Data management systems for the bovine viral diarrhoea eradication programme in Switzerland.

A programme to eradicate bovine viral diarrhoea was launched in Switzerland in 2008 with the aim of eradicating the causal virus. During the first year of the programme, the entire population of 1.6 million cattle were tested for the presence of the virus; in the following three years an additional 1.8 million calves were tested. The complexity of information generated during the eradication programme, together with a tight schedule, made computerised data management a necessity. To organise, coordinate and supervise the programme, extensions were made to the computerised information system ISVet, of the Swiss Veterinary Service, which provides automated documents for both the Veterinary Service and private veterinarians. Specific data are accessible by user groups via the BVD-Web platform, ISVet and the Swiss animal movement database. The functionalities of the structure and the reports needed to control the progress of the programme are described in detail. The authors also discuss the major advantages, disadvantages and pitfalls when planning an eradication programme using a national centralised database over a distributed computer network.

[Clinical itinerary for heart failure: a program designed by primary care practitioners in Geneva]. / Itinéraire clinique pour l'insuffisance cardiaque: un programme conçu par des médecins de premier recours genevois.

Episodes of heart failure impact on patients' quality of life as well as their morbidity and mortality. This article describes a series of interventions designed by a group of primary care practitioners in Geneva. Some interventions aim to improve patients' autonomy in identifying the first signs of heart failure to act immediately. Others focus on patients' motivation to adopt appropriate behaviours (physical activity, etc.). And finally others have the objective to improve coordination between ambulatory and hospital care, as well as the transmission of clinical information. The implementation of these interventions highlights the need for individualised objectives of care in complex cases where patients have several co-morbidities and/or complicated social situations. In these situations an interdisciplinary approach is also essential.

Immunohistochemical diagnosis of persistent infection with Bovine Viral Diarrhea Virus (BVDV) on skin biopsies.

Detection of persistent infection with BovineViral Diarrhea Virus (BVDV) is essential for both epidemiological and clinical reasons. In addition to the classical virological methods such as virus isolation in tissue culture, ELISA and RT-PCR, immunohistochemistry of skin biopsies has become a useful and reliable tool. Assuming that the presence of BVDV antigen in skin structures is restricted to persistent infection, this method could differentiate from transient infection. In order to answer this question, 6 calves were experimentally infected orally with a non-cytopathic genotype 1 BVDV strain belonging to the subtype k.The calves developed fever, mucopurulent nasal discharge, coughing and leucopenia with relative lymphopenia. Immunohistochemistry of skin biopsies taken daily up to day 13-post infection did not reveal any evidence of BVDV infection. BVDV was, however, isolated from blood samples on cell cultures. Anti-NS3-antibody-ELISA and serum neutralization tests showed that all six calves seroconverted. We conclude that in acute BVDV infections, with genotype 1 and the subtypes found in Switzerland (b, e, h and k) viral antigen is not found in epidermal structures of the skin. In contrast, persistently infected animals test positive for BVD viral antigen by immunohistochemistry of the skin.

Genetic heterogeneity of pestiviruses of ruminants in Switzerland.

We have genetically analyzed ruminant pestiviruses. All >150 bovine viral diarrhea (BVD) viruses isolated from cattle in Switzerland belonged to genotype 1, with subgenogroups e, h, k and b found in decreasing frequency. To date, representatives of subgenogroup k have been detected in Switzerland only. Despite serological evidence of Border disease in sheep, only few Border disease viruses have been isolated, all of which belong to the novel group 3. Serological evidence suggested that pestivirus infections may occur also in wild ruminants in Switzerland but no isolates are available for analysis. In addition, we describe two pestiviruses, one a cell culture contaminant and the other isolated from a buffalo, that cluster with a recently proposed novel pestivirus species.

Comparison of patient satisfaction with ambulatory visits in competing health care delivery settings in Geneva, Switzerland.

OBJECTIVES: To measure satisfaction with medical visits in various health care settings and to assess the extent to which differences in satisfaction scores between health care settings can be attributed to patients' characteristics. DESIGN: This was a cross sectional survey to measure seven dimensions of patient satisfaction. SETTINGS: Ambulatory visits to 'gatekeepers' or specialists in a newly established managed care organisation, a private group practice, or a university hospital outpatient clinic in Geneva, Switzerland. PATIENTS: There were altogether 1027 adult patients (81% participation rate). RESULTS: Patients who consulted physicians in the private group practice reported higher levels of satisfaction (overall mean 83.2 on a scale between 0 and 100) than university clinic patients (79.7), patients of independent specialists within the managed plan (78.5), and patients of managed plan gatekeepers (69.8, intergroup differences p < 0.001). Differences between settings were reduced after adjustment for sex, age, country of origin, general practitioner versus specialist visit, and scheduled versus urgent visit (adjusted scores: 80.8, 78.8, 77.6, and 72.7 in the four settings, p < 0.001). Intergroup differences were largest for general satisfaction, but small and non-significant for satisfaction with explanations given by the physician and for time spent with the patient. CONCLUSIONS: Patient satisfaction varied widely between health care settings. Differences in satisfaction ratings could be ascribed only partly to disparities in patient populations. Patients of managed plan gatekeepers were least satisfied, presumably because they could not choose their physician freely. Comparison of patient satisfaction across health care settings can provide a basis for targeted quality improvement initiatives.

Resistive and elastic unloading to assist spontaneous breathing does not change functional residual capacity.

Resistive and/or elastic unloading (a negative ventilator impedance, otherwise termed proportional assist ventilation) may be a useful means to assist spontaneous breathing. This only applies if the ventilator accurately provides pressure changes at the airway opening (P(ao)) proportional to the instantaneous flow and/or volume signal of spontaneous breathing and no significant phase lag. We designed such an infant ventilator, which controls the P(ao) by a negative feedback loop, and superimposes a second positive feedback circuit to generate unloading. To test this mode and the ventilator's accuracy in performing the synchronized pressure changes, we examined the functional residual capacity (FRC). We hypothesized that unloading by itself would not alter FRC because P(ao) should return to a preset baseline at end-expiration, and furthermore, that FRC could be actively altered by changing the baseline. Five anesthetized, tracheotomized, spontaneously breathing rabbits [respiratory system compliance 22.4 +/- 4.6 mL/kPa (mean +/- SEM)] were exposed to end-expiratory P(ao) levels of 0, 0.2, 0.4, and 0.6 kPa. At each of these levels a period of regular continuous positive airway pressure (CPAP) was alternated with a period of unloading (-40 mL/kPa ventilator compliance combined with -3 kPa/L/s ventilator resistance). FRC measured by a sulfur hexafluoride washout technique was virtually identical on CPAP and during unloading at equal end-expiratory P(ao) (difference, 1.41% +/- 0.95%), but FRC increased upon elevation of the end-expiratory P(ao) by 29.4 +/- 3.6 mL/kPa on CPAP and 30.2 +/- 3.2 at unloading (difference NS). We conclude that FRC is not destabilized by unloading, but that during unloading, as during CPAP, it depends on the end-expiratory P(ao).

Comparison of lung volume measurements by antero-posterior chest X-ray and the SF6 washout technique in mechanically ventilated infants.

While anterior/posterior chest x-rays (CXR) are routinely performed to estimate lung volume (LV) and adjust ventilator settings, the precise measurement of LV requires additional sophistication. In 31 infants ventilated because of surfactant deficiency (n=23), bronchopulmonary dysplasia (n=7), or pulmonary hypoplasia (n=1) with either intermittent positive pressure (n=18) or high frequency oscillation (n=13) (gestational age 23-39 weeks (median 26 weeks); birthweight 550-2780 g (median 840 g); age at measurement 1-91 days (median 6 days); weight at study time (WST) 675-3000 g (median 938 g)), we investigated whether LV, as measured by the sulfur hexafluoride (SF6) washout technique, could by estimated from CXR by: 1) the sum (A+B) of the right (A) and left (B) lung fields areas; 2) the product (LxW) of the distances from the right apex to the right costophrenic angle (L) and between both costophrenic angles (W); 3) the diaphragm position relative to the posterior parts of the ribs (DP); and 4) the lung radiolucency (RL, grades 0-4). Correlations between A+B (r=0.44) or LxW (r=0.37) and LV were poor, but improved when A+B, LxW, and LV were normalized to WST: (A+B)/WST vs. LV/WST (r=0.74), and LxW/WST vs. LV/WST (r=0.67). DP (r=0.13) and RL (Spearman's rho=0.17) did not correlate with LV/WST. A multiple linear regression analysis led to the following best-fit equation: LV/WST=2.58 (A+B)/WST - 5.47 DP + 42.2 (r=0.83). We concluded that an estimate of LV from CXR lacked sufficient accuracy. DP and RL did not correlate with LV measured by SF6 washout.

Titration of continuous positive airway pressure by the pattern of breathing: analysis of flow-volume-time relationships by a noninvasive computerized system.

Infants can defend or even dynamically elevate their functional residual capacity with additional respiratory muscle work by retarding early expiratory airflow (V) with postinspiration inspiratory muscle activity and/or laryngeal narrowing, or by starting inspiration before expiration to the relaxation volume has been completed. In order to study the effect of continuous positive airway pressure (CPAP) on both phenomena in 23 infants (birthweight 1,746 +/- 417 g), we elevated the airway pressure stepwise in 0.2 kPa increments. A computerized bedside flow-volume (V/V) analysis was used for evaluation. In 16 "responders" early expiration braking decreased and "premature inspiratory interruption" was postponed at an "appropriate CPAP level." The linear segment (relaxation line) of the V/V-loop was lengthened until expiratory time reached a maximum. Elevation of CPAP beyond this level again produced a rapid, shallow pattern, often combined with flow acceleration late in expiration (recruitment of expiratory muscles). In the remaining seven infants (non-responders) these latter signs of excessive airway pressure already occurred at the lowest CPAP levels applied during the "titration trials." Respiratory rate without CPAP was different between responders (84 +/- 17/min) and non-responders (46 +/- 17/min). This approach for determining the appropriate CPAP level might reduce the risk of respiratory muscle fatigue.

Intravenous glucose tolerance after Whipple's procedure in patients with chronic pancreatitis--relative influence of occlusion of the pancreatic duct.

An intravenous glucose tolerance test was carried out to compare chronic pancreatitis patients (n = 17) who had undergone partial duodenopancreatectomy with (n = 9) and without (n = 8) occlusion of the residual pancreatic duct by Prolamin. The results obtained in 10 healthy volunteers were plotted as background information reflecting the normal metabolic response. Insulin- and C-peptide secretion were greatly decreased after both resection alone, and resection plus occlusion. However, the glucose tolerance (integrated glucose; K-values) appeared relatively well preserved in the two groups. The decrease in insulin appeared more marked after resection plus occlusion as compared with the non-occluded group. It is concluded that partial duodenopancreatectomy without or with ductal occlusion impairs insulin secretion, and leaves tolerance to an intravenous glucose load relatively stable. The mechanism underlying the latter observation is unknown at present.

The effect of infection with bovine viral diarrhea virus on the fertility of Swiss dairy cattle.

Bovine viral diarrhea virus is a major cattle pathogen with a worldwide distribution. Animals may be infected with BVD virus transiently or persistently. Transient infection leads to protective immunity. Persistent infection is unique because it is associated with an immunotolerance that is specific to the infecting strain of BVD virus. Persistent infection results from viral invasion of fetuses between the second and fourth month of development. Such animals are of prime importance in the epidemiology of BVD because they shed large amounts of virus, and thus serve as a constant source of infection for non-immune animals. Infection of pregnant animals during the first two months of gestation may result in an increased rate of return to estrus. Animals infected in the period of five months to birth may abort or give birth to calves with malformations. The effects of BVD virus on fertility and gestation are well documented from experimental infection. However, much less is known of the extent of losses under field conditions. The main reason for this may be the multitude of other causes of increased return rates and gestation failures. In addition, the incidence of infection with BVD virus may vary over time and depends on management practices. In this study, we investigated the impact of BVD virus on gestation failures under field conditions in a large cattle-breeding area of Switzerland, where no specific measures to control BVD are in effect. Our approach consisted of relating seroconversions to BVD virus with the rate of return to estrus, abortion, and birth of calves with apparent malformations. These parameters of fertility were compared to those of animals immune to BVDV infection due to previous exposure to the virus and animals without seroconversion. Our data show that infection with BVD virus during the first 45 days of gestation did not influence the rate of return to estrus. By contrast, we observed a statistically significant increase in the abortion rate in mid-term gestation (Days 46 to 210) while no such effect was observed in the later stages of gestation. No clinically manifest malformations were observed in the offspring of animals that had seroconverted to BVD virus. In our study population the prevalence of BVDV antibody positive cattle varied only slightly between 78% and 80% over the period of observation. Our data showed that 7% (CI: 2.4-14%) of fetal deaths may be attributable to infection with BVD virus.

A newly designed oscillating viscometer for blood viscosity measurements.

A newly designed type of oscillating viscometer is described. The viscometer consists of either a tube or a rod oscillating at a resonance frequency with amplitudes in the micro- and nanometer range. A fluid flowing through the tube or surrounding the rod damps the torsional oscillations. The increase in the damping depends on the viscosity of the fluid and is used to determine viscosity. It was found that viscosity measurements are feasible during blood flow. This new type of viscometer may be useful to the study of biophysical properties of blood at the wall surface during flow and give new insights into blood flow. The device allows direct viscosity measurement on blood directly as it is drawn from the vein through the tube without any anticoagulant.

Rheological properties of blood as assessed with a newly designed oscillating viscometer.

A newly designed type of oscillating viscometer was tested for blood viscosity measurements. The viscometer consists of a probe (either a tube or a rod) oscillating at a resonance frequency with amplitudes in the micro- and nanometer range. The torsional oscillations are dampened by fluids flowing through the tube or surrounding the rod. The degree of damping depends on the viscosity of the fluid, which allows to measure viscosity. Data obtained with these instruments were compared with those obtained with a conventional Couette viscometer. An increase of erythrocyte aggregation by the addition of dextran 70 in vitro led to the expected increase of viscosity in the Couette viscometer; in the oscillating tube viscometer, however, it remained unchanged, which may be explained by a decreased erythrocyte concentration near the tube wall due to increased aggregation and flow of erythrocytes in the tube center. In ex vivo experiments on blood flowing without anticoagulant directly through the tube viscometer an inverse correlation between viscosity and fibrinogen concentration was found. This is in contrast to actual knowledge and may indicate that high fibrinogen levels have a beneficial rheological effect at the tube or vessel wall. Our data suggest that the new oscillating tube viscometer is an interesting tool, which may contribute to a more comprehensive understanding of blood flow.

Spongy hydroxyapatite in hand surgery--a five year follow-up.

Twenty-two patients were treated for enchondromas or cysts of the hand by curettage and complete filling of the defect with hydroxyapatite. Postoperatively no complications occurred and marginal osseous integration was radiologically complete after 6 to 8 weeks. Patients were re-examined after a minimum of 5 years after operation and the functional and aesthetic results were excellent in all patients. Radionuclide imaging showed identical bone activity to that in the contralateral healthy hand and there were no signs of inflammation.

Prevalence of cattle infected with bovine viral diarrhoea virus in Switzerland.

A cross-sectional study was made in a major cattle-breeding area of Switzerland to investigate the prevalence and local distribution of animals antibody positive to bovine viral diarrhoea (BVD) virus and of persistently infected animals. The sample size and statistical analysis took into account the possible clustering of persistently infected animals on individual farms. Of 3440 animals tested on 121 farms, 1982 were found to have antibodies to BVD virus (95 per cent confidence interval for the population prevalence: 57.6+/-4.5 per cent) and 22 were persistently infected (estimate for the population prevalence: 0.64+/-0.34 per cent). The detection of persistent infection in animals less than seven months old was improved either by retesting one year later, by using an antigen-capture ELISA or, in selected cases, by the analysis of original serum samples by reverse-transcription PCR. The results showed that the prevalence of persistent infection may be underestimated by as much as one-third when antigen detection alone is used. None of the 121 farms investigated was free of antibody-positive animals and one in eight herds had at least one animal that was persistently infected. The prevalence of antibodies was lowest in seven- to 12-month-old animals (22.9 per cent) and highest in animals aged five years or over (84.9 per cent).

[Current models in health insurance and health care delivery]. / Nouveaux modèles d'assurance-maladie et gestion des soins.

Health care organizations similar to American HMOs have recently appeared in Switzerland. They elicit many reactions, both in the general public and among the medical profession. In contrast to traditional health insurance, HMOs organize and actively manage health care delivered to their members. This paper reviews the historical background of similar organizations in Europe and in the United States, and focuses in particular on the recent evolution and fragmentation of the concept of "managed care". Follows a discussion of the mechanisms and the side-effects of various tools used to manage care, both in managed care settings and by traditional health insurance plans. It appears that all of health care is managed, that all management tools have potential side effects, and that use of some management tools implies a redistribution of the respective roles of plan members, administrators, and physicians. The authors suggest that the complexity of health care management requires a more active implication of the health professions in that process.

A ventilator generating a positive or negative internal compliance.

This paper describes technical details of a ventilator for altering the resistive and elastic load placed on respiratory muscles during spontaneous breathing in intubated infants. Positive or negative values for ventilator resistance and/or ventilator compliance can be chosen by superimposing the weighted sum of the flow and/or the volume signal over the input to a pressure controller within the pressure feedback control system of the ventilator. The aim of the study was to compare values of the ventilator's compliance (Cv), as measured with a ventilation mechanics calculator, with those Cv values set by the ventilator's Cv control knob on the front panel. Another aim was to compare measured values of total compliance of a combined ventilator-lung model system (Ct) with the values expected according to theory where 1/Ct = 1/Cv + 1/C1m (Eq. alpha; C1m is the lung model's compliance). The Cv values set on the front panel were nearly identical to those measured (Cvm = 0.97 * Cvs + 0.54) over the whole tested range from -20 to +20 ml/kPa. Similarly, the measured Ct values were almost equal to those expected according to Eq. alpha; the standard deviation of the relative residuals was 2.7% for elastic loading and 12.4% for elastic unloading. We conclude that the ventilator described in this study can effectively provide both elastic loading and elastic unloading of spontaneous breathing, as expected according to theory.

[Timing of soft tissue reconstruction in severe crush injury of the upper extremity]. / Zeitpunkt der Weichteilrekonstruktion bei schweren Quetschtraumen im Bereich der oberen Extremität.

Complex injuries of the distal forearm and the hand by industrial machines often require extensive reconstructive procedures. Crush injuries with soft tissue damage extending over the limits of visible injury require a special approach. Large soft tissue defects often have to be covered by extensive flap procedures. The optimum point of time for plastic reconstruction is an essential question and represents a controversial issue in the literature. To be able to compare different patient cohorts in the future, we classify crush injuries into five clinically relevant categories. In the course of this review article, three different cases of severe crush injuries of the upper extremity are representatively discussed. Two patients were reconstructed in a secondary procedure, one patient in the acute phase. Definite coverage of soft tissue defects in severe crush injuries should be performed secondarily after 5-7 days since the extent of damage in this special form of trauma can often only be judged after a few days and the reconstruction of bones, vessels and tendons is completed.

[Primary hyperparathyroidism--experiences with concomitant diseases, symptoms, preoperative diagnosis and surgical procedure over a period of 14 years]. / Primärer Hyperparathyreoidismus--Erfahrungen zu Begleitkrankheiten, Symptomatologie, präoperativer Diagnostik und operativem Vorgehen whrend einer Periode von 14 Jahren.

In a 14-years period (1970-1984) eight-three patients were operated on for primary hyperparathyroidism (pHPT) at the University Hospital of Erlangen. Special attention was paid to associated diseases, symptoms, preoperative diagnostic parameters were serum calcium, parathyroid hormone in venous blood, cyclic AMP in 24 h-urine. In 15.7% only borderline increased serum calcium values were measured. Ulcer incidence in pHPT was 19% as compared with approx. 7% in the general population. There was no increased incidence of pancreatitis in pHPT. The possibility of an association of pHPT with the Multiple Endocrine Neoplasia (MEN) syndrome was emphasized and measures of early diagnosis proposed.

[Hand injury in polytrauma. A retrospective study of 782 cases]. / Die Handverletzung beim Polytrauma. Eine retrospektive Studie an 782 Fällen.

The incidence of hand injuries in multiple trauma is not well investigated. Between 1980 and 1986, 782 multiple trauma patients received primary treatment at the University Hospital of Erlangen. At the time of the study, 22% (n = 173) of these patients had died. 93% of the patients met with a traffic accident. In 20% of the multiple trauma patients, additional hand injuries were seen. 75% of these injuries were closed fractures of hand and wrist. The severity of multiple trauma had no influence on the incidence of hand injury. Young people between twenty and fourty years of age were mostly affected in multiple trauma, with increased incidence of hand injuries especially after motorcycle accidents. Delay of diagnosis of hand injuries was rare.