Carmen A. Pfortmueller

Adult Asylum Seekers from the Middle East Including Syria in Central Europe: What Are Their Health Care Problems?

Background Forced displacement related to persecution and violent conflict has reached a new peak in recent years. The primary aim of this study is to provide an initial overview of the acute and chronic health care problems of asylum seekers from the Middle East, with special emphasis on asylum seekers from Syria. Methods Our retrospective data analysis comprised adult patients presenting to our emergency department between 01.11.2011 and 30.06.2014 with the official resident status of an “asylum seeker” or “refugee” from the Middle East. Results In total, 880 patients were included in the study. Of these, 625 (71.0%) were male and 255 (29.0%) female. The median age was 34 (range 16–84). 222 (25.2%) of our patients were from Syria. The most common reason for presentation was surgical (381, 43.3%), followed by medical (321, 36.5%) and psychiatric (137, 15.6%). In patients with surgical presentations, trauma-related problems were most common (n = 196, 50.6%). Within the group of patients with medical presentation, acute infectious diseases were most common (n = 141, 43.9%), followed by neurological problems (n = 70, 21.8%) and gastrointestinal problems (n = 47, 14.6%). There were no differences between Syrian and non-Syrian refugees concerning surgical or medical admissions. The most common chronic disorder of unclear significance was chronic gastrointestinal problems (n = 132, 15%), followed by chronic musculoskeletal problems (n = 108, 12.3%) and chronic headaches (n = 78, 8.9%). Patients from Syria were significantly younger and more often suffered from a post-traumatic stress disorder than patients of other nationalities (p<0.0001, and p = 0.05, respectively). Conclusion Overall a remarkable number of our very young group of patients suffered from psychiatric disorders and unspecified somatic symptoms. Asylum seekers should be carefully evaluated when presenting to a medical facility and physicians should be aware of the high incidence of unspecified somatic symptoms in this patient population.In general, there is no major difference between asylum seekers from Syria when compared to other nationalities of asylum seekers from the Middle East.

Fall-related emergency department admission: fall environment and settings and related injury patterns in 6357 patients with special emphasis on the elderly

Principals. Throughout the world, falls are a major public health problem and a socioeconomic burden. Nevertheless there is little knowledge about how the injury types may be related to the aetiology and setting of the fall, especially in the elderly. We have therefore analysed all patients presenting with a fall to our Emergency Department (ED) over the past five years. Methods. Our retrospective data analysis comprised adult patients admitted to our Emergency Department between January 1, 2006, and December 31, 2010, in relation to a fall. Results. Of a total of 6357 patients 78% (n = 4957) patients were younger than 75 years. The main setting for falls was patients home (n = 2239, 35.3%). In contrast to the younger patients, the older population was predominantly female (56.3% versus 38.6%; P < 0.0001). Older patients were more likely to fall at home and suffer from medical conditions (all P < 0.0001). Injuries to the head (P < 0.0001) and to the lower extremity (P < 0.019) occurred predominantly in the older population. Age was the sole predictor for recurrent falls (OR 1.2, P < 0.0001). Conclusion. Falls at home are the main class of falls for all age groups, particularly in the elderly. Fall prevention strategies must therefore target activities of daily living. Even though falls related to sports mostly take place in the younger cohort, a significant percentage of elderly patients present with falls related to sporting activity. Falls due to medical conditions were most likely to result in mild traumatic brain injury.

D-dimer to Rule Out Pulmonary Embolism in Renal Insufficiency

BACKGROUND D-dimer levels are often elevated in renal insufficiency. The diagnostic accuracy of D-dimer to rule out pulmonary embolism in patients with renal insufficiency is unclear. METHODS We evaluated the data of patients presenting to our Emergency Department and receiving computed tomography angiography to rule out pulmonary embolism with measurement of D-dimer and creatinine. Glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration formula. RESULTS There were 1305 patients included; 1067 (82%) had an estimated glomerular filtration rate (eGFR) exceeding 60 mL/min, 209 (16%) 30-60 mL/min, and 29 (2%) <30 mL/min. One hundred fifty-two patients (12%) had D-dimer below 500 μg/L. eGFR (R = -0.1122) correlated significantly with D-dimer (P <.0001). One hundred sixty-nine patients (13%) were found to have pulmonary embolism. Sensitivity of D-dimer for patients with an eGFR >60 mL/min was 96% (confidence interval [CI], 0.93-0.99) and 100% (CI, 100-100) for those with 30-60 mL/min, while specificity decreased significantly with impaired renal function. Area under the curve of the receiver operating characteristic for D-dimer was 0.734 in patients with an eGFR of >60 mL/min, and 0.673 for 30-60 mL/min. CONCLUSIONS D-dimer levels were elevated in patients with an eGFR <60 mL/min, but proved to be highly sensitive for the exclusion of pulmonary embolism. However, because almost all patients with impaired renal function had elevated D-dimer irrespective of the presence of pulmonary embolism, studies should be performed to determine renal function-adjusted D-dimer cutoffs.

Dog Bite Injuries: Primary and Secondary Emergency Department Presentations-A Retrospective Cohort Study

Dog bites in humans are a complex problem, embracing both public health and animal welfare. The primary aim of this study is to examine primary and secondary presentations related to dog bite injuries in adults. Methods. We retrospectively assessed all adult patients admitted with a dog bite injury to the Emergency Department of Bern University Hospital. Results. A total of 431 patients were eligible for the study. Forty-nine (11.4%) of all patients were admitted with secondary presentations. Bites to the hands were most common (177, 41.1%). All patients (47, 100%) with secondary presentations were admitted because of signs of infection. The median time since the dog bite was 3.8 days (SD 3.9, range 1–21). Thirty-one patients had already been treated with antibiotic; coamoxicillin was the most common primary antibiotic therapy (27/47 patients, 57.4%). Patients with injuries to the hand were at increased risk of secondary presentations (OR 2.08, 95% CI 1.21–3.55, P < 0.006). Conclusion. Dog bite injuries to the hands are a major problem. They often lead to infectious complications. Immediate antibiotic therapy should carefully be evaluated for each patient.

Diagnostic accuracy of calculated serum osmolarity to predict dehydration in older people: adding value to pathology laboratory reports.

Objectives To assess which osmolarity equation best predicts directly measured serum/plasma osmolality and whether its use could add value to routine blood test results through screening for dehydration in older people. Design Diagnostic accuracy study. Participants Older people (≥65 years) in 5 cohorts: Dietary Strategies for Healthy Ageing in Europe (NU-AGE, living in the community), Dehydration Recognition In our Elders (DRIE, living in residential care), Fortes (admitted to acute medical care), Sjöstrand (emergency room) or Pfortmueller cohorts (hospitalised with liver cirrhosis). Reference standard for hydration status Directly measured serum/plasma osmolality: current dehydration (serum osmolality >300 mOsm/kg), impending/current dehydration (≥295 mOsm/kg). Index tests 39 osmolarity equations calculated using serum indices from the same blood draw as directly measured osmolality. Results Across 5 cohorts 595 older people were included, of whom 19% were dehydrated (directly measured osmolality >300 mOsm/kg). Of 39 osmolarity equations, 5 showed reasonable agreement with directly measured osmolality and 3 had good predictive accuracy in subgroups with diabetes and poor renal function. Two equations were characterised by narrower limits of agreement, low levels of differential bias and good diagnostic accuracy in receiver operating characteristic plots (areas under the curve >0.8). The best equation was osmolarity=1.86×(Na++ K+)+1.15×glucose+urea+14 (all measured in mmol/L). It appeared useful in people aged ≥65 years with and without diabetes, poor renal function, dehydration, in men and women, with a range of ages, health, cognitive and functional status. Conclusions Some commonly used osmolarity equations work poorly, and should not be used. Given costs and prevalence of dehydration in older people we suggest use of the best formula by pathology laboratories using a cutpoint of 295 mOsm/L (sensitivity 85%, specificity 59%), to report dehydration risk opportunistically when serum glucose, urea and electrolytes are measured for other reasons in older adults. Trial registration numbers: DRIE: Research Register for Social Care, 122273; NU-AGE: ClinicalTrials.gov NCT01754012.

Multimorbidity in adult asylum seekers: A first overview

Principals Over the last two decades, the total annual number of applications for asylum in the countries of the European Union has increased from 15,000 to more than 300,000 people. The aim of this study was to give a first overview on multimorbidity of adult asylum seekers. Methods Our retrospective Swiss single center data analysis examined multimorbidity of adult asylums seekers admitted to our ED between 1 January 2000 and 31 December 2012. Results A total of 3170 patients were eligible for the study; they were predominantly male (2392 male, 75.5% versus 778 female, 24.5). The median age of the patients was 28 years (range 28–82). The most common region of origin was Africa (1544, 48.7%), followed by the Middle East (736, 23.6%). 2144 (67.6%) of all patients were not multimorbid. A total of 1183 (37.7%) of our patients were multimorbid. The mean Charlson comorbidity index was 0.25 (SD 1.1, range 0–12). 634 (20%) of all patients sufferem from psychiatric diseases, followed by chronic medical conditions (12.6%, 399) and infectious diseases (4.7%, 150). Overall, 11% (349) of our patients presented as a direct consequence of prior violence. Patients from Sri Lanka/India most often suffered from addictions problems (50/240, 20.8%, p<0.0001). Infectious diseases were most frequent in patients from Africa (6.6%), followed by the Balkans and Eastern Europe/Russia (each 3.8%). Conclusion The health care problems of asylum seekers are manifold. More than 60% of the study population assessed in our study did not suffer from more than one disease. Nevertheless a significant percentage of asylum seekers is multimorbid and exhibits underlying psychiatric, infectious or chronic medical conditions despite their young age.

Hypoglycemia is associated with increased mortality in patients with acute decompensated liver cirrhosis

PRINCIPALS The liver plays an important role in glucose metabolism, in terms of glucolysis and gluconeogenesis. Several studies have shown that hyperglycemia in patients with liver cirrhosis is associated with progression of the liver disease and increased mortality. However, no study has ever targeted the influence of hypoglycemia. The aim of this study was to assess the association of glucose disturbances with outcome in patients presenting to the emergency department with acute decompensated liver cirrhosis. METHODS Our retrospective data analysis comprised adult (≥ 16 years) patients admitted to our emergency department between January 1, 2002, and December 31, 2012, with the primary diagnosis of decompensated liver cirrhosis. RESULTS A total of 312 patients were eligible for study inclusion. Two hundred thirty-one (74.0%) patients were male; 81 (26.0%) were female. The median age was 57 years (range, 51-65 years). Overall, 89 (28.5%) of our patients had acute glucose disturbances; 49 (15.7%) of our patients were hypoglycemic and 40 (12.8%) were hyperglycemic. Patients with hypoglycemia were significantly more often admitted to the intensive care unit than hyperglycemic patients (20.4% vs 10.8%, P < .015) or than normoglycemic patients (20.4% vs 10.3%, P < .011), and they significantly more often died in the hospital (28.6% hypoglycemic vs 7.5% hyperglycemic, P < .024; 28.6% hypoglycemic vs 10.3% normoglycemic P < .049). Survival analysis showed a significantly lower estimated survival for hypoglycemic patients (36 days) than for normoglycemic patients (54 days) or hyperglycemic patients (45 days; hypoglycemic vs hyperglycemic, P < .019; hypoglycemic vs normoglycemic, P < .007; hyperglycemic vs normoglycemic, P < .477). CONCLUSION Hypoglycemia is associated with increased mortality in patients with acute decompensated liver cirrhosis. It is not yet clear whether hypoglycemia is jointly responsible for the increased short-term mortality of patients with acute decompensated liver cirrhosis or is only a consequence of the severity of the disease or the complications.

Acetate-buffered crystalloid fluids: Current knowledge, a systematic review

INTRODUCTION The concept of fluid resuscitation with balanced solutions containing acetate is relatively new. The knowledge about acetate mostly originates from nephrological research, as acetate was primarily used as a dialysis buffer where much higher doses of acetate are infused. The aim of this review is to give an overview of the advantages and disadvantages of an acetate-buffered crystalloid fluid when compared with other crystalloid infusates. METHODS We report trials with the primary object of comparing an acetate-buffered infusion solute to another crystalloid infusate. A systematic literature search of MEDLINE and the Cochrane Controlled Clinical trials register was conducted to identify suitable studies. RESULTS The search strategy used produced 1205 potential titles. After eliminating doubles, 312 titles and abstracts were screened, and 31 references were retrieved for full-text analysis. A total of 27 scientific studies were included in the study. CONCLUSION Acetate-buffered crystalloid solutes do have a favorable influence on microcirculation. To what extent the acetate-buffered crystalloids influence kidney function is controversially discussed and not yet clear. Metabolic alkalosis did not occur in a single study in humans after an acetate-buffered infusate; potassium levels stayed stable in all studies. Cardiac output and contractility seem to be positively influenced; nonetheless, data on maintenance of a target blood pressure remain inconclusive. Whether acetate-buffered crystalloid fluids lead to lower rates of acute kidney injury and increased survival when compared with normal saline is yet unclear and may depend on the amount of fluid administered.

Electrolyte Disorders and In-Hospital Mortality during Prolonged Heat Periods: A Cross-Sectional Analysis

Background Heat periods during recent years were associated with excess hospitalization and mortality rates, especially in the elderly. We intended to study whether prolonged warmth/heat periods are associated with an increased prevalence of disorders of serum sodium and potassium and an increased hospital mortality. Methods In this cross-sectional analysis all patients admitted to the Department of Emergency Medicine of a large tertiary care facility between January 2009 and December 2010 with measurements of serum sodium were included. Demographic data along with detailed data on diuretic medication, length of hospital stay and hospital mortality were obtained for all patients. Data on daily temperatures (maximum, mean, minimum) and humidity were retrieved by Meteo Swiss. Results A total of 22.239 patients were included in the study. 5 periods with a temperature exceeding 25°C for 3 to 5 days were noticed and 2 periods with temperatures exceeding 25°C for more than 5 days were noted. Additionally, 2 periods with 3 to 5 days with daily temperatures exceeding 30°C were noted during the study period. We found a significantly increased prevalence of hyponatremia during heat periods. However, in the Cox regression analysis, prolonged heat was not associated with the prevalence of disorders of serum sodium or potassium. Admission during a heat period was an independent predictor for hospital mortality. Conclusions Although we found an increased prevalence of hyponatremia during heat periods, no convincing connection could be found for hypernatremia or disorders of serum potassium.

Normal saline versus a balanced crystalloid for goal-directed perioperative fluid therapy in major abdominal surgery: a double-blind randomised controlled study

Background: This double‐blind randomised controlled trial investigated whether normal saline or a balanced crystalloid has distinct effects on vasopressor use in patients undergoing major abdominal surgery. Methods: Patients received either normal saline 0.9% or an acetate‐buffered crystalloid for intraoperative volume replacement in a goal‐directed fashion. The primary outcome was need for vasopressors; the secondary outcomes were the total dose of catecholamines, total perioperative fluid, and unplanned intensive care admissions. Results: This study was terminated early for safety reasons. A total of 60 out of the planned 240 patients were randomized. Thirty patients received normal saline and 30 patients received the balanced crystalloid, with a total volume of 3427 (2732–4130) ml and 3144 (1673–4926), respectively. The normal‐saline group developed hyperchloraemic metabolic acidosis. More patients needed vasopressors for circulatory support in the normal‐saline group compared with the buffered crystalloid group (97% vs 67%, respectively; P=0.033). The median weight and anaesthesia duration‐adjusted dose of norepinephrine were 0.11 (0.00–0.45) ng kg−1 min−1 and 0.00 (0.00–0.00) kg−1 min−1 in the normal‐saline and balanced‐crystalloid groups, respectively (P=0.003). Cox regression revealed that the need for vasopressors was related to a high volume of administered fluid, normal‐saline resuscitation, and lower mean arterial blood pressure. There was no difference between the groups in total perioperative fluid and unplanned intensive‐care‐unit admissions. Between‐group differences in the duration of anaesthesia did not influence the necessity for a vasopressor. Conclusions: Compared with patients receiving a balanced crystalloid, normal saline in patients undergoing major abdominal surgery was associated with an increased need for vasopressor support. This should be interpreted in view of the large volume of fluid resuscitation and the small sample size because of the preliminary termination of the study. Clinical trial registration: EudraCT 2014–004867–19, NCT 02414555.