Joseph Osterwalder

Comparative efficacy of three mumps vaccines during disease outbreak in eastern Switzerland: cohort study

After the introduction of immunisation against measles, mumps, and rubella, numerous outbreaks of mumps were reported in the 1980s and ‘90s in Switzerland and southern Europe.1 2 The Rubini strain is still widely used in Europe,3 and we report here a large outbreak of mumps in a population with a high vaccination rate and examine the differential efficacy of the three vaccine strains. An outbreak was investigated in a small village in Switzerland. All children (ages 5-13) were included in the cohort. Information on immunisation status was obtained from vaccine certificates. The person who investigated the cases of mumps was blinded with regard to the vaccination status. A case was defined if mumps virus was isolated on culture, if a doctor confirmed the diagnosis, or if the typical clinical picture was described in a sibling of a patient with confirmed disease. The absence of IgG antibodies to mumps virus served as confirmation of full susceptibility to …

Diagnostic validity of ultrasound in patients with persistent wrist pain and suspected occult ganglion.

Until recently, the presence of occult ganglions could be determined only by surgical exploration. This prospective study investigated the reliability of ultrasound in the diagnosis of occult ganglions in a patient series over 4 years. The sensitivity, specificity, and accuracy of ultrasound, as well as its positive and negative predictive values, were determined in 83 patients suspected of having an occult wrist ganglion and who had persistent pain and consented to an operation. Examinations were carried out with a 7.5-MHz linear probe and spacer. Outcome of surgery and histologic examination served as the gold standard in 168 patients who had undergone ultrasound; 89 underwent surgery. In 83 patients for whom enough information was available to allow statistical assessment, sensitivity, specificity, and accuracy rates of 88%, 85%, and 87% were respectively obtained. In dorsal wrist ganglions (75%), better results were obtained: a sensitivity rate of 93%, a specificity rate of 86%, and an accuracy rate of 91%. It was concluded that ultrasound of the wrist can be used as a first-line imaging procedure in clinically inconclusive situations and that ultrasound evidence of an occult dorsal ganglion is a reliable indicator for surgery.

Effectiveness of mask ventilation in a training mannikin. A comparison between the Oxylator EM100 and the bag-valve device

The demands for an optimal ventilation apparatus are that it can be easily handled, achieves a sufficiently high ventilation volume, and minimizes gastric inflation. Our aim was therefore to carry out a study in a training mannikin to find out whether the Oxylator EM100, compared with the bag, obtains improved ventilation and a decrease in gastric inflation. In a randomized crossover study, 72 subjects were selected (24 physicians, 44 nurses and 4 auxiliary nurses), chosen from the operating theatre, emergency department and intensive care unit of two hospitals. We used the Ambu-Bag Mark III with mask No. 4, the Oxylator EM100 with a pressure setting of 35 cm H2O run in the manual setting, the Ambu-Man C mannikin as well as the Ambu-CPR computer program. The resuscitation cycles of the standard two-rescuers adult procedure lasted 3 min each, with a 3-min pause between the crossover procedure. The participants could improve their ventilatory volume with the Oxylator EM100 by 635 ml (95% confidence interval 578-692 ml) compared with the bag ventilation. The number of subjects who could attain a mean ventilatory volume of 800 ml or more increased from 15% to 98.6% (P < 0.001). Compared with the bag, the increase of adequate respirations (> or = 800 ml) obtained by the Oxylator EM100 for the individual participants amounted to a median of 91% (P < 0.001). Moreover, conventional ventilation caused in 42% one or several instances of gastric inflation, whereas no such reactions occurred with the Oxylator EM100. The Oxylator EM100 showed significantly better results in the mannikin than the bag. Of most importance is a significant lowering of gastric inflation and less so a marked increase in ventilatory volume. Our trial procedure with a relatively high lung compliance and a high oesophageal sphincter opening simulated favorable conditions. Owing to a large in vivo variability of these magnitudes, a direct testing in real patients with circulatory arrest is indicated.

State of Emergency Medicine in Switzerland: a national profile of emergency departments in 2006

BackgroundEmergency departments (EDs) are an essential component of any developed health care system. There is, however, no national description of EDs in Switzerland. Our objective was to establish the number and location of EDs, patient visits and flow, medical staff and organization, and capabilities in 2006, as a benchmark before emergency medicine became a subspecialty in Switzerland.MethodsIn 2007, we started to create an inventory of all hospital-based EDs with a preliminary list from the Swiss Society of Emergency and Rescue Medicine that was improved with input from ED physicians nationwide. EDs were eligible if they offered acute care 24 h per day, 7 days per week. Our goal was to have 2006 data from at least 80% of all EDs. The survey was initiated in 2007 and the 80% threshold reached in 2012.ResultsIn 2006, Switzerland had a total of 138 hospital-based EDs. The number of ED visits was 1.475 million visits or 20 visits per 100 inhabitants. The median number of visits was 8,806 per year; 25% of EDs admitted 5,000 patients or less, 31% 5,001-10,000 patients, 26% 10,001-20,000 patients, and 17% >20,000 patients per year. Crowding was reported by 84% of EDs with >20,000 visits/year. Residents with limited experience provided care for 77% of visits. Imaging was not immediately available for all patients: standard X-ray within 15 min (70%), non-contrast head CT scan within 15 min (38%), and focused sonography for trauma (70%); 67% of EDs had an intensive care unit within the hospital, and 87% had an operating room always available.ConclusionsSwiss EDs were significant providers of health care in 2006. Crowding, physicians with limited experience, and the heterogeneity of emergency care capabilities were likely threats to the ubiquitous and consistent delivery of quality emergency care, particularly for time-sensitive conditions. Our survey establishes a benchmark to better understand future improvements in Swiss emergency care.

A randomised prospective study to evaluate a rapid HIV-antibody assay in the management of cases of percutaneous exposure amongst health care workers.

A rapid start of post-exposure prophylaxis with an antiretroviral regime is recommended after percutaneous exposure to blood from an HIV-positive source. Since the HIV-antibody status of the source is usually not known at the time of injury, antiretroviral treatment is started pending the results of HIV testing of the source. A randomised prospective study was designed to compare the use of a rapid-screening assay in the management of cases of percutaneous exposure with the conventional procedure. Prior to the comparative study, the accuracy of a rapid-screening assay performed by non-laboratory trained personnel was evaluated. 123 blinded HIV-positive and HIV-negative samples were correctly identified. In a randomised comparison with the conventional procedure, the application of the rapid-screening assay resulted in a significant reduction of psychological stress, drug use and cost. The estimated net benefit per case was CHF 93.-(62 US

What benefits does ultrasound-guided axillary block for brachial plexus anaesthesia offer over the conventional blind approach in hand surgery?:

). This study strongly supports the use of the rapid-screening assay in the management of post-exposure prophylaxis for HIV after percutaneous exposure in health care workers.

Risk of falls and bleeding in elderly patients with acute venous thromboembolism.

Axillary block for brachial plexus anaesthesia is a popular anaesthetic technique for hand surgery with different approaches. We investigated the efficacy of the blind and ultrasound-guided approaches administered by a hand surgeon. A total of 141 patients were prospectively randomized to Group A without and Group B with ultrasound guidance. The principal variables evaluated were number of failures, duration of surgery, time to onset of anaesthesia, volume of anaesthetic injected, and complications. The success rate and the mean time to onset of anaesthesia were significantly better under ultrasound guidance. The duration of surgery and the rate of complications did not differ. Ultrasound-guided plexus anaesthesia is markedly more effective than the blind technique when performed by a hand surgeon.

Anticoagulation management practices and outcomes in elderly patients with acute venous thromboembolism: A clinical research study

Whether or not a high risk of falls increases the risk of bleeding in patients receiving anticoagulants remains a matter of debate.

The Adherence to Initial Processes of Care in Elderly Patients with Acute Venous Thromboembolism

Whether anticoagulation management practices are associated with improved outcomes in elderly patients with acute venous thromboembolism (VTE) is uncertain. Thus, we aimed to examine whether practices recommended by the American College of Chest Physicians guidelines are associated with outcomes in elderly patients with VTE. We studied 991 patients aged ≥65 years with acute VTE in a Swiss prospective multicenter cohort study and assessed the adherence to four management practices: parenteral anticoagulation ≥5 days, INR ≥2.0 for ≥24 hours before stopping parenteral anticoagulation, early start with vitamin K antagonists (VKA) ≤24 hours of VTE diagnosis, and the use of low-molecular-weight heparin (LMWH) or fondaparinux. The outcomes were all-cause mortality, VTE recurrence, and major bleeding at 6 months, and the length of hospital stay (LOS). We used Cox regression and lognormal survival models, adjusting for patient characteristics. Overall, 9% of patients died, 3% had VTE recurrence, and 7% major bleeding. Early start with VKA was associated with a lower risk of major bleeding (adjusted hazard ratio 0.37, 95% CI 0.20–0.71). Early start with VKA (adjusted time ratio [TR] 0.77, 95% CI 0.69–0.86) and use of LMWH/fondaparinux (adjusted TR 0.87, 95% CI 0.78–0.97) were associated with a shorter LOS. An INR ≥2.0 for ≥24 hours before stopping parenteral anticoagulants was associated with a longer LOS (adjusted TR 1.2, 95% CI 1.08–1.33). In elderly patients with VTE, the adherence to recommended anticoagulation management practices showed mixed results. In conclusion, only early start with VKA and use of parenteral LMWH/fondaparinux were associated with better outcomes.

Strengths and weaknesses of chest compression training: a preliminary retrospective study.

Background We aimed to assess whether elderly patients with acute venous thromboembolism (VTE) receive recommended initial processes of care and to identify predictors of process adherence. Methods We prospectively studied in- and outpatients aged ≥65 years with acute symptomatic VTE in a multicenter cohort study from nine Swiss university- and non-university hospitals between September 2009 and March 2011. We systematically assessed whether initial processes of care, which are recommended by the 2008 American College of Chest Physicians guidelines, were performed in each patient. We used multivariable logistic models to identify patient factors independently associated with process adherence. Results Our cohort comprised 950 patients (mean age 76 years). Of these, 86% (645/750) received parenteral anticoagulation for ≥5 days, 54% (405/750) had oral anticoagulation started on the first treatment day, and 37% (274/750) had an international normalized ratio (INR) ≥2 for ≥24 hours before parenteral anticoagulation was discontinued. Overall, 35% (53/153) of patients with cancer received low-molecular-weight heparin monotherapy and 72% (304/423) of patients with symptomatic deep vein thrombosis were prescribed compression stockings. In multivariate analyses, symptomatic pulmonary embolism, hospital-acquired VTE, and concomitant antiplatelet therapy were associated with a significantly lower anticoagulation-related process adherence. Conclusions Adherence to several recommended processes of care was suboptimal in elderly patients with VTE. Quality of care interventions should particularly focus on processes with low adherence, such as the prescription of continued low-molecular-weight heparin therapy in patients with cancer and the achievement of an INR ≥2 for ≥24 hours before parenteral anticoagulants are stopped.