Annual Report: Division of Acute Disease Prevention, Emergency Response, and Environmental Health 2015 April 25, 2016

This report is a result of the ADPER & EH division management team retreat that was held on July 30 and 31, 2015 where a gap was identified in our communication with customers, especially when it came to sharing information about planning efforts. The purpose of this report is to provide a comprehensive look at what ADPER & EH has accomplished in the past year as well as what we are working on for the future. It also serves as an annual informational resource for stakeholders, local partners, policy makers and the general public.

Médecine d'urgence [Emergency medicine: updates 2012].

We review some of the most influential papers from 2012 in the different aspects of emergency medicine, such as prehospital medicine, resuscitation, early diagnosis and timely ED discharge and treatment. In particular, intramuscular benzodiazepines have been shown to be efficient in prehospital status epilepticus, epinephrines usefulness in cardiopulmonary resuscitation has been challenged, colloids have been shown to be deleterious in the treatment of severe sepsis and septic shock, the time window for thrombolysis in acute stroke will probably be extended, acute pyelonephritis treatment duration can be decreased, new D-dimers thresholds for older patients may prevent further diagnosis tests, and hs-Troponin may allow earlier discharge of low coronary risk patients.

Phosphorus utilization by corn as affected by green manure, nitrogen and phosphorus fertilizers

The objective of this work was to evaluate the utilization by corn plants of P from triple superphosphate fertilizer labeled with 32P (32P‑TSP), and of P from soil as affected by N rates and by the green manures (GM) sunn hemp (Crotalaria juncea) and millet (Pennisetum glaucum). The experiment was carried out using pots filled with 5 kg Oxisol (Rhodic Hapludox). A completely randomized design was used, in a 4x4x2 factorial arrangement, with four replicates. The treatments were: four P rates as TSP (0, 0.175, 0.350, and 0.700 g P per pot); four N rates as urea (0, 0.75, 1.50, and 2.25 g N per pot); and sunn hemp or millet as green manure. The additions of N and P by the GM were taken into account. After grain physiologic maturation, corn dry matter, P contents, accumulated P, and P recovery in the different treatments were measured. 32P‑TSP recovery by corn increased with N increasing rates, and decreased with increasing rates of 32P‑TSP. The mineral fertilizer provides most of the accumulated P by corn plants. The recovery of 32P‑TSP by corn was 13.12% in average. The green manure species influence the assimilation of 32P‑TSP by the plants.

Do Objective Measures of Blood Alcohol Concentrations Make More Sense than Self-reports in Emergency Department Studies?

Purpose: Concerns about self-reports have led to calls for objective measures of blood alcohol concentration (BAC). The present study compared objective measures with self-reports. Methods: BAC from breath or blood samples were obtained from 272 randomly sampled injured patients who were admitted to a Swiss emergency department (ED). Self-reports were compared a) between those providing and refusing a BAC test, and b) to estimated peak BAC (EPBAC) values based on BACs using the Widmark formula. Results: Those providing BACs were significantly (P < 0.05) younger, more often male, and less often reported alcohol consumption before injury, but consumed higher quantities when drinking. Eighty-eight percent of those with BAC measures gave consistent reports (positive or negative). Significantly more patients reported consumption with negative BAC measures (N = 29) than vice versa (N = 3). Duration of consumption and times between injury and BAC measurement predicted EPBAC better than did the objective BAC measure. Conclusions: There is little evidence that patients who provide objective BAC measures deliberately conceal consumption. ED studies must rely on self-reports, eg, take the time period between injury and ED admission into account. Clearly, objective measures are of clinical relevance, eg, to provide optimal treatment in the ED. However, they may be less relevant to establishing effects in an epidemiologic sense, such as estimating risk relationships. In this respect, efforts to increase the validity and reliability of self-reports should be preferred over the collection of additional objective measures.

EZ-IO intraosseous device implementation in a pre-hospital emergency service : a prospective study and review of the literature

Introduction : La prise en charge des patients critiques nécessite dans la majorité des situations l'obtention rapide d'un accès vasculaire, afin d'administrer des médicaments, des solutés de remplissage, ou des produits sanguins. La mise en place d'un accès vasculaire peut s'avérer difficile chez ces patients. En cas d'échec de pose d'une voie veineuse périphérique, des abords vasculaires alternatifs existent. Il s'agit essentiellement de la pose d'une voie veineuse centrale, la réalisation d'une dénudation veineuse, ou la pose d'une voie intra-osseuse. Depuis le développement de dispositifs d'insertion « semi-automatique » à la fin des années 90, la voie intra-osseuse, traditionnellement réservée aux cas pédiatriques, est de plus en plus fréquemment utilisée chez les patients adultes. Le Service des Urgences du CHUV a introduit en 2009 les dispositifs d'insertion d'aiguilles intra-osseuses de type EZ-IO® (perceuse électrique), en salle de réanimation des urgences vitales (déchoquage), ainsi qu'au sein du secteur préhospitalier pour les interventions du SMUR de Lausanne et de l'hélicoptère REGA de la base de Lausanne. Par cette étude, nous voulions mettre en évidence les aspects épidémiologiques des patients ayant dû être perfusés par cet abord dans un contexte préhospitalier, ainsi que les circonstances cliniques ayant justifié un tel usage, le taux de succès, les éventuelles complications, les médicaments perfusés et la mortalité des patients ayant bénéficié de ce dispositif. Méthode: Chaque patient ayant bénéficié de la mise en place d'une voie intra-osseuse par EZ-IO® du 1er janvier 2009 au 31 décembre 2011 a été inclus. Les données récoltées étaient l'âge, le sexe, l'indication à la mise en place de l'intra-osseuse, la localisation, le taux de succès, les médicaments et fluides administrés, les complications, la mortalité à 48 heures et à la sortie de l'hôpital. Tous les articles mentionnant l'utilisation de ΙΈΖ-ΙΟ® dans des situations cliniques ont également été analysés par une revue de littérature structurée exhaustive, afin de comparer nos résultats avec les données de la littérature. Résultats : Cinquante-huit patients, représentant 60 intra-osseuses EZ-IO®, ont été inclus. Leur âge moyen (47 ans), le taux de succès (90%), les indications, la localisation de l'aiguille (98% au niveau du tibia proximal) et le taux de complications (0%) correspondent aux valeurs trouvées dans la littérature. Le taux de survie de nos patients est de 38% à 48 heures et de 29% à la sortie de l'hôpital. De nombreux médicaments ou solutés de perfusion ont été administrés; l'adrénaline restant le médicament le plus fréquemment administré par cette voie. Dans 7 cas, les patients ont bénéficié d'une induction d'anesthésie par voie intra-osseuse. La revue de littérature a permis de compiler 30 études distinctes, représentant un total de 1603 accès vasculaires de type EZ-IO®. Conclusion : La voie intra-osseuse s'avère fiable et rapide pour obtenir un accès vasculaire, avec un taux de complications très faible et permet l'administration d'un grand nombre de substances. D'autres études sont nécessaires pour évaluer l'impact de la voie intra osseuse, notamment en termes de mortalité, de complications tardives, ainsi que d'analyse coût/bénéfice de ce matériel.

Alcohol and cannabis use as risk factors for injury--a case-crossover analysis in a Swiss hospital emergency department.

BACKGROUND: There is sufficient and consistent evidence that alcohol use is a causal risk factor for injury. For cannabis use, however, there is conflicting evidence; a detrimental dose-response effect of cannabis use on psychomotor and other relevant skills has been found in experimental laboratory studies, while a protective effect of cannabis use has also been found in epidemiological studies. METHODS: Implementation of a case-crossover design study, with a representative sample of injured patients (N = 486; 332 men; 154 women) from the Emergency Department (ED) of the Lausanne University Hospital, which received treatment for different categories of injuries of varying aetiology. RESULTS: Alcohol use in the six hours prior to injury was associated with a relative risk of 3.00 (C.I.: 1.78, 5.04) compared with no alcohol use, a dose-response relationship also was found. Cannabis use was inversely related to risk of injury (RR: 0.33; C.I.: 0.12, 0.92), also in a dose-response like manner. However, the sample size for people who had used cannabis was small. Simultaneous use of alcohol and cannabis did not show significantly elevated risk. CONCLUSION: The most surprising result of our study was the inverse relationship between cannabis use and injury. Possible explanations and underlying mechanisms, such as use in safer environments or more compensatory behavior among cannabis users, were discussed.

Neck complaints in the pediatric emergency department: a consecutive case series of 170 children.

OBJECTIVES: To describe the spectrum of pathologies responsible for neck ailments in a primary care pediatric emergency setting and evaluate their outcome. METHODS: All children aged 16 years or younger, who presented to the emergency department of the Children's Hospital of Lausanne during a 1-year period, were retrospectively identified and charts were reviewed. Causes of neck complaints were classified as traumatic (group 1), infectious (group 2), postural (group 3), or miscellaneous (group 4) according to the final diagnosis. History and physical examination findings, radiological and laboratory results, as well as patient outcomes were recorded. RESULTS: During the study period, 28,722 children were observed in the emergency department, and 170 were identified as having neck complaints. The number of patients with neck ailments in group 1 was 105 (62%). Group 2 contained 33 patients (19%), of which 28 (16.5%) had a viral infection and 5 (2.9%) had a bacterial infection. Group 3 contained 30 children (17.6%) and group 4 contained 2 children (1.2%). Cervical spine radiography was performed on an emergency basis in 60 children (57 in group 1, 2 in group 2, and 1 in group 3). Significant abnormalities were observed in 6 children. Cervical computed tomography (CT) was performed in 9 children, from which 5 were in group 1, 3 were in group 2, and 1 was in group 4. The CT scan revealed pathologic findings in 6 children. Follow-up data were available in 135 patients (79.4%), of which 129 (95.6%) experienced complete recovery in less than 2 weeks. Admission to the hospital was necessary in 4 children (1 in group 1 and 3 in group 2), including 2 for emergency surgical drainage of retropharyngeal abscesses. One child with posttraumatic torticollis was treated conservatively as an outpatient and recovered in 7 weeks. One child was had his/her condition eventually diagnosed with osteoid osteoma and treated with oral nonsteroidal anti-inflammatory drug. CONCLUSIONS: Most cases of neck ailments in children presenting to the emergency department were due to trauma or infection, which were effectively managed as outpatients. When signs and symptoms suggested an emergent cause, CT provided a definitive diagnosis. The evaluation of a child presenting with acute neck complaints should be based on history and physical examination. Plain radiographs and CT scan are contributive in selected cases.

Clinical relevance of L-carnitine-supplemented total parenteral nutrition in postoperative trauma. Metabolic effects of continuous or acute carnitine administration with special reference to fat oxidation and nitrogen utilization.

Carnitine-free total parenteral nutrition (TPN) is claimed to result in a carnitine deficiency with subsequent impairment of fat oxidation. The present study was designed to evaluate the possible benefit of carnitine supplementation on postoperative fat and nitrogen utilization. Sixteen patients undergoing total esophagectomy were evenly randomized and received TPN without or with L-carnitine supplementation (74 mumol.kg-1.d-1) during 11 postoperative days. On day 11, a 4-h infusion of L-carnitine (125 mumol/kg) was performed in both groups. The effect of supplementation was evaluated by indirect calorimetry, N balance, and repeated measurements of plasma lipids and ketone bodies. Irrespective of continuous or acute supplementation, respiratory quotient and fat oxidation were similarly maintained throughout the study in both groups whereas N balance appeared to be more favorable without carnitine. We conclude that carnitine-supplemented TPN does not improve fat oxidation or promote N utilization in the postoperative phase.

Release Process Effectiveness - Case of Operating Room Management Software

Työn päätavoitteena oli tuoda esiin tärkeimmät julkistamisprosessin tehokkuuteen vaikuttavat tekijät. Tutkimuksessa tarkasteltiin aihetta julkistamisprojektien vetäjän näkökulmasta. Kirjallinen selvitys kattaa keskeisimmät ohjelmistoprosessin, palvelun laadun sekä projektihallinnan teoriat. Kokeellisena aineistona käytettiin asiakkailta ja myynnin sekä käyttöönoton organisaatioilta tullutta palautetta ja asiantuntijahaastatteluita. Case-tuotteena tarkasteltiin suuren kansainvälisen yrityksen jälleenmyymää leikkaussalihallinnan ohjelmistoa. Tärkeimpiä julkistamisprosessin tehokkuuteen vaikuttavia tekijöitä ovat tiekartan ja julkistamispakettien sisällön hallinta, projektin aikataulujen pitäminen, rehellinen ja nopea kommunikaatio myyntikanavaan ja asiakkaille, sekä hyvin toteutettu testaus. Työssä käydään läpi esimerkkistrategioita kehittymiseen näillä alueilla.

Transfusion practice in early trauma management

Introduction: Blood transfusions carry risks and complications. At the University Hospital of Lausanne the need for transfusion in early trauma resuscitation is based on clinical judgment and standard laboratory tests. We aimed to assess the transfusion practice for trauma patients during their early management. Method: Based on 2008 data from the Lausanne Trauma Registry of Acute Care (TRAC), we analyzed all adult trauma patients admitted to the shock room who received blood products or pro-coagulants in shock room and/or during their emergency operation. Demographics, physiological parameters and lab tests were recorded at arrival and at the end of anesthesiologic management. Coagulopathy was defined as PT <70%, PTT >60 sec, Fibrinogen <1 g/l or Thrombocytes <100 x 109 g/l. Results: In 2008, 323 trauma-patients were included in TRAC. 55 patients (17%) received blood products or pro-coagulants. 44 (83%) had an ISS >15 (med 29, IQR 10-35.5). 43 (78.2%) needed an emergency intervention. Coagulopathy was present in 25 patients (45.5%) at arrival vs. 30 (54.5%) after resuscitation (p = 0.446).

Tuotteen valmistuksen kehittäminen kaizen-projektin avulla

Diplomityön tavoitteena oli laatia Abloy Oy:n ovensuljinyksikölle malli kaizenprojektille sekä toteuttaa yksi tällainen kehitysprojekti. Kaizen on japania ja tarkoittaa suomeksi jatkuvaa parantamista. Kaizen on pienin askelin tapahtuvaa jatkuvaa kehittämistä, joka perustuu vanhan osaamisen tehokkaampaan hyväksikäyttöön. Teoriaosuudessa tutustutaan kirjallisuuden perusteella lean- ja JOT-teorioihin, jotka ovat osa Abloy Oy:n yrityksen strategiaa. Niiden lähestymistapa on hyvin asiakaslähtöinen. Kaizen-projekteilla pystytään kehittämään omaa toimintaa parantaen samalla asiakaspalvelua. Kaizen-projektin tavoitteena oli poistaa mahdollisimman paljon lisäarvoa tuottamattomia toimintoja aukipitolaitteen DC191 valmistuksesta ja saada tuotteen kokonaisläpimenoaikaa lyhyemmäksi. Tavoitteena oli myös lisätilan järjestäminen mahdollisesti tuleville kokoonpanopöydille. Projektin avulla aukipitolaitteen DC191 valmistuksesta poistettiin paljon turhia työvaiheita.Lisäksi selvitettiin ja ratkaistiin valmistuksen pahimmat ongelmat.

Effect of physical exercise on glycogen turnover and net substrate utilization according to the nutritional state.

To determine the metabolic effects of a single bout of exercise performed after a meal or in the fasting state, nine healthy subjects were studied over two 8-h periods during which net substrate oxidation was monitored by indirect calorimetry. On one occasion, exercise was performed 90 min after ingestion of a meal labeled with [U-13C]glucose [protocol meal-exercise (M-E)]. On the second occasion, exercise was performed after an overnight fast and was followed 30 min later by ingestion of an identical meal [protocol exercise-meal (E-M)]. Energy balances were similar in both protocols, but carbohydrate balance was positive (42.2 +/- 5.1 g), and lipid balance was negative (-11.1 +/- 2.0) during E-M, whereas they were nearly even during M-E. Total glycogen synthesis was calculated as carbohydrate intake minus oxidation of exogenous 13C-labeled carbohydrate (calculated from 13CO2 production). Total glycogen synthesis was increased by 90% (from 47.6 +/- 3.8 to 90.7 +/- 5.4 g, P < 0.0001) during E-M vs. M-E. Endogenous glycogen breakdown was calculated as net carbohydrate oxidation minus oxidation of exogenous carbohydrate and was increased by 44% (from 35.8 +/- 5.6 to 51.7 +/- 6.6 g, P < 0.004) during E-M. It is concluded that exercise performed in the fasting state stimulates glycogen turnover and fat oxidation.

Utilization of Knowledge Management in Business Process Modeling and Process Improvements

Tutkimuksen tavoitteena on tutkia telekommunikaatioalalla toimivan kohdeyrityksen ohjelmistojen toimitusprosessia° Tutkimus keskittyy mallintamaan toimitusprosessin, määrittelemään roolit ja vastuualueet, havaitsemaan ongelmakohdat ja ehdottamaan prosessille kehityskohteita. Näitä tavoitteita tarkastellaan teoreettisten prosessimallinnustekniikoiden ja tietojohtamisen SECI-prosessikehyksen läpi. Tärkein tiedonkeruun lähde oli haastatteluihin perustuva tutkimus, johon osallistuvat kaikki kohdeprosessiin kuuluvat yksiköt. Mallinnettu toimitusprosessi antoi kohdeyritykselle paremman käsityksen tarkasteltavasta prosessista ja siinä toimivien yksiköiden rooleistaja vastuualueista. Parannusehdotuksia olivat tiedonjaon kanavoinnin määritteleminen, luottamuksen ja sosiaalisten verkostojen parantaminen, ja tietojohtamisen laajamittainen implementointi.