Swiss medical weekly最新文献

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Background and aim: Direct-acting antivirals (DAAs) have revolutionised the management of chronic hepatitis C. We analysed the use of different generations of DAAs over time in Switzerland and investigated factors predictive of treatment failure.

Methods: This retrospective study was conducted within the framework of the Swiss Association for the Study of the Liver and the Swiss Hepatitis C Cohort Study; it included all patients with chronic hepatitis C treated with DAAs between January 2015 and December 2019 at eight Swiss referral centres.

Results: A total of 3088 patients were included; 57.3% were male, and the median age was 54 years. Liver cirrhosis was present in 23.9% of the cohort, 87.8% of whom were compensated. The overall sustained virological response (SVR) rate (defined as undetectable HCV RNA at week 12 after the first course of DAA-based treatment) was 96.2%, with an increase over time. The rate of treatment failure dropped from 8.3% in 2015 to 2.5% in 2019. Multivariable analysis revealed that female sex, the use of the latest generation of pangenotypic DAA regimens, Caucasian origin, and genotype (gt) 1 were associated with SVR, whereas the presence of active hepatocellular carcinoma (HCC), gt 3, and increasing liver stiffness were associated with treatment failure. Notably, the presence of active HCC during treatment increased the risk of DAA failure by a factor of almost thirteen.

Conclusions: SVR rates increased over time, and the highest success rates were identified after the introduction of the latest generation of pangenotypic DAA regimens. Active HCC, gt 3 and increasing liver stiffness were associated with DAA failure.

Introduction: The impact of impaired kidney function on healthcare use among medical hospitalisations with multimorbidity and frailty is incompletely understood. In this study, we assessed the prevalence of acute kidney injury (AKI) and chronic kidney disease (CKD) among multimorbid medical hospitalisations in Switzerland and explored the associations of kidney disease with in-hospital outcomes across different frailty strata.

Methods: This observational study analysed nationwide hospitalisation records from 1 January 2012 to 31 December 2020. We included adults (age ≥18 years) with underlying multimorbidity hospitalised in a medical ward. The study population consisted of hospitalisations with AKI, CKD or no kidney disease (reference group), and was stratified by three frailty levels (non-frail, pre-frail, frail). Main outcomes were in-hospital mortality, intensive care unit (ICU) treatment, length of stay (LOS) and all-cause 30-day readmission. We estimated multivariable adjusted odds ratios (OR) and changes in percentage of log-transformed continuous outcomes with 95% confidence intervals (CI).

Results: Among 2,651,501 medical hospitalisations with multimorbidity, 198,870 had a diagnosis of AKI (7.5%), 452,990 a diagnosis of CKD (17.1%) and 1,999,641 (75.4%) no kidney disease. For the reference group, the risk of in-hospital mortality was 4.4%, for the AKI group 14.4% (adjusted odds ratio [aOR] 2.56 [95% CI 2.52-2.61]) and for the CKD group 5.9% (aOR 0.98 [95% CI 0.96-0.99]), while prevalence of ICU treatment was, respectively, 10.5%, 21.8% (aOR 2.39 [95% CI 2.36-2.43]) and 9.3% (aOR 1.01 [95% CI 1.00-1.02]). Median LOS was 5 days (interquartile range [IQR] 2.0-9.0) in hospitalisations without kidney disease, 9 days (IQR 5.0-15.0) (adjusted change [%] 67.13% [95% CI 66.18-68.08%]) in those with AKI and 7 days (IQR 4.0-12.0) (adjusted change [%] 18.94% [95% CI 18.52-19.36%]) in those with CKD. The prevalence of 30-day readmission was, respectively, 13.3%, 13.7% (aOR 1.21 [95% CI 1.19-1.23]) and 14.8% (aOR 1.26 [95% CI 1.25-1.28]). In general, the frequency of adverse outcomes increased with the severity of frailty.

Conclusion: In medical hospitalisations with multimorbidity, the presence of AKI or CKD was associated with substantial additional hospitalisations and healthcare utilisation across all frailty strata. This information is of major importance for cost estimates and should stimulate discussion on reimbursement.

Background: In the context of an ageing population and increasing health needs, primary care reform is needed and several new models have emerged, including the introduction of case managers in general practitioner practices.

Aim: To describe the frequency of case managers in general practices in eleven Western countries between 2012 and 2019 and to investigate the characteristics of general practitioners and their practices associated with case manager frequency.

Methods: A secondary analysis of the Commonwealth Fund International Health Policy Surveys of Primary Care Physicians, which were international cross-sectional studies conducted in 2012, 2015 and 2019. Random samples of general practitioners were selected in 11 Western countries (2012: n = 9776; 2015: n = 12,049; 2019: n = 13,200). The use of case managers in general practitioner practices was determined with the question "Does your practice use personnel, such as nurses or case managers, to monitor and manage care for patients with chronic conditions that need regular follow-up care?", with possible answers "Yes, within the practice", "Yes, outside the practice", "Yes, both within and outside the practice" or "No". Other variables characterising general practitioners and their practices were considered. Mixed-effects logistic regression was performed.

Results: The frequency of case managers within general practitioner practices varied greatly by country, with an overall trend towards an increase from 2012 to 2019. In the multivariate analysis, more case managers were found in practices located in small towns (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.2-1.7) and in rural areas (OR 1.9; 95% CI 1.5-2.4) compared to cities. The frequency of case managers was higher in larger practices, as shown in comparisons of practices in the second, third and fourth quartile of full-time equivalent employee counts compared to those in the first quartile (Q2: OR 1.7, 95% CI 1.4-1.9; Q3: OR 2.1, 95% CI 1.6-2.9; Q4: OR 3.8, 95% CI 3.0-4.9). There was no significant difference in frequency with respect to the age and sex of the general practitioners.

Conclusion: The use of case managers in general practitioner practices is a promising approach, but its practice varies greatly. This practice has been developing in Western countries and is tending to increase. The implementation of case managers seems to be associated with certain characteristics linked to general practitioner practices (practice location, practice size), whereas it does not seem to depend on the personal characteristics of general practitioners, such as age or sex.

Aims: Anthracycline-based chemotherapy has well-known cardiotoxic effects, butmay also cause skeletal muscle myopathy and negatively affect cardiorespiratory fitness and quality of life. The effectiveness of exercise training in improving cardiorespiratory fitness and quality of life during chemotherapy is highly variable. We set out to determine how the effect of exercise training on cardiorespiratory fitness (primary outcome) and quality of life (secondary outcome) in cancer patients is affected by the type of therapy they receive (cardiotoxic therapy with or without anthracyclines; non-cardiotoxic therapy) and the timing of the exercise training (during or after therapy).

Methods: Consecutive patients with cancer who participated in an exercise-based cardio-oncology rehabilitation programme at a university hospital in Switzerland between January 2014 and February 2022 were eligible. Patients were grouped based on chemotherapy (anthracycline vs non-anthracycline) and timing of exercise training (during vs after chemotherapy). Peak oxygen uptake (VO2) was assessed with cardiopulmonary exercise testing (n = 200), and quality of life with the Functional Assessment of Cancer Therapies questionnaire (n = 77). Robust linear models were performed for change in peak VO2 including type and timing of cardiotoxic therapies, age, training impulse and baseline peak VO2; change in quality of life was analysed with cumulative linked models.

Results: In all patients with valid VO2 (n = 164), median change in peak VO2 from before to after exercise training was 2.3 ml/kg/min (range: -10.1-15.9). The highest median change in peak VO2 was 4.1 ml/kg/min (interquartile range [IQR]: 0.7-7.7) in patients who completed exercise training during non-anthracycline cardiotoxic or non-cardiotoxic therapies, followed by 2.8 ml/kg/min (IQR: 1.2-5.3) and 2.3 ml/kg/min (IQR: 0.1-4.6) in patients who completed exercise training after anthracycline and after non-anthracycline cardiotoxic or non-cardiotoxic therapies, respectively. In patients who completed exercise training during anthracycline therapy, peak VO2 decreased by a median of -2.1 ml/kg/min (IQR: -4.7-2.0). In the robust linear model, there was a significant interaction between type and timing of cancer treatment for anthracycline therapy, with greater increases in peak VO2 when exercise training was performed after anthracycline therapy. For quality of life, higher baseline scores were negatively associated with changes in quality of life.

Conclusion: In our cohort, the increase in cardiorespiratory fitness was diminished when exercise training was performed concurrently with anthracyclines. For patients with cardiotoxic treatments other than anthracyclines, cardiorespiratory fitness and quality of life was not associated with timing of exercise training.

Background: Benign tracheal stenosis is relatively rare but remains a significant chronic disease due to its drastic symptoms including dyspnoea and inspiratory stridor, and consequent negative effect on quality of life. Traditionally, the surgical approach by resection of the stenotic tracheal segment has been the therapy of choice. However, endoscopic techniques have arisen and may offer a safe and less invasive alternative.

Objectives: The aim of the retrospective study was to evaluate procedure-related safety and outcome of endoscopic treatment of benign tracheal stenosis at a single centre.

Methods: The study included all patients at our institution who between 2013 and 2022 had received endoscopic treatment of benign tracheal stenosis by rigid tracheoscopy, radial incision by electric papillotomy needle and dilation (endoscopic tracheoplasty) followed by triamcinolone acetonide as a local submucosal injection and additionally, from 2020, budesonide inhalation.

Results: A total of 22 patients were treated in a total of 38 interventions, each resulting in immediate improvement of symptoms. There were no peri-interventional complications or mortality. Of the 38 interventions, 11 received no triamcinolone acetonide administration, resulting in a 54.5% recurrence rate after an average of 21.1 (±18.0) months, while 27 had local triamcinolone acetonide, with a 37% recurrence rate. Since 2020, we additionally initiated post-interventional budesonide inhalation as recurrence prophylaxis for newly admitted patients and patients with recurrences(n = 8), of whom only one (12.5%) has to date experienced a recurrence.

Conclusion: Our results indicate that endoscopic tracheoplasty offers a safe and successful, minimally invasive alternative to open surgery for patients with benign tracheal stenosis. We recommend local administration of triamcinolone into the mucosa as an additional treatment to decrease the risk of recurrence. However, given the uncontrolled study design and low sample size, safety and effectiveness cannot be conclusively demonstrated. Nonetheless, our findings suggest promising avenues for further investigation. Further studies on the additional benefit of inhaled corticosteroids are warranted.

Aim of the study: The mistreatment of older adults is a global and complex problem with varying prevalence. As there are no data on the prevalence of elder mistreatment in European emergency department populations, we aimed to translate and culturally adapt the Emergency Department Senior Abuse Identification (ED Senior AID) tool for German use, assess the positive screen rate for elder mistreatment with the German version, and compare characteristics of patients who screened positive and negative.

Methods: To assess the prevalence of elder mistreatment, we created a German version of the ED Senior AID tool. This tool identifies intentional or negligent actions by a caregiver or trusted person that cause harm or risk to an older adult. Then, the German ED Senior AID tool was applied to all consecutively presenting patients aged ≥65 years at our academic emergency department in the Northwest of Switzerland from 25 April to 30 May 2022. Usability was defined as the percentage of patients with completed assessments using the German ED Senior AID tool.

Results: We included 1010 patients aged ≥65 years, of whom 29 (2.9%) screened positive with the ED Senior AID tool. The patients who screened positive were older, more severely cognitively impaired, hospitalised more frequently, and presented with higher frailty scores than those who screened negative. Mortality up to 100 days after presentation was comparable in all patients (p = 0.861), regardless of their screening result. The tool showed good usability, with 73% of assessments completed.

Conclusion: This is the first prospective investigation on the prevalence of elder mistreatment in a European emergency department setting. Overall, 2.9% of patients screened positive using a validated screening tool translated into German.

Trial registration: This study was registered with the National Institute of Health on ClinicalTrials.gov with the registration number NCT05400707.