Helicopter rescue involving the winching of a physician.

INTRODUCTION: We sought to study the operational and medical aspects of helicopter rescue missions involving the use of a winch.¦SETTING: A single helicopter-based medical service of a pre-alpine region of Switzerland.¦METHODS: We prospectively studied consecutive primary rescue interventions involving winching of a physician, from October 1, 1998 to October 1, 2002. Demographic, medical and operational aspects as well as outcome at 48 hours were analyzed.¦RESULTS: We included 133 patients. Most (74%) were male, with traumatic injuries (77%). The median scene time of the nine severely injured patients (Injury Severity Scale [ISS] > 15) was significantly longer compared with the other patients (54 vs 37 minutes; P < .05). The main medical procedures performed were orotracheal intubation (n = 5), fracture reductions (n = 5), major analgesia with sedation (n = 4), and intravenous fluid administration of more than 1,500 mL (n = 4). Fourteen (10%) patients suffering from minor injuries were triaged by the physician and not airlifted to the hospital. All 133 patients were alive at 48 hours. Sixty-nine (52%) were still hospitalized. No secondary interhospital transfer was required.¦CONCLUSION: Our study provides a better knowledge of injury profile, medical aspects, and outcomes of patients rescued necessitating a winching procedure.

The role of imaging in acute ischemic stroke.

Neuroimaging has expanded beyond its traditional diagnostic role and become a critical tool in the evaluation and management of stroke. The objectives of imaging include prompt accurate diagnosis, treatment triage, prognosis prediction, and secondary preventative precautions. While capitalizing on the latest treatment options and expanding upon the "time is brain" doctrine, the ultimate goal of imaging is to maximize the number of treated patients and improve the outcome of one the most costly and morbid disease. A broad overview of comprehensive multimodal stroke imaging is presented here to affirm its utilization.

Extrait des constitutions de la maison de Sorbonne.

Acquis le 4 ventôse an VI (22 février 1798) suite à un envoi de mss. par le bureau du triage des titres au conservateur des manuscrits de la Bibliothèque nationale; cf. B.n.F., département des Manuscrits, Archives Modernes 492, registre des acquisitions du département des Manuscrits an II-an XIV (1793-1805), f. 23 "Un petit vol. in 12 sur vélin, contenant les statuts en latin du collège de Sorbonne par Robert de Sorbon son fondateur".

Hyperkalemia. A prognostic factor during acute severe hypothermia.

When hypothermic patients appear to be dead, the decision to resuscitate may be difficult due to lack of reliable criteria of death. To discover useful prognostic indicators, we reviewed the hospital charts of nine hypothermic victims of snow avalanches (group A: median value of rectal temperature, 29.6 degrees C; range, less than 12 degrees C to 34 degrees C) and of 15 patients with hypothermia following acute drug intoxication and/or cold exposure (group B: 28.8 degrees C; range, 25.5 degrees C to 32 degrees C. In group A, plasma potassium level on admission was extremely high (14.5 mmol/L; range, 6.8 to 24.5 mmol/L) compared with that obtained in group B (3.5 mmol/L; range, 2.7 to 5.3 mmol/L). All patients in group A were in cardiorespiratory arrest. None could be successfully resuscitated despite effective rewarming by cardiopulmonary bypass or peritoneal lavage. In contrast, all of the patients in group B recovered from hypothermia, including two in cardiorespiratory arrest. Thus, extreme hyperkalemia during acute hypothermia appears to be a reliable marker of death. It might be used to select those patients in whom heroic resuscitation efforts can be useful.

TraumaHawk: Improving Treatment for Crash Victims Using Photos and a Smartphone App

Photographic documentation of crashed vehicles at the scene can be used to improve triage of crash victims. A U.S. expert panel developed field triage rules to determine the likelihood of occupants sustaining serious injuries based on vehicle damage that would require transport to a trauma center (Sasser et al., 2011). The use of photographs for assessing vehicle damage and occupant compartment intrusion as it correlates to increased injury severity has been validated (Davidson et al., 2014). Providing trauma staff with crash scene photos remotely could assist them in predicting injuries. This would allow trauma care providers to assess the appropriate transport, as well as develop mental models of treatment options prior to patient arrival at the emergency department (ED). Crash-scene medical response has improved tremendously in the past 20-30 years. This is in part due to the increasing number of paramedics who now have advanced life support (ALS) training that allows independence in the field. However, while this advanced training provides a more streamlined field treatment protocol, it also means that paramedics focused on treating crash victims may not have time to communicate with trauma centers regarding crash injury mechanisms. As a result, trauma centers may not learn about severe trauma patients until just a few minutes before they arrive. The information transmitted by the TraumaHawk app allows interpretation of injury mechanisms from crash scene photos at the trauma center, providing clues about the type and severity of injury. With strategic crash scene photo documentation, trained trauma professionals can assess the severity and patterns of injury based on exterior crush and occupant intrusion. Intrusion increases the force experienced by vehicle occupants, which translates into a higher level of injury severity (Tencer et al., 2005; Assal et al., 2002; Mandell et al., 2010). First responders have the unique opportunity to assess the damaged vehicle at the crash scene, but often the mechanism of injury is limited or not even relayed to ED trauma staff. To integrate photographic and scene information, an app called TraumaHawk was created to capture images of crash vehicles and send them electronically to the trauma center. If efficiently implemented, it provides the potential advantage of increasing lead-time for preparation at the trauma center through the crash scene photos. Ideally, the result is better treatment outcomes for crash victims. The objective of this analysis was to examine if the extra lead-time granted by the TraumaHawk app could improve trauma team activation time over the current conventional communication method.

Diagnosis of right ventricular dysfunction in acute pulmonary embolism using helical computed tomography.

Forty-six consecutive patients with pulmonary embolism (PE) who underwent pulmonary angiography, helical computed tomography (CT), and echocardiography in the investigators' emergency department were studied. It was determined that the CT right ventricular (RV)/left ventricular (LV) end-diastolic area ratio was correlated with PE obstruction and echocardiography. A CT RV/LV area ratio &gt;1 had a sensitivity of 88% and a specificity of 88% in diagnosing significant PE. The present study suggests that helical CT may be used as a triage tool in acute PE for selecting high-risk patients, using calculation of the RV/LV area ratio to detect RV dysfunction.

Characterization of Tollip in the Interleulkin-1 Receptor/Toll Like Receptors signaling pathways

SUMMARY IL-1R and TLRs are key players in innate immunity and inflammation. Tollip was identified as a component of IL-1RI, TLR2 and TLR4 signaling complexes that activate NF-κB and MAP kinase pathways. Tollip was previously shown as a negative regulator of NF-κB and MAP Kinase activation. We have characterized the role of Tollip in IL-R/TLRs induced signaling by the analysis of the Tollip deficient mice. We showed that NF-κB and MAPK (p38, JNK, or ERK1/2) signaling appeared normal in Tollip deficient cells following stimulation with IL-1β, lipopolysaccharide (LPS), and other TLR ligands. Also IL-1β and TLRs ligands induced activation of immune cells was indistinguishable from wild-type cells. Strikingly, in Tollip deficient mice the production of the inflammatory cytokines, IL-6 or TNF-α was significantly reduced relative to control mice after treatment with physiological doses of IL-1β or LPS, whereas no difference was observed at high doses of stimulation with LPS or in LPS induced septic shock. Therefore, Tollip could be critical for regulation of optimal responses to IL-1β and LPS, in addition to its role as negative regulator of the signaling. We also studied the role of Tollip as an endocytic adaptor for IL-1R endocytosis. We could show that Il-1R is ubiquitinated after IL-1β stimulation, and that Tollip's CUE domain binds IL-1RI in an ubiquitin-dependent manner. We followed IL-1R internalization and Tollip localization by confocal microscopy. Consistent with a role for Tollip in sorting of ubiquitinated IL-1RI, a significant amount of Tollip was also localized at the late endosomal compartment. We could show that Tollip is required for efficient lysosomal targeting of ubiquitinated IL-1R1, In the absence of Tollip or in Tollip deficient cells reconstituted with a Tollip mutant (defective in ubiquitin binding) IL-1RI accumulates in enlarged late endosomes. In addition, Tollip was shown to interact with, another endocytic adapter, Toml, and both interact with IL-1RI. In conclusion, we showed that Tollip is required for IL-1β and LPS signaling for cytokine production. In addition we showed and that Tollip has a role as an endocytic adapter, necessary for efficient trafficking and lysosomal degradation of IL-1RI. Resumé Le récepteur à l'interleukine-1 (IL-1R) et les récepteurs "Toll-like" (TLRs) sont des acteurs cruciaux de la réponse immunitaire innée et de l'inflammation. La proteine Tollip a été identifiée comme étant un élément des complexes de signalisation, induits par les récepteurs IL-1RI, TLR-2 et TLR-4, qui mènent à l'activation de la voie des MAP kinases et de NF-κB. Dans de précédentes études, il a été montré que Tollip pouvait inhiber ces deux voies de signalisation. Nous avons voulu caractériser plus précisément le rôle de Tollip dans l'activation des voies de signalisation mitées par IL-1R/TLRs en utilisant une lignée murine déficiente pour la protéine Tollip. Ainsi, en absence de Tollip, les cascades d'activation de NF-κB et MAPK (p38, JNK, or ERK1/2) ne semblent pas affectées après stimulation avec IL-1β, lipopolysaccharide (LPS) ou d' autres ligands des TLR. La réponse des cellules du système immunitaire induite par la stimulation avec IL-1β et les ligands des TLR est également comparable entre les souris sauvages et les souris deficientes pour Tollip. Par contre, dans cette lignée murine, la production de cytokines proinflammatoires IL-6 et TNFα induite par la stimulation à dose physiologique de IL-1β or LPS, est réduite. Cependant, lors de stimulation à plus hautes doses de LPS ou pendant un choc septique induit par de LPS, cette réduction n'est pas observée. Ces résultats montrent que Tollip pourrait avoir un rôle déterminant dans l'activation optimale en réponse à l' IL-1β et au LPS qui s'ajoute à sa fonction inhibitrice des mêmes voies de signalisation. Nous avons aussi étudié le rôle de Tollip comme molécule adaptatatrice du mécanisme endocytique d'internalisation de l' IL-1RI. Ainsi, l' IL-1R est ubiquitiné après stimulation par l' IL-1β , permettant à Tollip de se lier au récepteur. Cette interaction est réalisée entre le domaine CUE de Tollip et l'IL-1R via l'ubiquitine. L'internalisation et la localisation intracellulaire de l'IL-1RI et de Tollip ont été observés par microscopie confocale. En accord avec le rôle de Tollip dans le triage et la recirculation des IL-1R ubiquitiné, une quantité importante de Tollip été détectée dans l' endosome tardif. Nous avons pu démontrer que Tollip était nécessaire pour diriger efficacement ubiquitiné vers les lysosomes. Dans des cellules déficientes pour Tollip, ou reconstituées avec un mutant de Tollip (MF/AA) incapable de lier l'ubiquitine, IL-1RI s'accumule dans des vesicules anormales de l'endosome tardif. Dans ce travail, nous avons pu confirmer et préciser la fonction de la protéine Tollip dans l' activation de la production de cytokines induites par l' IL-1p and le LPS lors de l'inflammation et découvrir son rôle d'adaptateur dans l' internalisation et l'endocytose de l' IL-1RI.

Verbrennungen--Von der Bagatelle zur Katastrophe [Burns--from trifle case to mass casualty]

Burn injuries are very frequent, most being trifle cases. Nevertheless every year about 200 patients need to be treated in one of the two specialised Swiss burns centres. Admission criteria are burns > 15% body surface or burns to critical areas (face neck, hands, genitalia, joints) and electrical injuries. The paper reviews the physiophathology of the burn wound which differs depending on the thermal or electrical aetiology. The airway may be threatened due to true inhalation, but also to burns to the face or neck. In major burns >20% body surface in adults, or > 10% in children, fluid resuscitation will be required; oral hydration is generally sufficient by smaller burns. Surgical treatment of 2nd and 3rd degree burns starts within the first 24 days after injury. While complex treatment is generally available in peace time, a major accident such as a disco-fire that can generate hundreds casualties in a few minutes, can threaten our system and force the adoption of triage rules, and simplified treatments. Attitudes to adopt in such conditions are discussed.

Emergency department visits for non-life-threatening conditions : evolution over 13 years in a Swiss urban teaching hospital

INTRODUCTION: A large proportion of visits to our Emergency Department (ED) are for non-life-threatening conditions. We investigated whether patients' characteristics and reasons for consultation had changed over 13 years. METHODS: Consecutive adult patients with non-life-threatening conditions at triage were included in the spring of 2000 and in the summer of 2013. In both years patients completed a similar questionnaire, which addressed their reasons for consultation and any previous consultation with a general practitioner (GP). RESULTS: We included 581 patients in 2013 vs 516 in 2000, with a mean age of 44.5 years vs 46.4 years (p=0.128). Of these patients, 54.0% vs 57.0% were male (p=0.329), 55.5% vs 58.7% were Swiss (p=0.282), 76.4% were registered with a GP in both periods, but self-referral increased from 52.0% to 68.8% (p<0.001); 57.7% vs., 58.3% consulted during out-of- hours (p=0.821). Trauma-related visits decreased from 34.2% to 23.7% (p<0.001). Consultations within 12 hours of onset of symptoms dropped from 54.5% to 30.9%, and delays of ≥1 week increased from 14.3% to 26.9% (p<0.001). The primary motive for self-referral remained unawareness of an alternative, followed in 2013 by dissatisfaction with the GP's treatment or appointment. Patients who believed that their health problem would not require hospitalisation increased from 52.8% to 74.2% and those who were actually hospitalised decreased from 24.9% to 13.9% (all p<0.001). CONCLUSION: The number of visits for non-life-threatening consultations continue to increase. Our ED is used by a large proportion of patients as a convenient alternative source of primary care.

Prediction of multiple infections after severe burn trauma: a prospective cohort study.

OBJECTIVE: To develop predictive models for early triage of burn patients based on hypersusceptibility to repeated infections. BACKGROUND: Infection remains a major cause of mortality and morbidity after severe trauma, demanding new strategies to combat infections. Models for infection prediction are lacking. METHODS: Secondary analysis of 459 burn patients (≥16 years old) with 20% or more total body surface area burns recruited from 6 US burn centers. We compared blood transcriptomes with a 180-hour cutoff on the injury-to-transcriptome interval of 47 patients (≤1 infection episode) to those of 66 hypersusceptible patients [multiple (≥2) infection episodes (MIE)]. We used LASSO regression to select biomarkers and multivariate logistic regression to built models, accuracy of which were assessed by area under receiver operating characteristic curve (AUROC) and cross-validation. RESULTS: Three predictive models were developed using covariates of (1) clinical characteristics; (2) expression profiles of 14 genomic probes; (3) combining (1) and (2). The genomic and clinical models were highly predictive of MIE status [AUROCGenomic = 0.946 (95% CI: 0.906-0.986); AUROCClinical = 0.864 (CI: 0.794-0.933); AUROCGenomic/AUROCClinical P = 0.044]. Combined model has an increased AUROCCombined of 0.967 (CI: 0.940-0.993) compared with the individual models (AUROCCombined/AUROCClinical P = 0.0069). Hypersusceptible patients show early alterations in immune-related signaling pathways, epigenetic modulation, and chromatin remodeling. CONCLUSIONS: Early triage of burn patients more susceptible to infections can be made using clinical characteristics and/or genomic signatures. Genomic signature suggests new insights into the pathophysiology of hypersusceptibility to infection may lead to novel potential therapeutic or prophylactic targets.

Development of a systematic computer vision-based method to analyse and compare images of false identity documents for forensic intelligence purposes-Part I: acquisition, calibration and validation issues

Following their detection and seizure by police and border guard authorities, false identity and travel documents are usually scanned, producing digital images. This research investigates the potential of these images to classify false identity documents, highlight links between documents produced by a same modus operandi or same source, and thus support forensic intelligence efforts. Inspired by previous research work about digital images of Ecstasy tablets, a systematic and complete method has been developed to acquire, collect, process and compare images of false identity documents. This first part of the article highlights the critical steps of the method and the development of a prototype that processes regions of interest extracted from images. Acquisition conditions have been fine-tuned in order to optimise reproducibility and comparability of images. Different filters and comparison metrics have been evaluated and the performance of the method has been assessed using two calibration and validation sets of documents, made up of 101 Italian driving licenses and 96 Portuguese passports seized in Switzerland, among which some were known to come from common sources. Results indicate that the use of Hue and Edge filters or their combination to extract profiles from images, and then the comparison of profiles with a Canberra distance-based metric provides the most accurate classification of documents. The method appears also to be quick, efficient and inexpensive. It can be easily operated from remote locations and shared amongst different organisations, which makes it very convenient for future operational applications. The method could serve as a first fast triage method that may help target more resource-intensive profiling methods (based on a visual, physical or chemical examination of documents for instance). Its contribution to forensic intelligence and its application to several sets of false identity documents seized by police and border guards will be developed in a forthcoming article (part II).

Identification of Low-Risk Patients with Acute Symptomatic Pulmonary Embolism for Outpatient Therapy.

RATIONALE: Patients with acute symptomatic pulmonary embolism (PE) deemed to be at low risk for early complications might be candidates for partial or complete outpatient treatment. OBJECTIVES: To develop and validate a clinical prediction rule that accurately identifies patients with PE and low risk of short-term complications and to compare its prognostic ability with two previously validated models (i.e., the Pulmonary Embolism Severity Index [PESI] and the Simplified PESI [sPESI]) METHODS: Multivariable logistic regression of a large international cohort of patients with PE prospectively enrolled in the RIETE (Registro Informatizado de la Enfermedad TromboEmbólica) registry. MEASUREMENTS AND MAIN RESULTS: All-cause mortality, recurrent PE, and major bleeding up to 10 days after PE diagnosis were determined. Of 18,707 eligible patients with acute symptomatic PE, 46 (0.25%) developed recurrent PE, 203 (1.09%) bled, and 471 (2.51%) died. Predictors included in the final model were chronic heart failure, recent immobilization, recent major bleeding, cancer, hypotension, tachycardia, hypoxemia, renal insufficiency, and abnormal platelet count. The area under receiver-operating characteristic curve was 0.77 (95% confidence interval [CI], 0.75-0.78) for the RIETE score, 0.72 (95% CI, 0.70-0.73) for PESI (P < 0.05), and 0.71 (95% CI, 0.69-0.73) for sPESI (P < 0.05). Our RIETE score outperformed the prognostic value of PESI in terms of net reclassification improvement (P < 0.001), integrated discrimination improvement (P < 0.001), and sPESI (net reclassification improvement, P < 0.001; integrated discrimination improvement, P < 0.001). CONCLUSIONS: We built a new score, based on widely available variables, that can be used to identify patients with PE at low risk of short-term complications, assisting in triage and potentially shortening duration of hospital stay.

Trends and characteristics of attendance at the emergency department of a Swiss university hospital: 2002-2012.

BACKGROUND: The numbers of people attending emergency departments (EDs) at hospitals are increasing. We aimed to analyse trends in ED attendance at a Swiss university hospital between 2002 and 2012, focussing on age-related differences and hospital admission criteria. METHODS: We used hospital administrative data for all patients aged ≥16 years who attended the ED (n = 298,306) at this university hospital between 1 January 2002, and 31 December 2012. We descriptively analysed the numbers of ED visits according to the admission year and stratified by age (≥65 vs <65 years). RESULTS: People attending the ED were on average 46.6 years old (standard deviation 20 years, maximum range 16‒99 years). The annual number of ED attendances grew by n = 6,639 (27.6%) from 24,080 in 2002 to 30,719 in 2012. In the subgroup of patients aged ≥65 the relative increase was 42.3%, which is significantly higher (Pearson's χ2 = 350.046, df = 10; p = 0.000) than the relative increase of 23.4% among patients <65 years. The subgroup of patients ≥65 years attended the ED more often because of diseases (n = 56,307; 85%) than accidents (n = 9,844; 14.9%). This subgroup (patients ≥65 years) was also more often admitted to hospital (Pearson's χ2 = 23,377.190; df = 1; p = 0.000) than patients <65 years. CONCLUSIONS: ED attendance of patients ≥65 years increased in absolute and relative terms. The study findings suggest that staff of this ED may want to assess the needs of patients ≥65 years and, if necessary, adjust the services (e.g., adapted triage scales, adapted geriatric screenings, and adapted hospital admission criteria).

Lääkintähuollon ja materiaalihallinnon yhtenäisen RFID-seurannan perusteita

Tässä diplomityössä tarkastellaan radiotaajuisen tunnistamisteknologian (RFID) seurannan yhtenäisiä perusteita puolustusvoimien lääkintähuollolle ja materiaalihallinnolle. Nykytilaa selvitettiin pääpainona lääkintähuollon ja materiaalihallinnon osa-alueet ja samalla tarkasteltiin koko puolustusvoimien RFIDtekniikan käyttöä. Puolustusvoimissa RFID-teknologiaa käytetään myös vaatehuollon ja kulunvalvonnan toiminnoissa. Tämän työn teoriaosuudessa tarkastellaan RFID-tekniikkaa ja sen komponentteja sekä niiden hyödyntämistä eri sektoreilla ja logistiikassa. Työn empiirisessä osuudessa selvitetään, mitkä ovat puolustusvoimien tarpeet RFID:n käytöllä ja vaatimuksia ensihoidon kiireellisyysluokittelulle (TRIAGE) sekä materiaalihallinnon ja niiden kautta saatavalle tilannekuvalle. Työn tuloksena saadaan perusteita puolustusvoimien RFID-ratkaisujen suunnittelun pohjaksi.

Helicopter emergency medical rescue for the traumatized: experience in the metropolitan region of Campinas, Brazil

OBJECTIVE: To analyze the profile of patients served by the air medical rescue system in the Metropolitan Region of Campinas, evaluating: triage and mobilization criteria; response time; on-site care and transport time; invasive procedures performed in the Pre-Hospital Care (PHC); severity of patients; morbidity and mortality.METHODS: We conducted a prospective, descriptive study in which we analyzed medical records of patients rescued between July 2010 and December 2012. During this period, 242 victims were taken to the HC-Unicamp. Of the 242 patients, 22 were excluded from the study.RESULTS: of the 220 cases evaluated, 173 (78.6%) were male, with a mean age of 32 years. Blunt trauma was the most prevalent (207 cases - 94.1%), motorcycle accidents being the most common mechanisms of injury (66 cases - 30%), followed by motor vehicle collisions (51 cases - 23.2%). The average response time was 10 ± 4 minutes and the averaged total pre-hospital time was 42 ± 11 minutes. The mean values of the trauma indices were: RTS = 6.2 ± 2.2; ISS = 19.2 ± 12.6; and TRISS = 0.78 ± 0.3. Tracheal intubation in the pre-hospital environment was performed in 77 cases (35%); 43 patients (19.5%) had RTS of 7.84 and ISSd"9, being classified as over-triaged. Of all patients admitted, the mortality was 15.9% (35 cases).CONCLUSION: studies of air medical rescue in Brazil are required due to the investments made in the pre-hospital care in a country without an organized trauma system. The high rate of over-triage found highlights the need to improve the triage and mobilization criteria.