Repatriations and 28-day mortality of ill and injured travellers: 12 years of experience in a Swiss emergency department

QUESTIONS UNDER STUDY Many persons are travelling all over the world; the elderly with pre-existing diseases also travel to places with less developed health systems. Reportedly, fewer than 0.5% of all travellers need repatriation. We aimed to analyse and examine people who are injured or ill while abroad, where they travelled to and by what means they were repatriated. METHODS Retrospective cross-sectional study with adult patients repatriated to a single level 1 trauma centre in Switzerland (2000-2011). RESULTS A total of 372 patients were repatriated, with an increasing trend per year. Of these, 67% were male; the median age was 56 years. Forty-nine percent sustained an injury, and 13% had surgical and 38% medical pathologies. Patients with medical conditions were older than those with injuries or surgical emergencies (p <0.001). Seventy-three percent were repatriated from Europe. For repatriation from Africa trauma was slightly more frequent (53%, n = 17) than illnesses, whereas for most other countries illnesses and trauma were equally distributed. Injured patients had a median Injury Severity Score of 8. The majority of illnesses involved the nervous system (38%), mainly stroke. Forty-five percent were repatriated by Swiss Air Ambulance, 26% by ground ambulance, 18% by scheduled flights with or without medical assistance and two patients injured near the Swiss boarder by helicopter. The 28-day mortality was 4%. CONCLUSIONS The numbers of travellers repatriated increased from 2000 to 2011. About half were due to illnesses and half due to injuries. The largest group were elderly Swiss nationals repatriated from European countries. As mortality is relatively high, special consideration to this group of patients is warranted.

Preferences for the organization of long-term follow-up in adolescent and young adult cancer survivors.

PURPOSE As survival rates of adolescent and young adult (AYA) cancer patients increase, a growing number of AYA cancer survivors need follow-up care. However, there is little research on their preferences for follow-up care. We aimed to (1) describe AYA cancer survivors' preferences for the organization and content of follow-up care, (2) describe their preferences for different models of follow-up, and (3) investigate clinical and sociodemographic characteristics associated with preferences for the different models. METHODS AYA cancer survivors (diagnosed with cancer at age 16-25 years; ≥5 years after diagnosis) were identified through the Cancer Registry Zurich and Zug. Survivors completed a questionnaire on follow-up attendance, preferences for organizational aspects of follow-up care (what is important during follow-up, what should be included during appointments, what specialists should be involved, location), models of follow-up (telephone/questionnaire, general practitioner (GP), pediatric oncologist, medical oncologist, multidisciplinary team), and sociodemographic characteristics. Information on tumor and treatment was available through the Cancer Registry Zurich and Zug. RESULTS Of 389 contacted survivors, 160 (41.1 %) participated and 92 (57.5 %) reported still attending follow-up. Medical aspects of follow-up care were more important than general aspects (p < 0.001). Among different organizational models, follow-up by a medical oncologist was rated higher than all other models (p = 0.002). Non-attenders of follow-up rated GP-led follow-up significantly higher than attenders (p = 0.001). CONCLUSION Swiss AYA cancer survivors valued medical content of follow-up and showed a preference for medical oncologist-led follow-up. Implementation of different models of follow-up care might improve accessibility and attendance among AYA cancer survivors.

Income in Adult Survivors of Childhood Cancer.

INTRODUCTION Little is known about the impact of childhood cancer on the personal income of survivors. We compared income between survivors and siblings, and determined factors associated with income. METHODS As part of the Swiss Childhood Cancer Survivor Study (SCCSS), a questionnaire was sent to survivors, aged ≥18 years, registered in the Swiss Childhood Cancer Registry (SCCR), diagnosed at age <21 years, who had survived ≥5 years after diagnosis of the primary tumor. Siblings were used as a comparison group. We asked questions about education, profession and income and retrieved clinical data from the SCCR. We used multivariable logistic regression to identify characteristics associated with income. RESULTS We analyzed data from 1'506 survivors and 598 siblings. Survivors were less likely than siblings to have a high monthly income (>4'500 CHF), even after we adjusted for socio-demographic and educational factors (OR = 0.46, p<0.001). Older age, male sex, personal and parental education, and number of working hours were associated with high income. Survivors of leukemia (OR = 0.40, p<0.001), lymphoma (OR = 0.63, p = 0.040), CNS tumors (OR = 0.22, p<0.001), bone tumors (OR = 0.24, p = 0.003) had a lower income than siblings. Survivors who had cranial irradiation, had a lower income than survivors who had no cranial irradiation (OR = 0.48, p = 0.006). DISCUSSION Even after adjusting for socio-demographic characteristics, education and working hours, survivors of various diagnostic groups have lower incomes than siblings. Further research needs to identify the underlying causes.

AN INVESTIGATION INTO THE EFFECT OF TESTOSTERONE ON THE QUANTITATIVE MAINTENANCE OF SPERMATOGENESIS IN THE HYPOPHYSECTOMIZED ADULT RAT (PHARMACOKINETICS, MORPHOMETRY, STATISTICS)

Administration of gonadotropins or testosterone (T) will maintain qualitatively normal spermatogenesis and fertility in hypophysectomized (APX) rats. However, quantitative maintenance of the spermatogenic process in APX rats treated with T alone or in combination with follicle stimulating hormone (FSH) has not been demonstrated. Studies reported here were conducted to determine whether it would be possible to increase intratesticular testosterone (ITT) levels in APX rats to those found in normal animals by administration of appropriate amounts of testosterone propionate (TP) and if under these conditions spermatogenesis can be maintained quantitatively. Quantitative analysis of spermatogenesis was performed on stages VI and VII of the spermatogenic cycle utilizing criteria of Leblond and Clermont (1952) all cell types were enumerated. In a series of experiments designed to investigate the effects of T on spermatogenesis, TP was administered to 60 day old APX rats twice daily for 30 days in doses ranging from 0.6 to 15 mg/day or from 0.6 to 6.0 mg/day in combination with FSH. The results of this study demonstrate that the efficiency of transformation of type A to type B spermatogonia and the efficacy of the meiotic prophase are related to ITT levels, and that quantitatively normal completion of the reduction division requires normal ITT levels. The ratio of spermatids to spermatocytes in the vehicle-treated APX rats was 1:1.38; in the APX rats treated with 15 mg of TP it was 1:4.0 (the theoretically expected number). This study is probably the first to demonstrate: (1) the pharmacokinetics of TP, (2) the profile and quantity of T-immunoactivity in both serum and testicular tissue of APX and IC rats as well as APX rats treated with TP alone or in combination with FSH, (3) the direct correlation of serum T and ITT levels in treated APX rats (r = 0.9, p < 0.001) as well as in the IC rats (r = 0.9, p < 0.001), (4) the significant increase in the number of Type B spermatogonia, preleptotene and pachytene spermatocytes and round spermatids in TP-treated APX rats, (5) the correlation of the number of round spermatids formed in IC rats to ITT levels (r = 0.9, p < 0.001), and (6) the correlation of the quantitative maintenance of spermatogenesis with ITT levels (r = 0.7, p < 0.001) in the testes of TP-treated APX rats. These results provide direct experimental evidence for the key role of T in the spermatogenic process. ^

The impact of traditional psychiatric services and case management services on the functioning of people with schizophrenia: A cross-national study in Nova Scotia and Texas

The purpose of this study was to determine the impact of traditional psychiatric services with case management services on the functioning of people with schizophrenia. Traditional services were defined as routine clinic services consisting of medication follow-along, psychotherapy, and support services. Case management consisted of activities involved in linking, planning, and monitoring services for the outpatient client who has schizophrenia. The target population was adult schizophrenics who had been receiving outpatient clinic services for a minimum of six months. Structured interviews were conducted using standardized scales (e.g., Quality of Life, Self-Efficacy, and Brief Symptom Inventory) with 78 outpatient client volunteers from two sites: Nova Scotia (Canada) and Texas (USA). The researcher tested for differences in psychiatric symptomatology, recidivism, and quality of life for persons with schizophrenia receiving traditional psychiatric services in Nova Scotia and traditional plus case management services in Texas. Data were collected from the structured interviews and medical records review forms. Types of services were blocked into low and high levels of Intensity (frequency x minutes) and compared to determine the relative contribution of each. Finally, the role of clients' self-efficacy was tested as an intervening variable. Although the findings did not support the hypotheses in the direction anticipated, there were some interesting and useful results. From the Nova Scotia site, clients who received low levels of services were hospitalized less compared to the Texas site. The more psychotic a patient was the higher their involvement in medication follow-along and the more monitoring they received. The more psychotherapy received, the lower the reported satisfaction with social relationships. Of particular interest is the role that self-efficacy played in improved client outcomes. Although self-efficacy scores were related to improved functioning, the mechanism for this still needs to be clarified through subsequent research. ^

An evaluation of the centers for Medicare & Medicaid Services' Hospital Acquired Conditions and Present on Admission Indicator Reporting program

Objective: This dissertation evaluated three aspects of the Centers for Medicare and Medicaid Services' Hospital Acquired Conditions and Present on Admission Indicator Reporting program (HACPOA program) to produce three journal articles for publication. ^ Methods: All payer admission records from state inpatient databases from Arizona, New Jersey and Washington states were analyzed for the year 2008. However some analyses required a sample of adult only Medicare patients in the first two studies. California's inpatient data (2004 – 2010) was also analyzed in the third study to examine the reporting and non-payment program elements' impact on the incidence of hospital acquired conditions. ^ Results: Majority diagnoses reported in inpatient prospective payment systems hospitals were present on admission. However, some diagnoses are still coded as "not present on admission" and "insufficient documentation to determine whether or not conditions are present on admission or not". This is important because it reveals that hospital complications still occur in hospitals. Hospital fall and trauma injuries were the most common hospital acquired conditions observed in this study. Predictors of hospital fall injuries include age, gender, number of diagnoses, number of procedures, number of chronic conditions while predictors of hospital trauma injuries include number of e-codes, number of diagnoses and the presence of chronic conditions on a patient's admission records. Finally, the implementation of the present on admission reporting requirement increased reports of certain hospital acquired conditions while the non-payment policy element in the Hospital Acquired Conditions program reduced the incidence of hospital fall and trauma injuries in particular. ^ Conclusion: The implementation of the Hospital Acquired Conditions and Present on Admission Indicator Reporting program has made the state inpatient database a more useful source of data capable of now identifying hospital complications. The reporting and nonpayment program elements in the HACPOA program have also impacted the incidence of hospital acquired conditions. ^

A Renewed Day for Family Preservation

The philosophy and principles of family preservation have emerged in new forms over the past eight years. From the Family Preservation and Support Act of 1993 to the Adoption and Safe Families Act (ASFA) of today, the value of the family to individuals and society is clear. While family preservation "programs" per se may not be as plentiful, the principals are founding almost every array of services from children, corrections, D.D. to mental health and work with the elderly. The Administration's priorities of healthy marriage, fatherhood, incarcerated parents, and faith-based programs reflect a family-centered approach to social issues. This redefining of the village will require our renewed efforts to articulate the importance of family centered practice and policy.

Immobilisation data of juvenile and adult male and female Weddell seals at Drescher Inlet from expeditions DRE1990 and DRE1992

Fourten Weddell seals (Leptonychotes weddellii) and two crabeater seals (Lobodon carcinophaga) were immobilised at Drescher Inlet (Riiser Larsen Ice Shelf), eastern Weddell Sea coast, between January and February 1990 using a combination of ketamine, xylazine, and diazepam. Eleven Weddell seals were drugged once, and two and one were drugged two and three times each, coming to a total of 18 immobilisation procedures. Another 16 seals were immobilised between January and February 1992. Ten seals were drugged once, and three and two were drugged two and three times each, coming to a total of 25 immobilisation procedures. Narcoses were terminated with yohimbine. Data as given by doi:10.1594/PANGAEA.438920 were selected for publication. Data sets doi:10.1594/PANGAEA.438921 and doi:10.1594/PANGAEA.438926 followed the same methods and dose regimes.

Dive track profile, intermandibular angel sensor profile and immobilisation data of adult female Weddell seals at Drescher Inlet from expedition DRE2003

Determination of when and where animals feed and how much they consume is fundamental to understand their ecology and role in ecosystems. However, the lack of reliable data on feeding habits of wild animals, and particularly in marine endotherms, attests to the difficulty in doing this. A promising recent development proposes using a Hall sensor-magnet System - the inter-mandibular angle sensor (IMASEN) attached to animals' jaws to elucidate feeding events. We conducted trials on captive pinnipeds by feeding IMASEN-equipped animals with prey to examine the utility of this system. Most feeding events were clearly distinguishable from other jaw movements; only small prey items might not be resolved adequately. Based on the results of this study we examined feeding events from free-ranging Weddell seals fitted with IMASENs and dead-reckoners during December 2003 at Drescher Inlet (Riiser Larsen Ice Shelf, eastern Weddell Sea coast), and present data on prey capture and ingestion in relation to the three-dimensionalmovement patterns of the seals. A total of 19 Weddell seals were immobilised by using a combination of ketamine, xylazine, and diazepam. Eight seals were drugged once, six two times, and two and three were drugged three and four times each, coming to a total of 38 immobilisation procedures. Narcoses were terminated with yohimbine (doi:10.1594/PANGAEA.438931).

Dive depth profile and immobilisation data of adult male and female Weddell seals at Drescher Inlet from expedition DRE1998

Adult male and female Weddell seals (Leptonychotes weddellii) were fitted with Time-depth recorders (TDR) at Drescher Inlet (Riiser Larsen Ice Shelf), eastern Weddell Sea coast, in February 1998. Eight of 15 data sets were selected for analyses to investigate the seals' foraging behaviour (doi:10.1594/PANGAEA.511465, doi:10.1594/PANGAEA.511454, doi:10.1594/PANGAEA.511456, doi:10.1594/PANGAEA.511457, doi:10.1594/PANGAEA.511459, doi:10.1594/PANGAEA.511462, doi:10.1594/PANGAEA.511466, doi:10.1594/PANGAEA.511467). These data sets provided simultaneous dive records of eight seals over eight days. The seals primarily foraged within two depth layers, these being from the sea surface to 160 m where temperature and salinity varied considerably, and from 340 to 450 m near the bottom where temperature was lowest and salinity highest, with little variation. While pelagic and benthic diving occurred during daylight, the seals foraged almost exclusively in the upper water column at night. Trawling during daytime confirmed that Pleuragramma antarcticum were by far the most abundant fish both in the pelagial and close to the bottom. Pelagic night-hauls at 110-170 m depth showed highly variable biomass of P. antarcticum with a peak at around midnight. The temporal changes in the local abundance of P. antarcticum, particularly in the pelagial, may explain the trends in the seals' pelagic and benthic foraging activities. This is the first study which describes the jaw movements of a hunting seal which are presumably indicative of feeding events. Trophic links from the Weddell seal to fish, zooplankton and krill, Euphausia superba, are discussed. Another seven data sets did not overlap substantially with the selected time frame (doi:10.1594/PANGAEA.511458, doi:10.1594/PANGAEA.511460, doi:10.1594/PANGAEA.511464, doi:10.1594/PANGAEA.511468, doi:10.1594/PANGAEA.511469, doi:10.1594/PANGAEA.511453, doi:10.1594/PANGAEA.511463). A total of 25 Weddell seals were immobilised during the study period using a combination of ketamine, xylazine, and diazepam. Seven seals were drugged once, 15 seals two times, and three were drugged three times, coming to a total of 46 immobilisation procedures. Narcoses were terminated with yohimbine (doi:10.1594/PANGAEA.438933).

Increased feeding and nutrient excretion of adult antarctic krill, Euphausia superba, exposed to enhanced carbon dioxide (CO2)

Ocean acidification has a wide-ranging potential for impacting the physiology and metabolism of zooplankton. Sufficiently elevated CO2 concentrations can alter internal acid-base balance, compromising homeostatic regulation and disrupting internal systems ranging from oxygen transport to ion balance. We assessed feeding and nutrient excretion rates in natural populations of the keystone species Euphausia superba (Antarctic krill) by conducting a CO2 perturbation experiment at ambient and elevated atmospheric CO2 levels in January 2011 along the West Antarctic Peninsula (WAP). Under elevated CO2 conditions (~672 ppm), ingestion rates of krill averaged 78 µg C/individual/d and were 3.5 times higher than krill ingestion rates at ambient, present day CO2 concentrations. Additionally, rates of ammonium, phosphate, and dissolved organic carbon (DOC) excretion by krill were 1.5, 1.5, and 3.0 times higher, respectively, in the high CO2 treatment than at ambient CO2 concentrations. Excretion of urea, however, was ~17% lower in the high CO2 treatment, suggesting differences in catabolic processes of krill between treatments. Activities of key metabolic enzymes, malate dehydrogenase (MDH) and lactate dehydrogenase (LDH), were consistently higher in the high CO2 treatment. The observed shifts in metabolism are consistent with increased physiological costs associated with regulating internal acid-base equilibria. This represents an additional stress that may hamper growth and reproduction, which would negatively impact an already declining krill population along the WAP.

CM101-mediated recovery of walking ability in adult mice paralyzed by spinal cord injury

CM101, an antiangiogenic polysaccharide derived from group B streptococcus, was administered by i.v. injection 1 hr post-spinal-cord crush injury in an effort to prevent inflammatory angiogenesis and gliosis (scarring) in a mouse model. We postulated that gliosis would sterically prevent the reestablishment of neuronal connectivity; thus, treatment with CM101 was repeated every other day for five more infusions for the purpose of facilitating regeneration of neuronal function. Twenty-five of 26 mice treated with CM101 survived 28 days after surgery, and 24 of 26 recovered walking ability within 2–12 days. Only 6 of 14 mice in the control groups survived 24 hr after spinal cord injury, and none recovered function in paralyzed limbs. MRI analysis of injured untreated and treated animals showed that CM101 reduced the area of damage at the site of spinal cord compression, which was corroborated by histological analysis of spinal cord sections from treated and control animals. Electrophysiologic measurements on isolated central nervous system and neurons in culture showed that CM101 protected axons from Wallerian degeneration; reversed γ-aminobutyrate-mediated depolarization occurring in traumatized neurons; and improved recovery of neuronal conductivity of isolated central nervous system in culture.

Expansion in vitro of adult murine hematopoietic stem cells with transplantable lympho-myeloid reconstituting ability

Elucidation of mechanisms that regulate hematopoietic stem cell self-renewal and differentiation would be facilitated by the identification of defined culture conditions that allow these cells to be amplified. We now demonstrate a significant net increase (3-fold, P < 0.001) in vitro of cells that are individually able to permanently and competitively reconstitute the lymphoid and myeloid systems of syngeneic recipient mice when Sca-1+lin− adult marrow cells are incubated for 10 days in serum-free medium with interleukin 11, flt3-ligand, and Steel factor. Moreover, the culture-derived repopulating cells continued to expand their numbers in the primary hosts at the same rate seen in recipients of noncultured stem cells. In the expansion cultures, long-term culture-initiating cells increased 7- ± 2-fold, myeloid colony-forming cells increased 140- ± 36-fold, and total nucleated cells increased 230- ± 62-fold. Twenty-seven of 100 cultures initiated with 15 Sca-1+lin− marrow cells were found to contain transplantable stem cells 10 days later. This frequency of positive cultures is the same as the frequency of transplantable stem cells in the original input suspension, suggesting that most had undergone at least one self-renewal division in vitro. No expansion of stem cells was seen when Sca-1+TER119− CD34+ day 14.5 fetal liver cells were cultured under the same conditions. These findings set the stage for further investigations of the mechanisms by which cytokine stimulation may elicit different outcomes in mitotically activated hematopoietic stem cells during ontogeny and in the adult.

Mutual recognition in goods and services: an economic perspective. Bruges European Economic Policy (BEEP) Briefing 2/2002

Mutual recognition is a remarkable innovation facilitating economic intercourse across borders. In the EU's internal goods market it has been helpful in tackling or avoiding the remaining obstacles, namely, regulatory barriers between Member States. However, there is a curious paradox. Despite the almost universal acclaim of the great merits of mutual recognition the principle has, in and by itself, contributed only modestly to the actual realisation of free movement in the single market. It is also surprising that economists have not or hardly underpinned their widespread appreciation for the principle by providing rigorous analysis which could substantiate the case for mutual recognition for policy makers. Business in Europe has shown a sense of disenc hantment with the principle because of the many costs and uncertainties in its application in actual practice. The purpose of the present paper is to provide the economic and strategic arguments for employing mutual recognition much more systematically in the single market for goods and services. The strategic and the "welfare" gains are analysed and adetailed exposition of the fairly high information , transaction and compliance costs is provided. The information costs derive from the fact that mutual recognition remains a distant abstraction for day-to-day business life. Understandably, verifying the "equivalence" of objectives of health and safety between Member States is perceived as difficult and uncertain. This sentiment is exacerbated by the complications of interpreting the equivalence of "effects". In actual practice, these abstractions are expected to override clear and specific national product or services rules, which local inspectors or traders may find problematic without guidance. The paper enumerates several other costs including, inter alia, the absence of sectoral rule books and the next-to-prohibitive costs of monitoring of the application of the principle. The basic problems in applying mutual recognition in the entire array of services are inspected, showing why the principle can only be used in a limited number of services markets and even there it may contribute only modestly to genuine free movement and competitive exposure. A special section is devoted to a range of practical illustrations of the difficulties business experiences when relying on mutual recognition. Finally, the corollary of mutual recognition - regulatory competition - is discussed in terms of a cost/benefits analysis compared to what is often said to be the alternative , that is "harmonisation" , in EU parlance the "new approach" to approximation. The conclusion is that the manifold benefits of mutual recognition for Europe are too great to allow the present ambiguities to continue. The Union needs much more pro-active approaches to reduce the costs of mutual recognition as well as permanent monitoring structures for its application to services (analogous to those already successfully functioning in goods markets). Above all, what is required is a "mutual recognition culture" so that the EU can better enjoy the fruits of its own regulatory ingenuity.

Adult attention-deficit/hyperactivity disorder and nicotine withdrawal: a qualitative study of patient perceptions

Background: Nicotine use has been reported to ameliorate symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD). Furthermore, adults with ADHD have a relatively high prevalence of cigarette smoking and greater difficulty abstaining from smoking. Overall, though, there is scant literature investigating the beliefs, perceptions and experiences of smokers with ADHD regarding smoking cessation and withdrawal. Methods: Our participants (n = 20) fulfilling criteria for ADHD and a past or current dependence from nicotine were recruited from the in- and outpatient clinic of the Zurich University Psychiatric Hospital and the Psychiatric Services Aargau (Switzerland). We conducted in-depth interviews to explore their motivations to quit, past experiences with and expectations about quitting using a purposeful sampling plan. The sample was selected to provide diversity in relation to level of nicotine dependence, participation in a smoking-cessation program, gender, age, martial status and social class. Mayring’s qualitative content analysis approach was used to evaluate findings. Results: Adult smokers with ADHD had made several attempts to quit, experienced intense withdrawal symptoms, and relapsed early and often. They also often perceived a worsening of ADHD symptoms with nicotine abstinence. We identified three motives to quit smoking: 1) health concerns, 2) the feeling of being addicted, and 3) social factors. Most participants favored a smoking cessation program specifically designed for individuals with ADHD because they thought ADHD complicated their nicotine withdrawal and that an ADHD-specific smoking cessation program should address specific symptoms of this disorder. Conclusions: Since treatment initiation and adherence associate closely with perception, we hope these findings will result in better cessation interventions for the vulnerable subgroup of smokers with ADHD. Keywords: ADHD, Nicotine, Withdrawal, Subjective, Qualitative, Narrative