Swiss medical weekly最新文献

Technological advancements have significantly reshaped diabetes care. Diabetes and technology now encompass the hardware, devices and software required to treat diabetes mellitus. In Switzerland, these technologies are being increasingly adopted, especially by people living with type 1 diabetes, where continuous glucose monitoring (CGM) and automated insulin delivery (AID) systems are considered standards of care. This document provides a comprehensive overview of all diabetes-related technologies currently available in Switzerland. It details their technical specifications, indications for use across diverse populations, compatibility, reimbursement regulations and practical guidance for implementation. Recommendations extend to special populations: children and adolescents, pregnant women, older adults, and people with type 2 diabetes or other specific diabetes types (e.g. maturity-onset diabetes of the young [MODY] or pancreatogenic diabetes). In youth with type 1 diabetes, early adoption of continuous glucose monitoring and automated insulin delivery systems is strongly encouraged and is supported by the Swiss Society of Paediatric Endocrinology and Diabetology. During pregnancy, achieving and maintaining strict glycaemic targets is crucial for reducing pregnancy-related complications. Continuous glucose monitoring and automated insulin delivery improve glycaemic metrics and neonatal outcomes. In older adults, technologies can reduce hypoglycaemia risk and simplify management. For people with type 2 diabetes, continuous glucose monitoring and insulin pumps have shown benefits in glycaemic control, with growing evidence supporting the use of automated insulin delivery systems. The document also highlights the expanding role of telemedicine and remote monitoring. While offering greater accessibility and patient-centred care, these tools raise challenges in terms of digital literacy, interoperability and data protection. Finally, the integration of diabetes and technology into diabetes care requires structured education. Diabetes self-management education and support programmes such as Functional Insulin Therapy (FIT) are essential to help people acquire the knowledge and skills necessary to manage insulin therapy and use diabetes technology effectively and safely. Overall, these recommendations aim to support effective and equitable use of diabetes technology throughout Switzerland and to guide healthcare providers, patients and policymakers towards improving diabetes outcomes.

Aims: Cardiac amyloidosis (CA) characterised by myocardial amyloid accumulation is likely underdiagnosed. The distribution and extent of myocardial amyloid deposits remain unclear. With the emergence of disease-modifying drugs for ATTR and AL amyloidoses, early detection has become increasingly important. We aim to determine the frequency, clinical relevance and distribution of amyloid subtypes in cardiac amyloidosis in an autopsy cohort.

Methods: We retrospectively analysed consecutive unselected adult autopsies with cardiac amyloidosis over 10 years (January 2014 - December 2023). Two pathologists applied a biventricular semi-quantitative scoring system for interstitial and vascular amyloid deposits. Histopathological findings were correlated with ante mortem clinical data.

Results: Cardiac amyloidosis was found in 104 of 1972 autopsies (5%) with 91% neither diagnosed nor suspected ante mortem based on documentation in digital medical records. Ninety-eight patients (94%) had amyloid transthyretin-cardiac amyloidosis (ATTR-CA) and six (6%) amyloid light chain-cardiac amyloidosis (AL-CA). AL-CA patients were younger than ATTR-CA patients (mean ± SD: 73.2 ± 15.3 vs 84.2 ± 8.1, p = 0.006) and systemic amyloidosis was more frequent (100% vs 38%, p = 0.003). Female patients (40.4%) were significantly older (mean ± SD: 85.8 ± 8.1 years) than males (82.0 ± 9.2 years, p = 0.23), and male sex was associated with clinical suspicion and diagnosis (88.9% in males vs 11.1% in females, p = 0.06). A high vascular amyloid score correlated with systemic amyloidosis (left ventricle, p = 0.003; right ventricle, p = 0.013). Right ventricular amyloid burden was strongly linked to clinical suspicion and detection (p = 0.001).

Conclusions: Our autopsy analysis found that most cardiac amyloidosis cases were undiagnosed ante mortem, especially ATTR-CA in older patients with less systemic involvement. Underdiagnosis was more pronounced in females. Our findings suggest that high vascular amyloid burden contributes to systemic amyloidosis and links right ventricular amyloid to clinical suspicion and detection.

Aims: Heterogeneous results regarding changes in the risk of preterm births and other perinatal outcomes during COVID-19-related restrictions (lockdowns) have been reported. We aimed to investigate the association between adverse birth outcomes and the initial COVID-19-related lockdown in Switzerland in 2020.

Aims: Heterogeneous results regarding changes in the risk of preterm births and other perinatal outcomes during COVID-19-related restrictions (lockdowns) have been reported. We aimed to investigate the association between adverse birth outcomes and the initial COVID-19-related lockdown in Switzerland in 2020.

Methods: We included singleton births recorded in the nationwide statistics of outpatient midwifery services in Switzerland (2018-2020). Using logistic regression, we estimated odds ratios (ORs) with 95% confidence intervals (CIs) for the risk of three birth outcomes between 16 March 2020 and 10 May 2020 (lockdown period) compared to any time between January 2018 and the start of the lockdown period. The outcomes of interest were preterm birth (<37 weeks), caesarean section and an Apgar score <7 at 5 minutes of age. Analyses were adjusted for calendar day and month and for geographical region. We conducted sensitivity analyses by geographic region.

Results: Of 218,273 singleton births between January 2018 and December 2020, 5.3% were preterm births, 30.2% were caesarean sections and 2.2% resulted in a newborn with an Apgar score <7 at 5 minutes. The risk of preterm birth was slightly but not statistically significantly higher during the lockdown period in Switzerland (OR: 1.09, 95% CI: 0.97-1.22). This was driven by an OR for preterm birth of 2.05 (95% CI: 1.10-3.85) for the canton of Ticino, which accounted for most COVID-19 infections during this time, but with no meaningful change in risk of preterm birth in other regions of Switzerland. We did not observe any change in the proportion of caesarean sections during the lockdown period. The Switzerland-wide risk of a recorded Apgar score <7 at 5 minutes had an OR of 1.41 (95% CI: 1.19-1.69), again driven by the highest OR of 4.60 (95% CI: 1.70-12.34) in the canton of Ticino as well as increased ORs in Geneva (2.40, 95% CI: 1.20-4.70) and Bern (2.84, 95% CI: 1.79-4.48).

Conclusions: The risk of birth outcomes remained unchanged during the first COVID-19 lockdown in 2020 in most parts of Switzerland. The cause of the observed increased risk of preterm birth in Ticino needs to be followed up, as sample size was small and a chance finding cannot be ruled out.

Objective: We aimed to assess the extent of cardiac-related hospitalisations among adult congenital heart disease (ACHD) patients followed at Swiss regional ACHD centres.

Background: In Switzerland, adult congenital heart disease patients are followed at specialised ACHD centres. According to the Swiss recommendations for standards of adult congenital heart disease care,ACHD centres are categorised as regional and supraregional centres. In contrast to regional centres, supraregional centres require staffing for congenital cardiac surgery and complex congenital cardiac interventions.

Methods: Adult congenital heart disease patients enrolled in the SACHER registry and followed at one of three regional ACHD centres (University Hospital Basel, St Gallen Cantonal Hospital, Lucerne Cantonal Hospital) from May 2014 to March 2022 were included. Data were abstracted by chart review and included demographics, clinical and surgical history, follow-up duration and cardiac-related hospitalisations during follow-up.

Results: In total, 1031 patients (accounting for 22% of patients from the entire SACHER cohort) were included (570 at University Hospital Basel, 231 at St Gallen Cantonal Hospital, 230 at Lucerne Cantonal Hospital). During a median (IQR) follow-up of 3 (1-5) years, there were 237 hospitalisations (100 [42%] emergencies) among 136 (13%) patients. The majority of admissions (157, 66%), occurred at the regional centre. Arrhythmias (49 of 64 admissions, 77%) and heart failure hospitalisations (26 of 34, 76%) were mainly managed locally. The main reasons for referral to supraregional ACHD centres were heart surgery (32/56, 57%) and complex structural percutaneous interventions (pulmonary valve replacement [3/3, 100%] and balloon dilation of aortic coarctation [7/7, 100%]).

Conclusion: In Switzerland, regional ACHD centres provide an important contribution to the management of the growing cohort of adult congenital heart disease patients. Most hospitalisations were managed locally. This was particularly true for emergencies, arrhythmia and heart failure hospitalisations. The main reasons for referral to supraregional ACHD centres were complex percutaneous interventions.

Study aims: Although surgeons face ethical questions and conflicts in daily practice, surgical education lacks ethics training. This study explores the relevance of clinical ethics consultations in addressing ethical conflicts and their potential role in surgical education.

Methods: This study explored the role of clinical ethics consultations (CECs) between 2012 and 2021 in both formal and informal surgical ethics education. First, data from each clinical ethics consultation were retrieved from the electronic medical database of the clinical ethics consultation services of the University Hospital Basel (USB) and the University Psychiatric Clinics Basel (UPK). Second, the data were analysed using thematic and contextual analysis. In the final step, the analysis included the identification of the educational focus. The methodological approach aimed to provide a detailed exploration of the role of clinical ethics consultations in surgical ethics education, despite the inherent constraints associated with document analysis and practical limitations regarding participant observation and interviewing.

Results: Of the 359 clinical ethics consultations examined, 38 were related to surgical interventions and conditions. Surgeons were involved in all 38 clinical ethics consultations, but surgical residents were involved in only 17 (45%), including 10 (26%) that they had requested themselves. These 17 clinical ethics consultations met the inclusion criteria and were suitable for in-depth analysis. Analysis of the ethical topics (maximum of three per case) revealed four main themes: patients' wishes (n = 8), treatment planning (n = 5), treatment of somatic diseases in patients with additional mental disorders (n = 5), and challenges in dealing with patients' representatives/relatives (n = 4).

Conclusions: Ethical issues faced by surgical residents are often unrelated to primary surgical concerns. Despite the importance of ethical decision-making training in medical education, residents participated in less than half of clinical ethics consultations. Surgical faculty should involve residents in interdisciplinary discussions and clinical ethics consultations to increase awareness. Surgical curricula should incorporate resources to improve ethics-related decision-making skills.

Study aims: Abdominal and retroperitoneal sarcomas are rare and heterogeneous. Despite a considerable number of sarcoma centres in Switzerland, only very limited data is available regarding clinical outcomes after primary surgical treatment. In this study, we retrospectively analysed a cohort of 157 patients treated at a Swiss sarcoma centre, aiming to assess whether the clinical outcomes in our cohort are comparable to those reported by international centres.

Methods: Overall, 271 patients with abdominal and retroperitoneal sarcomas, treated between January 2012 and December 2022, were available. Patients with malignant disease and primary resection were included. The primary endpoint was overall survival, while secondary endpoints included disease-free survival, incidence of histological subtypes, completeness of surgical resection and tumour rupture.

Results: Ultimately 157 patients with primary, resectable soft tissue sarcoma were included in the analysis. Median follow-up after surgery was 52.6 months (95% confidence interval [CI]: 42.24-62.95). Median overall survival was 87.9 months (95% CI: 54.95-120.74); by subgroup, 117.5 months for gastrointestinal stroma tumour (95% CI: 76.96-158.00), 61.8 months for liposarcoma (95% CI: 40.16-83.36), 117.8 months for leiomyosarcoma (95% CI not achieved) and 100.2 months for other rare subtypes (95% CI: 59.65-111.30). Forty-four (28%) patients developed tumour recurrence.

Conclusions: Overall outcomes in this series are comparable to those from large international registries. A national data registry might help to improve reporting of clinical data and assure quality of care of Swiss sarcoma patients.

Study aims: Data on the usefulness of advance directives for end-of-life decision-making in intensive care units (ICUs) are scarce. The primary aim of the present study was to investigate the prevalence of advance directives in patients of two Swiss ICUs. To contextualise how advance directives are created, interpreted and translated into clinical practice and which patient profiles influence whether and how patients choose to formulate advance directives, secondary objectives included analysing their content, clinical translation, and associated patient characteristics and outcomes.

Methods: The retrospective cohort study was carried out at two tertiary Swiss ICUs.Data were collected from patients with advance directives treated in ICUs >48 hours from 2020 to 2022.The primary endpoint was the prevalence of advance directives and their content regarding life-prolonging measures, including cardiopulmonary resuscitation (CPR).

Results: Of the 5242 patients included, 313 (6.0%) had advance directives. While 290/313 (92.7%) consented to life-prolonging measures other than CPR, CPR was less frequently desired (217/313 [69.3%]). 14.0% (18/129) requested CPR despite declining life-prolonging measures. Fewer women consented to life-prolonging measures and/or CPR than men, whereas prior ICU stays were associated with higher consent rates. Of 104 treatment adaptations, 53 (51.0%) aligned with advance directives, while 33/104 adaptations (31.7%) were based on presumed poor prognosis and 4/104 (3.9%) on surrogate decisions. While patients declining life-prolonging measures experienced faster treatment changes, survival and functional outcomes did not differ based on consent status.

Conclusions: The prevalence of patients with advance directives admitted to Swiss ICUs is low, and substantial obstacles must be overcome in clinical practice. Inconsistent or contradictory contenthighlightsa need for better preemptive communication and documentation of patients' wishes. Respecting patient autonomy in choosing to forgo life-prolonging measures might not be associated with a lower likelihood of survival or functional outcomes.

Trial registration:  https://clinicaltrials.gov NCT04348318.

Study aims: Older adult patients admitted to hospital are often multimorbid, polymedicated and thus more susceptible to medication-related problems. To improve medication safety for this patient population, the University Hospital of Bern's Department of Geriatrics hosts clinical pharmacists on its ward rounds as part of an interprofessional collaboration project called PharmVisit. This study aimed to describe the interventions recommended by those clinical pharmacists and their rates of acceptance by physicians.

Methods: The PharmVisit pilot project involved geriatricians and clinical pharmacists separately preparing for weekly ward rounds. Pharmacists used a checklist for medication reviews and the Swiss Association of Public Health Administration and Hospital Pharmacists (GSASA) classification tool for characterisation of recommendations. All patients residing on the ward during the study period were included. Outside the patient's room, clinicians and pharmacists, accompanied by a nurse, discussed the ongoing drug therapy and recommended beneficial medication adjustments resulting from the re-evaluation of treatment indications, potential drug-drug interactions, dose adjustments, optimised dosages and forms of administration, and medication omissions. Afterwards, all the parties, including the patient, discussed the medication changes at the bedside. Type and number of recommendations by clinical pharmacists were tabulated as primary outcomes. Acceptance rate as a secondary outcome was calculated based on the number of pharmacists' recommendations compared to the number of prescriptions adapted directly during ward rounds.

Results: From July 2023 to April 2024, 46 ward rounds were documented, resulting in 480 recommended interventions for 221 patients. The top reasons for recommending interventions, categorised according to the GSASA tool, were dosing issues (17%), medication omissions (15%) and no apparent indication (13%). Clinical pharmacists made the most recommendations on issues involving pain medication (analgesics and opioids, 4% and 2%, respectively), laxative drugs (4%), proton-pump inhibitors (4%), hypnotics and sedatives (2%), and drugs for obstructive airway diseases (2%), reflecting the most problematic drugs identified in studies nationally and internationally. The overall acceptance rate of PharmVisit recommendations was 54%. An additional 33% of recommended interventions were referred to a senior physician for a decision or to the primary care provider in the discharge letter. The most frequently and directly accepted intervention recommendations were optimising administration modalities (77%), medication exchange or substitution (71%) and medication discontinuation (62%).

Conclusion: This project emphasised how including clinical pharmacists in interprofessional ward round teams enabled the integration and consideration of more viewpoint

Adrenal gland transplantation has only been performed in rare cases, with variable results in terms of functional activity. Consequently, there is a lack of evidence in endocrine management and tapering hormone replacement therapy after such transplantations. We report on a simultaneous pancreas-kidney and adrenal gland allotransplantation in a 48-year-old female patient with type 1 diabetes and severe autoimmune adrenal insufficiency. Surgery was uneventful, without major surgical morbidity. Pancreas and kidney graft function were excellent from the beginning. Adrenal graft function was difficult to assess and steroid tapering was not well tolerated and hampered clinical recovery. Despite the evidence of adequate graft perfusion and initially even measurable levels of cortisol production, persistent adrenal graft function was not obtained, and the patient remained on hormone replacement therapy. Simultaneous pancreas-kidney and adrenal gland transplantation is technically safe, without the need for major surgical modifications or adjustments in immunosuppression. However, it should only be performed in combination with a kidney or pancreas-kidney transplant, which justifies the lifelong immunosuppression. The major challenge remains the postoperative endocrine management, with steroid tapering and adequate assessment of adrenal graft function. Patients should be followed by an interdisciplinary team involving endocrinologists, nephrologists and transplant surgeons.

Study aim: Treatment of stage III non-small-cell lung cancer (NSCLC) has evolved rapidly in recent years. To improve our understanding of real-world outcomes in Switzerland, we report on our institutional experience at an academic lung cancer centre and describe treatment patterns and clinical outcomes over a multi-year period.

Methods: Patients diagnosed with stage III NSCLC between 2013 and 2023 were included in an ethics-approved institutional database. Based on tumour board decisions, the initial treatment strategy was defined for each patient. Overall and progression-free survival were calculated using the Kaplan-Meier method. A multivariate Cox regression analysis was performed to study the impact of different factors on clinical outcomes.

Results: A total of 315 patients with stage III NSCLC were included. Patients were a median of 68 years old, and two-thirds were male. The most common stage at diagnosis was IIIA (56%), followed by stage IIIB (36%) and IIIC (8%). A curative treatment approach was pursued in 88% of patients, and over 90% of these received definitive local treatment (surgery and/or radiotherapy). Rates of 1-year overall and progression-free survival improved from 64% and 47%, respectively, in 2013-2016, to 82% and 70% in 2020-2023. However, 49% of patients developed locoregional and/or distant recurrence. Results of the multivariate analysis are presented in the manuscript.

Conclusions: Almost 90% of patients with stage III NSCLC underwent treatment with curative intent, with rates of treatment adherence that compared favourably to the literature. Although survival outcomes appear to have improved in recent years, the rates of disease recurrence remain high, reflecting a need for further improvements.