Impaired sleep predicts onset of low back pain and burnout symptoms: evidence from a three-wave study.

In a three-wave questionnaire study of 405 working participants, who were initially free of low back pain (LBP) and emotional exhaustion, sleep problems were evaluated as a potential risk factor for the development of LBP and burnout up to three years later. Prospective risk paths were compared between the sexes and between two age-groups (18 to 45 years and older than 45 years). A longitudinal structural equation model showed a good fit with empirical data (RMSEA = .04, SRMR = .06, CFI = .97). Prospective risk paths between the latent constructs showed sleep problems to significantly predict self-reported LBP (ß = .15, p = .011) and burnout (ß = .24, p < .001) two years later. Sleep problems also predicted the occurrence of burnout three years later (ß = .18, p = .002). Sleep-related risk of burnout after two years was greater in older than younger participants (ßolder = .42 vs. ßyounger = .13, p < .001). Sleep problems seem to precede LBP and burnout in working individuals. Health promotion initiatives should use sleep quality as an important early risk indicator, and interventions should focus on promoting better quality sleep, in an attempt to reduce the incidence of LBP and burnout.

Effective therapy to reduce edema after total knee arthroplasty Multi-layer compression therapy or standard therapy with cool pack - a randomized controlled pilot trial / Lymphologischer Kompressionsverband oder Standardbehandlung mit Kältepackung zur Schwellungsreduktion nach Knietotalprothesen-Operation. Eine randomisiert-kontrollierte, einfach verblindete Pilotstudie

Background: After total knee arthroplasty (TKA) efficient control and reduction of postoperative edema is of great importance. Aim: The aim of this pilot study (EKNZ 2014 ­ 225 DRKS00006271) was to investigate the effectiveness of multi-layer compression therapy (MLCT) to reduce edema in the early period after surgery compared to the standard treatment with Cool Pack. Methods: In this randomized controlled pilot trial, sixteen patients after TKA were randomized into an intervention group (IG) or a control group (CG). Circumferential measurements were used to assess edema. Secondary outcomes were range of motion (ROM), pain (numeric rating scale, NRS) and function as measured with the fast Self Paced Walking Test (fSPWT). Results: Clinically relevant differences in edema reduction between the two groups were found in the early postoperative period and at the six weeks follow up. Six days postoperatively the group time interaction (IE) in favor of the IG were −3.8 cm (95 % CI: −5.1; −2.4) when measured 10 cm proximal to the joint space and −2.7 cm (CI: −4.1; −1.3) when measured 5 cm proximally. We further observed differences in secondary outcomes in favor of the CG. Six days postoperatively the IE for knee flexion was ­8.3 ° (CI: −22.0; 5.4) and for the fSPWT it was 12.8 seconds (CI: −16.4; 41.3). Six weeks postoperatively these differences diminished. Conclusions: The findings suggest that MLCT could be an alternative treatment to reduce postoperative edema in patients after total knee arthroplasty. Eventually possible negative effects on early knee flexion and function must be considered.

The Toxoplasma gondii rhoptry protein ROP18 is an Irga6-specific kinase and regulated by the dense granule protein GRA7.

In mice, avirulent strains (e.g. types II and III) of the protozoan parasite Toxoplasma gondii are restricted by the immunity-related GTPase (IRG) resistance system. Loading of IRG proteins onto the parasitophorous vacuolar membrane (PVM) is required for vacuolar rupture resulting in parasite clearance. In virulent strain (e.g. type I) infections, polymorphic effector proteins ROP5 and ROP18 cooperate to phosphorylate and thereby inactivate mouse IRG proteins to preserve PVM integrity. In this study, we confirmed the dense granule protein GRA7 as an additional component of the ROP5/ROP18 kinase complex and identified GRA7 association with the PVM by direct binding to ROP5. The absence of GRA7 results in reduced phosphorylation of Irga6 correlated with increased vacuolar IRG protein amounts and attenuated virulence. Earlier work identified additional IRG proteins as targets of T. gondii ROP18 kinase. We show that the only specific target of ROP18 among IRG proteins is in fact Irga6. Similarly, we demonstrate that GRA7 is strictly an Irga6-specific virulence effector. This identifies T. gondii GRA7 as a regulator for ROP18-specific inactivation of Irga6. The structural diversity of the IRG proteins implies that certain family members constitute additional specific targets for other yet unknown T. gondii virulence effectors.

Metabolic syndrome in patients on first-line antiretroviral therapy containing zidovudine or tenofovir in rural Lesotho, Southern Africa.

OBJECTIVE: To assess the prevalence of metabolic syndrome (MetS) among patients in rural Lesotho who are taking first-line antiretroviral therapy (ART) containing either zidovudine or tenofovir disoproxil. METHODS: Cross-sectional survey in 10 facilities in Lesotho among adult (≥16 years) patients on non-nucleoside reverse transcriptase inhibitor (NNRTI)-based first-line ART for ≥6 months. MetS was defined according to the International Diabetes Federation criteria. RESULTS: Among 1166 patients (65.8% female), 22.2% (95% CI: 19.3-25.3) of women and 6.3% (4.1-9.1) of men met the IDF definition of MetS (P < 0.001). In both sexes, there was no significant difference in MetS prevalence between NNRTIs. However, in women taking zidovudine as nucleoside reverse transcriptase inhibitor (NRTI), MetS prevalence was 27.9%, vs. 18.8% in those taking tenofovir. In the multivariate logistic regression allowing for socio-demographic and clinical covariates, ART containing zidovudine was associated with MetS in women (aOR 2.17 (1.46-3.22), P < 0.001) but not in men. CONCLUSION: In this study, taking ART containing zidovudine instead of tenofovir disoproxil was an independent predictor of MetS in women but not in men. This finding endorses WHO's recommendation of tenofovir as preferred NRTI.

Pessimistic back beliefs and lack of exercise: a longitudinal risk study in relation to shoulder, neck, and back pain.

This cross-lagged-panel study tested the validity of the German version of the back beliefs questionnaire (BBQ) in predicting pain in the shoulders, neck, and back. A random sample of 2860 individuals participated at baseline, and 73% responded at one-year follow-up. Structural equation modeling was used to carry out a model comparison to evaluate whether paths differed between individuals with and without initial back pain and between those who exercised at baseline and those who did not. Factor analysis showed eight of the nine original items loaded on the expected common factor. High BBQ scores at baseline significantly predicted an increase in shoulder, neck, and back pain in individuals with current back pain (ß = .11, p < .05), but not in other respondents (ß = .02, p = .259). Similarly, baseline BBQ scores predicted the increase in shoulder, neck, and back pain among those who did not exercise (ß = .15, p < .05), but not in those who did (ß = .04, ns). The risk of negative back beliefs preceding an increase in shoulder, neck, and back pain was greatest for those with current back pain who did not exercise (ß = .29, p < .05). The findings confirmed the validity of the German BBQ. Cognitive behavioral interventions should address pessimistic back beliefs in high-risk groups.

A Simple Guideline Reduces the Need for Red Blood Cell Transfusions in Swiss Hospitals: A Prospective, Multicentre, Before-and-After Study in Elective Hip and Knee Replacement.

INTRODUCTION: Optimising the use of blood has become a core task of transfusion medicine. Because no general guidelines are available in Switzerland, we analysed the effects of the introduction of a guideline on red blood cell (RBC) transfusion for elective orthopaedic surgery. METHODS: Prospective, multicentre, before-and-after study comparing the use of RBCs in adult elective hip or knee replacement before and after the implementation of a guideline in 10 Swiss hospitals, developed together with all participants. RESULTS: We included 2,134 patients, 1,238 in 7 months before, 896 in 6 months after intervention. 57 (34 or 2.7% before, 23 or 2.6% after) were lost before follow-up visit. The mean number of transfused RBC units decreased from 0.5 to 0.4 per patient (0.1, 95% CI 0.08-0.2; p = 0.014), the proportion of transfused patients from 20.9% to 16.9% (4%, 95% C.I. 0.7-7.4%; p = 0.02), and the pre-transfusion haemoglobin from 82.6 to 78.2 g/l (4.4 g/l, 95% C. I. 2.15-6.62 g/l, p < 0.001). We did not observe any statistically significant changes in in-hospital mortality (0.4% vs. 0%) and morbidity (4.1% vs. 4.0%), median hospital length of stay (9 vs. 9 days), follow-up mortality (0.4% vs. 0.2%) and follow-up morbidity (6.9% vs. 6.0%). CONCLUSIONS: The introduction of a simple transfusion guideline reduces and standardises the use of RBCs by decreasing the haemoglobin transfusion trigger, without negative effects on the patient outcome. Local support, training, and monitoring of the effects are requirements for programmes optimising the use of blood.

Situs ambiguus in a Brown Swiss cow with polysplenia: case report.

BACKGROUND: Laterality defects are rare in cattle and usually manifest as asplenia or polysplenia syndrome. These syndromes may be associated with situs ambiguus, which is a dislocation of some but not all internal organs. The objective of this report was to describe the clinical and post-mortem findings including the macroscopic and microscopic anatomy of selected organs in a cow with polysplenia and situs ambiguus. CASE PRESENTATION: A 3.5-year-old Brown Swiss cow was referred to the Department of Farm Animals, Vetsuisse Faculty, University of Zurich, because of poor appetite and recurrent indigestion. A diagnosis of situs ambiguus was based on the results of physical examination, ultrasonography, exploratory laparotomy and post-mortem examination. The latter revealed that the rumen was on the right side and lacked compartmentalisation. There were two spleens, one on the left (26.5 x 12.0 cm) and one on the right (20.5 x 5.5 cm), and the omasum was located craniolateral to the ruminoreticulum on the left. The abomasum was located on the right, although it had initially been displaced to the left. The three-lobed liver occupied the left and central cranioventral aspect of the abdominal cavity (cavum abdominis). Only the right and left hepatic veins (vena hepatica dextra and sinistra) drained into the thoracic segment of the caudal vena cava (vena cava caudalis), and histological changes in the liver were indicative of impaired haemodynamics. The mesojejunum was not fused with the mesentery of the spiral loop (ansa spiralis) of the ascending colon (colon ascendens). The latter was folded and the transverse colon (colon transversum) ran caudal to the cranial mesenteric artery (arteria mesenteria cranialis). Fibrotic constrictions were seen in the lumen of the caecum and proximal loop (ansa proximalis) of the ascending colon. Both kidneys were positioned retroperitoneally in a lumbar position. The lumbar segment of the caudal vena cava did not descend to the liver and instead drained into the right azygous vein (vena azygos dextra). CONCLUSIONS: Recurrent digestive problems and poor production in this patient may have been caused by a lack of rumen compartmentalisation, abnormal abomasal motility, constrictions in the large intestine (intestinum crassum) and fibrosis of the liver. The abomasum had abnormal motility most likely because it was anchored inadequately and only at its cranial aspect to the liver by the lesser omentum (omentum minus) and to the dorsal abdominal wall and rumen by a short greater omentum (omentum majus).

First seconds in a building's life-in situ synchrotron X-ray diffraction study of cement hydration on the millisecond timescale.

Setting cement: highly dynamic hydration processes that occur during the first seconds of cement hydration were studied by time-resolved synchrotron X-ray diffraction. Polycarboxylate ether additives were found to influence the formation of the initial crystalline hydration products on a molecular level.

Sleep quality, the neglected outcome variable in clinical studies focusing on locomotor system; a construct validation study.

BACKGROUND: In addition to general health and pain, sleep is highly relevant to judging the well-being of an individual. Of these three important outcome variables, however, sleep is neglected in most outcome studies.Sleep is a very important resource for recovery from daily stresses and strains, and any alteration of sleep will likely affect mental and physical health, especially during disease. Sleep assessment therefore should be standard in all population-based or clinical studies focusing on the locomotor system. Yet current sleep assessment tools are either too long or too specific for general use. METHODS: Based on a literature review and subsequent patient-based rating of items, an expert panel designed a four-item questionnaire about sleep. Construct validation of the questionnaire in a random sample of the German-speaking Swiss population was performed in 2003. Reliability, correlation, and tests for internal consistency and validity were analyzed. RESULTS: Overall, 16,634 (70%) out of 23,763 eligible individuals participated in the study. Test-retest reliability coefficients ranged from 0.72 to 0.87, and a Cronbach's alpha of 0.83 indicates good internal consistency. Results show a moderate to good correlation between sleep disturbances and health perception, and between sleep disturbances and overall pain. CONCLUSIONS: The Sleep Standard Evaluation Questionnaire (SEQ-Sleep) is a reliable and short tool with confirmed construct validity for sleep assessment in population-based observational studies. It is easy to administer and therefore suitable for postal surveys of the general population. Criterion validity remains to be determined.

Methods for the Measurement of Early Events in Toxoplasma gondii Immunity in Mouse Cells.

Critical steps in resistance of mice against Toxoplasma gondii occur in the first 2 or 3 h after the pathogen has entered a cell that has been exposed to interferon γ (IFNγ). The newly formed parasitophorous vacuole is attacked by the IFNγ-inducible IRG proteins and disrupted, resulting in death of the parasite and necrotic death of the cell. Here we describe some techniques that we have used to describe and quantify these events in different combinations of the host and the parasite.

Beliefs about back pain predict the recovery rate over 52 consecutive weeks.

OBJECTIVES: This study examined the course of low-back pain over 52 weeks following current pain at baseline. Initial beliefs about the inevitability of the pain's negative consequences and fear avoidance beliefs were examined as potential risk factors for persistent low-back pain. METHODS: On a weekly basis over a period of one year, 264 participants reported both the intensity and frequency of their low-back pain and the degree to which it impaired their work performance. In a multilevel regression analysis, predictor variables included initial low-back pain intensity, age, gender, body mass index, anxiety/depression, participation in sport, heavy workload, time (1-52 weeks), and scores on the "back beliefs" and "fear-avoidance beliefs" questionnaires. RESULTS: The group mean values for both the intensity and frequency of weekly low-back pain, and the impairment of work performance due to such pain showed a recovery within the first 12 weeks. In a multilevel regression of 9497 weekly measurements, greater weekly low-back pain and impairment were predicted by higher levels of work-related fear avoidance beliefs. A significant interaction between time and the scores on both the work-related fear-avoidance and back beliefs questionnaires indicated faster recovery and pain relief over time in those who reported less fear-avoidance and fewer negative beliefs. CONCLUSIONS: Negative beliefs about the inevitability of adverse consequences of low-back pain and work-related, fear-avoidance beliefs are independent risk factors for poor recovery from low-back pain.

Measuring limitations in activities of daily living: a population-based validation of a short questionnaire.

PURPOSE: A newly developed questionnaire assessing limitations in activity of daily living (LADL-Q) that should improve assessment of LADL is tested in a large population-based validation study. METHODS: This survey was paper-based. Overall, 16,634 individuals who were representative of the working population in the German-speaking part of Switzerland participated in the study. Item analysis was used the final version of the LADL-Q to four items per subscale that correspond to potential problems in three body regions (back and neck, upper extremities, lower extremities). Analysis included tests for reliability, internal consistency, dimensionality and convergent validity. RESULTS: Test-retest reliability coefficients after 2 weeks ranged from 0.82 to 0.99 (Mdn = 0.87), with no item having a coefficient below 0.60. The median item-total coefficients ranged between moderate and good. Correlation coefficients between LADL-Q subscales and three validated clinical instruments (Western Ontario and McMaster Universities osteoarthritis index, shoulder pain disability index, Oswestry) ranged from 0.63 to 0.81. In structural equation modeling the three subscales were significantly related with two important outcomes in occupational rehabilitation: self-reported general health and daily task performance. CONCLUSION: The new LADL-Q is a brief, reliable and valid tool for assessment of LADL in studies on musculoskeletal health.

Author Correction: Molecular mechanism for the control of virulent Toxoplasma gondii infections in wild-derived mice.

The original version of this Article contained an error in the Acknowledgements, which incorrectly omitted the following: 'C.C., C.A., and J.C.H. were supported by the Fundação Calouste Gulbenkian through a grant from the Instituto Gulbenkian de Ciência and by the research infrastructure Congento, project LISBOA-01-0145-FEDER-022170, co-financed by Lisboa Regional Operational Programme (Lisboa 2020), under the Portugal 2020 Partnership Agreement, through the European Regional Development Fund (ERDF), and Foundation for Science and Technology (Portugal).' This has been corrected in both the PDF and HTML versions of the Article.

Molecular mechanism for the control of virulent Toxoplasma gondii infections in wild-derived mice.

Some strains of the protozoan parasite Toxoplasma gondii (such as RH) are virulent in laboratory mice because they are not restricted by the Immunity-Related GTPase (IRG) resistance system in these mouse strains. In some wild-derived Eurasian mice (such as CIM) on the other hand, polymorphic IRG proteins inhibit the replication of such virulent T. gondii strains. Here we show that this resistance is due to direct binding of the IRG protein Irgb2-b1CIM to the T. gondii virulence effector ROP5 isoform B. The Irgb2-b1 interface of this interaction is highly polymorphic and under positive selection. South American T. gondii strains are virulent even in wild-derived Eurasian mice. We were able to demonstrate that this difference in virulence is due to polymorphic ROP5 isoforms that are not targeted by Irgb2-b1CIM, indicating co-adaptation of host cell resistance GTPases and T. gondii virulence effectors.

Differences across health care systems in outcome and cost-utility of surgical and conservative treatment of chronic low back pain: a study protocol.

BACKGROUND: There is little evidence on differences across health care systems in choice and outcome of the treatment of chronic low back pain (CLBP) with spinal surgery and conservative treatment as the main options. At least six randomised controlled trials comparing these two options have been performed; they show conflicting results without clear-cut evidence for superior effectiveness of any of the evaluated interventions and could not address whether treatment effect varied across patient subgroups. Cost-utility analyses display inconsistent results when comparing surgical and conservative treatment of CLBP. Due to its higher feasibility, we chose to conduct a prospective observational cohort study. METHODS: This study aims to examine if1. Differences across health care systems result in different treatment outcomes of surgical and conservative treatment of CLBP2. Patient characteristics (work-related, psychological factors, etc.) and co-interventions (physiotherapy, cognitive behavioural therapy, return-to-work programs, etc.) modify the outcome of treatment for CLBP3. Cost-utility in terms of quality-adjusted life years differs between surgical and conservative treatment of CLBP. This study will recruit 1000 patients from orthopaedic spine units, rehabilitation centres, and pain clinics in Switzerland and New Zealand. Effectiveness will be measured by the Oswestry Disability Index (ODI) at baseline and after six months. The change in ODI will be the primary endpoint of this study. Multiple linear regression models will be used, with the change in ODI from baseline to six months as the dependent variable and the type of health care system, type of treatment, patient characteristics, and co-interventions as independent variables. Interactions will be incorporated between type of treatment and different co-interventions and patient characteristics. Cost-utility will be measured with an index based on EQol-5D in combination with cost data. CONCLUSION: This study will provide evidence if differences across health care systems in the outcome of treatment of CLBP exist. It will classify patients with CLBP into different clinical subgroups and help to identify specific target groups who might benefit from specific surgical or conservative interventions. Furthermore, cost-utility differences will be identified for different groups of patients with CLBP. Main results of this study should be replicated in future studies on CLBP.

Influence of preoperative functional status on outcome after total hip arthroplasty.

BACKGROUND: International registries with large, heterogeneous patient populations provide excellent research opportunities for studying factors that influence treatment outcomes after total hip arthroplasty. In the present study, we used a European multinational database to investigate whether there is an association between three functional variables (preoperative pain, mobility, and motion) and functional outcome. METHODS: We performed a retrospective cohort study on preoperative and follow-up clinical data that were prospectively entered into the International Documentation and Evaluation System European hip registry between 1967 and 2002. The inclusion criteria for this study were an age of more than twenty years, an underlying diagnosis of osteoarthritis, and a Charnley class-A functional designation at the time of surgery. A total of 12,925 patients (13,766 total hip arthroplasties) who met these criteria were entered into the analysis. Three functional variables (pain, mobility, and motion) that were assessed preoperatively were evaluated postoperatively at various follow-up examinations for a maximum of ten years. RESULTS: Six thousand four hundred and one patients could walk longer than ten minutes preoperatively; of these, 57.1% had a walking capacity of more than sixty minutes at the time of the most recent follow-up. In comparison, 6896 patients had a preoperative walking capacity of less than ten minutes and only 38.9% of these patients could walk more than sixty minutes at the time of the most recent follow-up. The difference was significant (p < 0.01). Similarly, 10,375 patients had a preoperative hip flexion range of >70 degrees ; of these, 74.7% had a flexion range of >90 degrees at the time of the most recent follow-up. In comparison, 2793 patients had a preoperative hip flexion range of <70 degrees and only 62.6% of these patients had a flexion range of >90 degrees at the time of the most recent follow-up. The difference was also significant (p < 0.01). Lasting, complete, or almost complete pain relief was achieved by >80% of the patients following total hip arthroplasty regardless of their preoperative categorization of pain. CONCLUSIONS: Patients with poor preoperative walking capacity and hip flexion are less likely to achieve an optimal outcome with regard to walking and motion. In contrast, there is no correlation between the preoperative pain level and pain alleviation, which is generally good and long-lasting after total hip arthroplasty.

Exploring Supervisor-Related Job Resources as Mediators between Supervisor Conflict and Job Attitudes in Hospital Employees.

BACKGROUND: Conservation of resources theory assumes loss of resources as a cause of job strain. In hospital work, conflicts with supervisors are tested to predict lower resources, that is, supervisory social support, participation possibilities, and appreciation. All three resources are expected to predict, in turn, experienced stress (job strain) and lower job satisfaction, lower affective commitment, and a higher resigned attitude towards the job (job attitudes). METHODS: The sample included 1,073 employees from 14 Swiss hospitals (n = 604 nurses, n = 81 physicians, n = 135 medical therapists, and n = 253 technical and administrative staff). Of the total sample, 83.1% were female and 38.9% worked full-time. The median tenure was between 7 years and 10 years. Constructs were assessed by online questionnaires. Structural equation modeling was used to test mediation. RESULTS: Structural equation modeling confirmed the negative association of conflict with supervisors and job resources. Tests of indirect paths to resources as a link between conflicts with supervisors and job attitudes were significant. For nurses, social support, participation and appreciation showed a significant indirect path, while among medical technicians the indirect paths included social support and appreciation, and among physicians only appreciation showed a significant indirect path. In medical therapists no indirect path was significant. Job resources did not mediate the link between conflict with supervisors and stress in any occupational group. CONCLUSION: Conflicts with supervisors are likely to reduce job resources and in turn to lower job attitudes. Work design in hospitals should, therefore, address interpersonal working conditions and conflict management in leadership development.

The impact of Toxoplasma gondii on the mammalian genome.

Nobody doubts that infections have imposed specialisations on the mammalian genome. However sufficient information is usually missing to attribute a specific genomic modification to pressure from a specific pathogen. Recent studies on mechanisms of mammalian resistance against the ubiquitous protozoan parasite, Toxoplasma gondii, have shown that the small rodents presumed to be largely responsible for transmission of the parasite to its definitive host, the domestic cat, possess distinctive recognition proteins, and interferon-inducible effector proteins (IRG proteins) that limit the potential virulence of the parasite. The phylogenetic association of the recognition proteins, TLR11 and TLR12, with T. gondii resistance is weak, but there is evidence for reciprocal polymorphism between parasite virulence proteins and host IRG proteins that strongly suggests current or recent coevolution.

Reciprocal virulence and resistance polymorphism in the relationship between Toxoplasma gondii and the house mouse.

Virulence in the ubiquitous intracellular protozoon Toxoplasma gondii for its natural intermediate host, the mouse, appears paradoxical from an evolutionary standpoint because death of the mouse before encystment interrupts the parasite life cycle. Virulent T. gondii strains secrete kinases and pseudokinases that inactivate the immunity-related GTPases (IRG proteins) responsible for mouse resistance to avirulent strains. Such considerations stimulated a search for IRG alleles unknown in laboratory mice that might confer resistance to virulent strains of T. gondii. We report that the mouse IRG system shows extraordinary polymorphic complexity in the wild. We describe an IRG haplotype from a wild-derived mouse strain that confers resistance against virulent parasites by interference with the virulent kinase complex. In such hosts virulent strains can encyst, hinting at an explanation for the evolution of virulence polymorphism in T. gondii. DOI:http://dx.doi.org/10.7554/eLife.01298.001.

Do we need new personalized emergency telehealth solutions? A survey of 100 emergency department patients and a first report of the swiss limmex emergency wristwatch: an original study.

Development of new personal mobile and wireless devices for healthcare has become essential due to our aging population characterized by constant rise in chronic diseases that consequently require a complex treatment and close monitoring. Personal telehealth devices allow patients to adequately receive their appropriate treatment, followup with their doctors, and report any emergency without the need of the presence of any caregivers with them thus increasing their quality of life in a cost-effective fashion. This paper includes a brief overview of personal telehealth systems, a survey of 100 consecutive ED patients aged >65 years, and introduces "Limmex" a new GSM based technology packaged in a wristwatch. Limmex can by a push of a button initiate multiple emergency call and establish mobile communication between the patient and a preselected person, institution, or a search and rescue service. To the best of our knowledge, Limmex is the first of its kind worldwide.