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.

If hunters end up in the emergency room: a retrospective analysis of hunting injuries in a swiss emergency department.

Aim. to characterize the mechanisms, patterns, and outcomes of nonfatal hunting-related injuries in patients presenting to Bern University Hospital, Switzerland, and compare these to reports of hunting injuries worldwide. Methods. patients presenting with hunting-related injuries to the Emergency Department at Bern University hospital from 2000 to 2014 were identified by retrospectively searching the department database using the keyword "hunt." Each case was analyzed in terms of the patient age and gender, the mechanism and pattern of injury, and management and patient follow-up. Results. 19 patients were identified. 16 were male with a mean age of 50 years (range: 16-74). Mechanisms of injury included firearm-related injuries, falls, and knife wounds. The most common patterns of injury were head injuries (7), followed by injuries to the upper (5) or lower limb (5) and trunk (2). Over half of the patients were admitted, and nine required emergency surgery. Conclusion. Nonfatal hunting accidents in Bern, Switzerland, are largely caused by firearms and falls and tend to occur in male hunters with a mean age of 50 years. The most common patterns of injury are orthopedic and head injuries, often requiring surgery. These findings are consistent with international studies of nonfatal hunting accidents.

Emergency management of ischemic stroke in children.

OPINION STATEMENT Children who present with acute neurological symptoms suggestive of a stroke need immediate clinical assessment and urgent neuroimaging to confirm diagnosis. Magnetic resonance imaging (MRI) is the investigation of first choice due to limited sensitivity of computed tomography (CT) for detection of ischaemia. Acute monitoring should include monitoring of blood pressure and body temperature, and neurological observations. Surveillance in a paediatric high dependency or intensive care unit and neurosurgical consultation are mandatory in children with large infarcts at risk of developing malignant oedema or haemorrhagic transformation. Thrombolysis and/or endovascular treatment, whilst not currently approved for use in children, may be considered when stroke diagnosis is confirmed within 4.5 to 6 h, provided there are no contraindications on standard adult criteria. Standard treatment consists of aspirin, but anticoagulation therapy is frequently prescribed in stroke due to cardiac disease and extracranial dissection. Steroids and immunosuppression have a definite place in children with proven vasculitis, but their role in focal arteriopathies is less clear. Decompressive craniotomy should be considered in children with deteriorating consciousness or signs of raised intracranial pressure.

Evidence for Emergency Vaccination Having Played a Crucial Role to Control the 1965/66 Foot-and-Mouth Disease Outbreak in Switzerland.

Foot-and-mouth disease (FMD) is a highly contagious disease that caused several large outbreaks in Europe in the last century. The last important outbreak in Switzerland took place in 1965/66 and affected more than 900 premises and more than 50,000 animals were slaughtered. Large-scale emergency vaccination of the cattle and pig population has been applied to control the epidemic. In recent years, many studies have used infectious disease models to assess the impact of different disease control measures, including models developed for diseases exotic for the specific region of interest. Often, the absence of real outbreak data makes a validation of such models impossible. This study aimed to evaluate whether a spatial, stochastic simulation model (the Davis Animal Disease Simulation model) can predict the course of a Swiss FMD epidemic based on the available historic input data on population structure, contact rates, epidemiology of the virus, and quality of the vaccine. In addition, the potential outcome of the 1965/66 FMD epidemic without application of vaccination was investigated. Comparing the model outcomes to reality, only the largest 10% of the simulated outbreaks approximated the number of animals being culled. However, the simulation model highly overestimated the number of culled premises. While the outbreak duration could not be well reproduced by the model compared to the 1965/66 epidemic, it was able to accurately estimate the size of the area infected. Without application of vaccination, the model predicted a much higher mean number of culled animals than with vaccination, demonstrating that vaccination was likely crucial in disease control for the Swiss FMD outbreak in 1965/66. The study demonstrated the feasibility to analyze historical outbreak data with modern analytical tools. However, it also confirmed that predicted epidemics from a most carefully parameterized model cannot integrate all eventualities of a real epidemic. Therefore, decision makers need to be aware that infectious disease models are useful tools to support the decision-making process but their results are not equal valuable as real observations and should always be interpreted with caution.

Revascularization Treatment of Emergency Patients with Acute ST-Segment Elevation Myocardial Infarction in Switzerland: Results from a Nationwide, Cross-Sectional Study in Switzerland for 2010-2011

BACKGROUND: Cardiovascular diseases are the leading cause of death worldwide and in Switzerland. When applied, treatment guidelines for patients with acute ST-segment elevation myocardial infarction (STEMI) improve the clinical outcome and should eliminate treatment differences by sex and age for patients whose clinical situations are identical. In Switzerland, the rate at which STEMI patients receive revascularization may vary by patient and hospital characteristics. AIMS: To examine all hospitalizations in Switzerland from 2010-2011 to determine if patient or hospital characteristics affected the rate of revascularization (receiving either a percutaneous coronary intervention or a coronary artery bypass grafting) in acute STEMI patients. DATA AND METHODS: We used national data sets on hospital stays, and on hospital infrastructure and operating characteristics, for the years 2010 and 2011, to identify all emergency patients admitted with the main diagnosis of acute STEMI. We then calculated the proportion of patients who were treated with revascularization. We used multivariable multilevel Poisson regression to determine if receipt of revascularization varied by patient and hospital characteristics. RESULTS: Of the 9,696 cases we identified, 71.6% received revascularization. Patients were less likely to receive revascularization if they were female, and 80 years or older. In the multivariable multilevel Poisson regression analysis, there was a trend for small-volume hospitals performing fewer revascularizations but this was not statistically significant while being female (Relative Proportion = 0.91, 95% CI: 0.86 to 0.97) and being older than 80 years was still associated with less frequent revascularization. CONCLUSION: Female and older patients were less likely to receive revascularization. Further research needs to clarify whether this reflects differential application of treatment guidelines or limitations in this kind of routine data.

Geomorphology and spectrophotometry of Philae's landing site on comet 67P/Churyumov-Gerasimenko

Context. On 12 November 2014 the European mission Rosetta succeeded in delivering a lander, named Philae, on the surface of one of the smallest, low-gravity and most primitive bodies of the solar system, the comet 67P/Churyumov-Gerasimenko (67P). Aims. The aim of this paper is to provide a comprehensive geomorphological and spectrophotometric analysis of Philae's landing site (Agilkia) to give an essential framework for the interpretation of its in situ measurements. Methods. OSIRIS images, coupled with gravitational slopes derived from the 3D shape model based on stereo-photogrammetry were used to interpret the geomorphology of the site. We adopted the Hapke model, using previously derived parameters, to photometrically correct the images in orange filter (649.2 nm). The best approximation to the Hapke model, given by the Akimov parameter-less function, was used to correct the reflectance for the effects of viewing and illumination conditions in the other filters. Spectral analyses on coregistered color cubes were used to retrieve spectrophotometric properties. Results. The landing site shows an average normal albedo of 6.7% in the orange filter with variations of similar to 15% and a global featureless spectrum with an average red spectral slope of 15.2%/100 nm between 480.7 nm (blue filter) and 882.1 nm (near-IR filter). The spatial analysis shows a well-established correlation between the geomorphological units and the photometric characteristics of the surface. In particular, smooth deposits have the highest reflectance a bluer spectrum than the outcropping material across the area. Conclusions. The featureless spectrum and the redness of the material are compatible with the results by other instruments that have suggested an organic composition. The observed small spectral variegation could be due to grain size effects. However, the combination of photometric and spectral variegation suggests that a compositional differentiation is more likely. This might be tentatively interpreted as the effect of the efficient dust-transport processes acting on 67P. High-activity regions might be the original sources for smooth fine-grained materials that then covered Agilkia as a consequence of airfall of residual material. More observations performed by OSIRIS as the comet approaches the Sun would help interpreting the processes that work at shaping the landing site and the overall nucleus.

Driving and emergency braking may be impaired after tibiotalar joint arthrodesis: conclusions after a case series.

PURPOSE To assess whether reaction time (RT) and movement time (MT), as the two components of the total brake response time (TBRT) and brake force (BF) are different in patients with a foot joint arthrodesis in comparison to controls. METHODS The study was a comparative case series in a driving simulator under realistic driving conditions. Mobile patients without a walker, ≥6 months after surgery who were driving a car and had no neurological co-morbidity, knee or hip joint prosthesis were included in the study. The selection criteria resulted in 12 patients with right tibiotalar joint arthrodesis (TTJA) and 12 patients with another right foot joint arthrodesis (OFJA), who were compared to 17 individuals without any ankle-joint pathology. For TBRT, an empirical safe driving threshold of 700 ms was used. The outcome measures were RT, MT, TBRT, BF and McGuire score. RESULTS MT (p = 0.034) and TBRT (p = 0.026) were longer in TTJA patients in comparison with the controls. Also, more patients with TTJA than patients with OFJA and controls exceeded the safe driving threshold (p = 0.028). The outcomes in OFJA patients and in controls were comparable. The McGuire score was similar between the TTJA and OFJA patients (p = 0.26). CONCLUSIONS Significantly slower MT and TBRT, and significantly more patients exceeding the safe driving threshold, were observed after a tibiotalar-joint arthrodesis in comparison to the controls. Patients with OFJAs were not significantly different from the controls. Driving and emergency braking may be impaired after tibiotalar-joint arthrodesis.

Der Bericht des Hilfsfonds (Emergency-Fund) von 1929 [Nachricht]

Abraham Ulitzur

The role of STAT3 in the emergency neutrophil response

Neutrophils are an essential component of innate immunity, serving to provide an immediate response to microbial invasion. In response to emergency situations such as an infection, serum levels of granulocyte colony-stimulating factor (G-CSF) are induced, causing a boost in neutrophil production and a rapid mobilization of bone marrow neutrophils to the blood, where they can circulate to clear foreign pathogens. Signal transducer and activator of transcription 3 (STAT3) is a principal downstream signaling intermediate of the G-CSF receptor. Mice null for STAT3 are embryonic lethal; therefore, to examine the role that STAT3 has in granulocytic development and function in vivo, we utilized a conditional knockout mouse that deletes functional STAT3 in the hematopoietic system (referred to herein as STAT3-deficient). Using this model, we show that STAT3 is required for G-CSF-induced expansion of granulocytic progenitor cells within the bone marrow and for acute G-CSF-dependent neutrophil mobilization into the blood. Thus, STAT3 has a critical role in the immediate G-CSF-response in vivo. Sustained G-CSF exposure causes skewed granulocytic production and mobilization in STAT3-deficient mice, suggesting an atypical granulocytic developmental pathway. To determine if STAT3-deficient neutrophils were functional, we examined neutrophil chemotaxis, since neutrophil function relies on proper chemoattractant-induced migration to infected tissue sites. STAT3-deficient neutrophils have impaired chemotaxis in response to the potent neutrophil chemoattractants MIP-2 and KC, both ligands for the chemokine receptor CXCR2. Additionally, STAT3-deficient mice have a defect in NIIP-2-induced acute neutrophil mobilization in vivo. Chemotaxis in response to fMLP and SDF-1, which utilize distinct seven-transmembrane chemokine receptors, was similar between wild type and STAT3-deficient neutrophils, suggesting that STAT3 specifically regulates CXCR2-mediated migration. MIP-2-induced activation of the Raf/MEK/ERK signaling cascade, which we show is required for MIP-2-dependent neutrophil chemotaxis, was impaired in STAT3-deficient neutrophils. Interestingly, acute G-CSF administration induced CXCR2 expression and Raf/MEK/ERK activation in neutrophils from wild type mice, whereas these responses were abrogated in neutrophils from STAT3-deficient mice. Thus, STAT3 regulation of CXCR2 functions may also contribute to STAT3's control of the acute G-CSF mobilization response. These combined results place STAT3 as a critical intermediate in neutrophil migration and G-CSF-induced neutrophil production responses required for emergency granulopoiesis. ^

Minority preferences and disease types for non-emergent emergency department usage in a CHIP population

Background. Of the over five million annual pediatric visits to U.S. emergency departments, one-third to one-half are for non-emergent conditions. Minorities are more likely to utilize the emergency department (ED) for non-emergent conditions. Very little research has analyzed the role of illness type, perceived need, or family preferences in explaining this disparity. ^ Objectives. This study examined racial-ethnic differences in preferences for care among non-emergent users of the ED. ^ Research design. A random selection of pediatric non-emergent ED users within a single CHIP managed care plan were surveyed regarding attitudes and health care preferences. Preferences for ED utilization were analyzed by racial-ethnic category, controlling for illness type, child and guardian age, education level, language, and perceived need. ^ Results. A total of 250 families were surveyed. Most respondents reported having a regular doctor, satisfaction with their physician, and ready access to their physician. Fifteen percent of White, 39% of Hispanic, and 38% of Black families reported they preferred the emergency department for ill care. In multivariate analysis, Whites families were significantly less likely to prefer the emergency department for ill visits (odds ratio, 0.12; 95% confidence interval 0.03-0.55) compared to Blacks and Hispanics. ^ Conclusions. Racial-ethnic disparities in non-emergent ED utilization may be partially explained by different preferences for care. ^ Key words: children, emergency department, preferences for care, disparities ^

Introduction to public health preparedness for disaster and emergency response

The unprecedented attacks of September 11, 2001, and the subsequent anthrax-related events thrust our nation's often forgotten public health system into the forefront of public attention. A strong public health system with a well-prepared workforce plays a critical role in preparing for and responding to the threat of bioterrorism and other disasters and emergencies. Technical expertise is critical as is a basic awareness and understanding of core public health competencies especially as they relate to disaster and emergency response is also imperative for a public health agency to function as a vital Emergency Response team member. Ideally this training should begin at the Public Health graduate level so as to provide the baseline core tools to be able to function as a vital team member when they are practicing out in the real world. Online learning is an efficient and effective method for providing public health education to in a flexible format to meet the needs of busy student-professions. This Public Health Disaster Preparedness online course developed during an Emergency Response state program practicum is a practical and proficient approach to accomplish this endeavor. ^