[Add-on-LUCAS2™ resuscitation at NEF Innsbruck]. / Add-on-LUCAS2™-Reanimation am NEF Innsbruck.

STUDY GOAL: The study goals were to analyze the course and compare it with patients who were only resuscitated manually as well as to record the influencing factors in patients in whom the mechanical chest compression aid LUCAS2™ was used as an add-on treatment at the NEF Innsbruck. MATERIAL AND METHODOLOGY: Retrospective history data analysis of patients in the study period from 01.01.2014 to 31.12.2019 of the NEF Innsbruck from the German Resuscitation Register (GRR), in which LUCAS2™ was used as an add-on treatment according to an emergency doctor's order. RESULT: A total of 123 add-on LUCAS2™ applications (18.8%) were performed in 653 resuscitations. Of all patients 16.2% survived the first 30 days. By using add-on-LUCAS2TM application 7.3% (9/123) of all add-on LUCAS2TM resuscitations and 1.4% (n = 9) of all CPR survived. Cardiac arrest was observed in 8/9 add-on LUCAS2™ 30-day survivors and bystander CPR was performed and 8/9 showed ventricular fibrillation as the primary rhythm. Compared to manual CPR alone, add-on LUCAS2™ resuscitation was used highly significantly (p < 0.001) more frequently in younger, male patients, in public, in shockable initial rhythms and during transport, and significantly more frequently in observed cardiac arrest (p < 0.05). The 30-day mortality with additive lysis treatment was 100%. DISCUSSION: By using add-on LUCAS2™ CPR a percentage increase in survival rate can be achieved and thus appears advantageous (1.4% in our study). This means that high-quality CPR can be carried out on patients with favorable prognostic factors, even with technically complex rescue operations (turntable ladder, staircase, transport in an ambulance) and thus transport can be made possible; however, there is a higher admission rate under CPR and thus the treatment target decision is shifted to the shock room.

Kyasanur forest disease: a state-of-the-art review.

Kyasanur forest disease (KFD) virus is a flavivirus that can be transmitted to humans from monkeys or other mammals through hard ticks (Haemaphysalis spinigera). The disease is endemic to 16 districts in 5 states of Southern India and is reported in the dry season, most commonly in humans travelling to the forests in these areas. The aim of this systematic review is to raise awareness of the clinical and laboratory manifestation of KFD among physicians and travel medicine practitioners. A total of 153 articles were screened of which 16 articles that met the inclusion and exclusion criteria were included for qualitative analysis. KFD is an acute haemorrhagic fever with a biphasic component in some individuals. The second phase is usually marked by neurological symptoms. Leucopoenia, thrombocytopenia and elevated transaminases are the hallmarks of the first phase of KFD. The diagnostic modality of choice in the first few days of illness is polymerase chain reaction assay, whereas serology is used in the late phase. In the absence of a specific antiviral treatment, the clinical management of patients is limited to supportive care. Avoidance of exposure and vaccination is recommended to prevent this infection.

[Evaluation of cancelled emergency physician missions and patient handovers in the area of Innsbruck : Retrospective assessment of physician-staffed emergency medical service cancellations and handovers from the emergency physician to the emergency medical service in 2017 and 2018]. / Evaluierung der NEF-Fehl- und Übergabeeinsätze im Raum Innsbruck : Retrospektive Auswertung der NEF-Stornierungen und Übergabeeinsätze vom Notarzt an den Rettungsdienst in den Jahren 2017 und 2018.

BACKGROUND: Human and vehicle resource management indicates a good emergency medical system (EMS). Frequently, an emergency medical technician (EMT) is the first responder to the emergency, which negates the necessity for an emergency physician (EP) and is just as sensible as handing over a stable patient to the EMT for transport to the hospital. The Austrian EMS is utilized by EMTs, in cases of potential life-threatening emergencies the dispatch center dispatches an additional team with an on-board EP. During the years 2017-2018 nearly every fifth EP mission in Innsbruck (including surrounding areas) ended in a cancellation. The numbers of patient handovers from EP to EMT are slightly lower with mission cancellations resulting in every fourth patient. Therefore, due to the high number of cancellations and handovers evaluated in this study, the findings suggest that there is a potential need to re-evaluate procedures. The re-evaluation of these procedures could determine whether these cancellations/handovers were justified or if an over hasty decision making was at fault. All cases considered in this study were from the Innsbruck and Telfs EP bases between 1 January 2017 and 13 December 2018. METHODS: Out of a total of 96,908 emergency dispatches, there were 2470 cancellation/handover occurrences. These occurrences consisted of 1190 cancellations and 1280 patient handovers from the EP to the EMT. Patients who were transferred to the University Hospital Innsbruck were included in these figures. The protocols of the emergency dispatches have been filtered from the so-called CarPC. They have subsequently been grouped into cancellation and handover categories. The clinical diagnoses of the patients with inpatient treatment were evaluated from the hospital information system (KIS) of the University Hospital Innsbruck. This was done with the help of the so-called emergency physician indications catalogue of the German Medical Council. The diagnosis was documented in the hospital information system. The emergency protocols from the EMTs were also evaluated retrospectively. The Innsbruck based EP patients are hospitalized in the Innsbruck Hospital due their geographical position. When there is no need for a specific intervention the patients of the EPs based in Telfs are transferred to a local hospital. When a specific intervention is necessary, patient care must be provided by the University Hospital Innsbruck. Due to the privacy practices of the Innsbruck Medical University "vote of ethics" only the data of patients transferred to the Innsbruck Clinic can be evaluated. The information provided from the EPs based in Innsbruck was exclusively from the University Hospital Innsbruck's anesthesiologists. The physicians from the Telfs EP base are of mixed medical specialities. All of them, however, have an emergency medical physician diploma, in addition to the ius practicandi. Lastly, there are no EPs in Innsbruck or Telfs, who have any special obligations during their duty. RESULTS: The results show that in 210 cases (8.5%) the indications for the EP, based on the emergency physician indications catalogue of the German Medical Council were given. Also, 8.7% of all cancellations and 8.4% of patient handovers were not justified. Patients with emergency indications had a longer hospitalization. The EP base EMS Innsbruck had more cancellations than the EP base EMS Telfs. The EMS Innsbruck also had more cancellations than patient handovers. Conversely, the EMS Telfs had more patient handovers than cancellations. On the weekends between 6:00 pm and 6:00 am there were less cancellations and handovers from both EP bases. The documentation from the EMT protocols was incomplete in 284 cancellations (23.9% of the cancellations) and 339 handovers (26.5% of the handovers), 35 patients after cancellations (2.9%), 35 patients after handovers (2.7%) needed intensive care treatment, 20 patients after cancellations (1.7% of all cancellations), and 24 patients after handovers (1.9% of all handovers) who needed intensive care treatment had a critical diagnosis. In 40 cases of patient handovers, the EP was alerted to another emergency follow-up within 10 min. CONCLUSION: In Austria, the introduction of a standardized emergency indication checklist might help dispatch centers to provide a more accurate dispatch as well as all EMS team members. Furthermore, a better traceability system (according to EP cancellations and patient handovers from the EP to the EMT) could be achieved. The documentation requirements should be more precise by all members of the EMT staff, not only for the legal aspects but also for improving the overall management quality. Intense education and training as well as diagnosis feedbacks could help to reduce the number of risky cancellations/patient handovers.

Prevalence rates of six selected infectious diseases among African migrants and refugees: a systematic review and meta-analysis.

The objective of this paper was to systematically review the literature on the prevalence of selected infectious diseases among migrants/refugees of African origin and to provide policy makers and health care professionals with evidence-based information. We pursued a systematic review and meta-analysis to determine the prevalence of six selected infectious diseases (i.e., syphilis, helminthiasis, schistosomiasis, intestinal protozoa infections, hepatitis B, and hepatitis C) among migrants/refugees of African origin. Three electronic databases (i.e., PubMed, EMBASE, and ISI Web of Science) were searched without language restrictions. Relevant data were extracted and random-effects meta-analyses conducted. Only adjusted estimates were analyzed to help account for heterogeneity and potential confounding. We assessed the quality of evidence using the GRADE approach. The results were stratified by geographical region. Ninety-six studies were included. The evidence was of low quality due to the small numbers of countries, infectious diseases, and participants included. African migrants/refugees had median (with 95% confidence interval [95% CI]) prevalence for syphilis, helminthiasis, schistosomiasis, intestinal protozoa infection, hepatitis B, and hepatitis C of 6.0% [95% CI: 2.0-7.0%], 13.0% [95% CI: 9.5-14.5%], 14.0% [95% CI: 13.0-17.0%], 15.0% [95% CI: 10.5-21.0%], 10.0% [95% CI: 6.0-14.0%], and 3.0% [95% CI: 1.0-4.0%], respectively. We found high heterogeneity regardless of the disease (I 2; minimum 97.5%, maximum 99.7%). The relatively high prevalence of some infectious diseases among African migrants/refugees warrants for systematic screening. The large heterogeneity of the available published data does not allow for stratifying such screening programs according to the geographical origin of African migrants/refugees.

Ultrasound assessment of schistosomiasis.

In 2000, the World Health Organization (WHO) issued an ultrasound field protocol for assessing the morbidity due to Schistosoma (S.) haematobium and S. mansoni. The experience with this classification has recently been reviewed systematically. The WHO protocol was well accepted worldwide. Here we review the use of ultrasound to assess the morbidity due to schistosomiasis with emphasis on easy, quick, and reproducible ways that can be used in the field. Findings obtained with high-end ultrasound scanners in the hospital setting that might eventually have applications in the field are also described.

The intermediate host immune response in cystic echinococcosis.

Cystic echinococcosis (CE) is a chronic, complex and neglected zoonotic infection. In most cases, CE cysts and the intermediate host co-habit for a long time in the absence of symptoms and elicit very little inflammation. However, the immune interplay between the parasite and the host is complex, encompassing effective parasite-killing immune mechanisms implemented by the host, which in turn are modulated by the parasite. The immune response to the parasite has been exploited for the diagnosis of the disease and for the development of an effective vaccine to use in the natural intermediate host, but the mechanisms of parasite killing and immunomodulation are still unknown. Here, we reviewed the immune effector mechanisms and the strategies of immune evasion in the intermediate host.

Predominance of dfrG as determinant of trimethoprim resistance in imported Staphylococcus aureus.

To investigate the global occurrence of trimethoprim-sulfamethoxazole resistance and the genetic mechanisms of trimethoprim resistance, we analysed Staphylococcus aureus from travel-associated skin and soft-tissue infections treated at 13 travel clinics in Europe. Thirty-eight per cent (75/196) were trimethoprim-resistant and 21% (41/196) were resistant to trimethoprim-sulfamethoxazole. Among methicillin-resistant S. aureus, these proportions were 30% (7/23) and 17% (4/23), respectively. DfrG explained 92% (69/75) of all trimethoprim resistance in S. aureus. Travel to South Asia was associated with the highest risk of acquiring trimethoprim-sulfamethoxazole-resistant S. aureus. We conclude that globally dfrG is the predominant determinant of trimethoprim resistance in human S. aureus infection.

Louse-borne relapsing fever (Borrelia recurrentis) in an Eritrean refugee arriving in Switzerland, August 2015.

We report an imported case of louse-borne relapsing fever in a young adult Eritrean refugee who presented with fever shortly after arriving in Switzerland. Analysis of blood smears revealed spirochetes identified as Borrelia recurrentis by 16S rRNA gene sequencing. We believe that louse-borne relapsing fever may be seen more frequently in Europe as a consequence of a recent increase in refugees from East Africa travelling to Europe under poor hygienic conditions in confined spaces.

Molecular epidemiology suggests Venezuela as the origin of the dengue outbreak in Madeira, Portugal in 2012-2013.

An explosive epidemic occurred in Madeira Island (Portugal) from October 2012 to February 2013. Published data showed that dengue virus type 1 introduced from South America was the incriminated virus. We aim to determine the origin of the strain introduced to Madeira by travellers returning to Europe. Using phylogeographic analysis and complete envelope sequences we have demonstrated that the most probable origin of the strain is Venezuela.

Skin and soft tissue infections in intercontinental travellers and the import of multi-resistant Staphylococcus aureus to Europe.

Staphylococcus aureus is emerging globally. Treatment of infections is complicated by increasing antibiotic resistance. We collected clinical data and swabs of returnees with skin and soft tissue infections (SSTI) at 13 travel-clinics in Europe (www.staphtrav.eu). Sixty-two percent (196/318) SSTI patients had S. aureus-positive lesions, of which almost two-thirds (122/196) were Panton-Valentine leukocidin (PVL) positive. PVL was associated with disease severity, including hospitalization for SSTI (OR 5.2, 95% CI 1.5-18.2). In returnees with SSTI, longer travel and more intense population contact were risk factors for nasal colonization with PVL-positive S. aureus. Imported S. aureus frequently proved resistant to trimethoprim-sulfamethoxazole (21%), erythromycin (21%), tetracycline (20%), ciprofloxacin (13%), methicillin (12%) and clindamycin (8%). Place of exposure was significantly (p < 0.05) associated with predominant resistance phenotypes and spa genotypes: Latin America (methicillin; t008/CC24/304), Africa (tetracycline, trimethoprim-sulfamethoxazole; t084/CC84, t314/singleton, t355/CC355), South Asia (trimethoprim-sulfamethoxazole, ciprofloxacin; t021/CC21/318), South-East Asia (clindamycin; t159/CC272). USA300-like isolates accounted for 30% of all methicillin-resistant S. aureus imported to Europe and were predominantly (71%) acquired in Latin America. Multi-resistance to non-ß-lactams were present in 24% of imports and associated with travel to South Asia (ORcrude 5.3, 95% CI 2.4-11.8), even after adjusting for confounding by genotype (ORadjusted 3.8, 95% 1.5-9.5). Choosing randomly from compounds recommended for the empiric treatment of severe S. aureus SSTI, 15% of cases would have received ineffective antimicrobial therapy. These findings call for the development of regionally stratified guidance on the antibiotic management of severe imported S. aureus disease and put the infected and colonized traveller at the centre of interventions against the global spread of multi-resistant S. aureus.

Cutaneous leishmaniasis in Switzerland: first experience with species-specific treatment.

BACKGROUND: Different species of the genus Leishmania can cause cutaneous (CL) and mucosal leishmaniasis (ML). PCR-based tests allow a rapid diagnosis and determination of the species, thereby enabling species-oriented treatment. Such treatment procedures have not been evaluated to date. METHODS: Patients presenting with CL and ML between 1999 and 2011 were analysed retrospectively. PCR technology was used to diagnose the disease and identify the protozoan to the species level. RESULTS: A total of 61 cases were reviewed, including 58 patients with CL and three patients with ML. Treatment was effective in most patients. Treatment failure was reported in six patients with L. panamensis (one fluconazole, one ketoconazole), L. infantum (one excision, one fluconazole), L. tropica (one paromomycin/methylbenzethonium), L. braziliensis (1 paromomycin/methylbenzethonium). In 11 (18 %) patients treatment had to be interrupted due to adverse events, and in eight patients (13 %) a second treatment had to be applied. Treatment with meglumine antimoniate had to be interrupted in six patients, with QTc prolongation the reason for the interruption in three patients. CONCLUSIONS: Species-related, targeted treatment resulted in good responses in CL and ML lesions. Treatment recommendations for L. panamensis were changed from ketoconazole to miltefosine because of new evidence of treatment failures. Meglumine antimoniate should be restricted to species with poor response to alternative medications and should be used with caution in patients older than 60 years because of its toxicity. Treatment in immunosuppressed patients was successful, but relapses were observed when the immune system could not be restored. This is the first report on L. aethiopica from Egypt.

Ongoing outbreak of an acute muscular Sarcocystis-like illness among travellers returning from Tioman Island, Malaysia, 2011-2012.

As of 4 November, 2012, 100 patients with an acute muscular Sarcocystis-like illness associated with travel to Tioman Island, Malaysia, have been identified. Thirty-five travelled there mostly during July and August 2011 and 65 mostly during July and August 2012, suggesting an ongoing outbreak. Epidemiological investigations are ongoing. Public health agencies and practicing clinicians should be aware of this rarely-reported disease in humans and consider it as differential diagnosis in travellers returning from Tioman Island.

Human African trypanosomiasis in endemic populations and travellers.

Human African trypanosomiasis (HAT) or sleeping sickness is caused by the protozoan parasites Trypanosoma brucei (T.b.) gambiense (West African form) and T.b. rhodesiense (East African form) that are transmitted by the bite of the tsetse fly, Glossina spp.. Whereas most patients in endemic populations are infected with T.b. gambiense, most tourists are infected with T.b. rhodesiense. In endemic populations, T.b. gambiense HAT is characterized by chronic and intermittent fever, headache, pruritus, and lymphadenopathy in the first stage and by sleep disturbances and neuro-psychiatric disorders in the second stage. Recent descriptions of the clinical presentation of T.b. rhodesiense in endemic populations show a high variability in different foci. The symptomatology of travellers is markedly different from the usual textbook descriptions of African HAT patients. The onset of both infections is almost invariably an acute and febrile disease. Diagnosis and treatment are difficult and rely mostly on old methods and drugs. However, new molecular diagnostic technologies are under development. A promising new drug combination is currently evaluated in a phase 3 b study and further new drugs are under evaluation.

[Immunoscintigraphy for detection of inflammatory perioperative foci]. / Immunszintigraphie zur Aufdeckung entzündlicher perioperativer Foci.

The aim of our study was to evaluate the clinical usefulness of a monoclonal antibody (MAB; BW 250/183; Behringwerke, Germany) in patients with suspected perioperative septic foci. The MAB is directed against the nonspecific crossreacting antigen (NCA 95) which has been found on the surface of human neutrophil granulocytes and which represents a murine immunoglobulin isotype of IgG1. Immunoscintigraphy was performed by labelling the MAB with 740 MBq (20mCi) Tc-99m. Data acquisition followed 4 and 18 to 24 hours after administration by a digital Anger camera (APEX 409A, Elscint). 53 patients were investigated (31 female, 22 male; average age 39 years), 4 patients were twice, 1 patient was 3 times evaluated, which results in a total of 59 studies. 45 patients experienced operation within 12 hours after our investigation, which resulted in 36 true positive, 5 true negative, 3 false negative, and 1 false positive findings. This means a sensitivity of 92%, and specificity of 83%. Immunoscintigraphy with granulocyte antibodies can be performed at any time, the preparation of the radiopharmaceutical is simple, the image quality is high; the obtained information concerning localization and size of perioperative septic infections permits the determination of the optimal point of time for surgical intervention. The accumulation of activity was visible as early as 4 hours post application. SPECT would enhance the diagnostic accuracy, but this technique cannot be applied in all such patients.

[Blood-pool-SPECT for imaging portosystemic collaterals in portal hypertension]. / Blutpool-SPECT zur Darstellung von portosystemischen Kollateralen bei portaler Hypertension.

In 46 patients, 26 male and 20 female, age from 32 to 71 years (mean 47.4 +/- 11 years) a bloodpool-scintigraphy (BPS) with SPECT (single photon emission computed tomography) was performed. The in-vivo labelling of the erythrocytes with pyrophosphate and Tc-99m was performed in the usual way. The SPECT investigations were performed with a digital Anger-Camera (Elscint; Apex 401). In 14 patients without collaterals BPS was performed to compare the method with patients with liver diseases and collaterals. 29 patients with liver cirrhosis and portal hypertension were investigated with the BPS and additionally a scintisplenoportography (SSP) was performed. In patients with only cephalad collaterals all the results were concordant. In just 1 patient with cephalad and caudad collaterals we found a discordant result. In 8 patients we performed BPS, SSP and a katheterangiography (KA). Taking the KA as the "golden standard" we found a concordant result with the 3 methods in all patients with cephalad collaterals. In patients with cephalad and caudad collaterals we once found a discordant result with the SSP and twice with the BSP. In 2 patients the patency of surgical shunts were proved. 2 patients after sclerosis of the oesophageal varices have been proved by BPS and SSP and both patients showed good therapeutical results.

[Tumor diagnosis by immunoscintigraphy with anti-CEA antibodies (Tc-99m MAK BW 431/26)]. / Immunszintigraphische Tumordiagnostik mit Anti-CEA-Antikörpern (Tc-99m MAK BW 431/26).

We evaluated the clinical application of the monoclonal antibody MAb, BW 431/26, which is easy to label with Tc-99m for tumor localization. This is an anti-CEA antibody and a murine immunoglobulin (Ig G1, Isotype). We investigated patients with colorectal carcinoma (n = 14), with colorectal carcinoma recurrences (n = 24), breast carcinoma (n = 2), stomach carcinoma (n = 1), carcinoma of the urinary bladder (n = 3), lung carcinoma (n = 2) and patients with an elevated CEA level. In primary colorectal tumors (n = 14) all carcinomas were correctly localized by IS and ECT technique. In these patients the diagnosis was already known. The planar pictures showed a false negative result in 3 patients. In patients with colorectal recurrences the investigations were performed twice in 2 patients and three times in 1 patient. In these 31 ECT investigations we found 17 true positive results, 12 true negative results, 1 false positive result and 1 false negative result. The lesions were already visualized within 4 to 6 hours, but 24-hour pictures are desirable. SPECT pictures are absolutely necessary because sensitivity is considerably improved thereby. Elevated CEA levels increase the probability of a positive IS low CEA levels do not exclude positive tumor visualization. HAMA was found in only 1 patient, but follow-up investigations are indicated.