[A rare cause of acute abdomen in a young immunocompetent woman]. / Seltene Ursache eines akuten Abdomens bei einer jungen immunkompetenten Frau.

Streptococcus pyogenes is a human pathogenic, gram positive bacterium that primarily leads to pharyngitis or soft tissue infections. Primary peritonitis caused by S. pyogenes infection is rare and there are only a few published cases worldwide. Primary peritonitis due to other pathogens occurs in immunosuppressed conditions such as HIV or other chronic diseases. However, younger, healthy women are more likely to be affected by S. pyogenes peritonitis. At present, the underlying molecular mechanisms can only be speculated on. One possibility is that, similar to the clinical picture of streptococcal toxic shock syndrome (STSS), a specific serotype of the M protein in combination with inhibition of the cell response of neutrophil granulocytes could play a role. In addition to peritonitis, the clinical picture may include other organ manifestations such as acute kidney damage or circulatory dysregulation. In terms of treatment, rapid pathogen-directed empirical antibiotic therapy is the treatment of choice. If there is no indication of secondary peritonitis, diagnostic laparoscopy can be dispensed with in the further diagnostic work-up.

Oral transmucosal fentanyl citrate analgesia in prehospital trauma care: an observational cohort study.

BACKGROUND: Pain is one of the major prehospital symptoms in trauma patients and requires prompt management. Recent studies have reported insufficient analgesia after prehospital treatment in up to 43% of trauma patients, leaving significant room for improvement. Good evidence exists for prehospital use of oral transmucosal fentanyl citrate (OTFC) in the military setting. We hypothesized that the use of OTFC for trauma patients in remote and challenging environment is feasible, efficient, safe, and might be an alternative to nasal and intravenous applications. METHODS: This observational cohort study examined 177 patients who were treated with oral transmucosal fentanyl citrate by EMS providers in three ski and bike resorts in Switzerland. All EMS providers had previously been trained in administration of the drug and handling of potential adverse events. RESULTS: OTFC caused a statistically significant and clinically relevant decrease in the level of pain by a median of 3 (IQR 2 to 4) in NRS units (P < 0.0001). Multiple linear regression analysis showed a significant absolute reduction in pain, with no differences in all age groups and between genders. No major adverse events were observed. CONCLUSIONS: Prehospital administration of OTFC is safe, easy, and efficient for extrication and transport across all age groups, gender, and types of injuries in alpine environments. Side effects were few and mild. This could provide a valuable alternative in trauma patients with severe pain, without the delay of inserting an intravenous line, especially in remote areas, where fast action and easy administration are important.

Surgery goes EPA (Entrustable Professional Activity) - how a strikingly easy to use app revolutionizes assessments of clinical skills in surgical training.

OBJECTIVE: Entrustable Professional Activities (EPAs) are increasingly being used in competency-based medical education approaches. A general lack of time in clinical settings, however, prevents supervisors from providing their trainees with adequate feedback. With a willingness for more administrative tasks being low in both trainees and educators, the authors developed a radical user-friendly mobile application based on the EPA concept called "Surg-prEPAred". DESIGN: Surg-prEPAred is designed to collect micro-assessment data for building competency profiles for surgical residents according to their curriculum. The goal of Surg-prEPAred is to facilitate the performance and documentation of workplace-based assessments. Through aggregated data the app generates a personalized competency profile for every trainee. During a pilot run of 4 months, followed by ongoing usage of the application with a total duration of 9 months (August 2019 to April 2020), 32 residents and 33 consultants made daily use of the application as a rating tool. Every rating included knowledge, skills and professional attitudes of the trainees. Before the initiation of the App and after the 9-month trial period trainees and supervisors where both sent questionnaires to evaluate the user friendliness and effectiveness of the App. RESULTS: Five hundred ten App based assessments were generated. Out of 40 pre-defined EPAs, 36 were assessed. 15 trainees and 16 supervisors returned the questionnaires and stated the surg-prEPAred App as very valuable, effective and feasible to evaluate trainees in a clinical setting providing residents with an individual competence portfolio to receive precision medical education. CONCLUSIONS: The authors expectation is that the Surg-prEPAred App will contribute to an improvement of quality of medical education and thus to the quality of patient care and safety. In the future the goal is to have the App become an integral part of the official Swiss surgical curriculum accepted by the Swiss professional surgical society.

Routine follow-up imaging has limited advantage in the non-operative management of blunt splenic injury in adult patients.

BACKGROUND: To date, limited evidence exists regarding follow-up imaging during the non-operative management (NOM) of blunt splenic injury (BSI), especially concerning ultrasound as first-line imaging modality. The aim of this study was to investigate the incidence and time to failure of NOM as well as to evaluate the relevance of follow-up imaging. METHODS: All adult patients with BSI admitted to our level I trauma center, including two associated hospitals, between 01/01/2010 and 31/12/2017 were retrospectively analyzed. Demographic data, comorbidities, injury pattern, trauma mechanism, Injury Severity Score, splenic injury grade and free intra-abdominal fluid were reviewed. Additional analysis of indication, frequency, modality, results and consequences of follow-up imaging was performed. Risk factors for failure of NOM were evaluated using fisher's exact test. RESULTS: A total of 122 patients with a mean age of 43.8 ± 20.7 years (16-84 years) met inclusion criteria. Twenty patients (16.4%) underwent immediate intervention. One-hundred-and-two patients (83.6%) were treated by NOM. Failure of NOM occurred in 4 patients (3.9%). Failure was significantly associated with active bleeding (3 of 4 [75%] failures vs. 8 of 98 [8.2%] non-failures, OR 33.75, 95% CI 3.1, 363.2, p = 0.004), and liver cirrhosis (2 of 4 [50%] failures vs. 0 of 98 [0%] non-failures, OR 197, 95% CI 7.4, 5265.1, p = 0.001). Eighty patients (78.4%) in the NOM-Group received follow-up imaging by ultrasound (US, n = 51) or computed tomography (CT, n = 29). In 57 cases, routine imaging examinations were conducted (43 US and 14 CT scans) without prior clinical deterioration. Fifty-fife (96.4%) of these imaging results revealed no new significant findings. Every failure of NOM was detected following clinical deterioration in the first 48 h. CONCLUSION: To our knowledge this study includes the largest single centric patient cohort undergoing ultrasound as first-line follow-up imaging modality in the NOM setting of BSI in adult patients. The results indicate that a routine follow-up imaging, regardless of the modality, has limited therapeutic advantage. Indication for radiological follow-up should be based on clinical findings. If indicated, a CT scan should be used as preferred imaging modality.

Swiss chocolate and free beverages to increase the motivation for scientific work amongst residents: a prospective interventional study in a non-academic teaching hospital in Switzerland.

BACKGROUND: The success of a clinical trial depends on its recruitment of eligible patients; therefore, the recruitment period requires special attention. We hypothesized that with a new approach focused on continuous information and gratification, resident motivation to participate in scientific work will increase and recruitment rates will improve. METHODS: Our new recruitment approach was applied to the recruitment phase of two prospective randomized trials (registered at the German Clinical Trials Register). Randomization of these trials was performed first using blinded envelopes; later a soft drink machine was used as the delivery tool of randomization as a lighthearted motivation to join scientific work and to reward the resident with free soft drinks for each recruitment. Residents were informed about the trial via a lecture and by mail. To increase interest everyone received Swiss chocolate. With a multiple choice survey we investigated the success of our actions at 6 and 12 months. Recruitment rates of the trials were evaluated and associated with the motivational approaches. RESULTS: Our residents rated their awareness of the trials with median 9 (IQR 7;9) during the first and 8 (IQR 5;9) during the second survey and their interest in scientific work with median 7 (IQR 4;8) and 6 (IQR 5;8). The percentage of residents feeling highly motivated improved from 58% to 70%. The recruitment rates stayed stably high over time with 73% and 72% in trial 1 and 90% and 85% in trial 2; 24% of residents stated their motivation could be increased by gratifications. CONCLUSIONS: After implementation of our new recruitment approach we found positively motivated residents and high recruitment rates in the corresponding trials. We propose this procedure may help to ensure the successful initiation of clinical trials. Larger studies testing this approach are warranted.

Gallbladder Retrieval From Epigastric Versus Umbilical Port in Laparoscopic Cholecystectomy: A PRISMA-Compliant Meta-Analysis.

Purpose. To date, no evidence supports the retrieval of the gallbladder through a specific trocar site, and this choice is left to surgeons' preference. The aim of this meta-analysis was to investigate the influence of the trocar site used to extract the gallbladder on postoperative outcomes. Methods. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search of PubMed, Google Scholar, Cochrane Library, and EMBASE databases was performed. Terms used were: ("gallbladder" OR "cholecystectomy") AND "umbilical" AND ("epigastric" OR "subxiphoid"). Randomized trials comparing the gallbladder retrieval from different trocar sites were considered for further analysis. Results. Literature search revealed 145 articles, of which 7 matched inclusion criteria and reported adequate data about postoperative pain, operative time, port-site infections, and hernias. A total of 876 patients were included, and the gallbladder was extracted through epigastric or umbilical trocar site in 441 and in 435 patients, respectively. A statistically significant difference among groups was noted in terms of postoperative pain at 1, 6, 12, and 24 hours in favor of the umbilical trocar site (P < .001). No significant differences were noted in postoperative hernia and infection rate, nor in terms of operative time. Conclusions. This meta-analysis shows a statistically significant reduction in terms of postoperative pain at 1, 6, 12, and 24 hours after surgery when the gallbladder is extracted through the umbilical port. Retrieval time, infections, and hernias rate implicate no contraindication for the choice of a specific trocar site to extract specimens. Despite limitations of this study, the umbilical trocar should be favored as the first choice to retrieve the gallbladder.

Surgical Residents' Proficiency and Turnover May Affect the Overall Efficiency in an Emergency Department.

BACKGROUND: Within Emergency Department (ED), problem responsiveness and organizational capacity are extremely important for providing acute care. The "July effect" has been described as the period when junior doctors start new turnovers, possibly reflecting on hospital and ED efficiency. The objective of this study was to investigate the impact of residents' turnover on ED efficiency at a Swiss teaching hospital. METHODS: We retrospectively evaluated patients presenting with surgical needs to ED from June 2014 to January 2019. Data regarding gender, age, length of stay (LOS), resident doctors and level of urgency were collected and analyzed. RESULTS: We identified 27,767 surgical admissions treated by 92 residents. The LOS analysis within residents' period in the ED showed a progressive reduction over time, with 80% of proficiency achieved after 98 patients. The mean LOS was 257.3 and 237.6 min during and after the learning curve (p < 0.0001), although no difference was noted in triage level 1 patients (p = 0.813). By replacing 40-70% of residents (January and July), the LOS raised from 243.1 to 259.7 min (absolute difference 16.6 min, p < 0.001), but if only 10-20% of residents newly started, no difference was detected (p = 0.071). CONCLUSIONS: Our study demonstrates that surgical residents' turnover within the ED could affect the overall efficiency. The training period for new resident physicians was a caseload of 98 patients, respectively, 3 weeks of work. The impact of trainees' turnover was only relevant if more than 40% of the resident team is replaced at one time and only less urgent cases were affected.

Trauma care in German-speaking countries: have changes in the curricula led to changes in practice after 10 years?

PURPOSE: Traditionally, in the German-speaking countries, trauma patients are treated by general surgeons specialized in trauma surgery known as the Unfallchirurg. Over the last decade, a trend towards a lower influence of surgeons and a higher influence of subspecialties in the emergency department has been noted. With additional transformations in the health care system towards highly specialized medicine and the arising of new (sub-) specialties, diversification in the management of the trauma patient appears to occur. The new curricula for surgical disciplines providing trauma care will widen this issue even further, moreover, triggered by the Anglo-American medical model. The primary aim of this study was to evaluate the current situation in German-speaking countries concerning the management of trauma patients. The interfaces between emergency physicians, orthopaedic and general surgeons have been investigated concerning the management of the trauma patients. Additionally, different future scenarios have been evaluated. METHODS: An online questionnaire was submitted to members of the German Society of Trauma and Orthopaedic Surgery [Deutsche Gesellschaft für Orthopädie und Unfallchirurgie (DGOU)], including both general and orthopaedic surgeons, emergency physicians and also some members from Austria, the Netherlands and Switzerland. Questions dealt with demographic data, the current situation in the clinic of the responders in terms of management of mono- and polytrauma patients as well as fracture care. In addition, various future scenarios were evaluated. RESULTS: 293 members of the DGOU answered the questionnaire. The majority of the responders (45%) were orthopaedic surgeons and 34% were general trauma surgeons. Sixty-two per cent of hospitals run their emergency departments with emergency physicians. Treatment of both mono- and polytrauma patients in the emergency department is equally distributed between general and orthopaedic surgeons. Fracture care, however, is predominantly (65%) being performed by general trauma surgeons in both mono- and polytrauma patients. The majority of the respondents (80%) do not want to change the current situation and predict that in the future fracture care will still be performed by general surgeons' specialized in trauma surgery. Approximately two-thirds of the responders do not believe that emergency physicians will play a bigger role in the management of trauma patients in the future. CONCLUSION: Despite the growing importance of emergency physicians, separated in the emergency room between surgical and internal medicine fields, in the acute care of surgical patients in the emergency departments, their role in the management of the polytraumatized patients remains limited. More than 13 years after the new curricula for orthopaedic and general surgery have been implemented in Germany, fracture care is still predominantly provided by general surgeons specialized in trauma surgery. In conclusion, it seems that the general surgeon specialized in trauma surgery still plays and wants to play the key role in the management of the polytrauma patient and fracture care in German-speaking countries.

Acceptance of Ambulatory Laparoscopic Cholecystectomy in Central Switzerland.

BACKGROUND: Currently, most patients undergoing laparoscopic cholecystectomy (LC) in Switzerland are inpatients for 2-3 days. Due to a lack of available hospital beds, we asked whether day-case surgery would be an option for patients in central Switzerland. The questions of acceptability of outpatient LC and factors contributing to the acceptability thus arose. METHODS: Hundred patients suffering from symptomatic cholecystolithiasis, capable of communicating in German, and between 18 and 65 years old, were included. Patients received a pre-operative questionnaire on medical history and social situation when informed consent on surgery and participation in the study was obtained. Exclusion criteria were patients suffering from acute cholecystitis or any type of cancer; having a BMI >40 kg/m2; needing conversion to open cholecystectomy or an intraoperative drainage; and non-German speakers. Surgery was performed laparoscopically. Both surgeon and patient filled in a postoperative questionnaire. The surgeon's questionnaire listed medical and technical information, and the patients' questionnaire listed medical information, satisfaction with the treatment and willingness to be released on the same day. These data from both questionnaires were grouped into social and medical factors and analysed on their influence upon willingness to accept an ambulatory procedure. No outpatient follow-up apart from checking for readmission to our hospital within 1 month after discharge was performed. RESULTS: Of the 100 participants, one-third was male. More than two-thirds were Swiss citizens. Only one participant was ineligible for rapid release evaluation due to need of a drainage. Among the social factors contributing to the acceptability of ambulatory care, we found nationality to be relevant; Swiss citizens preferred an inpatient procedure, whereas non-Swiss citizens were significantly more willing to return home on the same day. Household size, sex and age did not correlate with a preference for inpatient care in our study population. Furthermore, medical input factors such as the surgeon's level of experience, operation time or use of local anaesthesia at the end of surgery had also no significant influence on whether patients preferred inpatient care or not. Medical output factors not found to contribute to the patients' decisions included co-morbidities or postoperative nausea and vomiting (PONV). Patients of experienced surgeons reported significantly less pain at the operation site. This was correlated with a somewhat increased willingness to accept ambulatory treatment. CONCLUSION: Given the choice, about half of the LC patients in central Switzerland prefer to stay in hospital overnight. PONV, age, sex or social surroundings were not predictive of the preferred treatment modality. Only being a non-Swiss citizen and experiencing little pain at the operation site due to the surgeon's skills seem to be factors that lead to a preference for ambulatory LC (ALC). Therefore, ALC in central Switzerland is most acceptable to non-Swiss citizens, operated upon by experienced surgeons.

Mechanical and electrostatic experiments with dust particles collected in the inner coma of comet 67P by COSIMA onboard Rosetta.

The in situ cometary dust particle instrument COSIMA (COmetary Secondary Ion Mass Analyser) onboard ESA's Rosetta mission has collected about 31 000 dust particles in the inner coma of comet 67P/Churyumov-Gerasimenko since August 2014. The particles are identified by optical microscope imaging and analysed by time-of-flight secondary ion mass spectrometry. After dust particle collection by low speed impact on metal targets, the collected particle morphology points towards four families of cometary dust particles. COSIMA is an in situ laboratory that operates remotely controlled next to the comet nucleus. The particles can be further manipulated within the instrument by mechanical and electrostatic means after their collection by impact. The particles are stored above 0°C in the instrument and the experiments are carried out on the refractory, ice-free matter of the captured cometary dust particles. An interesting particle morphology class, the compact particles, is not fragmented on impact. One of these particles was mechanically pressed and thereby crushed into large fragments. The particles are good electrical insulators and transform into rubble pile agglomerates by the application of an energetic indium ion beam during the secondary ion mass spectrometry analysis.This article is part of the themed issue 'Cometary science after Rosetta'.

High-molecular-weight organic matter in the particles of comet 67P/Churyumov-Gerasimenko.

The presence of solid carbonaceous matter in cometary dust was established by the detection of elements such as carbon, hydrogen, oxygen and nitrogen in particles from comet 1P/Halley. Such matter is generally thought to have originated in the interstellar medium, but it might have formed in the solar nebula-the cloud of gas and dust that was left over after the Sun formed. This solid carbonaceous material cannot be observed from Earth, so it has eluded unambiguous characterization. Many gaseous organic molecules, however, have been observed; they come mostly from the sublimation of ices at the surface or in the subsurface of cometary nuclei. These ices could have been formed from material inherited from the interstellar medium that suffered little processing in the solar nebula. Here we report the in situ detection of solid organic matter in the dust particles emitted by comet 67P/Churyumov-Gerasimenko; the carbon in this organic material is bound in very large macromolecular compounds, analogous to the insoluble organic matter found in the carbonaceous chondrite meteorites. The organic matter in meteorites might have formed in the interstellar medium and/or the solar nebula, but was almost certainly modified in the meteorites' parent bodies. We conclude that the observed cometary carbonaceous solid matter could have the same origin as the meteoritic insoluble organic matter, but suffered less modification before and/or after being incorporated into the comet.

Comet 67P/Churyumov-Gerasimenko sheds dust coat accumulated over the past four years.

Comets are composed of dust and frozen gases. The ices are mixed with the refractory material either as an icy conglomerate, or as an aggregate of pre-solar grains (grains that existed prior to the formation of the Solar System), mantled by an ice layer. The presence of water-ice grains in periodic comets is now well established. Modelling of infrared spectra obtained about ten kilometres from the nucleus of comet Hartley 2 suggests that larger dust particles are being physically decoupled from fine-grained water-ice particles that may be aggregates, which supports the icy-conglomerate model. It is known that comets build up crusts of dust that are subsequently shed as they approach perihelion. Micrometre-sized interplanetary dust particles collected in the Earth's stratosphere and certain micrometeorites are assumed to be of cometary origin. Here we report that grains collected from the Jupiter-family comet 67P/Churyumov-Gerasimenko come from a dusty crust that quenches the material outflow activity at the comet surface. The larger grains (exceeding 50 micrometres across) are fluffy (with porosity over 50 per cent), and many shattered when collected on the target plate, suggesting that they are agglomerates of entities in the size range of interplanetary dust particles. Their surfaces are generally rich in sodium, which explains the high sodium abundance in cometary meteoroids. The particles collected to date therefore probably represent parent material of interplanetary dust particles. This argues against comet dust being composed of a silicate core mantled by organic refractory material and then by a mixture of water-dominated ices. At its previous recurrence (orbital period 6.5 years), the comet's dust production doubled when it was between 2.7 and 2.5 astronomical units from the Sun, indicating that this was when the nucleus shed its mantle. Once the mantle is shed, unprocessed material starts to supply the developing coma, radically changing its dust component, which then also contains icy grains, as detected during encounters with other comets closer to the Sun.

Effect of intraoperative infiltration with local anesthesia on the development of chronic pain after inguinal hernia repair: a randomized, triple-blinded, placebo-controlled trial.

BACKGROUND: Chronic pain is a common complication after inguinal hernia repair. The objective of this randomized trial was to assess the effect of intraoperative infiltration with local anesthetic versus placebo on the development of chronic pain after inguinal hernia repair. METHODS: Patients with single- or double-sided inguinal hernia were enrolled in a randomized, controlled, triple-blinded trial with a sequential adaptive design. Hernias were randomized to 1 of 2 treatment groups. The intervention group received a local infiltration of 20 mL bupivacaine 0.25% and the placebo group 20 mL saline 0.9% at the end of the operation. Two interim analyses were performed according to predefined stopping criteria allowing for design and sample size adaption. The primary endpoint was chronic pain defined on a visual analog scale (VAS) as ≥30 in any quality (at rest, lying, walking, climbing stairs, and bending over) 3 months postoperatively. A logistic regression model was built to compare the incidence of chronic pain using generalized estimating equations to adjust for clustering in bilateral hernias. RESULTS: Among 357 patients, there were 406 hernias randomized. A total of 5.8% (10/173) experienced VAS ≥ 30 in any quality in the intervention group and 2.3% (4/174) in the placebo group (P = .114) at 3 months postoperatively. Multivariable analysis revealed no evidence of between-group differences for the development of any pain (odds ratio [OR], 1.03; 95% CI, 0.67-1.57; P = .905), whereas preoperative pain was an independent risk factor (OR, 2.52; 95% CI, 1.12-5.68; P = .025). CONCLUSION: We did not find any evidence that intraoperative infiltration of local anesthetic had an impact on the development of chronic postoperative pain.