Virtual Reality for Pain Relief in the Emergency Room (VIPER) - a prospective, interventional feasibility study.

BACKGROUND: Pain is one of the most common, yet challenging problems leading to emergency department (ED) presentation, despite the availability of a wide range of pharmacological therapies. Virtual reality (VR) simulations are well studied in a wide variety of clinical settings, including acute and chronic pain management, as well as anxiety disorders. However, studies in the busy environment of an adult ED are scarce. The aim of this study is to explore the feasibility and effectiveness of a VR simulation for pain and anxiety control in a convenience sample of adult ED patients presenting with traumatic and non-traumatic pain triaged 2-5 (i.e., urgent to non-urgent) with a pain rating of ≥ 3 on a numeric rating scale (NRS 0-10). METHODS: Prospective within-subject, repeated measures interventional feasibility pilot study at a Swiss University ED. The intervention consisted of a virtual reality simulation in addition to usual care. Pain and anxiety levels were measured using a verbally administered numeric rating scale (NRS) before and after the intervention. Information on patient experience was collected using established rating scales. RESULTS: Fifty-two patients were enrolled. The most common pain localisations were extremities (n = 15, 28.8%) and abdomen (n = 12, 23.1%). About one third of patients presented with trauma-associated pain (n = 16, 30.8%). Duration of pain was mainly acute (< 24 h) (n = 16, 30.8%) or subacute (> 24 h) (n = 32, 61.5%). The majority of patients were triage category 3, i.e. semi-urgent (n = 48, 92.3%). Significant reduction in pain (NRS median pre-VR simulation 4.5 (IQR 3-7) vs. median post-VR simulation 3 (IQR 2-5), p < 0.001), and anxiety levels (NRS median pre-VR simulation 4 (IQR 2-5) vs. median post-VR simulation 2 (IQR 0-3), p < 0.001) was achieved, yielding moderate to large effect sizes (Cohen's d estimate for pain reduction = 0.59 (95% CI 0.19-0.98), for anxiety level on NRS = 0.75 (95% CI 0.34-1.15). With medium immersion and good tolerability of the VR simulation, user satisfaction was high. CONCLUSIONS: Virtual reality analgesia for pain and anxiety reduction in the busy setting of an ED is feasible, effective, with high user satisfaction. Further randomized controlled studies are needed to better characterize its impact on pain perception and resource utilization.

Epistaxis in anticoagulated patients: Fewer hospital admissions and shorter hospital stays on rivaroxaban compared to phenprocoumon.

OBJECTIVES: Treatment of epistaxis in patients on anticoagulants is challenging and associated with higher admission rates and longer hospital stays compared with patients without anticoagulation. However, there is little information about epistaxis in patients taking new direct oral anticoagulants such as rivaroxaban compared with patients on traditional vitamin K antagonists such as phenprocoumon. DESIGN: Retrospective cohort study. SETTING: The study was conducted at the emergency department of the University Hospital Inselspital, Bern, Switzerland. PARTICIPANTS: All admissions to the emergency department of the University Hospital Inselspital, Bern, Switzerland from 1st July 2012 to 30th June 2016 with non-traumatic epistaxis on anticoagulant therapy with phenprocoumon or rivaroxaban were included. MAIN OUTCOME MEASURES: We compared clinical outcome parameters (admission rates, length of hospital stay and mortality) for both anticoagulant groups. RESULTS: We included 440 patients with epistaxis, 123 (28%) on rivaroxaban and 317 (72%) on phenprocoumon. Fewer hospital admissions and shorter hospital stays were found in patients under rivaroxaban (12 (10.4%) vs 57 (18.0%) patients, P=.033; 0.7±2.2 vs 1.5±3.7 days, P=.011) compared with phenprocoumon. Anterior epistaxis was more common in the rivaroxaban group in contrast to posterior epistaxis in patients on phenprocoumon (74 (60.2%) vs 139 (43.8%) patients, P=.002; 7 (5.7%) vs 39 (12.3%) patients, P=.042). CONCLUSIONS: Our data suggests that epistaxis on direct oral anticoagulation with rivaroxaban is associated with shorter hospital stays and fewer hospital admissions than epistaxis on vitamin K antagonist phenprocoumon.

Impact of proton pump inhibitor use on magnesium homoeostasis: a cross-sectional study in a tertiary emergency department.

BACKGROUND: To date, the use of proton pump inhibitors (PPIs) has been associated with a low risk of hypomagnesaemia and associated adverse outcomes. We hypothesised that a better risk estimate could be derived from a large cohort of outpatients admitted to a tertiary emergency department (ED). METHODS: A cross-sectional study was performed in 5118 patients who had measurements of serum magnesium taken on admission to a large tertiary care ED between January 2009 and December 2010. Hypomagnesaemia was defined as a serum magnesium concentration < 0.75 mmol/l. Demographical data, serum electrolyte values, data on medication, comorbidities and outcome with regard to length of hospital stay and mortality were analysed. RESULTS: Serum magnesium was normally distributed where upon 1246 patients (24%) were hypomagnesaemic. These patients had a higher prevalence of out-of-hospital PPI use and diuretic use when compared with patients with magnesium levels > 0.75 mmol/l (both p < 0.0001). In multivariable regression analyses adjusted for PPIs, diuretics, renal function and the Charlson comorbidity index score, the association between use of PPIs and risk for hypomagnesaemia remained significant (OR = 2.1; 95% CI: 1.54-2.85). While mortality was not directly related to low magnesium levels (p = 0.67), the length of hospitalisation was prolonged in these patients even after adjustment for underlying comorbid conditions (p < 0.0001). CONCLUSION: Use of PPIs predisposes patients to hypomagnesaemia and such to prolonged hospitalisation irrespective of the underlying morbidity, posing a critical concern.

[Disorders of serum sodium in emergency patients : salt in the soup of emergency medicine]. / Störungen des Natriumhaushalts beim Notfallpatienten : Salz in der Suppe der Notfallmedizin.

Electrolyte disorders are common and potentially fatal laboratory findings in emergency patients. Approximately 20 % of patients in the emergency department present with either hyponatremia or hypernatremia. Recently it was shown that disorders of serum sodium are not only an expression of the severity of the underlying disease but independent predictors for the outcome of patients. They directly influence patient daily life by causing not only gait and concentration disturbances but also an increased tendency to fall together with a reduced bone mass. Given these new data it is even more important to detect and adequately correct dysnatremia in patients in the emergency department. Acute, symptomatic dysnatremia should be corrected promptly by use of 3 % NaCl for hyponatremia and 5 % glucose for hypernatremia. A close monitoring of serum sodium concentration is, however, essential in any case of correction of hyponatremia or hypernatremia in order to avoid rapid overcorrection and subsequent complications. A profound knowledge of the mechanisms underlying the development of hyponatremia, e.g. diuretics, syndrome of inappropriate antidiuretic hormone secretion (SIADH), heart failure and cirrhosis of the liver and hypernatremia, e.g. dehydration, infusions, diuretics and osmotic diuresis is essential. The present article describes the epidemiology, etiology and correction of hyponatremia and hypernatremia on the basis of current knowledge with special emphasis on emergency department patients.

Development and usability testing of a fully immersive VR simulation for REBOA training.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving procedure for bleeding trauma patients. Being a rare and complex procedure performed in extreme situations, repetitive training of REBOA teams is critical. Evidence-based guidelines on how to train REBOA are missing, although simulation-based training has been shown to be effective but can be costly and complex. We aimed to determine the feasibility and acceptance of REBOA training using a fully immersive virtual reality (VR) REBOA simulation, as well as assess the confidence in conducting the REBOA procedure before and after the training. METHODS: Prospective feasibility pilot study of prehospital emergency physicians and paramedics in Bern, Switzerland, from November 2020 until March 2021. Baseline characteristics of trainees, prior training and experience in REBOA and with VR, variables of media use (usability: system usability scale, immersion/presence: Slater-Usoh-Steed, workload: NASA-TLX, user satisfaction: USEQ) as well as confidence prior and after VR training were accessed. RESULTS: REBOA training in VR was found to be feasible without relevant VR-specific side-effects. Usability (SUS median 77.5, IQR 71.3-85) and sense of presence and immersion (Slater-Usoh-Steed median 4.8, IQR 3.8-5.5) were good, the workload without under-nor overstraining (NASA-TLX median 39, IQR 32.8-50.2) and user satisfaction high (USEQ median 26, IQR 23-29). Confidence of trainees in conducting REBOA increased significantly after training (p < 0.001). CONCLUSIONS: Procedural training of the REBOA procedure in immersive virtual reality is possible with a good acceptance and high usability. REBOA VR training can be an important part of a training curriculum, with the virtual reality-specific advantages of a time- and instructor-independent learning.

Gender, age and ethnic aspects of analgesia in acute abdominal pain: is analgesia even across the groups?

BACKGROUND: Numerous studies have shown differences in pain perception between men and women, which may affect pain management strategies. AIM: Our primary aim was to investigate whether there are gender-based differences in pain management in patients admitted to our emergency department with acute, non-specific abdominal pain (NSAP). Our secondary aim was to evaluate if other factors influence administration of analgesia for patients admitted with NSAP. METHODS: From June 2007 to June 2008, we carried out a retrospective, gender-based, frequency-matched control study with 150 patients (75 consecutive men and 75 women) who presented with NSAP at our emergency department. Pain was documented using a numerical rating scale ('0' no pain, '10' most severe pain). A multinomial regression model was used to assess factors that might influence pain management. RESULTS: No statistically significant difference was seen between men and women with respect to pain management (P= 0.085). Younger patients were, however, more likely to receive weaker (P= 0.011) and fewer analgesics (P < 0.001). Patients with previous abdominal surgery (P= 0.012), known chronic pain conditions (P= 0.029) or relevant comorbidities (P= 0.048) received stronger analgesia. Nationality (P= 0.244), employment status (P= 0.988), time of admission (P= 0.487) and known psychiatric illness (P= 0.579) did not influence pain management. CONCLUSIONS: No statistically significant gender-dependent differences in pain management were observed. However, younger patients received less potent analgesic treatment. There is no reason for certain groups to receive suboptimal treatment, and greater efforts should be made to offer consistent treatment to all patients.

A 5-year follow up of patients discharged with non-specific abdominal pain: out of sight, out of mind?

BACKGROUND/AIM: Acute non-specific abdominal pain (NSAP) is prevalent in 6-25% of the general population and is a common cause of admission to the emergency department (ED). Despite involvement of substantial financial and human resources, there are few data on long-term outcome after initial diagnosis. The aim of this study was to evaluate long-term outcome of patients initially admitted with NSAP to an ED. METHODS: The study involves a 5-year follow-up analysis of prospectively collected data on 104 patients admitted to our ED in 2003 with NSAP. Primary end-point was clinical outcome 5 years after initial ED admission. Predictive risk factors were assessed using a multivariate regression model. RESULTS: 29 patients (28%) had recurring NSAP 5 years after initial ED admission, 76% of these patients received (multiple) diagnostic examinations and 13% eventually required diagnostic (or therapeutic) surgery. Although approximately half of patients with recurring NSAP eventually received a definite diagnosis, 30% still suffered from recurrent abdominal pain. Using regression analysis, no single factor in our dataset could be identified as a predictor for NSAP persistence. CONCLUSION: The long-term impact for patients initially admitted to our ED with acute NSAP is significant--28% of patients continue to suffer from recurring NSAP after 5 years. NSAP therefore remains, despite more advanced diagnostic tools, a true and, as yet, unsolved problem.

Can S-100B serum protein help to save cranial CT resources in a peripheral trauma centre? A study and consensus paper.

BACKGROUND: Cranial CT (CCT) is the gold standard to rule out traumatic brain injury. The serum level of the protein S-100B has recently been proposed as promising marker of traumatic brain injury. We prospectively investigated whether it might be a reliable tool for CCT triage in mild brain injury at a peripheral trauma centre with limited CT resources. METHODS: Patients with mild head injury and a Glasgow Coma Score of 13-15 admitted to the emergency department of a peripheral trauma centre were enrolled. Blood samples for S-100B analysis were obtained after clinical evaluation. The cut-off level for positive S-100B was 0.105 µg/l. All patients underwent CCT. The relationship between clinical findings, CCT results and S-100B levels was evaluated. RESULTS: 233 patients were enrolled. Median time between injury and sampling was 137 min. CCT was positive in 22 (9%) patients. Of these, 19 (8%) had positive serum S-100B levels. Overall, S-100B had a specificity of 12.2% and a sensitivity of 86.4%, with a positive predictive value of 12.8% and a negative predictive value of 85.7% as a selection tool for CCT triage in patients with mild head injury. CONCLUSION: The S-100B serum level showed a high sensitivity and negative predictive value in the screening of patients with mild head injury. The use of serum S-100B as a biomarker for CCT triage may improve patient screening and decrease the number of CCT scans performed. This would reduce unnecessary radiation exposure and free up capacity in the emergency rooms of peripheral hospitals to enable them to cope better with multiple admissions.

[A million football fans in a city of 120,000 inhabitants--a nightmare for emergency medicine and disaster management? Euro 2008 and the "Orange wonder of Berne"]. / 1.000.000 Fussballfans in einer Stadt mit 120.000 Einwohnern--ein notfallmedizinischer Albtraum? Die Euro 2008 und das "Oranje-Wunder von Bern"

The 2008 European Football Championship 2008 (Euro 08) is the largest sporting event ever organized in Switzerland. One million visitors came to the city of Berne during the event and the local airport in Bern/Belp registered 261 extra flights. For each football game there were 33,000 fans in the stadium and 100,000 fans in the public viewing zones.The ambulance corps and the Department of Emergency Medicine (ED) at Inselspital, University Hospital Berne, were responsible for basic medical care and emergency medical management. Injuries and illnesses were analyzed by a standardized score (NACA score). The preparation strategy as well as costs and patient numbers are presented in detail.A total of 30 additional ambulance vehicles were used, 4,723 additional working days (one-third medical professionals) were accumulated, 662 ambulance calls were registered and 240 persons needed medical care (62% Swiss, 28% Dutch and 10% other nationalities). Among those needing treatment 51 were treated in 1 of the 4 city hospitals. No injuries with NACA grades VI and VII occurred (NACA I: 4, NACA II: 17, NACA III: 16, NACA IV: 10 and NACA V: 4 patients). The city of Berne compensated the Inselspital Bern with a total of 112,603 Euros for extra medical care costs. The largest amount was spent on security measures (50,300 Euros) and medical staff (medical doctors 22,600 Euros, nurses 29,000 Euros). Because of the poor weather and the exemplary behavior of the fans, the course of events was rather peaceful.

Management of blunt injuries to the spleen.

BACKGROUND: Non-operative management (NOM) of blunt splenic injuries is nowadays considered the standard treatment. The present study identified selection criteria for primary operative management (OM) and planned NOM. METHODS: All adult patients with blunt splenic injuries treated at Berne University Hospital, Switzerland, between 2000 and 2008 were reviewed. RESULTS: There were 206 patients (146 men) with a mean(s.d.) age of 38.2(19.1) years and an Injury Severity Score of 30.9(11.6). The American Association for the Surgery of Trauma classification of the splenic injury was grade 1 in 43 patients (20.9 per cent), grade 2 in 52 (25.2 per cent), grade 3 in 60 (29.1 per cent), grade 4 in 42 (20.4 per cent) and grade 5 in nine (4.4 per cent). Forty-seven patients (22.8 per cent) required immediate surgery. Transfusion of at least 5 units of red cells (odds ratio (OR) 13.72, 95 per cent confidence interval 5.08 to 37.01), Glasgow Coma Scale score below 11 (OR 9.88, 1.77 to 55.16) and age 55 years or more (OR 3.29, 1.07 to 10.08) were associated with primary OM. The rate of primary OM decreased from 33.3 to 11.9 per cent after the introduction of transcatheter arterial embolization in 2005. Overall, 159 patients (77.2 per cent) qualified for NOM, which was successful in 143 (89.9 per cent). The splenic salvage rate was 69.4 per cent. In multivariable analysis age at least 40 years was the only factor independently related to failure of NOM (OR 13.58, 2.76 to 66.71). CONCLUSION: NOM of blunt splenic injuries has a low failure rate. Advanced age is independently associated with an increased failure rate.

Percutaneous cement augmentation for the treatment of depression fractures of the tibial plateau.

The management of insufficiency fractures of the tibial plateau in osteoporotic patients can be very challenging, since it is difficult to achieve a stable fixation, an essential condition for the patients' early mobilization. We present a minimally invasive technique for the treatment of proximal tibial plateau fractures, "tibiaplasty", using percutaneous polymethylmethacrylate augmentation. Five osteoporotic patients (7 fractures) with a non-traumatic insufficiency tibial plateau fracture were treated with this technique at the authors' institution from 2006 to 2008. The patients' median age was 79 (range 62-88) years. The intervention was performed percutaneously under general or spinal anesthesia; after the intervention, immediate full weight bearing was allowed. The technique was feasible in all patients and no complications related to the intervention were observed. All patients reported a relevant reduction in pain, were able to mobilize with full weight bearing and would undergo the operation again. No secondary loss of reduction or progression of arthrosis was observed in radiological controls; no revision surgery was required. Our initial results indicate that tibiaplasty is a good treatment option for the management of insufficiency in tibial plateau fractures in osteoporotic patients. The technique is minimally invasive, safe and allows immediate mobilization without restrictions. In our group of patients, we found excellent early to mid-term results.

Alcohol intoxication at a university hospital acute medicine unit--with special consideration of young adults: an 8-year observational study from Switzerland.

BACKGROUND: Many media reports suggest an increase in alcohol intoxication, particularly among young people. Indeed, several surveys on young people have confirmed this fact. These were based on self-declaration of alcohol consumption. However, there are few clinical data that show an increase in alcohol intoxication in hospitals. The aim of this study was to evaluate the number of alcohol intoxications in relation to the total number of patients and to look for a statistical trend. METHODS: Using their electronic database, the authors identified all patients with alcohol intoxication who were treated in the acute medical wing of our ED in the years 2000-2007. In the group aged 16-25 years, the authors searched for combined intoxication. RESULTS: The authors found a significant increase in alcohol intoxication in all age groups and also in young people aged below 25 years. There were more intoxicated males than females (male to female ratio 1.5:1). The age distribution of our intoxicated patients showed a peak at 35-45 years of age and repeated admissions were frequent in this age class. Drugs consumed together with alcohol in the age group 16-25 were mostly cannabis and cocaine. CONCLUSION: Episodic drinking is not only a problem in the 16-25 age group, it also concerns men of 35-45 years. This is a major public health problem in industrialised countries. Intoxicated patients are at acute risk of injuries and violence following alcohol abuse. Preventive measures should not only be limited to younger adults.

Are there risk factors in alpine skiing? A controlled multicentre survey of 1278 skiers.

OBJECTIVE: To analyse risk factors in alpine skiing. DESIGN: A controlled multicentre survey of injured and non-injured alpine skiers. SETTING: One tertiary and two secondary trauma centres in Bern, Switzerland. PATIENTS AND METHODS: All injured skiers admitted from November 2007 to April 2008 were analysed using a completed questionnaire incorporating 15 parameters. The same questionnaire was distributed to non-injured controls. Multiple logistic regression was performed. Patterns of combined risk factors were calculated by inference trees. A total of 782 patients and 496 controls were interviewed. RESULTS: Parameters that were significant for the patients were: high readiness for risk (p = 0.0365, OR 1.84, 95% CI 1.04 to 3.27); low readiness for speed (p = 0.0008, OR 0.29, 95% CI 0.14 to 0.60); no aggressive behaviour on slopes (p<0.0001, OR 0.19, 95% CI 0.09 to 0.37); new skiing equipment (p = 0.0228, OR 59, 95% CI 0.37 to 0.93); warm-up performed (p = 0.0015, OR 1.79, 95% CI 1.25 to 2.57); old snow compared with fresh snow (p = 0.0155, OR 0.31, 95% CI 0.12 to 0.80); old snow compared with artificial snow (p = 0.0037, OR 0.21, 95% CI 0.07 to 0.60); powder snow compared with slushy snow (p = 0.0035, OR 0.25, 95% CI 0.10 to 0.63); drug consumption (p = 0.0044, OR 5.92, 95% CI 1.74 to 20.11); and alcohol abstinence (p<0.0001, OR 0.14, 95% CI 0.05 to 0.34). Three groups at risk were detected: (1) warm-up 3-12 min, visual analogue scale (VAS)(speed) >4 and bad weather/visibility; (2) VAS(speed) 4-7, icy slopes and not wearing a helmet; (3) warm-up >12 min and new skiing equipment. CONCLUSIONS: Low speed, high readiness for risk, new skiing equipment, old and powder snow, and drug consumption are significant risk factors when skiing. Future work should aim to identify more precisely specific groups at risk and develop recommendations--for example, a snow weather index at valley stations.

[The war on (too many) fluids. New horizons in combat medicine]. / Krieg und Flüssigkeitsmanagement. Neue Horizonte.

In the coming years, our approach to the bleeding patient will have to change radically. The inevitable knowledge from the wars in Iraq and Afghanistan permits the prediction that conventional crystalloids will sooner or later disappear from volume replacement therapy. The dogma that fluids must always be given will be abandoned, to be replaced by the practice of careful and goal-directed resuscitation. In the near future, we would rely on designer fluids and sophisticated pharmacological agents to deliver personalized resuscitation based upon the specific needs of the individual patient.

qSOFA score not predictive of in-hospital mortality in emergency patients with decompensated liver cirrhosis.

BACKGROUND: Quick sequential organ failure assessement (qSOFA) has been validated for patients with presumed sepsis and the general emergency department (ED) population. However, it has not been validated in specific subgroups of ED patients with a high mortality. We aimed to investigate the prognostic performance of qSOFA with respect to in-hospital mortality, intensive care unit (ICU) admission, and length of hospitalisation in patients with decompensated liver cirrhosis. Furthermore, we compared qSOFA to systemic inflammatory response syndrome (SIRS), model of end stage liver disease score (MELD), and Child-Pugh criteria and evaluated whether addition of sodium (Na+) levels to qSOFA increases its prognostic performance. METHODS: This observational study included patients admitted with the diagnosis of decompensated liver cirrhosis. All patients with a complete set of vital parameters were included in this study. RESULTS: A total of 186 patients were included. A positive qSOFA score was not associated with in-hospital mortality, ICU admission, or length of hospitalisation (all p > 0.15). MELD scores reliably predicted need for ICU admission and in-hospital mortality (both p < 0.01), but not the length of hospitalisation. qSOFA-Na+ only moderately increased the diagnostic performance of qSOFA with regard to need for ICU admission (AUCICU[qSOFA] = 0.504 vs. AUCICU[qSOFA-Na+] = 0.609, p = 0.03), but not for in-hospital mortality (AUCdeath[qSOFA] = 0.513 vs. AUCdeath[qSOFA-Na+] = 0.592, p = 0.054). CONCLUSION: qSOFA does not predict in-hospital mortality, ICU admission or length of hospitalisation in patients with decompensated liver cirrhosis. Extension of qSOFA with a disease-specific component, the qSOFA-Na+, moderately increased the diagnostic ability of qSOFA.

Severe spinal injuries in alpine skiing and snowboarding: a 6-year review of a tertiary trauma centre for the Bernese Alps ski resorts, Switzerland.

OBJECTIVE: To analyse the epidemiological data, injury pattern, clinical features and mechanisms of severe spinal injuries related to alpine skiing and snowboarding. STUDY DESIGN: A six-year review of all adult patients with severe spinal injuries sustained from alpine skiing or snowboarding. SETTING: Tertiary trauma centre in Bern, Switzerland. PATIENTS AND METHODS: All adult patients (over 16 years of age) admitted to a tertiary trauma centre from 1 July 2000, through 30 June 2006, were reviewed using a computerised database. From these records, a total of 728 patients injured from snow sports were identified. Severe spinal injuries (defined as spinal fractures, subluxations, dislocations or concomitant spinal cord injuries) were found in 73 patients (17 female, 56 male). The clinical features of these patients were reviewed with respect to epidemiological factors, mechanism of injury, fracture pattern, and neurological status. RESULTS: The majority of severe spinal injuries (n = 63) were related to skiing. Fatal central-nervous injuries and transient or persistent neurological symptoms occurred in 28 patients (23 skiers, 5 snowboarders). None of the snowboarders suffered from persistent neurological sequelae. Snowboarders with severe spinal injuries (n = 10) were all male (p<0.05), and were significantly younger than skiers (p<0.001). The most commonly affected site was the lumbar spine. However, 39 patients (53.4%) suffered from injury pattern at two or more levels. CONCLUSIONS: With advances in technology and slope maintenance, skiers and snowboarders progress to higher skill levels and faster speeds more rapidly than ever before. Great efforts have been focused on reducing extremity injuries in snow sports, but until recently very little attention has been given to spinal injury prevention on the slopes. Suggestions for injury prevention include the use of spine protectors, participation on appropriate runs for ability level, proper fit and adjustment of equipment, and taking lessons with the goal of increasing ability and learning hill etiquette.

Forget the blood, not the stone! Microhaematuria in acute urolithiasis and the role of early CT scanning.

BACKGROUND: Although urinalysis is simple and inexpensive to perform, the finding of microhaematuria on urinalysis may be unreliable for diagnosing urolithiasis. OBJECTIVE: To evaluate microhaematuria as a diagnostic marker for urolithiasis compared with low-dose unenhanced multidetector computed tomography (MDCT) as the "gold standard". SETTING: A level 1 emergency department in a tertiary referral university teaching hospital. DESIGN: Retrospective analysis. METHODS: A study was undertaken to assess whether the finding of microhaematuria was diagnostic for urolithiasis using a low-dose unenhanced MDCT-based diagnosis as the reference standard by reviewing the records of all patients who presented to the emergency department with colicky flank pain and underwent a CT scan between January 2003 and December 2005. RESULTS: Urolithiasis was present (as defined by low-dose unenhanced MDCT) in 507/638 patients (79%); 341/638 (53%) were true positive for urolithiasis, 76 (12%) were true negative, 55 (9%) were false positive and 166 (26%) were false negative. Microhaematuria as a test for urolithiasis in patients presenting to the emergency department therefore has a sensitivity, specificity, positive predictive value and negative predictive value of 67%, 58%, 86% and 31%, respectively. 58% of the urinalysis results were negative for haematuria in the subset of patients with significant alternative diagnoses. CONCLUSIONS: The sensitivity, specificity and negative predictive value of microhaematuria on urinalysis for urolithiasis using unenhanced MDCT as the reference standard were low. This suggests that, when urolithiasis is clinically suspected, unenhanced MDCT is indicated without urinalysis being a prerequisite.

[Penetrating injuries to the pelvis]. / Penetrierende Beckenverletzung.

As criminality and weapon use increase, general and military surgeons are increasingly confronted with penetrating pelvic injuries both at home and on peacekeeping missions. Penetrating injuries to the iliac vascular axis are associated with considerable mortality, and thus the majority of these emergency patients arrive in a state of deep hypovolemic shock. Concomitant bowel injuries are present in one of five cases, resulting in contamination of the damaged area. Surgical options are simple lateral repair, ligation of the veins, temporary shunt insertion, and prosthetic graft interposition in the injured artery. In extremis ligation of the common or external iliac artery may be the only option to save the patient's life. Surgeons must be aware that damage control surgery and related methods may be needed early on to enable patient survival.

Aetiology of adult burns treated from 2000 to 2012 in a Swiss University Hospital.

BACKGROUND: Burns in Switzerland are frequent and lead to high economic and social costs. However, little is known about the aetiology of burns suffered by patients seeking treatment in hospital emergency departments. This knowledge could be used to develop preventive measures. METHODS: This retrospective analysis included all patients (≥16 years old) with acute thermal injuries of known cause admitted to the adult emergency department in Bern University Hospital (Switzerland, not a specialised burns unit) between 2000 and 2012. Clinical and sociodemographic data were extracted from medical records, i.e. the environment in which the burn occurred, as well as details of burn severity and aetiology. RESULTS: Seven hundred and one (701) patients with a mean age of 35.0±14.5 years (56% men) were included in the analysis. The winter season and the days around Christmas, turn of the year and Swiss National Day were identified as times with high risk of burns. Household (45%) and workplace (31%) were the most common locations/settings in which the burns occurred. Approximately every second burn was caused by scald, every fourth by flame and every seventh by hot objects. The analysis identified cooking, tar and electricity in workplace accidents, barbecues and the use of gasoline as aetiological factors in burns in leisure time, together with water in domestic thermal injuries. Burns occurred predominantly on non-protected skin on the hand and arms. The most severe burns were seen in electrical and flame burns. Men suffered more severe burns than women in all settings except psychopathology. CONCLUSIONS: The data suggest that the incidence and severity of burns in Switzerland could be reduced by preventive strategies and public campaigns, including education on fire protection systems, raising awareness about the times and locations where the risks of burns are greater, further improvement in workplace safety, particularly with cooking facilities and electrical equipment, and the development of innovative safety devices (i.e. machines, protective gloves). These findings have to be interpreted carefully, as this study includes only adult patients who presented in our ED and, in most cases, the burns covered less than 20% of the body surface.

The kick with the kite: an analysis of kite surfing related off shore rescue missions in Cape Town, South Africa.

BACKGROUND: This study analyses kite surfing related off shore rescue missions in Cape Town, South Africa with the aim of providing more information on the frequency, pattern, and severity of kite surfing related injuries. METHODS: The observation period for this study started on October 1, 2003 and ended on May 1, 2004 and included 30 air rescue missions. Data and information were collected prospectively. RESULTS: The Air Mercy Service in Cape Town Province responded to 30 requests for help. Twenty five accidents were attributed to inability to detach the kite from the harness. Injuries occurred in five incidents and included fractures of the upper arm, ribs and ankle, and lacerations and contusions to the head and neck. Two patients suffered from hypothermia and one experienced severe exhaustion. All surfers were rescued successfully and there were no fatal accidents. DISCUSSION: The risk potential of this new sport is unclear. Dangerous situations can occur despite proper training and safety precautions due to unpredictable conditions and difficulties with equipment. Safety should be stressed. Surfers should sailing with a fellow kiter and should wear a life vest. More efforts must be taken to make this booming new water sport safer.