with the prevalence of disorders of serum sodium or potassium. Admission during a heat period was an independent predictor for hospital mortality. CONCLUSIONS: Although we found an increased prevalence of hyponatremia during heat periods, no convincing connection could be found for hypernatremia or disorders of serum potassium.
    Tags: *Hospital Mortality, *Hot Temperature, Adult, Aged, Aged, 80 and over, Cross-Sectional Studies, Diuretics/administration & dosage/therapeutic use, Dose-Response Relationship, Drug, Female, Hospitalization/statistics & numerical data, Humans, Humidity, Male, Middle Aged, Prevalence, Proportional Hazards Models, Seasons, Switzerland/epidemiology, Water-Electrolyte Imbalance/*mortality.
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  • Righini, M., Van Es, J., Den Exter, P. L., Roy, P. M., Verschuren, F., Ghuysen, A., Rutschmann, O. T., et al. “Age-Adjusted D-Dimer Cutoff Levels To Rule Out Pulmonary Embolism: The Adjust-Pe Study”. Jama 311, no. 11: 1117-24. doi:10.1001/jama.2014.2135.
    Abstract: IMPORTANCE: D-dimer measurement is an important step in the diagnostic strategy of clinically suspected acute pulmonary embolism (PE), but its clinical usefulness is limited in elderly patients. OBJECTIVE: To prospectively validate whether an age-adjusted D-dimer cutoff, defined as age x 10 in patients 50 years or older, is associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. DESIGN, SETTINGS, AND PATIENTS: A multicenter, multinational, prospective management outcome study in 19 centers in Belgium, France, the Netherlands, and Switzerland between January 1, 2010, and February 28, 2013. INTERVENTIONS: All consecutive outpatients who presented to the emergency department with clinically suspected PE were assessed by a sequential diagnostic strategy based on the clinical probability assessed using either the simplified, revised Geneva score or the 2-level Wells score for PE; highly sensitive D-dimer measurement; and computed tomography pulmonary angiography (CTPA). Patients with a D-dimer value between the conventional cutoff of 500 microg/L and their age-adjusted cutoff did not undergo CTPA and were left untreated and formally followed-up for a 3-month period. MAIN OUTCOMES AND MEASURES: The primary outcome was the failure rate of the diagnostic strategy, defined as adjudicated thromboembolic events during the 3-month follow-up period among patients not treated with anticoagulants on the basis of a negative age-adjusted D-dimer cutoff result. RESULTS: Of the 3346 patients with suspected PE included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level lower than 500 microg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a D-dimer between 500 microg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%). The 3-month failure rate in patients with a D-dimer level higher than 500 microg/L but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI, 0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a nonhigh clinical probability, using the age-adjusted cutoff instead of the 500 microg/L cutoff increased the proportion of patients in whom PE could be excluded on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to 200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional false-negative findings. CONCLUSIONS AND RELEVANCE: Compared with a fixed D-dimer cutoff of 500 microg/L, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01134068.
    Tags: Acute Disease, Age Factors, Aged, Angiography, Diagnostic Errors, Emergency Service, Hospital, Europe/epidemiology, Female, Fibrin Fibrinogen Degradation Products/*analysis, Humans, Male, Outpatients, Prevalence, Probability, Prospective Studies, Pulmonary Embolism/blood/*diagnosis/epidemiology, Reference Values, Risk, Sensitivity and Specificity, Venous Thromboembolism/blood/*epidemiology.
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  • Junod Perron, N., Cullati, S., Hudelson, P., Nendaz, M., Dolmans, D., and van der Vleuten, C. “Impact Of A Faculty Development Programme For Teaching Communication Skills On Participants' Practice”. Postgrad Med J 90, no. 1063: 245-50. doi:10.1136/postgradmedj-2012-131700.
    Abstract: PURPOSE OF THE STUDY: A 6-month faculty development programme was designed to improve supervisors' feedback to junior doctors on their clinical communication skills (CS) and included both CS and teaching skills training. The aim of this study was to assess supervisors' views on the impact of the programme on their subsequent teaching and communication practice. STUDY DESIGN: 28 clinical supervisors at the Geneva University Hospitals, from either inpatient or outpatient settings (general internists or primary care specialists), undertook a six-session faculty development programme, between 2009 and 2011, and each completed a short questionnaire before and 1 month after the course. Between 3 and 6 months after the course, the participants were interviewed about their views on the impact of the course on their practice using a semistructured interview. Interviews were audiotaped and transcribed verbatim and analysed thematically. RESULTS: The percentage of participants who reported teaching CS at least once a week had increased from 5/26 (19%) to 8/26 (30%), p=0.07. Participants reported using teaching skills, especially giving structured feedback. Use of newly acquired teaching skills was more likely when participants had protected time for teaching or were involved in formal teaching activities. Even participants who reported minimal teaching activity found the newly acquired CS to be useful, both with their own patients and in other professional situations. The few participants who explicitly reported teaching regularly CS in practice had generally become formal teachers in CS training. CONCLUSIONS: A faculty development programme on how to teach CS is perceived to be useful by clinical supervisors to acquire new skills, but using them in the workplace appears to depend on creation of a supportive environment with protected time for teaching. Involving supervisors in formal communication teaching may be one way to ensure continued use of newly learned teaching skills.
    Tags: *Communication, *Staff Development, Attitude of Health Personnel, Clinical Competence/*standards, communication skills, Education, Medical, Graduate/*standards, faculty programme, Faculty, Medical, Female, Hospitals, University, Humans, Male, Physicians, practice, Professional Competence/standards, Program Development, Surveys and Questionnaires, Switzerland, teaching, transfer.
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  • Grossmann, F. F., Hasemann, W., Graber, A., Bingisser, R., Kressig, R. W., and Nickel, C. H. “Screening, Detection And Management Of Delirium In The Emergency Department - A Pilot Study On The Feasibility Of A New Algorithm For Use In Older Emergency Department Patients: The Modified Confusion Assessment Method For The Emergency Department (Mcam-Ed)”. Scand J Trauma Resusc Emerg Med 22, no. 1: 19. doi:10.1186/1757-7241-22-19.
    Abstract: BACKGROUND: Delirium in emergency department (ED) patients occurs frequently and often remains unrecognized. Most instruments for delirium detection are complex and therefore unfeasible for the ED. The aims of this pilot study were first, to confirm our hypothesis that there is an unmet need for formal delirium assessment by comparing informal delirium ratings of ED staff with formal delirium assessments performed by trained research assistants. Second, to test the feasibility of an algorithm for delirium screening, detection and management, which includes the newly developed modified Confusion Assessment Method for the Emergency Department (mCAM-ED) at the ED bedside. Third, to test interrater reliability of the mCAM-ED. METHODS: This was a pilot study with a pre-post-test design with two data collection periods before and after the implementation of the algorithm. Consecutive ED patients aged 65 years and older were screened and assessed in the ED of a tertiary care center by trained research assistants. The delirium detection rate of informal ratings by nurses and physicians was compared with the standardized mCAM-ED assessment performed by the research assistants. To show the feasibility at the ED bedside, defined as adherence of ED staff to the algorithm, only post-test data were used. Additionally, the ED nurses' assessments were analyzed qualitatively. To investigate the agreement between research assistants and the reference standard, the two data sets were combined. RESULTS: In total, 207 patients were included in this study. We found that informal delirium assessment was inappropriate, even after a teaching intervention: Sensitivity of nurses to detect delirium without formal assessment was 0.27 pretest and 0.40 post-test, whilst sensitivity of physicians' informal rating was 0.45 pre-test and 0.6 post-test. ED staff demonstrated high adherence to the algorithm (76.5%). Research assistants assessing delirium with the mCAM-ED demonstrated a high agreement compared to the reference standard (kappa = 0.729). CONCLUSIONS: Informal assessment of delirium is inadequate. The mCAM-ED proved to be useful at the ED bedside. Performance criteria need to be tested in further studies. The mCAM-ED may contribute to early identification of delirious ED patients.
    Tags: *Algorithms, *Disease Management, Age Distribution, Age Factors, Aged, Aged, 80 and over, Cross-Sectional Studies, Delirium/*diagnosis/epidemiology/therapy, Emergency Service, Hospital/*statistics & numerical data, Feasibility Studies, Female, Geriatric Assessment/*methods, Humans, Incidence, Male, Pilot Projects, Prevalence, Prospective Studies, Reproducibility of Results, Switzerland/epidemiology.
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  • Haller, D. M., Meynard, A., Lefebvre, D., Ukoumunne, O. C., Narring, F., and Broers, B. “Effectiveness Of Training Family Physicians To Deliver A Brief Intervention To Address Excessive Substance Use Among Young Patients: A Cluster Randomized Controlled Trial”. Cmaj 186, no. 8: E263-72. doi:10.1503/cmaj.131301.
    Abstract: BACKGROUND: Brief interventions delivered by family physicians to address excessive alcohol use among adult patients are effective. We conducted a study to determine whether such an intervention would be similarly effective in reducing binge drinking and excessive cannabis use among young people. METHODS: We conducted a cluster randomized controlled trial involving 33 family physicians in Switzerland. Physicians in the intervention group received training in delivering a brief intervention to young people during the consultation in addition to usual care. Physicians in the control group delivered usual care only. Consecutive patients aged 15-24 years were recruited from each practice and, before the consultation, completed a confidential questionnaire about their general health and substance use. Patients were followed up at 3, 6 and 12 months after the consultation. The primary outcome measure was self-reported excessive substance use (>/= 1 episode of binge drinking, or >/= 1 joint of cannabis per week, or both) in the past 30 days. RESULTS: Of the 33 participating physicians, 17 were randomly allocated to the intervention group and 16 to the control group. Of the 594 participating patients, 279 (47.0%) identified themselves as binge drinkers or excessive cannabis users, or both, at baseline. Excessive substance use did not differ significantly between patients whose physicians were in the intervention group and those whose physicians were in the control group at any of the follow-up points (odds ratio [OR] and 95% confidence interval [CI] at 3 months: 0.9 [0.6-1.4]; at 6 mo: 1.0 [0.6-1.6]; and at 12 mo: 1.1 [0.7-1.8]). The differences between groups were also nonsignificant after we restricted the analysis to patients who reported excessive substance use at baseline (OR 1.6, 95% CI 0.9-2.8, at 3 mo; OR 1.7, 95% CI 0.9-3.2, at 6 mo; and OR 1.9, 95% CI 0.9-4.0, at 12 mo). INTERPRETATION: Training family physicians to use a brief intervention to address excessive substance use among young people was not effective in reducing binge drinking and excessive cannabis use in this patient population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, no. ACTRN12608000432314.
    Tags: Adolescent, Alcoholism/*prevention & control/therapy, Attitude of Health Personnel, Cluster Analysis, Confidence Intervals, Female, Humans, Male, Odds Ratio, Patient Education as Topic, Physicians, Family/*education, Pilot Projects, Practice Patterns, Physicians', Substance-Related Disorders/*prevention & control/therapy, Switzerland, Treatment Outcome, Young Adult.
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  • Pfortmueller, C. A., Marti, M., Kunz, M., Lindner, G., and Exadaktylos, A. K. “Injury Severity And Mortality Of Adult Zebra Crosswalk And Non-Zebra Crosswalk Road Crossing Accidents: A Cross-Sectional Analysis”. Plos One 9, no. 3: e90835. doi:10.1371/journal.pone.0090835.
    Abstract: PRINCIPALS: Over a million people worldwide die each year from road traffic injuries and more than 10 million sustain permanent disabilities. Many of these victims are pedestrians. The present retrospective study analyzes the severity and mortality of injuries suffered by adult pedestrians, depending on whether they used a zebra crosswalk. METHODS: Our retrospective data analysis covered adult patients admitted to our emergency department (ED) between 1 January 2000 and 31 December 2012 after being hit by a vehicle while crossing the road as a pedestrian. Patients were identified by using a string term. Medical, police and ambulance records were reviewed for data extraction. RESULTS: A total of 347 patients were eligible for study inclusion. Two hundred and three (203; 58.5%) patients were on a zebra crosswalk and 144 (41.5%) were not. The mean ISS (injury Severity Score) was 12.1 (SD 14.7, range 1-75). The vehicles were faster in non-zebra crosswalk accidents (47.7 km/n, versus 41.4 km/h, p<0.027). The mean ISS score was higher in patients with non-zebra crosswalk accidents; 14.4 (SD 16.5, range 1-75) versus 10.5 (SD13.14, range 1-75) (p<0.019). Zebra crosswalk accidents were associated with less risk of severe injury (OR 0.61, 95% CI 0.38-0.98, p<0.042). Accidents involving a truck were associated with increased risk of severe injury (OR 3.53, 95%CI 1.21-10.26, p<0.02). CONCLUSION: Accidents on zebra crosswalks are more common than those not on zebra crosswalks. The injury severity of non-zebra crosswalk accidents is significantly higher than in patients with zebra crosswalk accidents. Accidents involving large vehicles are associated with increased risk of severe injury. Further prospective studies are needed, with detailed assessment of motor vehicle types and speed.
    Tags: Accidents, Traffic/mortality/*statistics & numerical data, Adult, Analysis of Variance, Cross-Sectional Studies, Humans, Kaplan-Meier Estimate, Odds Ratio, Retrospective Studies, Risk Factors, Switzerland/epidemiology, Wounds and Injuries/*epidemiology.
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  • Gero, D., Irinel Simion, N., Vuilleumier, H., Denys, A., Guiu, B., Demartines, N., and Bize, P. E. “Arterial Embolization In Idiopathic Spontaneous Intra-Peritoneal Hemorrhage: Case Report And Review”. Diagn Interv Imaging 95, no. 9: 873-5. doi:10.1016/j.diii.2013.12.006.
    Tags: Abdominal apoplexy, Arterial catheter embolization, Embolization, Therapeutic/*methods, Extravasation of Diagnostic and Therapeutic Materials/diagnostic imaging/therapy, Follow-Up Studies, Hemoperitoneum, Hemoperitoneum/diagnostic imaging/*therapy, Humans, Idiopathic spontaneous intra-peritoneal hemorrhage, Male, Middle Aged, Multidetector Computed Tomography, Rectum/blood supply, Superior rectal artery rupture.
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  • Szucs-Farkas, Z., Christe, A., Megyeri, B., Rohacek, M., Vock, P., Nagy, E. V., Heverhagen, J. T., and Schindera, S. T. “Diagnostic Accuracy Of Computed Tomography Pulmonary Angiography With Reduced Radiation And Contrast Material Dose: A Prospective Randomized Clinical Trial”. Invest Radiol 49, no. 4: 201-8. doi:10.1097/RLI.0000000000000016.
    Abstract: OBJECTIVE: The objective of the study was to test the diagnostic performance of low-dose computed tomography pulmonary angiography (CTPA) at peak tube voltage of 80 kVp with both reduced radiation and reduced contrast material (CM) dose. MATERIALS AND METHODS: In this single-center, single-blinded prospective randomized trial, 501 patients with body weights of less than 100 kg with suspected acute pulmonary embolism (PE) were assigned to normal-dose CTPA (100-kVp tube energy and 100-mL CM, 255 patients) and low-dose CTPA (80-kVp tube energy and 75-mL CM, 246 patients). Primary end points were evidence of PE in CTPA and accuracy of CTPA on a composite reference standard. Results were compared by calculating the odds ratio with the 95% confidence interval. RESULTS: The reference diagnosis was equivocal in 20 of the 501 patients. Diagnosis of CTPA was correct in 240 patients and incorrect in 5 in the normal-dose group. Computed tomography pulmonary angiography was correct in 230 patients and incorrect in 6 in the low-dose group (odds ratio, 1.25; 95% confidence interval, 0.38-4.16; P = 0.77). Sensitivity was 96.9% and 100% and specificity was 98.1% and 97.1% in the normal-dose and low-dose groups, respectively. No PE or PE-related death occurred during the 90-day follow-up. The size-specific dose estimates were 30% lower at 80 kVp (4.8 +/- 1.0 mGy) compared with that at 100 kVp (6.8 +/- 1.2 mGy; P < 0.001). CONCLUSIONS: The accuracy of low-dose CTPA at 80 kVp with a 30% reduced radiation dose and a 25% lower CM volume is not significantly different from that of normal-dose CTPA at 100 kVp in detecting acute PE in patients weighing less than 100 kg.
    Tags: *Radiation Dosage, Angiography/*methods, Contrast Media/administration & dosage, Dose-Response Relationship, Drug, Dose-Response Relationship, Radiation, Female, Humans, Iohexol/administration & dosage/*analogs & derivatives, Male, Middle Aged, Observer Variation, Prospective Studies, Pulmonary Embolism/*diagnostic imaging, Radiation Protection/*methods, Radiographic Image Enhancement/methods, Reproducibility of Results, Sensitivity and Specificity, Single-Blind Method, Tomography, X-Ray Computed/*methods.
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  • Lindner, G. “Dysnatremias In The Icu: Prospective Intervention Studies Needed”. Minerva Anestesiol 80, no. 10: 1074-5. https://www.ncbi.nlm.nih.gov/pubmed/24430010.
    Tags: *Hyponatremia, *Sodium, Humans, Intensive Care Units, Prospective Studies.
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  • Pfortmueller, C. A., Stotz, M., Lindner, G., Muller, T., Rodondi, N., and Exadaktylos, A. K. “Multimorbidity In Adult Asylum Seekers: A First Overview”. Plos One 8, no. 12: e82671. doi:10.1371/journal.pone.0082671.
    Abstract: PRINCIPALS: Over the last two decades, the total annual number of applications for asylum in the countries of the European Union has increased from 15,000 to more than 300,000 people. The aim of this study was to give a first overview on multimorbidity of adult asylum seekers. METHODS: Our retrospective Swiss single center data analysis examined multimorbidity of adult asylums seekers admitted to our ED between 1 January 2000 and 31 December 2012. RESULTS: A total of 3170 patients were eligible for the study; they were predominantly male (2392 male, 75.5% versus 778 female, 24.5). The median age of the patients was 28 years (range 28-82). The most common region of origin was Africa (1544, 48.7%), followed by the Middle East (736, 23.6%). 2144 (67.6%) of all patients were not multimorbid. A total of 1183 (37.7%) of our patients were multimorbid. The mean Charlson comorbidity index was 0.25 (SD 1.1, range 0-12). 634 (20%) of all patients sufferem from psychiatric diseases, followed by chronic medical conditions (12.6%, 399) and infectious diseases (4.7%, 150). Overall, 11% (349) of our patients presented as a direct consequence of prior violence. Patients from Sri Lanka/India most often suffered from addictions problems (50/240, 20.8%, p<0.0001). Infectious diseases were most frequent in patients from Africa (6.6%), followed by the Balkans and Eastern Europe/Russia (each 3.8%). CONCLUSION: The health care problems of asylum seekers are manifold. More than 60% of the study population assessed in our study did not suffer from more than one disease. Nevertheless a significant percentage of asylum seekers is multimorbid and exhibits underlying psychiatric, infectious or chronic medical conditions despite their young age.
    Tags: *Comorbidity, Adult, Aged, Aged, 80 and over, Emergency Service, Hospital/statistics & numerical data, Female, Geography, Hospitalization/statistics & numerical data, Humans, Male, Middle Aged, Refugees/*statistics & numerical data, Switzerland/epidemiology.
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2013

  • Lindner, G., Funk, G. C., Pfortmueller, C. A., Leichtle, A. B., Fiedler, G. M., Schwarz, C., Exadaktylos, A. K., and Puig, S. “D-Dimer To Rule Out Pulmonary Embolism In Renal Insufficiency”. Am J Med 127, no. 4: 343-7. doi:10.1016/j.amjmed.2013.12.003.
    Abstract: BACKGROUND: D-dimer levels are often elevated in renal insufficiency. The diagnostic accuracy of D-dimer to rule out pulmonary embolism in patients with renal insufficiency is unclear. METHODS: We evaluated the data of patients presenting to our Emergency Department and receiving computed tomography angiography to rule out pulmonary embolism with measurement of D-dimer and creatinine. Glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration formula. RESULTS: There were 1305 patients included; 1067 (82%) had an estimated glomerular filtration rate (eGFR) exceeding 60 mL/min, 209 (16%) 30-60 mL/min, and 29 (2%) <30 mL/min. One hundred fifty-two patients (12%) had D-dimer below 500 mug/L. eGFR (R = -0.1122) correlated significantly with D-dimer (P <.0001). One hundred sixty-nine patients (13%) were found to have pulmonary embolism. Sensitivity of D-dimer for patients with an eGFR >60 mL/min was 96% (confidence interval [CI], 0.93-0.99) and 100% (CI, 100-100) for those with 30-60 mL/min, while specificity decreased significantly with impaired renal function. Area under the curve of the receiver operating characteristic for D-dimer was 0.734 in patients with an eGFR of >60 mL/min, and 0.673 for 30-60 mL/min. CONCLUSIONS: D-dimer levels were elevated in patients with an eGFR <60 mL/min, but proved to be highly sensitive for the exclusion of pulmonary embolism. However, because almost all patients with impaired renal function had elevated D-dimer irrespective of the presence of pulmonary embolism, studies should be performed to determine renal function-adjusted D-dimer cutoffs.
    Tags: Aged, CT angiography, D-dimer, Emergency, Female, Fibrin Fibrinogen Degradation Products/*analysis, Humans, Male, Middle Aged, Pulmonary embolism, Pulmonary Embolism/*blood/*diagnosis/etiology, Renal insufficiency, Renal Insufficiency/complications, Retrospective Studies.
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  • Pfortmueller, C. A., Wiemann, C., Funk, G. C., Leichtle, A. B., Fiedler, G. M., Exadaktylos, A. K., and Lindner, G. “Hypoglycemia Is Associated With Increased Mortality In Patients With Acute Decompensated Liver Cirrhosis”. J Crit Care 29, no. 2: 316 e7-12. doi:10.1016/j.jcrc.2013.11.002.
    Abstract: PRINCIPALS: The liver plays an important role in glucose metabolism, in terms of glucolysis and gluconeogenesis. Several studies have shown that hyperglycemia in patients with liver cirrhosis is associated with progression of the liver disease and increased mortality. However, no study has ever targeted the influence of hypoglycemia. The aim of this study was to assess the association of glucose disturbances with outcome in patients presenting to the emergency department with acute decompensated liver cirrhosis. METHODS: Our retrospective data analysis comprised adult (>/= 16 years) patients admitted to our emergency department between January 1, 2002, and December 31, 2012, with the primary diagnosis of decompensated liver cirrhosis. RESULTS: A total of 312 patients were eligible for study inclusion. Two hundred thirty-one (74.0%) patients were male; 81 (26.0%) were female. The median age was 57 years (range, 51-65 years). Overall, 89 (28.5%) of our patients had acute glucose disturbances; 49 (15.7%) of our patients were hypoglycemic and 40 (12.8%) were hyperglycemic. Patients with hypoglycemia were significantly more often admitted to the intensive care unit than hyperglycemic patients (20.4% vs 10.8%, P < .015) or than normoglycemic patients (20.4% vs 10.3%, P < .011), and they significantly more often died in the hospital (28.6% hypoglycemic vs 7.5% hyperglycemic, P < .024; 28.6% hypoglycemic vs 10.3% normoglycemic P < .049). Survival analysis showed a significantly lower estimated survival for hypoglycemic patients (36 days) than for normoglycemic patients (54 days) or hyperglycemic patients (45 days; hypoglycemic vs hyperglycemic, P < .019; hypoglycemic vs normoglycemic, P < .007; hyperglycemic vs normoglycemic, P < .477). CONCLUSION: Hypoglycemia is associated with increased mortality in patients with acute decompensated liver cirrhosis. It is not yet clear whether hypoglycemia is jointly responsible for the increased short-term mortality of patients with acute decompensated liver cirrhosis or is only a consequence of the severity of the disease or the complications.
    Tags: Acute Disease, Adult, Aged, Decompensated liver cirrhosis, Female, Glucose disturbance, Hospitalization/statistics & numerical data, Humans, Hyperglycemia/mortality, Hypoglycemia, Hypoglycemia/*mortality, Intensive Care Units, Liver Cirrhosis/*mortality, Liver Failure, Acute/complications, Male, Middle Aged, Mortality, Retrospective Studies, Survival Analysis.
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  • Ulbrich, E. J., Anon, J., Hodler, J., Zimmermann, H., Sturzenegger, M., Anderson, S. E., and Boesch, C. “Does Normalized Signal Intensity Of Cervical Discs On T2 Weighted Mri Images Change In Whiplash Patients?”. Injury 45, no. 4: 784-91. doi:10.1016/j.injury.2013.11.009.
    Abstract: PURPOSE: We tested the hypothesis that whiplash trauma leads to changes of the signal intensity of cervical discs in T2-weighted images. METHODS AND MATERIALS: 50 whiplash patients (18-65 years) were examined within 48h after motor vehicle accident, and again after 3 and 6 months and compared to 50 age- and sex-matched controls. Signal intensity in ROI's of the discs at the levels C2/3 to C7/T1 and the adjacent vertebral bodies were measured on sagittal T2 weighted MR images and normalized using the average of ROI's in fat tissue. The contrast between discs and both adjacent vertebrae was calculated and disc degeneration was graded by the Pfirrmann-grading system. RESULTS: Whiplash trauma did not have a significant effect on the normalized signals from discs and vertebrae, on the contrast between discs and adjacent vertebrae, or on the Pfirrmann grading. However, the contrast between discs and adjacent vertebrae and the Pfirrmann grading showed a strong correlation. In healthy volunteers, the contrast between discs and adjacent vertebrae and Pfirrmann grading increased with age and was dependent on the disc level. CONCLUSION: We could not find any trauma related changes of cervical disc signal intensities. Normalized signals of discs and Pfirrmann grading changed with age and varied between disc levels with the used MR sequence.
    Tags: *Image Enhancement, *Magnetic Resonance Imaging, Adult, Aged, Cervical spine, Disc degeneration, Disc signal, Female, Humans, Image Interpretation, Computer-Assisted, Intervertebral Disc Degeneration/*pathology, Intervertebral Disc Displacement/*pathology, Male, Middle Aged, Mri, Reproducibility of Results, Sensitivity and Specificity, Time Factors, Trauma, Whiplash Injuries/complications/*pathology, Whiplash patients.
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  • Lindner, G., Pfortmueller, C. A., Braun, C. T., and Exadaktylos, A. K. “Non-Acute Myocardial Infarction-Related Causes Of Elevated High-Sensitive Troponin T In The Emergency Room: A Cross-Sectional Analysis”. Intern Emerg Med 9, no. 3: 335-9. doi:10.1007/s11739-013-1030-y.
    Abstract: To systematically investigate putative causes of non-coronary high-sensitive troponin elevations in patients presenting to a tertiary care emergency department. In this cross-sectional analysis, patients who received serial measurements of high-sensitive troponin T between 1 August 2010 and 31 October 2012 at the Department of Emergency Medicine were included. The following putative causes were considered to be associated with non-acute coronary syndrome-related increases in high-sensitive troponin T: acute pulmonary embolism, renal insufficiency, aortic dissection, heart failure, peri-/myocarditis, strenuous exercise, rhabdomyolysis, cardiotoxic chemotherapy, high-frequency ablation therapy, defibrillator shocks, cardiac infiltrative disorders (e.g., amyloidosis), chest trauma, sepsis, shock, exacerbation of chronic obstructive pulmonary disease, and diabetic ketoacidosis. During the study period a total of 1,573 patients received serial measurements of high-sensitive troponin T. Of these, 175 patients were found to have acute coronary syndrome leaving 1,398 patients for inclusion in the study. In 222 (30 %) of patients, no putative cause described in the literature could be attributed to the elevation in high-sensitive troponin T observed. The most commonly encountered mechanism underlying the troponin T elevation was renal insufficiency that was present in 286 patients (57 %), followed by cerebral ischemia in 95 patients (19 %), trauma in 75 patients (15 %) and heart failure in 41 patients (8 %). Non-acute coronary syndrome-associated elevation of high-sensitive troponin T levels is commonly observed in the emergency department. Renal insufficiency and acute cerebral events are the most common conditions associated with high-sensitive troponin T elevation.
    Tags: Aged, Cross-Sectional Studies, Emergencies, Emergency Service, Hospital, Female, Humans, Male, Middle Aged, Myocardial Infarction, Prospective Studies, Troponin T/*blood.
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  • Guessous, I. “Capsule Commentary On Fontil, Et Al. Physician Underutilization Of Effective Medications For Resistant Hypertension At Office Visits In The United States: Namcs 2006-2010”. J Gen Intern Med 29, no. 3: 516. doi:10.1007/s11606-013-2711-y.
    Tags: *Patient Admission, *Personnel Staffing and Scheduling, *Work Schedule Tolerance, Female, Humans, Internal Medicine/*education/*methods, Internship and Residency/*methods, Male.
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  • Sebo, P., Pechere-Bertschi, A., Herrmann, F. R., Haller, D. M., and Bovier, P. “Blood Pressure Measurements Are Unreliable To Diagnose Hypertension In Primary Care”. J Hypertens 32, no. 3: 509-17. doi:10.1097/HJH.0000000000000058.
    Abstract: OBJECTIVES: To evaluate the accuracy of blood pressure (BP) measurements performed by primary care physicians (PCPs), and to assess whether it improves following a short theoretical training. METHODS: Observational study in 26 primary care practices in Geneva, Switzerland. The PCPs were asked to measure BP on 10 volunteers, within the usual context of their practice. Two trained research assistants repeated the measures immediately after the PCPs. The PCPs were then randomized to receive detailed training documentation on standardized BP measurement (group I: 14 doctors) or information about high BP (group II: 12 doctors). Measures were repeated a few weeks later. We computed accuracy and diagnostic categorization of high BP comparing the PCPs' measurements to the average value of four measurements by the research assistants (gold standard). T-tests were used to compare measurements between the two educational groups, both at baseline and following exposure to the educational material. RESULTS: BP measurements were performed on 257 volunteers at baseline and 251 after training. At baseline, the mean BP difference between PCPs and the gold standard were 23.0 mmHg (21.3-24.6) for systolic and 15.3 mmHg (14.3-16.3) for DBP. Following training, the mean difference remained high [group I: 22.3 mmHg (20.4-24.2) and 14.4 mmHg (12.6-16.2); group II: 25.3 mmHg (22.7-27.9) and 17.0 mmHg (15.3-18.7)]. As a result, 24-32% volunteers were misdiagnosed as having systolic hypertension and 15-21% as having diastolic hypertension. CONCLUSION: Though widely used in the assessment of hypertension in ambulatory settings, in-office BP measurements are highly inaccurate, even following training.
    Tags: *Blood Pressure Determination/methods/statistics & numerical data, Adult, Blood Pressure, Female, Humans, Hypertension/*diagnosis/physiopathology, Male, Middle Aged, Physicians, Primary Care/education, Primary Health Care, Reproducibility of Results, Switzerland.
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  • Weiler, S., Basedow, J., Isenegger, J., Heverhagen, J., Meier, B., and Exadaktylos, A. “Cementing The Lungs”. Bmj 347, no. nov27 1: f6920-f6920. doi:10.1136/bmj.f6920.
  • Guessous, I., Gaspoz, J. M., Theler, J. M., and Kayser, B. “Eleven-Year Physical Activity Trends In A Swiss Urban Area”. Prev Med 59, no. 1: 25-30. doi:10.1016/j.ypmed.2013.11.005.
    Abstract: OBJECTIVE: Regular physical activity is a major health determinant. Little is known about physical activity trends. We evaluated whether adult physical activity levels are changing in a Swiss urban state (Geneva). METHOD: We analyzed 11-year trends of physical activity indicators, including 3+MET-minutes per week and physical activity outside working hours, in population representative adults (n=9320, aged 35-74years, 50% women), relating declared physical activity to socioeconomic status, lifestyle, and clinical and blood markers. RESULTS: Combining yearly cohorts from 1999 to 2009, we found a significant trend for increased physical activity levels. Weekly age and sex adjusted 3+MET-minutes per week increased from 3023 to 3752, between 1999 and 2009 (P=0.02). The increase also concerned physical activity outside working hours (+18kcal/day/year). There was a shift from low levels of physical activity levels towards higher activities. Physical activity indicators were associated with socioeconomic status, comorbidities, and biological and anthropometric measures. The trend for increased physical activity was more prominent over the latter 5years. CONCLUSION: We found that physical activity levels have increased in an urban Swiss state. The increase is significant but small, and further efforts to promote physical activity are therefore warranted.
    Tags: *Health Status Indicators, *Social Class, *Social Desirability, Adult, Aged, Body Mass Index, Chronic Disease/epidemiology/psychology, Cohort Studies, Comorbidity, Cross-Sectional Studies, Exercise/*physiology, Female, Follow-Up Studies, Humans, Longitudinal Studies, Male, Metabolic Equivalent, Middle Aged, Physical activity, Population, Risk Factors, Smoking/epidemiology/psychology, Surveys and Questionnaires, Switzerland/epidemiology, Trends, Urban Population/statistics & numerical data/*trends.
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