[Latin organ donation programme (LODP): an effective initiative to increase organ donation in Switzerland]. / Programme latin de don d'organes (PLDO): une initiative efficace pour augmenter les dons d'organes en Suisse.

The 1st federal transplant law was enforced in July 2007 with the obligation to promote quality and efficiency in the procedures for organ and tissue donation for transplantation. The Latin organ donation programme (LODP) created in 2008 aims to develop organ donation in 17 public hospitals in 7 Latin cantons, covering 2.2 million people; 29% of the Swiss population. The implementation of various effective measures by the LODP enabled the increase in the number of donors by 70% between 2008 and 2010, with four organs procured per donor; greatly exceeding the European average of three. The results show that LODP has successfully professionalised the system and we can only hope that similar organisations will be put into place throughout Switzerland.

Epidemiologic variables and outcome of 1972 young patients with acute myocardial infarction. Data from the GISSI-2 database. Investigators of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2).

BACKGROUND: Acute myocardial infarction in younger patients is uncommon, occurring mainly in men. The recent introduction of thrombolysis improved survival, left ventricular function, and infarct size. OBJECTIVE: To evaluate characteristics and clinical outcome of the patients younger than 50 years randomized in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico study. All patients received a thrombolytic treatment. METHODS: The 11483 patients were divided into 3 age subgroups: younger than 50 years (17.2%), between 50 and 70 years (60.2%), and older than 70 years (22.6%). All relations between variables were first determined by an unadjusted analysis. An adjusted analysis was performed by multiple logistic regression models for in-hospital and 6-month mortality. RESULTS: While older patients had a significantly higher rate of a history of hypercholesterolemia, diabetes, and hypertension, smoking and a positive family history were significantly more frequent in younger patients. Total in-hospital and 6-month mortality were significantly lower in patients younger than 50 years (2.7% and 1.2%, respectively) than in patients between 50 and 70 years old (6.9% and 2.7%) and those older than 70 years (21.1% and 8.4%). After multivariate analysis, the predictive value of age was confirmed. CONCLUSIONS: Our findings, based on a large group of patients who received thrombolytic treatment, suggest that younger age is a significant independent indicator of a favorable prognosis after acute myocardial infarction.

Physical restraint in the ICU: does it prevent device removal?

BACKGROUND: Physical restraint is frequently used in the intensive care setting but little is known regarding its clinical scenario and effectiveness in preventing adverse events (AEs), defined as device removal. METHODS: We carried out a prospective observational study in three Intensive Care Units on 120 adult high-risk patients. The effectiveness of physical restraint was evaluated using the propensity score methodology in order to obtain comparable groups. RESULTS: Physical restraint was applied in 1371 of 3256 (43%) nurse shifts accounting for 120 patients. Substantial agitation, the nurse's judgement of insufficient sedation and sedative drug reduction were positively associated with physical restraint, whereas the presence of analgesics at admission, increased disease gravity and the treating hospital as the most substantial variable showed a negative association. Eighty-six AEs were observed in 44 patients. Quiet (SAS=1-4), unrestrained patients accounted for 40 cases, and agitated (SAS≥5) but physically restrained patients for 17 cases. The presence of any type of physical restraint had a protective effect against any type of AE (OR=0.28; CI 0.16-0.51). The observed AEs showed a limited impact on the patients' course of illness. No physical harm related to physical restraint was reported. CONCLUSION: Physical restraint efficiently averts AEs. Its application is mainly driven by local habits. Typically, the almost recovered, apparently calm and hence unrestrained patient is at greatest risk for undesirable device removal. The control/interpretation of the patient's analgo-sedation might be inappropriate.

Essential and non-essential amino acid requirement in injured patients receiving total parenteral nutrition.

The metabolic derangements of injury are known to influence nitrogen (N) requirements whilst less is known about individual amino acid (AA) requirements. This study was designed to investigate prospectively N vs AA requirement in 36 injured patients treated with total parenteral nutrition (TPN). The non-protein caloric input was 30 kcal kg-1 day-1 and three AA solutions were assessed containing the same AAs but in different proportion. Overall N intake was set at 0.35 g N kg-1 day-1 for solution A and B and 0.24 g N kg-1 day-1 for solution C. Solution B was similar to A, both being enriched in branched chain AAs (BCAA: 0.69 g kg-1 day-1 in B compared with 0.55 g kg-1 day-1 in A) while decreased in aromatic and sulphurated forms (1.75 times the normal need). Solution C was designed to maintain a daily input of BCAA similar to A (0.52 g kg-1 day-1) but with the supply of aromatic and sulphurated AA between solutions A and B, the supply of other AAs (lysine, theonine, histidine, arginine, glycine) being dependent on the selected N intake. For all the essential AAs the supply was always greater than normal allowances. Increasing BCAA over 0.55 g kg-1 day-1 did not improve N balance when N intake was 0.35 g kg-1 day-1, whilst nutrition with solution C was unable to maintain N balance. Moreover we found indirect evidence that this N intake, 0.52 g kg-1 day-1 was more sparing than 0.37 g kg-1 day-1 of BCAA.(ABSTRACT TRUNCATED AT 250 WORDS)

[Emergency medical system in Bellinzona (South Switzerland): a sensible, affordable model with use of ambulance and helicopter]. / Notarztsystem in Bellinzona (Südschweiz): ein sinnvolles, kostengünstiges Modell mit Einsatz der Ambulanz und des Helikopters.

Use of a mobile coronary care unit is a well recognized institution, but it often fails because of excessive costs. By means of an emergency physician working in the intensive care unit we have organized an economical rescue system by both helicopter and ambulance meeting the requirements of pre- and hospital treatment of the patients.

[Poisoning with cholinesterase inhibitors]. / Intoxikation mit Cholinesterasehemmern.

A 32-year-old woman who had ingested 300 ml of a potent cholinesterase inhibitor insecticide (Fonofos) with suicidal intent became progressively comatose and finally suffered respiratory arrest. Tracheal intubation, mechanical ventilation, vigorous gastric lavage and intravenous administration of atropine and obidoxime brought about complete clinical recovery within 24 hours of ingestion of this potentially fatal dose of Fonofos.

[Copper poisoning caused by humidifiers?]. / Kupferintoxikation durch Atemluftbefeuchter?

Humidifiers are rapidly contaminated with organisms and become a dangerous source of bacterial propagation unless special measures are taken. The growth of these organisms can be completely avoided by introducing metallic copper into the reservoir of humidifiers, as proposed as early as 1970 by Dean. The authors demonstrate experimentally that only nebulizers, in contrast to draw-over humidifiers and "bubblers", yield measurable quantities of copper. In a clinical study urine copper and plasma levels were measured in patients ventilated through a humidifier working on the draw-over principle. The results were compared with another group of patients ventilated with an aerosol of water containing copper. Copper excretion in the urine of this group rose well above the upper limit of normal between the second and fourth day, whereas copper in the urine of the first group (draw-over) remained within the normal range all the time. With a few exceptions the copper level in the plasma of both groups remained within normal limits. Plasma caeruloplasmin determination in both groups revealed no abnormal levels, a fact which appears to indicate that an overdose of copper could virtually be excluded. Nor were there clinical symptoms of copper intoxication.

["Soft" parameters and invisible resuscitation]. / I parametri soft e la rianimazione invisibile.

Caring for a patient implies performing technical interventions and caring for the whole person, recognising his/her personal life, habits, family, wills. The working experience of an intensive care unit of Bellinzona is described: the theoretical framework that led the health team to start this new approach to intensive care patients and its translation in everyday practice. Verbal and non verbal communication skills (with the patient and the team) are pivotal in this approach; relatives are considered partners in the care of the patient and an essential element of the caring environment. Nurses identified meaningful data (soft data) related to living experience of the patient, to the interaction with the healing environment, his/her patterns of communication, and their use in the intensive care unit is described.

[Post-traumatic coma and pre-traumatic memory]. / Le coma post-traumatique et la mémoire pré-traumatique.

Instead of thinking that it is impossible to enter in the internal world of a comatose patient, we are now put before a new and encouraging prospective, that of the possibility, even though minimal, of influencing the vital residual organisation of the patient and to induce him perhaps to accept again external stimulations, which previously were too intense. As loss of conscience often causes loss of memory, our intention was to examine the problem of memory loss in comatose patients after accidents. The analysis of 50 questionnaires distributed to trauma-patients awakening from a comatose state and interviews give clear indications that: 1) the patients remember absolutely nothing during the time of the coma; 2) in the majority of cases (34) the patients remember in the moment preceding the accident a clear autodestructive tendency especially if they were the cause of the accident; and 3) almost all patients (41) agree to have benefited greatly from the trauma itself and from its memory.

[Contraindications of thrombolytic therapy in acute myocardial infarct]. / Kontraindikationen der thrombolytischen Therapie beim akuten Myokardinfarkt.

In 43 Swiss hospitals, 824 patients have been included in the ISIS-3 trial with suspected or proven myocardial infarction. Another 504 patients with proven myocardial infarction have been excluded for various reasons and have been registered in the study log-book (total 1328 patients). The usual clinical contraindications for thrombolysis are listed and discussed in this paper. 1/3 of those patients excluded from the trial had not received thrombolysis without clear contraindications (age, diabetes, anticoagulation, candidates for a pace-maker) and another 27% have had only relative contraindications (resuscitation, puncture, ulcer pain, hypertension). The new guidelines for thrombolytic therapy allowed more patients to benefit from this therapy.

[Utilization of helicopters for the prevention of secondary cerebral lesions in severe craniocerebral injuries]. / Helikoptereinsatz zur Vermeidung zerebraler Sekundärschäden bei schweren Schädelhirntraumata.

The prehospital emergency treatment of craniocerebral trauma tries to avoid secondary cerebral lesions by controlling respiration and circulation. The therapy consists of heavy sedation with Midazolam, analgesia with morphine, artificial hyperventilation, PaO2 over 12 kPa and average arterial pressure above 80 mmHg. Our series of 46 patients recovered between 1982-1988 had a hospital mortality of 23%. 46% of the patients were polytraumatized. A normal neurologic state 6 months from the accident was registered in 86.4%. For 13.6% it was slightly pathological and no vigilant coma state was reported. The most effective rehabilitation method at the site of the accident has to secure the cerebral oxygen supply and reduce potential increase in intracranial pressure for avoid secondary cerebral lesions.

Long-term safety of an early ACE-inhibitor treatment of patients with acute myocardial infarction: results of the 3 year follow-up period on 696 Swiss patients randomized to the ISIS-4 trial. ISIS-Switzerland Study Group.

Several large scale clinical trials showed that early ACE inhibitor treatment in patients with acute myocardial infarction reduced 30-day mortality. While the short-term evidence of benefit and risks appears to be consistent among trials, scarce data are available with respect to the long-term effects of short-term treatments. This study shows that the early reduction in mortality rate observed among patients treated with captopril persists for up to 3 years. This suggests that the benefit achieved in the acute phase in not lost even after a long period of time.

Pharmacokinetics of midazolam administered by continuous intravenous infusion to intensive care patients.

OBJECTIVE: To determine the pharmacokinetics of continuously infused midazolam in patients during intensive care. DESIGN: Descriptive trial. SETTING: General ICU in a Swiss hospital. SUBJECTS: Eight critically ill patients requiring mechanical ventilation. INTERVENTIONS: To achieve an appropriate level of long-term sedation, the rate of iv infusion of midazolam in ICU patients was adjusted individually to between 6 and 15 mg/hr. Blood samples were taken during and after the continuous infusion of midazolam. MEASUREMENTS: Measurements included plasma concentration time profiles of midazolam and pharmacokinetic parameters, such as elimination half-life, clearance, and volume of distribution. RESULTS: The elimination half-life was prolonged (mean 5.4 vs. 2.3 hrs) and the volume of distribution was larger (3.1 vs. 0.9 L/kg) in patients vs. healthy volunteers. The clearance did not differ between groups (6.3 vs. 4.9 mL/min/kg in patients vs. volunteers, respectively). CONCLUSIONS: The increased volume of distribution in our critically ill patients is the major determinant for the observed slower elimination of midazolam. It is unlikely that the hepatic metabolism of midazolam was impaired in these patients.

Attitudes and behavior of young European adults towards the donation of organs--a call for better information.

Public perception of organ donation critically affects the availability of organ transplantation in the Western world. To assess the attitude of young adults towards the donation of organs and to investigate potential factors influencing their knowledge and actual behavior regarding organ transplantation, we evaluated a handout questionnaire survey of all Swiss-Italian recruits during six of the years 1989-98 (n = 7272). The attitude of recruits towards organ donation did not change significantly within the 10-year survey period: 61% of young men would personally donate their organs in the case of brain death, 13% would refuse, and 26% had not made up their mind. If they had to decide for close relatives, 50% would consent; 60% of recruits neither knew their next of kin's attitude nor had informed them about their own opinion; 80% felt they were insufficiently informed about organ transplantation. A significantly more positive attitude towards organ donation was found among men who felt they were sufficiently informed, who had close next of kin who were aware of their personal attitude (p < 0.0001), who had contacts with transplanted persons (p < 0.015), or who believed in an existence after death (p < 0.001; chi2-test). Our results suggest that there is potentially large support towards organ donation in this population. To minimize the high rate of indecisiveness, young adults need more appropriate information on the subject and they ask for it.

[ACE-inhibitors in acute heart infarct]. / ACE-Hemmer beim akuten Herzinfarkt.

The use of ACE-inhibitors in heart failure has been established over the past years. Their use is of uncertain value in the early phases of myocardial infarction, where they are supposed to prevent left ventricular dilatation. More recent studies (ISIS-4, GISSI-3) have tested early treatment by ACE-inhibitors in the acute phase of myocardial infarction. On one hand, it was possible to disprove reservations about risks (hypotension)n in a large cohort; on the other hand, a further reduction of mortality in hospitalized patients by 7% has been shown, corresponding to five patient lives saved for 1000 treated patients. Thus, after institution of the customary therapy of myocardial infarction (inhibitor of platelet aggregation, thrombolysis, beta-blocker) and after exclusion of specific contraindications (hypotension < 100 mmHg, renal failure) ACE-inhibitors could be administered in the acute phase of myocardial infarction. An analysis of the results from these large trials will show whether ACE-inhibitors may benefit groups of patients at particular risks (Killip > 1, age > 70 years, preceding renal failure) noticeably. ACE-inhibitors remain the treatment of choice in patients with developing left ventricular failure.

[The inducers of stress in a hospital department]. / Induttori di stress in un ente ospedaliero.

The stress level of general medical ward (18), intensive care (15) and emergency department nurses (13) was measured with a questionnaire. For 13 intensive care and 3 emergency department nurses stress level was measured also with a computerized system (COMES). Main sources of stress among nursing personnel are death and dying, and workload. There are no differences between full time and part time nurses and apparently intensive care and emergency department nurses do not experience more stress than general medical ward nurses.

[Time loss in the therapy of acute heart infarct]. / Zeitverlust in der Therapie des akuten Herzinfarkts.

As part of the ISIS study, the prehospitalization phase in 570 patients with acute myocardial infarction was evaluated and protocolled in 34 Swiss hospitals. The aim was to assess whether the time lapse between onset of pain symptoms and start of treatment could be shortened. It was felt that, particularly in the case of lethal cardiac arrhythmias, rapid intervention could secure reversal or controlled relief of symptoms and/or conduction disorders. The study protocol recorded the specific time lapses between onset of symptoms and notification of the physician, notification of the physician and hospital admission, and between hospital admission and therapeutic action. The longest time lapse observed was the patient's delay (57%). Delay by the patient was shortened when pain symptoms (a) occurred during daytime, (b) were preceded by symptoms in the week before the infarction, (c) occurred at work, and (d) occurred during exercise, particularly in the company of unknown persons. The longest time lapse observed in hospital was associated with the night shift. The time lost through delay in contacting a doctor, the main factor in delaying therapeutic action in acute myocardial infarction, is very difficult to influence since the target group for a public information campaign is hard to identify. On the other hand, the "door to needle" time lapse observed in hospital can be reduced by the introduction of clear-cut guidelines.

Computer-aided self-observation psychological stressors in an ICU.

We have developed a procedure for a computer-aided self-observation method in stressful situations. Staff members of an ICU recorded their experiences on a computer placed in the ICU, immediately after having experienced a stressful event. The computer asked for and stored psychologically relevant information about cognitive, affective and behavioural aspects. An external stress memory of an ICU was established, allowing a personal/institution-orientated stress diagnosis to be made on the basis of 192 episodes. Sixteen nurses in an intensive care unit in a Swiss hospital used this methodology for 12 weeks. One hundred and ninety-two stressful events were recorded (12 episodes per person), forming a good sample of the stressful episodes for the unit. To the same 16 nurses and 31 nurses at the same hospital (N total = 47) the Nursing Stress Scale was administered. The results from both groups showed that problems dealing with death and work load were predominant. Nurse characteristics such as levels of training (unskilled, skilled) and experience (number of years working as a nurse) were analysed by different statistical procedures and related to their stress experience.