Volume 150, No. 3940

Philippe Meyer, Henri Lu, Roger Hullin (Author)

Patiromer and medication optimisation in heart failure with reduced ejection fraction: a Swiss perspective

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Despite medical advances, heart failure remains a major public health issue and is associated with considerable morbidity and mortality. Suboptimal use of evidence-based therapies and lack of medication up-titration play important roles in this regard. Hyperkalaemia is a frequent and potentially harmful finding which hinders treatment optimisation in patients with heart failure. In this review, heart failure experts from two Swiss academic hospitals discuss the principles of general pharmacological therapy in heart failure with reduced ejection fraction and the different treatment options for chronic hyperkalaemia, focusing on patiromer, a recently available potassium binder. Patiromer has been accepted for reimbursement since 1 August 2020 in Switzerland, and has been shown in several clinical trials to safely reduce potassium levels over the long term, thereby allowing up-titration or maintenance of renin-angiotensin-aldosterone inhibitors in patients with chronic kidney disease, including those with heart failure. Whether this promising approach improves outcomes in patients with heart failure and reduced ejection fraction is currently under investigation.

Danielle Vuichard-Gysin, Rami Sommerstein, Romain Martischang, Stephan Harbarth, Stefan P. Kuster, Laurence Senn, Andreas Widmer (Author)

Candida auris – recommendations on infection prevention and control measures in Switzerland

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Candida auris, a globally emerging pathogen, has been repeatedly introduced into European healthcare settings, leading to large and long-lasting nosocomial outbreaks. The pathogen has already been isolated in Switzerland, requiring clinicians and microbiologists to become alert. This is the first comprehensive guidance document on prevention and control of C. auris in Swiss acute care hospitals. It brings to light the most recent evidence from published original articles and reviews. We emphasise the importance of quickly identifying this yeast by means of screening in order to prevent an outbreak that could be difficult to contain. Key containment strategies include reinforcing early detection, hand hygiene, application of strict contact precautions for colonised and infected patients, and thorough specific environmental cleaning and disinfection.

Serge Ferrari, Kurt Lippuner, Olivier Lamy, Christian Meier (Author)

2020 recommendations for osteoporosis treatment according to fracture risk from the Swiss Association against Osteoporosis (SVGO)

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Current guidelines from the Swiss Association against Osteoporosis (SVGO) dating from 2015 recommend therapy for men and women at increased fracture risk, specifically those with a vertebral or hip fracture; those with bone mineral density T-score <−2.5 at spine or hip; and those with a high 10-year probability of a major osteoporotic fracture as calculated by using FRAX. However no specific treatment recommendations have been made so far in our country to guide therapy according to the baseline level of risk. We now define four risk subgroup categories (imminent and very high, high, moderate, low) and propose an algorithm for osteoporosis therapy according to the level of fracture risk.

Pierre-André Michaud, Manuel Diezi, Linda Guihard, Martine Jacot-Guillarmod, Peter Kleist, Dominique Sprumont, Pascale Wenger (Author)

Including adolescents of childbearing potential in clinical trials with possible exposure to teratogenic medication: a challenge for paediatricians and researchers

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The issue of contraception and pregnancy tests among minor adolescent women participating in clinical trials, whether healthy or suffering from a disease, represents a challenging issue for paediatricians and researchers, given the potential harmful effect of various therapeutic procedures being tested. First, they need to gauge at what age or developmental stage they need to impose pregnancy tests and contraception. Second, if the adolescent denies any sexual activity, it may be ethically questionable to impose such procedures. Third, these professionals must deal with the issue of confidentiality, taking into account the fact that some adolescents engage in penetrative sexual intercourse without their parents or caregivers knowing. Fourth, in such cases, they must assess the extent to which a minor adolescent can be considered as competent (capable of making autonomous decisions) and deserves privacy and confidentiality. There is indeed a legal obligation for the provider to check that sexual experiences and intercourse take place within a safe relationship. Fifth, if the prescription of contraception is warranted, they have to decide who should assist the adolescent in choosing the method. Finally, with the occurrence of a positive pregnancy test, they may face the rare instance of a competent minor adolescent who refuses to inform her parents. This article has been developed by a group of experts under the auspices of swissethics, the Swiss Association of Research Ethics Committees and SwissPedNet, the umbrella organisation that coordinates the paediatric research in Switzerland. The paper reviews how to address practical and ethical questions regarding minor adolescents of childbearing potential enrolled in a clinical trial that may involve teratogenic medication and offers a series of concrete advice and tools for dealing with problematic situations.

Most paediatric protocols stipulate that adolescents included in clinical trials involving potentially teratogenic drugs should undergo pregnancy tests and use contraception. The circumstances in which such requirements are undertaken, however, has not been sufficiently addressed.

The recommendations presented in this article will assist researchers in assessing which circumstances apply when considering minor adolescents as individuals with childbearing potentials. It also offers concrete suggestions for tackling such situations.

Trieu H.N. Ngo, Aurélien Traverso, Swati Chopra, Hassen Hassani, Xavier Crevoisier (Author)

Long-term evaluation of the distal transverse plantar approach for Morton’s neuroma excision

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BACKGROUND

There is currently no consensus on the ideal approach for the operative treatment of Morton’s neuroma. The distal transverse plantar approach aims at optimal exposure without the scar complications associated with the longitudinal plantar approach. Long-term evaluation based on validated outcome instruments is lacking. The main purpose of this retrospective study was to evaluate the long-term clinical outcome of this approach using validated function and scar evaluation scores.

METHODS

Forty-nine patients operated on at our institution were examined clinically by two independent observers using the Foot and Ankle Ability Measure (FAAM) and the Vancouver Scar Scale (VSS). Patients who underwent neurectomy alone and those who had additional foot surgery were compared.

RESULTS

Assessment at a mean of 7.9 years (range 4–12) postoperatively revealed a mean FAAM score of 84.8 ± 25% and a mean VSS score of 1.57 ± 1.7. Patients who underwent neurectomy alone had higher FAAM scores at follow up. We observed no complication that required an additional procedure.

CONCLUSIONS

The transverse plantar approach results in good objective outcome scores, including scar healing, in the long term. This is our preferred technique because, in our experience, it offers optimal visualisation of the nerve, does not require deep dissection and allows the exposure of two adjacent web spaces of the foot through a single incision.

Boldizsar Kovacs, Sven Reek, Christian Sticherling, Beat Schaer, André Linka, Peter Ammann, Roman Brenner, Nazmi Krasniqi, Andreas S Müller, Omer Dzemali, Richard Kobza, Christian Grebmer, Laurent Haegeli, Jan Berg, Kurt Mayer, Jürg Schläpfer, Giulia Domenichini, Tobias Reichlin, Laurent Roten, Haran Burri, Urs Eriksson, Ardan M. Saguner, Jan Steffel, Firat Duru, Swiss Medical Weekly (Author)

Use of the wearable cardioverter-defibrillator – the Swiss experience

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INTRODUCTION

Sudden cardiac death caused by malignant arrhythmia can be prevented by the use of defibrillators. Although the wearable cardioverter defibrillator (WCD) can prevent such an event, its role in clinical practice is ill defined. We investigated the use of the WCD in Switzerland with emphasis on prescription rate, therapy adherence and treatment rate.

MATERIALS AND METHODS

The Swiss WCD Registry is a retrospective observational registry including patients using a WCD. Patients were included from the first WCD use in Switzerland until February 2018. Baseline characteristics and data on WCD usage were examined for the total study population, and separately for each hospital.

RESULTS

From 1 December 2011 to 18 February 2018, a total of 456 patients (67.1% of all WCDs prescribed in Switzerland and 81.1% of all prescribed in the participating hospitals) were included in the registry. Up to 2017 there was a yearly increase in the number of prescribed WCDs to a maximum of 271 prescriptions per year. The mean age of patients was 57 years (± 14), 81 (17.8%) were female and mean left ventricular ejection fraction (EF) was 32% (± 13). The most common indications for WCD use were new-onset ischaemic cardiomyopathy (ICM) with EF ≤35% (206 patients, 45.2%), new-onset nonischaemic cardiomyopathy (NICM) with EF ≤35% (115 patients, 25.2%), unknown arrhythmic risk (83 patients, 18.2%), bridging to implantable cardioverter-defibrillator implantation or heart transplant (37 patients, 8.1%) and congenital/inherited heart disease (15 patients, 3.3%). Median wear duration was 58 days (interquartile range [IQR] 31–94) with a median average daily wear time of 22.6 hours (IQR 20–23.2). Seventeen appropriate therapies from the WCD were delivered in the whole population (treatment rate: 3.7%) to a total of 12 patients (2.6% of all patients). The most common underlying heart disease in patients with a treatment was ICM (13/17, 76.5%). There were no inappropriate treatments.

CONCLUSION

The use of WCDs has increased in Switzerland over the years for a variety of indications. There is high therapy adherence to the WCD, and a treatment rate comparable to previously published registry data.

Stefan Ammann, Eckehart Schoell, Ricardo Nieves Ortega, Roland Bingisser (Author)

Ultrasound-guided regional anaesthesia and reduction of distal radius fractures in an emergency department

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OBJECTIVES

Distal radius fractures are among the most common fractures. Ultrasound is gaining importance in the treatment of and as a tool to diagnose distal radius fractures, guide regional anaesthesia and support reductions. Our aim was to demonstrate safety, feasibility and outcome in patients with a distal radius fractures undergoing ultrasound-guided regional anaesthesia (UGRA) with ultrasound-guided reduction (UGR), as compared with procedural sedation for the reduction.

METHODS

This retrospective cohort study was carried out in the emergency department of the University Hospital Basel (Switzerland) between February 2014 and October 2017. Adults with an isolated forearm fracture were eligible. The intervention group was treated with UGRA of the brachial plexus and subsequent ultrasound-assisted fracture reduction. Patients in the control group received usual care, which is blind fracture reduction with extension and immobilisation under procedural sedation.

RESULTS

71 patients were enrolled in the intervention group and 142 were to the control group. There was one (1.4%) complication (pneumothorax) in the UGR group. Twenty-five patients (35%) in the intervention group and 67 patients (47%) in the control group underwent surgery. The association between surgery and study group was not significant (p = 0.08). The patient’s age was negatively associated with surgery (p <0.001). The association between surgery and study group was significant in patients ≥60 years (p = 0.035).

CONCLUSION

The combination of ultrasound-guided regional anaesthesia and ultrasound-guided reduction of distal radius fractures is feasible. Safety was shown by 70 out of 71 cases of UGRA being without complication. Effectiveness regarding the necessity of subsequent operation was comparable to usual care; in patients over 60 it may be lower with UGR.

Erika Harju, Manya Jerina Hendriks, Katharina Roser, Gisela Michel (Author)

Healthcare professionals’ opinions on psychological screening in follow-up care for childhood cancer survivors

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INTRODUCTION

Implementation of screening for psychological distress in populations at risk, as recommended in existing guidelines, can be challenging on different levels: structural, organisational and personal (provider and patient). A specific group at risk for psychological distress, including anxiety and depression, is the growing population of childhood cancer survivors (CCS). In many countries, including Switzerland, the standardised assessment of psychological late effects during follow-up care is not yet established. The emotion thermometer, a short and validated assessment tool to screen for psychological distress, might facilitate implementation of psychological screening in Swiss CCS follow-up care.

AIMS OF THE STUDY

To inform implementation strategy and assess readiness of centres to integrate standardised psychological screening, we conducted a cross-sectional survey. We describe healthcare professionals’ opinions on (i) the current standard of psychological screening in follow-up care, (ii) their experience using the emotion thermometer, and (iii) perceived barriers and facilitators of possible implementation of psychological screening, including the emotion thermometer.

METHODS

We contacted 49 healthcare professionals involved in CCS follow-up care in all nine paediatric oncology clinics in Switzerland. The electronic survey included closed and open questions.

RESULTS

A majority of the healthcare professionals (17/24, 71%) stated that assessment of psychological distress is currently not standard in follow-up care. On the contrary, about half of them (11/24, 46%) think that psychological distress is adequately assessed in follow-up care. None of the participants had any previous experience with the emotion thermometer. After being informed about the emotion thermometer, nearly 80% (19/24) agree that it appears to be a good screening instrument and support the idea of regular application during follow-up care. Facilitators of implementation included the instrument’s brevity, its ability to visualise psychological topics and raising awareness of the need to think about the psychological side of follow-up care. Barriers included lack of time, the additional effort and the perception that instead an informal assessment would be sufficient. Concerns about using an artificial assessment, rather than a natural conversation, were also expressed.

CONCLUSIONS

There is overall agreement that screening for psychological late effects is not yet standard in follow-up care in Switzerland. It is important to mitigate perceived barriers and concerns of healthcare professionals to enable a successful implementation of psychological distress screening according to the established standards of care.