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Ruff G, Iannuzzi L, Ross F. Treating a case of diabetic stump ulceration after Chopart's amputation with total contact casting. J Vasc Surg Cases Innov Tech 2024; 10:101589. [PMID: 39282212 PMCID: PMC11401217 DOI: 10.1016/j.jvscit.2024.101589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/11/2024] [Indexed: 09/18/2024] Open
Abstract
Chopart's amputation is a limb length-preserving amputation that retains function but often suffers from stump ulcerations. We report a case of a 68-year-old male patient with poorly controlled type 2 diabetes mellitus and peripheral arterial disease who underwent left Chopart's amputation, presenting subsequently with nonhealing ulcers at the Chopart stump and heel for >1 year. Total contact casting was initiated, resulting in rapid wound healing without further interventions. This case highlights total contact casting's effectiveness in managing ulcerations post-Chopart's amputation, potentially preventing revision amputations, and extending its usefulness to complex foot anatomy in patients with diabetes and peripheral arterial disease.
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Affiliation(s)
- Garrett Ruff
- Helen L. and Martin S. Kimmel Hyperbaric & Advanced Wound Healing Center, NYU Grossman School of Medicine, New York, NY
| | - Louis Iannuzzi
- Department of Physical Therapy, Helen L. and Martin S. Kimmel Hyperbaric & Advanced Wound Healing Center, NYU Grossman School of Medicine, New York, NY
| | - Frank Ross
- Department of Surgery, Helen L. and Martin S. Kimmel Hyperbaric and Advanced Wound Healing Center, NYU Langone Health, NYU Grossman School of Medicine, New York, NY
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Fu XL, Ding H, Miao WW, Mao CX, Zhan MQ, Chen HL. Global recurrence rates in diabetic foot ulcers: A systematic review and meta-analysis. Diabetes Metab Res Rev 2019; 35:e3160. [PMID: 30916434 DOI: 10.1002/dmrr.3160] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/22/2019] [Accepted: 03/17/2019] [Indexed: 12/23/2022]
Abstract
Recurrence rates of diabetic foot ulcers vary widely in the published literature. The aim of this systematic review is to estimate recurrence rates of diabetic foot ulcers. We did a PubMed search and performed a review of reference lists for studies reporting recurrence of diabetic foot ulcers. The weighted relative risk (RR) and corresponding 95% confidence interval (CI) for recurrence was estimated. Forty-nine studies reporting recurrence of diabetic foot ulcers were included. A pooled estimate for recurrence rate was 22.1% per person-year (py) (95% CI, 19.0-25.2%). Recurrence rate was 24.9% per py in Europe (95% CI, 20.0%-29.7%), 17.8% per py in North America (95% CI, 12.7%-22.9%), 16.9% per py in Africa (95% CI, 4.7%-29.0%), and 17.0% per py in Asia (95% CI, 11.1%-23.0%). Turkey had the highest recurrence rate of 44.4% per py (95% CI, 24.9%-63.9%), and Bangladesh had the lowest of 4.3% per py (95% CI, 2.3%-6.3%). Recurrence rates of diabetic foot ulcers before 2002, between 2002 and 2008, and after 2008 were 22.2% per py (95% CI, 17.6%-26.8%), 21.9% per py (95% CI, 17.0%-26.8%), and 21.8% per py (95% CI, 16.3%-27.2%), respectively. Recurrence rates of diabetic foot ulcers are high. Recurrence rates vary widely in different regions and have decreased recently. More attention towards recurrence of diabetic foot ulcers is urgently required.
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Affiliation(s)
- Xue-Lei Fu
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Hui Ding
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Wei-Wei Miao
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Chun-Xing Mao
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Min-Qi Zhan
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Hong-Lin Chen
- School of Public Health, Nantong University, Nantong, China
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Fejfarová V, Pavlů J, Bém R, Wosková V, Dubský M, Němcová A, Jirkovská A, Sixta B, Sutoris K, Thieme F, Armstrong DG, Vrátná E, Hazdrová J, Lánská V. The Superiority of Removable Contact Splints in the Healing of Diabetic Foot during Postoperative Care. J Diabetes Res 2019; 2019:5945839. [PMID: 31637262 PMCID: PMC6766149 DOI: 10.1155/2019/5945839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/14/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Off-loading is one of the crucial components of diabetic foot (DF) therapy. However, there remains a paucity of studies on the most suitable off-loading for DF patients under postoperative care. The aim of our study was to evaluate the effect of different protective off-loading devices on healing and postoperative complications in DF patients following limb preservation surgery. METHODS This observational study comprised 127 DF patients. All enrolled patients had undergone foot surgery and were off-loaded empirically as follows: wheelchair+removable contact splint (RCS) (group R: 29.2%), wheelchair only (group W: 48%), and wheelchair+removable prefabricated device (group WP: 22.8%). We compared the primary (e.g., the number of healed patients, healing time, and duration of antibiotic (ATB) therapy) and secondary outcomes (e.g., number of reamputations and number and duration of rehospitalizations) with regard to the operation regions across all study groups. RESULTS The lowest number of postoperative complications (number of reamputations: p = 0.028; rehospitalizations: p = 0.0085; and major amputations: p = 0.02) was in group R compared to groups W and WP. There was a strong trend toward a higher percentage of healed patients (78.4% vs. 55.7% and 65.5%; p = 0.068) over a shorter duration (13.7 vs. 16.5 and 20.3 weeks; p = 0.055) in the R group, as well. Furthermore, our subanalysis revealed better primary outcomes in patients operated in the midfoot and better secondary outcomes in patients after forefoot surgery-odds ratios favouring the R group included healing at 2.5 (95% CI, 1.04-6.15; p = 0.037), reamputations at 0.32 (95% CI, 0.12-0.84; p = 0.018), and rehospitalizations at 0.22 (95% CI, 0.08-0.58; p = 0.0013). CONCLUSIONS This observational study suggests that removable contact splint combined with a wheelchair is better than a wheelchair with or without removable off-loading device for accelerating wound healing after surgical procedures; it also minimises overall postoperative complications, reducing the number of reamputations by up to 77% and the number of rehospitalizations by up to 66%.
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Affiliation(s)
- Vladimíra Fejfarová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jaroslav Pavlů
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Robert Bém
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Veronika Wosková
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Michal Dubský
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Andrea Němcová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Alexandra Jirkovská
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Bedřich Sixta
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Karol Sutoris
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Filip Thieme
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), University of Southern California (USC), Los Angeles, USA
| | - Eliška Vrátná
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jitka Hazdrová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Věra Lánská
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Mohammedi K, Potier L, François M, Dardari D, Feron M, Nobecourt-Dupuy E, Dolz M, Ducloux R, Chibani A, Eveno DF, Crea Avila T, Sultan A, Baillet-Blanco L, Rigalleau V, Velho G, Tubach F, Roussel R, Dupré JC, Malgrange D, Marre M. The evaluation of off-loading using a new removable oRTHOsis in DIABetic foot (ORTHODIAB) randomized controlled trial: study design and rational. J Foot Ankle Res 2016; 9:34. [PMID: 27555884 PMCID: PMC4994157 DOI: 10.1186/s13047-016-0163-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 08/09/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Off-loading is essential for diabetic foot management, but remains understudied. The evaluation of Off-loading using a new removable oRTHOsis in DIABetic foot (ORTHODIAB) trial aims to evaluate the efficacy of a new removable device "Orthèse Diabète" in the healing of diabetic foot. METHODS/DESIGN ORTHODIAB is a French multi-centre randomized, open label trial, with a blinded end points evaluation by an adjudication committee according to the Prospective Randomized Open Blinded End-point. Main endpoints are adjudicated based on the analysis of diabetic foot photographs. Orthèse Diabète is a new removable off-loading orthosis (PROTEOR, France) allowing innovative functions including real-time evaluation of off-loading and estimation of patients' adherence. Diabetic patients with neuropathic plantar ulcer or amputation wounds (toes or transmetatarsal) are assigned to one of 2 parallel-groups: Orthèse Diabète or control group (any removable device) according to a central computer-based randomization. Study visits are scheduled for 6 months (days D7 and D14, and months M1, M2, M3, and M6). The primary endpoint is the proportion of patients whose principal ulcer is healed at M3. Secondary endpoints are: the proportion of patients whose principal ulcer is healed at M1, M2 and M6; the proportion of patients whose initial ulcers are all healed at M1, M2, M3, and M6; principal ulcer area reduction; time-related ulcer-free survival; development of new ulcers; new lower-extremity amputation; infectious complications; off-loading adherence; and patient satisfaction. The study protocol was approved by the French National Agency for Medicines and Health Products Safety, and by the ethics committee of Saint-Louis Hospital (Paris). Comprehensive study information including a Patient Information Sheet has been provided to each patient who must give written informed consent before enrolment. Monitoring, data management, and statistical analyses are providing by UMANIS Life Science (Paris), independently to the sponsor. Since 27/10/2013, 13 centres have agreed to participate in this study, 117 participants were included, and 70 have achieved the study schedules. The study completion is expected for the end of 2016, and the main results will be published in 2017. CONCLUSION ORTHODIAB trial evaluates an innovating removable off-loading device, seeking to improve diabetic foot healing (ClinicalTrials.gov identifier: NCT01956162).
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Affiliation(s)
- Kamel Mohammedi
- Department of Endocrinology, Diabetes, and Nutrition, DHU FIRE, Bichat-Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France ; INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Louis Potier
- Department of Endocrinology, Diabetes, and Nutrition, DHU FIRE, Bichat-Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France ; INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France ; Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France
| | - Maud François
- Centre Hospitalier Universitaire de Reims, Service d'Endocrinologie, Diabète, Nutrition, Reims, France
| | - Dured Dardari
- Department of Diabetology, Endocrinology and Nutrition, Centre hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Marilyne Feron
- Department of Endocrinology, Diabetes, and Nutrition, DHU FIRE, Bichat-Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Estelle Nobecourt-Dupuy
- Department of Diabetology, Endocrinology and Nutrition, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Manuel Dolz
- Endocrinology Department, Hôpital Bégin, Saint-Mandé, France
| | - Roxane Ducloux
- APHP, Hôpital Corentin-Celton, Centre de Cicatrisation du Pied du Diabétique, Issy-les-Moulineaux, France
| | - Abdelkader Chibani
- Department of Diabetology, Endocrinology and Nutrition, Centre Hospitalier de Gonesse, Gonesse, France
| | - Dominique-François Eveno
- Department of functional rehabilitation, Centre Hospitalier La Tourmaline, Saint Herblain, France
| | - Teresa Crea Avila
- Department of Diabetology, Centre Hospitalier Régional de Metz - Thionville, Endocrinology and Nutrition, Thionville, France
| | - Ariane Sultan
- Endocrinology-Diabetology-Nutrition Department, CHRU Montpellier, Montpellier, France ; INSERM U1046, University of Montpellier 1, Montpellier, France
| | | | - Vincent Rigalleau
- Nutrition and Diabetology Unit, CHU de Bordeaux, Haut Lévèque Hospital, Pessac, France ; University of Bordeaux, Bordeaux, France
| | - Gilberto Velho
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Florence Tubach
- Département d'Epidémiologie et Recherche Clinique, APHP, CIC-EC 1425, Centre de Pharmacoépidémiologie (Cephepi), Paris, France ; Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France
| | - Ronan Roussel
- Department of Endocrinology, Diabetes, and Nutrition, DHU FIRE, Bichat-Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France ; INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France ; Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France
| | - Jean-Claude Dupré
- Department of Endocrinology, Diabetes, and Nutrition, DHU FIRE, Bichat-Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Dominique Malgrange
- Centre Hospitalier Universitaire de Reims, Service d'Endocrinologie, Diabète, Nutrition, Reims, France
| | - Michel Marre
- Department of Endocrinology, Diabetes, and Nutrition, DHU FIRE, Bichat-Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France ; INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France ; Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France
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Bus SA, van Deursen RW, Armstrong DG, Lewis JEA, Caravaggi CF, Cavanagh PR. Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes Metab Res Rev 2016; 32 Suppl 1:99-118. [PMID: 26342178 DOI: 10.1002/dmrr.2702] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Footwear and offloading techniques are commonly used in clinical practice for preventing and healing of foot ulcers in persons with diabetes. The goal of this systematic review is to assess the medical scientific literature on this topic to better inform clinical practice about effective treatment. METHODS We searched the medical scientific literature indexed in PubMed, EMBASE, CINAHL, and the Cochrane database for original research studies published since 1 May 2006 related to four groups of interventions: (1) casting; (2) footwear; (3) surgical offloading; and (4) other offloading interventions. Primary outcomes were ulcer prevention, ulcer healing, and pressure reduction. We reviewed both controlled and non-controlled studies. Controlled studies were assessed for methodological quality, and extracted key data was presented in evidence and risk of bias tables. Uncontrolled studies were assessed and summarized on a narrative basis. Outcomes are presented and discussed in conjunction with data from our previous systematic review covering the literature from before 1 May 2006. RESULTS We included two systematic reviews and meta-analyses, 32 randomized controlled trials, 15 other controlled studies, and another 127 non-controlled studies. Several randomized controlled trials with low risk of bias show the efficacy of therapeutic footwear that demonstrates to relief plantar pressure and is worn by the patient, in the prevention of plantar foot ulcer recurrence. Two meta-analyses show non-removable offloading to be more effective than removable offloading for healing plantar neuropathic forefoot ulcers. Due to the limited number of controlled studies, clear evidence on the efficacy of surgical offloading and felted foam is not yet available. Interestingly, surgical offloading seems more effective in preventing than in healing ulcers. A number of controlled and uncontrolled studies show that plantar pressure can be reduced by several conservative and surgical approaches. CONCLUSIONS Sufficient evidence of good quality supports the use of non-removable offloading to heal plantar neuropathic forefoot ulcers and therapeutic footwear with demonstrated pressure relief that is worn by the patient to prevent plantar foot ulcer recurrence. The evidence base to support the use of other offloading interventions is still limited and of variable quality. The evidence for the use of interventions to prevent a first foot ulcer or heal ischemic, infected, non-plantar, or proximal foot ulcers is practically non-existent. High-quality controlled studies are needed in these areas.
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Affiliation(s)
- S A Bus
- Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - R W van Deursen
- School of Health Care Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - D G Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, Arizona, USA
| | - J E A Lewis
- Cardiff and Vale University Health Board and Cardiff School of Health Science, Cardiff Metropolitan University, Cardiff, UK
| | - C F Caravaggi
- University Vita Salute San Raffaele and Diabetic Foot Clinic, Istituto Clinico Città, Studi, Milan, Italy
| | - P R Cavanagh
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Centre, Seattle, WA, USA
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Dallimore SM, Kaminski MR. Tendon lengthening and fascia release for healing and preventing diabetic foot ulcers: a systematic review and meta-analysis. J Foot Ankle Res 2015; 8:33. [PMID: 26300980 PMCID: PMC4546251 DOI: 10.1186/s13047-015-0085-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 06/22/2015] [Indexed: 11/10/2022] Open
Abstract
Background Diabetic foot ulcers have a devastating impact on an individual’s health-related quality of life and functional status. Additionally, diabetic foot ulcers impose a significant economic burden on our health care systems as a result of complications such as infection, hospitalisation and amputation. The current gold standard treatment for diabetic foot ulcers is total contact casting. However, the rate of ulcer recurrence is high, indicating the need for more effective long-term treatment options. Therefore, the aim of this study was to systematically identify, critique and evaluate all literature investigating the effectiveness of Achilles tendon lengthening, gastrocnemius recession and selective plantar fascia release in healing and preventing diabetic foot ulcers. Review Searches were conducted in MEDLINE, CINAHL, AMED, EMBASE and The Cochrane Library from the earliest available date to November 2014. Methodological quality of included studies was assessed using the Downs and Black checklist. Data from randomised-controlled trials were analysed using random effects meta-analysis. For all other studies, data were analysed descriptively. Eleven studies (614 participants) were included in the review, with a median sample size of 29 participants. Meta-analysis of two randomised-controlled trials found that there was no statistically significant difference between Achilles tendon lengthening or gastrocnemius recession and total contact casting for time to healing of diabetic foot ulcers (mean difference, MD, 8.22 days; 95 % CI, −18.99 to 35.43; P = 0.55; I2 = 34 %) and the rate of ulcers healed (risk ratio, RR, 1.06; 95 % CI, 0.94 to 1.20; P = 0.34; I2 = 41 %). The rate of ulcer recurrence was significantly lower following Achilles tendon lengthening or gastrocnemius recession than total contact casting (RR, 0.45; 95 % CI, 0.28 to 0.72; P < 0.001; I2 = 0 %). Conclusions Achilles tendon lengthening and gastrocnemius recession appear to be effective surgical treatments for healing diabetic foot ulcers. The rate of ulcer recurrence was lower following Achilles tendon lengthening or gastrocnemius recession procedures compared to total contact casting treatment alone. Therefore, these surgical procedures may provide viable treatment options for the management and prevention of diabetic foot ulcers. Further rigorous randomised-controlled trials with longer follow-up are required to determine the long-term effectiveness and safety of these procedures. Electronic supplementary material The online version of this article (doi:10.1186/s13047-015-0085-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah M Dallimore
- Eastern Health Podiatry Department, Maroondah Hospital, Davey Drive, Ringwood East, VIC 3135 Australia
| | - Michelle R Kaminski
- Eastern Health Podiatry Department, Angliss Hospital, Albert Street, Upper Ferntree Gully, VIC 3156 Australia
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Dayer R, Assal M. Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing. ACTA ACUST UNITED AC 2009; 91:487-93. [DOI: 10.1302/0301-620x.91b4.21598] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed. The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal. We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.
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Affiliation(s)
- R. Dayer
- Department of Orthopaedics, University of Geneva Hospitals, 24 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland
| | - M. Assal
- Department of Orthopaedics, University of Geneva Hospitals, 24 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland
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