Six degrees of separation: the small world of medical education.

CONTEXT: Conventional wisdom has it that everyone on earth is on average only six steps away from knowing any other person through 'a friend of a friend'. On a local level, however, many people experience that most of their acquaintances know each other. It is thus hard to imagine how such a highly clustered group could be so well connected to the rest of the world. In this paper, we investigate how co-authorship connects scholars in medical education and whether the six degrees of separation hypothesis also applies to the network of authors in the field. METHODS: We constructed a mathematical graph from publication data obtained on the top three journals in the field and analysed it using social network analysis methods. We found Lorelei Lingard to be one centre of the network of co-authors and determined the numbers of authors who were one, two or more steps away from her. We further created a website that makes it possible to identify the shortest path from any author in the field to any other, including links to the connecting papers. RESULTS: The analysis covered 16 653 papers by a total of 24 258 different authors. Co-authorship connected authors into 68 663 unique pairs, of which 61 937 had co-authored only one article; 67.43% of all authors were linked to each other through a 'co-author of a co-author'. The average shortest path between any two authors in this network was 5.98 (min 1, max 17); the average distance to Lorelei Lingard was 4.17 (min 1, max 10). CONCLUSION: The field of medical education represents what social network analysts term 'a small world network'. Making the connections between its actors visible may provide a new perspective on social phenomena that occur in this world, including peer review, citation and conference invitations.

[Medical extended reality in digital emergency medicine : From education to clinical application]. / Medical Extended Reality in der digitalen Notfallmedizin : Von der Ausbildung zur klinischen Anwendung.

BACKGROUND: Emergency medicine faces the challenge of providing optimal care with limited resources. Especially in rare but critical situations (high-acuity low occurrence [HALO] situations), sound expertise is essential. Previous training approaches are time-limited and resource-intensive. AIM OF THE WORK: Medical extended reality (MXR) offers promising solutions. This article gives insight into the different areas of MXR and shows the application of MXR in emergency medicine using the HALO-MXR concept as an example. RESULTS AND DISCUSSION: MXR encompasses augmented reality (AR), virtual reality (VR) and mixed reality (MR). AR overlays digital information on the real world, enhancing perception and enabling interactive elements. VR creates an artificial three-dimensional (3D) environment in which the user is immersed. MR combines real and virtual elements. MXR offers advantages such as location-independent learning, virtual mentoring and scalability. However, it cannot replace existing training formats, but should be embedded in an overall concept. The HALO-MXR concept at Inselspital Bern includes e­learning, simulation-based training in VR and on-site, and HALO-Assist support through augmented reality. HALO-Assist provides around-the-clock AR support for HALO procedures via audio and video communication as well as overlayed annotations, objects and flowcharts. CONCLUSION: The integration of MXR into emergency medicine promises more efficient use of resources and enhanced training opportunities. The HALO-MXR concept demonstrates how MXR effectively combines simulation-based training in VR and AR assist to enhance the application of HALO procedures.

Is language an issue? Accuracy of the German computerized diagnostic decision support system ISABEL and cross-validation with the English counterpart.

OBJECTIVES: Existing computerized diagnostic decision support tools (CDDS) accurately return possible differential diagnoses (DDx) based on the clinical information provided. The German versions of the CDDS tools for clinicians (Isabel Pro) and patients (Isabel Symptom Checker) from ISABEL Healthcare have not been validated yet. METHODS: We entered clinical features of 50 patient vignettes taken from an emergency medical text book and 50 real cases with a confirmed diagnosis derived from the electronic health record (EHR) of a large academic Swiss emergency room into the German versions of Isabel Pro and Isabel Symptom Checker. We analysed the proportion of DDx lists that included the correct diagnosis. RESULTS: Isabel Pro and Symptom Checker provided the correct diagnosis in 82 and 71 % of the cases, respectively. Overall, the correct diagnosis was ranked in 71 , 61 and 37 % of the cases within the top 20, 10 and 3 of the provided DDx when using Isabel Pro. In general, accuracy was higher with vignettes than ED cases, i.e. listed the correct diagnosis more often (non-significant) and ranked the diagnosis significantly more often within the top 20, 10 and 3. On average, 38 ± 4.5 DDx were provided by Isabel Pro and Symptom Checker. CONCLUSIONS: The German versions of Isabel achieved a somewhat lower accuracy compared to previous studies of the English version. The accuracy decreases substantially when the position in the suggested DDx list is taken into account. Whether Isabel Pro is accurate enough to improve diagnostic quality in clinical ED routine needs further investigation.

Effects of a computerised diagnostic decision support tool on diagnostic quality in emergency departments: study protocol of the DDx-BRO multicentre cluster randomised cross-over trial.

INTRODUCTION: Computerised diagnostic decision support systems (CDDS) suggesting differential diagnoses to physicians aim to improve clinical reasoning and diagnostic quality. However, controlled clinical trials investigating their effectiveness and safety are absent and the consequences of its use in clinical practice are unknown. We aim to investigate the effect of CDDS use in the emergency department (ED) on diagnostic quality, workflow, resource consumption and patient outcomes. METHODS AND ANALYSIS: This is a multicentre, outcome assessor and patient-blinded, cluster-randomised, multiperiod crossover superiority trial. A validated differential diagnosis generator will be implemented in four EDs and randomly allocated to a sequence of six alternating intervention and control periods. During intervention periods, the treating ED physician will be asked to consult the CDDS at least once during diagnostic workup. During control periods, physicians will not have access to the CDDS and diagnostic workup will follow usual clinical care. Key inclusion criteria will be patients' presentation to the ED with either fever, abdominal pain, syncope or a non-specific complaint as chief complaint. The primary outcome is a binary diagnostic quality risk score composed of presence of an unscheduled medical care after discharge, change in diagnosis or death during time of follow-up or an unexpected upscale in care within 24 hours after hospital admission. Time of follow-up is 14 days. At least 1184 patients will be included. Secondary outcomes include length of hospital stay, diagnostics and data regarding CDDS usage, physicians' confidence calibration and diagnostic workflow. Statistical analysis will use general linear mixed modelling methods. ETHICS AND DISSEMINATION: Approved by the cantonal ethics committee of canton Berne (2022-D0002) and Swissmedic, the Swiss national regulatory authority on medical devices. Study results will be disseminated through peer-reviewed journals, open repositories and the network of investigators and the expert and patients advisory board. TRIAL REGISTRATION NUMBER: NCT05346523.

Automated identification of diagnostic labelling errors in medicine.

OBJECTIVES: Identification of diagnostic error is complex and mostly relies on expert ratings, a severely limited procedure. We developed a system that allows to automatically identify diagnostic labelling error from diagnoses coded according to the international classification of diseases (ICD), often available as routine health care data. METHODS: The system developed (index test) was validated against rater based classifications taken from three previous studies of diagnostic labeling error (reference standard). The system compares pairs of diagnoses through calculation of their distance within the ICD taxonomy. Calculation is based on four different algorithms. To assess the concordance between index test and reference standard, we calculated the area under the receiver operating characteristics curve (AUROC) and corresponding confidence intervals. Analysis were conducted overall and separately per algorithm and type of available dataset. RESULTS: Diagnoses of 1,127 cases were analyzed. Raters previously classified 24.58% of cases as diagnostic labelling errors (ranging from 12.3 to 87.2% in the three datasets). AUROC ranged between 0.821 and 0.837 overall, depending on the algorithm used to calculate the index test (95% CIs ranging from 0.8 to 0.86). Analyzed per type of dataset separately, the highest AUROC was 0.924 (95% CI 0.887-0.962). CONCLUSIONS: The trigger system to automatically identify diagnostic labeling error from routine health care data performs excellent, and is unaffected by the reference standards' limitations. It is however only applicable to cases with pairs of diagnoses, of which one must be more accurate or otherwise superior than the other, reflecting a prevalent definition of a diagnostic labeling error.

Barriers to seeking emergency care during the COVID-19 pandemic may lead to higher morbidity and mortality - a retrospective study from a Swiss university hospital.

AIMS OF THE STUDY: While COVID-19 significantly overburdens emergency rooms (ERs) and hospitals in affected areas, ERs elsewhere report a marked decrease in patient numbers. This study aimed to investigate the assumption that patients with urgent problems currently avoid the ER. METHODS: Electronic health records from the ER of a large Swiss university hospital were extracted for three periods: first, the awareness phase (ap) from the publication of the national government’s initiative “How to protect ourselves” on 1 March 2020 to the lockdown of the country on 16 March; second, the mitigation phase (mp) from 16–30 March; finally, patients presenting in March 2019 were used as a control group. We compared parameters including a critical illness as the discharge diagnosis (e.g., myocardial infarction, stroke, sepsis and ER death) using logistic and linear regression, as well as 15-day bootstrapped means and 95% confidence intervals for the control group. RESULTS: In the three periods, a total of 7143 patients were treated. We found a 24.9% (42.5%) significant decline in the number of patients presenting during the ap (mp). Patients presenting during the mp were more likely to be critically ill. There was an increase of 233% and 367% (ap and mp, respectively) of ER deaths (none related to COVID-19) compared with the control period. Apart from polytrauma (increase of 5% in the mp), all other critical illnesses as discharge diagnosis showed a lower incidence in descriptive analysis. Significantly more patients died in the ER in both the ap and mp. CONCLUSIONS: Barriers to seeking emergency care during COVID-19 pandemic may lead to higher morbidity and mortality. Healthcare authorities and hospitals must ensure low barriers to treatment and business as usual for all patients.

Predictors of High Resource Consumption in Alcohol Intoxicated Patients in the Emergency Department.

Background: previous studies have reported that the incidence of alcohol-related visits to emergency departments (ED) has increased, but little is known about how the necessary resources per visit have changed, or about the predictors and reasons for resource consumption. Methods: a retrospective analysis was performed of all consultations with a primary or secondary diagnosis of acute alcohol intoxication admitted to the ED of Bern University Hospital, Switzerland, between 1 June 2012, and 31 May 2017. Clinical characteristics and resource consumption were extracted and analysed over time. Results: in all, 196,045 ED consultations included 2586 acute alcohol intoxications, corresponding to 1.3% of the total. The incidences of acute alcohol intoxications have tended to increase over the last five years, and a growing number of visits have consumed high resources (consultations above the 75th percentile for total resource consumption). High resource consumption was associated with greater age and the male gender (p < 0.001). The main predictors of resource consumption were fractures (Odds ratio (OR): 3.9, 95% CI 2.8-5.3, p < 0.001), dislocations (OR 3.7, 95%: 1.5-9.1, p < 0.001), and traumatic brain injury (3.5, 2.5-5.1, p < 0.001). Consultations consuming high resources mostly required radiology resources (45%); consultations consuming low or normal resources mostly required physicians' work (45%) or nurses' work (27%). Conclusions: the number of alcohol intoxications consuming high resources has increased over the last five years. Acute alcohol intoxication associated with trauma is resource intensive, especially with regard to radiology resources. This underlines the need for further efforts to prevent alcohol-related traffic accidents, for examples.

Distraction osteogenesis enhances remodeling of remote bones of the skeleton: a pilot study.

Bone injuries have a systemic influence on the remodeling of bone. This effect has not been examined concerning its extent and duration. We measured the systemic effect of distraction osteogenesis on the remodeling of bones of the axial skeleton by means of the mineral apposition rate and bone formation rate in an animal experiment. Distraction osteogenesis was performed on the tibiae of 24 mature Yucatan minipigs. After a 4-day latency period, the tibiae were distracted 2 mm/day for 10 days. The ensuing consolidation phase lasted 10 days. Three fluorescent labeling substances were applied intravenously: calcein green at the second postoperative day, tetracycline 1 day after the end of the distraction phase, and xylene orange 2 days before sacrifice. We prepared ground sections from the ninth right ribs. The mineral apposition rate and bone formation rate were measured histomorphometrically on labeled osteons. The median mineral apposition rate during distraction was 2.39 microm/day (2.12-2.62 microm/day), which was higher than the rate during consolidation (median, 1.62 microm/day; 1.54-1.84 microm/day). The median bone formation rate confirmed this result and was 840.51 microm(2)/day (744.20-1148.26 microm(2)/day) during distraction and 384.25 microm(2)/day (330.84-467.71 microm(2)/day) during consolidation. Thus, a short period of distraction osteogenesis appears to have an anabolic effect on the mineral apposition rate of remote cortical bone.

Presentations Related to Acute Paracetamol Intoxication in an Urban Emergency Department in Switzerland.

AIM: To investigate the characteristics of Emergency Department (ED) presentations due to acute paracetamol intoxication. METHODS: Retrospective observational study of patients presenting to the ED of Bern University Hospital between May 1, 2012, and October 31, 2018, due to a paracetamol overdose (defined as intake of >4 g/24 h). Cases were identified using the full-text search of the electronic patient database and were grouped into intentional (suicidal/parasuicidal) and unintentional intoxications (e.g., patient unaware of maximal daily dose). RESULTS: During the study period, 181 cases were included and 143 (79%) of those were intentional. Compared to the patients in the unintentional group, patients in the intentional group were more often female (85% vs 45%, p < 0.001) and younger (median age 23.0 vs 43.5 years, p < 0.001), more frequently suffered from psychiatric comorbidities (93%, (including 49% with borderline personality disorder) vs 24%, p < 0.001), and paracetamol was more often taken as a single dose (80% vs 13%, p < 0.001). Although the median daily ingested dose was lower in the unintentional than in the intentional group (8.2 g vs 12.9 g, p < 0.001), patients in the unintentional group presented later (29% vs 84% within 24 h of ingestion, p < 0.001), included more cases of acute liver failure (nine (24%) vs six (4%), p < 0.001), and were more often hospitalised (24% vs 52% treated as outpatients, p=0.002). There were no significant differences between the groups regarding drug-induced liver injury (seven cases (5%) in the intentional and one (3%) in the unintentional group) or fatalities (one in each group). CONCLUSIONS: The majority of presentations due to paracetamol poisoning were intentional, most commonly in female patients with borderline personality disorder. Patients with unintentional paracetamol intoxication had worse outcomes with respect to acute liver failure and hospitalisation. Future preventive measures should raise awareness of paracetamol toxicity in the general population and encourage particular attention and frequent follow-ups when prescribing paracetamol for vulnerable groups.

Strengthening Emergency Care Systems to Mitigate Public Health Challenges Arising from Influxes of Individuals with Different Socio-Cultural Backgrounds to a Level One Emergency Center in South East Europe.

Emergency center visits are mostly unscheduled, undifferentiated, and unpredictable. A standardized triage process is an opportunity to obtain real-time data that paints a picture of the variation in acuity found in emergency centers. This is particularly pertinent as the influx of people seeking asylum or in transit mostly present with emergency care needs or first seek help at an emergency center. Triage not only reduces the risk of missing or losing a patient that may be deteriorating in the waiting room but also enables a time-critical response in the emergency care service provision. As part of a joint emergency care system strengthening and patient safety initiative, the Serbian Ministry of Health in collaboration with the Centre of Excellence in Emergency Medicine (CEEM) introduced a standardized triage process at the Clinical Centre of Serbia (CCS). This paper describes four crucial stages that were considered for the integration of a standardized triage process into acute care pathways.

Increased Urgent Care Center Visits by Southeast European Migrants: A Retrospective, Controlled Trial from Switzerland.

We investigated whether immigrants from Southeast Europe (SE) and Swiss patients have different reasons for visiting the emergency department (ED). Our retrospective data analysis for the years 2013⁻2017 describes the pattern of ED consultations for immigrants from SE living in Switzerland (Canton Bern), in comparison with Swiss nationals, with a focus on type of referral and reason for admission. A total of 153,320 Swiss citizens and 12,852 immigrants from SE were included in the study. The mean age was 51.30 (SD = 21.13) years for the Swiss patients and 39.70 (SD = 15.87) years for the SE patients. For some countries of origin (Albania, Bosnia and Herzegovina, and Turkey), there were highly statistically significant differences in sex distribution, with a predominance of males. SE immigrants had a greater proportion of patients in the lower triage level (level 3: SE: 67.3% vs. Swiss: 56.0%) and a greater proportion of patients in the high triage level than the Swiss population (level 1: SE: 3.4% vs. Swiss: 8.8%). SE patients of working age (16⁻65 years) were six times more often admitted by ambulance than older (≥65 years) SE patients, whereas this ratio was similar in the Swiss population. In both groups, the fast track service was primarily used for patients of working age (<65) and more than three times more often in the SE than the Swiss group (SE: 39.1%, Swiss: 12.6%). We identified some indications for access to primary care in emergency departments for immigrants and highlighted the need for attention to the role of organizational characteristics of primary health care in Switzerland. We highlighted the need for professional support to improve the quality of healthcare for immigrants. In the future, we will need more primary care services and general practitioners with a migrant background.

Development, implementation and first insights of a time- and location-independent longitudinal postgraduate curriculum in emergency medicine.

Introduction, background and context: There have been few reports on the implementation of a structured curriculum for emergency medicine, as emergency medicine is not yet an established medical specialty for training in many European countries, including Switzerland and Germany. Because of the non-plannable workload in the emergency setting, common training approaches are often difficult to implement. Need-assessments of emergency medicine trainees commonly identify a need for interactive, time-independent ways of learning that integrate modern forms of knowledge transfer. Methods: In the present study, we assess the local needs of emergency medicine specialists and trainees for a curriculum in emergency medicine and elaborate possible solutions for the implementation of this curriculum, taking into account the special needs in a highly dynamic, unplannable environment, such as an interdisciplinary emergency department. Results: We describe the development of the emergency medicine curriculum on the basis of the six steps proposed by Kern for curriculum development in medical education, as well as the implementation, lessons learned and interval evaluation. Conclusions: The combination of multiple teaching formats, ranging from time- and location-independent solutions such as podcasted lectures to simulation-based training sessions, as well as small-group workshops and skill training sessions, might be a valuable approach to implementing a state-of-the-art curriculum in a busy emergency department.

Severity and pattern of injuries caused by Swiss wrestling (Schwingen): first retrospective study at a level I University Emergency Department in Switzerland.

BACKGROUND: This article addresses typical injury patterns related to the traditional Swiss folk wrestling, 'Schwingen'. This is a fight between two competitors with its own rules, grips and throws. A variety of injuries have been occasionally reported. The aim of this study was to characterise all cases of Schwingen injuries treated in the University Hospital of Bern from January 2006 to July 2016. METHODS: To assess the frequency, type and outcome of Schwingen injuries, database search was performed of all inpatient and outpatient cases related to Schwingen that were admitted to Bern University Hospital from January 2006 to December 2016. RESULTS: A total of 32 such patients could be identified. Apart from a single woman, all patients were male. 31 of the 32 players were Swiss. One patient was admitted to the intermediate care unit, eight patients underwent surgery, two were hospitalised for further treatment and two were given a plaster. 17 other patients were given medications such as painkillers. One was dismissed without further treatment and another one left the hospital on his own. Typical injury patterns varied from simple lesions to distortions and fractures as well as head injuries and other neurological complications. CONCLUSION: The majority of injuries caused by Schwingen are not life threatening. Nevertheless, there is always the potential of head injuries and neurological deficits. Apart from the economic loss due to treatment costs and sick leave, these injuries can be disabling for life. It should therefore be obligatory for all players to evaluate preventive measures.

Systemic application of growth hormone for enhancement of secondary and intramembranous fracture healing.

Hormones are known to influence bone metabolism and cellular mechanisms of fracture healing. Recent technologies in molecular biology offer recombinant production of hormones, which makes them applicable for pharmacological use. To investigate the effect of systemic growth hormone (GH) application experiments were performed in micropig animal models. Systemic daily subcutaneous injection of species-specific recombinant GH was investigated in Yucatan micropigs to evaluate the effect on secondary fracture healing in a standardized gap model (1 cm) and on intramembranous bone formation in distraction osteogenesis (DO). Quantitative computed tomography (qCT), biomechanical testing, measurement of systemic insulin-like growth factor 1 (IGF-1) levels as well as histomorphometric analyses were performed to investigate differences in regenerate formation. Systemic GH administration significantly increased the torsional stability of the regenerate in comparison to the contralateral side in both experiments. qCT showed accelerated fracture bridging in the GH-treated animals in bone defect healing, while in DO histomorphometry elicited larger callus areas in the case of GH application. Systemic IGF-1 levels were significantly increased in both GH-treated groups. These experiments show that the systemic administration of recombinant GH accelerates fracture healing in standardized animal models. Clinical studies have now been initiated in order to prove the safety and the effectiveness of this therapeutical option.

Ultrasound can predict regenerate stiffness in distraction osteogenesis.

Assessing the regenerate strength in distraction osteogenesis is crucial for clinical treatment. Several methods have been used to achieve this, including plain radiography, digital radiography, quantitative computed tomography, dual energy xray absorptiometry, and ultrasound. The aim of the current study was to investigate the use of ultrasound in monitoring regenerate formation and to correlate this to biomechanical testing results. An osteotomy was done on the tibia of 30 Yucatan micropigs and an Ilizarov-type half-ring external fixator was mounted. After a 5-day latency period, the tibias were distracted for 10 days and then left to consolidate for 10 days. Seven ultrasound examinations were done during Day 15 through Day 25. After sacrifice, the bone mineral density was measured using quantitative computed tomography. Maximum load and torsional stiffness were measured and correlated with ultrasound measurements and bone mineral density. The ultrasound penetration depth and the bone mineral density correlated closely with torsional stiffness. Ultrasound can be a noninvasive predictor of bone regenerate strength in the early phase of distraction osteogenesis, which may reduce the need for radiographs.