Volume 149, No. 1516

Markus J. Wilhelm, Devdas T. Inderbitzin, Diana Reser, Maximilian Halbe, Koen Van Tillburg, Roland Albrecht, Stefan M. Müller, Urs Wenger, Marco Maggiorini, Alain Rudiger, Dominique Bettex, Reto Schüpbach, Alberto Weber, Stefano Benussi, Ludwig K. Von Segesser, Andreas J. Flammer, Francesco Maisano, Frank Ruschitzka (Author)

Outcome of inter-hospital transfer of patients on extracorporeal membrane oxygenation in Switzerland

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AIMS OF THE STUDY

An extracorporeal membrane oxygenation system (ECMO), as a bridge to either recovery, a ventricular assist device (VAD), or heart or lung transplantation, may be the only lifesaving option for critically ill patients suffering from refractory cardiac, respiratory or combined cardiopulmonary failure. As peripheral hospitals may not offer ECMO treatment, tertiary care centres provide specialised ECMO teams for on-site implantation and subsequent patient transfer on ECMO to the tertiary hospital. This study reports the results of the largest ECMO transportation programme in Switzerland and describes its feasibility and safety.

METHODS

Patients transported on ECMO by our mobile ECMO team to our tertiary centre between 1 September 2009 and 31 December, 2016 underwent retrospective analysis. Implantation was performed by our specialised ECMO team (primary transport) or by the medical staff of the referring hospital (secondary transport) with subsequent transfer to our institution. Type of ECMO, transport data, patient baseline characteristics, operative variables and postoperative outcomes including complications and mortality were collected from medical records.

RESULTS

Fifty-eight patients were included (three patients excluded: one repatriation, two with incomplete medical records). Thirty-five patients (60%) received veno-venous, 22 (38%) veno-arterial and one patient (2%) veno-venoarterial ECMO. Forty-nine (84%) patients underwent primary and nine (16%) secondary transport. Thirty-five (60%) patients were transferred by helicopter and 23 (40%) by ambulance, with median distances of 38.1 (13–225) km and 21 (3-71) km respectively. No clinical or technical complications occurred during transportation. During hospitalisation, three patients had ECMO-associated complications (two compartment syndrome of lower limb, one haemothorax after central ECMO upgrade). Median days on ECMO was 8 (<1–49) and median days in hospital was 17 (<1–122). ECMO weaning was successful in 41 patients (71%), on-transport survival was 100%, 40 patients survived to discharge (69%), and overall survival was 67% (39 patients) at a median follow-up of 58 days (<1–1441). Cumulative survival was significantly affected by cardiogenic shock vs. ARDS (p = 0.001), veno-arterial and veno-venoarterial vs. veno-venous ECMO (p = 0.001) and after secondary vs. primary transport (p <0.001). The ECMO weaning rate was significantly lower after secondary transfer (22%, two patients, both vaECMO) vs. primary transfer (80%, p = 0.002, 39 patients of which 35 (71%) had vvECMO).

CONCLUSIONS

The first results of our ECMO transportation programme show its feasibility, safety and efficacy without on-site implant or on-transport complications or mortality. The favourable early survival may justify the large effort with respect to logistics, costs and manpower. With rising awareness, referring centres may increasingly consider this lifesaving option at an early stage, which may further improve outcomes.

Emmanuelle Jaquet, Baris Gencer, Reto Auer, Karine Moschetti, Olivier Muller, Christian M. Matter, Thomas F. Lüscher, Francois Mach, Nicolas Rodondi, Patrick Bodenmann, David Nanchen (Author)

Association between income and control of cardiovascular risk factors after acute coronary syndromes: an observational study

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BACKGROUND

The role of income in cardiovascular disease prevention after an acute coronary syndrome (ACS) remains unclear. We aimed to assess the association between income and control of cardiovascular risk factors one year after an ACS in a country with universal health insurance.

METHODS

Between 2013 and 2014, we studied 255 consecutive patients with ACS in an observational study in a university hospital in Switzerland in which self-reported household income was assessed. We classified patients into two categories based on the median income in Switzerland: higher than CHF 6000 (€ 5300) or less than or equal to CHF 6000 (€ 5300) per month. One year after discharge, patients were evaluated for the achievement of lipid and blood pressure targets, smoking cessation and drug adherence. Multivariate odds ratios (OR) were adjusted for age, sex, education, living status and working status.

RESULTS

Overall, 52.2% (n = 133) of patients with ACS were in the low-income category and 47.8% (n = 122) were in the high-income category. One year after discharge, high-income patients had higher rates of smoking cessation (64.2 vs 30.1%, multivariate-adjusted odds ratio (OR) 3.82, 95% confidence interval (CI) 1.58–9.24) and blood pressure target achievement (78.6 vs 60.2%, multivariate-adjusted OR 2.19, 95% CI 1.09–4.41) compared to those in the low-income category. There were no differences regarding adherence to drugs or lipid control between the two income groups.

CONCLUSION

A high household income was associated with a higher rate of smoking cessation and better control of blood pressure one year after ACS, independently of education, living status and working status.

Tobias Schneider, Dominik Pfister, Andreas Wörner, Wilhelm Ruppen (Author)

Characteristics of children and adolescents at the Switzerland-wide first ambulatory interdisciplinary pain clinic at the University Children’s Hospital Basel – a retrospective study

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AIMS OF THE STUDY

Given the long history of underestimating chronic pain in children and adolescents, we lack valid data on its assessment and treatment. The psychological and economic burden for patients, their families and society is substantial. The aim of this study was to assess patient characteristics of the first ambulatory interdisciplinary clinic for children and adolescents with chronic pain in Switzerland and compare them with data from other international centres.

METHODS

All patients of the ambulatory interdisciplinary pain clinic at the University Children’s Hospital in Basel during the period from 4 January 2012 to 4 July 2016 were included in this retrospective study. Data were collected from the patients’ medical records and from a questionnaire, which the patients and their parents received and completed in advance of their first visit. Demographic information, pain, referral, social environment, therapies and school absences of the patients were statistically analysed with means, percentages, 95% confidence intervals (CIs) and standard deviations (SDs).

RESULTS

Of the 135 patients included in this study, 80% were female and the mean age of all patients was 13.95 years (95% CI 13.5–14.4). The commonest pain presentations were: musculoskeletal (38%, 95% CI 0.30–0.46), back (25%, 95% CI 0.18–0.33), multiple regions (21%, 95% CI 0.15–0.28) and headache (7%, 95% CI 0.03–0.12). Mean duration of pain until the patients came to the clinic was 24.5 months (95% CI 19.82–29.22). Physiotherapy (71%, 95% CI 0.63–0.79) and non-opioids (50%, 95% CI 0.42–0.59) were the most used therapies before the first meeting. Psychotherapy (52%, 95% CI 0.44–0.61), most often using a psychosomatic therapeutic approach (psychosomatic therapy) 34% (95% CI 0.26–0.42), physiotherapy (36%, 95% CI 0.27–0.44) and non-opioids (33%, 95% CI 0.25–0.42) afterwards. The mean number of school absences during the last month before the first visit was 5.1 days per month (95% CI 3.48–6.73). The parents of our study participants suffered more often from psychiatric diseases than the mean Swiss population.

CONCLUSIONS

The average of more than 2 years of pain before referral to the clinic seems to be a long time. Assuming that specialised support is mandatory for young patients with complex pain syndromes, the referral time should be reduced. Furthermore, patients with headache were underrepresented in Basel compared with other centres. Interestingly, in our study, patients’ parents suffered more often from psychiatric diseases than the mean Swiss population.

Patrick E. Beeler, Emmanuel Eschmann, Markus Schneemann, Jürg Blaser (Author)

Negligible impact of highly patient-specific decision support for potassium-increasing drug-drug interactions – a cluster-randomised controlled trial

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BACKGROUND AND OBJECTIVE

Clinical decision support (CDS) might improve management of potassium-increasing drug-drug interactions (DDI). We studied CDS with five features intended to increase effectiveness: (i) focus on serious DDIs, (ii) fewer notifications, (iii) presentation of current laboratory results, (iv) timing (when adverse event becomes likelier), (v) removal of notification when appropriate.

METHODS

We conducted a 1-year, hospital-wide, cluster-randomised controlled trial in the inpatient setting at a large tertiary-care academic medical centre. Three CDS types were implemented: monitoring reminders (unknown potassium, no monitoring ordered), elevated potassium warnings (≥4.9 mEq/l), and hyperkalaemia alerts (≥5.5 mEq/l). The primary endpoint was the frequency of potassium-monitoring intervals >72 h.

RESULTS

We analysed 15,272 and 18,981 stays with 2804 and 2057 potassium-increasing DDIs in the intervention and control groups, respectively. Patient-specific notifications: displayed were 869 reminders (1 per 3.2 potassium-increasing DDIs), 356 warnings (1:7.9), and 62 alerts (1:45.2). Nevertheless, insufficiently monitored DDIs were not reduced (intervention 451 of 9686 intervals >72 h [4.66%]; control 249 of 6140 [4.06%]). The only secondary outcome improved was the length of potassium monitoring intervals (intervention group mean 22.9 h, control 23.7 h; p <0.001). However, in the intervention group, during 50 of 2804 observed potassium-increasing DDI periods (1.78%) one or more serum potassium values ≥ 5.5mEq/l were measured, in the control group, during 27 of 2057 (1.31%; p = 0.20).

CONCLUSIONS

A highly patient-specific CDS feature combination had a negligible impact on the management of potentially serious potassium-increasing DDIs and was unable to improve safety among hospitalised patients.

Trial registration number

The study was registered at ClinicalTrials.gov (NCT02020317).

Claudio Caviezel, Rolf Schuepbach, Bastian Grande, Isabelle Opitz, Marco Zalunardo, Walter Weder, Sven Hillinger (Author)

Establishing a non-intubated thoracoscopic surgery programme for bilateral uniportal sympathectomy

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AIM OF THE STUDY

Non-intubated, video-assisted thoracoscopic surgery (NiVATS) has been successfully developed in several centres worldwide. Local anaesthesia techniques and techniques to perform thoracoscopic surgery on a spontaneously breathing lung are the two key elements which must be adopted to establish a NiVATS programme. We established NiVATS by performing bilateral, uniportal sympathectomies, and compared it to classical video-assisted thoracoscopic surgery (VATS) under general anaesthesia with double-lumen intubation.

METHODS

Ten consecutive bilateral VATS sympathectomies were compared with ten consecutive NiVATS procedures. Nineteen of the procedures were for palmar hyperhidrosis and one was for facial blushing. Duration of anaesthesia, surgery and hospitalisation, perioperative complications, side effects and quality of life before and after sympathectomy were analysed.

RESULTS

Median age was 26.5 years (range 17–55) and mean BMI in the NiVATS group was 21.8 (range 19.1–26.3). NiVATS sympathectomies were performed as outpatient procedures significantly more often (9/10 vs 3/10, p = 0.008). Quality of life was significantly increased after sympathectomy in all patients, with no significant differences between the NiVATS and the VATS groups. There were no differences between the two groups regarding compensatory sweating (40 vs 50%, p = 0.66). The duration of anaesthesia, not including the time required for the surgery, was significantly shorter in the NiVATS group (p <0.001). The duration of surgery, from the first local anaesthesia until the last skin suture, was significantly longer in the NiVATS group (p = 0.04), but showed a constant decline during the learning curve, from 95 minutes initially to 48 minutes for the last procedure. Costs were significantly lower in the NiVATS group (p = 0.04).

CONCLUSION

Thoracoscopic sympathectomy is a suitable procedure with which to establish a NiVATS programme. Patients are usually young and of healthy weight, facilitating the learning curve for the local anaesthesia techniques and the surgery. Compared to VATS, sympathectomy is more likely to be performed as an outpatient procedure and has a lower cost, while safety and efficacy are maintained.

Sergio U. Dani (Author)

A curious association of chronic homeopathic arsenic ingestion with nonspecific symptoms in a Swiss teenager

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Arsenic is a toxicant that has no dose threshold below which exposures are not harmful. Here I report a curious association of chronic homeopathic arsenic ingestion with nonspecific symptoms in a Swiss teenager. For about 4 years she had taken globules of a freely purchasable homeopathic remedy containing inorganic arsenic (iAs), infinitesimally diluted to D6 (average arsenic content per single globule: 0.85 ± 0.08 ng). In the previous 7 months she had taken 20 to 50 globules daily (average 30 ng arsenic daily). She complained of nausea, stomach and abdominal cramps, diarrhoea and flatulence, headache, dizziness, anxiety, difficulty concentrating, insomnia, snoring, leg cramps and fatigue, loss of appetite, increased thirst and sweating, reduced diuresis, weight gain, paleness and coolness of both hands with a furry feeling of the hands, eczema of the hands, arms and legs, conjunctivitis and irregular menstruation. The physical and laboratory examinations showed a body mass index of 30 kg/m², acne vulgaris, bilateral spotted leukonychia, eczema of hands, arms and legs, non-pitting oedema of the legs, elevated plasma alkaline phosphatase activity, folate deficiency and severe vitamin D3 insufficiency. The arsenic concentration in her blood was <0.013 µmol/l, and arsenic was undetectable in her scalp hair. The total iAs concentration was 116 nmol/l in the morning urine and 47 nmol/l in the afternoon urine. The urinary arsenic concentration decreased and the patient’s complaints improved upon interruption of the arsenic globules, vitamin D3, thiamine and folic acid supplementation, and symptomatic therapy. It is concluded that an avoidable toxicant such as inorganic arsenic, for which no scientific safe dose threshold exists, should be avoided and not be found in over-the-counter medications.