Referral practice among Swiss and non-Swiss walk-in patients in an urban surgical emergency department

To assess the relationship between nationality, gender and age and use of health services among patients visiting an urban university hospital emergency department (ED).

Is computer-assisted telephone triage safe? A prospective surveillance study in walk-in patients with non-life-threatening medical conditions

Background Patients often establish initial contact with healthcare institutions by telephone. During this process they are frequently medically triaged. Purpose To investigate the safety of computer-assisted telephone triage for walk-in patients with non-life-threatening medical conditions at an emergency unit of a Swiss university hospital. Methods This prospective surveillance study compared the urgency assessments of three different types of personnel (call centre nurses, hospital physicians, primary care physicians) who were involved in the patients' care process. Based on the urgency recommendations of the hospital and primary care physicians, cases which could potentially have resulted in an avoidable hazardous situation (AHS) were identified. Subsequently, the records of patients with a potential AHS were assessed for risk to health or life by an expert panel. Results 208 patients were enrolled in the study, of whom 153 were assessed by all three types of personnel. Congruence between the three assessments was low. The weighted κ values were 0.115 (95% CI 0.038 to 0.192) (hospital physicians vs call centre), 0.159 (95% CI 0.073 to 0.242) (primary care physicians vs call centre) and 0.377 (95% CI 0.279 to 0.480) (hospital vs primary care physicians). Seven of 153 cases (4.57%; 95% CI 1.85% to 9.20%) were classified as a potentially AHS. A risk to health or life was adjudged in one case (0.65%; 95% CI 0.02% to 3.58%). Conclusion Medical telephone counselling is a demanding task requiring competent specialists with dedicated training in communication supported by suitable computer technology. Provided these conditions are in place, computer-assisted telephone triage can be considered to be a safe method of assessing the potential clinical risks of patients' medical conditions.

Why do walk-in patients prefer a busy urban emergency department during office hours? A pilot survey of 200 consecutive patients from Switzerland

In Switzerland, more and more patients go directly to the emergency department, bypassing general practitioners. However, a mixture of non-urgent walk-in patients and acute emergencies in the same emergency department can inevitably make it more difficult to provide genuine emergencies with rapid treatment, leading to deterioration in the quality of emergency services, and tending to increase on-floor mortality and morbidity, together with higher overall costs.

New Shuttle Vector-Based Expression System To Generate Polyhistidine-Tagged Fusion Proteins in Staphylococcus aureus and Escherichia coli.

Four Staphylococcus aureus-Escherichia coli shuttle vectors were constructed for gene expression and production of tagged fusion proteins. Vectors pBUS1-HC and pTSSCm have no promoter upstream of the multiple cloning site (MCS), and this allows study of genes under the control of their native promoters, and pBUS1-Pcap-HC and pTSSCm-Pcap contain the strong constitutive promoter of S. aureus type 1 capsule gene 1A (Pcap) upstream of a novel MCS harboring codons for the peptide tag Arg-Gly-Ser-hexa-His (rgs-his6). All plasmids contained the backbone derived from pBUS1, including the E. coli origin ColE1, five copies of terminator rrnB T1, and tetracycline resistance marker tet(L) for S. aureus and E. coli. The minimum pAMα1 replicon from pBUS1 was improved through either complementation with the single-strand origin oriL from pUB110 (pBUS1-HC and pBUS1-Pcap-HC) or substitution with a pT181-family replicon (pTSSCm and pTSSCm-Pcap). The new constructs displayed increased plasmid yield and segregational stability in S. aureus. Furthermore, pBUS1-Pcap-HC and pTSSCm-Pcap offer the potential to generate C-terminal RGS-His6 translational fusions of cloned genes using simple molecular manipulation. BcgI-induced DNA excision followed by religation converts the TGA stop codon of the MCS into a TGC codon and links the rgs-his6 codons to the 3' end of the target gene. The generation of the rgs-his6 codon-fusion, gene expression, and protein purification were demonstrated in both S. aureus and E. coli using the macrolide-lincosamide-streptogramin B resistance gene erm(44) inserted downstream of Pcap. The new His tag expression system represents a helpful tool for the direct analysis of target gene function in staphylococcal cells.

“But look: we have sat here too long”: Hilary Mantel’s tightrope walk of present-tense usage

Even after Hilary Mantel has won the Man Booker prize two times in a row with Wolf Hall and Bring up the Bodies, her novelistic account of the life of Thomas Cromwell, her intriguing decision to write these historical novels in the present tense gave cause to surprisingly little extended comment beyond a perfunctory nod to its evocation of immediacy. This presents not only a lacunae in the discussion about Mantel’s novels, but is also symptomatic for a change in the contemporary critical evaluation of present-tense narration in general. If present-tense narration once used to be a marker for experimental daring and might even have implied a certain hostility towards fictionality, Mantel’s novels give ample evidence that literary sensibilities have changed. In order to understand the scope and nature of this change, my paper puts Mantel’s use of the present tense in the context of both the historical development of present-tense usage and the ample contemporary landscape of present-tense narration. This allows me to show that the complexities of present-tense usage belie a reduction of its effect to an evocation of immediacy. Rather, I argue, Mantel uses it for a delicate tightrope walk between proximity and distance, history and fiction, authenticity and imagination.

The utility of preoperative six-minute-walk distance in lung transplantation

RATIONALE The use of 6-minute-walk distance (6MWD) as an indicator of exercise capacity to predict postoperative survival in lung transplantation has not previously been well studied. OBJECTIVES To evaluate the association between 6MWD and postoperative survival following lung transplantation. METHODS Adult, first time, lung-only transplantations per the United Network for Organ Sharing database from May 2005 to December 2011 were analyzed. Kaplan-Meier methods and Cox proportional hazards modeling were used to determine the association between preoperative 6MWD and post-transplant survival after adjusting for potential confounders. A receiver operating characteristic curve was used to determine the 6MWD value that provided maximal separation in 1-year mortality. A subanalysis was performed to assess the association between 6MWD and post-transplant survival by disease category. MEASUREMENTS AND MAIN RESULTS A total of 9,526 patients were included for analysis. The median 6MWD was 787 ft (25th-75th percentiles = 450-1,082 ft). Increasing 6MWD was associated with significantly lower overall hazard of death (P < 0.001). Continuous increase in walk distance through 1,200-1,400 ft conferred an incremental survival advantage. Although 6MWD strongly correlated with survival, the impact of a single dichotomous value to predict outcomes was limited. All disease categories demonstrated significantly longer survival with increasing 6MWD (P ≤ 0.009) except pulmonary vascular disease (P = 0.74); however, the low volume in this category (n = 312; 3.3%) may limit the ability to detect an association. CONCLUSIONS 6MWD is significantly associated with post-transplant survival and is best incorporated into transplant evaluations on a continuous basis given limited ability of a single, dichotomous value to predict outcomes.