Swiss medical weekly最新文献

No abstract available.

Aims of the study: Health equity is a key component of quality of care and an objective for a growing number of quality improvement projects for deontological, ethical, public health and economic reasons. To monitor equity in the delivery of health services in Switzerland, there is a need to implement valid, measurable and actionable equity indicators, along with vulnerability stratifiers such as migrant status, which could lead to differences in quality of care. The aim of this study was to develop a set of healthcare equity indicators and stratifiers targeting inpatient and outpatient populations and to test their feasibility.

Methods: A scoping literature review and inputs from a national interprofessional expert taskforce provided a set of indicators and vulnerability stratifiers. The most valid and measurable indicators and stratifiers were retained using a Delphi process. They were then operationalised, and their implementation tested in three Swiss hospitals from the three language regions.

Results: A taskforce of 18 experts, including a patient representative, selected 11 indicators that evaluate structures, processes and outcomes, and five vulnerability stratifiers. Although most indicators and stratifiers could be implemented in all three hospitals, data availability was limited for some variables, including patient satisfaction and access to interpreters for foreign-language patients.

Conclusions: The equity indicators and stratifiers identified by this two-stage process have content validity, wide patient coverage and are focused on inequities in the healthcare system that are actionable through improvement projects. Both the indicators and the project methodology could be replicated in institutions aiming for more equitable care.

Aims: The aim of the present study was to evaluate the performance of various artificial intelligence (AI)-powered chatbots (commercially available in Switzerland up to June 2023) in solving a theoretical cardiology board exam and to compare their accuracy with that of human cardiology fellows.

Methods: For the study, a set of 88 multiple-choice cardiology exam questions was used. The participating cardiology fellows and selected chatbots were presented with these questions. The evaluation metrics included Top-1 and Top-2 accuracy, assessing the ability of chatbots and fellows to select the correct answer.

Results: Among the cardiology fellows, all 36 participants successfully passed the exam with a median accuracy of 98% (IQR 91-99%, range from 78% to 100%). However, the performance of the chatbots varied. Only one chatbot, Jasper quality, achieved the minimum pass rate of 73% correct answers. Most chatbots demonstrated a median Top-1 accuracy of 47% (IQR 44-53%, range from 42% to 73%), while Top-2 accuracy provided a modest improvement, resulting in a median accuracy of 67% (IQR 65-72%, range from 61% to 82%). Even with this advantage, only two chatbots, Jasper quality and ChatGPT plus 4.0, would have passed the exam. Similar results were observed when picture-based questions were excluded from the dataset.

Conclusions: Overall, the study suggests that most current language-based chatbots have limitations in accurately solving theoretical medical board exams. In general, currently widely available chatbots fell short of achieving a passing score in a theoretical cardiology board exam. Nevertheless, a few showed promising results. Further improvements in artificial intelligence language models may lead to better performance in medical knowledge applications in the future.

Background: Swiss climate scenarios predict increases in the frequency and intensity of extreme heat episodes in the future. For the effective prevention of heat-related mortality, several aspects of the population's vulnerability to heat must be understood on a local level.

Methods: A nationwide analysis of individual death records was conducted, enabling a more comprehensive understanding than typical heat studies based on aggregated data. A total of 320,306 individual death records from the Swiss National Cohort with precise address information during the warm season (May to September) from 2003-2016 were linked to indoor and outdoor high-resolution daily temperature estimates. A time-stratified case-crossover study combined with distributed lag non-linear models was then performed to assess the temperature-mortality associations for various causes of death and to estimate the potential effect modification of individual characteristics. Additionally, it was explored whether the effect of extreme heat changed over time in regions with and without cantonal heat-health action plans (HHAPs).

Results: Using the temperature with the lowest cause-specific mortality risk (minimum mortality temperature) as the reference temperature, extreme heat (defined as ambient daily maximum temperature reaching 33 °C) was associated with a strong increase in all-cause mortality (odds ratio (OR): 1.21, 95% CI: 1.17-1.25) and disease-specific mortality from Alzheimer's disease and dementia (OR: 1.67, 95% CI: 1.48-1.88), COPD (OR: 1.37, 95% CI: 1.12-1.67), diabetes (OR: 1.34, 95% CI: 1.06-1.70), and myocardial infarction (OR: 1.26, 95% CI: 1.10-1.44). Indoor temperatures above 24 °C were found to be critical for mortality. The population most vulnerable to heat included older adults (≥75 years), unmarried individuals, people with a low education level, older women with low neighbourhood socioeconomic position, and men under 75 years old with low socioeconomic position. Overall, the risk of heat-related all-cause mortality in 2009-2016 was lower than that in 2003-2008. The decrease was significantly stronger in the region where cantonal HHAPs were implemented.

Conclusions: This study provides important information for planning targeted and effective measures to reduce heat-related health risks in Switzerland. It demonstrates that HHAPs contribute to reducing heat-related mortality, although they may not reach the high-risk population of individuals with low socioeconomic position. Future prevention efforts should also target the less privileged population, including people younger than 75 years.

Aims of the study: Spinal muscular atrophy (SMA) is a degenerative neuromuscular disorder leading to muscle hypotonia, weakness, and respiratory and bulbar impairment. Infants with SMA have an increased risk of respiratory tract infections (RTI) including severe respiratory syncytial virus (RSV) infections. Therefore, guidelines for the treatment of SMA recommend RSV prophylaxis with palivizumab for patients aged below two years who have compromised motor functions ("non-sitters"). Since palivizumab is not approved for RSV prophylaxis in SMA patients in Switzerland, payers usually do not grant cost approvals for this indication. Therefore, this study aimed to investigate the frequency of severe RTI among SMA patients focusing on RSV infections requiring hospital treatment and to determine the long-term impact of RSV infections on the natural history of SMA.

Methods: A single-centre cohort study at the tertiary paediatric Neuromuscular Centre Zurich, Switzerland, including data of SMA patients with a genetic-based therapy initiated below two years of age between May 2019 and December 2022. All hospitalisations were analysed with a focus on severe RTI and especially RSV infections, and their impact on nutritional and respiratory function. The costs of inpatient treatment of RSV infections were determined and compared with estimated expenses for RSV prophylaxis with palivizumab.

Results: 12 SMA patients (median age at treatment initiation: 3.5 months, range: 0-17 months) were followed for a cumulative period of 25.75 years (7 SMA type 1; 5 SMA type 2 including one presymptomatic individual). With an incidence rate of 2.34 per patient-year, the risk of severe RTI was especially high in SMA type 1 (versus 0.1 in SMA type 2, p = 0.044). A total of 37 hospitalisations (279 hospital days) was necessary for the treatment of RTI in general; 9 of them were attributed to RSV infections (in 5 SMA type 1 patients; 84 hospital days). Only 3/12 SMA patients had received seasonal RSV prophylaxis with palivizumab. No RSV infections requiring hospital treatment occurred in patients while receiving seasonal RSV prophylaxis. During RTI, nutritional support had to be commonly initiated and continued after discharge. In 3/7 SMA type 1 patients, non-invasive ventilation was started during acute treatment for RTI and continued to the end of follow-up.

Conclusion: We observed a high risk of RTI, especially RSV infections, among young SMA patients. Failure to adhere to established care protocols, for example by omitting RSV prophylaxis, may be linked to a heightened risk of morbidity in these children.

Dengue fever, endemic to most tropical and subtropical countries, is a major cause of illness in travellers, but severe dengue, hospitalisation and death are considered rare in this population. Two vaccines against dengue fever, Dengvaxia® and Qdenga®, are available. While there is no recommendation for the use of Dengvaxia® in travellers, Qdenga® has been licensed for travellers in many European countries since December 2022, most recently (29 July 2024) in Switzerland by Swissmedic. The Swiss Expert Committee for Travel Medicine (ECTM), having assessed available data on the Qdenga® vaccine, issues the following recommendations: (1) Vaccination against dengue fever virus with Qdenga® is not recommended for persons with no previous dengue fever infection. (2) Vaccination with Qdenga® may be recommended for travellers aged 6 years and older who have evidence of previous dengue infection, defined as (a) a laboratory-confirmed dengue infection (PCR, antigen or seroconversion) or (b) a compatible history of dengue infection with a positive IgG serological test AND expected exposure to a region with significant dengue transmission. Travel medicine advisors should provide clear information in accessible language on the complexity of dengue vaccines and the risk/benefit evaluation for their use in travellers.

Background: Recent trends in Switzerland indicate a concerning rise in simultaneous polysubstance use among adolescents, a practice marked by the concurrent or sequential consumption of multiple psychoactive substances, notably alcohol and cannabis, alongside prescription medications (e.g. benzodiazepines) and illicit drugs, resulting in dozens of fatal outcomes. However, data on simultaneous polysubstance use and evidence-based approaches to effective prevention is lacking.

Aims of the study: The study aimed to explore and gain insights into use patterns, use settings, use motives, harm-reduction strategies, concerns associated with substance use, and support and counselling services from the point of view of adolescents practicing simultaneous polysubstance use in Switzerland.

Methods: An exploratory study was conducted via an online survey (n = 116) and two focus group discussions with affected Swiss adolescents aged 14 to 20. A mixed-methods approach was applied to gain insights and better understand the phenomenon of simultaneous polysubstance use among Swiss adolescents. Quantitative survey data obtained between November 2021 and March 2023 by means of convenience sampling - organised by distributing flyers (in three national languages) among several project partners, on the internet, over social media and by word of mouth - was analysed descriptively, whereas qualitative survey data and focus group data were thematically explored. A concurrent nested design was employed, utilising quantitative findings as a core foundation for addressing research questions, while qualitative findings were instrumental in validating and providing contextual depth to the results.

Results: Our findings reveal a preference of the sample for combining alcohol with cannabis and/or other substances (e.g. benzodiazepines or hard drugs) in social settings, driven by diverse motives, including enhancement of experiences and partly maladaptive coping mechanisms leading to self-medication. Despite some awareness of the potential harms, there is a significant reliance on peer-shared strategies for harm reduction, highlighting a gap in formal support and counselling services, some of which are perceived by adolescents as lacking empathy and relevance.

Conclusions: This study underscores the urgency of developing targeted, youth-centred interventions that resonate with the lived realities of adolescents, aiming not only to reduce substance use but also to address the broader psychosocial factors contributing to simultaneous polysubstance use. By shedding light on the complex dynamics of adolescent polysubstance use, our research contributes to the ongoing dialogue on effective prevention strategies, advocating for a holistic approach encompassing education, policy reform and community support to tackle this multifaceted public health challenge.

Immunoglobulins for intravenous use (IVIgs) and subcutaneous use (SCIgs) can prevent recurrent and severe infections in patients with secondary antibody deficiencies that are frequently linked to haematological/oncological malignancies as well as other clinical conditions and their respective treatments. Even so, as IVIgs and SCIgs are costly and their supply is limited, their clinical use must be optimised. The aim of this position paper is to provide structured practical guidance on the optimal use of IVIgs and SCIgs in secondary antibody deficiencies, particularly in haematological and oncological practice. The authors agree that the occurrence of severe infections is a prerequisite for the use of IVIgs. Serum IgG levels in general as well as IgG subclass levels can be additional indicators of whether a patient could benefit from IVIgs. Responsiveness to vaccines can help to identify immunodeficiency. Patients with chronic lymphocytic leukaemia or multiple myeloma who are receiving respective treatment, especially B-cell depletion therapy, but also some patients with autoimmune diseases are prone to antibody deficiencies and need IVIgs. For the optimal use of IVIgs and to maximise their potential benefit, the indication must be individually assessed for each patient. As a primary treatment goal, the authors define a sufficient prophylaxis of severe infections, which can be supported by normalising IgG levels. If the initiated treatment is insufficient or linked to intolerable adverse reactions, switching the product within the class of IVIgs or changing to a different batch of the same product can be considered. Pausing treatment can also be considered if there are no infections, which happens more frequently in summer, but treatment needs to be resumed once infections return. These structured recommendations for IVIg treatment in patients with secondary antibody deficiency may provide guidance for clinical practice and therefore help to allocate IVIgs to those who will benefit the most, without overusing valuable resources.