[Integrative medicine: what's new in 2023]. / Médecine intégrative : ce qui a changé en 2023.

To illustrate the news of 2023 in integrative medicine, the authors summarized four particularly relevant studies. The first highlights one of the foundational principles of integrative medicine, describing the importance of respecting patient preference in the choice of a therapeutic approach, promoting their «empowerment¼. The second article proposes methodological recommendations to improve the scientific value of studies assessing the efficacy and mechanisms of non-pharmacological approaches. Finally, the last two articles are randomized studies designed to either demonstrate the feasibility and effect of hypnosis in geriatrics, or evaluate the efficacy of a several combined complementary approaches for cancer-related fatigue.

Dans cette nouvelle édition consacrée aux nouveautés en médecine intégrative, les auteurs ont choisi de résumer quatre études particulièrement pertinentes parmi les articles publiés en 2023. La première souligne l'un des principes fondateurs de la médecine intégrative en décrivant l'importance du respect de la préférence du patient dans le choix d'une approche thérapeutique, favorisant leur « empowerment ¼. La deuxième propose des recommandations méthodologiques afin d'améliorer la valeur scientifique des études de l'efficacité et des mécanismes d'approches non pharmacologiques. Enfin, les deux dernières sont des études randomisées visant à démontrer, d'une part, la faisablité et l'effet de l'hypnose en gériatrie et, d'autre part, l'efficacité d'une combinaison d'approches complémentaires pour lutter contre la fatigue liée au cancer.

Occurrence of sensitive topics during ward round: an ancillary analysis of the BEDSIDE-OUTSIDE trial.

OBJECTIVE: Discussing sensitive topics (eg, medical uncertainty, social issues, non-adherence) during ward rounds is challenging and may negatively impact patient satisfaction with the healthcare they are receiving. In the previous multicentre randomised BEDSIDE-OUTSIDE trial focusing on communication during ward rounds, we investigated the interplay between sensitive topics and low reported satisfaction with care. DESIGN: Pre-planned secondary analysis of a randomised controlled trial. For this analysis data of the original trial was pooled across intervention groups. SETTING: Three Swiss teaching hospitals. PARTICIPANTS: Adult patients hospitalised for medical care. INTERVENTIONS: We analysed predefined sensitive health topics and specific elements of communication from audiotapes recorded during ward rounds, for both patients dealing with and without sensitive topics. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary endpoint was overall patient satisfaction with care; measured on a Visual Analogue Scale from 0 to 100. Secondary endpoints included duration of ward rounds and further satisfaction outcomes. RESULTS: Of the 919 included patients, 474 had at least one sensitive topic including medical uncertainty (n=251), psychiatric comorbidities (n=161), tumour diagnosis (n=137) and social issues (n=125). Compared with patients without sensitive topics, patients with sensitive topics reported lower satisfaction with care (mean (SD), 87.7 (±14.6) vs 90.2 (±12.1), adjusted difference -2.5 (95% CI -4.28 to -0.72), p=0.006. Among patients with sensitive topics, risk factors for low satisfaction included several parameters concerning patient-physician interaction such as disagreements during ward rounds (mean (SD), 14/212 (6.6%) vs 41/254 (16.1%), adjusted OR 2.78 (95% CI 1.47 to 5.27), p=0.002). CONCLUSIONS: A large proportion of medical inpatients must deal with sensitive health topics. This is associated with lower satisfaction with care, particularly if the patient perceives the interaction with doctors during ward rounds as unsatisfactory. Educating physicians on specific communication techniques may help improve care for these patients. TRIAL REGISTRATION NUMBER: NCT03210987.

The Disclosure of Bad News Over the Phone vs. in Person and its Association with Psychological Distress: a Systematic Review and Meta-Analysis.

BACKGROUND: Communicating bad news such as a new cancer diagnosis to patients may have a major impact on their well-being. We investigated differences in patients' psychological distress due to the disclosure of bad news by telephone compared to in person in a systematic review and meta-analysis. METHODS: We included all studies that investigated anxiety, depressive or post-traumatic stress disorder (PTSD) symptoms in adult patients in whom bad news by telephone compared to in person were disclosed. We systematically searched PubMed, Embase, PsycINFO and CINAHL from the inception of each database to October 18, 2022. We included randomized and non-randomized trials. RESULTS: We screened 5944 studies and included 11 studies in the qualitative analysis and 9 in the meta-analyses, including four randomized controlled trials. Overall, the quality of studies was moderate to good. There was no difference regarding psychological distress when bad news was disclosed by telephone compared to in person with similar symptom levels of anxiety (3 studies, 285 participants; standardized mean difference [SMD] 0.10 [95% CI -0.15 to 0.35]), depression (3 studies, 284 participants; SMD 0.10 [95% CI -0.30 to 0.49]), and PTSD (2 studies, 171 participants; SMD -0.01 [95% CI -0.48 to 0.36]). Results were similar for satisfaction with care. DISCUSSION: This meta-analysis found no difference regarding psychological distress regardless if bad news were disclosed by telephone or in person, but there were overall only few and heterogeneous studies with a small number of eligible patients. The findings suggest that the modality of disclosure might play a secondary role and the way in which the bad news are communicated might be more important.

Smartphone-Based Psychotherapeutic Interventions in Blended Care of Cancer Survivors: Nested Randomized Clinical Trial.

BACKGROUND: Cancer is related to not only physical but also mental suffering. Notably, body image disturbances are highly relevant to cancer-related changes often persisting beyond recovery from cancer. Scalable and low-barrier interventions that can be blended with face-to-face psychotherapy for cancer survivors are highly warranted. OBJECTIVE: The aim of the study is to investigate whether smartphone-based bodily interventions are more effective to improve the mood of patients with cancer than smartphone-based fairy tale interventions (control intervention). METHODS: We recruited patients with cancer in 2 Swiss hospitals and conducted daily, fully automated smartphone-based interventions 6 times a week for 5 consecutive weeks, blended with weekly face-to-face group body psychotherapy. We applied 2 types of smartphone-based interventions using a within-subject design, randomly assigning patients daily to either bodily interventions or fairy tales. Each intervention type was presented 3 times a week. For this secondary analysis, 3-level mixed models were estimated with mood assessed by the 3 Multidimensional Mood Questionnaire subscales for good-bad mood, wakefulness, and calmness as key indicators. In addition, the effects on experience of presence, vitality, and burden assessed with visual analog scales were investigated. RESULTS: Based on the data from s=732 interventions performed by 36 participants, good-bad mood improved (ß=.27; 95% CI 0.062-0.483), and participants became calmer (ß=.98; 95% CI 0.740-1.211) following smartphone-based interventions. Wakefulness did not significantly change from pre- to postsmartphone-based intervention (ß=.17; 95% CI -0.081 to 0.412). This was true for both intervention types. There was no interaction effect of intervention type with change in good-bad mood (ß=-.01; 95% CI -0.439 to 0.417), calmness (ß=.22; 95% CI -0.228 to 0.728), or wakefulness (ß=.14; 95% CI -0.354 to 0.644). Experience of presence (ß=.34; 95% CI 0.271-0.417) and vitality (ß=.35; 95% CI 0.268-0.426) increased from pre- to postsmartphone-based intervention, while experience of burden decreased (ß=-0.40; 95% CI -0.481 to 0.311). Again, these effects were present for both intervention types. There were no significant interaction effects of intervention type with pre- to postintervention changes in experience of presence (ß=.14; 95% CI -0.104 to 0.384), experience of vitality (ß=.06; 95% CI -0.152 to 0.265), and experience of burden (ß=-.16; 95% CI -0.358 to 0.017). CONCLUSIONS: Our results suggest that both smartphone-based audio-guided bodily interventions and fairy tales have the potential to improve the mood of cancer survivors. TRIAL REGISTRATION: ClinicalTrials.gov NCT03707548; https://clinicaltrials.gov/study/NCT03707548. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s40359-019-0357-1.

Group-based body psychotherapy improves appreciation of body awareness in post-treatment cancer patients: A non-randomized clinical trial.

Introduction: Cancer-related impairments often co-occur with bodily disturbances. Body psychotherapy (BPT) can improve bodily wellbeing, yet evidence in cancer survivors is scarce. Hence, we aimed to evaluate whether blended group BPT alleviates bodily disturbances in post-treatment cancer patients. Methods: We conducted a bi-center study (registered in ClinicalTrials.gov, under No. NCT03707548), applying a pre-post convergent parallel design of weekly group BPT interspersed with smartphone-based ambulatory interventions using a waiting-period comparator. We included patients with completed curatively intended treatment for malignant neoplasms, suffering from bodily disturbances. The primary outcome was body image disturbances. Secondary outcomes were experiencing and appreciating body awareness, mental wellbeing, and health-related quality of life. Results: Forty patients (mean age 51.7 years) attended group BPT. Mixed-effect linear regression models contrasting intervention with the waiting period did not show statistically significant differences regarding the primary outcome [Pre-post difference contrasts: 1.44, 95% confidence interval (CI): -1.51 to 4.93, p = 0.339]. However, patients showed greater improvements in appreciating body awareness, measured by the "Body Mindfulness Questionnaire" (BMQ), from pre- to post-intervention as compared to the waiting period (pre-post difference contrasts: 7.31 95% CI: 4.15-10.47, Bonferroni-Holm corrected q = 0.0002). Discussion: We found no evidence that blended group BPT was effective in improving body image disturbances in post-treatment cancer patients, but found indications for an increase in body awareness appreciation. Clinical trial registration: ClinicalTrials.gov, identifier NCT03707548.

Procedures of brain death diagnosis and organ explantation in a tertiary medical centre - a retrospective eight-year cohort study.

AIM OF THE STUDY: To assess the frequency and variables associated with the need for ancillary tests to confirm suspected brain death in adult patients, and to assess the time from brain death to organ explantation in donors. We further sought to identify modifiable factors influencing the time between brain death and start of surgery. METHODS: Medical records and the Swiss organ allocation system registry were screened for all consecutive adult patients diagnosed with brain death at an intensive care unit of a Swiss tertiary medical centre from 2013 to 2020. The frequency and variables associated with the performance of ancillary tests (i.e., transcranial doppler, digital subtraction angiography, and computed tomography angiography) to confirm brain death were primary outcomes; the time from death to organ explantation as well as modifying factors were defined as secondary outcomes. RESULTS: Among 91 patients with a diagnosis of brain death, 15 were not explanted and did not undergo further ancillary tests. Of the remaining 76 patients, who became organ donors after brain death, ancillary tests were performed in 24%, most frequently in patients with hypoxic-ischaemic encephalopathy. The leading presumed causes of death (not mutually exclusive) were haemorrhagic strokes (49%), hypoxic-ischaemic encephalopathies (33%) and severe traumatic brain injuries (22%). Surgery for organ explantation was started within a median of 16 hours (interquartile range [IQR] 13-18) after death with delay increasing over time (nonparametric test for trend p = 0.05), mainly due to organ allocation procedures. Patients with brain death confirmed during night shifts were explanted earlier (during night shifts 14.3 hours, IQR 11.8-16.8 vs 16.3 hours, IQR 13.5-18.5 during day shifts; p = 0.05). CONCLUSIONS: Ancillary tests to confirm brain death are frequently performed, mainly in resuscitated patients. The delay to surgery for organ explantation after confirmed brain death was longer during day shifts, increased over time and was mainly determined by organ allocation procedures.

[Decision Making in Code Status Discussions]. / Entscheidungsfindung in Gesprächen zu Reanimationsmassnahmen.

Decision Making in Code Status Discussions Abstract. The decision process regarding possible resuscitation measures in case of a cardiac arrest is a typical example of a shared decision-making in which patients and physicians contribute equally. To be able to make informed decisions, patients require information regarding possible advantages and disadvantages of the respective decision options. That is why physicians should discuss the consequences of resuscitation attempts versus focusing on palliative measures. What are patients' preferences and needs? These are important factors that can be very individual and therefore have to be incorporated in the decision-making process accordingly. Prolonging life and preventing death is fundamental for many people, however in some settings alleviating discomfort is a more appropriate goal. Especially in polymorbid patients with life-limiting, palliative diseases resuscitation measures often may not show any benefit but rather prolong suffering. In these settings it is particularly important to discuss the limited therapeutic but palliative options with patients.

Prediction of Postictal Delirium Following Status Epilepticus in the ICU: First Insights of an Observational Cohort Study.

OBJECTIVES: To identify early predictors of postictal delirium in adult patients after termination of status epilepticus. DESIGN: Retrospective study. SETTING: ICUs at a Swiss tertiary academic medical center. PATIENTS: Status epilepticus patients treated on the ICUs for longer than 24 hours from 2012 to 2018. INTERVENTIONS: None. METHODS: Primary outcome was postictal delirium during post-status epilepticus treatment defined as an Intensive Care Delirium Screening Checklist greater than or equal to 4. Associations with postictal delirium were secondary outcomes. A time-dependent multivariable Cox proportional hazards model was used to identify risks of postictal delirium. It included variables that differed between patients with and without delirium and established risk factors for delirium (age, sex, number of inserted catheters, illness severity [quantified by the Sequential Organ Failure Assessment and Status Epilepticus Severity Score], neurodegenerative disease, dementia, alcohol/drug consumption, infections, coma during status epilepticus, dose of benzodiazepines, anesthetics, and mechanical ventilation). MEASUREMENTS AND MAIN RESULTS: Among 224 patients, post-status epilepticus Intensive Care Delirium Screening Checklist was increased in 83% with delirium emerging in 55% with a median duration of 2 days (interquartile range 1-3 d). Among all variables, only the history of alcohol and/or drug consumption was associated with increased hazards for delirium in multivariable analyses (hazard ratio = 3.35; 95% CI, 1.53-7.33). CONCLUSIONS: Our study provides first exploratory insights into the risks of postictal delirium in adult status epilepticus patients treated in the ICU. Delirium following status epilepticus is frequent, lasting mostly 2-3 days. Our findings that with the exception of a history of alcohol and/or drug consumption, other risk factors of delirium were not found to be associated with a risk of postictal delirium may be related to the limited sample size and the exploratory nature of our study. Further investigations are needed to investigate the role of established risk factors in other status epilepticus cohorts. In the meantime, our results indicate that the risk of delirium should be especially considered in patients with a history of alcohol and/or drug consumption.

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study.

INTRODUCTION: In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient's perspective. METHODS AND ANALYSIS: A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated. ETHICS AND DISSEMINATION: This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study. TRIAL REGISTRATION NUMBER: NCT04321005. PROTOCOL VERSION: Version 2 (13 December 2019).

Oncologist recommendation matters!-Predictors of psycho-oncological service uptake in oncology outpatients.

OBJECTIVE: Highly distressed cancer patients often do not use psycho-oncological services (POS). Research on predictors of POS uptake has mainly focused on patient-related variables and less on communication variables, so we examined the link between patient-oncologist communication (ie, talking about psychosocial distress, providing detailed information, and recommending POS) and POS uptake. METHODS: We conducted a prospective, observational study in an Oncology Outpatient Clinic in Switzerland. Predictors (ie, patient-related variables and patient's reports of the patient-oncologist communication) were assessed via semistructured interviews, and information on outpatient POS uptake was assessed after 4 months. For statistical analysis, a multivariate logistic regression was performed. RESULTS: Of 333 participants (mean age 61 years; 55% male; 54% distress thermometer ≥5), 77 (23%) had used POS during a 4-month period. Patients who reported an oncologist-recommended POS (odds ratio [OR] = 6.27, 95% confidence interval [CI] = 3.14-12.85) and those who were not sure if they had received a recommendation (OR = 4.64, 95% CI = 1.83-11.97) were more likely to attend POS than those who reported receiving no recommendation. Talking about psychosocial distress (OR = 0.74, 95% CI = 0.38-1.46) and providing detailed information about POS did not predict POS uptake (OR = 1.06, 95% CI = 0.46-2.38). CONCLUSIONS: Oncologists' expert recommendations to attend POS were strongly associated with patients' uptake of POS. The central role played by oncologists should be accounted for in stepped psycho-oncological care when POS referral pathways are defined.

A clinical trial of group-based body psychotherapy to improve bodily disturbances in post-treatment cancer patients in combination with randomized controlled smartphone-triggered bodily interventions (KPTK): study protocol.

BACKGROUND: Disturbances in bodily well-being represent one key source of suffering and impairment related to cancer. There is growing evidence that body psychotherapy (BPT) is efficacious for the treatment of various mental disorders. However, with regard to cancer patients, evidence is scarce. The aims of this project are to evaluate whether bodily disturbances in post-treatment cancer patients can be improved by group BPT, and to estimate the efficacy of intermittent smartphone-triggered bodily interventions. METHODS: The project is a bi-center study with two participating centers in Switzerland, applying a pre-post convergent parallel design of a weekly group BPT using a waiting-period comparator, including a nested RCT during the group BPT phase. During the BPT phase, either a smartphone-triggered bodily intervention or a smartphone-triggered control intervention is provided at random over 5 consecutive weeks, on 6 days weekly. Patients who had received curatively intended treatment for any malignant neoplasm (treatment being completed ≥3 months) and are suffering from bodily disturbances are screened to assess eligibility. Sample size estimation is based on an a priori power analysis. We plan to include a total of N = 88 subjects, aiming at at least 52 completers. Patients are surveyed three times (baseline assessment (T0), pre- (T1) and post-intervention assessment (T2)), and on a daily basis along BPT during five consecutive weeks. The primary outcome, bodily disturbances, is assessed using the 'Body Image Scale'(BIS). For the secondary outcomes standardized questionnaires are used to assess changes in experience of presence and vitality, mood, body mindfulness, somatic symptoms and somatic symptom disorder, quality of life, anxiety, and depression including suicidal tendency, vitality and mental health, as well as group cohesion. Using semi standardized interviews (at T0 and T2), we aim to explore the relation of BPT with bodily disturbances and body image in post-treatment cancer patients, as well as the acceptance and burden of the intervention. DISCUSSION: The proposed study has strong potential benefits for cancer patients, as it may pave the way for new therapeutic approaches to treat bodily disturbances, which persist despite curative tumor therapy. These may considerably improve patients' biopsychosocial well-being and quality of life. TRIAL REGISTRATION: ClinicalTrials.gov NCT03707548 (registered 9 October 2018; retrospectively registered).

Proof of principle: the predisposition, infection, response, organ failure sepsis staging system.

OBJECTIVE: In an effort to improve upon the traditional sepsis syndrome definitions, the predisposition, infection, response, organ dysfunction (PIRO) model was proposed to better characterize sepsis. The objective of this investigation was to derive and validate a sepsis staging system based on the PIRO concept that risk stratifies patients with suspected infection. DESIGN: Three independent, observational, prospective cohorts were studied. A derivation cohort (n = 2,132) was used to create the PIRO score, identifying independent predictors of mortality. Individual values were assigned to create the weighted integer score for each parameter, yielding the final PIRO score. The prognostic performance was then investigated in independent internal (n = 4,618) and external (n = 1,004) validation cohorts. SETTING: Two large U.S. tertiary care centers. PATIENTS: Patients admitted to the hospital from the emergency department with suspected infection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The PIRO staging system was created by combining components of predisposition (age, chronic obstructive pulmonary disease, liver disease, nursing home residency, and malignancy with and without metastasis), infection (pneumonia and cellulitis), response (tachypnea, bandemia, and tachycardia), and organ dysfunction (renal, respiratory, cardiac, metabolic, and hematologic). The derived PIRO score showed stepwise increase in mortality with increasing points and high discriminatory ability with an area under the curve of 0.90 in the derivation cohort, 0.86 in internal validation, and 0.83 in external validation. CONCLUSIONS: This study provides evidence-based support for the PIRO approach to sepsis staging. Future efforts may utilize this approach with additional parameters (e.g., genetics and novel biochemical markers) to develop further the PIRO stratification system.

The value of serum procalcitonin level for differentiation of infectious from noninfectious causes of fever after orthopaedic surgery.

BACKGROUND: Early diagnosis of postoperative orthopaedic infections is important in order to rapidly initiate adequate antimicrobial therapy. There are currently no reliable diagnostic markers to differentiate infectious from noninfectious causes of postoperative fever. We investigated the value of the serum procalcitonin level in febrile patients after orthopaedic surgery. METHODS: We prospectively evaluated 103 consecutive patients with new onset of fever within ten days after orthopaedic surgery. Fever episodes were classified by two independent investigators who were blinded to procalcitonin results as infectious or noninfectious origin. White blood-cell count, C-reactive protein level, and procalcitonin level were assessed on days 0, 1, and 3 of the postoperative fever. RESULTS: Infection was diagnosed in forty-five (44%) of 103 patients and involved the respiratory tract (eighteen patients), urinary tract (eighteen), joints (four), surgical site (two), bloodstream (two), and soft tissues (one). Unlike C-reactive protein levels and white blood-cell counts, procalcitonin values were significantly higher in patients with infection compared with patients without infection on the day of fever onset (p = 0.04), day 1 (p = 0.07), and day 3 (p = 0.003). Receiver-operating characteristics demonstrated that procalcitonin had the highest diagnostic accuracy, with a value of 0.62, 0.62, and 0.71 on days 0, 1, and 3, respectively. In a multivariate logistic regression analysis, procalcitonin was a significant predictor for postoperative infection on days 0, 1, and 3 of fever with an odds ratio of 2.3 (95% confidence interval, 1.1 to 4.4), 2.3 (95% confidence interval, 1.1 to 5.2), and 3.3 (95% confidence interval, 1.2 to 9.0), respectively. CONCLUSIONS: Serum procalcitonin is a helpful diagnostic marker supporting clinical and microbiological findings for more reliable differentiation of infectious from noninfectious causes of fever after orthopaedic surgery.

The farmer who didn't need a wheel barrow.

We report the difficulties encountered in diagnosing leptospirosis in an 85-year-old man who presented with non-specific signs and symptoms. Initially, a wide haematologic and oncologic work-up without significant results was performed, as symptoms of several organ dysfunctions emerged and the clinical course showed a rapid deterioration. After several days without a definite diagnosis, the infection was finally detected after reviewing all results and considering the patient's profession as a farmer. After receiving appropriate antibiotic treatment the patient recovered fully.