Training trauma teams in the Nordic countries: an overview and present status

Background:  During the last decade there has been an increased interest in the organisation and quality of trauma care in the Nordic countries. Still, most patients are initially cared for at hospitals with low caseloads of severe trauma. More than 200 hospitals offer initial care to trauma patients. Training of trauma teams using simulators or simulated patients has evolved in the same period, as one important factor to overcome lack of practical training. This overview describes the present state of trauma team training in the Nordic countries.
Methods:  Members of a Nordic working group on the use of simulation in medicine reviewed present literature on training with simulation and described the present use of team training in their own countries during winter 2004.
Results:  There is an increasing amount of evidence indicating that training of teams with simulation reduces treatment errors and improves performance. The training activities do not need to be complex, but skilled debriefing seems necessary. Few Nordic hospitals train their trauma teams. The training activities vary considerably between and within countries.
Conclusion:  There is considerable evidence supporting an increased use of experience gained in other high-risk domains where training in communication, leadership and decision-making is the focus for safety and improvement efforts. There is a need for more widespread training of trauma teams. The different training activities actually undertaken should be scientifically evaluated.     

泰素周疗和三周疗法作为卵巢癌一线化疗的多中心对照研究

目的比较泰素周疗和铂尔定联合化疗与泰素3周疗法和铂尔定联合化疗作为卵巢癌一线化疗的效果,观察两种联合方案的毒性作用及两种联合方案对卵巢癌患者两年生存期的影响。方法采用多中心对照研究的方法,将手术后病理学诊断为晚期卵巢上皮癌的125例患者分为两组。（1）周疗组：51例患者,泰素60—80mg／m^2,每周给药1次,共6次。铂尔定（药释曲线=5．0）仅在第1周,第4周用完泰素后给药。8周为1个疗程,化疗6周,休息2周。2个疗程（16周）后评价疗效。（2）3周疗法组：74例,泰素175mg／m^2,3h静脉滴注。铂尔定：（药释曲线面积为5．0）,每疗程的第一天联合应用泰素＋铂尔定,3周为1个疗程,用药6个疗程（18周）后评价疗效。结果（1）CAl25下降情况：经手术和化疗后102例（81．6％）患者CAl25呈现满意的下降,其中3周疗法组为58例（78．4％）,周疗组为44例（86．3％）,两组比较差异无统计学意义（P〉0．05）。（2）病情复发和未控情况：①总的复发和／或未控病例有32例,占26．4％。3周疗法组复发和／或未控病例有22例（29．7％）,其中停化疗〉6个月的复发有8例,停化疗〈6月的复发有9例,肿瘤持续进展为5例。周疗组复发和／或未控病例有10例（19．6％）,其中停化疗〉6个月的复发有2例,停化疗〈6个月的复发有6例,肿瘤持续进展为2例,两组在病情复发和未控发生率上差异无显著意义（P〉0．05）。②肿瘤复发平均时间：3周疗法组平均复发时问为15．7个月,周疗组平均复发时问为13．6个月（P〉0．05）。③无瘤生存时问（progress—free survival,PFS）3周疗法组平均复发时间为16．5个月,周疗组平均复发时问为15．6个月（P〉0．05）。④生存情况：3周疗法组1年生存率为95．2％,2年生存率为78．7％;周疗组1年生存率为93．9％,2年生存率为85．3％,两组在1年和2年生存率上差异无统计学意义意义（P〉0．05）。（3）毒副反应的情况：在血液毒性方面：3周疗法组,有34例发生3—4度骨髓抑制,发生率为45．9％,周疗组有14例发生3—4度骨髓抑制,发生率为27．5％,两组差异有统计学意义（P〈0．05）。在神经毒性方面3周疗法的发生率略低于周疗组,但差异无统计学意义（P〉0．05）。其他的毒性反应,两组比较差异无统计学意义（P〉0．05）。结论（1）泰素的临床疗效周疗与3周疗法相同。（2）泰素周疗的骨髓抑制发生率明显低于3周疗法,其他的毒性作用与3周疗法比较差异无统计学意义。（3）泰素周疗的毒副反应较轻,更适用于年迈体弱的患者和门诊化疗。     

Tachon's syndrome (suracute back and/or thoracic pain following local injections of corticosteroids). A report of 318 French cases

OBJECTIVES: To assess the frequency, features, and outcome of excruciating lumbar, dorsal, and/or thoracic pain following injections of local corticosteroids in rare instances. METHODS: A questionnaire mailed to 500 French rheumatologists. RESULTS: Three hundred and eighteen cases were reported by 92 rheumatologists (one event per 8000 injections or 6.5 years of practice), following injections into lumbar epidural space (39%), an upper limb (30%), a lower limb (mostly the heel) (24%), or other locations (7%), of cortivazol (67%), hydrocortisone (25%), betamethasone (7%), or paramethasone (1%). Symptoms occurred 1-5 min (78%) or less than 1 min (22%) after injection, and highly acute axial pain usually lasted for less than 5 min (34%) or 5-15 min (51%). In addition to pain in lumbar (84%) and/or dorsal regions (25%) [often preceded or associated with thoracic pain (36%)], other signs were: anxiety (87%), shortness of breath (64%), facial flushing (64%), diffuse sweating (41%), agitation (29%), transient cough (23%), abdominal pain (20%), transient hypertension (15%), paleness (10%), hypotension (8%), diarrhoea (3%) and headache (3%). None of these patients was known to be allergic, and urticaria developed in only 2%. Outcome was favourable in all cases (even though 4/318 patients were transiently hospitalised) with an overall duration of 25 +/- 71 min. Another injection was performed later in 146/318 cases (46%), but Tachon's syndrome recurred in only 20 of these 146 patients (14%). CONCLUSION: The outcome of this impressive syndrome seems excellent. Tachon's syndrome might be the venous counterpart of Nicolau's syndrome (injection of corticosteroids in an artery).     

Withdrawal of fluticasone propionate from combined salmeterol/fluticasone treatment in patients with COPD causes immediate and sustained disease deterioration: a randomised controlled trial

BACKGROUND: Guidelines recommend inhaled corticosteroids (ICS) as maintenance treatment for patients with chronic obstructive pulmonary disease (COPD) with a post-bronchodilator forced expiratory volume in 1 second (FEV1) <50% predicted and frequent exacerbations, although they have only a small preventive effect on the accelerated decline in lung function. Combined treatment with ICS and long acting beta2 agonists (LABA) may provide benefit to the stability of COPD, but it is unknown if withdrawal of ICS will result in disease deterioration. METHODS: The effects of 1 year withdrawal of the ICS fluticasone propionate (FP) after a 3 month run-in treatment period with FP combined with the LABA salmeterol (S) (500 microg FP + 50 microg S twice daily; SFC) were investigated in patients with COPD in a randomised, double blind study. 497 patients were enrolled from 39 centres throughout the Netherlands; 373 were randomised and 293 completed the study. RESULTS: The drop out rate after randomisation was similar in the two groups. Withdrawal of FP resulted in a sustained decrease in FEV1: mean (SE) change from baseline -4.4 (0.9)% (S) v -0.1 (0.9)% (SFC); adjusted difference 4.1 (95% CI 1.6 to 6.6) percentage points (p<0.001). Corresponding figures for the FEV1/FVC ratio were -3.7 (0.8)% (S) v 0.0 (0.8)% (SFC) (p = 0.002). The annual moderate to severe exacerbation rate was 1.6 and 1.3 in the S and SFC groups, respectively (adjusted rate ratio 1.2; 95% CI 0.9 to 1.5; p = 0.15). The mean annual incidence rate of mild exacerbations was 1.3 (S) v 0.6 (SFC), p = 0.020. An immediate and sustained increase in dyspnoea score (scale 0-4; mean difference between groups 0.17 (0.04), p<0.001) and in the percentage of disturbed nights (6 (2) percentage points, p<0.001) occurred after withdrawal of fluticasone. CONCLUSIONS: Withdrawal of FP in COPD patients using SFC resulted in acute and persistent deterioration in lung function and dyspnoea and in an increase in mild exacerbations and percentage of disturbed nights. This study clearly indicates a key role for ICS in the management of COPD as their discontinuation leads to disease deterioration, even under treatment with a LABA.     

Clinical consequences of PKHD1 mutations in 164 patients with autosomal-recessive polycystic kidney disease (ARPKD)

BACKGROUND: ARPKD is associated with mutations in the PKHD1 gene on chromosome 6p12. Most cases manifest peri-/neonatally with a high mortality rate in the first month of life while the clinical spectrum of surviving patients is much more variable than generally perceived. METHODS: We examined the clinical course of 164 neonatal survivors (126 unrelated families) over a mean observation period of 6 years (range 0 to 35 years). PKHD1 mutation screening was done by denaturing high-performance liquid chromatography (DHPLC) for the 66 exons encoding the 4074 aa fibrocystin/polyductin protein. RESULTS AND CONCLUSION: This is the first study that reports the long-term outcome of ARPKD patients with defined PKHD1 mutations. The 1- and 10-year survival rates were 85% and 82%, respectively. Chronic renal failure was first detected at a mean age of 4 years. Actuarial renal survival rates [end point defined as start of dialysis/renal transplantation (RTX) or by death due to end-stage renal disease (ESRD)] were 86% at 5 years, 71% at 10 years, and 42% at 20 years. All but six patients (92%) had a kidney length above or on the 97th centile for age. About 75% of the study population developed systemic hypertension. Sequelae of congenital hepatic fibrosis and portal hypertension developed in 44% of patients and were related with age. Positive correlations could further be demonstrated between renal and hepatobiliary-related morbidity suggesting uniform disease progression rather than organ-specific patterns. PKHD1 mutation analysis revealed 193 mutations (70 novel ones; 77% nonconservative missense mutations). No patient carried two truncating mutations corroborating that one missense mutation is indispensable for survival of newborns. We attempted to set up genotype-phenotype correlations and to categorize missense mutations. In 96% of families we identified at least one mutated PKHD1 allele (overall detection rate 76.6%) indicating that PKHD1 mutation screening is a powerful diagnostic tool in patients suspected with ARPKD.     

Guidelines for the sociomedical assessment of performance in patients suffering from inflammatory bowel disease

The following guidelines were developed for the medical assessment services of the German Federal Insurance Institute for Salaried Employees (BfA). Starting from day-to-day practice, criteria and attributes to guide decisions for a systemization of the sociomedical assessment of performance in inflammatory bowel disease (Crohn's disease, ulcerative colitis) were compiled. The guidelines aim at standardising the sociomedical assessment of performance and help to make the decision-making process more transparent -- e. g. for the assessment of applications for decreased earning capacity benefits. The guidelines summarise typical manifestations of inflammatory bowel disease and describe the necessary medical information for the sociomedical assessment of performance. Relevant assessment criteria for the medical history, clinical examination, and for diagnostic tests are illustrated. The assessment of the individual's capacity is outlined, taking occupational factors into account. Following the determination of dysfunctions the remaining abilities and disabilities, respectively, are deduced and compared with occupational demands. Finally, inferences are drawn regarding the occupational capacity of the individual.     

A case-control study of domestic kitchen microbiology and sporadic Salmonella infection

The microbiology of domestic kitchens in the homes of subjects who had suffered sporadic Salmonella infection (cases) was compared with control domestic kitchens. Case and control dishcloths and refrigerator swabs were examined for the presence of Salmonella spp., total Enterobacteriaceae counts and total aerobic colony counts. Salmonella spp. were isolated from both case and control dishcloths and refrigerators but there were no significant differences between the two groups. Colony counts were similar in case and control dishcloths and refrigerator swabs. There was no relationship between the total counts and presence of Salmonella . There was no evidence that cases of Salmonella infection were more likely to have kitchens which were contaminated with these bacteria or have higher bacterial counts than controls. Total bacterial counts were poor indicators of Salmonella contamination of the domestic kitchen environment. Further factors which could not be identified by a study of this design may increase risk of Salmonella food poisoning. These factors may include individual susceptibility of the patient. Alternatively, sporadic cases of Salmonella food poisoning may arise from food prepared outside the home.     

Cigarette smoking and completed suicide among middle-aged men: a population-based cohort study in Japan

PURPOSE: To clarify whether cigarette smoking was associated with completed suicide in a cohort of middle-aged Japanese men. METHODS: A total of 45,209 out of 57,714 men, aged 40 to 69 years, in nine public health centers across Japan responded to a self-administered questionnaire that included questions regarding their smoking history. The questionnaire was distributed in 1990 (Cohort I) and in 1993 and 1994 (Cohort II). By the end of 2000, 173 suicides were identified by death certificates. RESULTS: After adjusting for potential confounders, current smokers had a marginally higher risk of suicide than never smokers. Current smokers with more than 60 pack-years of cigarette smoking had a more than two-fold higher risk of suicide than never smokers (pooled multivariate relative risk=2.1; 95% confidence interval, 1.1, 4.0), but a significant dose-response relationship between pack-years of smoking and suicide was not found. The risk of suicide increased significantly with increasing numbers of cigarettes smoked per day (p for trend=0.036). Smoking status, duration of quitting, duration of smoking, and age at the start of smoking were not significantly associated with suicide risk. CONCLUSION: Our results suggest that heavy smoking, particularly a large number of cigarettes per day at baseline was associated with an increased risk of suicide independent of several potential confounders.