Resident work hour restrictions do not improve patient safety in surgery: a critical appraisal based on 7 years of experience in Switzerland

In 2005 the Swiss government implemented new work-hour limitations for all residency programs in Switzerland, including a 50-hour weekly limit. The reduction in the working hours of doctors in training implicate an increase in their rest time and suggest an amelioration of doctors' clinical performance and consequently in patients' outcomes and safety - which was not detectable in a preliminary study at a large referral center in Switzerland. It remains elusive why work-hour restrictions did not improve patient safety. We are well advised to thoroughly examine and eliminate the known adverse effects of reduced work-hours to improve our patients' safety.

Long-term follow up (37-69 years) of patients with bladder exstrophy treated with ureterosigmoidostomy: uro-nephrological outcome

OBJECTIVE: To describe the urological and nephrological long-term outcome of patients born with classical bladder exstrophy treated with bilateral ureterosigmoidostomies in early childhood. PATIENTS AND METHOD: Out of 42 patients born with bladder exstrophy in Switzerland between 1937 and 1968, 25 participated in this study; seven had died, seven were lost to follow up and three refused consent. Assessment included chart review, clinical examination, and assessment of renal function and morphology. RESULTS: After a follow-up period of 37-69 years ((mean 50 years), 13 of the 25 participants (52%) had their ureterosigmoidostomy still in place. All others had different forms of urinary diversions. Fifteen (60%) patients had normal renal function or mild chronic kidney disease as assessed by estimated glomerular filtration rate. Three patients were on renal replacement therapy. MRI (n=16) showed 10 morphologically normal kidneys. One patient suffered from adenocarcinoma of the colon, five had benign colonic polyps, one urethral papillary carcinoma and 18 no evidence of tumor. CONCLUSION: The majority of our patients have normal or mildly impaired renal function and a well functioning ureterosigmoidostomy. This is remarkable, given the fact that ureterosigmoidostomies are considered to be refluxing high-pressure reservoirs at risk of renal injury and malignancy.

Incidence and outcome of progressive multifocal leukoencephalopathy over 20 years of the Swiss HIV Cohort Study

BACKGROUND: We investigated the incidence and outcome of progressive multifocal leukoencephalopathy (PML) in human immunodeficiency virus (HIV)-infected individuals before and after the introduction of combination antiretroviral therapy (cART) in 1996. METHODS: From 1988 through 2007, 226 cases of PML were reported to the Swiss HIV Cohort Study. By chart review, we confirmed 186 cases and recorded all-cause and PML-attributable mortality. For the survival analysis, 25 patients with postmortem diagnosis and 2 without CD4+ T cell counts were excluded, leaving a total of 159 patients (89 before 1996 and 70 during 1996-2007). RESULTS: The incidence rate of PML decreased from 0.24 cases per 100 patient-years (PY; 95% confidence interval [CI], 0.20-0.29 cases per 100 PY) before 1996 to 0.06 cases per 100 PY (95% CI, 0.04-0.10 cases per 100 PY) from 1996 onward. Patients who received a diagnosis before 1996 had a higher frequency of prior acquired immunodeficiency syndrome-defining conditions (P = .007) but similar CD4+ T cell counts (60 vs. 71 cells/microL; P = .25), compared with patients who received a diagnosis during 1996 or thereafter. The median time to PML-attributable death was 71 days (interquartile range, 44-140 days), compared with 90 days (interquartile range, 54-313 days) for all-cause mortality. The PML-attributable 1-year mortality rate decreased from 82.3 cases per 100 PY (95% CI, 58.8-115.1 cases per 100 PY) during the pre-cART era to 37.6 cases per 100 PY (95% CI, 23.4.-60.5 cases per 100 PY) during the cART era. In multivariate models, cART was the only factor associated with lower PML-attributable mortality (hazard ratio, 0.18; 95% CI, 0.07-0.50; P < .001), whereas all-cause mortality was associated with baseline CD4+ T cell count (hazard ratio per increase of 100 cells/microL, 0.52; 95% CI, 0.32-0.85; P = .010) and cART use (hazard ratio, 0.37; 95% CI, 0.19-0.75; P = .006). CONCLUSIONS: cART reduced the incidence and PML-attributable 1-year mortality, regardless of baseline CD4+ T cell count, whereas overall mortality was dependent on cART use and baseline CD4+ T cell count.

Separation of the Ribbon from globally distributed energetic neutral Atom Flux using the first five Years of Ibex Observations

The Interstellar Boundary Explorer (IBEX) observes the IBEX ribbon, which stretches across much of the sky observed in energetic neutral atoms (ENAs). The ribbon covers a narrow (~20°-50°) region that is believed to be roughly perpendicular to the interstellar magnetic field. Superimposed on the IBEX ribbon is the globally distributed flux that is controlled by the processes and properties of the heliosheath. This is a second study that utilizes a previously developed technique to separate ENA emissions in the ribbon from the globally distributed flux. A transparency mask is applied over the ribbon and regions of high emissions. We then solve for the globally distributed flux using an interpolation scheme. Previously, ribbon separation techniques were applied to the first year of IBEX-Hi data at and above 0.71 keV. Here we extend the separation analysis down to 0.2 keV and to five years of IBEX data enabling first maps of the ribbon and the globally distributed flux across the full sky of ENA emissions. Our analysis shows the broadening of the ribbon peak at energies below 0.71 keV and demonstrates the apparent deformation of the ribbon in the nose and heliotail. We show global asymmetries of the heliosheath, including both deflection of the heliotail and differing widths of the lobes, in context of the direction, draping, and compression of the heliospheric magnetic field. We discuss implications of the ribbon maps for the wide array of concepts that attempt to explain the ribbon's origin. Thus, we present the five-year separation of the IBEX ribbon from the globally distributed flux in preparation for a formal IBEX data release of ribbon and globally distributed flux maps to the heliophysics community.

Processing 20 years of SLR observations to GNSS satellites

We process 20 years of SLR observations to GPS and GLONASS satellites using the reprocessed 3-day and 1-day microwave orbits provided by the Center for Orbit Determination in Europe (CODE) for the period 1994-2013. We study the dependency of the SLR residuals on the type, size, and a number of corner cubes in satellite laser reflector arrays (LRA). We show that the mean SLR residuals and the RMS of residuals depend on the coating of LRA and the block or type of GNSS satellites. The SLR mean residuals are also a function of the equipment used at SLR stations including detector types and detecting modes.

(Table 1) Lake elevation change derived from 4 or more years of measurements

In this study, ICESat altimetry data are used to provide precise lake elevations of the Tibetan Plateau (TP) during the period of 2003-2009. Among the 261 lakes examined ICESat data are available on 111 lakes: 74 lakes with ICESat footprints for 4-7 years and 37 lakes with footprints for 1 -3 years. This is the first time that precise lake elevation data are provided for the 111 lakes. Those ICESat elevation data can be used as baselines for future changes in lake levels as well as for changes during the 2003-2009 period. It is found that in the 74 lakes (56 salt lakes) examined, 62 (i.e. 84%) of all lakes and 50 (i.e. 89%) of the salt lakes show tendency of lake level increase. The mean lake water level increase rate is 0.23 m/year for the 56 salt lakes and 0.27 m/year for the 50 salt lakes of water level increase. The largest lake level increase rate (0.80 m/year) found in this study is the lake Cedo Caka. The 74 lakes are grouped into four subareas based on geographical locations and change tendencies in lake levels. Three of the four subareas show increased lake levels. The mean lake level change rates for subareas I, II, III, IV, and the entire TP are 0.12, 0.26, 0.19, -0.11, and 0.2 m/year, respectively. These recent increases in lake level, particularly for a high percentage of salt lakes, supports accelerated glacier melting due to global warming as the most likely cause.

The Grundgesetz After 50 Years: Analyzing Changes in the German Constitution. CES Germany & Europe Working Papers, No. 09.3, December 1999

Fifty years after its original drafting, the German constitution has seen its text amended many times. Indeed, among OECD countries, the Grundgesetz has one of the highest rates of constitutional change. This paper analyzes these changes. It does so in a quantitative manner in its first section, before proceeding to ask how the numerous changes can be explained. Three approaches from the legal and political science literature are presented: one emphasizing historical-structural factors, one analyzing changes as constitutional revisionism, and an institutional approach which focuses on the conditions for constitutional amendment. The strengths and weaknesses of each approach are then compared and contrasted, before the article concludes with an assessment of the characteristics of Gemuw constitutional policy.

Benthic and planktic foraminiferal stable isotope record and coccolith abundance spanning the last 500,000 years of ODP Hole 121-758C

The Indian Summer Monsoon (ISM) is an inter-hemispheric and highly variable ocean-atmosphere-land interaction that directly affects the densely populated Indian subcontinent. Here, we present new records of palaeoceanographic variability that span the last 500,000 years from the eastern equatorial Indian Ocean, a relatively under-sampled area of ISM influence. We have generated carbon and oxygen stable isotope records from three foraminiferal species from Ocean Drilling Program Site 758 (5°N, 90°E) to investigate the oceanographic history of this region. We interpret our resultant Dd18O (surface-thermocline) record of upper water-column stratification in the context of past ISM variability, and compare orbital phase relationships in our Site 758 data to other climate and monsoon proxies in the region. Results suggest that upper water-column stratification at Site 758, which is dominated by variance at precession and half-precession frequencies (23, 19 and 11 ka), is forced by both local (5°N) insolation and ISM winds. In the precession (23 ka) band, stratification minima at Site 758 lag northern hemisphere summer insolation maxima (precession minima) by 9 ka, which is consistent with Arabian Sea ISM phase estimates and suggests a common wind forcing in both regions. This phase implicates a strong sensitivity to both ice volume and southern hemisphere insolation forcing via latent heat export from the southern subtropical Indian Ocean. Additionally, we find evidence of possible overprinting of millennial-scale events during glacial terminations in our stratification record, which suggests an influence of remote abrupt climate events on ISM dynamics.

Start looking South: The refugee convention 50 years on

A review essay on books by (1) Efika Feller, Volker Turk, & Frances Nicholson (Eds), Refugee Protection in International Law: UNHCR's Global Consultations on International Protection (Cambridge, UK: Cambridge U Press, 2003); (2) Niklaus Steiner, Mark Gibney & Gil Loescher (Eds), Problems of Protection: The UNHCR, Refugees and Human Rights (New York: Routledge, 2003); & (3) Joanne Van Selm, Khotine Kamanga, John Morrison, Aninia Nadig, Sanja Spoljar-Vrzina, & Loes Van Willigen (Eds), The Refugee Convention at Fifty: A View from Forced Migration Studies (Maryland, Lexington, 2003).

Does health assessment improve health outcomes in Indigenous people? An RCT with 13 years of follow-up

Objective: To examine the impact of a multi-component health assessment on mortality and morbidity in Kimberley Aboriginal residents during a 13-year follow-up. Method. A population-based randomised controlled trial using linked hospital, cancer and death records to evaluate outcomes in 620 intervention and 6,736 control subjects. Results: The intervention group had a higher rate of first-time hospitalisation for any reason (IRR = 1.37; 95 % Cl 1.25-1.50), a higher rate of injury-related hospital episodes (IRR = 1.31; 95 % Cl 1.15-1.48) and a higher notification rate of alcohol-related cancers. There was a smaller difference in the rates of multiple hospitalisations (IRR = 1.14; 95 % Cl 0.751.74) and no improvement in overall mortality compared with controls (IRR = 1.08; 95 % Cl 0.91-1.29). Conclusions: There was no overall mortality benefit despite increased health service contact associated with the intervention. Implications: Although not influencing mortality rates, multi-component health assessment may result in a period of increased health service use in Aboriginal and Torres Strait Islander populations, thus constituting an 'intervention'. However, this should not be confused with systematic and sustained interventions and investment in community development to achieve better health outcomes.