Schweizerische medizinische Wochenschrift最新文献

Bloodstream infections (are associated with high mortality. The incidence of bloodstream infections is increasing worldwide, with a shift towards multiresistant pathogens such as methicillin-resistant Staphylococcus aureus, enterococci and Candida spp. This study analysed retrospectively 1814 episodes of bacteraemia from 1993 to 1997 at a single tertiary care centre. True bloodstream infections was defined as clinical sepsis and positive blood culture without evidence for contamination of skin bacteria. Of the 1814 episodes, 380 (20.9%) were contaminated, resulting in 1434 true episodes of bloodstream infection. 42% were nosocomial bloodstream infections and one fourth were primary bloodstream infections. The incidence of bloodstream infections increased from 13.0/10,000 patient-days (1993) to 15.8/10,000 patient-days (1997). Mortality increased from 15.4% (1993) to 21% (1997) (p = 0.059). The five most frequently isolated microorganisms were Escherichia coli, Staphylococcus aureus, Streptococcus pneumoniae, coagulase-negative staphylococci and streptococci. The distribution of bacteria did not change over time from 1993 to 1998. Multiresistant bacteria such as methicillin-resistant Staphylococcus aureus, enterococci, Pseudomonas spp. and yeasts were isolated in less than 5% of episodes. In addition, there is a trend towards decreasing resistance, in contrast to most other institutions in Southern Europe and the US. Further analyses and studies are necessary to answer questions raised by this retrospective study.

Background: The study aim was to analyse the diagnostic and therapeutic approach to selected infectious diseases, in particular with regard to the use of antibiotics, in the light of current guidelines and the problem of developing resistance.

Methods: A questionnaire was sent to all physicians with a general or internal medicine practice in the Cantons Basel-Stadt and Basel-Landschaft, Switzerland.

Results: Of 440 physicians, 286 (65%) took part in the study. The most frequent diagnoses of infection were cystitis (16.6%), flu-like syndrome (16.4%), acute bronchitis (12.3%), and tonsillopharyngitis (10.1%). The most frequent indications for antimicrobial therapy were cystitis (19.9%), acute sinusitis (14.1%), acute bronchitis (11.5%), and tonsillopharyngitis (9.2%). Macrolides (24.0%), aminopenicillins (22.6%), and fluoroquinolones (16.8%) were the most frequently prescribed antibiotics.

Conclusions: The majority of physicians diagnosed and treated according to rational principles. However, a few exceptions were found, e.g. omission of x-ray in the diagnosis of pneumonia (24%), the use of antibiotics in the treatment of viral diseases and antibiotic therapy for tonsillopharyngitis despite a negative rapid antigen detection test against group A streptococci (75%).

We report on 4 cases of severe icteric leptospirosis. Three patients developed renal failure requiring haemodialysis and one required mechanic ventilation for 10 days. On entry all patients presented with severe myalgia, particularly in the calves, jaundice, oligo-anuria and severe thrombocytopenia. In one case an acute abdomen-like presentation led to exploratory laparotomy. We believe that the abdominal pain was mainly due to rhabdomyolysis of the abdominal wall. The outcome was favorable in all cases and recovery of renal function was observed after a few days to several weeks. Three out of 4 patients were infected in southern Switzerland. This observation underscores the importance of wild and domestic animals as a leptospira reservoir. Patients presenting with acute renal failure and jaundice, but only mild-to-moderate elevation of transaminases, are suspect for leptospirosis regardless of travel to a tropical or subtropical country.

Objective: To study the question of how long maternal IgG antibodies against measles, mumps and rubella persist in infants.

Methods: Sera of children aged 0-16 months who had been hospitalised in our institution between 1994 and 1999 were identified from our routine serum collection. Exclusion criteria were: preterm delivery; suspected measles, mumps or rubella illness or exanthema of unknown aetiology; transfusion of blood products in the 6 months preceding serum collection; foreign-born mother; previous MMR immunisation. IgG antibodies were measured by use of commercially available ELISA kits.

Results: 254 serum specimens were analysed. Age distribution of patients was as follows: 0-3 months n = 58; > 3-6 months n = 48; > 6-9 months n = 52; > 9-12 months n = 42; > 12-16 months n = 54. The following seroprevalence rates for IgG antibodies were found (measles/mumps/rubella): 0-3 months 97%/62%/91%; > 3-6 months 40%/2%/42%; > 6-9 months 4%/2%/10%; > 9-12 months 2%/0%/12%; > 12-16 months 0%/7%/7%.

Conclusions: Our results demonstrate high levels of passive immunity against measles and rubella in Swiss infants during the first months of life, whereas immunity against mumps appears to be considerably less reliable. Beyond the first 3 months of life, IgG antibodies against all 3 illnesses are lacking in the majority of patients; beyond 12 months of age they are only rarely detectable. These results raise the question whether the first MMR immunisation, currently recommended at the age of 15 months in Switzerland, should be brought forward.

Background: Tick-borne human granulocytic ehrlichiosis (HGE) has not been diagnosed in Switzerland, although the HGE agent has been identified in ticks and animal reservoirs and human infections have been suspected on the basis of serological surveys.

Methods: We retrospectively tested sera of 48 persons with antibodies to B. burgdorferi and/or tick-borne encephalitis virus for the presence of antibodies to E. phagocytophila (a surrogate marker of the agent of HGE), and reviewed their charts with regard to clinical manifestations possibly associated with a tick-borne infection. We then prospectively examined EDTA blood of 80 patients who presented with fever 7 to 21 days after a tick bite for the presence of the HGE agent (using nested PCR and microscopic examination of blood smears) and anti-E. phagocytophila antibodies. We also collected clinical data.

Results: The retrospective study revealed 12 persons (25%) with anti-E. phagocytophila antibody titers > or = 1:80, suggesting coinfection with HGE and either Lyme Borrelia or tick-borne encephalitis virus. Among these, 7 patients presented with clinical manifestations compatible with HGE disease. The prospective investigation identified 8 patients (10%) with anti-E. phagocytophila antibody titers > or = 1:80, and 7 of these presented with signs and symptoms suggesting HGE. The HGE agent, however, was detected neither by PCR nor by microscopic examination.

Conclusions: Serological and clinical data suggest the occurrence of an HGE-like agent as well as of coinfections with HGE and B. burgdorferi or tick-borne encephalitis virus in Switzerland. However, the HGE agent was not identified in persons living in Switzerland.

The hand-foot syndrome (HFS) is an erythematous skin lesion of the palma and planta of the hand and feet is most often caused by cytostatic chemotherapy. The impact on the patients' quality of life depends on the extent of the disease. The pathogenesis of the hand-foot syndrome has not yet been sufficiently clarified and it can only be treated symptomatically. We performed an extensive literature search in Medline to evaluate the current state of knowledge concerning the hand-foot syndrome and conclude with practical advice to physicians treating patients with hand-foot syndrome.

Background: The onset of sexual activity represents an important development stage with positive aspects, such as love, discovery, intimate relationships, plans for the future, but also with fears of pregnancy, of sexually transmitted diseases and of AIDS.

Objective: To study perceptions, attitudes, and behaviour related to sexual life, AIDS and contraception; to explore the onset of first sexual relationships and the process of choice of a contraceptive method by the adolescents, in order to improve prevention programmes for young people.

Method: Analysis of data from a Swiss national survey on adolescent sexuality using a computerised self-administered questionnaire, involving 2075 girls and 2208 boys between the ages of 16 and 20. The use of computers helps improve confidentiality, response rates and acceptability since survey questions are limited to the subjects' sexual experience only.

Results: The young people's responses emphasised the importance of emotion in sexual relationships, girls choosing intimacy and fidelity while boys attached more importance to physical pleasure. Three out of four respondents have had a sexual experience and one out of two have had penetrative sexual intercourse. The percentages of condom or oral contraception use are high: at first sexual intercourse, 86.5% used one or the other, while 7.4% did not declare any contraceptive method. The percentages are lower when age at first intercourse is below 15 years, when a girl had an older partner (age difference 7 years and more) and when the 1st relationship is a casual one. During their first stable relationship 41.1% of girls and 30.9% of boys say they have changed their contraceptive method from condom to contraceptive pill, 2.4% of girls and 2.9% of boys say they have given up any form of contraception. Among girls, condom use at first sexual intercourse with a new partner decreases in favour of oral contraception between first and last steady relationships (75.6 vs 58.0%, p < 0.05), the decrease being insignificant between the first and last casual relationships (73.5 and 62.2%, n.s.). Among boys the rates of condom use are equal at first intercourse with the first and last partner (steady relationship: 74.1 and 77.2%; causal relationship: 78.3 and 76.2% respectively).

Conclusion: The use of condoms is high among Swiss adolescents, particularly at first sexual intercourse. By integrating the prevention of sexually transmitted diseases and of unwanted pregnancies, preventive programmes would address adolescents' needs more effectively.

Introduction: Chronic gastrooesophageal reflux disease (GERD) is the most common benign pathology of the upper gastrointestinal tract in the western world. We report our experience of laparoscopic antireflux surgery.

Patients and methods: 49 patients underwent laparoscopic antireflux surgery at our clinic between 1994 and 1999. 48 patients were followed up in a retrospective study. Mean follow-up was 30 months (2-66). 31 patients (64.6%) were male and 17 female (35.4%). Mean age was 48 years (26-74). The surgical method was tailored to the case: total Nissen fundoplication (87.5%) was indicated after ruling out oesophageal motility disorders by manometry. In 6 patients (12.5%) with coexisting dysphagia or pathological manometry, partial posterior fundoplication (Toupet) was performed.

Results: Mean operating time of 215 minutes (125-420) for the first 10 Nissens was significantly reduced to 119 minutes (70-190) for the last 10 procedures with increasing experience of the surgeon. No severe intraoperative complications occurred and mortality was 0%. Conversion rate was 4.2%. Mean hospital stay was 6.1 days (1-36). At follow-up 93.7% were free of reflux symptoms without medication, and only one patient (2.1%) suffered from regular reflux which had to be treated with PPI daily. 2 patients (4.2%) took PPI only occasionally. Persistent dysphagia occurred in 7 patients (14.8%). 5 (10.5%) underwent one or more endoscopic dilatations, after which 3 patients (6.3%) reported an improvement of dysphagia. No patient needed reoperation on due to mechanical complications. 1 patient (2.1%) developed a paraoesophageal hernia 4.5 years after a Nissen procedure. According to the Visick Score, 95.8% of all patients were satisfied with their outcome (Visick I/II).

Conclusions: With careful investigation and indication, laparoscopic antireflux surgery is a safe and effective alternative method to long-term medication with PPI in the treatment of gastrooesophageal reflux disease. Morbidity is low. Persistent postoperative dysphagia can be reduced with either a short and floppy total fundoplication or a partial wrap.

Radiotherapy of breast cancer, cervical cancer, testicular tumours and lymphoma is one of the most effective therapy options. Damage to the nervous system, in particular the brachial and lumbar plexus, is rare and typically leads to development of progressive sensory disturbances and motor weakness after years-long latency. We present two cases exemplifying the diagnostic problems in differentiating between radiation-induced injury and recurrence of the primary tumour. A clinical course with sensorimotor symptoms and signs progressing over months, electomyographic recording of myokymic discharges, and absence of a space-occupying mass suggest late-onset radiation-induced plexopathy. The literature on pathogenesis and incidence of radiation-induced plexopathy is reviewed.