Attitudes towards career choice and general practice: a cross-sectional survey of medical students and residents in Tyrol, Austria.

BACKGROUND: The global primary healthcare workforce is declining, leading to a shortage of general practitioners. Although various educational models aim to increase interest in general practice, effective interventions are limited. The reasons for this low appeal among medical graduates remain unclear. METHODS: This cross-sectional study surveyed medical students' and residents' attitudes towards general practice in Tyrol, Austria. The online questionnaire addressed professional values, general practice-related issues, personal professional intentions, and demographics. Data analysis employed chi-square tests and multivariate logistic regression to explore predictors of interest in general practice. RESULTS: The study included 528 students and 103 residents. Key values identified were stable positions, assured income, and work-family reconciliation. General practice was recognised for long-term patient relationships and patient contact, with students attributing more positive work-environmental characteristics and higher reputation to it than residents. Few participants (students: 3.2%, residents: 11.7%) had opted for general practice; about half were considering it as career option. Reasons not to choose general practice were preferences for other specialties, intrinsic characteristics of general practice, workload, insufficient time for the patients, financial pressures, low reputation, and perceived mediocre training quality. Predictors of interest in general practice included perception of independent decision-making, importance of work-family balance (students), better practical experiences in general practice during medical school (students and residents), younger age, and perceiving general practice as offering a promising future (residents). Both groups felt underprepared by medical school and/or general practice training for general practice roles. The attractiveness of specialist medicine over general practice was related to clearer content boundaries, better career opportunities, and higher incomes. CONCLUSIONS: According to these results, measures to improve attractiveness of general practice should focus on (i) high-quality undergraduate education including practical experiences, and (ii) on ensuring professional autonomy, work-family reconciliation, and job stability. Efforts to encourage more graduates to pursue this essential healthcare sector are crucial for strengthening primary healthcare and public health services. TRIAL REGISTRATION: The study has not been registered as it did not include a direct medical intervention on human participants.

Trust in Conventional Healthcare and Utilization of Complementary and Alternative Medicine in South Tyrol, Italy: A Population-Based Cross-Sectional Survey.

Background: This study explored the link between trust in conventional healthcare and consultations with complementary and alternative medicine (CAM) providers in South Tyrol, Italy's linguistically diverse region. Methods: A representative cross-sectional survey of 1,388 South Tyrolean adults assessed trust in conventional healthcare, general practitioners, and complementary and alternative medicine consultation frequencies and their determinants using chi-square tests and Kendall-Tau-b correlations. Results: Seventy percent trusted the traditional healthcare system, with general practitioners as the primary trusted professionals. Trust is correlated with higher education and linguistic compatibility. A 5% subgroup, mostly women and multilinguals with lower education levels, showed uncertain trust. Over 80% had seen a general practitioner in the last year, while distrust was correlated with complementary and alternative medicine consultations. German and Ladin speakers, with higher education levels, were notably inclined towards complementary and alternative medicine consultations. Conclusions: Trust in South Tyrolean healthcare varied according to education level and language. While general practitioners remain central, there is a marked shift towards complementary and alternative medicine among specific groups.

Vaccine hesitancy in South Tyrol: a narrative review of insights and strategies for public health improvement.

Introduction: This review examines vaccine hesitancy in South Tyrol, Italy, a region characterized by cultural and linguistic diversity. The critical need for vaccination to control infectious diseases contrasts with the region's low vaccination rates, which pose a significant public health challenge. Methods: Based on literature, reports, and studies, we used PubMed, Embase, and Google Scholar to explore vaccine hesitancy in South Tyrol. It emphasizes the analysis of historical, cultural, and socioeconomic factors, and focuses on quantitative surveys and qualitative interviews to understand the roots of vaccine hesitancy. Results: In two studies with four reports, mistrust in health policies and institutions, misinformation, and cultural and linguistic barriers were identified as key factors contributing to vaccine hesitancy in South Tyrol. These factors are accentuated by the region's unique sociopolitical landscape, which influences public health policies and vaccination initiatives. Conclusions: These findings highlight the need for public health strategies specifically tailored to South Tyrol. Recommended actions include developing culturally sensitive and multilingual communication campaigns, increasing community involvement, and rebuilding trust in healthcare systems. These approaches are essential for addressing the specific challenges in South Tyrol, thereby improving vaccine uptake and overall public health outcomes.

Fluids in the ICU: which is the right one?

The administration of fluids is one of the most common interventions in the intensive care unit. The effects and side effects of intravenous fluids depend on the amount administered and their specific composition. Intravenous fluid solutions are either considered crystalloids (for example 0.9% saline, lactated Ringer's solution) or colloids (artificial colloids such as gelatins, and albumin). This narrative review summarizes the physiological principles of fluid therapy and reviews the most important studies on crystalloids, artificial colloids and albumin in the context of critically ill patients.

Distinct smell and taste disorder phenotype of post-acute COVID-19 sequelae.

PURPOSE: Olfactory dysfunction (OD) commonly accompanies coronavirus disease 2019 (COVID-19). We investigated the kinetics of OD resolution following SARS-CoV-2 infection (wild-type and alpha variant) and its impact on quality of life, physical and mental health. METHODS: OD prevalence was assessed in an ambulatory COVID-19 survey (n = 906, ≥ 90 days follow-up) and an observational cohort of ambulatory and hospitalized individuals (n = 108, 360 days follow-up). Co-occurrence of OD with other symptoms and effects on quality of life, physical and mental health were analyzed by multi-dimensional scaling, association rule mining and semi-supervised clustering. RESULTS: Both in the ambulatory COVID-19 survey study (72%) and the observational ambulatory and hospitalized cohort (41%) self-reported OD was frequent during acute COVID-19. Recovery from self-reported OD was slow (survey: median 28 days, observational cohort: 90 days). By clustering of the survey data, we identified a predominantly young, female, comorbidity-free group of convalescents with persistent OD and taste disorders (median recovery: 90 days) but low frequency of post-acute fatigue, respiratory or neurocognitive symptoms. This smell and taste disorder cluster was characterized by a high rating of physical performance, mental health, and quality of life as compared with convalescents affected by prolonged fatigue or neurocognitive complaints. CONCLUSION: Our results underline the heterogeneity of post-acute COVID-19 sequelae calling for tailored management strategies. The persistent smell and taste disorder phenotype is characterized by good clinical, physical, and mental recovery and may pose a minor challenge for public health. STUDY REGISTRATION: ClinicalTrials.gov: NCT04661462 (survey study), NCT04416100 (observational cohort).

Controversies Surrounding Albumin Use in Sepsis: Lessons from Cirrhosis.

This narrative review critically examines the role of albumin in sepsis management and compares it to its well-established application in liver cirrhosis. Albumin, a key plasma protein, is effective in the management of fluid imbalance, circulatory dysfunction, and inflammation-related complications. However, its role in sepsis is more intricate and characterized by ongoing debate and varied results from clinical studies. In sepsis, the potential benefits of albumin include maintaining vascular integrity and modulating inflammation, yet its consistent clinical efficacy is not as definitive as that in cirrhosis. This review evaluated various clinical trials and evidence, highlighting their limitations and providing practical insights for clinicians. It emphasizes identifying sepsis patient subgroups that are most likely to benefit from albumin therapy, particularly exploring the correction of hypoalbuminemia. This condition, which is significantly corrected in patients with cirrhosis, may have similar therapeutic advantages in sepsis. The potential effectiveness of albumin in the low-volume resuscitation and deresuscitation phases of sepsis management was noted. Given the safety concerns observed in cirrhosis, such as pulmonary edema and hypervolemia associated with albumin therapy, cautious integration of albumin into sepsis treatment is mandatory. Personalized albumin therapy is advocated for tailoring strategies to the specific needs of each patient, based on their clinical presentation and underlying conditions. The need for further research to delineate the role of albumin in sepsis pathophysiology is underscored. The review emphasizes the importance of conducting trials to assess the effectiveness of albumin in correcting hypoalbuminemia in sepsis, its impact on patient outcomes, and the establishment of appropriate dosing and administration methods. This approach to albumin use in sepsis management is posited as a way to potentially improve patient outcomes in this complex clinical scenario while being mindful of the lessons learned from its use in cirrhosis.

Phenotyping of Acute and Persistent Coronavirus Disease 2019 Features in the Outpatient Setting: Exploratory Analysis of an International Cross-sectional Online Survey.

BACKGROUND: Long COVID, defined as the presence of coronavirus disease 2019 (COVID-19) symptoms ≥28 days after clinical onset, is an emerging challenge to healthcare systems. The objective of the current study was to explore recovery phenotypes in nonhospitalized individuals with COVID-19. METHODS: A dual cohort, online survey study was conducted between September 2020 and July 2021 in the neighboring European regions Tyrol (TY; Austria, n = 1157) and South Tyrol (STY; Italy, n = 893). Data were collected on demographics, comorbid conditions, COVID-19 symptoms, and recovery in adult outpatients. Phenotypes of acute COVID-19, postacute sequelae, and risk of protracted recovery were explored using semi-supervised clustering and multiparameter least absolute shrinkage and selection operator (LASSO) modeling. RESULTS: Participants in the study cohorts were predominantly working age (median age [interquartile range], 43 [31-53] years] for TY and 45 [35-55] years] for STY) and female (65.1% in TY and 68.3% in STY). Nearly half (47.6% in TY and 49.3% in STY) reported symptom persistence beyond 28 days. Two acute COVID-19 phenotypes were discerned: the nonspecific infection phenotype and the multiorgan phenotype (MOP). Acute MOP symptoms encompassing multiple neurological, cardiopulmonary, gastrointestinal, and dermatological symptoms were linked to elevated risk of protracted recovery. The major subset of individuals with long COVID (49.3% in TY; 55.6% in STY) displayed no persistent hyposmia or hypogeusia but high counts of postacute MOP symptoms and poor self-reported physical recovery. CONCLUSIONS: The results of our 2-cohort analysis delineated phenotypic diversity of acute and postacute COVID-19 manifestations in home-isolated patients, which must be considered in predicting protracted convalescence and allocating medical resources.

Challenges and experiences of general practitioners during the course of the Covid-19 pandemic: a northern Italian observational study-cross-sectional analysis and comparison of a two-time survey in primary care.

BACKGROUND: General practitioners (GPs) have been among the frontline workers since the outbreak of the Covid-19 pandemic. Reflecting and analyzing the ongoing pandemic response of general practice provides essential information and serves as a precondition for outlining future health policy strategies. OBJECTIVE: To investigate the effects of the pandemic on GPs' daily work and well-being and to describe needs for improvement in primary care highlighted by the pandemic. METHODS: A 2-time cross-sectional online survey involving GPs in a northern Italian region was conducted in September 2020 and March/April 2021. RESULTS: Eighty-four GPs (29.6% of invited GPs) participated in the first survey, and 41 GPs (14.4%) in the second survey. Most GPs experienced a notable workload increase which was tendentially higher during the advanced stages of the pandemic. A notable increase between the first and the second survey was noted regarding the frequency of Covid-related patient contacts and phone calls. Communication with health authorities and hospitals was rated as improvable. Psychological distress among GPs tended to increase over time; female GPs were more affected in the first survey. Most practices introduced major changes in their workflow, mainly appointment-based visits and separating Covid-19-suspected patients. Availability of protective equipment considerably increased over time. In the second survey, the GPs felt more prepared to self-protection and outpatient treatment of Covid-affected patients. CONCLUSION: The work of GPs has been substantially impacted by the ongoing Covid-19 pandemic. Efforts should be undertaken to efficiently strengthen primary care which plays an important role in pandemic events.

The Covid-19 pandemic has considerably impacted the way of daily working of general practitioners (GPs). Several studies have been conducted which reflected the immediate response of general practice to the pandemic at its early stages, but studies assessing the ongoing situation are missing. This study responded to this need and aimed to illustrate the challenges, difficulties, and the personal well-being of GPs during the first pandemic wave and during the second/third pandemic wave. The study consisted of a 2-time online survey of GPs in a northern Italian province. The 84 GPs participating in the first survey and 41 GPs participating in the second survey indicated a notable workload increase due to the pandemic. The availability of protective equipment and of clinical guidance about how to treat Covid-19-affected patients in their homes was poor at the beginning but increased considerably over time. Psychological distress was slightly increasing. Most GPs modified their workflow and practice organization. Adequate support for general practice is required in pandemic events to enable GPs to provide safe and high-quality care; needs for improvement especially concern the provision of resources and the communication with public health institutions and hospitals.

Human albumin and 6% hydroxyethyl starches (130/0.4) in cardiac surgery: a meta-analysis revisited.

BACKGROUND: A meta-analysis of randomized controlled trials was recently published in BMC Surgery that compared the use of human albumin with 6% hydroxyethyl starches 130/0.4 for cardiopulmonary bypass prime and perioperative fluid management in pediatric and adult cardiac surgery patients. The two plasma expanding solutions are described as equivalent for efficacy and safety outcomes, and, on that basis, the preferential use of hydroxyethyl starches 130/0.4 was recommended for economic reasons because of the higher unit costs of human albumin solutions. RESULTS: In addition to the fact that trials were mostly small, single-center studies and the number of total participants was low, making the meta-analysis underpowered for several outcomes, selective reporting of data for ICU length of stay was identified. Re-calculation of statistics at higher precision showed that ICU length of stay of patients in the human albumin group was significantly shorter than that of patients in the 6% hydroxyethyl starches 130/0.4 group (standard mean difference - 0.181, 95% confidence interval - 0.361 to - 0.001, P = 0.049), which may offset any proposed economic advantage of using 6% hydroxyethyl starches 130/0.4. At the same time, the renal safety of 6% hydroxyethyl starches 130/0.4 in surgical patients is under regulatory review. CONCLUSIONS: Underpowered trials and selective reporting may impair the validity of the meta-analysis. A more cautious conclusion about the interchangeability between human albumin and 6% hydroxyethyl starches 130/0.4 in cardiac surgery should have been reached.

Moderator Effect of Hypoalbuminemia in Volume Resuscitation and Plasma Expansion with Intravenous Albumin Solution.

Intravenous administration of crystalloid or colloid solutions is the most common intervention for correcting hypovolemia in intensive care unit patients. In critical illness, especially sepsis and severe trauma, vascular wall permeability increases, and trans-endothelial escape of serum albumin, the major oncotic plasma constituent, contributes to the development of hypoalbuminemia and edema formation. The volume effects of intravenous human albumin solution exceed those of crystalloid solutions. If hypoalbuminemia is an effect moderator, the crystalloid-to-albumin ratio of fluid resuscitation volumes is not well characterized. Randomized controlled trials have confirmed that intravenous administration of human albumin solutions for volume resuscitation results in a lower net fluid balance compared with crystalloids, and smaller infusion volumes may be sufficient for hemodynamic stabilization when human albumin solutions are used. This narrative review summarizes the current evidence and conclusions drawn regarding the role of hypoalbuminemia in volume resuscitation. In the 'Saline versus Albumin Fluid Evaluation' study using 4% human albumin solution or saline, the saline-to-albumin ratio of study fluids was significantly higher in patients with baseline serum albumin concentrations of 25 g/L or less as compared to patients with baseline serum albumin concentrations of more than 25 g/L. In patients receiving renal replacement therapy, intravenous administration of 20-25% human albumin solution reduces intradialytic hypotension and improves fluid removal better than saline if serum albumin levels are similarly reduced. These data suggest that hypoalbuminemia acts as an effect moderator in volume resuscitation and plasma expansion with albumin solution. The volume effectiveness of intravenous human albumin solution in resuscitation appears to be greater when the serum albumin levels are low. In clinical situations, serum albumin concentrations per se may inform when and how to include intravenous albumin in fluid resuscitation if large amounts of crystalloids are needed, which requires further studies.

Antithrombin as Therapeutic Intervention against Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation: Lessons Learned from COVID-19-Associated Coagulopathy.

Recent research has contributed significantly to our understanding of the pathogenesis of acute disseminated intravascular coagulation. COVID-19 can be considered as a new underlying condition of disseminated intravascular coagulation. In this narrative review, current evidence is presented regarding biomarker differences between sepsis-induced and COVID-19-associated coagulopathies, supporting the importance of acquired antithrombin deficiency in the early differential diagnosis of septic coagulopathy and its potential impact on treatment with endogenous anticoagulants. Establishing new scoring systems for septic coagulopathy in combination with endogenous anticoagulant biomarker activities may allow for the identification of those in the heterogeneous population of sepsis patients who are more likely to benefit from targeted specific treatment interventions.

Expert-based medication reviews to reduce polypharmacy in older patients in primary care: a northern-Italian cluster-randomised controlled trial.

BACKGROUND: Evidence regarding clinically relevant effects of interventions aiming at reducing polypharmacy is weak, especially for the primary care setting. This study was initiated with the objective to achieve clinical benefits for older patients (aged 75+) by means of evidence-based reduction of polypharmacy (defined as ≥8 prescribed drugs) and inappropriate prescribing in general practice. METHODS: The cluster-randomised controlled trial involved general practitioners and patients in a northern-Italian region. The intervention consisted of a review of patient's medication regimens by three experts who gave specific recommendations for drug discontinuation. Main outcome measures were non-elective hospital admissions or death within 24 months (composite primary endpoint). Secondary outcomes were drug numbers, hospital admissions, mortality, falls, fractures, quality of life, affective status, cognitive function. RESULTS: Twenty-two GPs/307 patients participated in the intervention group, 21 GPs/272 patients in the control group. One hundred twenty-five patients (40.7%) experienced the primary outcome in the intervention group, 87 patients (32.0%) in the control group. The adjusted rates of occurrence of the primary outcome did not differ significantly between the study groups (intention-to-treat analysis: adjusted odds ratio 1.46, 95%CI 0.99-2.18, p = 0.06; per-protocol analysis: adjusted OR 1.33, 95%CI 0.87-2.04, p = 0.2). Hospitalisations as single endpoint occurred more frequently in the intervention group according to the unadjusted analysis (OR 1.61, 95%CI 1.03-2.51, p = 0.04) but not in the adjusted analysis (OR 1.39, 95%CI 0.95-2.03, p = 0.09). Falls occurred less frequently in the intervention group (adjusted OR 0.55, 95%CI 0.31-0.98; p = 0.04). No significant differences were found regarding the other outcomes. Definitive discontinuation was obtained for 67 (16.0%) of 419 drugs rated as inappropriate. About 6% of the prescribed drugs were PIMs. CONCLUSIONS: No conclusive effects were found regarding mortality and non-elective hospitalisations as composite respectively single endpoints. Falls were significantly reduced in the intervention group, although definitive discontinuation was achieved for only one out of six inappropriate drugs. These results indicate that (1) even a modest reduction of inappropriate medications may entail positive clinical effects, and that (2) focusing on evidence-based new drug prescriptions and prevention of polypharmacy may be more effective than deprescribing. TRIAL REGISTRATION: Current Controlled Trials (ID ISRCTN: 38449870), date: 11/09/2013.

Hypoalbuminemia as Surrogate and Culprit of Infections.

Hypoalbuminemia is associated with the acquisition and severity of infectious diseases, and intact innate and adaptive immune responses depend on albumin. Albumin oxidation and breakdown affect interactions with bioactive lipid mediators that play important roles in antimicrobial defense and repair. There is bio-mechanistic plausibility for a causal link between hypoalbuminemia and increased risks of primary and secondary infections. Serum albumin levels have prognostic value for complications in viral, bacterial and fungal infections, and for infectious complications of non-infective chronic conditions. Hypoalbuminemia predicts the development of healthcare-associated infections, particularly with Clostridium difficile. In coronavirus disease 2019, hypoalbuminemia correlates with viral load and degree of acute lung injury and organ dysfunction. Non-oncotic properties of albumin affect the pharmacokinetics and pharmacodynamics of antimicrobials. Low serum albumin is associated with inadequate antimicrobial treatment. Infusion of human albumin solution (HAS) supplements endogenous albumin in patients with cirrhosis of the liver and effectively supported antimicrobial therapy in randomized controlled trials (RCTs). Evidence of the beneficial effects of HAS on infections in hypoalbuminemic patients without cirrhosis is largely observational. Prospective RCTs are underway and, if hypotheses are confirmed, could lead to changes in clinical practice for the management of hypoalbuminemic patients with infections or at risk of infectious complications.

Beautiful small: Misleading large randomized controlled trials? The example of colloids for volume resuscitation.

In anesthesia and intensive care, treatment benefits that were claimed on the basis of small or modest-sized trials have repeatedly failed to be confirmed in large randomized controlled trials. A well-designed small trial in a homogeneous patient population with high event rates could yield conclusive results; however, patient populations in anesthesia and intensive care are typically heterogeneous because of comorbidities. The size of the anticipated effects of therapeutic interventions is generally low in relation to relevant endpoints. For regulatory purposes, trials are required to demonstrate efficacy in clinically important endpoints, and therefore must be large because clinically important study endpoints such as death, sepsis, or pneumonia are dichotomous and infrequently occur. The rarer endpoint events occur in the study population; that is, the lower the signal-to-noise ratio, the larger the trials must be to prevent random events from being overemphasized. In addition to trial design, sample size determination on the basis of event rates, clinically meaningful risk ratio reductions and actual patient numbers studied are among the most important characteristics when interpreting study results. Trial size is a critical determinant of generalizability of study results to larger or general patient populations. Typical characteristics of small single-center studies responsible for their known fragility include low variability of outcome measures for surrogate parameters and selective publication and reporting. For anesthesiology and intensive care medicine, findings in volume resuscitation research on intravenous infusion of colloids exemplify this, since both the safety of albumin infusion and the adverse effects of the artificial colloid hydroxyethyl starch have been confirmed only in large-sized trials.