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

BACKGROUND Emergency 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. METHODS In 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. RESULTS In 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. CONCLUSIONS Swiss 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.

Persistent Deadlock in Multilateral Trade Negotiations: The Case of Doha

The history of the General Agreement on Tariffs and Trade negotiations is full of anecdotes on missed deadlines, failed ministerial conferences, and brinkmanship situations. Tactics such as walking away from the table or sleep-depriving night sessions are legendary in the context of attempting to overcome impasse in negotiations. This article traces and explains the recurrent deadlock in the Doha Round negotiations. It identifies four structural/contextual factors – ideas, institutions, interests, and information – as necessary for understanding and anticipating potential deadlocks. The article also offers a definition of deadlock, and discusses a set of factors highlighted in the international relations literature that explain the existence and persistence of deadlock. With the help of game theory, it then illustrates the challenges faced by actors during trade negotiations. The article concludes by outlining two general scenarios for the Doha Development Agenda and discusses their implications for the World Trade Organization.

Sudden death in a case of sickle cell anemia: post-mortem computed tomography and autopsy correlation from a radiologist's perspective

Sickle cell anemia (SCA) is a hemolytic disease characterized by the production of abnormal hemoglobin chains and distorted red blood cell morphology or sickling. "Sickle cell crisis" includes vaso-occlusive crisis, a plastic crisis, sequestration crisis, haemolytic crisis and often culminating in serious complications, organ damage and even sudden death. Post-mortem computed tomography (PMCT) findings of sickle cell disease have never been reported in literature. This case of sudden death from acute hemolytic crisis in SCA where post-mortem computed tomography (PMCT) and autopsy findings complemented each other, both revealing findings invisible to the other and both crucial to the case.

To see or not to see – Ambiguous findings on post-mortem cross-sectional imaging in a case of ruptured abdominal aortic aneurysm

We present a case of a ruptured abdominal aortic aneurysm (AAA) with ambiguous accessory findings on post-mortem computed-tomography (PMCT), post-mortem magnetic resonance (PMMR) imaging, and PMCT-angiography (PMCTA) suggestive of thoracic aortic dissection. The diagnosis of ruptured AAA was confirmed by autopsy; however, there was no aortic dissection. The imaging findings that mimicked the presence of aortic dissection might have been an atypical presentation of post-mortem clotting or sedimentation. This case is an ideal example to illustrate benefits, limitations, and challenges of post-mortem cross-sectional imaging. It serves as a reminder that both, training as well as correlation of imaging findings with autopsy are fundamental to improve our understanding of radiologic findings on post-mortem cross-sectional imaging.

A case of EDTA-dependent pseudothrombocytopenia: simple recognition of an underdiagnosed and misleading phenomenon

1. BMC Clin Pathol. 2014 May 1;14:19. doi: 10.1186/1472-6890-14-19. eCollection 2014. A case of EDTA-dependent pseudothrombocytopenia: simple recognition of an underdiagnosed and misleading phenomenon. Nagler M, Keller P, Siegrist D, Alberio L. Author information: Department of Hematology and Central Hematology Laboratory, Inselspital University Hospital and University of Berne, CH-3010 Berne, Switzerland. BACKGROUND: EDTA-dependent pseudothrombocytopenia (EDTA-PTCP) is a common laboratory phenomenon with a prevalence ranging from 0.1-2% in hospitalized patients to 15-17% in outpatients evaluated for isolated thrombocytopenia. Despite its harmlessness, EDTA-PTCP frequently leads to time-consuming, costly and even invasive diagnostic investigations. EDTA-PTCP is often overlooked because blood smears are not evaluated visually in routine practice and histograms as well as warning flags of hematology analyzers are not interpreted correctly. Nonetheless, EDTA-PTCP may be diagnosed easily even by general practitioners without any experiences in blood film examinations. This is the first report illustrating the typical patterns of a platelet (PLT) and white blood cell (WBC) histograms of hematology analyzers. CASE PRESENTATION: A 37-year-old female patient of Caucasian origin was referred with suspected acute leukemia and the crew of the emergency unit arranged extensive investigations for work-up. However, examination of EDTA blood sample revealed atypical lymphocytes and an isolated thrombocytopenia together with typical patterns of WBC and PLT histograms: a serrated curve of the platelet histogram and a peculiar peak on the left side of the WBC histogram. EDTA-PTCP was confirmed by a normal platelet count when examining citrated blood. CONCLUSION: Awareness of typical PLT and WBC patterns may alert to the presence of EDTA-PTCP in routine laboratory practice helping to avoid unnecessary investigations and over-treatment. PMCID: PMC4012027 PMID: 24808761 [PubMed]

Hybrid bodies in cyborg sports? The case of Oscar Pistorius

The capabilities of postmodern biotechnology inevitably lead to questioning if it is morally acceptable to use all possibilities offered by technology. In sport, this very complex issue is dealt with by drawing clear boundaries between naturalness and artificiality. Currently, new biotechnology is constantly being produced and with this, boundaries between naturalness and artificiality, between normal and abnormal, human and hybrid are constantly shifting . “Human enhancement” is a fascinating prism that reflects contemporary questions of participation, justice, equality and the autonomy of the subject in all social fields. The area of elite sports is particularly affected by “human enhancement”, according to the principle of exceeding what has come before, of aiming higher, faster and further. This paper analyses the postulated “naturalness” in the regulative and normalising function in the area of elite sports, in connection with Foucault’s theory of governmentality. The example of the South African sprinter Oscar Pistorius appears to be particularly suited to illustrate current definition difficulties in the area of disabled and non-disabled people in differentiated competitive sports. His is a vivid example of a multifaceted body-sociological analysis of current sport culture and the construction of reality or naturalness in the framework of the discourse of drafting and negotiating the accreditation for sprint competitions of non-disabled athletes, most recently in the London Olympics 2012. Using the case study of Oscar Pistorius, the negotiating processes in relation to the argumentation logic, dynamics and resistance in shifting distinctions are presented in detail using the fundamental documents of the IOC, IPC, CAS and IAAF. Represented through the inclusion and exclusion processes are hierarchies of the body that are (re)consolidated and transformed. The central question emerges as to how the worth of equal opportunity and fairness in regard to “naturalness” can be reconsolidated or transformed.

„The plug and the bug“ – a case of coronary embolism in bacterial endocarditis

Systemic embolism is a classic complication of infective endocarditis. Coronary involvement and acute myocardial infarction (MI) are rare and increase mortality significantly. Recognising this unusual entity is crucial to provide adequate care. Percutaneous coronary intervention and thrombus aspiration is preferred to thrombolysis, which classically increases intracerebral hemorrhage risk. The present article describes the case of an acute inferior ST-elevated MI due to a Streptococcus salivarius endocarditis in a patient with known bicuspid aortic valve.

The strength of badenya ties: siblings and social security in old age – the case of urban Burkina Faso

In urban Burkina Faso, siblings play a decisive role in local social security. Badenya, the unity of children of the same mother, compensates in particular for the economic failure of an eldest son no longer in a position to fulfill his familial duties. Although the institution of badenya is strengthened as it increasingly comes into play to help a family avoid social marginalization, it is also overburdened, which makes its future uncertain. This article enhances the anthropological understanding of kinship by focusing on sibling relationships. Findings are based on interviews conducted between 2007 and 2010 with two generations in households in Bobo-Dioulasso and on participant-observation over the course of more than a dozen research stays since 1989.

The use of bougie-guided insertion of a laryngeal mask airway device in neonatal piglets after unexpected complications

After marked airway obstruction with laryngeal mask (LM) placement in neonate piglets, anatomical observations in cadavers revealed a large epiglottis advancing markedly over the soft palate. CT imaging in vivo confirmed that the LM pushes the epiglottis caudally thereby obstructing the larynx. As a new approach, in 20 piglets a flexible PVC bougie placed under laryngoscopy was used to guide the LM to the correct position at the larynx. Placement of the bougie was easy and the LM was positioned successfully in all piglets at first attempt. In 14 piglets, the epiglottis was positioned dorsal to the soft palate before LM insertion and had to be pushed downwards to advance the bougie. In case of failure of LM placement with potential airway obstruction, the use of a bougie to guide the LM over the epiglottis was simple, rapid, and improved the success rate without complication.

Esthetic outcomes following immediate and early implant placement in the anterior maxilla: a systematic review.

PURPOSE The objectives of this systematic review are (1) to quantitatively estimate the esthetic outcomes of implants placed in postextraction sites, and (2) to evaluate the influence of simultaneous bone augmentation procedures on these outcomes. MATERIALS AND METHODS Electronic and manual searches of the dental literature were performed to collect information on esthetic outcomes based on objective criteria with implants placed after extraction of maxillary anterior and premolar teeth. All levels of evidence were accepted (case series studies required a minimum of 5 cases). RESULTS From 1,686 titles, 114 full-text articles were evaluated and 50 records included for data extraction. The included studies reported on single-tooth implants adjacent to natural teeth, with no studies on multiple missing teeth identified (6 randomized controlled trials, 6 cohort studies, 5 cross-sectional studies, and 33 case series studies). Considerable heterogeneity in study design was found. A meta-analysis of controlled studies was not possible. The available evidence suggests that esthetic outcomes, determined by esthetic indices (predominantly the pink esthetic score) and positional changes of the peri-implant mucosa, may be achieved for single-tooth implants placed after tooth extraction. Immediate (type 1) implant placement, however, is associated with a greater variability in outcomes and a higher frequency of recession of > 1 mm of the midfacial mucosa (eight studies; range 9% to 41% and median 26% of sites, 1 to 3 years after placement) compared to early (type 2 and type 3) implant placement (2 studies; no sites with recession > 1 mm). In two retrospective studies of immediate (type 1) implant placement with bone graft, the facial bone wall was not detectable on cone beam CT in 36% and 57% of sites. These sites had more recession of the midfacial mucosa compared to sites with detectable facial bone. Two studies of early implant placement (types 2 and 3) combined with simultaneous bone augmentation with GBR (contour augmentation) demonstrated a high frequency (above 90%) of facial bone wall visible on CBCT. Recent studies of immediate (type 1) placement imposed specific selection criteria, including thick tissue biotype and an intact facial socket wall, to reduce esthetic risk. There were no specific selection criteria for early (type 2 and type 3) implant placement. CONCLUSIONS Acceptable esthetic outcomes may be achieved with implants placed after extraction of teeth in the maxillary anterior and premolar areas of the dentition. Recession of the midfacial mucosa is a risk with immediate (type 1) placement. Further research is needed to investigate the most suitable biomaterials to reconstruct the facial bone and the relationship between long-term mucosal stability and presence/absence of the facial bone, the thickness of the facial bone, and the position of the facial bone crest.

Die akute Hanrverhaltung in der Praxis

Acute urinary retention is a common emergency condition in elderly men. Transurethral and suprapubic catheterization are easy and safe procedures provided that a few simple rules are followed. Primarily, a transurethral catheter is placed if there is no urethral injury or stricture. Local anaesthesia of the urethra up to the sphincter region and a well-stretched penis warrant an atraumatic insertion of the catheter into the bladder. The use of a thick catheter with a round tip or of a catheter with a bended tip under rectal guidance facilitate the insertion of the catheter in difficult conditions. Alternatively, a suprapubic catheterization can be performed provided that no contraindication such as history or suspicion of transitional cell carcinoma is present. Optimal interventional conditions using ultrasound-guidance are mandatory in patients after abdominal surgery and with hemorrhagic diathesis in view of a safe and straight-forward placement of the suprapubic catheterization. In case of persistent bleeding after insertion of a suprapubic catheter, the suprapubic catheter should be replaced by one with a balloon blocked and kept under tension for several minutes.

Gender-Fair language and professional self-reference: The case of female psychologists in Polish

The struggle to achieve gender equality is accompanied by efforts to introduce gender-fair language. In languages with grammatical gender this implies the use of gender-appropriate forms (feminine for women and masculine for males). In the present research, results of a mixed method approach—a corpus analysis, a survey, and an experiment—provide consistent evidence that in Polish, feminine forms are still infrequent in women’s self-reference and that women psychologists continue to use masculine titles. Moreover, a qualitative inquiry examines the reasons why women prefer masculine over feminine job titles. Integrating findings from the two-stage design, we are able to identify the obstacles to promoting social change with the help of language and to understand the reasons behind them.

Why do individuals behave differently in commons dilemmas?: The case of alpine farmers using common property pastures in Grindelwald, Switzerland

The sustainable use of common-pool resources depends on users’ behaviour with regards to appropriation and provision. Most knowledge about behaviour in such situations comes from experimental research. As experiments take place in confined environments, motivational drivers and actions in the field might differ. This paper analyses farmers’ use of common property pastures in Grindelwald, Switzerland. Binary logistic regression is applied to survey data to explore the effect of farmers’ attributes on livestock endowment, appropriation and provision behaviour. Furthermore, Q methodology is used to assess the impact of broader contextual variables on the sustainability of common property pastures. It is shown that the strongest associations exist between (a) socio-economic attributes and change in livestock endowment; (b) norms and appropriation behaviour; and (c) area and pay-off and provision behaviour. Relevant contextual variables are the economic value of the resource units, off-farm income opportunities, and the subsidy structure. We conclude that with increasing farm size farmers reduce the use and maintenance of common property. Additionally, we postulate that readiness to maintain a resource increases with appropriation activities and the net returns generated from appropriation.

MRI findings in a case of canine tick born meningoencephalomyelitis

Tick borne encephalitis virus (TBE) is an endemic infectious agent in northeastern Switzerland causing mainly meningoencephalomyelitis in dogs. We report a canine case of tick born meningoencephalomyelitis resulting in flaccid tetraplegia and, subsequently, fatal respiratory failure. Magnetic resonance imaging (MRI) demonstrated intra-axial bilateral, symmetric, and hyperintense lesions in T2-weighted and Fluid Attenuated Inversion Recovery (FLAIR) sequences affecting thalamus, basal nuclei, cerebral white matter and ventral horns of the caudal cervical spine. These radiological findings overlap those described during flavivirus encephalitis affecting human beings. These lesions in MRI and diffusion weighted images correlated with areas of vasogenic edema detected histopathologically. In endemic regions, clinicians should be aware that bilateral, symmetrical hyperintense thalamic lesions in T2WI can be suggestive of flavivirus infection in dogs with encephalitis