Showing papers in "Swiss Medical Weekly in 2002"

Musculoskeletal involvement of brucellosis in different age groups: a study of 195 cases

Abstract: Objective: The aim of the present study was to determine the distribution and characteristics of arthritis in 195 patients with musculoskeletal involvement due to brucellosis in different age groups in the southeastern region of Turkey. Patients and methods; We carried out a retrospective analysis of 283 patients with brucellosis records and identified 195 with musculoskeletal involvement. Patients were classified into acute-subacute ( 12 months) brucellosis. Patients were also classified into three age groups: <15 years old (group A), 15-45 years (group B), and over 45 years (group C). In addition, patients were classified into five subgroups according to type of arthritis: peripheral arthritis, polyarthritis, spondylitis, sacroiliitis, and spondylitis/sacroiliitis. Results: 195 (69%) ofthe 283 patients [138 female (49%), 145 male (51%)] had musculoskeletal involvement. Of the patients with musculoskeletal involvement 113 (58%) were female and 82 (42%) were male, ranging in age from 3 to 71 years (mean age 33.14 ′ 15.03). Of 195 patients studied, 39 (14%) were <15 years old (group A), 122 (43%) were aged 15-45 (group B), and 34 (12%) were over 45 (group C). The most commonly affected joints were the sacroiliac joint in 108 patients (55%), peripheral joints in 106 (54%), and spondylitis in 60 (31%). Of 108 patients with sacroiliitis, 19 were in group A, 76 in group B, and 13 in group C. Bilateral sacroiliitis was less common in group B (23 patients) than in groups A (3) and C (3) (p <0.05). Spondylitis was more common in group B (18%). Sacroiliitis and polyarthritis were more common than other types of musculoskeletal involvement in females, whereas in males the distribution of all types was similar. In patients aged under 15 and 15-45, sacroiliitis and polyarthritis were common compared with other types of arthritis, but the distribution was similar in patients over 45. Conclusion: In southeastern Anatolia musculoskeletal involvement in brucellosis is frequent. The series presented suggests that musculoskeletal involvement in group A is higher than groups A and C. The prevalence of musculoskeletal involvement appears to differ according to age, sex and clinical type.

Endoplasmic reticulum storage diseases

Abstract: The endoplasmic reticulum represents the cell's quality control site for accurate folding of secretory and membrane proteins. Quality control is achieved through the association of ER chaperones with unfolded or misfolded polypeptide chains. In the ER stress response, upregulation of chaperones occurs as a consequence of misfolded proteins accumulating in the ER lumen; if these proteins fail to assume their native structure, they are retained in the ER and targeted for degradation by the proteasome. ER storage diseases (ERSDs) are a group of genetically based disorders in which mutant proteins fail to pass the ER quality control. Because all eukaryotic cells contain the ER, the clinical phenotype of ERSDs is very heterogeneous. Disease may result from the mere lack of the mutant protein in question and/or may be caused indirectly by toxic effects of the misfolded protein or aggregates thereof on the cell. Additionally, the cell's reaction to the ER stress may include signaling pathways which are ultimately detrimental. Experimentally, ERSDs serve as models to study the cellular reactions to a variety of perturbations. In particular, understanding the links between ER stress and cell degeneration may give valuable insights into the pathogenesis of other diseases where the accumulation of indigestible toxic material leads to cell injury.

Peroxisome proliferator-activated receptors (PPARs): from metabolic control to epidermal wound healing.

Abstract: Peroxisome proliferator-activated receptors control many cellular and metabolic processes. They are transcription factors belonging to the family of ligand-inducible nuclear receptors. Three isotypes called PPARalpha, PPARbeta/delta and PPARgamma have been identified in lower vertebrates and mammals. They display differential tissue distribution and each of the three isotypes fulfills specific functions. PPARalpha and PPARgamma control energy homoeostasis and inflammatory responses. Their activity can be modulated by drugs such as the hypolipidaemic fibrates and the insulin sensitising thiazolidinediones (pioglitazone and rosiglitazone). Thus, these receptors are involved in the control of chronic diseases such as diabetes, obesity, and atherosclerosis. Little is known about the main function of PPARbeta, but it has been implicated in embryo implantation, tumorigenesis in the colon, reverse cholesterol transport, and recently in skin wound healing. Here, we present recent developments in the PPAR field with particular emphasis on both the function of PPARs in lipid metabolism and energy homoeostasis (PPARalpha and PPARgamma), and their role in epidermal maturation and skin wound repair (PPARalpha and PPARbeta).

Insulin resistance syndrome: interaction with coagulation and fibrinolysis.

Abstract: Insulin resistance represents a common metabolic abnormality leading to cardiovascular disease, the major cause of morbidity and mortality in most parts of the world. Insulin resistance is also associated with an increased risk of type 2 diabetes which is strongly associated with obesity. The insulin resistance of obese people and subjects with type 2 diabetes is characterised by defects at many levels, affecting insulin receptor concentration, glucose transport mechanisms and the activities of intracellular enzymes. Around 25% of western populations show some features of the insulin resistance syndrome (often referred to as syndrome X or the metabolic syndrome) ie, a clustering of metabolic, atheromatous risk factors, including hypertriglyceridaemia, hyperinsulinaemia, hyper-tension, hypercholesterinaemia and obesity. However, the known metabolic cardiovascular risk factors associated with the insulin resistance syndrome do not sufficiently explain the excess vascular risk attributed to this syndrome. The observation, that increased plasma plasminogen activator inhibitor 1 (PAI-1) levels were associated with insulin resistance and atherothrombosis added for the first time a pathological basis for an association of the insulin resistance syndrome not only with metabolic, atheromatous (atherosclerotic) risk but also with atherothrombotic risk. It is very likely that not only PAI-1, but also other abnormalities in haemostatic variables contribute to this excess vascular risk. Knowledge of how haemostatic variables cluster with classical metabolic risk factors associated with the insulin resistance syndrome could help to better understand the pathogenesis of cardiovascular diseases. Indeed, many coagulation and fibrinolytic proteins have been shown to be associated with features of the insulin resistance syndrome and these associations suggest that some coagulation and fibrinolytic proteins have a role in atherothrombotic disorders, principally through an association with other established metabolic (atheromatous) risk factors in the presence of underlying insulin resistance. Interestingly, new therapeutic approaches in the prevention and treatment of insulin resistance do show some influence on coagulation and fibrinolysis. The newest drugs are the thiazolidinediones, a totally novel class of insulin sensitisers. They have the potential to offer improvements both in glycaemic control and in cardiovascular events.

Inhibition of the TNF-pathway: use of infliximab and etanercept as remission-inducing agents in cases of therapy-resistant chronic inflammatory disorders.

Abstract: Objective To examine the potential of the two tumour necrosis factor (TNF) inhibitors infliximab and etanercept as remission-inducing agents in chronic therapy-resistant inflammatory disorders of immune or non-immune pathogenesis. Methods 14 patients with adult Still's disease/macrophage activation syndrome (4), Wegener's disease (3), Behcet's disease (3), keratoscleritis (1), lymphomatous tracheo-bronchitis (1) Cogan's syndrome (1), and rapidly destructive crystal arthropathy (1) were treated with infliximab (n = 10) and etanercept (n = 4). All patients showed organ-threatening progression of their diseases with resistance to conventional immunosuppressive medication. Therapeutic benefit was assessed clinically and by documenting organ-specific functional and morphological alterations. Side effects were compared with the data of our clinic's rheumatoid arthritis (RA) patients treated by TNF inhibitors. Results A rapid and dramatic beneficial effect was documented in 9 patients and a moderate one in 5. Best responses (clinical and laboratory parameters) were seen in patients with macrophage activation syndrome/adult Still's disease and Behcet's disease, while the results were less impressive in those with Wegener's disease, Cogan's syndrome, idiopathic cerato-scleritis and lymphomatous tracheobronchitis. In all cases immunosuppressive agents and systemic glucocorticoids could be reduced or discontinued. Conclusions TNF inhibition may be highly effective in patients with severe, therapy-resistant chronic inflammatory disorders.

Abortion in woman caused by caprine Chlamydophila abortus (Chlamydia psittaci serovar 1).

Abstract: On a farm housing cattle and goats an abortion storm occurred affecting 50% of the goats during the lambing season 2000/2001. In one of three investigated caprine abortions Chlamydophila abortus could be identified as aetiology, During this time a pregnant woman (pregnancy week 19/20) had contact with aborting goats. She developed a severe generalized infection and aborted. The placenta contained Chlamydophila abortus shown by immunohistochemistry and PCR. The aim of the present case report is to alert medical doctors about the potential zoonotic risk of ovine/caprine abortions.

Reactive macrophage activation syndrome: a simple screening strategy and its potential in early treatment initiation.

Abstract: Questions under study starting treatment of reactive macrophage activation syndromes as early as possible (rMAS, haemophagocytic lymphohistiocytosis), e.g., with intravenous immunoglobulins (IVIG), seems to be essential for optimal outcome. However, there is no diagnostic gold standard which reliably indicates need for early treatment. We used a simple screening strategy consisting of serum ferritin measurements and/or morphological assessment of haemophagocytosis and compared the studied patient population with published series. Methods Retrospective analysis of clinical and laboratory data of 57 patients experiencing 60 episodes of rMAS. Results Screening by serum ferritin measurements and/or morphological assessment of haemophagocytosis of patients presenting with a systemic inflammatory response syndrome (SIRS) indicates that rMAS might be considerably more frequent than stated in the literature. Serum ferritin exceeded >10,000 microg/L in 91% rMAS episodes. Although the patient population studied was otherwise similar in most aspects to the published rMAS series, the fact that 40% of patients fulfilled the criteria for Still's disease (SD) as the disorder underlying rMAS is remarkable and questions the distinct nature of the two diseases. IVIG responders and non-responders did not differ regarding their initial characteristics with exception to the timepoint of IVIG administration, confirming the importance of early treatment initiation. Malignancy-associated rMAS however, has a poor prognosis and seems to be refractory to manipulation with IVIG in most instances, even when responding initially. Conclusions rMAS has to be considered in patients with a SIRS- or SD-like clinical presentation. Hyperferritinaemia >or=10,000 microg/l seems to be a good marker for defining patients with or at risk for developing rMAS and should be completed with a morphological assessment of haemophagocytosis. The perception of acute SD and rMAS as two distinct entities has to be questioned at least in a subgroup of patients.

Neuroplasticity--an important factor in acute and chronic pain.

Abstract: The nociceptive system is not just a system for the conduction of pain impulses from the periphery to the brain. We now know that plastic changes can take place in the periphery, the spinal cord and also in higher brain centres following injury or inflammation. These changes may increase the magnitude of the perceived pain and may contribute to the development of chronic pain syndromes. Although our knowledge is growing, we are now almost more confused as to how we should intervene in order to attenuate or inhibit nearoplasticity. The present review examines the current knowledge on mechanism, clinical significance and prevention of neuroplastic changes.

Antifungal chemotherapy: advances and perspectives.

Abstract: Invasive fungal infections have emerged as important causes of morbidity and mortality in immunocompromised patients. In response to this challenge, the field of antifungal chemotherapy has considerably expanded. Fluconazole and itraconazole, introduced in the late 1980s, were the first durably useful alternatives to amphotericin B deoxycholate. The clinical development of the lipid formulations of amphotericin B, and, more recently, that of novel echinocandin derivatives and improved antifungal triazoles each represent milestones in antifungal drug research that have further amplified our therapeutic options. Major progress has been made in harmonising disease definitions, in defining the paradigms of antifungal intervention, and in designing and implementing clinical trials. Standardised methods for in vitro susceptibility testing of yeasts and filamentous fungi have become available, and pharmacodynamic concepts have entered preclinical and clinical drug development. This article reviews the evolution of therapeutic options over the past decade, advances in chemoprevention and empirical antifungal therapy, progress in early diagnosis and pre-emptive therapy, the promise of the new echinocandins and second generation triazoles, as well as perspectives for combination therapies and adjuvant immunoreconstitution. Invasive fungal infections will remain a frequent and important complication of modern medicine; the current momentum in the field of laboratory and clinical antifungal drug research provides hope for substantial progress in prevention and management of these life-threatening infections in the near future.

Genetic risk factors of chronic obstructive pulmonary disease.

Abstract: Cigarette smoking is the major risk factor for chronic obstructive pulmonary disease (COPD). However, only a minority of cigarette smokers develop symptomatic disease. Family and twin studies suggest that genetic factors also contribute to the development of COPD. We present a detailed literature review of the genes which have been investigated as potential risk factors for this disease.

Severe traumatic brain injury in children--are the results improving?

Abstract: Questions under study: Traumatic brain injury (TBI) remains an important cause of mortality and morbidity in children. Medical management is constantly being refined, and thus results should improve. The aim of the present study was to analyse our data of recent years and to compare them with previous series (1978-83 and 1988-92). Patients and methods: The data of 51 children (1 month to 16 years old) with severe blunt TBI treated in our unit from 1994 to 1998 were analyzed retrospectively. Severe TBI was defined by immediate loss of consciousness and an admission Glasgow coma scale (GCS) <8. Outcome was classified by using the Glasgow outcome scale (GOS) 6 to 12 months after injury. Results: 35 patients (69%) showed a good outcome (GOS 4 and 5), 14 died (GOS 1), one survived in a permanent vegetative state (GOS 2), and another was severely disabled (GOS 3) (GOS 1-3 = bad outcome, 31%). Bad outcome was associated with low GCS (i.e. 3 and 4), fixed and dilated pupils at admission, invisible basal cisterns on first computerized tomography, and presence of coagulopathy. Moderate to severe intracranial hypertension was also significantly related to bad outcome in the 26 patients with intracranial pressure monitoring. Compared to our first series severity of TBI was unchanged, and the incidence of multiple injury and consumption coagulopathy was less frequent. Intubation rate prior to admission to the centre increased from 35% to 94%. Intensive care measures (duration of mechanical ventilation, use of hypothermia, mannitol, thiopentone etc.) were less aggressive. The rate of good outcome remained unchanged (69% vs. 60%). Conclusions: Despite changing management policies, results were comparable with those of our former series. This fact underlines the importance of primary injury and the secondary role of intensive care management on final outcome.

Monotoring adherence to prescribed medication in type 2 diabetic patients treated with sulfonylureas

Abstract: Data on adherence to prescribed medication amongst diabetics are scarce. The purpose of this study was to collect information about the dynamics and patterns of compliance of elderly patients with type 2 diabetes mellitus on oral treatment by using different assessment techniques.

Bronchial provocation tests: the rationale for using inhaled mannitol as a test for airway hyperresponsiveness.

Abstract: The use of histamine and methacholine is well established for identifying airway hyperresponsiveness (AHR) but the AHR to these agents is not specific for asthma diagnosis. Further, these agents do not identify or exclude exercise-induced asthma (EIA) so they are inappropriate for some occupational and sporting assessments. Measurement of AHR by pharmacological agents has other limitations in that a positive response does not necessarily identify a person who will respond to inhaled steroids and responses do not differentiate between doses of steroids. As most asthmatics remain hyperresponsive to these agents after treatment they have not been useful for guiding steroid dose reduction. Bronchial provocation tests (BPTs) with physical stimuli such as exercise, eucapnic voluntary hyperpnea and hypertonic saline have provided useful information on presence and severity of asthma and EIA. These tests however, can be time consuming and require more resources compared with the pharmacological tests. To simplify testing, a challenge has been developed that uses a dry powder of mannitol administered from a simple hand-held device. The mannitol is given in increasing doses from capsules containing from 5 mg to 40 mg. Mannitol responsiveness identifies people with EIA and those who will respond to inhaled steroids. Mannitol responsiveness is reduced following treatment with inhaled steroids, and some subjects become unresponsive within 6 to 8 weeks. Responsiveness to mannitol can be used to predict risk of exacerbation during back titration of steroids. Should this BPT become more readily available it would be the first to provide a common operating standard for use in the laboratory, office, or field.

Prevalence of asymptomatic celiac disease in adolescents of eastern Switzerland.

Abstract: BACKGROUND: The prevalence of symptomatic CD in Switzerland is thought to be 1 in 1,000 inhabitants. As in other countries, oligo- and asymptomatic CD is being diagnosed with increasing frequency in all age groups. AIM: To assess the prevalence of asymptomatic CD in adolescents in eastern Switzerland. METHOD: Between September 1999 and July 2000 total serum IgA titres, anti-endomysium IgA (EMA) titres and anti-human tissue transglutaminase IgA (hTTG) titres were measured in the serum of healthy 11- to 18-year-old Swiss lower and upper secondary school students. RESULTS: Of the 1,450 students (871 f = 60.1%, CI 95%) tested, 11 (10 f) had elevated levels of both EMA and TTG. The diagnosis of CD was confirmed in eight of these students by mucosal jejunal morphology (Marsh III); one exhibited normal histology. Two of the 11 students refused to undergo mucosal biopsy. None of the students, however, had symptoms suggestive of CD, nor were they stunted or underweight, and none of them had family members with known CD. All of the eight students with enteropathy went on a glutenfree diet and felt subjectively better than on a normal diet. Of the remaining students, 38 (2.6%) had family members with known CD. None of those with the relevant family history had elevated EMA or TTG levels. CONCLUSION: Asymptomatic CD is common. It occurs in 1 in 132 (0.75%) Swiss adolescents. The absence of subjectively recognisable symptoms suggestive of family history or other risk factors makes it difficult to diagnose this type of CD.

Female genital mutilation in Switzerland: a survey among gynaecologists

Abstract: QUESTION UNDER STUDY: To evaluate the situation of Female Genital Mutilation (FGM) in Switzerland. METHODS: Through a questionnaire, Swiss gynaecologists were asked if they have been confronted to FGMs, if they have been asked to perform infibulations and FGMs. The health representatives (Kantonsarzte/medecins cantonaux) were interviewed on FGM activity at the Canton level. Swiss Medical Schools were asked if FGM was included in the pregraduate curriculum, and an estimated prevalence rate for FGMs in Switzerland was gathered. RESULTS: Among Swiss gynaecologists, 20% reported having been confronted with patients presenting with FGM and among them 40% had been asked about reinfibulation. Gynaecologists are occasionally asked about the possibility of performing FGMs in Switzerland. No activity concerning FGM is reported by health authorities in the Cantons. Teaching about FGM is not included in the curriculum of any of the Swiss medical schools. Approximately 6,700 girls at risk and women who have undergone FGM live in Switzerland. CONCLUSION: The extent to which gynaecologists are confronted to women with FGM may justify further action to try to better understand the situation in Switzerland. Improvement of care by better education of health care providers (guidelines) and prevention of new cases by women's education should also be considered.

Evaluation of a Platelet Function Analyser (PFA-100) in patients with a bleeding tendency.

Abstract: Objective: To investigate pre-analytical variables and the diagnostic performance of the platelet function analyser (PFA-100®), a new device to test primary haemostasis in vitro by simulating platelet adhesion and aggregation under high shear stress Methods: Venous whole citrated blood is aspirated through a capillary towards an aperture of a collagen coated membrane containing either adenosine diphosphate (ADP) or epinephrine (EPI) The time needed for occluding this aperture by plug formation is called closure time (CT) and was assessed in 70 healthy subjects and 43 patients with a suspected mild bleeding disorder Abbreviations ADP adenosine diphosphate APTT activated partial thromboplastin time ASA acetylsalicylic acid BT bleeding time CT closure time EPI epinephrine GP IIb/IIIa glycoproteins lib and IIIa PFA-100® platelet function analyser PRP platelet rich plasma PT prothrombin time TXA2 thromhoxane A2 vWD von Willebrand disease vWF von Willebrand factor Results: The reference range for the PFA-100® was found to be 82-159 s for EPI-CT and 625-1205 s for ADP-CT Duplicate analyses revealed a mean coefficient of variations of 71% (EPI-CT) and 57% (ADP-CT) The EPI- and ADP-CT of blood samples collected in the evening were significantly longer (p = 0002 and p = 0004, respectively) than the CT of blood samples collected in the morning Acetylsalicylic acid (100 mg, 300 mg or 500 mg) administered as a single dose or daily on 10 consecutive days resulted in a prolongation of the EPI-CT, whereas the ADP-CT was not affected EPI-CT was more sensitive in detecting acetylsalicylic acid (ASA) ingestion than was the bleeding time (BT) Sensitivity and specificity of the PFA-100® to detect von Willebrand disease (vWD) were comparable to the results obtained with the BT Conclusion: The PFA-100® represents a simple and easy to use test for investigation of primary haemostasis Limitations of the system are: special citrated whole blood has to be proceeded within 05 to 4 h after sampling, duplicate measurements are necessary, and the results differ between blood sampled in the morning or in the afternoon The data indicate that the test is sensitive to ASA intake and vWD Its use is preferable to BT determination, because it is less invasive and more sensitive to abnormalities of primary haemostasis

Open regulation and practice in assisted dying.

Abstract: The Netherlands, Oregon and Switzerland are the only areas in the world where assistance in dying has legally been practised in recent years. This article provides a detailed comparison of the history of the origins, legislation, monitoring systems and the extent of assistance in dying in these three places. It shows that the actual practice in Switzerland which, unlike Oregon, also allows assistance in suicide by means of infusions or gastric tubes, can today be technically quite similar to the permitted practice of active euthanasia on request in the Netherlands. Considering the preconditions restricting these practices, Swiss regulations are the most open, in that the law requires neither a medical second opinion (as in both the Netherlands and Oregon) nor the existence of a terminal illness (as in Oregon) as prerequisite to assistance in dying. In 2001, the proportion of assisted deaths (as reported to the authorities) in all deaths was almost ten times higher in the Netherlands (1.5% of all deaths) then in Oregon (<0.1% of all deaths) or Switzerland (0.2% of all deaths). The analysis of the different normative concepts underlying legislation reveals that in the Netherlands the basis for non-prosecution lies in the conflict of the physician's duties to respect life versus relief of suffering, while in the USA and in Switzerland the right-to-die concept plays a major role. These two concepts allow appreciation of distinctions between the roles of the physician in end-of-life practices and between assisted suicide and voluntary active euthanasia.

Serum C-reactive protein in children with adenovirus infection.

Abstract: Objectives: (1) To evaluate serum C-reactive protein (CRP) concentrations in children with adenovirus infection, and (2) to compare CRP concentrations in adenovirus and influenza virus infection. Patients and Methods: Retrospective, comparative single-center study conducted in Emergency Department patients of a paediatric tertiary care center. Comparison of CRP in adenovirus infection and influenza was performed in patient groups stratified according to age and duration of fever. Results: In 87 children with adenovirus infection (median age, 1.5 years; interquartile range, 0.9-3.0), CRP levels of 2 years) and duration of fever (≤3 vs. >3 days) (p <0.001). In adenovirus infection CRP concentrations were unrelated to age, duration of fever and severity of illness, as judged by the extent of mucosal involvement and by the frequency and duration of hospitalisation. Conclusion: Paediatric adenovirus infection is associated with substantially elevated CRP concentrations in the absence of secondary bacterial infection. CRP levels were independent of the duration of illness, indicating that adenoviruses trigger an immediate inflammatory host response resembling invasive bacterial infection.

Smoking among adolescents: relation to school success, socioeconomic status nutrition and self-esteem.

Abstract: Objective Smoking is a worldwide health problem This study was designed to evaluate the current status and to examine some potential factors affecting smoking among adolescents Design Descriptive, cross-sectional study Setting Community based study Subjects Of all middle and high school students in Edirne, Turkey, 883 (683%) were randomly sampled Mean age of the subjects was 150 +/- 18 years Method A self-applied questionnaire was used to collect demographic data, smoking status, school success, nutritional behaviour and self-esteem The influence of different factors on smoking was evaluated with a logistic regression model Results There were 89 active smokers (111%) with the critical age of 15 years for smoking commitment 609 students (719%) were exposed to environmental tobacco smoke Nutritional behaviour rich in vegetables (OR = 0813), high school success (OR = 0807), longer time reserved for homework (OR = 0718) and eating breakfast (OR= 0353) were significantly associated with a lower smoking rate Having a mother, who smoked (OR = 2155), increasing age (OR = 1704), increasing number of siblings (OR = 1351) and eating fast food (OR = 1150) were associated with significantly higher smoking rates Conclusion An educational programme aimed at changing behaviour and attitude to tobacco smoking and including nutritional counselling with high emphasis on the transition age from early to late adolescence may be a successful primary prevention In addition projects designed to improve school performance may lead to a reduction in smoking rates while providing an investment in the future of the teenagers

Coercive procedures and facilities in Swiss psychiatry.

Abstract: BACKGROUND: Coercive measures in psychiatry,although in many cases effective in violence management and injury reduction, have been criticised from a consumerist point of view. METHOD: A questionnaire regarding coercive facilities and procedures was dispatched to the charge nurses of 86 acute psychiatric admission wards in German speaking Switzerland covering a catchment area of 75% of the Swiss population. RESULTS: 95% of all wards responded rendering the survey representative. The majority of wards have seclusion rooms and 55% of charge nurses perceive seclusion facilities as adequate. Two to twenty staff members are involved in overwhelming dangerous patients and some discontent is expressed at the haphazard fashion in which such events occur. Almost 70% of the wards use a form for reporting, 42 % of wards keep statistics on violent incidents and 17% of wards have access to these data. Of all wards 84% register injections against patients' will, 83% seclusion, and 78% mechanical restraint and a minority of wards register the coercive administration of oral medication, forced nutrition, threats of coercive measures in case of pharmacological non-compliance. DISCUSSION: Isolation, the coercive administration of medicine and restraint techniques are sensitive forms of treatment. Deficits reported by the charge nurses point to the need for enhanced facilities and improved forms of coercion management such as training in the use of mechanical restraints and the overwhelming of dangerous patients. CONCLUSION: The data show considerable differences in the facilities, the use, and the recording of coercive measures in the area under scrutiny. Language: en

Complementary and alternative medicine in asthma: do they work?

Abstract: Objective An increasing number of patients with asthma are attracted by complementary and alternative medicine (CAM). Therefore, it is of importance that scientific evidence about the efficacy of this type of therapy is regarded. Method We searched the electronic databases Medline, Embase and the Cochrane Library for controlled trials and systematic reviews to evaluate the evidence of the most popular alternative therapies, i.e. acupuncture, homeopathy, breathing techniques, herbal and nutritional therapies. Results Claims that acupuncture is effective for the treatment of asthma are not based on well-performed clinical trials. The role of homeopathy in the treatment of asthma needs further evaluation. Breathing techniques, e.g. improved control of breathing by yoga, may contribute to the control of asthma symptoms, but due to the small number of controlled trials and due to the small number of patients it is not possible to make firm judgments. Herbal remedies cannot be recommended based on the available evidence. Recommendations for a diet high in vitamin C and marine fatty acids are not harmful, but evidence for clinically meaningful effects are scant. Conclusion Up to now evidence is lacking that alternative forms of medicine are more effective than placebo in asthma. However, lack of evidence does not always mean that treatment is ineffective, but it could mean that effectiveness has not been adequately investigated. High quality research as in conventional therapy should be fostered in complementary medicine.

Update on cryptogenic organising pneumonia (idiopathic bronchiolitis obliterans organising pneumonia).

Abstract: Organising pneumonia, defined by intraalveolar buds of connective tissue, may be a disorder secondary to a determined cause (infectious agents, drugs) or occurring in a specific context (as the connective tissue disorders). It may also be a cryptogenic interstitial pneumonia with characteristic clinical and imaging features and especially an excellent response to corticosteroids.

Epidemiology of methicillin-resistant Staphylococcus aureus: results of a nation-wide survey in Switzerland

Abstract: OBJECTIVE: To assess the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) in Switzerland. MATERIAL AND METHODS: One-year national survey of all MRSA cases detected in a large sample of Swiss healthcare institutions (HCI). Analysis of epidemiological and molecular typing data (PFGE) of MRSA strains. RESULTS: During 1997, 385 cases of MRSA were recorded in the 5 university hospitals, in 33 acute care community hospitals, and 14 rehabilitation or long-term care institutions. Half of the cases were found at the University of Geneva Hospitals where MRSA was already known to be endemic (41.1 cases/10,000 admissions). The remaining cases (200) were distributed throughout Switzerland. The highest rates (>100 cases/10,000 admissions) were reported from non-acute care institutions. Rates ranged from 3.3 to 41.1 cases/10,000 admissions for university hospitals (mean 15.5); 0.67 to 90.4 for community hospitals (mean 4.8), and 28.2 to 315 for non-acute care institutions reporting MRSA (mean 85.7). Forty percent of MRSA patients were infected, while 60% were only colonised. The leading infection sites were skin and soft tissue (21%), surgical site (15%), and the urinary tract (26%). Whereas in Eastern Swiss HCI most MRSA cases occurred in acute care hospitals (n = 47, 98%), rehabilitation and long-term care institutions accounted for an important number of the identified cases (n = 107, 38%) in Western Switzerland. CONCLUSION: Low rates of MRSA were still observed in Swiss HCI, despite one outlying acute care centre with endemic MRSA and some nonacute care institutions with epidemic MRSA. Rehabilitation and long-term care institutions contributed to a substantial proportion of cases in Western Switzerland and may constitute a significant reservoir. Overall, a national approach to surveillance and control of MRSA is mandatory in order to preserve a still favourable situation, and to decrease the risk of epidemic MRSA dissemination.

Clinical experience of surgical therapy in 207 patients with thoracic hydatidosis over a 12-year-period.

Abstract: Principles: Hydatid disease is the most severe helminthic zoonosis, with a major medical, social, and economic impact in Turkey. The aim of this study was to evaluate retrospectively 207 patients diagnosed with hydatid cyst and treated surgically in our department between January 1990 and December 2001. Methods: Hundred and ninety three patients were male and 14 female. They ranged in age from 19 to 72 years (mean 25.3 years). The most common presenting symptoms were cough, expectoration and chest pain. The surgical approach was thoracotomy in 198 patients, bilateral staged thoracotomies in 5 patients, median sternotomy in one patient and video-assisted thoracic surgery in 3 patients. Results: Hundred and thirty eight of the 265 intrapulmonary cystic lesions were found in the right lung and 127 in the left lung. Intrathoracic extrapulmonary cystic lesions were detected in 13 patients. 38 patients also had cystic lesions in the liver. Conservative sur-gical procedures were adopted except for small wedge resections in 8 patients, segmentectomy in 4 patients and lobectomy in one. Operative and postoperative mortality was nil. Albendazole treatment was given to patients who had multiple intrathoracic cysts or additional hepatic cysts after 1994. Conclusions: Our preferred surgical techniques for removal of cysts were conservative surgical procedures such as enucleation of cysts or removal by cystotomy. Radical procedures such as pneumonectomy, lobectomy and segmentectomy should be avoided as far as possible.

Acute epiglottis in adults.

Abstract: Acute epiglottitis can be a serious life-threatening disease because of its potential for sudden upper airway obstruction. It is a well-recognised entity in children but it is uncommon in adults and therefore is often misdiagnosed. In this retrospective study we present twelve cases of acute epiglottitis in adults. The diagnosis was made by visualisation of the epiglottis using fibreoptic laryngoscopy. The illness was managed using a standardised management protocol (see Appendix). The most frequent symptoms were odynophagia (100%), inability to swallow secretions (83%), sore throat (67%), dyspnoea (58%) and hoarseness (50%). Body temperature was elevated (>37.2 degrees C) in 75% and 50% of the patients had tachycardia (>100 bpm). The supposedly typical sign of stridor was found in only 42% of the cases. A routine oropharyngeal examination does not exclude epiglottitis, 44% of our patients had a normal oropharynx and the diagnosis could only be made following fibreoptic laryngoscopy. Nasotracheal intubation was necessary in four patients. A 40-year-old man with sore throat, hoarseness, cough and odynophagia was initially seen by a physician. With the suspected diagnosis of an infection - induced exacerbation of bronchial asthma, he was treated with antibiotics, paracetamol und corticosteroids. On admission six hours later the patient was in coma. The diagnosis was not made until conventional oral endotracheal intubation (without a tracheotomy set placed at the bedside) was attempted. Unfortunately the intubation failed and the patient died. Medical management of epiglottitis in adults includes an antibiotics, NSAIDs and possibly inhalation with adrenaline. The maintenance of an adequate open airway is the main concern in adults as well as in children. Although most adults have no signs of airway obstruction, the clinical threshold for insertion of an airway should remain low, as it is the only way of preventing death. A high index of suspicion is needed to recognise this rare disease correctly and patients must be admitted to a hospital with intensive care facilities, where the diagnosis can be confirmed and intubation performed if necessary and thus reduce the mortality rate.

An evaluation of patient satisfaction amongst family practice patients with diverse ethnic backgrounds.

Abstract: Objective: The aim of this study was to examine the impact of patients' ethnic diversity on the patient satisfaction rates Design: We used the methodology developed in an international EUROPE study The patients were asked to fill in self-administered questionnaires on their evaluations of the care received in the year prior to the survey The instrument consists of 23 questions regarding specific family physicians' tasks evaluated on a 5 point Likert scale Setting: Primary care practices of the National Railway Primary Health Care Services in Slovenia Study participants: A questionnaire was handed out to 600 patients cared for by 10 physicians Main outcome measures: Percentages of highly satisfied patients in groups of patients with different ethnic backgrounds Results: We achieved 657 % response rate The overall satisfaction was lower in non-Slovenian patients, however was not significant (836 vs 858 points, p = NS) Non-Slovenian patients were less satisfied with regard to: "quick relief of their symptoms", "helping them to feel well so as to be able to perform their normal daily activities", physicians' "thoroughness" and their explanations concerning what the patients wanted to know about their symptoms and/or illness In a multivariate analysis Slovenian nationality predicted higher patient satisfaction with the clinical "performance" of physicians Conclusions: As family practice remains an important source of primary health care for all patients, the providers should address the needs of all members of society regardless their social or cultural background Undergraduate and postgraduate curricula have to address communication skills emphasising cultural differences

Feasibility of the new WHO classification of pulmonary neuroendocrine tumours.

Abstract: Primary pulmonary neuroendocrine tumours present a heterogeneous group of tumours causing problems in diagnosis and treatment. The new WHO classification of lung tumours was published in 1999 in order to improve this situation by combining morphology, immunohistochemistry and clinical background for diagnosis. The aim of our study was to evaluate the feasibility of this classification and to discuss the consequences of modified diagnostic criteria. 50 cases of neuroendocrine tumours and 50 poorly differentiated lung tumours diagnosed in the years 1981-1994 were independently evaluated by three pathologists. The diagnosis of all 27 typical carcinoids (TC) was given by all authors, however, no unanimous agreement was achieved in one of three atypical carcinoids (AC) and two of four large cell neuroendocrine carcinomas (LCNEC). While typical and atypical carcinoids can be distinguished by the number of mitoses or presence of necrosis it was found that the most difficult diagnostic factor for large cell neuroendocrine carcinoma is the recognition of its light-microscopic neuroendocrine features. In consequence it must be distinguished not only from atypical carcinoid or small cell lung carcinoma (SCLC), but also from poorly differentiated carcinoma. Immunohistochemistry is important for the diagnosis of this entity but also for non-small cell lung carcinoma with neuroendocrine differentiation (of which 1 case was detected in our series) There was agreement on the diagnosis of small cell carcinomas in all but one case. The results indicate the excellent reproducibility of the WHO classification.

Climatic change: possible impacts on human health.

Abstract: This paper addresses a number of problems relating to climatic change and human health. Following an introduction outlining the overarching issues, a short summary is given on climatic change and its anthropogenic causes. The rest of the paper then focuses on the direct and indirect impacts of global climatic change on health. Direct effects comprise changes in the hygrothermal stress response of humans, atmospheric pollution, water quality and availability; indirect effects include the potential for the spread of vector-borne diseases outside their current range. The paper concludes with some comments on possible response strategies aimed at alleviating the adverse effects of climatic change on human health.

Impaired sensorimotor gating in schizophrenia with deficit and with nondeficit syndrome.

Abstract: Questions under study: Prepulse inhibition (PPI) is the normal suppression of the startle reflex when the intense startling stimulus is preceded by a barely detectable prepulse. PPI has been proposed to reflect a measure of sensorimotor gating or filtering. Deficits in PPI has been found in schizophrenia in various prepulse Conditions. The aim of this study was to investigate whether deficits in particular prepulse conditions relate to psychopathological syndromes. Methods: Schizophrenia was subgrouped into patients with deficit and with nondeficit syndrome using the schedule of Kirkpatrick. Schizophrenia with deficit syndrome (N = 46), schizophrenia with nondeficit syndrome (N = 21), and controls (N = 44) were compared in an acoustic startle paradigm assessing PPI (30, 60, 120,240 and 2000 ms inter-stimulus intervals). A mixed ANOVA was used to analyse the PPI-data. Results: Schizophrenia with deficit syndrome showed a PPI-deficit in the 60 ms prepulse condition and a reduced facilitation in the 2000 ms prepulse condition, whereas PPI in patients with nondeficit syndrome was impaired in the 240 ms prepulse condition. Conclusions: The different patterns of PPI in deficit and nondeficit patients appear to relate to the heterogeneity of schizophrenia. Thus, this study may explain the various findings in previous PPI studies in the field of schizophrenia.