Association of part-time clinical work with well-being and mental health in General Internal Medicine: A survey among Swiss hospitalists.

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.

Challenges in the transition from resident to attending physician in general internal medicine: a multicenter qualitative study.

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.

Droplet precautions on-site (DroPS) during the influenza season 2018/2019: a possible alternative to single room isolation for respiratory viral infections.

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.

Pulmonary Histoplasmosis Mimicking Metastatic Lung Cancer: A Case Report.

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.

Does multifaceted nutritional education improve malnutrition management?

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.

Vitamin D Deficiency and Unclear Abdominal Pain in Patients from Low- and Middle-Income Countries.

Background: Abdominal pain is one of the commonest symptoms in emergency departments (EDs). Diagnosis demands full attention and critical thinking, since many diseases manifest atypically and the consequences of overlooking the symptoms may be disastrous. Despite intensive diagnostic procedures, some cases remain elusive and unclear abdominal pain (UAP) is not infrequent. Emerging evidence supports the hypothesis that functional pain might be attributed to vitamin D deficiency (VDD). People with darker or covered skin are predisposed to developing VDD. Patients in Switzerland stemming from low- and middle-income countries (LMIC) are such a population. Aim: To identify cases with UAP in LMIC patients and to compare vitamin D status with a control group. Methods: A retrospective single-center case-control study was carried out from 1 January 2013 to 31 August 2016 in all adult patients (more than 16 years old) stemming from LMIC and presenting at the university ED of Bern with abdominal pain. Vitamin D status was retrieved from these cases when available. The control group consisted of patients without abdominal pain or metabolic diseases and was matched (1:1) to the cases for age, gender, body mass index, geographic distribution, and season of vitamin D estimation. Results: A total of 10,308 cases from LMIC were reported to the ED. In total, 223 cases were identified with UAP. The status of vitamin D was available for 27 patients; 27 matched individuals were subsequently retrieved for the control group. Women made up 56.7% of the UAP group and 43.3% of the control group. The most common origin of the LMIC subjects was southern Europe (20.4%), followed by southern Asia (16.7%) and Eastern Europe (13%). Fourteen UAP patients exhibited severe VDD (< 25 nmol/L) versus one in the control group (p = 0.001). The difference remained significant if the patients were identified as having VDD (<50 nmol/L) or not (p = 0.024). Comparison of the means indicated that the UAP group had lower vitamin D levels than the control group (41.3 vs. 53.7 nmol/L, respectively), but this difference was marginal (p = 0.060) and not statistically significant. After adjustment for potential confounders, including gender, mean vitamin D levels remained non-significantly different between groups. In the sub-group analysis, vitamin D levels were lower in women than in men (p = 0.037), compared to the respective controls. Conclusion: This study showed for the first time that patients from LMIC who presented to ED with UAP displayed VDD. Validation from larger studies is warranted to evaluate the linkage of VDD with UAP.

Influences on the implementation of Mini-CEX and DOPS for postgraduate medical trainees' learning: A grounded theory study.

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.

Hookworms in Emergency Department: The ＂Vampire＂ Within.

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.

Physicians' attitudes toward, use of, and perceived barriers to clinical guidelines: a survey among Swiss physicians.

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.

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.

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.

Simple training tool is insufficient for appropriate diagnosis and treatment of malnutrition: A pre-post intervention study in a tertiary center.

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.

["Not to be taken lightly"]. / Auf die leichte Schulter genommen.

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.

Emergency department admissions to a prison hospital: a retrospective cohort study from Switzerland.

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.

Bilateral posterior ischaemic optic neuropathy after severe diabetic ketoacidosis, cardiopulmonary resuscitation and respiratory failure.

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.

Glucocorticoid treatment, immobility, and constipation are associated with nutritional risk.

PURPOSE: The hypothesis of this clinical study was to determine whether glucocorticoid use and immobility were associated with in-hospital nutritional risk. METHODS: One hundred and one patients consecutively admitted to the medical wards were enrolled. Current medical conditions, symptoms, medical history, eating and drinking habits, diagnosis, laboratory findings, medications, and anthropometrics were recorded. The Nutrition Risk Score 2002 (NRS-2002) was used as a screening instrument to identify nutritional risk. RESULTS: The results confirmed that glucocorticoid use and immobility are independently associated with nutritional risk determined by the NRS-2002. Constipation could be determined as an additional cofactor independently associated with nutritional risk. CONCLUSIONS: Glucocorticoid treatment, immobility, and constipation are associated with nutritional risk in a mixed hospitalized population. The presence of long-time glucocorticoid use, immobility, or constipation should alert the clinician to check for nutritional status, which is an important factor in mortality and morbidity.

Risk factors promoting hypertensive crises: evidence from a longitudinal study.

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.

Extracorporeal shock wave lithotripsy for distal ureteral calculi: what a powerful machine can achieve.

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.