Trinkerszenen im öffentlichen Raum: ein Städtevergleich.

Ein ethnographischer Vergleich von Trinkerszenen in fünf Schweizer Städten zeigt eine zunehmende Reglementierung und konsumorientierte Ökonomisierung des öffentlichen Raums und entsprechende Ausgrenzungsmechanismen gegenüber den sich dort aufhaltenden Gruppen. Die Politik der Städte weist jedoch auch erhebliche Unterschiede auf.

Invasive Candida infections in the ICU

Invasive candidiasis, including candidemia and deep-seated Candida infections, is a severe opportunistic infection with an overall mortality in ICU patients comparable to that of severe sepsis/septic shock. With an incidence ranging from 5 to 10 cases per 1000 ICU admissions, invasive candidiasis represents 510% of all ICU-acquired infections. Although a high proportion of critically ill patients is colonised with Candida spp., only 540% develop an invasive infection. The occurrence of this complication is difficult to predict and an early diagnosis remains a major challenge. Indeed, blood cultures are positive in a minority of cases and often late in the course of infection. New non-culture based laboratory techniques may contribute to early diagnosis and management of invasive candidiasis. Recent data suggest that prediction rules based on risk factors, clinical and microbiological parameters or monitoring of Candida colonisation may efficiently identify critically ill patients at high risk of invasive candidiasis who may benefit of preventive or pre-emptive antifungal therapy. In many cancer centres, exposure to azoles antifungals has been associated with an epidemiological shift from Candida albicans to non-albicans Candida species with reduced antifungal susceptibility or intrinsic resistance. This trend has not been observed in recent surveys on candidemia in non-immunocompromised ICU patients. Prophylaxis, pre-emptive or empirical antifungal treatment are possible approaches for prevention or early management of invasive candidiasis. However, the selection of high-risk patients remains critical for an efficient management aimed at reducing the number needed to treat and thus avoiding unnecessary treatments associated with the emergence of resistance, drug toxicity and costs.

Kinder als Mitbetroffene von häuslicher Gewalt : die Vernetzung der betroffenen Kinder mit der Opferhilfe im Kanton Bern

Dans le présent travail, on se pose les questions de savoir si, dans le canton de Berne, il existe un besoin d'agir et d'intégrer les enfants touchés par la violence conjugale (on parle ici des actes de violence entre les parents) à l'aide aux victimes d'infractions. Le travail se concentre sur des enfants de moins de 12 ans, dont les parents, conscients de leur violence, se sont annoncés eux-mêmes à un centre de consultation. Les enfants n'ont aucune offre de soutien (par ex : protection de droit civil de l'enfant). Ces parents sont donc les personnes de contact de référence capables de défendre les intérêts des enfants, ce sont eux qui peuvent mettre les enfants en contact avec les systèmes de soutien appropriés. Généralement, à cet âge, les enfants ne peuvent pas encore chercher de l'aide eux-mêmes. Les centres de consultation sont donc les seules institutions d'état qui, dans de tels cas, offrent des aides de soutien, qui connaissent la situation des enfants, et qui par l'intermédiaire des parents, ont un contact indirect avec les enfants. In der vorliegenden Arbeit wird den Fragen nachgegangen, ob im Kanton Bern ein Handlungsbedarf besteht, Kinder, die von häuslicher Gewalt (hier verstanden als Gewalthandlungen zwischen den Eltern) betroffen sind, mit der Opferhilfe zu vernetzen? Der Fokus der Arbeit liegt auf Kindern unter 12 Jahren, deren gewaltbetroffene Elternteile sich aufgrund des eigenen Gewalterlebens selbständig bei einer Opferhilfeberatungsstelle gemeldet haben. Ihre Kinder sind mit keinem Unterstützungsangebot vernetzt (z.B. zivilrechtlicher Kindesschutz). Diese Elternteile sind die zentralen Ansprechpersonen für die Belange der Kinder, sie können die Kinder mit geeigneten Unterstützungssystemen vernetzen. Die Kinder selbst können sich in diesem Alter in der Regel noch nicht selbständig Hilfe organisieren. Die Opferhilfeberatungsstellen sind damit die einzigen staatlichen Institutionen, die in solchen Fällen Unterstützungsleistungen bieten, von der Situation der Kinder Kenntnis haben und über die gewaltbetroffenen Eltern auch indirekten Kontakt zu den Kindern haben.

Non-invasive detection of coronary endothelial response to sequential handgrip exercise in coronary artery disease patients and healthy adults.

OBJECTIVES: Our objective is to test the hypothesis that coronary endothelial function (CorEndoFx) does not change with repeated isometric handgrip (IHG) stress in CAD patients or healthy subjects. BACKGROUND: Coronary responses to endothelial-dependent stressors are important measures of vascular risk that can change in response to environmental stimuli or pharmacologic interventions. The evaluation of the effect of an acute intervention on endothelial response is only valid if the measurement does not change significantly in the short term under normal conditions. Using 3.0 Tesla (T) MRI, we non-invasively compared two coronary artery endothelial function measurements separated by a ten minute interval in healthy subjects and patients with coronary artery disease (CAD). METHODS: Twenty healthy adult subjects and 12 CAD patients were studied on a commercial 3.0 T whole-body MR imaging system. Coronary cross-sectional area (CSA), peak diastolic coronary flow velocity (PDFV) and blood-flow were quantified before and during continuous IHG stress, an endothelial-dependent stressor. The IHG exercise with imaging was repeated after a 10 minute recovery period. RESULTS: In healthy adults, coronary artery CSA changes and blood-flow increases did not differ between the first and second stresses (mean % change ±SEM, first vs. second stress CSA: 14.8%±3.3% vs. 17.8%±3.6%, p = 0.24; PDFV: 27.5%±4.9% vs. 24.2%±4.5%, p = 0.54; blood-flow: 44.3%±8.3 vs. 44.8%±8.1, p = 0.84). The coronary vasoreactive responses in the CAD patients also did not differ between the first and second stresses (mean % change ±SEM, first stress vs. second stress: CSA: -6.4%±2.0% vs. -5.0%±2.4%, p = 0.22; PDFV: -4.0%±4.6% vs. -4.2%±5.3%, p = 0.83; blood-flow: -9.7%±5.1% vs. -8.7%±6.3%, p = 0.38). CONCLUSION: MRI measures of CorEndoFx are unchanged during repeated isometric handgrip exercise tests in CAD patients and healthy adults. These findings demonstrate the repeatability of noninvasive 3T MRI assessment of CorEndoFx and support its use in future studies designed to determine the effects of acute interventions on coronary vasoreactivity.

Diagnosis of invasive candidiasis in the ICU.

Invasive candidiasis ranges from 5 to 10 cases per 1,000 ICU admissions and represents 5% to 10% of all ICU-acquired infections, with an overall mortality comparable to that of severe sepsis/septic shock. A large majority of them are due to Candida albicans, but the proportion of strains with decreased sensitivity or resistance to fluconazole is increasingly reported. A high proportion of ICU patients become colonized, but only 5% to 30% of them develop an invasive infection. Progressive colonization and major abdominal surgery are common risk factors, but invasive candidiasis is difficult to predict and early diagnosis remains a major challenge. Indeed, blood cultures are positive in a minority of cases and often late in the course of infection. New nonculture-based laboratory techniques may contribute to early diagnosis and management of invasive candidiasis. Both serologic (mannan, antimannan, and betaglucan) and molecular (Candida-specific PCR in blood and serum) have been applied as serial screening procedures in high-risk patients. However, although reasonably sensitive and specific, these techniques are largely investigational and their clinical usefulness remains to be established. Identification of patients susceptible to benefit from empirical antifungal treatment remains challenging, but it is mandatory to avoid antifungal overuse in critically ill patients. Growing evidence suggests that monitoring the dynamic of Candida colonization in surgical patients and prediction rules based on combined risk factors may be used to identify ICU patients at high risk of invasive candidiasis susceptible to benefit from prophylaxis or preemptive antifungal treatment.

Invasive candidiasis: comparison of management choices by infectious disease and critical care specialists.

OBJECTIVE: To compare the management of invasive candidiasis between infectious disease and critical care specialists. DESIGN AND SETTING: Clinical case scenarios of invasive candidiasis were presented during interactive sessions at national specialty meetings. Participants responded to questions using an anonymous electronic voting system. PATIENTS AND PARTICIPANTS: Sixty-five infectious disease and 51 critical care physicians in Switzerland. RESULTS: Critical care specialists were more likely to ask advice from a colleague with expertise in the field of fungal infections to treat Candida glabrata (19.5% vs. 3.5%) and C. krusei (36.4% vs. 3.3%) candidemia. Most participants reported that they would change or remove a central venous catheter in the presence of candidemia, but 77.1% of critical care specialists would start concomitant antifungal treatment, compared to only 50% of infectious disease specialists. Similarly, more critical care specialists would start antifungal prophylaxis when Candida spp. are isolated from the peritoneal fluid at time of surgery for peritonitis resulting from bowel perforation (22.2% vs. 7.2%). The two groups equally considered Candida spp. as pathogens in tertiary peritonitis, but critical care specialists would more frequently use amphotericin B than fluconazole, caspofungin, or voriconazole. In mechanically ventilated patients the isolation of 10(4) Candida spp. from a bronchoalveolar lavage was considered a colonizing organism by 94.9% of infectious disease, compared to 46.8% of critical care specialists, with a marked difference in the use of antifungal agents (5.1% vs. 51%). CONCLUSIONS: These data highlight differences between management approaches for candidiasis in two groups of specialists, particularly in the reported use of antifungals.

Impact of targeted antifungal prophylaxis in heart transplant recipients at high risk for early invasive fungal infection.

BACKGROUND: Invasive fungal infection (IFI) is associated with high mortality after heart transplantation (HTx). After two undiagnosed fatal cases of early disseminated fungal infections in our heart transplant program, a retrospective analysis was conducted to identify risk factors for the development of IFI and implement a new antifungal prophylaxis policy. METHODS: Clinical characteristics of HTx recipients hospitalized in our center (2004-2010) were recorded (Period 1), and risk factors associated with IFI were investigated using Cox regression analysis. From October 2010 to October 2012 (Period 2), targeted caspofungin prophylaxis was administered to all recipients at high risk for IFI, based on the results of the Period 1 analysis. RESULTS: During Period 1, 10% (6/59) of the patients developed IFI at a median onset of 9 days after transplantation. By multivariate analysis, the use of posttransplant extracorporeal membrane oxygenation (ECMO) was the strongest predictor for fungal infection (OR, 29.93; 95% CI, 1.51-592.57, P=0.03), whereas renal replacement therapy (RRT) and Aspergillus colonization were significant predictors only by univariate analysis. During Period 2, only 4% (1/26) of the patients developed IFI. In patients at high risk for IFI, antifungal prophylaxis was administered to 17% (4/23) in Period 1 versus 100% (13/13) in Period 2 (P<0.01). By survival analysis, antifungal prophylaxis was associated with a reduction in 90-day IFI incidence (HR, 0.14; 95% CI, 0.03-0.84, P=0.03) and 30-day mortality (HR, 0.25; 95% CI, 0.09-0.8, P=0.02). CONCLUSION: Extracorporeal membrane oxygenation was identified an important risk factor for IFI after HTx, and its use may require targeted administration of antifungal prophylaxis in the immediate posttransplant period.

Minimally invasive versus open transforaminal lumbar interbody fusion: evaluating initial experience.

The aim of this study was to compare our experience with minimally invasive transforaminal lumbar interbody fusion (MITLIF) and open midline transforaminal lumbar interbody fusion (TLIF). A total of 36 patients suffering from isthmic spondylolisthesis or degenerative disc disease were operated with either a MITLIF (n = 18) or an open TLIF technique (n = 18) with an average follow-up of 22 and 24 months, respectively. Clinical outcome was assessed using the visual analogue scale (VAS) and the Oswestry disability index (ODI). There was no difference in length of surgery between the two groups. The MITLIF group resulted in a significant reduction of blood loss and had a shorter length of hospital stay. No difference was observed in postoperative pain, initial analgesia consumption, VAS or ODI between the groups. Three pseudarthroses were observed in the MITLIF group although this was not statistically significant. A steeper learning effect was observed for the MITLIF group.