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Bretagne L, Mosimann S, Roten C, Perrig M, Genné D, Essig M, Mancinetti M, Méan M, Darbellay Farhoumand P, Huber LC, Weber E, Knoblauch C, Schoenenberger AW, Frick S, Wenemoser E, Ernst D, Bodmer M, Aujesky D, Baumgartner C. Association of part-time clinical work with well-being and mental health in General Internal Medicine: A survey among Swiss hospitalists. PLoS One 2023; 18:e0290407. [PMID: 37768911 PMCID: PMC10538797 DOI: 10.1371/journal.pone.0290407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/08/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Burnout and low job satisfaction are increasing among the General Internal Medicine (GIM) workforce. Whether part-time compared to full-time clinical employment is associated with better wellbeing, job satisfaction and health among hospitalists remains unclear. MATERIALS AND METHODS We conducted an anonymized cross-sectional survey among board-certified general internists (i.e. hospitalists) from GIM departments in 14 Swiss hospitals. Part-time clinical work was defined as employment of <100% as a clinician. The primary outcome was well-being, as measured by the extended Physician Well-Being Index (ePWBI), an ePWBI ≥3 indicating poor wellbeing. Secondary outcomes included depressive symptoms, mental and physical health, and job satisfaction. We compared outcomes in part-time and full time workers using propensity score-adjusted multivariate regression models. RESULTS Of 199 hospitalists invited, 137 (69%) responded to the survey, and 124 were eligible for analysis (57 full-time and 67 part-time clinicians). Full-time clinicians were more likely to have poor wellbeing compared to part-time clinicians (ePWBI ≥3 54% vs. 31%, p = 0.012). Part-time compared to full-time clinical work was associated with a lower risk of poor well-being in adjusted analyses (odds ratio 0.20, 95% confidence interval 0.07-0.59, p = 0.004). Compared to full-time clinicians, there were fewer depressive symptoms (3% vs. 18%, p = 0.006), and mental health was better (mean SF-8 Mental Component Summary score 47.2 vs. 43.2, p = 0.028) in part-time clinicians, without significant differences in physical health and job satisfaction. CONCLUSIONS Full-time clinical hospitalists in GIM have a high risk of poor well-being. Part-time compared to full-time clinical work is associated with better well-being and mental health, and fewer depressive symptoms.
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Affiliation(s)
- Lisa Bretagne
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefanie Mosimann
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
| | - Christine Roten
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Perrig
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Genné
- Department of Internal Medicine, Hospital of Biel-Bienne, Bienne, Switzerland
| | - Manfred Essig
- Department of General Internal Medicine, Tiefenau Hospital, Bern, Switzerland
| | - Marco Mancinetti
- Department of Medicine, University and Hospital of Fribourg, Fribourg, Switzerland
| | - Marie Méan
- Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | | | - Lars C Huber
- Department of General Internal Medicine, Stadtspital Zürich Triemli, Zürich, Switzerland
| | - Elisabeth Weber
- Department of General Internal Medicine, Stadtspital Zürich Waid, Zürich, Switzerland
| | - Christoph Knoblauch
- Department of General Internal Medicine, Hospital of Nidwalden, Stans, Switzerland
| | - Andreas W Schoenenberger
- Department of General Internal Medicine, Cantonal Hospital of Münsterlingen, Münsterlingen, Switzerland
| | - Sonia Frick
- Department of General Internal Medicine, Hospital of Limmattal, Schlieren, Switzerland
| | - Eliane Wenemoser
- Department of General Internal Medicine, Hospital Region of Oberaargau, Langenthal, Switzerland
| | - Daniel Ernst
- Department of General Internal Medicine, Hospital of Thun, Thun, Switzerland
| | - Michael Bodmer
- Department of General Internal Medicine, Cantonal Hospital of Zug, Baar, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Birrer M, Perrig M, Hobi F, Gfeller C, Atkinson A, Egger M, Bartholdi C, Aujesky D, Marschall J, Sommerstein R. Droplet precautions on-site (DroPS) during the influenza season 2018/2019: a possible alternative to single room isolation for respiratory viral infections. Antimicrob Resist Infect Control 2022; 11:2. [PMID: 35000584 PMCID: PMC8743058 DOI: 10.1186/s13756-021-01038-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 12/02/2021] [Indexed: 11/12/2022] Open
Abstract
Background The guideline-driven and widely implemented single room isolation strategy for respiratory viral infections (RVI) such as influenza or respiratory syncytial virus (RSV) can lead to a shortage of available hospital beds. We discuss our experience with the introduction of droplet precautions on-site (DroPS) as a possible alternative. Methods During the 2018/19 influenza season we introduced DroPS on several wards of a single tertiary care center, while other wards maintained the traditional single room isolation strategy. On a daily basis, we evaluated patients for the development of respiratory symptoms and screened those with a clinical diagnosis of hospital-acquired respiratory viral infection (HARVI) for influenza/RSV by molecular rapid test. If negative, it was followed by a multiplex respiratory virus PCR. We report the concept of DroPS, the feasibility of the strategy and the rate of microbiologically confirmed HARVI with influenza or RSV infection on the DroPS wards compared to wards using the traditional single room isolation strategy. Results We evaluated all hospitalised patients at risk for a HARVI, 741 (72%) on the DroPS wards and 293 (28%) on the regular wards. The hospital-acquired infection rate with influenza or RSV was 2/741 (0.3%; 1× influenza A, 1× RSV) on the DroPS wards and 2/293 (0.7%; 2× influenza A) on the regular wards. Conclusions Droplet precautions on-site (DroPS) may be a simple and potentially resource-saving alternative to the standard single room isolation strategy for respiratory viral infections. Further studies in a larger clinical context are needed to document its safety. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-01038-y.
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Roten C, Baumgartner C, Mosimann S, Martin Y, Donzé J, Nohl F, Kraehenmann S, Monti M, Perrig M, Berendonk C. Challenges in the transition from resident to attending physician in general internal medicine: a multicenter qualitative study. BMC Med Educ 2022; 22:336. [PMID: 35501754 PMCID: PMC9063076 DOI: 10.1186/s12909-022-03400-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 04/18/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND The attending physician in general internal medicine (GIM) guarantees comprehensive care for persons with complex and/or multiple diseases. Attendings from other medical specialties often report that transitioning from resident to attending is burdensome and stressful. We set out to identify the specific challenges of newly appointed attendings in GIM and identify measures that help residents better prepare to meet these challenges. METHODS We explored the perceptions of 35 residents, attendings, and department heads in GIM through focus group discussions and semi-structured interviews. We took a thematic approach to qualitatively analyze this data. RESULTS Our analysis revealed four key challenges: 1) Embracing a holistic, patient centered perspective in a multidisciplinary environment; 2) Decision making under conditions of uncertainty; 3) Balancing the need for patient safety with the need to foster a learning environment for residents; and 4) Taking on a leader's role and orchestrating an interprofessional team of health care professionals. Newly appointed attendings required extensive practical experience to adapt to their new roles. Most attendings did not receive regular, structured, professional coaching during their transition, but those who did found it very helpful. CONCLUSIONS Newly appointed attending physician in GIM face a number of critical challenges that are in part specific to the field of GIM. Further studies should investigate whether the availability of a mentor as well as conscious assignment of a series of increasingly complex tasks during residency by clinical supervisors will facilitate the transition from resident to attending.
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Affiliation(s)
- Christine Roten
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefanie Mosimann
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Faculty of Health, Medicine & Life Sciences, Maastricht University, 6229 ER, Maastricht, The Netherlands
| | - Yonas Martin
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jacques Donzé
- Division of Medicine, Hôpital Neuchâtelois, Neuchâtel, Switzerland
| | - Felix Nohl
- Department of General Internal Medicine, Regionalspital Emmental, Burgdorf, Switzerland
| | - Simone Kraehenmann
- Division of General Internal Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Matteo Monti
- Department of Internal Medicine and Medical Education Unit, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Martin Perrig
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Ruegg G, Zimmerli S, Trachsel M, Berezowska S, Engelbrecht S, Martin Y, Perrig M. Pulmonary Histoplasmosis Mimicking Metastatic Lung Cancer: A Case Report. Diagnostics (Basel) 2021; 11:diagnostics11020328. [PMID: 33671319 PMCID: PMC7922209 DOI: 10.3390/diagnostics11020328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 11/16/2022] Open
Abstract
Histoplasmosis is a well-known endemic fungal infection but experience in non-endemic regions is often limited, which may lead to delayed diagnosis and extensive testing. The diagnosis can be especially challenging, typically when the disease first presents with pulmonary nodules accompanied by hilar and mediastinal lymphadenopathy, suggesting a much more common malignant disease. In this situation, a greater FDG uptake in draining lymph nodes in comparison with the associated lung nodule seen in [18F]FDG-PET/CT, the so-called "flip-flop fungus" sign, can help to orientate further diagnostic measures. We report a case of a 56-year-old woman living in Switzerland, a non-endemic region, whose diagnosis of imported histoplasmosis was delayed since the findings had been initially misinterpreted as pulmonary malignancy. Further, histological workup was inconclusive due to lack of specific fungal staining, leading to ineffective treatment and non-resolving disease. This paper intends to highlight the pitfalls in diagnosing Histoplasma capsulatum and presents images of particularities of fungal infections in [18F]FDG-PET/CT, which in our case showed a "flip-flop fungus" sign.
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Affiliation(s)
- Gion Ruegg
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.T.); (Y.M.); (M.P.)
- Department of Intensive Care Medicine, University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence: ; Tel.: +41-31-632-5300; Fax: +41-31-632-1771
| | - Stefan Zimmerli
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Maria Trachsel
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.T.); (Y.M.); (M.P.)
| | - Sabina Berezowska
- Institute of Pathology, University of Bern, 3008 Bern, Switzerland;
- Department of Laboratory Medicine and Pathology, Institute of Pathology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Swantje Engelbrecht
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Yonas Martin
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.T.); (Y.M.); (M.P.)
| | - Martin Perrig
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.T.); (Y.M.); (M.P.)
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Reber E, Messmer Ivanova A, Cadisch P, Stirnimann J, Perrig M, Roten C, Stanga Z. Does multifaceted nutritional education improve malnutrition management? Nutrition 2020; 78:110810. [PMID: 32544848 DOI: 10.1016/j.nut.2020.110810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/11/2020] [Accepted: 02/27/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Malnutrition is a challenging issue in hospitals, but mostly reversible. However, despite being associated with increased morbidity and mortality risk, malnutrition is hardly recognized and treated. There is a strong need to raise awareness of treating residents to improve patients' nutritional management. This study aimed to investigate the impact of an educational intervention on residents' nutritional knowledge, perception, and prescribed nutritional therapies. METHODS This prospective intervention study was conducted at the Department of General Internal Medicine of the Bern University Hospital. Nutritional risk was evaluated in consecutive patients admitted to the wards using the Nutritional Risk Screening 2002 and the number of prescribed nutritional therapies were assessed. The educational intervention included an interactive case discussion headed by nutritional medicine consultants. A pocket card with basic nutritional information was handed out. Each resident's nutritional knowledge was checked with a multiple choice test before the intervention, immediately after, and after 2 months. RESULTS In total, 609 patients were included (121 preintervention, 161 postintervention phase I, 327 postintervention phase II). Overall prevalence of malnutrition was 35%. The percentage of prescribed nutritional therapies was 36%. There was no significant difference between the phases (46% preintervention, 52% postintervention phase I, 27% postintervention phase II) or between the test results (mean percentage of correct answers 61 ± 15%; 57 ± 12%, and 60 ± 10%). CONCLUSIONS The multimodal intervention failed to achieve both objectives, as neither residents' knowledge and awareness nor the number of prescribed therapies could be increased. Nutritional risk remains highly prevalent; thus, innovative and more effective teaching strategies are needed to increase knowledge, abilities, and skills to fight malnutrition.
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Affiliation(s)
- Emilie Reber
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, Switzerland.
| | - Anna Messmer Ivanova
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, Switzerland
| | - Patricia Cadisch
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, Switzerland
| | - Jessica Stirnimann
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, Switzerland
| | - Martin Perrig
- Department of General Internal Medicine, Bern University Hospital, Switzerland
| | - Christine Roten
- Department of General Internal Medicine, Bern University Hospital, Switzerland
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, Switzerland
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Lörwald AC, Lahner FM, Mooser B, Perrig M, Widmer MK, Greif R, Huwendiek S. Influences on the implementation of Mini-CEX and DOPS for postgraduate medical trainees' learning: A grounded theory study. Med Teach 2019; 41:448-456. [PMID: 30369283 DOI: 10.1080/0142159x.2018.1497784] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Introduction: In order for Mini-Clinical Evaluation Exercise (Mini-CEX) and Direct Observation of Procedural Skills (DOPS) to actually have a positive effect on trainees' learning, the way in which the tools are implemented is of key importance. However, there are many factors influencing their implementation. In this study, we aim to develop a comprehensive model of such factors. Methods: Using a constructivist grounded theory approach, we performed eight focus groups. Participants were postgraduate trainees and supervisors from three different specialties; all were experienced with Mini-CEX and/or DOPS. Data were analyzed for recurring themes, underlying concepts and their interactions using constant comparison. Results: We developed a model demonstrating how the implementation of Mini-CEX and DOPS for trainees' learning is influenced by 13 factors relating to four categories: organizational culture (e.g. value of teaching and feedback), work structure (e.g. time for Mini-CEX and DOPS, faculty development), instruments (e.g. content of assessment), and users (e.g. relationship between trainees and supervisors), and their interaction. Conclusions: We developed a complex model of influencing factors relating to four categories. Consideration of this model might support successful implementation and trainees' learning with Mini-CEX and DOPS.
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Affiliation(s)
- Andrea C Lörwald
- a Department of Assessment and Evaluation , Institute of Medical Education , Bern , Switzerland
| | - Felicitas-Maria Lahner
- a Department of Assessment and Evaluation , Institute of Medical Education , Bern , Switzerland
| | - Bettina Mooser
- a Department of Assessment and Evaluation , Institute of Medical Education , Bern , Switzerland
| | - Martin Perrig
- b Department of General Internal Medicine , Bern University Hospital University of Bern , Bern , Switzerland
| | - Matthias K Widmer
- c Department of Cardiovascular Surgery , Bern University Hospital University of Bern , Bern , Switzerland
| | - Robert Greif
- d Department of Anaesthesiology and Pain Therapy , Bern University Hospital University of Bern , Bern , Switzerland
| | - Sören Huwendiek
- a Department of Assessment and Evaluation , Institute of Medical Education , Bern , Switzerland
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Doulberis M, Papaefthymiou A, Kountouras J, Polyzos SA, Srivastava DS, Perrig M, Katsinelos P, Özgüler O, Kotronis G, Gialamprinou D, Papamichos S, Ingold J, Xanthis A, Exadaktylos AK. Hookworms in Emergency Department: The "Vampire" Within. J Acute Med 2018; 8:135-148. [PMID: 32995216 PMCID: PMC7517929 DOI: 10.6705/j.jacme.201812_8(4).0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 09/27/2018] [Indexed: 06/11/2023]
Abstract
Hookworms infection is a soil-transmitted helminthic disease particularly endemic in developing counties of tropical regions. It is attributed mainly to two human pathogens nematodes namely Necator americanus and Ancylostoma duodenale. Although the disease has been characterized as "neglected" is very diffi cult to be eliminated and the economic consequences are great. Worms are fed with blood of hosts in small intestine and cause typically iron deficiency anemia with relevant symptoms as well as eosinophilia. Patients admitted in emergency department claim often diffuse general symptoms, whereas cases with obscure gastrointestinal bleeding can be seen. Within this brief review, after introducing some basic elements of hookworms' epidemiology, taxonomy and socioeconomic problem is emphasized, pathogenesis, and life cycle of parasite are concisely explained. Furthermore, clinical manifestations often or rarely seen in emergency department are described. Therapeutic options are also enclosed. Awareness of the problem and critical thinking of patients coming from endemic regions could result to identifying more hookworm cases and their therapy will efficiently alleviate not only the patients per se but health system and societies as well.
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Affiliation(s)
- Michael Doulberis
- University Hospital Inselspital Bern Department of General Internal Medicine Bern Switzerland
- Aristotle University of Thessaloniki Department of Internal Medicine, Second Medical Clinic, Ippokration Hospital Thessaloniki, Macedonia Greece
| | | | - Jannis Kountouras
- Aristotle University of Thessaloniki Department of Internal Medicine, Second Medical Clinic, Ippokration Hospital Thessaloniki, Macedonia Greece
| | - Stergios A Polyzos
- Thessaloniki First Department of Pharmacology, Medical School, Aristotle University of Thessaloniki Macedonia Greece
| | | | - Martin Perrig
- University Hospital Inselspital Bern Department of General Internal Medicine Bern Switzerland
| | - Panagiotis Katsinelos
- Aristotle University of Thessaloniki Department of Internal Medicine, Second Medical Clinic, Ippokration Hospital Thessaloniki, Macedonia Greece
| | - Onur Özgüler
- General Hospital Bürgerspital Department of Emergency Medicine Solothurn Switzerland
| | - Georgios Kotronis
- General Hospital Agios Pavlos of Thessaloniki Department of Internal Medicine Thessaloniki, Macedonia Greece
| | - Dimitra Gialamprinou
- Aristotle University of Thessaloniki Department of Pediatrics, Papageorgiou University Hospital Thessaloniki, Macedonia Greece
| | - Spyros Papamichos
- University Hospital Inselspital Bern Department of Hematology Bern Switzerland
| | - Jonas Ingold
- Tiefenau Hospital of Bern Department of General Internal Medicine Bern Switzerland
| | - Andreas Xanthis
- Aristotle University of Thessaloniki Department of Internal Medicine, Second Medical Clinic, Ippokration Hospital Thessaloniki, Macedonia Greece
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Birrenbach T, Kraehenmann S, Perrig M, Berendonk C, Huwendiek S. Physicians' attitudes toward, use of, and perceived barriers to clinical guidelines: a survey among Swiss physicians. Adv Med Educ Pract 2016; 7:673-680. [PMID: 28008300 PMCID: PMC5167524 DOI: 10.2147/amep.s115149] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Little is known about the attitudes toward, use of, and perceived barriers to clinical guidelines in Switzerland, a country with no national guideline agency. Moreover, there is no available data on the objective assessment of guideline knowledge in Switzerland. Therefore, we conducted a study at a large university's Department of General Internal Medicine in Switzerland to assess physicians' attitudes toward, use of, perceived barriers to, and knowledge of clinical guidelines. PARTICIPANTS AND METHODS Ninety-six physicians (residents, n=78, and attendings, n=18) were invited to take part in a survey. Attitudes toward, self-reported use of, and barriers hindering adherence to the clinical guidelines were assessed using established scales and frameworks. Knowledge of the guidelines was objectively tested in a written assessment comprising of 14 multiple-choice and 3 short answer case-based questions. RESULTS Fifty-five participants completed the survey (residents, n=42, and attendings, n=13; overall response rate 57%). Of these, 50 took part in the knowledge assessment (residents, n=37, and attendings, n=13; overall response rate 52%). Attitudes toward guidelines were favorable. They were considered to be a convenient source of advice (94% agreement), good educational tools (89% agreement), and likely to improve patient quality of care (91% agreement). Self-reported use of guidelines was limited, with only one-third reporting using guidelines often or very often. The main barriers to guideline adherence were identified as lack of guideline awareness and familiarity, applicability of existing guidelines to multimorbid patients, unfavorable guideline factors, and lack of time as well as inertia toward changing previous practice. In the assessment of guideline knowledge, the scores were rather modest (mean ± standard deviation: 60.5%±12.7% correct answers). CONCLUSION In general, this study found favorable physician attitudes toward clinical guidelines. However, several barriers hindering guideline implementation were identified. The importance of improving guideline implementation was supported by modest results in a guideline knowledge test.
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Affiliation(s)
- Tanja Birrenbach
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simone Kraehenmann
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Perrig
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Berendonk
- Department of Assessment and Evaluation, Institute of Medical Education, Medical Faculty Bern, Bern, Switzerland
| | - Soeren Huwendiek
- Department of Assessment and Evaluation, Institute of Medical Education, Medical Faculty Bern, Bern, Switzerland
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Perrig M, Berendonk C, Rogausch A, Beyeler C. Sustained impact of a short small group course with systematic feedback in addition to regular clinical clerkship activities on musculoskeletal examination skills--a controlled study. BMC Med Educ 2016; 16:35. [PMID: 26821664 PMCID: PMC4731988 DOI: 10.1186/s12909-016-0554-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 01/22/2016] [Indexed: 05/07/2023]
Abstract
BACKGROUND The discrepancy between the extensive impact of musculoskeletal complaints and the common deficiencies in musculoskeletal examination skills lead to increased emphasis on structured teaching and assessment. However, studies of single interventions are scarce and little is known about the time-dependent effect of assisted learning in addition to a standard curriculum. We therefore evaluated the immediate and long-term impact of a small group course on musculoskeletal examination skills. METHODS All 48 Year 4 medical students of a 6 year curriculum, attending their 8 week clerkship of internal medicine at one University department in Berne, participated in this controlled study. Twenty-seven students were assigned to the intervention of a 6×1 h practical course (4-7 students, interactive hands-on examination of real patients; systematic, detailed feedback to each student by teacher, peers and patients). Twenty-one students took part in the regular clerkship activities only and served as controls. In all students clinical skills (CS, 9 items) were assessed in an Objective Structured Clinical Examination (OSCE) station, including specific musculoskeletal examination skills (MSES, 7 items) and interpersonal skills (IPS, 2 items). Two raters assessed the skills on a 4-point Likert scale at the beginning (T0), the end (T1) and 4-12 months after (T2) the clerkship. Statistical analyses included Friedman test, Wilcoxon rank sum test and Mann-Whitney U test. RESULTS At T0 there were no significant differences between the intervention and control group. At T1 and T2 the control group showed no significant changes of CS, MSES and IPS compared to T0. In contrast, the intervention group significantly improved CS, MSES and IPS at T1 (p < 0.001). This enhancement was sustained for CS and MSES (p < 0.05), but not for IPS at T2. CONCLUSIONS Year 4 medical students were incapable of improving their musculoskeletal examination skills during regular clinical clerkship activities. However, an additional small group, interactive clinical skills course with feedback from various sources, improved these essential examination skills immediately after the teaching and several months later. We conclude that supplementary specific teaching activities are needed. Even a single, short-lasting targeted module can have a long lasting effect and is worth the additional effort.
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Affiliation(s)
- Martin Perrig
- />Department of General Internal Medicine, University Hospital of Berne, Berne, Switzerland
| | - Christoph Berendonk
- />Assessment and Evaluation Unit, Institute of Medical Education, University of Berne, 3010 Berne, Switzerland
| | - Anja Rogausch
- />Assessment and Evaluation Unit, Institute of Medical Education, University of Berne, 3010 Berne, Switzerland
| | - Christine Beyeler
- />Assessment and Evaluation Unit, Institute of Medical Education, University of Berne, 3010 Berne, Switzerland
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Aeberhard C, Birrenbach T, Joray M, Mühlebach S, Perrig M, Stanga Z. Simple training tool is insufficient for appropriate diagnosis and treatment of malnutrition: A pre-post intervention study in a tertiary center. Nutrition 2015; 32:355-61. [PMID: 26724958 DOI: 10.1016/j.nut.2015.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 09/15/2015] [Accepted: 09/18/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To improve malnutrition awareness and management in our department of general internal medicine; to assess patients' nutritional risk; and to evaluate whether an online educational program leads to an increase in basic knowledge and more frequent nutritional therapies. METHODS A prospective pre-post intervention study at a university department of general internal medicine was conducted. Nutritional screening using Nutritional Risk Score 2002 (NRS 2002) was performed, and prescriptions of nutritional therapies were assessed. The intervention included an online learning program and a pocket card for all residents, who had to fill in a multiple-choice questions (MCQ) test about basic nutritional knowledge before and after the intervention. RESULTS A total of 342 patients were included in the preintervention phase, and 300 were in the postintervention phase. In the preintervention phase, 54.1% were at nutritional risk (NRS 2002 ≥3) compared with 61.7% in the postintervention phase. There was no increase in the prescription of nutritional therapies (18.7% versus 17.0%). Forty-nine and 41 residents (response rate 58% and 48%) filled in the MCQ test before and after the intervention, respectively. The mean percentage of correct answers was 55.6% and 59.43%, respectively (which was not significant). Fifty of 84 residents completed the online program. The residents who participated in the whole program scored higher on the second MCQ test (63% versus 55% correct answers, P = 0.031). CONCLUSIONS Despite a high ratio of malnourished patients, the nutritional intervention, as assessed by nutritional prescriptions, is insufficient. However, the simple educational program via Internet and usage of NRS 2002 pocket cards did not improve either malnutrition awareness or nutritional treatment. More sophisticated educational systems to fight malnutrition are necessary.
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Affiliation(s)
- Carla Aeberhard
- Department of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital and University of Bern, Bern, Switzerland.
| | - Tanja Birrenbach
- Department of General Internal Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Maya Joray
- Department of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Stefan Mühlebach
- Division of Clinical Pharmacy and Epidemiology and Hospital Pharmacy, University of Basel, Basel, Switzerland
| | - Martin Perrig
- Department of General Internal Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Zeno Stanga
- Department of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital and University of Bern, Bern, Switzerland; Department of General Internal Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
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Aeberhard C, Stanga Z, Perrig M, Birrenbach T. ["Not to be taken lightly"]. Praxis (Bern 1994) 2015; 104:919-923. [PMID: 26286496 DOI: 10.1024/1661-8157/a002103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A 78 year old patient with type 2 diabetes mellitus was hospitalized because of weakness and poor nutritional status. For several years, he suffered from an unintended weight loss and chronic, pulpy diarrhea. On examination, we found a severe loss of muscle and fat tissue as well as difficulty swallowing. An adequate nutritional therapy with combined parenteral and enteral nutrition was implemented under regular monitoring of electrolytes and volume status, under which the state of health improved noticeably, while steatorrhea improved under substitution of pancreatic enzymes.
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Affiliation(s)
- Carla Aeberhard
- 1 Universitätspoliklinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital, Inselspital Bern
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12
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Eichelberger M, Joray ML, Perrig M, Bodmer M, Stanga Z. Management of patients during hunger strike and refeeding phase. Nutrition 2014; 30:1372-8. [PMID: 25280415 DOI: 10.1016/j.nut.2014.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 03/28/2014] [Accepted: 04/02/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Hunger strikers resuming nutritional intake may develop a life-threatening refeeding syndrome (RFS). Consequently, hunger strikers represent a core challenge for the medical staff. The objective of the study was to test the effectiveness and safety of evidence-based recommendations for prevention and management of RFS during the refeeding phase. METHODS This was a retrospective, observational data analysis of 37 consecutive, unselected cases of prisoners on a hunger strike during a 5-y period. The sample consisted of 37 cases representing 33 individual patients. RESULTS In seven cases (18.9%), the hunger strike was continued during the hospital stay, in 16 episodes (43.2%) cessation of the hunger strike occurred immediately after admission to the security ward, and in 14 episodes (37.9%) during hospital stay. In the refeed cases (n = 30), nutritional replenishment occurred orally, and in 25 (83.3%) micronutrients substitutions were made based on the recommendations. The gradual refeeding with fluid restriction occurred over 10 d. Uncomplicated dyselectrolytemia was documented in 12 cases (40%) within the refeeding phase. One case (3.3%) presented bilateral ankle edemas as a clinical manifestation of moderate RFS. Intensive medical treatment was not necessary and none of the patients died. Seven episodes of continued hunger strike were observed during the entire hospital stay without medical complications. CONCLUSIONS Our data suggested that seriousness and rate of medical complications during the refeeding phase can be kept at a minimum in a hunger strike population. This study supported use of recommendations to optimize risk management and to improve treatment quality and patient safety in this vulnerable population.
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Affiliation(s)
- M Eichelberger
- Department of General Internal Medicine, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - M L Joray
- Department of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - M Perrig
- Department of General Internal Medicine, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - M Bodmer
- Department of General Internal Medicine, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Z Stanga
- Department of General Internal Medicine, Bern University Hospital, and University of Bern, Bern, Switzerland; Department of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital, and University of Bern, Bern, Switzerland.
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13
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Pfortmueller CA, Aulmann G, Lindner G, Perrig M, Müller TJ, Zimmermann H, Exadaktylos AK. Emergency department admissions to a prison hospital: a retrospective cohort study from Switzerland. Swiss Med Wkly 2013; 143:w13753. [PMID: 23443948 DOI: 10.4414/smw.2013.13753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION There are more than 10 million prison inmates throughout the world and this number is increasing continuously. Prisoners are a particularly vulnerable minority group that has special healthcare needs and demands on healthcare services and providers. The aim of this study was to give an overview of prisoners' healthcare problems leading to emergency department admission, in order to make recommendations to help to optimise treatment of this target group. METHODS Our retrospective data analysis comprised adult (age ≥16 years) prisoners admitted to our emergency department, in transit to admission to our hospital-associated medical prison ward, between 2nd February 2000 and 30th April 2012. RESULTS A total of 1703 patients were analysed. Of these, 78.2% (n = 1333) were male and 21.8% (n = 370) female. The mean age was 36.6 years (standard deviation 14.6, range 16-92 years). The most frequent reasons for presentation were psychiatric problems (43.4%; n = 739), followed by the need for medical treatment (31.6%; n = 539) and for surgical treatment (25.0%; n = 425). Patients with medical problems were significantly older than patients with psychiatric and surgical presentations (for both p <0.001). Patients with psychiatric problems were significantly younger than those with medical or surgical problems (p <0.001). A total of 130 (7.6%) of our patients were rehospitalised within the study period. CONCLUSION Prisoners are a vulnerable minority group within our society with limited access to medical care. Transfer of information between the emergency department and prison staff should be promoted. Further research should be carried out on prisoners' healthcare problems.
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14
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Wirth CD, Leitner C, Perrig M. Bilateral posterior ischaemic optic neuropathy after severe diabetic ketoacidosis, cardiopulmonary resuscitation and respiratory failure. BMJ Case Rep 2013; 2013:bcr-2012-008291. [PMID: 23417383 DOI: 10.1136/bcr-2012-008291] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
A 44-year-old male European with type I diabetes mellitus fell into diabetic ketoacidosis. In the emergency room, he developed an episode of asystole and respiratory failure requiring one cycle of cardiopulmonary resuscitation and extracorporeal membrane oxygenation (ECMO). Waking up 7 days later, he presented a bilateral complete loss of vision. Ophthalmological examination including funduscopy on days 1 and 10, after extubation, showed bilateral large round pupils non-reactive to light and a normal fundus. Neuroimaging studies, including MRI and MRA of the brain, were all within normal limits. A lumbar puncture and comprehensive serological testing excluded an infectious or rheumatic cause. An empirical high-dose intravenous steroid treatment administered for 5 days had no effect on his vision. His eye examination at 1.5 months follow-up showed a normal fundus except for progressive bilateral optic nerve disc pallor, which pointed towards the diagnosis of a posterior ischaemic optic neuropathy.
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Affiliation(s)
- Christina Doris Wirth
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland.
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15
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Saguner AM, Dur S, Perrig M, Schiemann U, Stuck AE, Burgi U, Erne P, Schoenenberger AW. Risk factors promoting hypertensive crises: evidence from a longitudinal study. Am J Hypertens 2010; 23:775-80. [PMID: 20395943 DOI: 10.1038/ajh.2010.71] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Current knowledge about risk factors promoting hypertensive crisis originates from retrospective data. Therefore, potential risk factors of hypertensive crisis were assessed in a prospective longitudinal study. METHODS Eighty-nine patients of the medical outpatient unit at the University Hospital of Bern (Bern, Switzerland) with previously diagnosed hypertension participated in this study. At baseline, 33 potential risk factors were assessed. All patients were followed-up for the outcome of hypertensive crisis. Cox regression models were used to detect relationships between risk factors and hypertensive crisis (defined as acute rise of systolic blood pressure (BP) > or =200 mm Hg and/or diastolic BP > or =120 mm Hg). RESULTS The mean duration of follow-up was 1.6 +/- 0.3 years (range 1.0-2.4 years). Four patients (4.5%) were lost to follow-up. Thirteen patients (15.3%) experienced hypertensive crisis during follow-up. Several potential risk factors were significantly associated with hypertensive crisis: female sex, higher grades of obesity, the presence of a hypertensive or coronary heart disease, the presence of a somatoform disorder, a higher number of antihypertensive drugs, and nonadherence to medication. As measured by the hazard ratio, nonadherence was the most important factor associated with hypertensive crisis (hazard ratio 5.88, 95% confidence interval 1.59-21.77, P < 0.01). CONCLUSIONS This study identified several potential risk factors of hypertensive crisis. Results of this study are consistent with the hypothesis that improvement of medical adherence in antihypertensive therapy would help to prevent hypertensive crises. However, larger studies are needed to assess potential confounding, other risk factors and the possibility of interaction between predictors.
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Abstract
Since the seventies, the practice of drug smuggling in the form of body packing has increased in the Western world. The goal of our study was to present an algorithm for the safe management of intracorporal drug transport based on clinical experience and current evidence. The retrospective study, conducted over the past four years in our hospital prison, analyzes and discusses the diagnostic and therapeutic concepts. Thirty-four patients hospitalized 37 times in a 48-month period were included. In 28 patients drug packages were identified. Only two patients suffered from serious complications. The study demonstrates that following a specifically designed management algorithm based on clinical experience and principles of evidence-based medicine can optimize risk management, improve quality assurance and patient safety.
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Affiliation(s)
- M Gsell
- Universitätsklinik für Allgemeine Innere Medizin, Inselspital, Universitätsspital Bern
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17
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Hurni C, Rauch A, Trost N, Perrig M, Bürgi U, Schoenenberger AW. [Pulmonary nodules in a patient on long-term steroid treatment]. Praxis (Bern 1994) 2008; 97:849-852. [PMID: 18754339 DOI: 10.1024/1661-8157.97.15.849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
We report on a patient who was chronically treated with steroids. She simultaneously developed pulmonary nocardiosis as well as a soft tissue infection and osteomyelitis by mycobacterium abscessus. Both infections are rare, but more frequently occur in immunocompromised hosts. The patient was healed after 12 month of adequate antibiotic treatment.
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Affiliation(s)
- Ch Hurni
- Klinik und Poliklinik für AlIgemeine Innere Medizin, Universität und Inselspital Bern
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18
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Schoenenberger AW, Erne P, Ammann S, Perrig M, Bürgi U, Stuck AE. Prediction of hypertensive crisis based on average, variability and approximate entropy of 24-h ambulatory blood pressure monitoring. J Hum Hypertens 2007; 22:32-7. [PMID: 17625588 DOI: 10.1038/sj.jhh.1002263] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Approximate entropy (ApEn) of blood pressure (BP) can be easily measured based on software analysing 24-h ambulatory BP monitoring (ABPM), but the clinical value of this measure is unknown. In a prospective study we investigated whether ApEn of BP predicts, in addition to average and variability of BP, the risk of hypertensive crisis. In 57 patients with known hypertension we measured ApEn, average and variability of systolic and diastolic BP based on 24-h ABPM. Eight of these fifty-seven patients developed hypertensive crisis during follow-up (mean follow-up duration 726 days). In bivariate regression analysis, ApEn of systolic BP (P<0.01), average of systolic BP (P=0.02) and average of diastolic BP (P=0.03) were significant predictors of hypertensive crisis. The incidence rate ratio of hypertensive crisis was 14.0 (95% confidence interval (CI) 1.8, 631.5; P<0.01) for high ApEn of systolic BP as compared to low values. In multivariable regression analysis, ApEn of systolic (P=0.01) and average of diastolic BP (P<0.01) were independent predictors of hypertensive crisis. A combination of these two measures had a positive predictive value of 75%, and a negative predictive value of 91%, respectively. ApEn, combined with other measures of 24-h ABPM, is a potentially powerful predictor of hypertensive crisis. If confirmed in independent samples, these findings have major clinical implications since measures predicting the risk of hypertensive crisis define patients requiring intensive follow-up and intensified therapy.
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Affiliation(s)
- A W Schoenenberger
- University Department of Geriatrics, Spital Netz Bern Ziegler and University of Bern, Bern, Switzerland.
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Abstract
Pituitary apoplexy, diabetes insipidus, thyroid storm, myxedema coma, parathyrotoxic crisis, hypocalcemia tetany, pheochromocytoma and Addison crisis, diabetic ketoacidosis, diabetic hyperosmolar nonketotic coma, hypoglycemia and carcinoid crisis are the most important endocrine crises. Some of them are common, others very rare. All physicians nevertheless need to have at least a basic knowledge of all of them, since symptoms and signs of endocrine crises overlap with those of other severe disease states, and the failure to recognise endocrine crises as such and to begin rapidly the specific therapy can have fatal consequences.
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Affiliation(s)
- U Bürgi
- Klinik und Poliklinik für Allgemeine Medizin, Inselspital, Bern.
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20
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Abstract
PURPOSE We assessed the efficacy of extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc., Marietta, Georgia) for distal ureteral calculi with the HM3 (Dornier Medical Systems, Inc.) lithotriptor. MATERIALS AND METHODS A total of 585 consecutive patients with distal ureteral calculi were treated with ESWL using an unmodified HM3 lithotriptor. Of these patients 67 referred for treatment only for whom no followup was available were excluded from further analysis. The remaining 518 cases were followed until they were radiologically documented to be stone-free or considered treatment failures. Before ESWL additional procedures were performed in 144 patients, including stone push back, ureteral catheter or Double-J (Medical Engineering Corp., New York, New York) stent placement, percutaneous nephrostomy, ureteral endoscopic maneuvers or stone basket manipulation. A total of 374 patients needed no preliminary treatment before ESWL. RESULTS Of the 518 patients 469 (91%) were successfully treated with 1 ESWL session, while 49 (9%) needed 2 or 3. Manipulation after ESWL was performed in 22 cases, including stent placement, percutaneous nephrostomy, ureteral endoscopic stone removal and a stone basket procedure. On day 1 after ESWL 327 patients (63%) were stone-free, 158 (30%) had less than 5 mm. fragments and 33 (7%) had more than 5 mm. fragments. At 3 months the stone-free rate increased to 97%. CONCLUSIONS These data show that ESWL for distal ureteral calculi with the powerful unmodified HM3 lithotriptor has a high success rate with a low rate of minimally traumatic manipulations before and after intervention. Results in terms of the re-treatment and stone-free rates are superior to those of any other second or third generation lithotriptor and comparable to the results of the best ureteroscopic series.
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Perrig M, Acosta F, Cottagnoud M, Gerber CM, Täuber MG, Cottagnoud P. Efficacy of gatifloxacin alone and in combination with cefepime against penicillin-resistant Streptococcus pneumoniae in a rabbit meningitis model and in vitro. J Antimicrob Chemother 2001; 47:701-4. [PMID: 11328789 DOI: 10.1093/jac/47.5.701] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Gatifloxacin penetrated well into cerebrospinal fluid (CSF) (49 +/- 11%), measured by comparison of AUC(CSF)/AUC(serum), and showed good bactericidal activity (leading to a decrease of 0.75 +/- 0.17 log10 cfu/mL/h) in the treatment of experimental meningitis in rabbits caused by a penicillin-resistant pneumococcal strain (MIC 4 mg/L). It was significantly more effective than the standard regimen, ceftriaxone with vancomycin, which led to a decrease of 0.53 +/- 0.17 log10 cfu/mL/h. The addition of cefepime to gatifloxacin slightly improved the killing rates (giving a decrease of 0.84 +/- 0.14 log10 cfu/mL/h). In vitro, synergy was demonstrated between cefepime and gatifloxacin by the chequerboard method (fractional inhibitory concentration index = 0.5) and by viable counts over 8 h.
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Affiliation(s)
- M Perrig
- Department of Internal Medicine, Zieglerspital, 3007 Berne, Switzerland
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Abstract
BACKGROUND A precise, non-invasive, non-toxic, repeatable, convenient and inexpensive follow-up of renal transplants, especially following biopsies, is in the interest of nephrologists. Formerly, the rate of biopsies leading to AV fistulas had been underestimated. Imaging procedures suited to a detailed judgement of these vascular malformations are to be assessed. METHODS Three-dimensional (3D) reconstruction techniques of ultrasound flow-directed and non-flow-directed energy mode pictures were compared with a standard procedure, gadolinium-enhanced nuclear magnetic resonance imaging angiography (MRA) using the phase contrast technique. RESULTS Using B-mode and conventional duplex information, AV fistulas were localized in the upper pole of the kidney transplant of the index patient. The 3D reconstruction provided information about the exact localization and orientation of the fistula in relation to other vascular structures, and the flow along the fistula. The MRA provided localization and orientation information, but less functional information. Flow-directed and non-flow-directed energy mode pictures could be reconstructed to provide 3D information about vascular malformations in transplanted kidneys. CONCLUSION In transplanted kidneys, 3D-ultrasound angiography may be equally as effective as MRA in localizing and identifying AV malformations. Advantages of the ultrasound method are that it is cheaper, non-toxic, non-invasive, more widely availability and that it even provides more functional information. Future prospective studies will be necessary to evaluate the two techniques further.
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Affiliation(s)
- M G Mohaupt
- Inselspital Bern, Departement Innere Medizin, Abteilung Nephrologie/Hypertonie, Switzerland
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Abstract
This article summarizes current recommendations for work-up and treatment of hypertension in elderly persons. The prevalence of hypertension in older persons is over 50 percent. A review of randomized controlled studies among older persons shows that treatment of hypertension reduces the risk of cardiovascular complications by about 30 to 50 percent. Since the absolute risk of cardiovascular disease at any given level of blood pressure in the elderly is three to four times greater than that in younger people, the potential benefit of antihypertensive treatment among older people is high. On the other hand, the potential risks of antihypertensive therapy need to be taken into account. The patients' other risk factors, pre-existing cardiovascular disease, and competing comorbid illnesses should be considered for treatment decisions. Baseline and follow-up control for detection of postural hypotension is emphasized.
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Affiliation(s)
- M Perrig
- Abteilung für Nephrologie, Inselspital, Bern
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