Therapeutische Umschau. Revue thérapeutique
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To learn from errors is not always easy, especially if they happened to others. This paper describes the organization and management of a critical incident reporting system for primary care physicians in Switzerland and reports about the difficulties and experiences during the first 18 months since the start of the program. It seems to be particularly difficult to enhance the attentiveness of physicians for apparently harmless daily critical incidents and to motivate them to report it even in an anonymous reporting system. As incentives for more intensive participation there are the hope for comments on reported cases by other participants and the expectation that reported errors will be avoided by the readers.
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Anticoagulants and antiplatelet agents are currently used during pregnancy as treatment or prophylaxis for thromboembolic disease. Main adverse events of these agents are bleeding episodes, which put the pregnancy at risk. Unfractionated and low molecular weight heparins are first-line treatment or prophylaxis for thromboembolism. ⋯ Coumarine derivatives are still contraindicated during pregnancy because of teratogenicity and/or bleeding. No adequate data are yet available on the safety profile of the new antiplatelet agents or the direct thrombin inhibitors. Special considerations are discussed on the risks of regional anesthesia, as well as on nursing during anticoagulation.
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The most frequent complication of an acute cerebral lesion is brain edema. With increasing size of brain edema an increase in intracranial pressure is observed. This leads to decreased cerebral perfusion and brain death. ⋯ Symptoms are headache, vomiting, vision disturbances and, with increased intracranial pressure, bradicardy, respiration disturbances and at the end brain death by compression of the cerebrum. Therapy is directed to the underlying disease. Unfortunately, even today specific therapeutical approaches are limited.
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Nutcracker fractures of the tarsal navicular and cuboid usually result from dislocations of the midtarsal (Chopart's) joint. The classic pathomechanism consists of forced adduction or abduction (medial or lateral stress) mostly in combination with axial force. ⋯ Classification of Chopart fracture-dislocations is based on the proposed pathomechanics and the direction of the dislocating force. The goals of open reduction and stable internal fixation of Chopart fracture-dislocations are realignment of the medial and lateral columns of the foot, restoration of joint congruity and temporal transfixation in case of ligamentous instability to ensure proper ligament healing.
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Tarsometatarsal dislocations or fracture dislocations represent infrequent, but severe injuries which endanger the structural and mechanical integrity of the midfoot if the diagnosis is missed initially. Delayed diagnosis may result in painful and disabling arthritis and the need for salvage reconstructive surgery. As such, the rationale of treatment should follow the principles of reconstruction of weight-bearing joint injuries. ⋯ Anatomic reduction and alignment are prerequisites for a good functional outcome. The reduction of the second metatarsal ray is the keystone and the first step of surgical reconstruction followed by the other structures involved. Since adequate stability is needed until definite healing has taken place the temporary transfixation of the corresponding tarsometatarsal joints employing small fragment positioning screws has substantial advantages compared with the traditional temporary K-wire arthrodesis.