Stroke events, and case fatalities in Switzerland based on hospital statistics and cause of death statistics

OBJECTIVE: In Switzerland there is a shortage of population-based information on stroke incidence and case fatalities (CF). The aim of this study was to estimate stroke event rates and both in- and out-of-hospital CF rates. METHODS: Data on stroke diagnoses, coded according to I60-I64 (ICD 10), were taken from the Federal Hospital Discharge Statistics database (HOST) and the Cause of Death database (CoD) for the year 2004. The number of total stroke events and of age- and gender-specific and agestandardised event rates were estimated; overall CF, in-hospital and out-of-hospital, were determined. RESULTS: Among the overall number of 13 996 hospital discharges from stroke (HOST) the number was lower in women (n = 6736) than in men (n = 7260). A total of 3568 deaths (2137 women and 1431 men) due to stroke were recorded in the CoD database. The number of estimated stroke events was 15 733, and higher in women (n = 7933) than in men (n = 7800). Men presented significantly higher age-specific stroke event rates and a higher age-standardised event rate (178.7/100 000 versus 119.7/100 000). Overall CF rates were significantly higher for women (26.9%) than for men (18.4%). The same was true of out-of-hospital CF but not of in-hospital CF rates. CONCLUSION: The data on estimated stroke events obtained indicate that stroke discharge rate underestimates the stroke event rate. Out-of-hospital deaths from stroke accounted for the largest proportion of total stroke deaths. Sex differences in both number of total stroke events and deaths could be explained by the higher proportion of women than men aged 55+ in the Swiss population.

Wavelet-denoising of electroencephalogram and the absolute slope method: a new tool to improve electroencephalographic localization and lateralization

OBJECTIVE: In ictal scalp electroencephalogram (EEG) the presence of artefacts and the wide ranging patterns of discharges are hurdles to good diagnostic accuracy. Quantitative EEG aids the lateralization and/or localization process of epileptiform activity. METHODS: Twelve patients achieving Engel Class I/IIa outcome following temporal lobe surgery (1 year) were selected with approximately 1-3 ictal EEGs analyzed/patient. The EEG signals were denoised with discrete wavelet transform (DWT), followed by computing the normalized absolute slopes and spatial interpolation of scalp topography associated to detection of local maxima. For localization, the region with the highest normalized absolute slopes at the time when epileptiform activities were registered (>2.5 times standard deviation) was designated as the region of onset. For lateralization, the cerebral hemisphere registering the first appearance of normalized absolute slopes >2.5 times the standard deviation was designated as the side of onset. As comparison, all the EEG episodes were reviewed by two neurologists blinded to clinical information to determine the localization and lateralization of seizure onset by visual analysis. RESULTS: 16/25 seizures (64%) were correctly localized by the visual method and 21/25 seizures (84%) by the quantitative EEG method. 12/25 seizures (48%) were correctly lateralized by the visual method and 23/25 seizures (92%) by the quantitative EEG method. The McNemar test showed p=0.15 for localization and p=0.0026 for lateralization when comparing the two methods. CONCLUSIONS: The quantitative EEG method yielded significantly more seizure episodes that were correctly lateralized and there was a trend towards more correctly localized seizures. SIGNIFICANCE: Coupling DWT with the absolute slope method helps clinicians achieve a better EEG diagnostic accuracy.

Supporting, Regulating, and Provisioning Hydrological Services

The natural regulation of the water cycle by tropical montane forests is an important ecosystem service. Within this chapter we focus on water balance and regulation of the water cycle. Differences of rainfall-runoff generation across scales change from a near-surface event water driven system in pristine rainforest-covered micro-catchments to a more groundwater pre-event water dominated one on the mesoscale. The highly dynamic discharges are often correlated with total suspended sediment loads. However, we also observed total suspended sediment peaks at times of low flow, indicating a decoupling of erosion and stream transport and a triggering of landslides not directly related to hydrological processes. We also summarize likely future trends of water-related ecosystem services and expect an increase in human use and benefits of fresh water use whereas changes in water regulation and water purification services remain unchanged on a high level.

Bioavailability of pharmaceuticals in waters close to wastewater treatment plants: use of fish bile for exposure assessment

Pharmaceuticals are ubiquitous in surface waters as a consequence of discharges from municipal wastewater treatment plants. However, few studies have assessed the bioavailability of pharmaceuticals to fish in natural waters. In the present study, passive samplers and rainbow trout were experimentally deployed next to three municipal wastewater treatment plants in Finland to evaluate the degree of animal exposure. Pharmaceuticals from several therapeutic classes (in total 15) were analyzed by liquid chromatography-tandem mass spectrometry in extracts of passive samplers and in bile and blood plasma of rainbow trout held at polluted sites for 10 d. Each approach indicated the highest exposure near wastewater treatment plant A and the lowest near that of plant C. Diclofenac, naproxen, and ibuprofen were found in rainbow trout, and their concentrations in bile were 10 to 400 times higher than in plasma. The phase I metabolite hydroxydiclofenac was also detected in bile. Hence, bile proved to be an excellent sample matrix for the exposure assessment of fish. Most of the monitored pharmaceuticals were found in passive samplers, implying that they may overestimate the actual exposure of fish in receiving waters. Two biomarkers, hepatic vitellogenin and cytochrome P4501A, did not reveal clear effects on fish, although a small induction of vitellogenin mRNA was observed in trout caged near wastewater treatment plants B and C.

Potentially avoidable 30-day hospital readmissions in medical patients: derivation and validation of a prediction model

IMPORTANCE Because effective interventions to reduce hospital readmissions are often expensive to implement, a score to predict potentially avoidable readmissions may help target the patients most likely to benefit. OBJECTIVE To derive and internally validate a prediction model for potentially avoidable 30-day hospital readmissions in medical patients using administrative and clinical data readily available prior to discharge. DESIGN Retrospective cohort study. SETTING Academic medical center in Boston, Massachusetts. PARTICIPANTS All patient discharges from any medical services between July 1, 2009, and June 30, 2010. MAIN OUTCOME MEASURES Potentially avoidable 30-day readmissions to 3 hospitals of the Partners HealthCare network were identified using a validated computerized algorithm based on administrative data (SQLape). A simple score was developed using multivariable logistic regression, with two-thirds of the sample randomly selected as the derivation cohort and one-third as the validation cohort. RESULTS Among 10 731 eligible discharges, 2398 discharges (22.3%) were followed by a 30-day readmission, of which 879 (8.5% of all discharges) were identified as potentially avoidable. The prediction score identified 7 independent factors, referred to as the HOSPITAL score: h emoglobin at discharge, discharge from an o ncology service, s odium level at discharge, p rocedure during the index admission, i ndex t ype of admission, number of a dmissions during the last 12 months, and l ength of stay. In the validation set, 26.7% of the patients were classified as high risk, with an estimated potentially avoidable readmission risk of 18.0% (observed, 18.2%). The HOSPITAL score had fair discriminatory power (C statistic, 0.71) and had good calibration. CONCLUSIONS AND RELEVANCE This simple prediction model identifies before discharge the risk of potentially avoidable 30-day readmission in medical patients. This score has potential to easily identify patients who may need more intensive transitional care interventions.

White blood cell count and mortality in patients with acute pulmonary embolism

Although associated with adverse outcomes in other cardiovascular diseases, the prognostic value of an elevated white blood cell (WBC) count, a marker of inflammation and hypercoagulability, is uncertain in patients with pulmonary embolism (PE). We therefore sought to assess the prognostic impact of the WBC in a large, state-wide retrospective cohort of patients with PE. We evaluated 14,228 patient discharges with a primary diagnosis of PE from 186 hospitals in Pennsylvania. We used random-intercept logistic regression to assess the independent association between WBC count levels at the time of presentation and mortality and hospital readmission within 30 days, adjusting for patient and hospital characteristics. Patients with an admission WBC count <5.0, 5.0-7.8, 7.9-9.8, 9.9-12.6, and >12.6 × 10(9) /L had a cumulative 30-day mortality of 10.9%, 6.2%, 5.4%, 8.3%, and 16.3% (P < 0.001), and a readmission rate of 17.6%, 11.9%, 10.9%, 11.5%, and 15.0%, respectively (P < 0.001). Compared with patients with a WBC count 7.9-9.8 × 10(9) /L, adjusted odds of 30-day mortality were significantly greater for patients with a WBC count <5.0 × 10(9) /L (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14-2.03), 9.9-12.6 × 10(9) /L (OR 1.55, 95% CI 1.26-1.91), or >12.6 × 10(9) /L (OR 2.22, 95% CI 1.83-2.69), respectively. The adjusted odds of readmission were also significantly increased for patients with a WBC count <5.0 × 10(9) /L (OR 1.34, 95% CI 1.07-1.68) or >12.6 × 10(9) /L (OR 1.29, 95% CI 1.10-1.51). In patients presenting with PE, WBC count is an independent predictor of short-term mortality and hospital readmission.

Reconstruction of a flash flood with large wood transport and its influence on hazard patterns in an ungauged mountain basin

The reconstruction of past flash floods in ungauged basins leads to a high level of uncertainty, which increases if other processes are involved such as the transport of large wood material. An important flash flood occurred in 1997 in Venero Claro (Central Spain), causing significant economic losses. The wood material clogged bridge sections, raising the water level upstream. The aim of this study was to reconstruct this event, analysing the influence of woody debris transport on the flood hazard pattern. Because the reach in question was affected by backwater effects due to bridge clogging, using only high water mark or palaeostage indicators may overestimate discharges, and so other methods are required to estimate peak flows. Therefore, the peak discharge was estimated (123 ± 18 m3 s–1) using indirect methods, but one-dimensional hydraulic simulation was also used to validate these indirect estimates through an iterative process (127 ± 33 m3 s–1) and reconstruct the bridge obstruction to obtain the blockage ratio during the 1997 event (~48%) and the bridge clogging curves. Rainfall–Runoff modelling with stochastic simulation of different rainfall field configurations also helped to confirm that a peak discharge greater than 150 m3 s–1 is very unlikely to occur and that the estimated discharge range is consistent with the estimated rainfall amount (233 ± 27 mm). It was observed that the backwater effect due to the obstruction (water level ~7 m) made the 1997 flood (~35-year return period) equivalent to the 50-year flood. This allowed the equivalent return period to be defined as the recurrence interval of an event of specified magnitude, which, where large woody debris is present, is equivalent in water depth and extent of flooded area to a more extreme event of greater magnitude. These results highlight the need to include obstruction phenomena in flood hazard analysis.

Into the abyss of Lake Geneva: the elemo interdisciplinary field investigation using the MIR submersibles

In summer 2011, the two Russian MIR sub- mersibles were brought to Switzerland to perform deep water dives in Lake Geneva. Research teams from several environmental science institutes, both national and inter- national, participated in this interdisciplinary effort to investigate the deeper parts of Lake Geneva. Using the MIRs allowed the scientists to see and precisely select the sites where they could extract specific sediment cores and carry out detailed in situ measurements at the sediment– water boundary. One focus site was the surrounding of the outlet of the wastewater treatment plant of the City of Lausanne, which discharges into the Vidy Bay. The investigations concentrated on the pollution of the local sediments, pollution-related ecotoxicological risks, micro- bial activity and spreading and removal of the effluents from the bay to the open waters of the lake. The other focus site was the Rhoˆne River delta and its subaquatic canyons, which formed as a result of the long-term interplay of the deposition of river-borne sediments and flood-triggered canyon erosion events.

Avoidable hospitalizations in Switzerland: a small area analysis on regional variation, density of physicians, hospital supply and rurality.

BACKGROUND Avoidable hospitalizations (AH) are hospital admissions for diseases and conditions that could have been prevented by appropriate ambulatory care. We examine regional variation of AH in Switzerland and the factors that determine AH. METHODS We used hospital service areas, and data from 2008-2010 hospital discharges in Switzerland to examine regional variation in AH. Age and sex standardized AH were the outcome variable, and year of admission, primary care physician density, medical specialist density, rurality, hospital bed density and type of hospital reimbursement system were explanatory variables in our multilevel poisson regression. RESULTS Regional differences in AH were as high as 12-fold. Poisson regression showed significant increase of all AH over time. There was a significantly lower rate of all AH in areas with more primary care physicians. Rates increased in areas with more specialists. Rates of all AH also increased where the proportion of residences in rural communities increased. Regional hospital capacity and type of hospital reimbursement did not have significant associations. Inconsistent patterns of significant determinants were found for disease specific analyses. CONCLUSION The identification of regions with high and low AH rates is a starting point for future studies on unwarranted medical procedures, and may help to reduce their incidence. AH have complex multifactorial origins and this study demonstrates that rurality and physician density are relevant determinants. The results are helpful to improve the performance of the outpatient sector with emphasis on local context. Rural and urban differences in health care delivery remain a cause of concern in Switzerland.

Local changes in neocortical circuit dynamics coincide with the spread of seizures to thalamus in a model of epilepsy

During the generalization of epileptic seizures, pathological activity in one brain area recruits distant brain structures into joint synchronous discharges. However, it remains unknown whether specific changes in local circuit activity are related to the aberrant recruitment of anatomically distant structures into epileptiform discharges. Further, it is not known whether aberrant areas recruit or entrain healthy ones into pathological activity. Here we study the dynamics of local circuit activity during the spread of epileptiform discharges in the zero-magnesium in vitro model of epilepsy. We employ high-speed multi-photon imaging in combination with dual whole-cell recordings in acute thalamocortical (TC) slices of the juvenile mouse to characterize the generalization of epileptic activity between neocortex and thalamus. We find that, although both structures are exposed to zero-magnesium, the initial onset of focal epileptiform discharge occurs in cortex. This suggests that local recurrent connectivity that is particularly prevalent in cortex is important for the initiation of seizure activity. Subsequent recruitment of thalamus into joint, generalized discharges is coincident with an increase in the coherence of local cortical circuit activity that itself does not depend on thalamus. Finally, the intensity of population discharges is positively correlated between both brain areas. This suggests that during and after seizure generalization not only the timing but also the amplitude of epileptiform discharges in thalamus is entrained by cortex. Together these results suggest a central role of neocortical activity for the onset and the structure of pathological recruitment of thalamus into joint synchronous epileptiform discharges.

Electrodiagnostic evaluation in feline hypertrophic muscular dystrophy

Standard needle electromyography (EMG) of 56 muscles and nerve conduction velocities (NCV) of the ulnar and common peroneal nerves were investigated in each of six cats affected with hypertrophic feline muscular dystrophy, 10 related heterozygote carriers and 10 normal cats. The EMG findings were considered normal in carrier and control cats, and consisted of 33% normal readings, 22% myotonic discharges, 18% fibrillation potentials, 11% prolonged insertional potentials, 10% complex repetitive discharges and 6% positive sharp waves in affected cats. Muscles of the proximal limbs were most frequently affected. No differences in NCV were found between the three cat groups. It was concluded that dystrophin-deficient dystrophic cats have widespread and frequent EMG changes, predominantly myotonic discharges and fibrillation potentials, which are most pronounced in the proximal appendicular muscles.

A multi-tracer study of groundwater origin and transit-time in the aquifers of the Venice region (Italy)

Located in the northeastern region of Italy, the Venetian Plain (VP) is a sedimentary basin containing an extensively exploited groundwater system. The northern part is characterised by a large undifferentiated phreatic aquifer constituted by coarse grain alluvial deposits and recharged by local rainfalls and discharges from the rivers Brenta and Piave. The southern plain is characterised by a series of aquitards and sandy aquifers forming a well-defined artesian multi-aquifer system. In order to determine origins, transit times and mixing proportions of different components in groundwater (GW), a multi tracer study (H, He/He, C, CFC, SF, Kr, Ar, Sr/Sr, O, H, cations, and anions) has been carried out in VP between the rivers Brenta and Piave. The geochemical pattern of GW allows a distinction of the different water origins in the system, in particular based on View the MathML source HCO3-,SO42-,Ca/Mg,NO3-, O, H. A radiogenic Sr signature clearly marks GW originated from the Brenta and Tertiary catchments. End-member analysis and geochemical modelling highlight the existence of a mixing process involving waters recharged from the Brenta and Piave rivers, from the phreatic aquifer and from another GW reservoirs characterised by very low mineralization. Noble gas excesses in respect to atmospheric equilibrium occur in all samples, particularly in the deeper aquifers of the Piave river, but also in phreatic water of the undifferentiated aquifers. He–H ages in the phreatic aquifer and in the shallower level of the multi-aquifer system indicate recharge times in the years 1970–2008. The progression of H–He ages with the distance from the recharge areas together with initial tritium concentration (H + Hetrit) imply an infiltration rate of about 1 km/y and the absence of older components in these GW. SF and Kr data corroborate these conclusions. H − He ages in the deeper artesian aquifers suggest a dilution process with older, tritium free waters. C Fontes–Garnier model ages of the old GW components range from 1 to 12 ka, yielding an apparent GW velocity of about 1–10 m/y. Increase of radiogenic He follows the progression of C ages. Ar, radiogenic He and C tracers yield model-dependent age-ranges in overall good agreement once diffusion of C from aquitards, GW dispersion, lithogenic Ar production, and He production-rate heterogeneities are taken into account. The rate of radiogenic He increase with time, deduced by comparison with C model ages, is however very low compared to other studies. Comparison with C and C data obtained 40 years ago on the same aquifer system shows that exploitation of GW caused a significant loss of the old groundwater reservoir during this time.

Hochwasser-«Katastrophen» in Basel vom 13. bis 21. Jahrhundert Rekonstruktion, Deutung und Lerneffekte

Magnitudes of peak discharges of 43 non-instrumentally measured Rhine river floods at Basel were reconstructed. The methodology is based on a range of different historic sources, containing flood information (including traditional urban inundation reference points from flood reports of medieval and early modern period chroniclers as well as 19th century journalists, flood marks, paintings and drawings, town maps, longitudinal and cross profiles etc.). These traditional pre-instrumental “flood information systems” still existed in the 19th century, when in 1808 the first instrumental hydrological measurements started. They thus could be calibrated with instrumental measurements in the 19th century overlapping period. The result is a 743 year long quantified Rhine river flood series. Floods of both periods (pre-instrumental as well as instrumental) can thus be directly compared for the very first time. The long-range consequences of rivers Kander and Aare deviations in 1714 and 1878 are reflected in a distinct change of magnitudes of peak discharges in Basel. A clear flood “disaster gap” appears in the 20th century. The lack of any extreme floods for such a long time is completely unique during the 743-year period of analysis. This result will influence the statistical assessment of once-in-a-century events, which might be of great interest for insurance campanies.

De novo loss- or gain-of-function mutations in KCNA2 cause epileptic encephalopathy.

Epileptic encephalopathies are a phenotypically and genetically heterogeneous group of severe epilepsies accompanied by intellectual disability and other neurodevelopmental features. Using next-generation sequencing, we identified four different de novo mutations in KCNA2, encoding the potassium channel KV1.2, in six isolated patients with epileptic encephalopathy (one mutation recurred three times independently). Four individuals presented with febrile and multiple afebrile, often focal seizure types, multifocal epileptiform discharges strongly activated by sleep, mild to moderate intellectual disability, delayed speech development and sometimes ataxia. Functional studies of the two mutations associated with this phenotype showed almost complete loss of function with a dominant-negative effect. Two further individuals presented with a different and more severe epileptic encephalopathy phenotype. They carried mutations inducing a drastic gain-of-function effect leading to permanently open channels. These results establish KCNA2 as a new gene involved in human neurodevelopmental disorders through two different mechanisms, predicting either hyperexcitability or electrical silencing of KV1.2-expressing neurons.

Risk factors for potentially avoidable readmissions due to end-of-life care issues

BACKGROUND Repeated hospitalizations are frequent toward the end of life, where each admission should be an opportunity to initiate advance-care planning to high-risk patients. OBJECTIVE To identify the risk factors for having a 30-day potentially avoidable readmission due to end-of-life care issues among all medical patients. DESIGN Nested case-control study. SETTING/PATIENTS All 10,275 consecutive discharges from any medical service of an academic tertiary medical center in Boston, Massachusetts between July 1, 2009 and June 30, 2010. MEASUREMENTS A random sample of all the potentially avoidable 30-day readmissions was independently reviewed by 9 trained physicians to identify the ones due to end-of-life issues. RESULTS Among 534, 30-day potentially avoidable readmission cases reviewed, 80 (15%) were due to an end-of-life care issue. In multivariable analysis, the following risk factors were significantly associated with a 30-day potentially avoidable readmission due to end-of-life care issues: number of admissions in the previous 12 months (odds ratio [OR]: 1.10 per admission, 95% confidence interval [CI]: 1.02-1.20), neoplasm (OR: 5.60, 95% CI: 2.85-10.98), opiate medications at discharge (OR: 2.29, 95% CI: 1.29-4.07), Elixhauser comorbidity index (OR: 1.16 per 5-point increase, 95% CI: 1.10-1.22). The discrimination of the model (C statistic) was 0.85. CONCLUSIONS In a medical population, we identified 4 main risk factors that were significantly associated with 30-day potentially avoidable readmission due to end-of-life care issues, producing a model with very good to excellent discrimination. Patients with these risk factors might benefit from palliative care consultation prior to discharge in order to improve end-of-life care and possibly reduce unnecessary rehospitalizations.