Revision Rate and Risk Factors After Lower Extremity Amputation in Diabetic or Dysvascular Patients.

This article reports the revision rate and possible risk factors for lower extremity amputations in patients with diabetes mellitus or peripheral arterial disease (PAD). Data were collected from 421 patients with diabetes mellitus or PAD who underwent amputations of the lower extremity at the authors' institution from 2002 to 2012. There was a 25.2% overall revision rate. Mean time from amputation to revision was 244 days (range, 2-2590 days). Patients with diabetes mellitus had a significantly higher rate of revision to a more proximal level compared with patients without diabetes mellitus (type 1: odds ratio [OR]=3.73; 95% confidence interval [CI], 1.21-11.52; P=.022; and type 2: OR=2.3; 95% CI, 1.07-4.95; P=.033). A significant increase in revision rates was observed from Fontaine stage 0 to IV (stage 0: 17.9%; stage IV, 34.7%; P=.03). Risk factors for revision were diabetic nephropathy (OR=2.26; 95% CI, 1.4-3.63; P=.001) and polyneuropathy (OR=1.68; 95% CI, 1.03-2.73; P=.037). Patients who underwent revision amputation had a significantly younger mean age than patients who did not undergo revision amputation (65.23 years [range, 40-92 years] vs 68.52 years [range, 32-96 years]; P=.013). Anticipated amputation in this patient population requires a multidisciplinary approach with optimization of the patient's health. In the authors' clinical practice, the determination of the appropriate amputation level is performed individually for each patient, considering the risk factors identified in this study and the patient's expected mobilization potential, social background, and acceptance of a more proximal primary amputation level.

Safety of Early High-Dose Recombinant Erythropoietin for Neuroprotection in Very Preterm Infants.

OBJECTIVE: To investigate the safety and short term outcome of high dose recombinant human erythropoietin (rhEpo) given shortly after birth and subsequently over the first 2 days for neuroprotection to very preterm infants. STUDY DESIGN: Randomized, double masked phase II trial. Preterm infants (gestational age 26 0/7-31 6/7 weeks) were given rhEpo (nt = 229; 3000 U/kg body weight) or NaCl 0.9% (nc = 214) intravenously at 3, 12-18, and 36-42 hours after birth. RESULTS: There were no relevant differences between the groups for short-term outcomes such as mortality, retinopathy of prematurity, intraventricular hemorrhage, sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia. At day 7-10, we found significantly higher hematocrit values, reticulocyte, and white blood cell counts, and a lower platelet count in the rhEpo group. CONCLUSIONS: Early high-dose rhEpo administration to very premature infants is safe and causes no excess in mortality or major adverse events. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00413946.

Impact of the DRG-based reimbursement system on patient care and professional practise: perspectives of Swiss hospital physicians.

QUESTIONS UNDER STUDY: The reimbursement system SwissDRG sets incentives for hospitals and providers to treat patients in a cost-efficient way. Arising conflicts between the commitment to the patient's well-being and the economic interests of the hospital can lead to an impairment of quality and equity of health care. We developed and used a monitoring tool to evaluate ethically relevant aspects related to DRGs by surveying physicians. METHODS: We surveyed a random sample of physicians working in Swiss hospitals, exploring potentially positive and negative effects of DRGs on patient care. RESULTS: A total of 382 physicians completed the questionnaire (response rate 47%). More than 90% judged quality of health care "very good" or "rather good", and 83% were satisfied with their job. The majority of physicians gave more consideration to economic issues in their clinical practise than they would have liked and had experienced various forms of over- and under-provision over the past six months. Overall, physicians considered patient-orientation deteriorating since the introduction of DRGs with no gains in efficiency. Professional principles could not be applied in all instances. CONCLUSIONS: Two years after the introduction of SwissDRG the quality of patient care and the job satisfaction is rated as good by most physicians. However, quality of care could be seriously compromised if more economic pressure is put on physicians in the future. Careful monitoring is needed to ensure that the needed focus on cost-containment and sustainability does not come at the expense of the high performance of the Swiss health care system.

Cancer comortality patterns in schizophrenia and psychotic disorders: a new methodological approach for unique databases.

The aim of this study was to determine the pattern of cancer comortality in deaths registered with schizophrenia and psychotic disorders. It focused on the question of whether the proportions of different types of cancer diverge when they are co-registered with schizophrenia/psychotic disorders or with other causes of death in mortality statistics. We developed an analysis approach applicable to common mortality statistics data when no linkage with morbidity databases or other registers is possible. The analysis covered Swiss mortality data from a 39-year period (1969 - 2007) and was confined to the most frequent cancers. We applied a two-step case-control analysis with bootstrapping (1000 repetitions). The cases were defined by the cancer-schizophrenia registrations for each specific cancer, whereas the controls were matched from the remaining cases (matching criteria: sex, age, region, subperiod). Cancers with deviant standardized mortality ratios (SMRs) included stomach cancer (1.6; 2.2 after reweighting), lung cancer (0.8; 0.5 after reweighting) and breast cancer (1.6; 1.5 after reweighting). The comortality pattern of cancers in schizophrenia and psychotic disorders diverges from the pattern found in other co-registered causes of death. The relatively low frequency of lung cancers is particularly paradoxical in view of the smoking habits of schizophrenia patients.

Is the work ability index useful to evaluate absence days in ankylosing spondylitis patients? A cross-sectional study.

BACKGROUND: The work incapacity of ankylosing spondylitis (AS) ranges between 3% and 50% in Europe. In many countries, work incapacity is difficult to quantify. The work ability index (WAI) is applied to measure the work ability in workers, but it is not well investigated in patients. AIMS: To investigate the work incapacity in terms of absence days in patients with AS and to evaluate whether the WAI reflects the absence from work. HYPOTHESIS: Absence days can be estimated based on the WAI and other variables. DESIGN: Cross-sectional design. SETTING: In a secondary care centre in Switzerland, the WAI and a questionnaire about work absence were administered in AS patients prior to cardiovascular training. The number of absence days was collected retrospectively. The absence days were estimated using a two-part regression model. PARTICIPANTS: 92 AS patients (58 men (63%)). INCLUSION CRITERIA: AS diagnosis, ability to cycle, age between 18 and 65 years. EXCLUSION CRITERIA: severe heart disease. PRIMARY AND SECONDARY OUTCOME MEASURES: Absence days. RESULTS: Of the 92 patients, 14 received a disability pension and 78 were in the working process. The median absence days per year of the 78 patients due to AS alone and including other reasons was 0 days (IQR 0-12.3) and 2.5 days (IQR 0-19), respectively. The WAI score (regression coefficient=-4.66 (p<0.001, CI -6.1 to -3.2), 'getting a disability pension' (regression coefficient=-106.8 (p<0.001, 95% CI -141.6 to -72.0) and other not significant variables explained 70% of the variance in absence days (p<0.001), and therefore may estimate the number of absence days. CONCLUSIONS: Absences in our sample of AS patients were equal to pan-European countries. In groups of AS patients, the WAI and other variables are valid to estimate absence days with the help of a two-part regression model.

Profile of travel-associated illness in children, Zürich, Switzerland.

BACKGROUND: The number of families traveling with their children to their country of origin and/or to tropical destinations has increased in Switzerland and includes a changing profile and multinational range of patients. Defining the profile of reported travel-associated illnesses will help to improve the prevention and treatment of such illnesses in children. METHODS: This study includes children aged up to 16 years who sought medical advice for a presumed travel-related illness at the emergency room of the University of Zürich Children's Hospital during the period July 2007 to December 2008. RESULTS: We analyzed data on 328 children (58.8% male, mean age: 4.62 y) who presented with travel-associated illness. Our analysis included 155 traditional (mainly tourist) travelers, 162 children who were visiting friends and relatives (VFR), and 11 immigrants. Some 11% were hospitalized. No deaths occurred. The main conditions recorded were diarrheal illness (39%), respiratory (28.7%) and febrile/systemic illness (13.4%). With increasing age, the proportion of children with diarrheal disease increased, while the proportion with respiratory illness declined. There were significant associations between geographic area of exposure and the profile of travel-related disease (p < 0.001). Among 36 children with more serious diseases requiring hospitalization, 12 (3.7% overall) presented with potentially serious diseases: malaria (n = 2), Salmonella typhi (n = 3), Salmonella paratyphi (n = 2), meningococcal meningitis (n = 1), tuberculosis (n = 2), visceral leishmania (n = 1), and hepatitis A (n = 1). Eleven of the 12 children presenting with these potentially serious illnesses were VFR or immigrant children. CONCLUSION: The main diagnoses for ill-returned Zürich children who presented for emergency care were diarrhea, respiratory, and febrile/systemic illness. A broad spectrum of morbidity was seen including meningococcal meningitis, malaria, tuberculosis, typhoid fever, leishmania, and hepatitis A. Diagnoses varied between geographic regions visited, and VFR child travelers constituted a large proportion of sick-returned children presenting for emergency care.

Birth cohort effects in neurological diseases: amyotrophic lateral sclerosis, Parkinson's disease and multiple sclerosis.

BACKGROUND: Generational differences in disease rates are the main subject of age-period-cohort (APC) analysis, which is mostly applied in cancer and suicide research. This study applied APC analysis to selected neurological diseases: amyotrophic lateral sclerosis (ALS), Parkinson's disease (PD) and multiple sclerosis (MS). METHODS: The analyses were based on Swiss mortality data. Age-stratified data has been available for MS, PD and ALS since 1901, 1921, and 1942, respectively. APC analysis was performed within the framework of logit models. Main effect models were extended by implementing nested effects, i.e. age effects nested in subperiods, in order to account for the fact that age profiles may change for reasons other than generational influences. RESULTS: In preliminary analyses, APC analysis yielded noteworthy birth cohort effects in all three diseases. After implementing nested effects, the birth cohort effects disappeared in ALS, and smoothed out in PD, where they were greater for the generations born before the 1920s. In MS, the birth cohort effects remained stable, and exhibited a peak in cohorts born in the 1910s and 1920s. CONCLUSIONS: APC analysis yielded some evidence for birth cohort effects, i.e. predisposing risk factors that may change in historical terms, in MS and PD, but probably not in ALS.

Irritable bowel syndrome among a cohort of European travelers to resource-limited destinations.

BACKGROUND: Travelers' diarrhea (TD) remains a frequent travel-associated infection. Between 4 and 32% of enteric infections were followed by a postinfectious irritable bowel syndrome (pIBS) with long-term sequelae in various settings. Travel-related IBS incidence rates are based on small studies and IBS predictors have not been sufficiently evaluated. METHODS: Adult travelers to resource-limited destinations participated in a prospective questionnaire-based cohort study. Demographics, travel characteristics, and medical history were assessed and those with functional or organic gastrointestinal disorders were excluded. Immediately after return from abroad, the volunteers completed a second questionnaire on TD, other health impairments, and on nutritional hygiene. Six-months post-travel, a follow-up questionnaire assessed IBS based on Rome III criteria. Risk factors were analyzed by multiple logistic regression. RESULTS: Among a total of 2,476 subjects analyzed (participation rate 72.4%), 38 (1.5%) developed new IBS, and the 6-month incidence rate for pIBS was 3.0% (95% CI 1.9-4.2) following TD. Significant risk factors were TD during the surveyed journey (OR 3.7; 95% 1.8-7.4), an adverse life event experienced within 12 months pre-travel (OR 3.1; 1.4-6.8), and a diarrheal episode experienced within 4 months pre-travel (OR 2.7; 95% CI 1.3-5.6). Following multiple diarrheal episodes, the risk of acquiring IBS increased by six times. CONCLUSIONS: In a large population of European travelers IBS had a lower incidence rate as compared to previous studies. Particular risk groups were identified; those may need to be protected.

Exposure to bioaerosols, respiratory health and lung-specific proteins: a prospective study in garbage and wastewater workers.

OBJECTIVES: To prospectively assess respiratory health in wastewater workers and garbage collectors over 5 years. METHODS: Exposure, respiratory symptoms and conditions, spirometry and lung-specific proteins were assessed yearly in a cohort of 304 controls, 247 wastewater workers and 52 garbage collectors. Results were analysed with random coefficient models and linear regression taking into account several potential confounders. RESULTS: Symptoms, spirometry and lung-specific proteins were not affected by occupational exposure. CONCLUSIONS: In this population no effects of occupational exposure to bioaerosols were found, probably because of good working conditions.

High incidence of independent second malignancies after non-muscle-invasive bladder cancer.

OBJECTIVE: The incidence of urogenital tumours is constantly increasing as a result of over-proportional ageing of the population in industrialized nations. Follow-up of non-muscle-invasive bladder cancer (NMIBC) primarily relies on the detection of either relapse or progression and does not include screening for second malignancies. This study investigated the incidence of independent non-urothelial second malignancies and associated risk factors in patients with NMIBC. MATERIAL AND METHODS: The charts of 380 consecutive patients (297 men and 83 women) with newly diagnosed NMIBC over a 16-year period at a Swiss hospital were analysed retrospectively. Age, stage of bladder tumour, smoking status, and occurrence of second and third malignancies were registered. Observed incidences of independent non-urothelial malignancies were compared with age- and gender-specific rates based on data from the National Institute for Cancer Epidemiology and Registration by calculating standardized incidence ratios (SIRs). RESULTS: Mean age at first NMIBC diagnosis was 69.9 years. Histological stage of the NMIBC was pTa in 241 patients (63.4%), pT1 in 102 (26.8%)and pTis in 37 (9.7%). During follow-up, 62 independent non-urothelial second or third malignancies were observed in 48 men (16.2%) and 10 women (12.0%). In male patients, prostate and lung cancer (SIR 4.3 and 5.7, respectively) were more frequent than expected in the general population, as were lung and uterine cancer in women. CONCLUSIONS: Follow-up in patients with NMIBC should pay special attention to independent non-urothelial malignancies. Investigations for non-urological malignant disease, especially for lung cancer, should form part of the standard follow-up in NMIBC patients.

Knowledge, attitudes, and practices of business travelers regarding influenza and the use of antiviral medication.

BACKGROUND: This study aimed to determine the knowledge, attitudes, and practices of Swiss business travelers with regard to influenza and the use of antiviral medication. METHODS: Questionnaires, available in three languages, were distributed manually and online through companies, organizations, and travel medicine specialists in Switzerland to business travelers who were traveling during the period January 2005 to April 2009. RESULT: In total, 661 questionnaires were fully completed and evaluated. A total of 58.9% (n = 388) of the respondents stated that they had contracted influenza in the past; some 48.6% (n = 321) of the travelers had been vaccinated against seasonal influenza at least once in their lifetime; 87.1% (n = 576) of the travelers knew that influenza can be transmitted by droplets; and 62.3% (n = 412) were aware of transmission by direct contact. Almost all respondents (96.8%; n = 633) recognized fever as a main symptom of influenza, 80.0% (n = 523) knew about muscular aches and pain, 79.5% (n = 520) about shivering, and 72.9% (n = 477) about joint pain. Some 38.0% (n = 250) of the respondents stated that the annual vaccination is their preferred prevention method for influenza, 35.6% (n = 234) would neither do an annual vaccination nor carry antiviral medication, 16.0% (n = 105) would carry antiviral medication, 8.5% (n = 56) would prefer to do both the annual vaccination and to carry antivirals, and 2.0% (n = 13) would use antivirals as influenza prophylaxis. Regarding prevention, the majority (78.9%; n = 498) of the travelers did not seek advice on influenza before going on their last business trip, 58.0% (n = 381) did not take any preventive measures against influenza, 27.2% (n = 179) had their annual vaccination, and 15.7% (n = 103) observed hand hygiene. Of the travelers, 9.7% (n = 64) carried antiviral medication on their last business trip and 7.0% (n = 46) actually used this medication. CONCLUSIONS: Business travelers have a good knowledge about the transmission and the symptoms of influenza but guidelines are needed that concisely address the indications for influenza vaccination in travelers and the carriage and use of antiviral medication.

Diarrhoea in a large prospective cohort of European travellers to resource-limited destinations.

BACKGROUND: Incidence rates of travellers' diarrhoea (TD) need to be updated and risk factors are insufficiently known. METHODS: Between July 2006 and January 2008 adult customers of our Centre for Travel Health travelling to a resource-limited country for the duration of 1 to 8 weeks were invited to participate in a prospective cohort study. They received one questionnaire pre-travel and a second one immediately post-travel. First two-week incidence rates were calculated for TD episodes and a risk assessment was made including demographic and travel-related variables, medical history and behavioural factors. RESULTS: Among the 3100 persons recruited, 2800 could be investigated, resulting in a participation rate of 89.2%. The first two-weeks incidence for classic TD was 26.2% (95%CI 24.5-27.8). The highest rates were found for Central Africa (29.6%, 95% CI 12.4-46.8), the Indian subcontinent (26.3%, 95%CI 2.3-30.2) and West Africa (21.5%, 95%CI 14.9-28.1). Median TD duration was 2 days (range 1-90). The majority treated TD with loperamide (57.6%), while a small proportion used probiotics (23.0%) and antibiotics (6.8%). Multiple logistic regression analysis on any TD to determine risk factors showed that a resolved diarrhoeal episode experienced in the 4 months pre-travel (OR 2.03, 95%CI 1.59-2.54), antidepressive comedication (OR 2.11, 95%CI 1.17-3.80), allergic asthma (OR 1.67, 95%CI 1.10-2.54), and reporting TD-independent fever (OR 6.56, 95%CI 3.06-14.04) were the most prominent risk factors of TD. CONCLUSIONS: TD remains a frequent travel disease, but there is a decreasing trend in the incidence rate. Patients with a history of allergic asthma, pre-travel diarrhoea, or of TD-independent fever were more likely to develop TD while abroad.

Influence of bowel preparation before 18F-FDG PET/CT on physiologic 18F-FDG activity in the intestine.

UNLABELLED: Our objective was to investigate the use of bowel preparation before (18)F-FDG PET/CT to reduce intestinal (18)F-FDG uptake. METHODS: Sixty-five patients with abdominal neoplasias were assigned either to a bowel-preparation group (n = 26) or to a native group (n = 39). (18)F-FDG activity was measured in the small intestine and the colon. RESULTS: In the 26 patients with bowel preparation, average maximal standardized uptake value (SUVmax) was 3.5 in the small intestine and 4.4 in the colon. In the 39 patients without bowel preparation, average SUVmax was 2.6 in the small intestine and 2.7 in the colon. (18)F-FDG activity impaired diagnosis in 6 patients (23%) in the bowel-preparation group and 11 patients (28%) in the native group (P = 0.5). SUVmax in the colon was significantly higher in the bowel-preparation group (P = 0.002), but SUVmax in the small intestine did not significantly differ between the 2 groups (P = 0.088). CONCLUSION: Bowel preparation increases (18)F-FDG activity in the large intestine and is therefore not useful before PET/CT.

Feasibility of integrated CT-liver perfusion in routine FDG-PET/CT.

OBJECTIVE: To integrate CT-perfusion into a routine, clinical contrast-enhanced (ce) PET/CT protocol for the evaluation of liver metastases and to compare functional CT and PET parameters. MATERIALS AND METHODS: Forty-six consecutive patients (mean age: 60 (34-82) years; 20 f, 26 m) with known liver lesions (colorectal metastases (n = 34), primary liver cancer (n = 4), breast cancer (n = 3), anal cancer, gastric cancer, esophageal cancer, GIST, duodenal cancer (all: n = 1) who were referred for staging or therapy follow-up by [18F]-Fluoro-2-deoxy-D-glucose-positron-emission-tomography/computed-tomography imaging (FDG-PET/CT) were included. After acquisition of a low-dose PET/CT, a split-injection (70-90 mL) ce-CT-protocol, including a 35-s CT-perfusion scan of the liver and a diagnostic ce-CT of the thorax and/or abdomen (70 s delay, iv-contrast volume: 90 mL, 4 mL/s) was performed. CT-perfusion parameters (BF, BV, MTT,) and semi-quantitative PET-parameters (SUVmax, SUVmean, TLG, PETvol) were analyzed and compared. RESULTS: CT-perfusion data could be obtained in all but one patient with shallow breathing. In all patients, diagnostic ce-PET/CT quality was adequate without the use of additional contrast media. Significant correlations (P < 0.05) were found for each of BF, BV, MTT, and SUVmax, further, BF and MTT correlated with TLG. Several other correlations were seen for other perfusion and PET-parameters. CONCLUSION: Combined CT-perfusion/PET/CT-protocol without the use of additional contrast media is feasible and can be easily integrated in clinical routine. Perfusion parameters and PET-parameters are only partly correlating and therefore have to be investigated further at fixed time points during the course of disease and therapy.

Association between catastrophizing and self-rated pain and disability in patients with chronic low back pain.

BACKGROUND: Catastrophizing plays an important role in models of pain chronicity, showing a consistent correlation with both pain intensity and disability. It is conceivable that these associations are mediated or confounded by other psychological attributes. OBJECTIVE: To examine the relative influence of catastrophizing and other psychological variables on pain and disability in patients with chronic low back pain. METHODS: Seventy-eight patients completed the Pain Catastrophizing Scale, Roland Morris Disability Questionnaire, Fear-Avoidance Beliefs Questionnaire (work/activity), Modified Somatic Perception Questionnaire, Modified Zung Depression Scale, and Pain Intensity scale. RESULTS: Catastrophizing was significantly correlated with both Pain intensity and Roland and Morris Disability, and with all other psychological variables (all p < 0.001). However, multiple regression analyses showed that Catastrophizing explained no significant variance in Pain intensity beyond that explained by the unique contributions of Modified Somatic Perception and Fear-Avoidance Beliefs (work) and explained no further variance in Disability beyond that explained by the unique contributions of Fear-Avoidance Beliefs (work) and Depression. CONCLUSION: These findings are consistent with previous models proposing that negative psychological attributes are associated with greater perceptions of pain and disability. Nonetheless, our study indicates that measures of catastrophizing show notable measurement overlap in multivariate models.

Staging pathways in recurrent colorectal carcinoma: is contrast-enhanced 18F-FDG PET/CT the diagnostic tool of choice?

UNLABELLED: (18)F-FDG PET/CT has gained wide acceptance for evaluation of recurrent colorectal carcinoma. However in clinical practice, contrast-enhanced CT (ceCT) is still the first-line restaging tool. The aim of this study was to investigate the value of contrast-enhanced PET/CT (cePET/CT) as a first-line restaging tool with a special focus on the importance of the use of intravenous contrast. METHODS: Fifty-four patients (17 women, 37 men; mean age, 60.3 y), referred for restaging of colorectal carcinoma, were examined with cePET/CT. Retrospective analysis was performed by 2 experienced readers by consensus: first, ceCT alone; second, non-cePET/CT; and third, cePET/CT. The number, localization, and diagnostic certainty of lesions were evaluated. Additionally, the therapeutic impact of the findings was determined. In 29 patients, histology, clinical imaging, and clinical follow-up served as the reference standard. In 25 patients, clinical follow-up and imaging served as the reference standard. RESULTS: Overall, non-cePET/CT delivered correct additional information to the ceCT findings in 27 of 54 patients (50%). This occurred in (a) 20 of 30 patients, where ceCT was found to be inconclusive, and in (b) 7 of 24 patients with conclusive ceCT findings, where non-cePET/CT found additional lesions, leading to a therapy modification in 5 patients. Compared with non-cePET/CT, cePET/CT revealed additional information in 39 of 54 patients (72%), with therapeutic relevance in 23 patients. This large number was primarily due to correct segmental localization of liver metastases, which is crucial for surgical therapy planning. CONCLUSION: On the basis of its higher accuracy and therapeutic impact compared with ceCT, our data suggest that cePET/CT might be considered as the first-line diagnostic tool for restaging in patients with colorectal cancer.

Exposure to ethylene oxide in hospitals: biological monitoring and influence of glutathione S-transferase and epoxide hydrolase polymorphisms.

Ethylene oxide is considered as a human carcinogen. A biomarker of exposure would be a useful instrument to assess the risk in occupationally exposed workers. This cross-sectional study aimed at examining (a) whether the urinary excretion of a metabolite of ethylene oxide, 2-hydroxyethyl mercapturic acid (HEMA), could be used for monitoring occupational exposure and (b) whether glutathione S-transferase (GST) and epoxide hydrolase genotypes influenced biological monitoring. Exposure to ethylene oxide was measured by personal sampling in 80 hospital workers (95% of those eligible). HEMA concentrations were determined in three urine samples (baseline, end of shift, and next morning) by liquid chromatography with tandem mass spectrometry. GSTs (GSTT1, GSTM1, and GSTP1) and epoxide hydrolase (EPHX1) were also genotyped. The influence of exposure, genotypes, and several other factors was examined in multiple regression analyses. Exposure was always <1 parts per million. On a group basis, exposure and a non-null GSTT1 genotype increased the HEMA concentrations in the urine sample collected at the end of the shift and these factors remained statistically significant after considering possible confounding or modifying factors.

Surfactant protein A, exposure to endotoxin, and asthma in garbage collectors and in wastewater workers.

Endotoxin causes an inflammation at the bronchial and alveolar level. The inflammation-induced increase in permeability of the bronchoalveolar epithelial barrier is supposed to cause a leakage of pneumoproteins. Therefore, their concentrations are expected to increase in the bloodstream. This study aimed at examining the association between occupational exposure to endotoxin and a serum pneumoprotein, surfactant protein A, to look for nonoccupational factors capable of confounding this association, and examine the relation between surfactant protein A and spirometry. There were 369 control subjects, 325 wastewater workers, and 84 garbage collectors in the study. Exposure to endotoxin was assessed through personal sampling and the Limulus amebocytes lysate assay. Surfactant protein A was determined by an in house sandwich enzyme-linked immunosorbent assay (ELISA) in 697 subjects. Clinical and smoking history were ascertained and spirometry carried out according to American Thoracic Society criteria. Multiple linear regression was used for statistical analysis. Exposure was fairly high during some tasks in wastewater workers but did not influence surfactant protein A. Surfactant protein A was lower in asthmatics. Interindividual variability was large. No correlation with spirometry was found. Endotoxin has no effect on surfactant protein A at these endotoxin levels and serum surfactant protein A does not correlate with spirometry. The decreased surfactant protein A secretion in asthmatics requires further study.

Swiss doctors' attitudes towards end-of-life decisions and their determinants: a comparison of three language regions.

OBJECTIVES: To investigate attitudes to end-of-life decisions, and the influence of cultural factors and of doctors' personal characteristics on these attitudes. METHOD: As part of a European research project (EURELD), a study on attitudes towards medical end-of-life decisions was conducted among doctors in the German-, French- and Italian-speaking areas of Switzerland. A written questionnaire was sent to a random sample of nine different types of specialist; it presented 14 statements on end-of-life decisions and doctors were asked whether they agreed or disagreed with them. RESULTS: The response rate was 64%. 1360 questionnaires were studied. The results show general agreement with statements on the alleviation of pain and other symptoms with possible life-shortening effect, as well as on non-treatment decisions. The language region was a strong determinant of agreement on some attitudes towards end-of-life decisions. Agreement on the use of lethal drugs and alleviation of pain and other symptoms with possible life-shortening effect was higher among French-speaking than among German- and Italian-speaking doctors. For nontreatment decisions, agreement was higher in the German-speaking region than in the French- and Italian-speaking regions of the country. Italian-speaking doctors were strongly opposed to any kind of end-of-life decision. Religious believers and those who attended a larger number of terminal patients tended to disagree more often with end-of-life decisions than the other doctors. CONCLUSIONS: In end-of-life decision-making, Switzerland represents "Europe in miniature". The impact on end-of-life decisions of cultural factors and the number of terminal patients attended needs further consideration.

Influenza virus infection in travelers to tropical and subtropical countries.

BACKGROUND: Influenza outbreaks have been reported among travelers, but attack rates and incidence are unknown. METHODS: A cohort study was conducted. Travelers to subtropical and tropical countries recruited at the University of Zurich Travel Clinic (Switzerland), January 1998 to March 2000, were investigated with pre- and posttravel assessment of hemagglutination inhibition and by questionnaire. RESULTS: Among 1450 travelers recruited who completed questionnaires and provided serum samples before departure, 289 (19.9%) reported febrile illness during or after traveling abroad; of these, 211 (73.0%) provided paired serum samples. Additionally, paired serum samples were collected from 321 frequency-matched afebrile control subjects among the remaining 1161 subjects of the study population. Seroconversion for influenza virus infection was demonstrated in 40 (2.8%) of all travelers; 18 participants (1.2%) had a > or = 4-fold increase in antibody titers. This corresponds to an incidence of 1.0 influenza-associated events per 100 person-months abroad. Among the 211 febrile participants, 27 (12.8%) had seroconversion, 13 (6.2%) with a > or = 4-fold increase; among the 321 afebrile control subjects, 13 (4.0%) had seroconversion, 5 (1.6%) with a > or = 4-fold increase. Twenty-five seroconverters (62.5%; P = .747) acquired influenza outside of the European epidemic season. Sixteen patients (40.0%) sought medical attention either abroad or at home, and 32 (80.0%) were asymptomatic at the time of completion of the survey. CONCLUSIONS: This survey indicates that influenza is the most frequent vaccine-preventable infection among travelers to subtropical and tropical countries. Infections occur mainly outside the domestic epidemic season, and they have a considerable impact. Pretravel vaccination should be considered for travelers to subtropical and tropical countries.