OBJECTIVE
About 50% of acute coronary syndromes occur in patients classified as being at low coronary risk. We aimed to assess the potential preventive benefit of carotid plaque imaging with ultrasound.
METHODSWe assessed the prevalence of “old” arteries (vascular age ≥70 years; VA70) in 3248 healthy subjects aged 40–65 years from the Swiss region of Olten and the German region of Koblenz. We compared sensitivity, specificity and discriminatory performance of SCORE, PROCAM and AGLA coronary risk calculators to detect VA70 for various decision thresholds and performed reclassification and cost-efficiency analysis.
RESULTSVA70 was found in one out of eight subjects. Sensitivity for VA70 was 6% at the 10% AGLA threshold in women and 30% in men in the Olten area, which was confirmed for the Koblenz area with PROCAM (sensitivity 8% in women, 56% in men). Results were similar for SCORE. The discriminatory performance ranged between 0.69 and 0.82. Reclassification from low risk to a higher risk category occurred in 17–35% of patients. Analysis showed that carotid imaging for CHF 100 per person was highly cost efficient.
CONCLUSIONSIn subjects aged 40–65 years, the prevalence of old arteries is one out of eight and the detection rate of AGLA and SCORE is lower in women (6% for PROCAM) than for men (30%) at the 10% threshold. Carotid imaging may be used to reclassify subjects from low to intermediate or high cardiovascular risk. Our method is highly cost efficient at a price of CHF 100 per examination.
OBJECTIVES
Most urinary tract infections (UTIs) are treated empirically with antibiotics, making comprehensive resistance surveillance data essential to guide empiric regimens. We describe trends in the antibiotic resistance of urinary Enterobacteriaceae isolates in Switzerland between 2009 and 2016.
METHODSWe analysed data from routinely collected Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis urinary samples from community and hospital settings in Switzerland. The data were collected by ANRESIS, the national laboratory-based antimicrobial resistance surveillance system. Our analyses focused on resistance to antibiotics commonly prescribed for UTIs for the period 2009–2016. Only the first isolate per patient per year was included.
RESULTS297,200 urinary samples were included in the analysis, of which 246,656 (83.0%) were E. coli isolates. Overall, E. coli showed high susceptibility to 3rd/4th-generation cephalosporins, nitrofurantoin and fosfomycin, with the annual proportions of resistant isolates <6%, <5% and <2%, respectively, for all study years. Resistance to fluoroquinolones was >14% and increased over time (from 14.5% in 2009 to 19.3% in 2016). Resistance to cotrimoxazole was >20% for the whole study period. K. pneumoniae (n = 32,757; 11.0%) showed low resistance to cotrimoxazole and quinolones (<11% and <12%, respectively), while for P. mirabilis (n = 17,787; 6.0%) the proportion of resistant isolates was <35% for cotrimoxazole and <18% for quinolones. Even though quinolone resistance remained low for both pathogens (<12% for K. pneumoniae and <18% for P. mirabilis), it increased significantly over time. Proportions of isolates resistant to 3rd/4th generation cephalosporins remained low (<5% for K. pneumoniae and <2% for P. mirabilis), but in the case of K. pneumoniae they increased over time.
CONCLUSIONSSwiss surveillance data confirm that resistance among uropathogenic E. coli isolates to nitrofurantoin and fosfomycin remains low. While resistance to 3rd/4th-generation cephalosporins also remains relatively low, it has been increasing and needs further surveillance. As for K. pneumoniae and P. mirabilis, high levels of susceptibility to 3rd-generation cephalosporins and quinolones were confirmed, while high prevalences of resistance to nitrofurantoin and fosfomycin discourage their use as first-line therapies for these pathogens.
INTRODUCTION
Oropharyngeal dysphagia (OD) is often observed in critically ill patients. In most affected patients OD persists throughout hospital stay and negatively impacts on clinical outcomes. Here we systematically explore routine clinical practice standards for recognition/screening, diagnosis and treatment of OD in accredited Swiss ICUs.
METHODSAn online, 23-item questionnaire-based survey was performed to investigate current standards of care for OD in Switzerland (DICE). All (n = 49) accredited Swiss teaching hospitals providing specialist training for adult intensive care medicine were contacted. Senior intensivists were interviewed on how they would screen for, diagnose and treat OD in the ICU.
RESULTSThe total response rate was 75.5%, with information available on all tertiary care academic centres. 67.6% (25/37) of institutions stated that they have established standard operating procedures for OD using a mostly sequential diagnostic approach (86.5%, 32/37). In 75.7% (28/37) of institutions, OD confirmation is performed without the use of instrumental techniques such as flexible (or fibre-endoscopic) evaluation of swallowing (FEES). Presumed key risk factors for OD were admission for acute neurological illness, long-term mechanical ventilation, ICU-acquired weakness and pre-existing neurological disease. Reported presumed OD-related complications typically include aspiration-induced pneumonia, increased rates of both reintubation and tracheostomy and increased ICU readmission rates.
CONCLUSIONSMany Swiss ICUs have established standard operating procedures, with most using sequential clinical approaches to assess ICU patients at risk of dysphagia. OD confirmation is mostly performed using non-instrumental techniques. In general, it appears that awareness of OD and ICU educational curricula can be further optimised.
Trial registration numberNCT 03487510
PURPOSE
Extra-abdominal desmoid tumours are benign and rare, and lead to a persistent treatment dilemma because of their high recurrence rate and their heterogeneous behaviour. The goal of this retrospective study was to evaluate the results of different treatment modalities for extra-abdominal desmoid tumours at four sarcoma treatment centres.
METHODSThe mean follow-up time for the 96 patients included in the study (63.5% female; mean age 38.9 years) was 8.4 years (2.0–40.5 years). The initial treatments were surgery (n = 44), surgery with radiation (n = 16), watchful waiting (n = 15), radiation only (n = 9), or systemic treatment (n = 12). Patient demographics, tumour sites, and the follow-up status of all patients were reviewed and evaluated for each of the treatment modalities.
RESULTSThe local recurrence rate was 45.5% in patients with primary surgical treatment and 37.5% following surgery combined with irradiation. Patients who were treated with radiation alone showed regressive (33.3%) or stable disease (66.6%). Systemic treatment alone resulted in disease progression in 41.7% of our patients. In the watchful waiting group, 73.3% showed stable disease, 20.0% showed spontaneous regression, and 6.7% showed progression after a mean follow-up of 4.1 years (2.0–11.5 years).
CONCLUSIONSOur results suggest that a watchful waiting approach should be the first line treatment in asymptomatic desmoid tumours. However, radiation can help improve local control rates in patients who have undergone surgery. Progression and local recurrence rates following systemic treatment were comparable to those observed in surgery combined with radiation.
AIMS OF THE STUDY
To analyse emergency department (ED) presentations related to acute medical problems after recreational use of prescription/over-the-counter (OTC) drugs in two major Swiss hospitals in order to identify the prevalence of specific drugs, vulnerable groups, time trends and local differences which could have major public health implications.
METHODSRetrospective analysis of cases presenting with signs/symptoms consistent with acute toxicity due to recreational use of prescription/OTC drugs from May 2012 to August 2017 at the ED of the University Hospital of Bern and from October 2013 to July 2017 at the ED of the University Hospital Basel. We investigated time trends, sex differences, patient characteristics and consumption patterns within three age groups (≥16 to <36 years; ≥36 to <56 years; ≥56 years).
RESULTSDuring the study period, 344 cases were included out of 1715 ED attendances due to acute drug toxicity and a total of 412,557 ED presentations. The use of prescription drugs in conjunction with illegal drugs was reported in nearly half the cases. The most frequently reported prescription drugs were benzodiazepines (64%, n = 220) and methadone (13%, n = 45). Forty-eight percent (n = 166) of all presentations occurred within the youngest age group. The analysis of time trends showed a significant increase in presentations in the youngest and the oldest groups in Basel (both p <0.05), while the trend remained stable over time in Bern for all age groups. While the number of presentations remained constant over time for men and women in Bern, a significant increase was found for the female cohort in Basel (p <0.05). Patients in all age groups presented with toxicities of predominantly minor severity.
CONCLUSIONThe prescription/OTC drugs most frequently leading to ED presentations after recreational use were sedative substances. A large proportion of the patients belonged to the youngest age group. A significant increase in presentations was seen in the youngest and oldest age groups and within women in Basel. This information can be used to inform health care providers so that they can adapt their prevention and treatment strategies in their communities.
AIM OF THE STUDY
The internal validity of double blinding in randomised placebo-controlled trials (RCTs) has become a target of criticism. The goal of this study was to investigate (a) how accurately the patients and their treating physicians were able to guess their assigned treatment, and (b) predictors for an accurate guess.
METHODSData on treatment estimation from patients (n = 382) and their physicians (n = 358 guesses) in an RCT investigating the role of adjunct prednisone for community-acquired pneumonia in a tertiary care setting were analysed. At discharge, patients and their physicians had to guess whether they had been assigned to the prednisone or to the placebo group. The alternative possibility was “uncertain”. Percentages and confidence intervals (CIs) were calculated for the proportion of patients guessing correctly. Chance finding was defined as having 50% or less correct guesses. To test for predictors for prednisone treatment guess, a mixed effects logistic regression model was performed.
RESULTSIn the prednisone group, 28.9% (55/190; 95% CI 22.6–36.0%) of the patients made a correct guess and the majority (61.6%, 117/190) was uncertain. In the placebo group, 13.0% (25/192; 95% CI 8.8–18.8%) guessed correctly, with the majority being uncertain (69.8%, 134/192). Physicians guessed correctly in 48.3% (87/180, 95% CI 40.8–55.9%) of cases in the prednisone group and in 66.3% (118/178, 95% CI 58.8–73.2%) of cases in the placebo group, which was above chance for the placebo group. The physicians were uncertain in 21.7% (39/180) of cases in the prednisone group, and in 15.2% (27/178) of cases in the placebo group. Significant predictors for guessing prednisone were the occurrence of hyperglycaemia (odds ratio [OR] 3.77, 95% CI 2.39–5.95; p<0.001) and a shorter time to clinical stability (OR 0.95, 95% CI 0.91–0.99; p = 0.02).
CONCLUSIONSWe confirmed that patient blinding was achieved in this study. Physicians made correct guesses more often than patients. Treatment estimation by both patients and physicians was led not only by the expectations of treatment effects of the study drug but also by known side effects of prednisone.
Trial registration no.:NCT00973154
OBJECTIVE
Behçet’s syndrome is a rare systemic autoimmune/autoinflammatory disease affecting mucocutaneous tissues, the skin and the eyes, as well as the joints, the central nervous system, the gastrointestinal tract and blood vessels. Because of the lack of clinical data in Switzerland, the aims of this cohort study were to calculate the disease prevalence and to analyse the disease manifestations and the immune-suppressive medication.
METHODSData were extracted from 52 patient charts. Thereafter, all patients were interviewed with a questionnaire and 46 had an additional physical examination and laboratory analyses. For calculation of prevalence, data of the national statistical bureau were used.
RESULTSA disease prevalence of 4.03/100,000 inhabitants was calculated. The mean delay between first disease manifestation and diagnosis was 8 years. It was 2 years longer for Swiss than for non-Swiss individuals (p = 0.45). The time intervals between diagnosis and occurrence of different organ manifestations ranged from +8 to −11 years. There was no difference in organ involvement between different ethnicities. Colchicine was prescribed for 52% of patients only, whereas tumour necrosis factor (TNF) inhibitors and glucocorticoids were most frequently prescribed (80 and 64%, respectively). In almost half of the patients, TNF blockers could be stopped and replaced by conventional immunosuppressive drugs.
CONCLUSIONThe data from this cohort of Behçet’s syndrome patients, the largest in Switzerland, documents a prevalence higher than anticipated. The diagnostic delay underlines an urgent need to improve awareness of the disease and allow timely treatment.
