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Swiss Emergency Research collection

2024

  • Gloor, Y. S., Mouterde, M., Terrier, J., Lenoir, C., Gosselin, P., Rollason, V., Reny, J. L., et al. “Cytochrome P450 Phenotyping Using The Geneva Cocktail Improves Metabolic Capacity Prediction In A Hospitalized Patient Population”. Br J Clin Pharmacol 91, no. 5: 1382-1395. doi:10.1111/bcp.16368.
    Abstract: AIMS: Liver cytochromes (CYPs) play an important role in drug metabolism but display a large interindividual variability resulting both from genetic and environmental factors. Most drug dose adjustment guidelines are based on genetics performed in healthy volunteers. However, hospitalized patients are not only more likely to be the target of new prescriptions and drug treatment modifications than healthy volunteers, but will also be more subject to polypharmacy, drug-drug interactions, or to suffer from disease or inflammation affecting CYP activities. METHODS: We compared predicted phenotype based on genetic data and measured phenotype using the Geneva cocktail to determine the extent of drug metabolizing enzyme variability in a large population of hospitalized patients (>500) and healthy young volunteers (>300). We aimed to assess the correlation between predicted and measured phenotype in the two populations. RESULTS: We found that, even in cases where the genetically predicted metabolizer group correlates well with measured CYP activity at group level, this prediction lacks accuracy for the determination of individual metabolizer capacities. Drugs can have a profound impact on CYP activity, but even after combining genetic and drug treatment information, the activity of a significant proportion of extreme metabolizers could not be explained. CONCLUSIONS: Our results support the use of measured metabolic ratios in addition to genotyping for accurate determination of individual metabolic capacities to guide personalized drug prescription.
    Tags: *Cytochrome P-450 Enzyme System/genetics/metabolism, Adult, Aged, cytochrome P450, Drug Interactions, drug metabolism, Female, Genotype, genotyping, Healthy Volunteers, Hospitalization, Humans, Male, Middle Aged, Pharmaceutical Preparations/metabolism, Phenotype, phenotyping, Young Adult.
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  • Meyer, H. G., Fah, K., and Christ, M. “An Atypical Presentation Of Acute Cholecystitis With Left Sided Chest Pain And St Elevation - A Case Report”. Open Access Emerg Med 16: 323-328. doi:10.2147/OAEM.S478102.
    Abstract: BACKGROUND: ST elevation combined with typical chest pain is an indication for acute coronary vascularization and is usually associated with acute myocardial infarction. Herein, we present an unusual case of ST elevation. CASE PRESENTATION: A 57-year-old male patient presented to the emergency department with chest pain radiating to both arms and the back. Typical clinical presentation and inferolateral ST elevations were suggestive of ST elevation myocardial infarction. Interestingly, coronary occlusion was excluded by coronary angiography. Despite extensive diagnostic workup, no underlying diagnosis was made. Four days later, the patient returned and reported pain in the right upper abdomen. Clinical presentation, laboratory analysis, and imaging features led to a diagnosis of calculous acute cholecystitis. Laparoscopic cholecystectomy was performed, and the diagnosis was confirmed. Electrocardiographic changes and pain resolved completely. CONCLUSION: Acute calculous cholecystitis is initiated by gallbladder distension due to biliary duct occlusion caused by gallstones. ST elevations in response to gallbladder distension have been demonstrated in animal models. We hypothesize that the ST elevations observed in this patient with chest pain were linked to stone-mediated distension of the gallbladder, leading to reflex coronary vasoconstriction.
    Tags: case report, chest pain, cope's sign, Ecg, electrocardiography, Stemi.
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  • Schranc, A., Daniels, J., Sudy, R., Fontao, F., Bijlenga, P., Plourde, G., and Quintard, H. “Safety Of Flow-Controlled Ventilation With Positive And Negative End-Expiratory Pressure In A Swine Model Of Intracranial Hypertension”. Intensive Care Med Exp 12, no. 1: 117. doi:10.1186/s40635-024-00703-x.
    Abstract: BACKGROUND: Patients with brain damage often require mechanical ventilation. Although lung-protective ventilation is recommended, the application of increased positive end-expiratory pressure (PEEP) has been associated with elevated intracranial pressure (ICP) due to altered cerebral venous return. This study investigates the effects of flow-controlled ventilation (FCV) using negative end-expiratory pressures (NEEP), on cerebral hemodynamics in a swine model of intracranial hypertension. METHODS: A model of intracranial hypertension involving bilateral trepan bolt holes was performed in 14 pigs. Pressure-controlled volume-guaranteed ventilation (PCV-VG) with PEEP and FCV using PEEP and then NEEP were applied. Intracranial pressure and oxygenation, as well as systemic hemodynamics and gas exchange parameters, were continuously monitored. Data were collected at baseline and at varying PEEP levels for both PCV-VG and FCV ventilation modalities. Following this, FCV ventilation and NEEP levels of -3, -6 and -9 cmH(2)O were applied. RESULTS: ICP remained stable with low PEEP levels, but significantly decreased with NEEP. Lower ICP following NEEP improved cerebral perfusion pressure and cerebral tissue oxygenation (p < 0.05 for all). FCV with NEEP at EEP-6 and EEP-9 significantly improved cardiac output and mean arterial pressure (MAP), compared to PCV-VG and FCV using PEEP (p < 0.05, respectively). There were no significant differences in gas exchange parameters between modalities (PCV-VG vs FCV), and between the application of PEEP or NEEP. No significant correlations were observed between DeltaICP and DeltaMAP. CONCLUSION: The application of FCV with NEEP appears to be a safe ventilation mode and offers an additional tool for controlling severe intracranial pressure episodes. These findings warrant validation in future studies and may lead to important potential applications in clinical practice.
    Tags: 34446/GE172A-B, 6 March 2023). All procedures were performed in accordance with, Animal Research Reporting of In Vivo Experiments (ARRIVE) guidelines. Consent for, Cerebral hemodynamics, current Swiss animal protection laws (LPA, RS455). The current report follows the, declare., Flow-controlled ventilation, in 2023. Competing interests: The authors have no conflict of interests to, Intracranial hypertension, Mechanical ventilation, Negative end-expiratory pressure, Positive end-expiratory pressure, presented as a poster at the Annual Congress of the European Respiratory Society, protocol was approved by the Animal Welfare Committee of the Canton of Geneva and, publication: Not applicable. Presentation: Preliminary data of this study were, the Experimental Committee of the University of Geneva, Switzerland (No..
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  • Pistritto, E., Schera, F. M. F., Vassilopoulou, E., Corsello, A., Alberti, I., Lava, S. A. G., Betti, C., et al. “Impact Of Adolescents' Binge Drinking On Blood Chemistry”. Eur J Pediatr 184, no. 1: 77. doi:10.1007/s00431-024-05862-3.
    Abstract: Adolescent binge drinking is increasingly common. This study investigates the anomalies in glucose, sodium, calcium, potassium, and acid-base homeostasis induced by binge drinking in adolescents. The records of teenagers who sought medical attention for binge drinking (ethanol level >/= 0.80 g/L) at the Pediatric Emergency Department, Ca' Granda Ospedale Maggiore Policlinico, Milan (Italy), spanning the years 2013 to 2023 were retrospectively analyzed. For this analysis, cases were selected if documented blood chemistry encompassed sodium, potassium, total calcium, glucose, acid-base balance, and lactic acid (only for those with metabolic acidosis). Included were 173 adolescents (female-to-male ratio 0.94), 13.2 to 18.4, median 16.4 years of age. Hypoglycemia (</= 3.3 mmol/L; N = 1, 0.6%), hyponatremia (</= 134 mmol/L; N = 7, 4.0%), hypernatremia (>/= 146 mmol/L; N = 3, 1.7%), hypocalcemia (</= 2.19 mmol/L; N = 0) hypercalcemia (>/= 2.61 mmol/L; N = 0), and hyperkalemia (>/= 5.1 mmol/L; N = 0) were infrequent. Acute respiratory acidosis (pCO(2) >/= 46 mm Hg; pH < 7.40; N = 101, 58%) was the most common acid-base imbalance, followed by respiratory alkalosis (pCO(2) </= 34 mm Hg; pH > 7.40; N = 10, 5.6%), and metabolic acidosis (HCO(3)(-) </= 19 mmol/L, pH < 7.40; N = 9, 5.2%). The lactic acid level was increased (>/= 2.1 mmol/L) in all cases with metabolic acidosis. Metabolic alkalosis (HCO(3)(-) >/= 28 mmol/L, pH > 7.40) never occurred. Hypokalemia (</= 3.4 mmol/L; N = 56, 32%) was prevalent, particularly in adolescents with normal acid-base equilibrium or metabolic acidosis, rather than respiratory acidosis or alkalosis.Conclusion: Adolescents who engage in binge drinking often experience a disrupted acid-base balance and hypokalemia, while glucose, sodium and calcium levels are rarely affected. What is known? * Binge drinking is becoming increasingly common among adolescents. * Conflicting data regarding the type and prevalence of biochemical disorders induced by binge drinking are available in this age group. What is new? * Acute respiratory acidosis is prevalent in adolescents with binge drinking, whereas respiratory alkalosis, metabolic acidosis, and hypoglycemia are uncommon. * Hypokalemia develops frequently.
    Tags: *Binge Drinking/blood/epidemiology, 4384_17.04.2024_P]) for the data analysis, which involved the use of anonymized, Acid-base balance, Acid-Base Equilibrium, Acid-Base Imbalance/blood, Adolescence, Adolescent, appropriate request. Generative Artificial Intelligence: Generative artificial, Binge drinking, Blood Glucose/analysis, Calcium/blood, Competing interests: Gregorio P Milani is currently one of the Editors of the, conducted, the consent to participant was not requested in agreement with current, European Journal of Pediatrics., Female, findings of this study can be obtained from the corresponding authors upon, Glucose, Humans, intelligence was used to improve readability and language of the manuscript., Italy/epidemiology, Lactic Acid/blood, legislation (Reg. UE 679/2016 and D.Lgs 196/2003 (Codice della Privacy) as, Maggiore Policlinico Milan (Italy) granted approval (ID 4384 - approval number:, Male, nature of the study and the nature of the Institution where the study was, of Helsinki. Consent to participate: Giving the observational retrospective, patient information. The study was conducted in accordance with the Declaration, Potassium, Potassium/blood, reported by D.Lgs 101/2018). Data Access Statement: The data supporting the, Retrospective Studies, Sodium, Sodium/blood.
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  • Kliem, P. S. C., Tisljar, K., Grzonka, P., Berger, S., Amacher, S. A., De Marchis, G. M., Dittrich, T. D., et al. “Effects Of A Scoring Aid On Glasgow Coma Score Assessment And Physicians' Comprehension: A Simulator-Based Randomized Clinical Trial”. J Neurol 272, no. 1: 57. doi:10.1007/s00415-024-12825-z.
    Abstract: PURPOSE: Examining the impact of scoring aids on the accuracy of assessing the Glasgow Coma Score (GCS) in a standardized trauma scenario (primary outcome). Evaluating physicians' understanding of the GCS assessment and clinical application (secondary outcome). MATERIALS AND METHODS: This randomized trial was performed at the simulator center of a Swiss tertiary academic medical hospital. Participants included intensivists, emergency physicians, internists, and neurologists. The setting involved a trauma patient portraying a GCS of 8 (eyes 1, verbal 2, motor 5). Participants were randomized to receiving or not receiving a scoring aid. Video/audio recordings of the assessments and questionnaires were analyzed by two investigators. RESULTS: Among 109 participants, 55 received a scoring aid. Overall, 52% scored correctly (score interquartile range 7-8); 43% scored too low and 90% scored within a range of +/- 1. A scoring aid increased accuracy (62% vs. 43%, p = 0.045) and participants' confidence, whilst decreasing assessment duration. Clinical experience further improved reliability. 89% found assessing a GCS of 8 most challenging, particularly with motor response evaluation (64%). 26% indicated tracheal intubation to be mandatory with a score of GCS </= 8. CONCLUSIONS: GCS assessment is improved by professional experience and a scoring aid, the use of which needs to be promoted in daily clinical practice. Frequent inaccuracy and misunderstanding regarding clinical applications may alter patient management and misguide treatment and prognosis. TRIAL REGISTRATION: ISRCTN registry (IDISRCTN12257237) https://www.isrctn.com/ISRCTN12257237 Retrospectively registered (last amendment 08/22/2023).
    Tags: (according to article 51(2) of the Human Research Act). Consent was received from, (payments from UCB). Stefano Bassetti reports no disclosures. Roland Bingisser, (SSGIM). Stephan Ruegg received unconditional research grants from UCB-pharma. He, *Glasgow Coma Scale/standards, *Physicians/standards, 10001C_192850/1 and 10531C_182422), the Gottfried Julia Bangerter-Rhyner, 33CM30_140338/1, Adult, against Epilepsy (no payments), Editor of EPILEPTOLOGIE (Journal of the Swiss, Bangerter-Rhyner-Stiftung, Berger reports no disclosures. Simon Amacher is supported by the Mach-Gaensslen, BMS/Pfizer. Tolga Dittrich was or is supported by the Swiss Heart Foundation, the, Clinical Competence/standards, Comprehension/physiology, De Quervain research grant, digital SRCTN registry (ID ISRCTN12257237) [20]. Consent for publication: Consent, Eisai, and UCB-pharma, and from serving as a consultant for Arvelle, Eisai,, Ethics approval and consent to participate: The study was approved by the local, ethics committee (EKNZRequ_2019-00168), who ascertained that this study complies, excellent young researchers of the University of Basel. He holds shares from, Female, Fondazione Dr. Ettore Balli, for publication was obtained from our author P.G. (seen in the picture) to, Foundation (8472/HEG-DSV), and the Swiss Society of General Internal Medicine, Foundation Switzerland and the Nora van Meeuwen-Haefliger Foundation of the, funding from UCB-pharma, and Swiss National Science Foundation Grants: grant, Glasgow Coma Score, Gottfried Julia Bangerter-Rhyner Foundation. He received personal grants from, he disclosed that he is the past president of the Swiss League, Humans, Intensive care, Johnson & Johnson, Roche, Lilly, Bristol-Myers Squibb, Merck, and Novo Nordisk., League against Epilepsy) (no payments), and Editor of the Swiss EEG Bulletin, Male, Middle Aged, Neurocritical care, number 320030_169379/1 and coapplicant for grants numbers 33CM30_125115/1 and, Pfizer, Novartis, Sandoz, and UCB-pharma. He does not hold any stocks of any, pharmaceutical industries or manufacturers of medical devices. He received, portray a participating physician in Fig. 1., Randomized controlled trial, received honoraria from serving on the scientific advisory boards of Arvelle,, received research grants from the Swiss National Foundation (No 320030_169379),, received travel honoraria by Bayer and speaker honoraria by Medtronic and, recordings of their performances. The Reporting Guidelines for Health Care, Reporting Trials) and STROBE (Strengthening The Reporting of OBservational, reports no disclosures. Stephan Marsch reports no disclosures. Raoul Sutter, Reproducibility of Results, Sabina Hunziker is supported by the Swiss National Foundation (SNF) (Ref, science funds of the University Hospital Basel, and the Research fund for, Science Funds [Wissenschaftsfonds] of the, Simulation Research-and extensions to the CONSORT (CONsolidated Standards Of, studies in Epidemiology) Statements-for randomized trials were followed. The, study was retrospectively registered online (last amendment 08/22/2023) at the, Swiss Neurological Society, Swisslife Jubilaumsstiftung for Medical Research, the Research Fund of the University Basel, the Scientific Society Basel, and the, the Swiss National Science Foundation, the volunteering physicians for the anonymized analyses of the video- and audio, Thermo Fisher GmbH. He, Tisljar reports no disclosures. Pascale Grzonka reports no disclosures. Sebastian, UCB-pharma and holds stocks from Novartis, Roche, Alcon, and Johnson & Johnson., University Hospital Basel and University of Basel, University of Basel, Switzerland. Gian Marco De Marchis was or is supported by, with the general ethical principles for research involving human subjects.
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  • Arleth, T., Baekgaard, J., Siersma, V., Creutzburg, A., Dinesen, F., Rosenkrantz, O., Heiberg, J., et al. “Early Restrictive Vs Liberal Oxygen For Trauma Patients: The Traumox2 Randomized Clinical Trial”. Jama 333, no. 6: 479-489. doi:10.1001/jama.2024.25786.
    Abstract: IMPORTANCE: Early administration of supplemental oxygen for all severely injured trauma patients is recommended, but liberal oxygen treatment has been associated with increased risk of death and respiratory complications. OBJECTIVE: To determine whether an early 8-hour restrictive oxygen strategy compared with a liberal oxygen strategy in adult trauma patients would reduce death and/or major respiratory complications. DESIGN, SETTING, AND PARTICIPANTS: This randomized controlled trial enrolled adult trauma patients transferred directly to hospitals, triggering a full trauma team activation with an anticipated hospital stay of a minimum of 24 hours from December 7, 2021, to September 12, 2023. This multicenter trial was conducted at 15 prehospital bases and 5 major trauma centers in Denmark, the Netherlands, and Switzerland. The 30-day follow-up period ended on October 12, 2023. The primary outcome was assessed by medical specialists in anesthesia and intensive care medicine blinded to the randomization. INTERVENTIONS: In the prehospital setting or on trauma center admission, patients were randomly assigned 1:1 to a restrictive oxygen strategy (arterial oxygen saturation target of 94%) (n = 733) or liberal oxygen strategy (12-15 L of oxygen per minute or fraction of inspired oxygen of 0.6-1.0) (n = 724) for 8 hours. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite of death and/or major respiratory complications within 30 days. The 2 key secondary outcomes, death and major respiratory complications within 30 days, were assessed individually. RESULTS: Among 1979 randomized patients, 1508 completed the trial (median [IQR] age, 50 [31-65] years; 73% male; and median Injury Severity Score was 14 [9-22]). Death and/or major respiratory complications within 30 days occurred in 118 of 733 patients (16.1%) in the restrictive oxygen group and 121 of 724 patients (16.7%) in the liberal oxygen group (odds ratio, 1.01 [95% CI, 0.75 to 1.37]; P = .94; absolute difference, 0.56 percentage points [95% CI, -2.70 to 3.82]). No significant differences were found between groups for each component of the composite outcome. Adverse and serious adverse events were similar across groups, with the exception of atelectasis, which was less common in the restrictive oxygen group compared with the liberal oxygen group (27.6% vs 34.7%, respectively). CONCLUSIONS AND RELEVANCE: In adult trauma patients, an early restrictive oxygen strategy compared with a liberal oxygen strategy initiated in the prehospital setting or on trauma center admission for 8 hours did not significantly reduce death and/or major respiratory complications within 30 days. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05146700.
    Tags: *Oxygen Inhalation Therapy/methods/adverse effects, *Oxygen/administration & dosage/adverse effects/blood, *Wounds and Injuries/blood/complications/mortality/therapy, Adult, Aged, Female, Humans, Injury Severity Score, Length of Stay, Male, Middle Aged, Oxygen Saturation, Time Factors, Trauma Centers, Treatment Outcome.
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  • Liu, K., Patey, C., Norman, P., Moellekaer, A. B., Lim, R., Alvarez, A., and Heymann, E. P. “Interventions To Reduce Burnout In Emergency Medicine: A National Inventory Of The Canadian Experience To Support Global Implementation Of Wellness Initiatives”. Intern Emerg Med 20, no. 4: 1245-1264. doi:10.1007/s11739-024-03811-4.
    Abstract: Burnout in healthcare workers is a global issue, with Emergency Medicine (EM) particularly impacted. Many countries have tried implementing wellness initiatives to reduce burnout and improve wellness. This paper summarizes interventions implemented in Canada to-date with the aim of supporting the design of wellness interventions in EDs globally. A systematic review and a grey literature search were completed in November 2023. Original studies in both English and French that included the implementation and evaluation of a wellness intervention in EDs in Canada were included. The study design, content of the intervention, target population, and outcomes were extracted and narratively analyzed. 13 studies were included. Each implemented a unique wellness intervention for EDs. All three studies (3/3, 100%) that included a structured wellness curriculum demonstrated significant improvement in burnout as measured by the Maslach Burnout Inventory, physical health (PCS-8), and Brief Resident Wellness Profile (BRWP). Other interventions included Ice Cream Rounds, therapy dogs, changing the duration of night shifts, and sessions on resilience and self-care. Our Canada-wide analysis of wellness interventions identified initiatives geared towards trainees, staff, or entire ED workface groups. Examples include educational programs, dedicated sessions for compassion literacy and resilience, critical events debriefing, and optimizing shift schedules. Structured wellness curriculums seem to be effective, and this area warrants further study. Moreover, we identify a need for global collaboration to build wellness programs and for more easily translatable standardized outcome measures for assessing the efficacy of wellness programs in EM.
    Tags: *Burnout, Professional/prevention & control/psychology, *Emergency Medicine/methods, *Health Promotion/methods/standards, Burnout, Canada, conflict of interest. Human and animal rights statement and Informed consent:, Emergency departments, Humans, International insights, Occupational resilience, This study did not involvement of human or animal participants., Wellness.
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  • Dawoud, A., Youness, R. A., Elsayed, K., Nafae, H., Allam, H., Saad, H. A., Bourquin, C., Szabo, C., Abdel-Kader, R., and Gad, M. Z. “Emerging Roles Of Hydrogen Sulfide-Metabolizing Enzymes In Cancer”. Redox Rep 29, no. 1: 2437338. doi:10.1080/13510002.2024.2437338.
    Abstract: Gasotransmitters play crucial roles in regulating many physiological processes, including cell signaling, cellular proliferation, angiogenesis, mitochondrial function, antioxidant production, nervous system functions and immune responses. Hydrogen sulfide (H(2)S) is the most recently identified gasotransmitter, which is characterized by its biphasic behavior. At low concentrations, H(2)S promotes cellular bioenergetics, whereas at high concentrations, it can exert cytotoxic effects. Cystathionine beta-synthetase (CBS), cystathionine-gamma-lyase (CSE), 3-mercaptopyruvate sulfurtransferase (3-MST), and cysteinyl-tRNA synthetase 2 (CARS2) are pivotal players in H(2)S biosynthesis in mammalian cells and tissues. The focus of this review is the regulation of the various pathways involved in H(2)S metabolism in various forms of cancer. Key enzymes in this process include the sulfide oxidation unit (SOU), which includes sulfide:quinone oxidoreductase (SQOR), human ethylmalonic encephalopathy protein 1 (hETHE1), rhodanese, sulfite oxidase (SUOX/SO), and cytochrome c oxidase (CcO) enzymes. Furthermore, the potential role of H(2)S methylation processes mediated by thiol S-methyltransferase (TMT) and thioether S-methyltransferase (TEMT) is outlined in cancer biology, with potential opportunities for targeting them for clinical translation. In order to understand the role of H(2)S in oncogenesis and tumor progression, one must appreciate the intricate interplay between H(2)S-synthesizing and H(2)S-catabolizing enzymes.
    Tags: *Hydrogen Sulfide/metabolism, *Neoplasms/metabolism/enzymology, Animals, cysteine aminotransferase (CAT), ethylmalonic encephalopathy protein 1 (ETHE1), H2s, Humans, metabolism, sulfide quinone oxidoreductase (SQOR), sulfite oxidase (SUOX).
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  • Koechlin, L., Boeddinghaus, J., Doudesis, D., Lopez-Ayala, P., Zimmermann, T., Rumora, K., du Fay de Lavallaz, J., et al. “Diagnostic And Prognostic Performance Of High-Sensitivity Cardiac Troponin T Vs I”. J Am Coll Cardiol 85, no. 4: 381-385. doi:10.1016/j.jacc.2024.10.076.
    Tags: (CH/F/21/90010), Programme Grant (RG/20/10/34966), and a Research Excellent Award, (FS/18/25/33454). Dr Lopez-Ayala has received research grants from the Swiss, (P400PM_191037/1), the Prof. Dr. Max Cloetta Foundation, the Margarete und Walter, (RE/18/5/34216) from the British Heart Foundation, 2024, has received speaker honoraria/consulting fees from Ablative Solutions,, Abbott, Abbott Diagnostics, Roche Diagnostics, Siemens Healthineers, and LumiraDx. Dr, Academy of Medical Sciences, and the Gottfried and Julia, acute myocardial infarction, Akademische Gesellschaft Basel", Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Inari, Medtronic, Merck, ReCor, analysis of the data, the preparation of the manuscript, or the decision to, and analysis, wrote the paper, and decided to publish. The sponsors had no role, and has, and has received honoraria or consultancy from, and has received research grants from the Swiss Heart Foundation. Dr, and has received speaker honoraria from, and has received speaker honoraria/consulting, and until May, authors designed the study, gathered, and analyzed the data, vouched for the data, award from the Medical Research Council (MR/N013166/1). Dr Ken Lee is supported, Bangerter-Rhyner Foundation, the Prince Charles Hospital Foundation, and a PHD, Bangerter-Rhyner-Foundation, Basel (Switzerland), the University Basel (Switzerland), Brahms Diagnostica,, Bayer, Boehringer Ingelheim, BMS, Idorsia, Novartis, Osler, Roche, Sanofi,, Bayer, Ortho Clinical Diagnostics, and Orion Pharma, outside the submitted work., Brahms, Idorsia, Novartis, LSI Medience Corporation, Ortho Clinical Diagnostics,, by a British Heart Foundation Clinical Research Training Fellowship, Coulter, Coulter, Brahms, Idorsia, LSI Medience Corporation, Ortho Clinical Diagnostics,, data or writing the manuscript. The manuscript and its contents have not been, diagnostic algorithms, Dr Mahfoud has been supported by Deutsche Gesellschaft fur Kardiologie, Deutsche, e-print servers. Dr Koechlin has received a research grant from the Swiss Heart, European Union, the University Hospital Basel, the University of Basel, Abbott,, Forschungsgemeinschaft (SFB TRR219, Project-ID 322900939), and Deutsche, Foundation (Australia) and the Emergency Care Foundation (New Zealand). The, Foundation, Brisbane, Australia. Dr Rubini has received speaker honoraria from, Foundation, outside the submitted work. Dr Wildi has received a research grant, Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation, Foundation, the University of Basel, the Swiss Academy of Medical Sciences and, from the "Freiwillige Akademische Gesellschaft Basel," the Gottfried and Julia, from the University of Basel and the Division of Internal Medicine, the Swiss, from the University of Edinburgh, grants from the Swiss National Science Foundation, the Swiss Heart Foundation,, has received research grants, has received research support from the Swiss National Science Foundation, Heart Foundation (FF20079 and FF21103), Herzstiftung, high-sensitivity cardiac troponin T and I, honoraria from Siemens and Roche Diagnostics. Dr Doudesis is supported by an, in designing or conducting the study and no role in gathering or analyzing the, institution. All other authors have reported that they have no relationships, Lichtenstein-Stiftung (3MS1038), and the University Hospital Basel, Medical, Servier, and Terumo. Dr Mills is supported by a Chair Award, Mueller has received research support from the Swiss National Science Foundation,, Nestelberger has received speaker honoraria/consulting honoraria from Beckman, Novartis, AstraZeneca, Boehringer Ingelheim, Roche, and Singulex. The Basel IX, Polymedco, Dr Risch, Roche Diagnostics, Siemens, and Abbott outside the submitted, prognostic, published previously and are not being considered for publication elsewhere in, Quidel, paid to the institution, outside the submitted work. Dr Wussler has, Quidel, Roche, Siemens, Singulex, and SpinChip Diagnostics. The BASEL VIII study, Quidel, Roche, Siemens, Singulex, Sphingotec, and SpinChip Diagnostics, received research support from the University of Basel and the Swiss Heart, received speaker honoraria/consulting honoraria from Abbott, Amgen, AstraZeneca, received speaker honoraria/consulting honoraria from Siemens, Beckman Coulter,, relevant to the contents of this paper to disclose. The investigated hs-cTn assay, Saarland University (former affiliation) has received scientific, scholarship from the University of Queensland and The Wesley Medical Research, Singulex, and SpinChip Diagnostics, all outside the current work and paid to the, Singulex, the University Hospital Basel (Switzerland), and the Emergency Medicine, study was supported by research grants from the Swiss National Science, submit the manuscript for publication., support from Ablative Solutions, Medtronic, and ReCor Medical, the Gottfried and Julia Bangerter-Rhyner Foundation, as well as the "Freiwillige, the KTI, the University Hospital Basel, the University of Basel, Abbott, Beckman, the Swiss Heart Foundation, the KTI, the University Hospital Basel, the, University of Basel, Abbott, AstraZeneca, Beckman Coulter, Boehringer Ingelheim,, was donated by the manufacturers, who had no role in the design of the study, the, was supported by research grants from the Swiss Heart Foundation, the KTI, the, whole or in part in any language, including publicly accessible web sites or, work and paid to the institution. Dr Boeddinghaus has received research grants.
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  • Liu, K., Young, C., Norman, P., Yaremko, H., Moellekaer, A. B., Lim, R., Heymann, E. P., and Patey, C. “Modulating Throughput: Practical Emergency Department (Ed) Flow Models From A Rural Canadian Ed To Directly Increase Patient Throughput”. Intern Emerg Med. doi:10.1007/s11739-024-03834-x.
  • Bar, S., Diaper, J., Fontao, F., Belin, X., Abrard, S., Albu, G., Dupont, H., Habre, W., and Schiffer, E. “Early And Concomitant Administration Of Norepinephrine And Ilomedin Improves Microcirculatory Perfusion Without Impairing Macrocirculation In An Intestinal Ischemia-Reperfusion Injury Swine Model: A Randomized Experimental Trial”. Shock 63, no. 4: 606-613. doi:10.1097/SHK.0000000000002533.
    Abstract: Background: Intestinal ischemia-reperfusion injury is associated with both macrocirculatory and microcirculatory failure. Association of a vasoconstrictor in combination with a vasodilator such as ilomedin may improve macrocirculation parameters, microcirculation perfusion and reduce endothelial dysfunction. The primary objective was to demonstrate a difference in mean arterial pressure (MAP) after intestinal reperfusion with the concomitant administration of norepinephrine and ilomedin during ischemia compared with traditional hemodynamic treatment strategies (fluid resuscitation and vasopressors only). Secondary objectives were to demonstrate an improvement in peripheral and intestinal microcirculatory perfusion and endothelial dysfunction after intestinal reperfusion using this association. Methods: We conducted a randomized preclinical trial in 21 large white pigs, in which a 2-h small bowel ischemia was performed using a segmental mesenteric occlusion model, followed by a 2-h reperfusion. Pigs were randomized into the following three groups: goal-directed fluid therapy, early administration of norepinephrine before reperfusion and early administration of ilomedin and norepinephrine before reperfusion. Macrocirculatory (MAP and Cardiac Index (CI), microcirculatory (Sublingual with SideStream Dark Field system and intestinal hemoglobin oxygen saturation with hyperspectral imaging) measurements and biological analysis (biomarkers of endothelial dysfunction) were performed. Results: There were no significant differences in the MAP ( P = 0.499) and the CI ( P = 0.659) between the three groups. Perfused vessel density in sublingual microcirculation was significantly higher immediately after reperfusion and 2 h after reperfusion in the early administration of ilomedin and norepinephrine group compared with the other two groups ( P < 0.05). Hemoglobin oxygen saturation measured at the intestinal level was significantly higher immediately after reperfusion in the early administration of ilomedin and norepinephrine group compared with the other two groups ( P < 0.01). There were no significant differences in biomarkers of endothelial dysfunction between the three groups. Creatinine, AST and alkaline phosphatases increased significantly 2 h after reperfusion in the early administration of ilomedin and norepinephrine group compared with baseline ( P < 0.05). Conclusions: Early administration of norepinephrine and ilomedin during ischemia improved short-term postreperfusion sublingual and intestinal microcirculation without worsening macrocirculatory parameters in an intestinal ischemia-reperfusion injury model. However, use of this strategy seemed to worsen both liver and kidney function.
    Tags: *Intestines/blood supply, *Microcirculation/drug effects, *Norepinephrine/therapeutic use/administration & dosage/pharmacology, *Reperfusion Injury/drug therapy/physiopathology, Animals, Disease Models, Animal, Male, Random Allocation, Swine.
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  • Wirz, Y. A., and Marti, F. “Repetition Of Sugammadex Up To An Equimolar Dose In Cases Of Accidental Subcutaneous Rocuronium Administration”. Eur J Anaesthesiol 42, no. 1: 86. doi:10.1097/EJA.0000000000001997.
  • Trolliet, M., Pasquier, M., Blancher, M., Albrecht, R., Lovis, A., Brugger, H., and Kottmann, A. “The Impact Of A Dedicated Checklist On The Quality Of Onsite Management Of Critically Buried Avalanche Victims In Cardiac Arrest In A Swiss Helicopter Emergency Medical Service”. Scand J Trauma Resusc Emerg Med 32, no. 1: 124. doi:10.1186/s13049-024-01300-3.
    Abstract: BACKGROUND: The management of avalanche victims in cardiac arrest (CA) is a challenging situation for rescuers. Despite existing specific management algorithms, previous studies have reported poor compliance with international guidelines and incomplete documentation and transmission of the information required for patient management. The Avalanche Victim Resuscitation Checklist (AVRC) was developed in 2014 in response by the International Commission for Mountain Emergency Medicine. Our aim was to assess the impact of the AVRC on the quality of onsite management of critically buried avalanche victims in CA, i.e. the compliance of management with international guidelines and the completeness of documentation of avalanche specific information. METHODS: We assessed compliance and documentation in a Swiss helicopter emergency medical service (HEMS) between January 2010 and April 2020. Victims buried for more than 24 h were excluded. RESULTS: In the 10-year study period, 87 critically buried avalanche victims in CA were treated by the HEMS, 44 of them after the introduction of the AVRC. Enough information was available to assess management compliance in over 90% of cases (n = 79). Inadequate management (n = 25, 32%) and incomplete documentation occurred more often in patients with a long burial duration. After the introduction of the AVRC, the compliance of patient management with the guidelines increased by 36% (from 59 to 95%, p < 0.05) and led to complete documentation of the required information for patient management. CONCLUSIONS: The use of the AVRC improves the quality of management of critically buried avalanche victims in CA and ensures complete documentation of avalanche specific information. Quality improvement efforts should focus on the management of avalanche victims with a long burial duration. The use of the AVRC enables identification and appropriate treatment of patients with hypothermic cardiac arrest.
    Tags: *Air Ambulances, *Avalanches, *Checklist, *Emergency Medical Services/standards, approval from the Cantonal Commission for Ethics in Human Research (Zurich,, Avalanche, Cardiac arrest, Cardiopulmonary Resuscitation/methods/standards, Checklist, Compliance, Documentation, Female, Guideline Adherence, Heart Arrest/therapy, Humans, Male, Not applicable. Competing interests: The authors declare no competing interests., Out-of-Hospital Cardiac Arrest/therapy, Quality, Retrospective Studies, Switzerland, Switzerland) on 6 March 2020 (protocol no. 2020-048). Consent for publication:.
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  • Taheri, O., Samain, J., Mauny, F., Puyraveau, M., Desmettre, T., and Marx, T. “Contribution Of Point-Of-Care Ultrasound In The Prehospital Management Of Patients With Non-Trauma Acute Dyspnea: A Systematic Review And Meta-Analysis”. Eur J Emerg Med 32, no. 2: 87-99. doi:10.1097/MEJ.0000000000001205.
    Abstract: Acute dyspnea is a common symptom whose management is challenging in prehospital settings. Point-of-care ultrasound (POCUS) is increasingly accessible because of device miniaturization. To assess the contribution of POCUS in the prehospital management of patients with acute nontraumatic dyspnea, we performed a systematic review on nontrauma patients of any age managed in the prehospital setting for acute dyspnea and receiving a POCUS examination. We searched seven databases and gray literature for English-language studies published from January 1995 to November 2023. Two independent reviewers completed the study selection, data extraction, and risk of bias assessment. The primary outcome was the assessment of the contribution of POCUS to feasibility, diagnostic, therapeutic, prognosis, patient referral, and transport vector modification. Twenty-three studies were included. The risk of bias assessment identified 3 intermediate-risk, 18 serious-risk, and 2 critical-risk studies. Three studies reported moderate to excellent feasibility for lung POCUS, and three studies reported poor to mediocre feasibility for cardiac POCUS. The median duration of the POCUS examination was less than 5 minutes (six studies). POCUS improved diagnostic identification (seven studies). The diagnostic accuracy of POCUS was excellent for pneumothorax (sensitivity = 100%, specificity = 100%, two studies), very good for acute heart failure (sensitivity = 71-100%, specificity = 72-95%, eight studies), good for pneumonia (sensitivity = 88%, specificity = 59%, one study), and moderate for pleural effusion (sensitivity = 26-53%, specificity = 83-92%, two studies). Treatment was modified in 11 to 54% of the patients (seven studies). POCUS had no significant effect on patient prognosis (two studies). POCUS contributed to patient referrals and transport vectors in 51% (four studies) and 25% (three studies) of patients, respectively. The evidence supports the use of POCUS for managing acute nontraumatic dyspnea in the prehospital setting in terms of feasibility, overall diagnostic contribution, and, particularly, lung ultrasound for acute heart failure diagnosis. Moreover, POCUS seems to have a therapeutic contribution. There is not enough evidence supporting the use of POCUS for pneumonia, pleural effusion, pneumothorax, chronic obstructive pulmonary disease, or asthma exacerbation diagnosis, nor does it support prognostic, patient referral, and transport vector contribution. A high level of evidence is lacking and needed.
    Tags: *Dyspnea/therapy/diagnostic imaging, *Emergency Medical Services/methods, *Point-of-Care Systems, Acute Disease, Humans, Pneumothorax/diagnostic imaging, Ultrasonography/methods.
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  • Lurtz, J., T, C. Sauter, and Jacob, C. “Factors Impacting The Adoption And Potential Reimbursement Of A Virtual Reality Tool For Pain Management In Switzerland: Qualitative Case Study”. Jmir Hum Factors 11: e59073. doi:10.2196/59073.
    Abstract: BACKGROUND: Pain and its adequate treatment are an issue in hospitals and emergency departments (EDs). A virtual reality (VR) tool to manage pain could act as a valuable complement to common pharmaceutical analgesics. While efficacy could be shown in previous studies, this does not assure clinical adoption in EDs. OBJECTIVE: The main aim of this study was to investigate which factors affect the adoption and potential reimbursement of a VR tool for pain management in the ED of a Swiss university hospital. METHODS: Key informant interviews were conducted using in-depth semistructured interviews with 11 participants reflecting the perspectives of all the relevant stakeholder groups, including physicians, nurses, patients, health technology providers, and health insurance and reimbursement experts. The interviews were recorded and transcribed, and the extracted data were systematically analyzed using a thematic analysis and narrative synthesis of emergent themes. A consolidated framework for eHealth adoption was used to enable a systematic investigation of the topic and help determine which adoption factors are considered as facilitators or barriers or as not particularly relevant for the tool subject of this study. RESULTS: According to the participants, the three key facilitators are (1) organizational environment; (2) tension for change, ease of use, and demonstrability; and (3) employee engagement. Further, the three key barriers to adoption are (1) workload, (2) changes in clinical workflow and habit, and (3) reimbursement. CONCLUSIONS: This study concludes that the adoption of a VR tool for pain management in the ED of the hospital subject of this study, although benefiting from a high tension for change in pain and workload management, is highly dependent on the respective organizational environment, engagement of the clinical staff, and reimbursement considerations. While tailored incentive structures and ambassador roles could benefit initial adoption, a change in the reimbursement landscape and further investigation of the positive effects on workflow effectiveness are required to drive long-term adoption.
    Tags: *Pain Management/economics/methods, *Qualitative Research, *Virtual Reality, acceptance, adoption, Adult, attitude, digital health, eHealth, emergency, Emergency Service, Hospital, experience, Female, hospital, Humans, implementation, Insurance, Health, Reimbursement, interview, Interviews as Topic, Male, mHealth, Middle Aged, mobile health, opinion, pain, perception, qualitative, reimbursement, Reimbursement Mechanisms, Switzerland, technology adoption, technology assessment, virtual reality, Vr.
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  • Dos Santos Rocha, A., Betello, M., Nikolaou, A., Sudy, R., Albu, G., and Schiffer, E. “Failure Of Neuromuscular Blockade Despite High Doses Of Rocuronium And Atracurium In A Patient With Colorectal Carcinoma: A Case Report”. Eur J Anaesthesiol 42, no. 1: 73-76. doi:10.1097/EJA.0000000000002076.
    Abstract: Resistance to the effects of rocuronium and other neuromuscular blocking agents (NMBA) has been previously reported, including delayed onset of relaxation, rapid recovery and incomplete paralysis under recommended doses. These conditions have been associated with denervation injury, burns, immobilisation, infections, metabolic disorders, and drug interactions. In this report, we describe the case of a young male without any known pre-disposing factor for NMBA resistance, who failed to attain muscle relaxation with non-depolarising NMBA despite high doses of rocuronium and atracurium during two surgeries for colorectal cancer, several months apart. Investigations for drug failure and genetic testing did not indicate a plausible cause. After chemotherapy and tumour resection, the patient underwent a third surgical procedure under general anaesthesia with normalised NMBA response. Patient's written consent was obtained for publication.
    Tags: *Atracurium/administration & dosage, *Colorectal Neoplasms/surgery, *Neuromuscular Blockade/methods/adverse effects, *Neuromuscular Nondepolarizing Agents/administration & dosage, *Rocuronium/administration & dosage, Adult, Androstanols/administration & dosage, Humans, Male.
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  • Zünd, S., Stuby, L., Suppan, L., Siebert, J. N., and Tinembart, J. M. “Impact Of The First Swiss Conference On Prehospital Emergency Care And Trauma Research (Spectre) On Paramedics' Intention To Engage In Research: Cross-Sectional Study”. In, 2024. doi:10.1016/j.jemermed.2024.11.017.
    Abstract: Background: In Switzerland, paramedics lack academic training, meaning they do not receive specialized education in the field of research. Like many other European countries, paramedics are seldom included in prehospital research. However, considering the significant gaps in knowledge within prehospital emergency medicine, educating and involving paramedics could markedly enhance prehospital emergency medicine research and decrease knowledge gap in this area. Study Objective: This cross-sectional study aimed to evaluate the impact of the inaugural Swiss Conference on Prehospital Emergency Care and Trauma Research on paramedics’ inclination to participate in prehospital research. Methods: A questionnaire was administered using Likert-type scales. All participants (100) were asked to answer a web-based questionnaire after attending the conference. Results: Out of 80 responses (80%), 72 were filled by paramedics and therefore included in the analysis. Participants were significantly more willing to engage in prehospital research after attending the conference (40/56, 71.4%) than before (23/56, 41.1%); p < 0.001. Among participants already actively involved, 46.7% (7/15) responded that the event had a positive impact on their level of involvement. The results revealed a noteworthy increase in willingness to engage in research. Conclusions: A one-day conference solely focused on pre-hospital scientific research serves as a motivating factor for paramedics to partake in research in this domain. Whether this will lead to a higher scientific output is unknown. © 2024 The Author
    Tags: emergency medical services, paramedic, public health systems research, research.
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  • Giovannoni, L., Pierzchala, K., De Roo, M., Braissant, O., Bruce, S., McLin, V. A., and Vutskits, L. “Effects Of Cholestasis And Hyperammonemia On Dendritic Spine Density And Turnover In Rat Hippocampal Neurons”. Sci Rep 14, no. 1: 29841. doi:10.1038/s41598-024-80871-8.
    Abstract: Adults and children with cholestatic liver disease are at risk for type C hepatic encephalopathy (HE) and may present lifelong neurocognitive impairment. While the underlying cellular and molecular mechanisms are still incompletely understood, ammonium and bile acids (BAs) seem to play a key role in this pathology, by crossing the blood-brain-barrier and modifying neuronal homeostasis and synaptic plasticity. This experimental study aimed to investigate the effects of ammonium and BAs on dendritic spines of rat hippocampal CA1 neurons. Taking advantage of the bile duct ligated (BDL) in vivo rat model and a hippocampal organotypic rat ex vivo slice model, we analyzed dendritic spine density in both models and spine turnover ex vivo. BDL rats showed decreased dendritic spine densities after 8 weeks, paralleled with increased concentrations of blood ammonium. In organotypic hippocampal slices, exposure to ammonium, tauro-alpha-muricholic and taurocholic acid induced a decrease in dendritic spine density during the first 3 days, followed by an increase in dendritic spinogenesis during days 4-5, resulting in an increased number of dendritic spines. These observations provide new insights into the effects of ammonium and BAs on dendritic spines and consequently synaptic plasticity in chronic cholestatic liver disease.
    Tags: *Cholestasis/pathology/metabolism, *Dendritic Spines/metabolism/pathology, *Hippocampus/pathology/metabolism, *Hyperammonemia/metabolism/pathology, Ammonium Compounds/metabolism, Animals, Bile Acids and Salts/metabolism, CA1 Region, Hippocampal/pathology/metabolism, Disease Models, Animal, Hepatic Encephalopathy/pathology/metabolism/etiology, Male, Neuronal Plasticity, Neurons/metabolism/pathology, Rats, Rats, Wistar.
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  • Stirnemann, J., Serratrice, J., Mann, T., Louge, P., Christophe, C., Samii, K., Pignel, R., et al. “Protocol For A Multicentric, Double-Blind, Randomised Controlled Trial Of Hyperbaric Oxygen Therapy (Hbot) Versus Sham For Treating Vaso-Occlusive Crisis (Voc) In Sickle Cell Disease (Scd) In Patients Aged 8 Years Or Older (Hbot-Scd Study)”. Bmj Open 14, no. 11: e084825. doi:10.1136/bmjopen-2024-084825.
    Abstract: INTRODUCTION: Sickle cell disease (SCD) is one of the most common genetic diseases in the world, annually affecting approximately 310 000 births and causing >100 000 deaths. Vaso-occlusive crisis (VOC) is the most frequent complication of SCD, leading to bone pain, thoracic pain (acute chest syndrome) and/or abdominal spasms. It is the main cause of mortality in patients with SCD, reducing life expectancy. Hyperbaric oxygen therapy (HBOT) is a safe and well-established method of increasing tissue oxygen delivery immediately by up to 10-fold to 20-fold. In the context of VOC, HBOT has the potential to limit sickling. A previous pilot study of nine patients showed the safety and potential benefits of HBOT on VOC-induced pain. Our study aimed to assess the clinical safety and effectiveness of HBOT for treating VOC, its biological mechanisms of actions and its cost-effectiveness. METHODS AND ANALYSIS: This is a multicentric, triple-blinded, randomised controlled trial. Patients aged 8 years or above with a diagnosed major form of SCD, presenting at one of the participating centres' emergency departments (EDs) with a VOC requiring level 3 analgesia (according to WHO definition), will be eligible. Exclusion criteria are pregnancy, mechanical ventilation, previous history of stroke or prior transcranial Doppler ultrasound anomaly, contraindication to HBOT and the need for above 2 L/min of oxygen. All patients will receive the usual care for VOCs, including hydration, analgesics, normobaric oxygen therapy and when medically indicated, antibiotic therapy and/or transfusions. Within 24 hours of their arrival in the ED (or longer in specific cases), and after obtaining informed consent, patients will be randomised into the HBOT intervention group (2.0 atmosphere absolute (ATA), 90 min, FIO(2)=1) or the sham group (1.3 ATA, 90 min, FIO(2)=0.21). After their first HBOT session, patients will return to their acute-care ward. Patients in both arms will undergo a second and third session within 24-36 hours of the first, unless their Visual Analogue Scale (VAS)-pain is </=2 without use of level 3 analgesics. The difference in the pain-VAS before and after HBOT and other outcomes will be compared between the intervention and sham groups. Our composite primary outcome will be (1) the change in global VAS-pain 6 hours after initiation of HBOT; (2) the number of patients with a VAS-pain score >4 and/or a morphine dosage >1 mg/hour intravenous after the HBOT/sham session. Other outcomes to be reported are morphine usage, length of stay, biological parameters, satisfaction, complications and cost. ETHICS AND DISSEMINATION: Ethical approval CER Geneva 2019-01707 (last submission V.5.1, 06.15.2023). The results of the studies will be disseminated by several media, including publications in peer-reviewed international medical journals, and presentations at national and/or international conferences. TRIAL REGISTRATION NUMBER: NCT04978116.
    Tags: *Anemia, Sickle Cell/complications/therapy, *Hyperbaric Oxygenation/methods, Adolescent, Adult, Anaemia, Child, Double-Blind Method, Emergency Service, Hospital, Female, Humans, Internal medicine, Male, Multicenter Studies as Topic, Randomized Controlled Trials as Topic, Young Adult.
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  • Legouis, D., Monard, C., Ourahmoune, A., Sgardello, S., Quintard, H., Criton, G., Sangla, F., and Schneider, A. “Differential Effects Of Thiamine And Ascorbic Acid In Clusters Of Septic Patients Identified By Latent Variable Analysis”. Crit Care 28, no. 1: 396. doi:10.1186/s13054-024-05188-4.
    Abstract: BACKGROUND: Thiamine and ascorbic acid have been proposed to mitigate the devastating consequences of sepsis and septic shock. To date, randomized controlled trials have failed to demonstrate a benefit of these therapies and heterogeneity of treatment effect is suspected. In this study, we aimed at assessing the heterogeneity of treatment effect of thiamine (B1) and the combination of B1 plus ascorbic acid (AA + B1) in critically ill patients with sepsis. METHODS: We conducted a bi-centric retrospective cohort study. All adult patients admitted to the ICU with sepsis or septic shock between January 2012 and August 2022 were included. Patient clusters were identified using latent variable analysis based on demographics and physiological variables obtained within 24 h of admission. Within each cluster and using inverse probability weighted Cox models, we compared in-hospital mortality between patients who received standard treatment (control), standard treatment plus B1 (B1 group), and standard treatment plus a combination of thiamine and ascorbic acid (AA + B1 group). RESULTS: A total of 3465 septic patients were included, 2183, 1054 and 228 in the standard, B1 and AA + B1 groups respectively. Five clusters of patients were identified in an unsupervised manner. The "Cluster Severe" included the most severely ill patients, the "Cluster Resp" patients presented with predominantly respiratory failure, the "Cluster Old" included elderly patients with multiple comorbidities, the "Cluster Fit" patients were young, healthy with low severity indices and "Cluster Liver" included patients with predominant liver failure. B1 treatment was associated with different outcomes across the five clusters. It was associated with a lower in-hospital mortality in the "Cluster Severe" and "Cluster Resp". On the other hand, the combination of thiamine and ascorbic acid was not associated with reduced mortality in any cluster but an increased mortality in"Cluster Old". CONCLUSIONS: These results reinforce the lack of efficacy of the combination of AA + B1 reported in recent trials and even raise concerns about potential harm in older patients with comorbidities. On the contrary, we reported improved ICU survival associated with B1 supplementation in the most severe patients and those with predominant respiratory failure, supporting the need for further trials in this specific population.
    Tags: *Ascorbic Acid/therapeutic use/pharmacology, *Sepsis/drug therapy/mortality, *Thiamine/therapeutic use/pharmacology, 2023-00147, Commission Cantonale d'Ethique de la Recherche). The study was, Adult, Aged, Aged, 80 and over, Ascorbic acid, by the local ethical committee for human studies of Geneva, Switzerland (CCER, Cluster Analysis, Cohort Studies, Female, HAT therapy, Hospital Mortality, Humans, Intensive Care Units/organization & administration/statistics & numerical data, interests: The authors declare no competing interests., Male, Middle Aged, performed according to the Declaration of Helsinki principles. Consent for, publication: All authors have approved the manuscript for submission. Competing, Retrospective Studies, Sepsis, Thiamine.
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  • Monaghan, M. N., Lang-Hodge, A. M., Chun, S., Lim, R., Lang, E., and Heymann, E. P. “Restructuring The Role Of Emergency Departments In The Healthcare Systems: A Vector To Improving Physician Resilience”. Intern Emerg Med 20, no. 2: 535-540. doi:10.1007/s11739-024-03814-1.
    Abstract: Healthcare systems are continuously evolving to respond to new geodemographic demands, among other challenges. At the forefront of this exercise of malleability, Emergency Departments (EDs) are often put to test as the default access point, while the rest of the system takes time to adapt. Once highly adaptable, years of cumulative strain have stressed the limits of the current organization of Emergency Departments (ED) within the healthcare system worldwide. The consequences are many, most notably for Emergency Physicians (EPs), who now face the highest rate of burnout among all medical specialties, with career resilience at an all-time low and diminished interest in the profession. Understanding how EDs are structured within their respective healthcare system provides a unique lens through which areas of improvement can be assessed. This paper discusses solutions to improve the overall structure of the healthcare system to help improve responsiveness, reduce relegation of tasks to the ED, and help improve working conditions and wellbeing for EPs.
    Tags: *Emergency Service, Hospital/organization & administration, *Physicians/psychology, *Resilience, Psychological, Burnout, Professional/psychology/prevention & control, conflict of interest. Human and animal rights statement: This article does not, contain any studies involving human participants or animals as it is a review of, Delivery of Health Care/organization & administration, Emergency department, Healthcare, Humans, Physician wellness, previously published data. Informed consent: Formal consent is not required for, Restructuring, this type of study., Wellbeing.
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  • Piletta-Zanin, A., Scherl, A., Benhamou, A., Braendle, G., Caubet, J. C., Graham, F., Grosgurin, O., et al. “The Severity Of Allergic Reactions In A Real-World Environment Is Independent Of The Eliciting Amounts Of Foods”. Allergy 80, no. 1: 238-247. doi:10.1111/all.16413.
    Abstract: INTRODUCTION: Patients with food allergies need personalized information on their risk of reaction in "real-life" situations. This multicentric study aimed to investigate the link during accidental reactions between the nature and amount of food allergens consumed in "real-life situation" and the severity of the symptoms. METHODS: Patients were prospectively recruited from December 1, 2020, to December 31, 2021, at the emergency departments in the Geneva University Hospitals and local pediatric emergency facilities, through an allergy outpatient clinic, at school and daycare facilities and trough their primary care physicians. Medical history of patients presenting reactions suggestive with immediate food allergy and suspected food samples were collected. Allergy diagnostic tests were retrospectively and prospectively collected. The samples were analyzed for their allergen content. RESULTS: We recruited 147 subjects with an accidental immediate-type allergic reaction to a food. We were able to collect 115 reaction-eliciting food samples allowing to quantify the allergen amount causing the reaction, as well as correlating this amount to the severity of the reaction. Children represented a large part of the reactors, and most reactions were to common food allergens such as tree nuts, cow's milk as well as peanuts and hen's egg. Reactions were mostly to prepackaged foods and seven reactions were to products with precautionary allergy labeling, or without labelling to the eliciting allergen. Reactions were of various degrees of severity, and independent to the amount of allergen ingested. DISCUSSION: The severity of reactions did not show a direct correlation with allergen quantity, emphasizing individual sensitivity. Some reactions occurred with allergen amounts significantly below the legal limit for mandatory labelling of 1 g/kg (1000 ppm) in Switzerland. The study also highlighted considerable variability in allergen concentrations in foods labeled with possible "contaminations" or "traces". These findings raise questions about the accuracy of allergen labeling and regulations in Switzerland.
    Tags: *Allergens/immunology/adverse effects, *Food Hypersensitivity/diagnosis/epidemiology/immunology/etiology, *Food/adverse effects, Adolescent, Adult, Child, Child, Preschool, Female, Humans, Infant, Male, Middle Aged, Prospective Studies, Retrospective Studies, Severity of Illness Index.
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  • Freund, Y., Kabrhel, C., Casey, S. D., Vinson, D. R., Stubblefield, W. B., Kline, J., Douillet, D., et al. “Ruling Out Pulmonary Embolism Safely: Standardized Reporting Of The Failure Rate”. Acad Emerg Med 32, no. 3: 360-362. doi:10.1111/acem.15055.
    Tags: article, computer assisted tomography, D dimer, deep vein thrombosis, diagnostic imaging, emergency physician, emergency ward, follow up, human, lung embolism, Note.
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  • Fehlmann, C. A., Loughlin, K. M., Cosgrif, E. J., Ferrick, J. F., van Oppen, J. D., and European Taskforce for Geriatric Emergency, Medicine. “Correction: Service Provision For Frailty In European Emergency Departments (Feed): A Survey Of Operational Characteristics”. Scand J Trauma Resusc Emerg Med 32, no. 1: 119. doi:10.1186/s13049-024-01293-z.
    Abstract: https://doi.org/10.1186/s13049-024-01234-w. Following the publication of the Original Article, the authors reported that they missed including two names from the collaborators’ list, namely Effie Polyzogopoulou (Greece) and Lluís Llauger (Spain). The original article has been updated to include the two names on the collaborators’ list. © The Author(s) 2024.
    Tags: cross-sectional study, erratum, human.
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  • Jossein, T., Mazzolai, L., Lorenzo Hernandez, A., Otalora Valderrama, S., Zdraveska, M., Rivas Guerrero, A., Lopez Ruiz, A., et al. “Failure Rate Of The Pulmonary Embolism Rule-Out Criteria Rule For Adults 35 Years Or Younger: Findings From The Riete Registry”. Acad Emerg Med 32, no. 4: 414-425. doi:10.1111/acem.15046.
    Abstract: BACKGROUND: The use of a computed tomography pulmonary angiogram to diagnose pulmonary embolism (PE) has increased, leading not only to higher PE diagnoses but also to overdiagnosis and unnecessary radiation exposure, even in young patients despite a lower PE incidence. The aim of this study was to assess the failure rate of the pulmonary embolism rule-out criteria 35 (PERC-35) rule developed to reduce unnecessary testing in individuals aged </=35 years among patients included in the Registro Informatizado de la Enfermedad TromboEmbolica Venosa (RIETE) Registry. METHODS: This retrospective cohort study used data from the RIETE Registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the missed PE rate using PERC-35 criteria. Secondary outcomes included the comparison of demographic and clinical characteristics, PE localization, treatment strategies, and outcomes between PERC-negative (PERC-35N) versus PERC-positive (PERC-35P) patients. RESULTS: Of 58,918 adult patients with acute PE, the PERC-35 rule demonstrated a low missed PE rate of 0.35% (n = 204), with an upper 95% confidence interval [CI] of 0.40%. The missed rate was 7.0% (95% CI 6.0%-7.9%) in the 18- to 35-year subgroup. Compared to PERC-35P patients, PERC-35N patients were younger (mean age 28.4 years), with a lower body mass index, and included a higher proportion of pregnant/postpartum women. PERC-35N patients had a significantly lower rate of chronic diseases and presented less frequently with dyspnea or syncope but more often with chest pain. They showed lower rates of positive D-dimer and troponin levels. PERC-35N patients experienced fewer major bleeding episodes, similar recurrence rates of PE/deep vein thrombosis, and no deaths during anticoagulation. CONCLUSIONS: The PERC-35 rule demonstrated a low failure rate to exclude PE in patients aged 18-35 years and could reduce imaging and radiation exposure in young patients with a low PE pretest probability if confirmed prospectively.
    Tags: *Computed Tomography Angiography, *Pulmonary Embolism/diagnosis/diagnostic imaging, Adult, diagnostic algorithm, Female, Humans, Male, Perc, pretest probability, pulmonary embolism, pulmonary embolism rule-out criteria rule, Registries, Retrospective Studies, Riete, Young Adult.
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  • Lenglart, L., Titomanlio, L., Bognar, Z., Bressan, S., Buonsenso, D., De, T., Farrugia, R., et al. “Surge Of Pediatric Respiratory Tract Infections After The Covid-19 Pandemic And The Concept Of "Immune Debt"”. J Pediatr 284: 114420. doi:10.1016/j.jpeds.2024.114420.
    Abstract: OBJECTIVE: To investigate a dose-response relationship between the magnitude of decrease in pediatric respiratory tract infections (RTIs) during the 2020 implementation of nonpharmaceutical interventions (NPIs) and the increase thereafter during NPI lifting. STUDY DESIGN: We conducted an interrupted, time-series analysis based on a multinational surveillance system. All patients <16 years of age coming to medical attention with various symptoms and signs of RTI at 25 pediatric emergency departments from 13 European countries between January 2018 and June 2022 were included. We used generalized additive models to correlate the magnitude of decrease of each RTI during NPI (such as social distancing) implementation and its subsequent increase during NPI lifting. Urinary tract infections served as control outcome. RESULTS: In total, 528 055 patients were included. We observed reductions in cases during the NPI period, from -76% (95% CI -113 to -53 in pneumonia) to -65% (95% CI -100 to -39 for tonsillitis/pharyngitis), followed by strong increases during NPI lifting, from +83% (95% CI 29-150 for tonsillitis/pharyngitis) to +329% (95% CI 149-517 for bronchiolitis). For each RTI, we found a significant association between the magnitude of decrease during NPI implementation and the increase during NPI lifting. Urinary tract infection cases remained stable. CONCLUSIONS: The magnitude of increase in RTI observed after NPI lifting was directly correlated to the magnitude of case reduction during NPI implementation, suggesting a "dose-response" relationship from an "immune debt" phenomenon. The likely rebound in RTIs should be expected when implementing and lifting NPI in the future.
    Tags: *COVID-19/epidemiology/prevention & control, *Respiratory Tract Infections/epidemiology/immunology, Adolescent, authors received no additional funding. N.O. reports travel grants from Pfizer,, Child, Child, Preschool, Covid-19, Europe/epidemiology, Female, grant/INSERM and R.N. by the National Institute for Health and Care, GSK, and Sanofi. No other authors have conflicts of interest to disclose., Humans, Infant, Interrupted Time Series Analysis, Male, nonpharmaceutical interventions, Pandemics, pediatrics, ResearchAcademic Clinical Lecturer (NIHR ACL) 2018-021-007 award. The other, respiratory tract infection, SARS-CoV-2.
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  • Yarnell, C. J., Paranthaman, A., Reardon, P., Angriman, F., Bassi, T., Bellani, G., Brochard, L., et al. “An International Factorial Vignette-Based Survey Of Intubation Decisions In Acute Hypoxemic Respiratory Failure”. Crit Care Med 53, no. 1: e117-e131. doi:10.1097/CCM.0000000000006494.
    Abstract: OBJECTIVES: Intubation is a common procedure in acute hypoxemic respiratory failure (AHRF), with minimal evidence to guide decision-making. We conducted a survey of when to intubate patients with AHRF to measure the influence of clinical variables on intubation decision-making and quantify variability. DESIGN: Factorial vignette-based survey asking "Would you recommend intubation?" Respondents selected an ordinal recommendation from a 5-point scale ranging from "Definite no" to "Definite yes" for up to ten randomly allocated vignettes. We used Bayesian proportional odds modeling, with clustering by individual, country, and region, to calculate mean odds ratios (ORs) with 95% credible intervals (CrIs). SETTING: Anonymous web-based survey. SUBJECTS: Clinicians involved in the decision to intubate. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Between September 2023 and January 2024, 2,294 respondents entered 17,235 vignette responses in 74 countries (most common: Canada [29%], United States [26%], France [9%], Japan [8%], and Thailand [5%]). Respondents were attending physicians (63%), nurses (13%), trainee physicians (9%), respiratory therapists (9%), and other (6%). Lower oxygen saturation, higher F io2 , noninvasive ventilation compared with high-flow, tachypnea, neck muscle use, abdominal paradox, drowsiness, and inability to obey were associated with increased odds of intubation; diagnosis, vasopressors, and duration of symptoms were not. Nurses were less likely than physicians to recommend intubation. Within a country, the odds of recommending intubation changed between clinicians by an average factor of 2.60; within a region, the same odds changed between countries by 1.56. Respondents from Canada (OR, 0.53; CrI, 0.40-0.70) and the United States (OR, 0.63; CrI, 0.48-0.84) were less likely to recommend intubation than respondents from most other countries. CONCLUSIONS: In this international, multiprofessional survey of 2294 clinicians, intubation for patients with AHRF was mostly decided based on oxygenation, breathing pattern, and consciousness, but there was important variation across individuals and countries.
    Tags: (CIHR) and the Interdepartmental Division of Critical Care Medicine at the, *Intubation, Intratracheal/statistics & numerical data, *Respiratory Insufficiency/therapy, Adult, and Zoll, Bayes Theorem, Care Medicine, University of Toronto. The remaining authors have disclosed that, Clinical Decision-Making, consultancy fees from Flowmeter. Drs. Brochard and Mellado-Artigas received, Fairley Professor of Critical Care at the Interdepartmental Division of Critical, Female, Foundation. Dr. Bellani receives lecturing fees from Draeger Medical and, funding from Medtronic and Fisher & Paykel. Dr. Brochard's institution received, funding from Stimit, Vitalaire, Cerebra Health, Sentec, and Philips. Dr. Goligher, funding from the Ministry of Education, Culture, Sports, Science and Technology,, He received support for article research from the CIHR. Dr., Humans, Hypoxia/therapy, Japan and the Japan Science and Technology Agency. Dr. Fowler is the H. Barrie, Male, Mellado-Artigas received funding from Merck (Sharp & Dohme). Dr. Yoshida received, Middle Aged, received funding from Getinge, Heecap, Lungpacer, BioAge, Stimit, Vyaire, Drager,, Surveys and Questionnaires, they do not have any potential conflicts of interest., University of Toronto trainee award. He reports grant funding from the JP Bickell.
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  • Noire, Y., Schmutz, T., Ribordy, V., Canse, A., and Pelaccia, T. “How Do Triage Nurses Use Their Know-Who To Make Decisions? A Pilot Exploratory Study”. Acad Emerg Med 32, no. 3: 348-350. doi:10.1111/acem.15049.
  • Steck, T. A., Neuschutz, K. J., Gernhardt, C., Hilti, J., and Minotti, B. “Older Man With Chronic Right Upper Quadrant Pain And Vomiting”. J Am Coll Emerg Physicians Open 5, no. 6: e13311. doi:10.1002/emp2.13311.
  • Gaye, B., Gaye, N., Singh, G., Madani, N., Lamptey, R., Kohen, J. E., Samb, A., et al. “Strategies For More Equitable Engagement For African Researchers”. Lancet Glob Health 13, no. 1: e14-e15. doi:10.1016/S2214-109X(24)00427-3.
  • Pluta, M., Darocha, T., Pasquier, M., Mendrala, K., and Kosinski, S. “Hypothermic Cardiac Arrest: Criteria For Extracorporeal Cardiopulmonary Resuscitation”. Resuscitation 204: 110410. doi:10.1016/j.resuscitation.2024.110410.
  • Benhamou, J., Espejo, T., Riedel, H. B., Dreher-Hummel, T., Garcia-Martinez, A., Gubler-Gut, B., Kirchberger, J., et al. “On-Site Physiotherapy In Older Emergency Department Patients Following A Fall: A Randomized Controlled Trial”. Eur Geriatr Med 16, no. 1: 205-217. doi:10.1007/s41999-024-01091-x.
    Abstract: PURPOSE: Greater fear of falling (FOF) is associated with an increased risk of falling in patients aged 65 and older. This study aims to assess the impact of physiotherapy on FOF in older patients and investigates the feasibility of such an intervention in the emergency department (ED) setting. METHODS: All patients aged 65 or older, who presented to the ED of the University Hospital Basel after a fall between January 2022 and June 2023 were screened for inclusion. Participants were assigned to an intervention or control group depending on the randomized presence or absence of a physiotherapist at inclusion. Both groups received the same fall prevention booklet. Physiotherapists instructed and performed exercises with patients in the intervention group. The primary outcome was the difference in FOF between groups 7 days post inclusion, assessed by short Falls Efficacy Scale International (sFES-I). Secondary outcomes included feasibility, overall reduction of FOF, patient satisfaction, the occurrence of falls post inclusion and the use of medical resources. RESULTS: Of the 1204 patients screened for inclusion, 104 older adults with a recent fall were enrolled (intervention: n = 44, control: n = 60); median age was 81 years and 59.1% were female. There was no between-group difference in FOF as measured by sFES-I within a week of inclusion (p = 0.663, effect size = 0.012 [95% confidence interval (CI) - 0.377 to 0.593]). Despite the intervention being deemed feasible from the physiotherapist's perspective, the study encountered challenges, such as low recruitment (with the planned sample size not being reached) and a notable dropout rate before the first follow-up. CONCLUSION: A physiotherapy intervention in the ED showed no improvement in FOF when compared to a control group. TRIAL REGISTRATION: Trial registration number and date NCT05156944, 01.12.2021.
    Tags: *Accidental Falls/prevention & control/statistics & numerical data, *Emergency Service, Hospital, *Fear/psychology, *Physical Therapy Modalities, Aged, Aged, 80 and over, by the local ethics committee (N degrees 2021-02165, 07.12.2021). Consent to, Emergency department, Falls, Feasibility, Female, Humans, in line with the principles of the Declaration of Helsinki. Approval was granted, included in the study., Male, non-financial interests to disclose. Ethical approval: This study was performed, Older, participate: Informed consent was obtained from all individual participants, Patient Satisfaction, Physiotherapy, Randomized controlled trial.
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  • van der Geest, Y., Chau, I., Wendel-Garcia, P. D., Buehler, P. K., Hautz, W., Filipovic, M., Hofmaenner, D. A., and Pietsch, U. “Eye Tracking During A Simulated Start Of Shift Safety Check: An Observational Analysis Of Gaze Behavior Of Critical Care Nurses”. J Intensive Care Soc 25, no. 4: 383-390. doi:10.1177/17511437241268160.
    Abstract: BACKGROUND: The handover and associated shift start checks by nurses of critical care patients are complex and prone to errors. However, which aspects lead to errors remains unknown. Fewer errors might occur in a structured approach. We hypothesized that specific gaze behavior during handover and shift start safety check correlates with error recognition. METHODS: In our observational eye tracking study, we analyzed gaze behavior of critical care nurses during handover and shift start safety check in a simulation room with built-in errors. Four areas of interest (AOI) were pre-defined (patient, respirator, prescriptions, monitor). The primary outcome were different gaze metrics (time to first fixation, revisits, first visual intake duration, average visual intake duration, dwell time) on AOIs. Parameters were analyzed by taking all errors in account, and by dividing them into minor and critical. RESULTS: Forty-three participants were included. All participants committed at least a minor error (n = 43, 100%), at least one critical error occurred in 29 participants (67%). Taking all errors into account, longer time to first fixation and more revisits were associated with an increased risk of missing errors (Time to First Fixation: OR 1.099 (95% CI 1.023-1.191, p = 0.0002), Revisits: OR 1.080 (95% CI 1.025-1.143, p = 0.0055)). CONCLUSION: Error detection during shift start safety check was associated with distinct gaze behavior. Nurses who recognized more errors had a shorter time to first fixation and less revisits. These gaze characteristics might correspond to a more structured approach. Further research is necessary, for example by implementing a checklist, to reduce errors in the future and improve patient safety.
    Tags: behavior monitoring, eye tracking technology, intensive care units, patient handoff, Patient safety, research, authorship, and/or publication of this article..
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  • Hsiao, K. H., Kalanzi, J., Watson, S. B., Murthy, S., Movsisyan, A., Kothari, K., Salio, F., and Relan, P. “Oral/Enteral Fluid Resuscitation In The Initial Management Of Major Burns: A Systematic Review And Meta-Analysis Of Human And Animal Studies”. Burns Open 8, no. 4: None. doi:10.1016/j.burnso.2024.100364.
    Abstract: BACKGROUND: Timely and safe intravenous (IV) fluid resuscitation for major burns may be difficult or impossible during mass casualty burn incidents. Oral/enteral fluid resuscitation may be an alternative. OBJECTIVES: To synthesize and assess certainty of evidence on oral/enteral fluid resuscitation as compared to IV or no fluid resuscitation for major burns. METHODS: PubMed, EMBASE, CINAHL, and Cochrane Library were searched on 8 September 2023. Primary quantitative studies meeting criteria as assessed by two reviewers were included. Meta-analyses for outcome effects of oral/enteral versus IV and of oral/enteral versus no fluid resuscitation were conducted. Evidence certainty was assessed using GRADE. RESULTS: Seven human and eight animal studies were included. Three human RCTs totalling 100 participants contributed to estimates. Compared to IV fluid resuscitation, oral/enteral fluid resuscitation is associated with a statistically insignificant increased risk of mortality (OR 1.33, 95% CI 0.33-5.36) but the evidence is very uncertain, and no difference in urine output (SMD -0.17, 95% CI -0.65-0.31) with moderate certainty of evidence. Eight controlled animal studies totalling 212 participants contributed to estimates. From these animal studies, enteral fluid resuscitation may increase mortality (OR 36.00, 95% CI 2.72-476.28), worsen creatinine levels (MD 22 mmol/L, 95% CI 15.8-28.2), and increase urine output (MD 1 ml/kg/h, 95% CI 0.55-1.45) compared to IV, but all with very low certainty of evidence. Again, from animal studies, all the evidence is very uncertain, but compared to no fluid resuscitation, enteral resuscitation is associated with a statistically insignificant reduction in mortality (OR 0.29, 95% CI 0.08-1.09), improved creatinine levels (SMD -3.48, 95% CI -4.69 to -2.28), and increased urine output (MD 0.55 ml/kg/h, 95% CI 0.38-0.72). CONCLUSIONS: Current evidence comparing oral/enteral and IV fluid resuscitation for major burns is limited and uncertain. However, where IV fluid resuscitation is unavailable or delayed, oral fluid resuscitation could be considered.
    Tags: Burns, Fluid therapy, Intravenous fluid, Mass casualty incidents, Oral fluid, Oral rehydration solution, personal relationships that could have appeared to influence the work reported in, this paper..
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  • Hsiao, K. H., Kalanzi, J., Watson, S. B., Murthy, S., Movsisyan, A., Kothari, K., Salio, F., and Relan, P. “Adapted Approaches To Initial Fluid Management Of Patients With Major Burns In Resource-Limited Settings: A Systematic Review”. Burns Open 8, no. 4: None. doi:10.1016/j.burnso.2024.100365.
    Abstract: BACKGROUND: Resource limitations in settings such as burn mass casualty incidents (MCIs) present challenges to the judicious fluid resuscitation required for major burns. Previous recommendations for burns care in MCIs have suggested certain adaptations from routine care, such as delaying intravenous (IV) fluid resuscitation until arrival at facility; using a fluid calculation formula that is independent of percentage of total body surface area (%TBSA) burned; or using fluid calculation formula based on time of arrival to first receiving facility rather than from time of injury, thus omitting 'catch-up' fluid. OBJECTIVES: To synthesize and assess certainty of evidence from resource-limited settings on the three adaptations to fluid resuscitation for patients with major burns in MCIs. METHODS: PubMed, EMBASE, CINAHL, and Cochrane Library were searched on 8 September 2023 with an update search on 8 July 2024. Primary quantitative studies in resource-limited settings meeting eligibility criteria as assessed by two reviewers were included. Where available, outcome effects for these adaptations compared to routine burns care were calculated. Evidence certainty was determined by GRADE. RESULTS: Two eligible studies were identified from 544 search results. One study with 48 participants provided very uncertain evidence that delayed IV fluid resuscitation may increase acute kidney injury compared to prehospital resuscitation (OR 2.48, 95% CI 0.58-10.62). The other study with a cohort of 10 children provided very uncertain evidence that calculating fluid requirements based on time of arrival to first receiving facility, i.e. omitting 'catch-up' fluids, may maintain adequate urine output and be associated with no complications of fluid over- or under-resuscitation. There were no studies on use of a simplified %TBSA-independent fluid calculation formula. CONCLUSIONS: There is very limited and uncertain evidence to inform on delayed IV fluid resuscitation, simplified %TBSA-independent formula, and omission of 'catch up' fluids for burns care in MCIs. Contextual factors, local values, preferences and feasibility also need to be considered.
    Tags: Burns, Disasters, Fluid therapy, Intravenous fluid, Mass casualty incidents, personal relationships that could have appeared to influence the work reported in, Resource-limited settings, this paper..
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  • Guidi, M., Previ, L., Mazza, D., Lucchina, S., Fusetti, C., Goldshmidt, S. B., Di Maro, A., et al. “Dorsal Cortical Screw Penetration In Volar Distal Radius Plating: Comparison Of 3 Fluoroscopic Views”. Plast Reconstr Surg Glob Open 12, no. 11: e6320. doi:10.1097/GOX.0000000000006320.
    Abstract: BACKGROUND: The skyline or dorsal tangential view (DTV) and the carpal shoot-through (CST) have been developed to enhance the intraoperative examination of the distal radius's dorsal cortex during open reduction and internal fixation with volar plates. This study aimed to assess the lateral view (LV), DTV, and CST's effectiveness in showcasing screws that penetrate the dorsal cortex. METHODS: Eighty patients, comprised of 42 women and 38 men with an average age of 53 years, underwent volar locking plate fixation for displaced distal radius fractures. The procedures incorporated the use of intraoperative LV, DTV, and CST views. Every view was meticulously examined to record the presence of screws that breached the dorsal cortex of the fractured region. RESULTS: Only 2 screws were found to protrude the dorsal cortex in the LV, demonstrating 100% specificity and 18.8% sensitivity. On the DTV, 9 screws were detected with the same specificity but increased sensitivity (75%). On the CST, all 12 screws were identified, making for 100% specificity and sensitivity. Of 501 distal screws, 13 (2.54%) penetrated the dorsal cortex, with an average length of 1.34 mm (range, 0.5-2 mm). These screws were subsequently replaced with shorter screws in 12 of 80 patients. CONCLUSIONS: The findings show that the CST and DTV are more precise and accurate than LV in identifying dorsal screw protrusion during distal radius volar plating. To minimize the likelihood of subsequent complications, it is highly advisable to implement these views in all procedures.
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  • Gray, D., Pasquier, M., Brugger, H., Musi, M., and Paal, P. “A Regional Modification To The Revised Swiss System For Clinical Staging Of Hypothermia Including Confusion”. Scand J Trauma Resusc Emerg Med 32, no. 1: 110. doi:10.1186/s13049-024-01273-3.
  • Yang, J., Henao, J. A. G., Dvornek, N., He, J., Bower, D. V., Depotter, A., Bajercius, H., et al. “Prior Knowledge-Guided Vision-Transformer-Based Unsupervised Domain Adaptation For Intubation Prediction In Lung Disease At One Week”. Comput Med Imaging Graph 118: 102442. doi:10.1016/j.compmedimag.2024.102442.
    Abstract: Data-driven approaches have achieved great success in various medical image analysis tasks. However, fully-supervised data-driven approaches require unprecedentedly large amounts of labeled data and often suffer from poor generalization to unseen new data due to domain shifts. Various unsupervised domain adaptation (UDA) methods have been actively explored to solve these problems. Anatomical and spatial priors in medical imaging are common and have been incorporated into data-driven approaches to ease the need for labeled data as well as to achieve better generalization and interpretation. Inspired by the effectiveness of recent transformer-based methods in medical image analysis, the adaptability of transformer-based models has been investigated. How to incorporate prior knowledge for transformer-based UDA models remains under-explored. In this paper, we introduce a prior knowledge-guided and transformer-based unsupervised domain adaptation (PUDA) pipeline. It regularizes the vision transformer attention heads using anatomical and spatial prior information that is shared by both the source and target domain, which provides additional insight into the similarity between the underlying data distribution across domains. Besides the global alignment of class tokens, it assigns local weights to guide the token distribution alignment via adversarial training. We evaluate our proposed method on a clinical outcome prediction task, where Computed Tomography (CT) and Chest X-ray (CXR) data are collected and used to predict the intubation status of patients in a week. Abnormal lesions are regarded as anatomical and spatial prior information for this task and are annotated in the source domain scans. Extensive experiments show the effectiveness of the proposed PUDA method.
    Tags: *Lung Diseases/diagnostic imaging, 3d/2d, Algorithms, Chest CT, Chest X-ray, competing financial interests or personal relationships that could have appeared, Humans, Intubation, Intratracheal/methods, Pneumonia, Prior knowledge, to influence the work reported in this paper., Tomography, X-Ray Computed/methods, Transformer, Unsupervised domain adaptation, Unsupervised Machine Learning.
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  • von Heymann, C., Afshari, A., Ahmed, A., Arnaoutoglou, E., Bolliger, D., Fenger-Eriksen, C., and Grottke, O. “Commentary On The Annexa-I Trial From The Guideline Group Of The European Society Of Anaesthesiology And Intensive Care (Esaic) On The Reversal Of Direct Oral Anticoagulants In Patients With Life Threatening Bleeding”. Eur J Anaesthesiol 41, no. 11: 867-868. doi:10.1097/EJA.0000000000002061.
  • van der Geest, Y., Marengo, L., Albrecht, R., Buehler, P. K., Wendel-Garcia, P. D., Hofmaenner, D. A., and Pietsch, U. “Prehospital Ultrasound Constitutes A Potential Distraction From The Observation Of Critically Ill Patients: A Prospective Simulation Study”. Scand J Trauma Resusc Emerg Med 32, no. 1: 109. doi:10.1186/s13049-024-01280-4.
    Abstract: BACKGROUND: Prehospital point-of-care ultrasound allows an unstable patient to be rapidly and accurately assessed. However, we are concerned that an excessive focus on the ultrasound device, in an already demanding emergency medical service environment, may distract from patient care, potentially leading to reduced situational awareness and the neglect of other crucial instruments, such as the patient monitor. Thus, in this study, we examined the influence of prehospital ultrasound on situational awareness, by studying the degree to which physicians were distracted from the patient monitor. METHODS: We observed HEMS physicians in a simulated setting and analysed their gaze behaviour using an eye tracker placed on three areas of interests: the ultrasound device, the patient and the patient monitor. In the course of the experiment, the simulated patient desaturated, which was presented on the patient monitor. The primary outcome was the fraction of gaze distribution across the three areas of interest, while secondary outcomes were different gaze metrics (dwell time, revisits, average duration of visual intake and entry time) on the patient monitor. We then compared the participants who noticed the patient's deterioration with those who did not. RESULTS: In 75% of cases, the severely decreased oxygen saturation went unnoticed during the test. Moreover, the gaze distribution of the two groups differed, with the group that recognised the deterioration focusing longer on the patient monitor (7.8% (95% CI 5-10.7) vs 0.1% (95% CI 0-0.3), p: 0.124). CONCLUSIONS: The task of performing an ultrasound examination appears to overwhelm some participants and distract them from other aspects of the scenario. Efforts to mitigate distractions and optimise the use of prehospital ultrasound, such as education, a focus on human factors aspects and standardisation, are crucial for maximising the potential benefits of prehospital ultrasound.
    Tags: *Critical Illness, *Emergency Medical Services/methods, *Ultrasonography/methods, 2023-01130, approval date: 21/09/2023, accordance with the 1964 Declaration of Helsinki and its later amendments or, Adult, Attention, Committee has approved the study protocol (Ethikkommission Ostschweiz, BASEC Nr., comparable ethical standards. Consent for publication Not applicable. Competing, Eye tracking, Female, Gaze behaviour, grundlegender visueller Verhaltensmuster und Einflusse auf das visuelle Verhalten, Hems, Human factor, Humans, in der Akutmedizin (Intensiv-Anasthesie und Notfallmedizin) im Rahmen ihrer, interests The authors declare that they have no competing interests., Male, Point-of-Care Systems, Prehospital ultrasound, professionellen Tatigkeit im simulierten Setting'). The study was carried out in, Prospective Studies, Situational awareness, study title (German): 'Untersuchung.
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  • Putzu, A., Grange, E., Schorer, R., Schiffer, E., and Gariani, K. “Continuous Peri-Operative Glucose Monitoring In Noncardiac Surgery: A Systematic Review”. Eur J Anaesthesiol 42, no. 2: 162-171. doi:10.1097/EJA.0000000000002095.
    Abstract: BACKGROUND: Glucose management is an important component of peri-operative care. The usefulness of continuous glucose monitoring (CGM) in noncardiac surgery is uncertain. OBJECTIVE: To systematically assess the glycaemic profile and clinical outcome of patients equipped with a CGM device during the peri-operative period in noncardiac surgery. DESIGN: Systematic review. DATA SOURCES: Electronic databases were systematically searched up to July 2024. ELIGIBILITY CRITERIA: Any studies performed in the peri-operative setting using a CGM device were included. Closed-loop systems also administering insulin were excluded. Analyses were stratified according to diabetes mellitus status and covered intra-operative and postoperative data. Outcomes included glycaemic profile (normal range 3.9 to 10.0 mmol l -1 ), complications, adverse events, and device dysfunction. RESULTS: Twenty-six studies (1016 patients) were included. Twenty-four studies were not randomised, and six used a control arm for comparison. In bariatric surgery, diabetes mellitus patients had a mean +/- SD glucose of 5.6 +/- 0.5 mmol l -1 , with 15.4 +/- 8.6% time below range, 75.3 +/- 5.5% in range and 9.6 +/- 6.7% above range. During major surgery, diabetes mellitus patients showed a mean glucose of 9.6 +/- 1.1 mmol l -1 , with 9.5 +/- 9.1% of time below range, 56.3 +/- 13.5% in range and 30.6 +/- 13.9% above range. In comparison, nondiabetes mellitus patients had a mean glucose of 6.4 +/- 0.6 mmol l -1 , with 6.7 +/- 8.4% time below range, 84.6 +/- 15.5% in range and 11.2 +/- 4.9% above range. Peri-operative complications were reported in only one comparative study and were similar in CGM and control groups. Device-related adverse events were rare and underreported. In 9.21% of cases, the devices experienced dysfunctions such as accidental removal and issues with sensors or readers. CONCLUSION: Due to the limited number of controlled studies, the impact of CGM on postoperative glycaemic control and complications compared with point-of-care testing remains unknown. Variability in postoperative glycaemic profiles and a device dysfunction rate of 1 in 10 suggest CGM should be investigated in a targeted surgical group.
    Tags: *Blood Glucose/metabolism/analysis, *Perioperative Care/methods, control/epidemiology/etiology, Diabetes Mellitus/blood/diagnosis, Humans, Monitoring, Physiologic/methods, Postoperative Complications/blood/diagnosis/prevention &, Surgical Procedures, Operative/adverse effects.
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  • Heymann, E. P., Lim, R., Maskalyk, J., Pulfrey, S., Chun, S., Osei-Ampofo, M., deSouza, K., Landes, M., and Lang, E. “Emergency Medicine: A Global Perspective On Its Past, Evolution, And Future”. Intern Emerg Med. doi:10.1007/s11739-024-03812-3.
    Abstract: Emergency Medicine (EM) has continuously evolved since its origins on the battlefields of eighteenth-century Europe. Adapting to emerging challenges in healthcare, it has, in the past 70 years, developed to become a critical safety net for society. Despite its resilience and many accomplishments, EM still faces significant challenges, including workforce attrition, resource constraints, and the need for ongoing innovation. This paper explores the various adaptations EM has implemented to meet the demands of healthcare systems globally. By examining these factors and challenges, the paper outlines a future roadmap for EM, emphasizing global equity, interdisciplinary collaboration, and sustained investment to ensure that EM remains robust in addressing future healthcare challenges.
    Tags: Artificial Intelligence, Development of Emergency Medicine, Emergency Medicine, Evolution, Future, Past, Present.
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  • Gisselbaek, M., Suppan, M., Minsart, L., Koselerli, E., Nainan Myatra, S., Matot, I., Barreto Chang, O. L., Saxena, S., and Berger-Estilita, J. “Representation Of Intensivists' Race/Ethnicity, Sex, And Age By Artificial Intelligence: A Cross-Sectional Study Of Two Text-To-Image Models”. Crit Care 28, no. 1: 363. doi:10.1186/s13054-024-05134-4.
    Abstract: BACKGROUND: Integrating artificial intelligence (AI) into intensive care practices can enhance patient care by providing real-time predictions and aiding clinical decisions. However, biases in AI models can undermine diversity, equity, and inclusion (DEI) efforts, particularly in visual representations of healthcare professionals. This work aims to examine the demographic representation of two AI text-to-image models, Midjourney and ChatGPT DALL-E 2, and assess their accuracy in depicting the demographic characteristics of intensivists. METHODS: This cross-sectional study, conducted from May to July 2024, used demographic data from the USA workforce report (2022) and intensive care trainees (2021) to compare real-world intensivist demographics with images generated by two AI models, Midjourney v6.0 and ChatGPT 4.0 DALL-E 2. A total of 1,400 images were generated across ICU subspecialties, with outcomes being the comparison of sex, race/ethnicity, and age representation in AI-generated images to the actual workforce demographics. RESULTS: The AI models demonstrated noticeable biases when compared to the actual U.S. intensive care workforce data, notably overrepresenting White and young doctors. ChatGPT-DALL-E2 produced less female (17.3% vs 32.2%, p < 0.0001), more White (61% vs 55.1%, p = 0.002) and younger (53.3% vs 23.9%, p < 0.001) individuals. While Midjourney depicted more female (47.6% vs 32.2%, p < 0.001), more White (60.9% vs 55.1%, p = 0.003) and younger intensivist (49.3% vs 23.9%, p < 0.001). Substantial differences between the specialties within both models were observed. Finally when compared together, both models showed significant differences in the Portrayal of intensivists. CONCLUSIONS: Significant biases in AI images of intensivists generated by ChatGPT DALL-E 2 and Midjourney reflect broader cultural issues, potentially perpetuating stereotypes of healthcare worker within the society. This study highlights the need for an approach that ensures fairness, accountability, transparency, and ethics in AI applications for healthcare.
    Tags: *Artificial Intelligence/statistics & numerical data/trends, absence of any commercial or financial relationships that could be construed as a, Adult, Age Factors, applicable. Competing interests OB received funding from the Harold Amos Medical, Artificial intelligence (AI), Bias, Cross-Sectional Studies, Demographic representation, epidemiology (STROBE) reporting guideline. [38] Consent for publication Not, Equity and inclusion (DEI), ethical committee waiver (Req-2024-00531) was obtained from the, Ethnicity/statistics & numerical data, Faculty Development Program and participated as an investigator for the clinical, Female, Humans, Intensive care, Intensive Care (ESAIC) Board of Directors and has received speaker fees from, Male, Medtronic(R). The remaining authors declare that the research was conducted in the, Medtronic(R)/Merck(R). JB-E is a member of the European Society of Anesthesiology and, Middle Aged, potential conflict of interest., Protection Acts and the study complied with the Declaration of Helsinki [37]. The, Racial Groups/statistics & numerical data, study adhered to the strengthening the reporting of observational studies in, Swissethics-University of Bern, Switzerland. The researchers followed the Data, trial OLIVER from Medtronic(R). SS has received speaker's fees from, United States.
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  • Edjinedja, K., Elfahim, O., Arnaud, E., Barakat, O., Desmettre, T., and Robert-Nicoud, S. “Multi-Agent Modeling And Discrete-Event Simulation For Analyzing The Responsiveness Of Pre-Hospital Emergency Services In The Event Of Mass Casualties Due To Rare Events”. In, 2024. doi:10.1109/ICTMOD63116.2024.10878164.
    Abstract: Mass casualty incidents due to unpredictable events such as natural disasters or epidemics constitute major public health. During these events, Emergency Medical Services (EMS) play a crucial role in the survival of victims. The main purpose of this special issue is to perform 'what if' analyses on the EMS, to test its response in case of mass casualty incidents. The proposed approach provides a methodology for designing a mesoscopic simulation model that integrates Discrete Event Simulation and Agent-Based Simulation. In addition, to evaluate the proposed model, many scenarios have been experimented with to understand and analyze the behavior of EMS. Alternatively, Reinforcement Learning (RL) was used during the simulation stage to learn the optimal resource management strategy. © 2024 IEEE.
    Tags: Agent-Based Simulation, Discrete Event Sim-ulation, Reinforcement Learning.
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  • Weber, D. M., Luckert, C., Kalisch, M., Subotic, U., Weil, R., and Seiler, M. “Buddy Taping After Reduction Of Displaced Extra-Articular Phalangeal Finger Fractures In Children: A Randomized Controlled Trial”. J Hand Surg Eur Vol 50, no. 5: 622-627. doi:10.1177/17531934241293338.
    Abstract: In this randomized controlled trial, we assessed the non-inferiority of buddy taping to splinting after reduction of displaced extra-articular proximal and middle phalangeal finger fractures in children. The primary outcome was the rate of secondary fracture displacements; the secondary outcomes were patient comfort, analgesic efficacy and total range of active motion 6 months after injury. Eighty-one patients participated: 43 with taping and 38 with splinting. Secondary displacement occurred in eight patients: five in the splinting group and three in the taping group. Risk difference was below the predefined non-inferiority of 10%. Patient comfort was significantly higher in the taping group, with no group differences for other parameters. Our previous study recommended taping for undisplaced finger fractures in children. With the current data, we recommend taping these finger fractures irrespective of displacement or need for reduction. We are encouraged to propose taping as an alternative to splinting for increased patient comfort, lower cost, and shorter application time.Level of evidence: I.
    Tags: *Athletic Tape, *Finger Injuries/therapy/surgery, *Finger Phalanges/injuries, *Fractures, Bone/therapy/surgery, Adolescent, article., Child, Child, Preschool, Children, Female, finger fracture, Humans, interest with respect to the research, authorship and/or publication of this, Male, phalangeal fractures, Range of Motion, Articular, Splints, treatment.
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  • Krummrey, G., Sauter, T. C., Hautz, W. E., Muller, M., and Schwappach, D. L. B. “Risk Factors For Wrong-Patient Medication Orders In The Emergency Department”. Jamia Open 7, no. 4: ooae103. doi:10.1093/jamiaopen/ooae103.
    Abstract: OBJECTIVES: This paper investigates the risk factors for wrong-patient medication orders in an emergency department (ED) by studying intercepted ordering errors identified by the "retract-and-reorder" (RaR) metric (orders that were retracted and reordered for a different patient by the same provider within 10 min). MATERIALS AND METHODS: Medication ordering data of an academic ED were analyzed to identify RaR events. The association of RaR events with similarity of patient names and birthdates, matching sex, age difference, the month, weekday, and hour of the RaR event, the elapsed hours since ED shift start, and the proximity of exam rooms in the electronic medical record (EMR) dashboard's layout was evaluated. RESULTS: Over 5 years (2017-2021), 1031 RaR events were identified among a total of 561 099 medication orders leading to a proportional incidence of 184 per 100 000 ED orders (95% CI: 172; 195). RaR orders were less likely to be performed by nurses compared to physicians (OR 0.54 [0.47; 0.61], P < .001). Furthermore, RaR pairs were more likely to have the same sex (OR 1.26 [95% CI 1.10; 1.43], P = .001) and the proximity of the exam rooms was closer (-0.62 [95% CI -0.77; -0.47], P = .001) compared to control pairs. Patients' names, birthdates, age, and the other factors showed no significant association (P > .005). DISCUSSION AND CONCLUSION: This study found no significant influence from factors such as similarity of patient names, age, or birthdates. However, the proximity of exam rooms in the user interface of the EMR as well as patients' same sex emerged as risk factors.
    Tags: electronic medical records (EMRs), emergency medicine, medication error, retract-and-reorder (RaR).
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  • Heymann, E. P., Lim, R., and Lang, E. “Improving Resilience And Wellbeing In Emergency Medicine”. Intern Emerg Med 20, no. 1: 213-214. doi:10.1007/s11739-024-03781-7.
  • Buclin, C. P., Doninelli, M., Bertini, L., Bodenmann, P., Cullati, S., Chiolero, A., Degiorgi, A., et al. “Monitoring Equity In The Delivery Of Health Services: A Delphi Process To Select Healthcare Equity Indicators”. Swiss Med Wkly 154, no. 10: 3714. doi:10.57187/s.3714.
    Abstract: AIMS OF THE STUDY: Health equity is a key component of quality of care and an objective for a growing number of quality improvement projects for deontological, ethical, public health and economic reasons. To monitor equity in the delivery of health services in Switzerland, there is a need to implement valid, measurable and actionable equity indicators, along with vulnerability stratifiers such as migrant status, which could lead to differences in quality of care. The aim of this study was to develop a set of healthcare equity indicators and stratifiers targeting inpatient and outpatient populations and to test their feasibility. METHODS: A scoping literature review and inputs from a national interprofessional expert taskforce provided a set of indicators and vulnerability stratifiers. The most valid and measurable indicators and stratifiers were retained using a Delphi process. They were then operationalised, and their implementation tested in three Swiss hospitals from the three language regions. RESULTS: A taskforce of 18 experts, including a patient representative, selected 11 indicators that evaluate structures, processes and outcomes, and five vulnerability stratifiers. Although most indicators and stratifiers could be implemented in all three hospitals, data availability was limited for some variables, including patient satisfaction and access to interpreters for foreign-language patients. CONCLUSIONS: The equity indicators and stratifiers identified by this two-stage process have content validity, wide patient coverage and are focused on inequities in the healthcare system that are actionable through improvement projects. Both the indicators and the project methodology could be replicated in institutions aiming for more equitable care.
    Tags: *Delivery of Health Care/standards, *Delphi Technique, *Health Equity, *Quality Indicators, Health Care, Health Services Accessibility, Healthcare Disparities, Humans, Quality Improvement, Quality of Health Care, Switzerland.
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  • Ker, K., Sentilhes, L., Shakur-Still, H., Madar, H., Deneux-Tharaux, C., Saade, G., Pacheco, L. D., et al. “Tranexamic Acid For Postpartum Bleeding: A Systematic Review And Individual Patient Data Meta-Analysis Of Randomised Controlled Trials”. Lancet 404, no. 10463: 1657-1667. doi:10.1016/S0140-6736(24)02102-0.
    Abstract: BACKGROUND: Tranexamic acid is a recommended treatment for women with a clinical diagnosis of postpartum haemorrhage, but whether it can prevent bleeding is unclear. We conducted a systematic review and individual patient data (IPD) meta-analysis of randomised controlled trials to assess the effects of tranexamic acid in women giving birth. METHODS: In this systematic review and IPD meta-analysis, we searched the WHO International Clinical Trials Registry Platform from database inception to Aug 4, 2024 for randomised trials that assessed the effects of tranexamic acid in women giving birth. Trials were eligible if they were prospectively registered, placebo-controlled, included more than 500 women, and had a low risk of bias for random sequence generation and allocation concealment. IPD were requested from the trial investigators. The primary outcomes were the numbers of women with life-threatening bleeding and thromboembolic events. We used a one-stage model to analyse the data and explored whether the effect of tranexamic acid varied by the underlying risk of life-threatening bleeding, type of birth, presence of moderate or severe anaemia, or timing of administration (before or after a diagnosis of postpartum haemorrhage). This study is registered with PROSPERO, CRD42022345775. FINDINGS: We analysed data on 54 404 women from five trials. We obtained IPD for 43 409 women from four trials and aggregate data on 10 995 women from one trial. All trials had a low risk of bias. Life-threatening bleeding occurred in 178 (0.65%) of 27 300 women in the tranexamic acid group versus 230 (0.85%) of 27 093 women in the placebo group (pooled odds ratio [OR] 0.77 [95% CI 0.63-0.93]; p=0.008). There was no evidence that the effect of tranexamic acid varied by the underlying risk of life-threatening bleeding, type of birth, presence of moderate or severe anaemia or timing of administration. No significant difference was identified between tranexamic acid and placebo groups with regard to thromboembolic events: 50 (0.2%) of 26 571 women in the tranexamic acid group had fatal or non-fatal thromboembolic events versus 52 (0.2%) of 26 373 women in the placebo group (pooled OR 0.96 [0.65-1.41]; p=0.82) with no significant heterogeneity identified in the subgroup analyses. INTERPRETATION: Tranexamic acid reduces the risk of life-threatening postpartum bleeding. We found no evidence that tranexamic acid increases the risk of thrombosis. Although we do not recommend the use of tranexamic acid in all women giving birth, consideration should be given to its use before a diagnosis of postpartum haemorrhage in women at high risk of death. FUNDING: The Bill & Melinda Gates Foundation.
    Tags: *Antifibrinolytic Agents/therapeutic use, *Postpartum Hemorrhage/drug therapy/prevention & control, *Tranexamic Acid/therapeutic use/adverse effects, Female, Humans, Pregnancy, Randomized Controlled Trials as Topic, Thromboembolism/prevention & control/drug therapy.
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  • Brunner, L., Siebert, J. N., Ehrler, F., Manzano, S., and Marti, J. “Evaluating The Economic Impact Of The Pedamines App In Reducing Medication Errors In Pediatric Emergency Care: Cost-Effectiveness Analysis”. J Med Internet Res 26: e52077. doi:10.2196/52077.
    Abstract: BACKGROUND: The administration of drugs in pediatric emergency care is a time-consuming process and is associated with a higher occurrence of medication errors compared with adult care. This is attributed to the intricacies of administration, which involve calculating doses based on the child's weight or age. To mitigate the occurrence of adverse drug events (ADEs), the PedAMINES (Pediatric Accurate Medication in Emergency Situations; Geneva University Hospitals) mobile app has been developed. This app offers a step-by-step guide for preparing and administering pediatric drugs during emergency interventions by automating the dose calculation process. Although previous simulation-based randomized controlled trials conducted in emergency care have demonstrated the efficacy of the PedAMINES app in reducing drug administration errors, there is a lack of evidence regarding its economic implications. OBJECTIVE: This study aims to evaluate the cost-effectiveness of implementing the PedAMINES app for 4 emergency drugs: epinephrine, norepinephrine, dopamine, and midazolam. METHODS: The economic evaluation was conducted by combining hospital data from 2019, previous trial outcomes, information extracted from existing literature, and PedAMINES maintenance costs. The cost per avoided medication error was calculated, along with the number of administrations needed to achieve a positive return on investment. Subsequently, Monte Carlo simulations were used to identify the key parameters contributing to result uncertainty. RESULTS: The study revealed the number of preventable errors per administration for the 4 examined drugs: 0.513 for epinephrine, 0.484 for norepinephrine, 0.500 for dopamine, and 0.671 for midazolam. The cost-effectiveness ratios per ADE prevented were computed as follows: US $4808 for epinephrine, US $9705 for norepinephrine, US $6957 for dopamine, and US $2074 for midazolam. Accounting for the economic impact of ADEs, the analysis estimated that 16 administrations of epinephrine, 17 of norepinephrine and dopamine, and 13 of midazolam would be required to attain a positive return on investment. This corresponds to roughly one-third of the annual administrations at a major university hospital in Switzerland. The primary factors influencing the uncertainty in the estimated cost per ADE include the cost of maintenance of the app, the likelihood of an ADE resulting from an administration error, and the frequency of underdosing in the trial's control group. CONCLUSIONS: A dedicated mobile app presents an economically viable solution to alleviate the health and economic burden of drug administration errors in in-hospital pediatric emergency care. The widespread adoption of this app is advocated to pool costs and extend the benefits on a national scale in Switzerland.
    Tags: *Cost-Benefit Analysis/methods, *Medication Errors/prevention & control/economics, *Mobile Applications/economics, adverse drug event, All authors declare no competing interests. The PedAMINES mobile app is owned by, ambulance care, Child, child care, cost-effectiveness, Cost-Effectiveness Analysis, dopamine, Dopamine/economics/therapeutic use, economic evaluation, emergency care, Emergency Medical Services/economics, employees of Geneva University Hospitals, JNS, FE, and SM may receive, epinephrine, Epinephrine/economics/administration & dosage/therapeutic use, evidence-based, Geneva University Hospitals and is not currently available for commercial use. As, health information technology, Humans, institutional benefits if the app is commercialized in the future., medical app, medication error, midazolam, Midazolam/therapeutic use/economics/administration & dosage, mobile phone, norepinephrine, Norepinephrine/economics/therapeutic use/administration & dosage, PedAMINES, pediatric, Pediatric Accurate Medication in Emergency Situations, pediatric care, pediatric emergency care, Pediatrics/economics/methods, Situations) app is not available on the Google Play Store or the Apple App Store., Switzerland.
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