Roland Bingisser

Delayed recognition of sepsis and inappropriate initial antibiotic therapy are associated with increased mortality and morbidity. The early detection of the causative organism in sepsis is an unmet clinical need. A novel multiplex real-time polymerase chain reaction (MRT-PCR) (SeptiFast®) technique may provide the microbiological diagnosis within six hours. We assessed the diagnostic accuracy of blood cultures and MRT-PCR in a comparative diagnostic cohort study in 110 consecutive adult patients presenting to the emergency department (ED) with suspected sepsis. We collected 205 corresponding PCR samples and blood culture (BC) pairs from the 110 patients. There was moderate to high concordance between PCR and BC with 181 (88%) matching and 24 (12%) mismatching samples. The diagnostic accuracy of MRT-PCR in detecting sepsis and its causative organism was comparable to that of BCs. The additional use of MRT-PCR significantly reduced the time to microbiological diagnosis as compared to ...

The effect of medication is always a balance between their beneficial effects and any adverse reactions they might elicit. The main risk for adverse drug events {ADEs) is polypharmacy, which is the simultaneous use of multiple drugs.This often applies to older patients, who suffer from multiple diseases and therefore take multiple medications. Thus, itis not surprising, that ADEs are frequention older patients and account up to 16% of emergency visits. It is still under discussion, whether age is an independent risk factor for ADEs. However, there are some age-related changes in the pharmacokinetic and pharmacodynamics properties of many drugs, which may influence the highly fragile balance between benefit and harm in older patients. Though there are multiple risk factors for and causes of ADEs, it could be shown that a lot of ADEs are preventable and even predictable: Budnitz eta/. showed that almost two thirds of emergency hospitalisations occur due to four medication classes: warfarin, oral antiplatelet agents, insulin and oral hypoglycaemic agents. Nevertheless, only 40-60% ofA DEs are recognized in the emergency department. This might be explained by the broad clinical symptoms, ranging from bleeding due to anticoagulants to the more nonspecific symptom of weakness due to hyponatraemia secondary to thiazide diuretics. Detecting and avoiding ADEs could be aided by using lists such as Beers criteria or STOPP/FART which list medications which are potentially inappropriate for older patients.

The novel high-sensitivity cardiac troponin (hs-cTn) 0h/1h-algorithm substantially improves the early triage of patient's assigned "rule-out" or "rule-in" of acute myocardial infarction (AMI), while diagnostic uncertainty remains in that 25-30% of patients assigned to "observe". We aimed to better characterize these patients. In a prospective multicenter diagnostic study, we applied the hs-cTnT 0h/1h-algorithm in 2213 unselected patients presenting with symptoms suggestive of AMI to the emergency department. The final diagnosis was adjudicated by two independent cardiologists using all available information. Survival at 720-days was the prognostic endpoint. Findings were validated using a hs-cTnI 0h/1h-algorithm. Twenty-four percent (n=523) of patients were assigned to "observe" by the hs-cTnT 0h/1h-algorithm. These patients differed significantly in multiple characteristics from "rule-out" and "rule-in" patients: they were older, in 75% male, and very often (57%) had pre-existing coronary artery disease (CAD). Diagnostic uncertainty for the presence of an AMI/UA was high. Only 39% of patients were suitable for coronary computed tomography angiography (CCTA). The most common final adjudicated diagnoses were non-cardiac disease (38%), non-coronary cardiac disease (24%), unstable angina (UA, 21%), and AMI (15%). Absolute hs-cTnT-changes within 3h had the highest diagnostic accuracy for AMI (AUC 0.86). Cumulative 720-day survival rate was 86%, which was significantly lower as compared to "rule-out" (p<0.001) and comparable to "rule-in" (p=ns). Findings were similar for the hs-cTnI "observe" zone. "Observe" patients are typically elderly men with pre-existing CAD and high long-term mortality. Absolute hs-cTn-changes within 3h, functional stress imaging and coronary angiography are the key diagnostic modalities.

Abstract  The primary purpose of this descriptive study was to determine patient preferences regarding pain control in the emergency department (ED) of a Swiss university hospital. Of further interest were the ratio of patients with pain without desire for treatment and whether this decision might be correlated to demographic differences. A total of 352 adult patients with acute painful illness or

The impact of neuraminidase inhibitors (NAIs) on Influenza-related pneumonia (IRP) is not established. Our objective was to investigate the association between NAI treatment and IRP incidence and outcomes in patients hospitalised with A(H1N1)pdm09 virus infection. A worldwide meta-analysis of individual participant data (IPD) from 20,634 hospitalised patients with laboratory confirmed A(H1N1)pdm09 (n=20,021) or clinically diagnosed (n=613) 'pandemic influenza'. The primary outcome was radiologically confirmed influenza-related pneumonia (IRP). Odds ratios (OR) were estimated using generalized linear mixed modelling, adjusting for NAI treatment propensity, antibiotics and corticosteroids. Among 20,634 included participants, 5,978 (29.0%) had IRP; conversely, 3,349 (16.2%) had confirmed absence of radiographic pneumonia (the comparator). Early NAI treatment (within 2 days of symptom onset) versus no NAI was not significantly associated with IRP [adj. OR 0.83 (95%CI 0.64 - 1.06...

Snoring is a marker for sleep apnea. Additionally, snoring per se is a cause of excessive vascular morbidity and an excessive risk for accidents. These health risks of snoring could be lowered by using CPAP (continuous positive airway pressure). Despite this evidence, CPAP-therapy is still limited to patients with hypersomnolence (excessive daytime sleepiness), due to conflicting results in the literature and the well-known lack of compliance in patients without hypersomnolence.

Snoring is a marker for sleep apnea. Additionally, snoring per se is a cause of excessive vascular morbidity and an excessive risk for accidents. These health risks of snoring could be lowered by using CPAP (continuous positive airway pressure). Despite this evidence, CPAP-therapy is still limited to patients with hypersomnolence (excessive daytime sleepiness), due to conflicting results in the literature and the well-known lack of compliance in patients without hypersomnolence.

The evaluation of dyspnea in the Emergency Department (ED) is a critical step in the diagnostic procedure, especially when cardiopulmonary disease is suspected. Because dyspnea is a symptom in which many different afferent mechanisms are involved, a large number of underlying causes must be considered, alone or in combination. Qualitative and quantitative aspects of difficult or laboured breathing may vary extremely between patients. Therefore, especially under time pressure in emergency situations, it is important to consider a very broad differential diagnosis, and at the same time use a standardized protocol or diagnostic algorithms for the initial work-up.In this article, a standardized work-up published by family practitioners is compared to a standardized work-up proposed by our ED. While practitioners may safely use a multi-step algorithmic approach, it is important in the ED to consider all possible serious underlying conditions at the same time. Over 90 % of all emergency situations are accounted for by only 7 different disease groups. Therefore, all of these must be considered simultaneously in a protocol that is useful for emergency physicians.

Blunt trauma is the most common mechanism of injury in patients with pneumomediastinum and may occur in up to 10% of patients with severe blunt thoracic and cervical trauma. In this case report we present a 24-year-old man with pneumomediastinum due to blunt chest trauma after jumping from a bridge into a river. He complained of persistent retrosternal pain with exacerbation during deep inspiration. Physical examination showed only a slight tenderness of the sternum and the extended Focused Assessment with Sonography for Trauma (e-FAST) was normal. Pneumomediastinum was suspected by chest X-ray and confirmed by computed tomography, which showed a lung contusion as probable cause of the pneumomediastinum due to the "Mackling effect." Sonographic findings consistent with pneumomediastinum, like the "air gap" sign, are helpful for quick bedside diagnosis, but the diagnostic criteria are not yet as well established as for pneumothorax. This present case shows that de...

To assess symptoms and characteristics of hyponatremia, the most common electrolyte disturbance in hospitalized individuals and a condition that is associated with substantial morbidity and mortality. Prospective observational multicenter study. Two Swiss academic centers. Individuals with profound hypoosmolar hyponatremia (sodium <125 mmol/L) (N = 298). All symptoms and complete medical history including current medications, therapy management, and in-hospital outcomes were recorded. The median age of all participants was 71 (interquartile range (IQR) 60-80), 195 (65%) were female, and mean serum sodium value on admission was 120 mmol/L (IQR 116-123 mmol/L). Frequent clinical symptoms were nausea (n = 130, 44%), acute vomiting (n = 91, 30%), generalized weakness (n = 205, 69%), fatigue (n = 175, 59%), gait disturbance (n = 92, 31%), recurrent falls (n = 47, 16%), and acute falls (n = 60, 20%). Fractures were reported in 11 participants (4%). More-severe symptoms such as acute ep...

To evaluate how the rating of the severity of sickness - as performed by the physician, nurse and patient - is associated with hospitalisation and acute morbidity. Prospective observational study, performed in the emergency department of a tertiary hospital. Patients, physicians and nurses were interviewed separately after the first contact from 21 October through to 11 November 2013. Of 2426 presenting patients, 1861 were screened, and 1196 were included. A total of 299 (25%) were hospitalised, 504 (42%) suffered acute morbidity. In the univariate analysis, the physician's, nurse's and patient's rating of severity of sickness, expressed on a scale from 0 to 10, was significantly associated with hospitalisation (physicians: OR 1.61, 95% CI 1.50-1.73; nurses: OR 1.52, 1.41-1.64; patients: OR 1.16, 1.10-1.22), and with acute morbidity (OR 1.49, 1.40-1.59; OR 1.39, 1.30-1.48 and OR 1.05, 1.003-1.09 respectively). The area under the curve of the receiver operating characteristic curves was 0.77, 0.72 and 0.61 for hospitalisation, and 0.72, 0.68 and 0.54 for acute morbidity. The interrater reliability was estimated by the intraclass correlation, which was 0.49 for physician/nurse, 0.17 for nurse/patient and 0.07 for physician/patient. In a multivariable analysis model consisting of age, male sex, ethnic origin, ratings of severity of sickness, symptoms, ability to go home and hospitalisation during the preceding 12 months, only age, and the physician's and nurses' rating of severity of sickness remained significantly associated with both outcomes. The first impression of severity of sickness was associated with hospitalisation and morbidity.

The evaluation of dyspnea in the Emergency Department (ED) is a critical step in the diagnostic procedure, especially when cardiopulmonary disease is suspected. Because dyspnea is a symptom in which many different afferent mechanisms are involved, a large number of underlying causes must be considered, alone or in combination. Qualitative and quantitative aspects of difficult or laboured breathing may vary extremely between patients. Therefore, especially under time pressure in emergency situations, it is important to consider a very broad differential diagnosis, and at the same time use a standardized protocol or diagnostic algorithms for the initial work-up.In this article, a standardized work-up published by family practitioners is compared to a standardized work-up proposed by our ED. While practitioners may safely use a multi-step algorithmic approach, it is important in the ED to consider all possible serious underlying conditions at the same time. Over 90 % of all emergency situations are accounted for by only 7 different disease groups. Therefore, all of these must be considered simultaneously in a protocol that is useful for emergency physicians.

Zusammenfassung Rund dreiviertel aller Antibiotika werden bei akuten Infektionen der Atemwege verschrieben. Da es sich meist um virale Infektionen handelt, ist dies oft überflüssig, denn diese sprechen nicht auf Antibiotika an. Je mehr Antibiotika verschrieben werden, desto stärker nehmen Antibiotikaresistenzen und Nebenwirkungen zu, und es wird immer schwieriger werden, zum Teil lebensbedrohliche Infektionen adäquat und effizient zu behandeln. Das Problem bei der Antibiotikaverschreibung ist die vielerorts hohe Erwartungshaltung für Antibiotika sowie das Fehlen eines geeigneten, schnell verfügbaren und verlässlichen Tests zur Differenzierung von bakteriellen und viralen Infekten. Bakterien produzieren im Blut Giftstoffe, die den Körper im Rahmen der Entzündungsreaktion dazu anregen, das Hormon Procalcitonin in höherer Menge zu produzieren als bei viralen Infekten. Im Vergleich zu gesunden Normalpersonen ist der Procalcitoninwert bei viralen Erkrankungen nur 10 bis 100-fach erhöht, ...

A central factor in the pathogenesis of inflammatory and fibrotic lung disease (adult respiratory distress syndrome, sarcoidosis, idiopathic pulmonary fibrosis) is the locally elevated number of alveolar macrophages (AM). An elevation in the production rate of AM, chemoattraction and differentiation of monocytes, or a diminution in the death rate might be underlying mechanisms. The aim of the present study was to investigate the modulatory role of endotoxin and cytokines on the death rate of human AM. Lipopolysaccharide (LPS) treatment resulted in a 4-fold increase (7.6 to 30.2%) of AM death. AM death was apoptotic as assessed by in situ DNA end labeling (ISDE), transmission electron microscopy, DNA gel electrophoresis, fluorometry of fragmented DNA, and an ELISA specific for histone-associated DNA fragments. Among the different bacterial cell wall components tested, LPS was the only inducer of apoptosis in human AM. None of the tested cytokines (interleukin-1 beta [IL-1 beta], IL-4, IL-6, IL-10, tumor necrosis factor-alpha [TNF-alpha], transforming growth factor-beta 2 [TGF-beta 2], interferon-gamma [IFN-gamma], macrophage colony-stimulating factor [M-CSF], granulocyte colony-stimulating factor [G-CSF], and granulocyte-macrophage colony-stimulating factor [GM-CSF]) was capable of enhancing the spontaneous rate of apoptosis. However, LPS-induced apoptosis was significantly enhanced by the macrophage-activating cytokine IFN-gamma, and reduced by the macrophage-deactivating cytokines IL-4, IL-10, and TGF-beta.

Upper respiratory tract involvement occurs in 1 to 6% of all patients with sarcoidosis. Dry cough, hoarseness, dyspnea and dysphagia are the main symptoms. The diagnosis is established by biopsy demonstrating granulomatous lesions. We report the case of a 22-year-old woman who presented with erythema nodosum, arthralgias and granulomatous lesions of the trachea, larynx and bronchi. Although the biopsies of the lesions were nondiagnostic, the diagnosis of acute sarcoidosis was made, and a steroid therapy was initiated. The patient recovered rapidly, and the lesions disappeared. The features and differential diagnosis of upper respiratory tract sarcoidosis are discussed.

In an emergency department (ED), discharge communication represents a crucial step in medical care. In theory, it fosters patient satisfaction and adherence to medication, reduces anxiety, and ultimately promotes better outcomes. In practice, little is known about the extent to which patients receiving discharge information understand their medical condition and are able to memorize and retrieve instructions. Even less is known about the ideal content of these instructions. Focusing on patients with chest pain, we systematically assessed physicians' and patients' informational preferences and created a memory aid to support both the provision of information (physicians) and its retrieval (patients). In an iterative process, physicians of different specialties (N = 47) first chose which of 81 items to include in an ED discharge communication for patients with acute chest pain. A condensed list of 34 items was then presented to 51 such patients to gauge patients' preferences. Patients' and physicians' ratings of importance converged in 32 of the 34 items. Finally, three experts grouped the 34 items into five categories: (1) information on diagnosis; (2) follow-up suggestions; (3) advice on self-care; (4) red flags; and (5) complete treatment, from which we generated the mnemonic acronym "InFARcT." Defining and structuring the content of discharge information seems especially important for ED physicians and patients, as stress and time constraints jeopardize effective communication in this context. Chest pain accounts for up to 10% of all patient presentations in emergency departments (EDs) (Konkelberg & Esterman, 2003). The majority of these patients will usually be discharged within hours, after exclusion of serious conditions such as myocardial infarction (Goodacre et al., 2011). A comprehensive workup of low- to intermediate-risk patients is not feasible in the ED (Reichlin et al., 2009). Yet many of these patients go on to suffer from repeated episodes of chest pain, associated with anxiety and uncertainty about diagnosis and outcome (Jones & Mountain, 2009). Effective discharge communication, empowering patients to understand and memorize medical information, should therefore be an integral part of patient care. It is a likely contributor to better outcomes (Bishop, Barlow, Hartley, & William, 1997; Kessels, 2003), higher patient satisfaction (Kessels, 2003), better adherence to medication (Cameron, 1996; Kessels, 2003), more adequate disease management, and reduced anxiety (Galloway et al., 1997; Mossman, Boudioni, & Slevin, 1999).

... Improving Outcomes in Elderly Patients with COPD Jörg D. Leuppi and Roland M. Bingisser Department of Internal Medicine and Emergency Department, University Hospital, Basel, Switzerland ... 36. Couser Jr JI, Guthmann R, Hamadeh MA, et al. ...