BACKGROUND AND AIMS
Elite athletes may use psychotropic substances for recreational reasons, (perceived) performance enhancement or self-medication. Causes can overlap. For athletes, substance use may be associated with various medical and social risks. Psychoactive substances include alcohol and nicotine, illicit and various prescription drugs, which all have a potential for abuse and dependence. This paper reviews the existing literature on the use of psychoactive substances and associated substance use disorders among elite athletes in terms of prevalence, patterns of use, as well as underlying causes and risk factors.
METHODSDue to the heterogeneous and partially fragmentary study data, a narrative approach with selection of applicable publications of a Medline search was chosen.
RESULTSThe most commonly used psychoactive substances among elite athletes were alcohol, nicotine, cannabis, stimulants and (prescription) opioids. Overall consumption rates are lower in professional sports than in the general population, but use of several substances (smokeless tobacco products, prescription opioids, stimulants) have high prevalence in specific sports and athlete groups. Substance use is subject to multiple risk factors and varies by substance class, sport discipline, country and gender, among other factors.
CONCLUSIONKnowledge on the underlying causes and patterns of substance use, as well as the prevalence of substance use disorders in professional sports, is still limited. High prevalence of various substances (i.e., nicotine, prescription opioids) may indicate potentially harmful patterns of use, requiring further research. Specific preventive and therapeutic concepts for the treatment of substance use disorders in elite athletes should be developed.
Colorectal cancer is the third most common cancer worldwide. Half of CRC patients develop liver metastases during the course of the disease, with a 5-year survival rate close to zero in the absence of therapy. Surgical resection remains the only possible curative option, and current guidelines recommend adjuvant chemotherapy, resulting in a 5-year survival rate exceeding 50%. Neoadjuvant systemic therapy is not indicated in cases with simple resection but should be offered to all patients with extensive bilobar disease. Personalised systemic treatment is essential to convert upfront non-resectable lesions to resectable ones. Anatomical resections, non-anatomical resections and two-stage hepatectomies can be performed though open or minimally invasive (laparoscopic or robotic) surgery.
The extent of a hepatic resection is limited by the risk of postoperative liver failure due to a too small liver remnant, inflow or outflow obstruction or insufficient biliary drainage. About 75% of patients are diagnosed with non-resectable liver metastases not amenable to a standard upfront resection. In recent years, effective therapeutic approaches have revolutionised liver surgery and new strategies have enabled the conversion of primarily non-resectable metastatic disease for resection. These strategies include oncological and surgical therapies, as well as combinations of the two. From an oncological perspective, colorectal liver metastases may be treated by systemic chemotherapy or immunotherapy, or selective intra-hepatic arterial infusion chemotherapy, depending on the extent of the disease and the mutational status. In surgery, we often apply two-stage strategies using portal vein occlusion, such as portal vein embolisation or ligation, or complex two-stage hepatectomy such as associating liver partition and portal vein ligation for staged hepatectomy. Other additive tools to reach curative resection are tumour ablations (electroporation, microwave or radiofrequency). The role of stereotactic radiation of liver metastases is not yet well defined. Modern radiation techniques, including image guidance, breath hold and gating, were only introduced for a larger patient population in recent years. Therefore, prospective studies with larger patient cohorts are still pending.
Over the last decade, liver transplantation has gained increasing attention in selective cases of non-resectable colorectal liver metastases, with promising cohort studies, but definitive recommendations must await the results of ongoing randomised controlled trials.
The optimal treatment of patients with colorectal liver metastases requires the timely association of various strategies, and all cases must be discussed at multidisciplinary team conferences. While colorectal liver metastases was a uniformly lethal condition a few decades ago, it has become amenable to curative therapies, with excellent quality of life in many scenarios. This review reports on up-to-date treatment modalities and their combinations in the treatment algorithm of colorectal liver metastases.
The Swiss societies of Infectious Diseases, Pediatric Cardiology and Cardiology and the Pediatric Infectious Disease Group of Switzerland present the current update on infective endocarditis prophylaxis in a joint initiative. The major focus of the revised recommendations is a comprehensive prevention campaign for all patients at risk for infective endocarditis. Antibiotic prophylaxis is recommended only for individuals at high risk. Within this high-risk group there is a ranking order, and the conditions are presented accordingly. Antibiotic prophylaxis is no longer recommended for patients with unrepaired ventricular septal defects and patent ductus arteriosus. Recommendations for antibiotic prophylaxis for the prevention of infective endocarditis are categorized in dental and non-dental interventions.
The rate of emergency operations for incarcerated and strangulated ventral hernias is about 10–15%, with worse outcomes than elective surgery. A recent laparoscopic technique called the enhanced-view totally extraperitoneal approach (eTEP) was shown to be indicated in elective repair of ventral and incisional hernias, and has a lower rate of postoperative morbidity than the Rives-Stoppa technique, while having the same indications. However, use of the eTEP laparoscopic technique in emergency ventral hernia repair has not yet been reported.
We report the case of a 57-year-old white male, with history of multiple abdominal interventions by laparotomy, admitted to the emergency department with progressive vomiting and periumbilical pain for 3 days. On clinical examination, we found a strangulated incisional para-umbilical hernia with local cellulitis and tenderness in the right flank. Abdominal computed tomography confirmed the diagnosis and showed some signs of thickening of the intestinal wall and multiple ventral hernias.
The patient was admitted and operated on the same day with use of the eTEP technique and without the need for intestinal resection. The patient was discharged on postoperative day 5. The main complication was the presence of a seroma diagnosed and drained by means of an extraperitoneal laparoscopy after 3 weeks. Total resolution of the seroma was confirmed at 1-year follow up. Incarcerated and strangulated ventral hernias are still classically treated by laparotomy. This case report shows for the first time that the eTEP procedure can be applied for abdominal wall surgery also in the emergency setting in selected patients. We hypothesise that this new procedure can be a promising approach leading fewer postoperative complications and shorter hospital stays.
BACKGROUND
Neurological disturbances after open inguinal hernia repair affect approximately one in ten patients. Sutureless, self-gripping meshes were developed with the aim of reducing postoperative neurological disturbances or neuralgia. This study assessed short- and long-term outcomes after open inguinal hernia repair using a self-gripping light-weight mesh in a peripheral teaching hospital.
METHODSPatients with uni- or bilateral inguinal hernia were included in this study. Open inguinal hernia repair was performed according to the Lichtenstein technique with a self-gripping, lightweight macroporous mesh. Postoperative follow-up was at 6 weeks after surgery and any long-term complications or recurrences were recorded up to 5 years postoperatively.
RESULTSThe median follow up time for all patients was 5–6 years and the median operation time was 40.0 minutes (inter quartile range 25.0–55.8). Of the 162 included patients, the mean numeric rating scale for pain (0 = no pain, 10 = excruciating pain) before hospital discharge was 2.7 (standard deviation [SD] 2.6) and 1.1 (SD 1.1) at 6 weeks postoperatively. The overall incidence of neurological disturbances at 6 weeks postoperatively was 11% when surgery was performed by the chief of surgery and 40% when it was performed by a senior consultant, 49% by chief-residents and 47% by supervised residents (p = 0.005). Patients with neurological disturbances were younger than asymptomatic patients (age 50, SD 15 vs 62, SD 17, p <0.001). The 1-, 3- and 5-year recurrence rates were 1%, 2% and 3%, respectively.
CONCLUSIONSThis study shows that open inguinal hernia repair using a self-gripping mesh is feasible, with a short operation time and low hernia recurrence rates in a peripheral teaching hospital. However, significant differences in neurological disturbances dependent on the surgeons experience were identified. Especially younger patients should be operated on by an experienced surgeon to reduce neurological disturbances and neuralgia.
AIMS
To identify the incidence of iatrogenic events leading to paediatric intensive care unit (PICU) admission and to analyse these patients regarding demographic, illness severity and outcome parameters.
MATERIAL AND METHODSThis was a retrospective case series. The computerised charts of all patients admitted to the multidisciplinary, tertiary, 18-bed PICU in 2014 were analysed. Iatrogenic events leading to PICU admission were identified and their preventability assessed. Underlying diseases, causes of iatrogenic events, illness severity at PICU admission, presence of complex chronic conditions, patient origin, length of stay on the PICU and outcome were analysed.
RESULTSThere were 138 admissions associated with iatrogenic events out of 1102 admissions (12.5%). Ninety iatrogenic events led to unplanned admissions and 48 cases concerned scheduled admissions, where the iatrogenic event would have led to PICU admission by itself or caused a second, planned PICU admission for re-operation. Iatrogenic complications during surgery (31% of all iatrogenic events), wrong management decisions / delayed diagnoses (20%) and nosocomial infections (14%) were the categories most often involved. Regarding origin of the patients, the greatest difference between iatrogenic event admissions and non-iatrogenic event admissions was found for the ward (21% vs 11%). The patients admitted for iatrogenic events had a higher mean expected mortality (8.4 vs 4.7%, p = 0.02) and a higher observed PICU mortality (5.8 vs 3.3%, p = 0.15). Of all iatrogenic events, 60.1% were judged to be preventable. The highest preventability rate was found in the categories “nosocomial infections” (100%) and “management decisions / delayed diagnoses” (92.9%).
CONCLUSIONIn our setting, the number of PICU admissions associated with iatrogenic events is significant and comparable to adult data on admission to ICU caused by iatrogenic events. The categories with most potential for improvement are nosocomial infections and the wrong management decisions / delayed diagnoses. Focused measures on these iatrogenic events may have a major impact on patient outcome, availability of PICU resources and healthcare costs.
AIMS OF THE STUDY
Non-adherence to immunosuppressive therapy in patients following solid organ transplantation is associated with an increased risk of transplant rejection and graft loss. A high pill burden can adversely affect patients’ implementation of their treatment regimens and may lead to omitting doses of medication. The aim of this study was to investigate medication implementation adherence in liver and kidney transplant recipients converted from twice-daily, immediate-release tacrolimus to once-daily, prolonged-release tacrolimus.
METHODSThis multicentre, non-interventional, observational, 12-month study evaluated implementation adherence in routine practice at five hospitals in Switzerland. Patients attended four clinical visits: at baseline (pre-conversion), and then at week 2, month 6 and month 12 post-conversion. Implementation was defined as consistently taking medication at the correct time and at the correct dose in order to achieve target tacrolimus trough levels. Implementation adherence was evaluated in three ways: using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) interview questionnaire (at baseline and month 12), investigator-rated patient adherence (recorded at all visits), and tacrolimus trough levels (assessed throughout the study; sub-therapeutic levels were predefined by the investigator on an individual patient basis, over-therapeutic levels were defined as tacrolimus trough levels >15 ng/ml). The primary composite endpoint was non-adherence according to the BAASIS at month 12, any post-conversion investigator adherence rating of “poor”, or sub-therapeutic or over-therapeutic tacrolimus trough levels at month 6 or 12. Secondary endpoints included: individual components of the composite non-adherence primary endpoint, tacrolimus pill burden, patient satisfaction, and adverse drug reactions.
RESULTSSeventy-five patients received prolonged-release tacrolimus; 68 patients (46 kidney and 22 liver transplant recipients) completed the study. Of these 68 patients, 24 had missing data for at least one component of the primary endpoint; therefore, data for the primary composite endpoint were evaluable for 44 patients. Most (81.8%; 36/44) patients were non-adherent for the composite endpoint. Sub-therapeutic tacrolimus trough levels outside of the predefined therapeutic range were the largest contributor to the composite endpoint, and were detected in 62.0% (31/50) of patients. Overall non-adherence according to the BAASIS was similar pre-conversion (30.7%) and at 12 months post-conversion (28.3%). Investigators rated adherence as “poor” for two patients. Prolonged-release tacrolimus decreased tacrolimus pill burden in 66.7% of patients. All patients were very satisfied / satisfied with prolonged-release tacrolimus; 75.0% found it easier to remember to take prolonged-release versus immediate-release tacrolimus. Twenty percent of patients reported adverse drug reactions, with infections being the most frequently reported (9.3%).
CONCLUSIONOverall, 1-year non-adherence rates were similar following conversion from immediate-release to prolonged-release tacrolimus; however, prolonged-release tacrolimus intake was more convenient. No new safety signals were detected.
BACKGROUND
SARS-CoV-2/COVID-19, which emerged in China in late 2019, rapidly spread across the world with several million victims in 213 countries. Switzerland was severely hit by the virus, with 43,000 confirmed cases as of 1 September 2020.
AIMIn cooperation with the Federal Office of Public Health, we set up a surveillance database in February 2020 to monitor hospitalised patients with COVID-19, in addition to their mandatory reporting system.
METHODSPatients hospitalised for more than 24 hours with a positive polymerase chain-reaction test, from 20 Swiss hospitals, are included. Data were collected in a customised case report form based on World Health Organisation recommendations and adapted to local needs. Nosocomial infections were defined as infections for which the onset of symptoms was more than 5 days after the patient’s admission date.
RESULTSAs of 1 September 2020, 3645 patients were included. Most patients were male (2168, 59.5%), and aged between 50 and 89 years (2778, 76.2%), with a median age of 68 (interquartile range 54–79). Community infections dominated with 3249 (89.0%) reports. Comorbidities were frequently reported, with hypertension (1481, 61.7%), cardiovascular diseases (948, 39.5%) and diabetes (660, 27.5%) being the most frequent in adults; respiratory diseases and asthma (4, 21.1%), haematological and oncological diseases (3, 15.8%) were the most frequent in children. Complications occurred in 2679 (73.4%) episodes, mostly respiratory diseases (2470, 93.2% in adults; 16, 55.2% in children), and renal (681, 25.7%) and cardiac (631, 23.8%) complications for adults. The second and third most frequent complications in children affected the digestive system and the liver (7, 24.1%). A targeted treatment was given in 1299 (35.6%) episodes, mostly with hydroxychloroquine (989, 76.1%). Intensive care units stays were reported in 578 (15.8%) episodes. A total of 527 (14.5%) deaths were registered, all among adults.
CONCLUSIONThe surveillance system has been successfully initiated and provides a robust set of data for Switzerland by including about 80% (compared with official statistics) of SARS-CoV-2/COVID-19 hospitalised patients, with similar age and comorbidity distributions. It adds detailed information on the epidemiology, risk factors and clinical course of these cases and, therefore, is a valuable addition to the existing mandatory reporting.
AIMS OF THE STUDY
Anticoagulation of patients with screen-detected atrial fibrillation may prevent ischaemic strokes. The STAR-FIB study programme aims to determine the age- and sex-specific prevalence of silent atrial fibrillation and to develop a clinical prediction model to identify patients at risk of undiagnosed atrial fibrillation in a hospitalised patient population.
METHODSThe STAR-FIB study programme includes a prospective cohort study and a case-control study of hospitalised patients aged 65–84 years, evenly distributed for both age and sex. We recruited 795 patients without atrial fibrillation for the cohort study (49.2% females; median age 74.8 years). All patients had three serial 7-day Holter ECGs to screen for silent atrial fibrillation. The primary endpoint will be any episode of atrial fibrillation or atrial flutter of ≥30 seconds duration. The age- and sex-specific prevalence of newly diagnosed atrial fibrillation will be estimated. For the case-control study, 120 patients with paroxysmal atrial fibrillation were recruited as cases (41.7% females; median age 74.6 years); controls will be randomly selected from the cohort study in a 2:1 ratio. All participants in the cohort study and all cases were prospectively evaluated including clinical, laboratory, echocardiographic and electrical parameters. A clinical prediction model for undiagnosed atrial fibrillation will be derived in the case-control study and externally validated in the cohort study.
CONCLUSIONSThe STAR-FIB study programme will estimate the age- and sex-specific prevalence of silent atrial fibrillation in a hospitalised patient population, and develop and validate a clinical prediction model to identify patients at risk of silent atrial fibrillation.
