Schweizerische medizinische Wochenschrift最新文献

In trauma patients it is mandatory to establish the exact reason for their hypotension. If hypovolaemia is most probably responsible for the hypotension, fluid resuscitation should be initiated. The therapy of choice is infusion of sugarless, isotonic crystalloids with a physiologic serum electrolyte composition. In patients with brain injuries a decrease in serum osmolality is not advisable and hypertonic fluids may therefore be considered. Human albumin preparations are no longer indicated, but synthetic colloids may be an adjunct to a pure crystalloid regime. Hydroxyethyl starch preparations with a molecular weight in the mean range are reasonable choices considering the individual advantages and disadvantages of the various colloids. Larger blood losses must be treated with blood components such as packed red cells, fresh frozen plasma and thrombocyte concentrates as indicated. There are no widely accepted values for laboratory or monitoring parameters in starting or stopping a given fluid therapy; these values are unquestionably influenced, among other things, by the patient history and the pattern of the injuries. Initial resuscitation (when to start, who should administer the fluid and how much) also remains a focus of heated controversy.

Patients after acute head injury are susceptible to secondary insults and therefore to secondary brain injury. A comprehensive approach, starting at the site of the accident, followed by emergency diagnosis and treatment in the appropriate emergency department of the trauma centre, intensive care and specific neurorehabilitation is the only way to minimise sequelae of primary brain lesions, prevent secondary brain damage and establish optimum frame conditions with respect to recovery from non-definite brain damage.

In trauma patients restoration of intravascular volume in an attempt to achieve normal systemic pressure faces the risk of increasing blood loss and thereby potentially affecting mortality. Due to the lack of controlled clinical trials in this field, the growing evidence that hypotensive resuscitation results in improved long-term survival mainly stems from experimental studies in animals. The main differences between concepts for the reduction of blood loss in systemic hypotension are between "deliberate hypotension" (synonym "controlled hypotension", used intraoperatively), "delayed resuscitation" (where the hypotensive period is intentionally prolonged until operative intervention) and "permissive hypotension" (where restrictive fluid therapy increases systemic pressure without reaching normotension). In this review the concept of "permissive hypotension" is delineated on the basis of macro- and microcirculatory changes secondary to hypovolaemia and low driving pressure, and the potential indications and limitations are discussed.

Invasive candidiasis is rare in the general population (about 8 episodes/100,000/year), but has a higher incidence in hospitalised patients (0.5/1000 admissions). It complicates about 10 per 1000 admissions in critical care, where it represents 10-15% of all nosocomial infections. Candidiasis remains difficult to diagnose and its mortality is as high as those of septic shock (40-60%). A better knowledge of the pathophysiology of the disease and the availability of triazole compounds that are less toxic than amphotericin have given rise to the concept of early empirical or preemptive treatment. Prophylaxis of invasive candidiasis, which is very effective, is based on risk factor identification. However, prophylaxis must be restricted to carefully selected groups of patients, to avoid the emergence of resistant strains and a shift in the distribution of pathogens from albicans to non-albicans strains under the pressure of antifungal agents.

Background: Tick-borne meningo-encephalitis (TBE) is caused by a flavivirus species that is transmitted from rodents to humans by Ixodes ticks. The clinical picture of central nervous system involvement varies from febrile headache to lethal encephalitis. To date no specific treatment exists, although protective active immunisation is available.

Methods: We present the clinical and epidemiological data from 73 patients with TBE who acquired the infection in Canton Thurgau in the years 1996-1999.

Results: Canton Thurgau is a state in eastern Switzerland with a population of 230,000. Within the last five years the reported cases of TBE have increased more than threefold. The area where infectious tick bites were registered has expanded from the western to the eastern part and now encompasses the entire state. The risk of infection is clearly related to frequent activities in wooded areas, though outdoor activities not in forests also carry a considerable risk. In > 80% of the cases a postviral neurasthenic syndrome develops involving absence from work for two months on average. In the elderly and patients who present with encephalitic symptoms, a worse outcome with persistent neurological symptoms or even death has been observed.

Conclusion: The increasing incidence of TBE, the expansion of infectious ticks to the east and high morbidity justify active immunisation against TBE on a broad scale in Canton Thurgau.

The purpose of this study was to assess the number of cases and the clinical aspects of Lyme borreliosis in French-speaking Switzerland. From July 1996 to December 1997, all laboratories performing serological tests for Lyme borreliosis sent a questionnaire to the treating physicians whenever the tests were positive. In addition, the physicians who diagnosed a case on clinical grounds only were also asked to report these cases. During this period, 1460 positive serological tests were recorded among approximately 10,360 performed (14%). A total of 775 questionnaires were returned (53%). In 3/4 of the cases, the test was ordered because of an acute clinical manifestation or a tick bite. The rest related to chronic symptoms or follow-up. In 504 cases (65%), diagnosis was considered certain or probable. These were erythema migrans in 46%, clinical manifestations of stage II in 33% (26 facial palsy, 20 acute arthritis, 5 benign cutaneous lymphocytoma) and chronic symptoms in 21% (23 acrodermatitis, 26 neuropathies, and 8 arthritis). The adjusted incidence, estimated on the basis of the treating physician's place of residence, ranged from 9/100,000 in Valais to 95/100,000 in Neuchâtel. This study indicates that Lyme borreliosis is a diagnosis frequently looked for and established in French-speaking Switzerland. Although erythema migrans is the main clinical manifestation, symptoms of stage II and III indicate that Lyme borreliosis is also responsible for relatively major systemic morbidity.

Background and objectives: The Swiss HIV Cohort Study (SHCS) was initiated in 1988 and represented the main scientific component of the comprehensive response to the AIDS epidemic in Switzerland. It brought together physicians and scientists from five university hospitals (Basel, Berne, Geneva, Lausanne and Zurich) and two Cantonal hospitals (Lugano and St. Gallen). The objective of SHCS was, and still is, to produce rapid, high quality patient-oriented medical research in the field of HIV infection.

Methods: SHCS is a prospective population-based cohort study. Any HIV-infected person aged > or = 16 years is eligible to participate. Data collection and study procedures are standardised. Data quality and protocol monitoring are conducted at the coordination and data centre in Lausanne. Detailed information on demographics, income, mode of HIV acquisition, risk behaviours, clinical events, laboratory results, treatment and treatment tolerance is collected at registration and at 6-monthly intervals.

Results: Since 1996, 10,600 persons have been enrolled and the SHCS study population is considered fairly representative of the HIV-infected population in Switzerland, at least in terms of gender and mode of HIV acquisition. In 1999, 4600 patients were actively followed up and more than 70% of patients were receiving highly active antiretroviral therapy (HAART). As a consequence, mortality and the incidence of HIV-related opportunistic infections have decreased significantly in the recent past. Between 1996 and 2000, 91 original manuscripts have been published by SHCS scientists and physicians, almost exclusively in peer-reviewed journals. A wide range of scientific questions have been addressed, including HIV primary infection, the natural history of HIV infection, the clinical and biological impact of HAART, drug resistance, risk factors for disease evolution including the timing of treatment initiation, the role of CD4 receptors, the validity of HIV surveillance reports, determinants of treatment access and tolerance, clinical trials of new drug combinations, the interruption of prophylaxis following a favourable response to HAART and issues relating to quality of life and interaction between income, social level and disease evolution.

Conclusion: The SHCS has had, and continues to have, a significant impact on medical practice, public health and research in Switzerland and beyond. It represents a network of excellence which has brought together and fostered intensive collaboration between physicians and institutions throughout this country and beyond. This was possible thanks to the support of the Federal Office of Public Health and the commitment of primary care physicians, researchers and patients. This project may be model for focused and prioritised multicentre and transdisciplinary research programmes.