Multimodal Remote Home Monitoring of Lung Transplant Recipients during COVID-19 Vaccinations: Usability Pilot Study of the COVIDA Desk Incorporating Wearable Devices.

Background and Objectives: Remote patient monitoring (RPM) of vital signs and symptoms for lung transplant recipients (LTRs) has become increasingly relevant in many situations. Nevertheless, RPM research integrating multisensory home monitoring in LTRs is scarce. We developed a novel multisensory home monitoring device and tested it in the context of COVID-19 vaccinations. We hypothesize that multisensory RPM and smartphone-based questionnaire feedback on signs and symptoms will be well accepted among LTRs. To assess the usability and acceptability of a remote monitoring system consisting of wearable devices, including home spirometry and a smartphone-based questionnaire application for symptom and vital sign monitoring using wearable devices, during the first and second SARS-CoV-2 vaccination. Materials and Methods: Observational usability pilot study for six weeks of home monitoring with the COVIDA Desk for LTRs. During the first week after the vaccination, intensive monitoring was performed by recording data on physical activity, spirometry, temperature, pulse oximetry and self-reported symptoms, signs and additional measurements. During the subsequent days, the number of monitoring assessments was reduced. LTRs reported on their perceptions of the usability of the monitoring device through a purpose-designed questionnaire. Results: Ten LTRs planning to receive the first COVID-19 vaccinations were recruited. For the intensive monitoring study phase, LTRs recorded symptoms, signs and additional measurements. The most frequent adverse events reported were local pain, fatigue, sleep disturbance and headache. The duration of these symptoms was 5-8 days post-vaccination. Adherence to the main monitoring devices was high. LTRs rated usability as high. The majority were willing to continue monitoring. Conclusions: The COVIDA Desk showed favorable technical performance and was well accepted by the LTRs during the vaccination phase of the pandemic. The feasibility of the RPM system deployment was proven by the rapid recruitment uptake, technical performance (i.e., low number of errors), favorable user experience questionnaires and detailed individual user feedback.

Motivation and personality factors of Generation Z high school students aspiring to study human medicine.

BACKGROUND: A new generation of medical students, Generation Z (Gen Z), is becoming the predominant population in medical schools and will join the workforce in a few years' time. Medicine has undergone serious changes in high-income countries recently. Therefore, it is unclear how attractive the medical profession still is for high school students of Gen Z. The aim of this study was to investigate what motivation leads Gen Z students in their choice to study human medicine, and how they see their professional future. Our study was guided by motivation theory and the influence of personality traits and other personal factors on students' choice of university major. METHODS: In a cross-sectional online survey, we included third- and fourth-year high school students in Northern Switzerland. We examined the importance of criteria when choosing a university major: personality traits, career motivation, life goals, and other considerations influencing the choice of human medicine versus other fields of study. Results Of 1790 high school students, 456 (25.5%) participated in the survey (72.6% women, mean age 18.4 years); 32.7% of the respondents aspired to major in medicine at university. For all respondents, the foremost criterion for selecting a field of study was 'interest in the field,' followed by 'income' and 'job security.' High school students aiming to study human medicine attached high importance to 'meaningful work' as a criterion; supported by 36.2% of those students answering that helping and healing people was a core motivation to them. They also scored high on altruism (p < 0.001 against all groups compared) and intrinsic motivation (p < 0.001) and were highly performance- (p < 0.001) and career-minded (p < 0.001). In contrast, all the other groups except the law/economics group had higher scores on extraprofessional concerns. CONCLUSIONS: Swiss Gen Z students aspiring to study human medicine show high intrinsic motivation, altruism, and willingness to perform, sharing many values with previous generations. Adequate work-life balance and job security are important issues for Gen Z. Regarding the current working conditions, the ongoing shortage of physicians, and recent findings on physicians' well-being, the potential for improvement and optimization is high.

Prosthetic valve endocarditis caused by Pseudomonas aeruginosa with variable antibacterial resistance profiles: a diagnostic challenge.

BACKGROUND: Infective endocarditis (IE) caused by gram-negative bacilli is rare. However, the incidence of this severe infection is rising because of the increasing number of persons at risk, such as patients with immunosuppression or with cardiac implantable devices and prosthetic valves. The diagnosis of IE is often difficult, particularly when microorganisms such as Pseudomonas aeruginosa, which rarely cause this infection, are involved. One of the mainstays for the diagnosis of IE are persistently positive blood cultures with the same bacteria, while polymicrobial bacteremia usually points to another cause, e.g. an abscess. The antimicrobial resistance profile of some P. aeruginosa strains may change, falsely suggesting an infection with several strains, thus further increasing the diagnostic difficulties. CASE PRESENTATION: A 66-year old male patient who had a transcatheter aortic valve implantation (TAVI) one year previously developed fever seven days after an elective inguinal hernia repair. During the following four weeks, P. aeruginosa with different antibiotic resistance profiles was repeatedly isolated from blood cultures. Repeated trans-esophageal echocardiograms (TEE) were negative and an infection by different P. aeruginosa strains was suspected. Extensive diagnostic workup for an infectious focus was performed with no results. Finally, an oscillating mass on the aortic valve was detected by TEE five weeks after the initial positive blood cultures. P. aeruginosa endocarditis was confirmed by culture of the surgically removed valve. Whole genome sequencing of the last two P. aeruginosa isolates (valve and blood culture) revealed identical strains, with genome mutations for AmpR, AmpD and OprD. CONCLUSIONS: The diagnosis of prosthetic valve endocarditis is particularly difficult for several reasons. The modified Duke criteria have a lower sensitivity for patients with prosthetic valve endocarditis and the infection may be caused by "unusual" pathogens such as P. aeruginosa. Patients with repeatedly positive blood cultures should make clinicians suspicious for endocarditis even if imaging studies are negative and if isolated pathogens are "unusual". Repeatedly positive blood cultures for P. aeruginosa should be considered as "persistent bacteremia" (suspicious for IE) even in the presence of different antibiotic susceptibility patterns, since P. aeruginosa might rapidly activate or deactivate resistance mechanisms depending on antibiotic exposition.

Tracing the decision-making process of physicians with a Decision Process Matrix.

BACKGROUND: Decision-making processes in a medical setting are complex, dynamic and under time pressure, often with serious consequences for a patient's condition. OBJECTIVE: The principal aim of the present study was to trace and map the individual diagnostic process of real medical cases using a Decision Process Matrix [DPM]). METHODS: The naturalistic decision-making process of 11 residents and a total of 55 medical cases were recorded in an emergency department, and a DPM was drawn up according to a semi-structured technique following four steps: 1) observing and recording relevant information throughout the entire diagnostic process, 2) assessing options in terms of suspected diagnoses, 3) drawing up an initial version of the DPM, and 4) verifying the DPM, while adding the confidence ratings. RESULTS: The DPM comprised an average of 3.2 suspected diagnoses and 7.9 information units (cues). The following three-phase pattern could be observed: option generation, option verification, and final diagnosis determination. Residents strove for the highest possible level of confidence before making the final diagnoses (in two-thirds of the medical cases with a rating of practically certain) or excluding suspected diagnoses (with practically impossible in half of the cases). DISCUSSION: The following challenges have to be addressed in the future: real-time capturing of emerging suspected diagnoses in the memory of the physician, definition of meaningful information units, and a more contemporary measurement of confidence. CONCLUSIONS: DPM is a useful tool for tracing real and individual diagnostic processes. The methodological approach with DPM allows further investigations into the underlying cognitive diagnostic processes on a theoretical level and improvement of individual clinical reasoning skills in practice.

Rictor in perivascular adipose tissue controls vascular function by regulating inflammatory molecule expression.

OBJECTIVE: Perivascular adipose tissue (PVAT) wraps blood vessels and modulates vasoreactivity by secretion of vasoactive molecules. Mammalian target of rapamycin complex 2 (mTORC2) has been shown to control inflammation and is expressed in adipose tissue. In this study, we investigated whether adipose-specific deletion of rictor and thereby inactivation of mTORC2 in PVAT may modulate vascular function by increasing inflammation in PVAT. APPROACH AND RESULTS: Rictor, an essential mTORC2 component, was deleted specifically in mouse adipose tissue (rictor(ad-/-)). Phosphorylation of mTORC2 downstream target Akt at Serine 473 was reduced in PVAT from rictor(ad-/-) mice but unaffected in aortic tissue. Ex vivo functional analysis of thoracic aortae revealed increased contractions and impaired dilation in rings with PVAT from rictor(ad-/-) mice. Adipose rictor knockout increased gene expression and protein release of interleukin-6, macrophage inflammatory protein-1α, and tumor necrosis factor-α in PVAT as shown by quantitative real-time polymerase chain reaction and Bioplex analysis for the cytokines in the conditioned media, respectively. Moreover, gene and protein expression of inducible nitric oxide synthase was upregulated without affecting macrophage infiltration in PVAT from rictor(ad-/-) mice. Inhibition of inducible nitric oxide synthase normalized vascular reactivity in aortic rings from rictor(ad-/-) mice with no effect in rictor(fl/fl) mice. Interestingly, in perivascular and epididymal adipose depots, high-fat diet feeding induced downregulation of rictor gene expression. CONCLUSIONS: Here, we identify mTORC2 as a critical regulator of PVAT-directed protection of normal vascular tone. Modulation of mTORC2 activity in adipose tissue may be a potential therapeutic approach for inflammation-related vascular damage.

The lower quality of preventive care among forced migrants in a country with universal healthcare coverage.

OBJECTIVE: To assess the association between socio-demographic factors and the quality of preventive care and chronic care of cardiovascular (CV) risk factors in a country with universal health care coverage. METHODS: Our retrospective cohort assessed a random sample of 966 patients aged 50-80years followed over 2years (2005-2006) in 4 Swiss university primary care settings (Basel/Geneva/Lausanne/Zürich). We used RAND's Quality Assessment Tools indicators and examined recommended preventive care among different socio-demographic subgroups. RESULTS: Overall patients received 69.6% of recommended preventive care. Preventive care indicators were more likely to be met among men (72.8% vs. 65.4%; p<0.001), younger patients (from 71.0% at 50-59years to 66.7% at 70-80years, p for trend=0.03) and Swiss patients (71.1% vs. 62.7% in forced migrants; p=0.001). This latter difference remained in multivariate analysis adjusted for gender, age, civil status and occupation (OR 0.68; 95% CI 0.54-0.86). Forced migrants had lower scores for physical examination and breast and colon cancer screening (all p≤0.02). No major differences were seen for chronic care of CV risk factors. CONCLUSION: Despite universal healthcare coverage, forced migrants receive less preventive care than Swiss patients in university primary care settings. Greater attention should be paid to forced migrants for preventive care.

Patient and physician gender concordance in preventive care in university primary care settings.

OBJECTIVE: To assess the quality of preventive care according to physician and patient gender in a country with universal health care coverage. METHODS: We assessed a retrospective cohort study of 1001 randomly selected patients aged 50-80 years followed over 2 years (2005-2006) in 4 Swiss university primary care settings (Basel, Geneva, Lausanne, Zürich). We used indicators derived from RAND's Quality Assessment Tools and examined percentages of recommended preventive care. Results were adjusted using hierarchical multivariate logistic regression models. RESULTS: 1001 patients (44% women) were followed by 189 physicians (52% women). Female patients received less preventive care than male patients (65.2% vs. 72.1%, p<0.001). Female physicians provided significantly more preventive care than male physicians (p=0.01) to both female (66.7% vs. 63.6%) and male patients (73.4% vs. 70.7%). After multivariate adjustment, differences according to physician (p=0.02) and patient gender (p<0.001) remained statistically significant. Female physicians provided more recommended cancer screening than male physicians (78.4 vs. 71.9%, p=0.01). CONCLUSIONS: In Swiss university primary care settings, female patients receive less preventive care than male patients, with female physicians providing more preventive care than male physicians. Greater attention should be paid to female patients in preventive care and to why female physicians tend to provide better preventive care.

Clinically relevant quality measures for risk factor control in primary care: a retrospective cohort study.

BACKGROUND: Assessment of the proportion of patients with well controlled cardiovascular risk factors underestimates the proportion of patients receiving high quality of care. Evaluating whether physicians respond appropriately to poor risk factor control gives a different picture of quality of care. We assessed physician response to control cardiovascular risk factors, as well as markers of potential overtreatment in Switzerland, a country with universal healthcare coverage but without systematic quality monitoring, annual report cards on quality of care or financial incentives to improve quality. METHODS: We performed a retrospective cohort study of 1002 randomly selected patients aged 50-80 years from four university primary care settings in Switzerland. For hypertension, dyslipidemia and diabetes mellitus, we first measured proportions in control, then assessed therapy modifications among those in poor control. "Appropriate clinical action" was defined as a therapy modification or return to control without therapy modification within 12 months among patients with baseline poor control. Potential overtreatment of these conditions was defined as intensive treatment among low-risk patients with optimal target values. RESULTS: 20% of patients with hypertension, 41% with dyslipidemia and 36% with diabetes mellitus were in control at baseline. When appropriate clinical action in response to poor control was integrated into measuring quality of care, 52 to 55% had appropriate quality of care. Over 12 months, therapy of 61% of patients with baseline poor control was modified for hypertension, 33% for dyslipidemia, and 85% for diabetes mellitus. Increases in number of drug classes (28-51%) and in drug doses (10-61%) were the most common therapy modifications. Patients with target organ damage and higher baseline values were more likely to have appropriate clinical action. We found low rates of potential overtreatment with 2% for hypertension, 3% for diabetes mellitus and 3-6% for dyslipidemia. CONCLUSIONS: In primary care, evaluating whether physicians respond appropriately to poor risk factor control, in addition to assessing proportions in control, provide a broader view of the quality of care than relying solely on measures of proportions in control. Such measures could be more clinically relevant and acceptable to physicians than simply reporting levels of control.

Validation of a diagnostic probability function for estimating probabilities of acute coronary syndrome.

BACKGROUND: We recently reported about the derivation of a diagnostic probability function for acute coronary syndrome (ACS). The present study aims to validate the probability function as a rule-out criterion in a new sample of patients. METHODS: 186 patients presenting with chest pain and/or dyspnea at one of the three participating hospitals' emergency rooms in Switzerland were included in the study. In these patients, information on a set of pre-specified variables was collected and a predicted probability of ACS was calculated for each patient. Approximately two weeks after the initial visit in the emergency room, patients were contacted by phone to assess whether a diagnosis of ACS was established. RESULTS: Of the 186 patients included in the study, 31 (17%) had an acute coronary syndrome. A risk probability for ACS below 2% was considered a rule-out criterion for ACS, leading to a sensitivity of 87% and a specificity of 17% of the rule. The characteristics of the study patients were compared to the cases from which the probability function was derived, and considerable deviations were found in some of the variables. CONCLUSIONS: The proposed probability function, with a 2% cut-off for ruling out ACS works quite well if the patient data lie within the ranges of values of the original vignettes. If the observations deviate too much from these ranges, the predicted probabilities for ACS should be seen with caution.

Close geographic association of human neoehrlichiosis and tick populations carrying "Candidatus Neoehrlichia mikurensis" in eastern Switzerland.

Neoehrlichiosis caused by "Candidatus Neoehrlichia mikurensis" is an emerging zoonotic disease. In total, six patients have been described in Europe, with the first case detected in 2007. In addition, seven patients from China were described in a report published in October 2012. In 2009, we diagnosed the first human case of "Ca. Neoehrlichia mikurensis" infection in the Zurich area (Switzerland). Here, we report two additional human cases from the same region, which were identified by broad-range 16S rRNA gene PCR. Both patients were immunocompromised and presented with similar clinical syndromes, including fever, malaise, and weight loss. A diagnostic multiplex real-time PCR was developed for specific detection of "Ca. Neoehrlichia mikurensis" infections. The assay is based on the signature sequence of a 280-bp fragment of the "Ca. Neoehrlichia mikurensis" 16S rRNA gene and incorporates a "Ca. Neoehrlichia mikurensis" species, a "Ca. Neoehrlichia" genus, and an Anaplasmataceae family probe for simultaneous screening. The analytical sensitivity was determined to be below five copies of the "Ca. Neoehrlichia mikurensis" 16S rRNA gene. Our results show that the assay is suitable for the direct detection of "Ca. Neoehrlichia mikurensis" DNA in clinical samples from, for example, blood and bone marrow. In addition, it allows for monitoring treatment response during antibiotic therapy. Using the same assay, DNA extracts from 1,916 ticks collected in four forests in close proximity to the patients' residences (<3 km) were screened. At all sampling sites, the minimal prevalence of "Ca. Neoehrlichia mikurensis" was between 3.5 to 8% in pools of either nymphs, males, or females, showing a strong geographic association between the three patients and the assumed vector.

Increasing patient engagement during virtual reality-based motor rehabilitation.

OBJECTIVE: To investigate the influence of different design characteristics of virtual reality exercises on engagement during lower extremity motor rehabilitation. DESIGN: Correlational study. SETTING: Spinal cord injury (SCI) rehabilitation center. PARTICIPANTS: Subjects with SCI (n=12) and control subjects (n=10). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Heart rate and electromyographic activity from both legs at the tibialis anterior, the gastrocnemius medialis, the rectus femoris, and the biceps femoris were recorded. RESULTS: Interactivity (ie, functionally meaningful reactions to motor performance) was crucial for the engagement of subjects. No significant differences in engagement were found between exercises that differed in feedback frequency, explicit task goals, or aspects of competition. CONCLUSIONS: Functional feedback is highly important for the active participation of patients during robotic-assisted rehabilitation. Further investigations on the design characteristics of virtual reality exercises are of great importance. Exercises should thoroughly be analyzed regarding their effectiveness, while user preferences and expectations should be considered when designing virtual reality exercises for everyday clinical motor rehabilitation.

Body weight telemetry is useful to reduce interdialytic weight gain in patients with end-stage renal failure on hemodialysis.

Lacking compliance with liquid intake restrictions is one of the major problems in patients on hemodialysis and causes an increased mortality. In 120 patients on hemodialysis with an average interdialytic weight gain (IWG) exceeding 1.5 kg on at least 2 days during the 4 weeks preceding the intervention, the effect of telemetric body weight measurement (TBWM) on IWG, ultrafiltration rate, and blood pressure was evaluated over a period of 3 months. Patients of the telemetric group (TG) were supplied with automatic scales, which transferred the weight via telemetry on a daily basis. In the case of IWG of more than 0.75 kg/24 h, a telephonic contact was made as required, and in the case of an IWG of more than 1.5 kg, telephonic contacting was obligatory along with the advice of a liquid intake restriction to 0.5 L/day until the next dialysis. The patients of the control group (CG) received standard treatment without telemetric monitoring. We examined specific data of the second interdialytic interval (IDI2) and the average within 1 week. The average difference of IWG between TG and CG was not significant before the start of the study but 0.2 kg (p=0.027) (IDI2)/0.27kg (p=0.001) (WP) at the end of the study, respectively. The average difference in the ultrafiltration rate within 1 week was 19.0 mL/h (p=0.282) (IDI2)/8.2 mL/h (p=0.409) before the start of the study but 28.4 mL/h (p=0.122) (IDI2)/30.9 mL/h (p=0.004) at the end of the study, respectively. Thus, TBWM is a feasible method for optimizing the IWG and reducing the ultrafiltration rate.

The worse we feel, the more intensively we need to stick together: a qualitative study of couples' emotional co-regulation of the challenge of multimorbidity.

Introduction: Being faced with multimorbidity (i.e., being diagnosed with at least two chronic conditions), is not only demanding in terms of following complicated medical regimes and changing health behaviors. The changes and threats involved also provoke emotional responses in the patients but also in their romantic partners. This study aims at exploring the ways of emotional co-regulation that couples facing multimorbidity express when interviewed together. Method: N = 15 opposite sex couples with one multimorbid patient after an acute health crisis that led to hospitalization were asked in a semi-structured interview about how they found ways to deal with the health situation, what they would recommend to other couples in a similar situation, and how they regulated their emotional responses. Interviews were analyzed qualitatively following open, axial, and selective coding, as in the grounded theory framework. Results: Emerging categories from the romantic partners' and the patients' utterances revealed three main categories: First, overlapping cognitive appraisals about the situation (from fighting spirit to fatalism) and we-ness (construing the couple self as a unit) emerged as higher order factor from the utterances. Second, relationship-related strategies including strategies aimed at maintaining high relationship quality in spite of the asymmetric situation like strengthening the common ground and balancing autonomy and equity in the couple were often mentioned. Third, some couples mentioned how they benefit from individual strategies that involve fostering individual resources of the partners outside the couple relationship (such as cultivating relationships with grandchildren or going outdoors to nature). Discussion: Results underline the importance of a dyadic perspective not only on coping with disease but also on regulating the emotional responses to this shared challenging situation. The utterances of the couples were in line with earlier conceptualizations of interpersonal emotion regulation and dyadic perspectives on we-disease. They broaden the view by integrating the interplay between individual and interpersonal regulation strategies and underline the importance of balancing individual and relational resources when supporting couples faced with chronic diseases.

A long-term retrospective observational study at a medium-sized medical oncology service in Switzerland: comparison of overall survival with a national cohort and adherence to treatment guidelines.

AIMS: There is a lack of national and international publicly available long-term survival outcome data from individual healthcare providers in medical oncology. In this study, the overall survival at a medium-sized medical oncology service at Olten Cantonal Hospital was evaluated and compared as a local benchmark report with national data from the Swiss Cancer Registries. Furthermore, adherence to treatment guidelines was investigated as an additional quality indicator. METHODS: The 1- and 5-year overall survival of all patients with breast cancer, testicular cancer, colon cancer, non-small-cell lung cancer, Hodgkin lymphoma, and diffuse large B-cell lymphoma in Switzerland from 2008 to 2017 with at least one outpatient visit at the in-house medical oncology service at Olten Cantonal Hospital was analysed and compared with the specific overall population-based outcome data provided by the National Agency for Cancer Registration (NACR), which were set as a national benchmark. Until 2020, no data from the Canton of Solothurn, to which Olten belongs, were reported to the NACR. Further, adherence to internationally recognized clinical guidelines for stage-specific treatment was assessed. RESULTS: Until September 8, 2020, data on 842 patients with a median follow-up period of 70 months were collected and analysed. The 1- and 5-year overall survival for colon and non-small cell cancer, Hodgkin lymphoma, and diffuse large B-cell lymphoma and the 5-year overall survival for testicular cancer in the Olten cohort did not significantly differ from the NACR data. The 1-year overall survival for testicular cancer was not comparable statistically. The 5-year overall survival for breast cancer (unadjusted for stage) was significantly higher in the NACR collective (84.5%) than in the Olten collective (79.7%) but not for the individual breast cancer stages. The Olten collective included approximately 2.5 times as many patients with stage 4 breast cancer (17.5%) as the NACR collective (6.9%). Approximately 92.4% of the patients in the curative setting and 85.8% of the patients in the palliative setting received first-line treatment according to guidelines. CONCLUSIONS: The statistically comparable local 1- and 5-year overall survival of the analysed malignancies, with adjustment for stage for the 5-year overall survival for breast cancer, is in line with the national benchmark. Adherence to treatment guidelines is high.

Acutely ill patients in internal medicine departments want treatment for undiagnosed, symptomatic skin conditions.

OBJECTIVE: Concomitant skin conditions may be neglected in internal medicine patients due to lack of knowledge or resources. Thus, we investigated the prevalence of undiagnosed skin conditions in this population. METHODS: 200 patients in a university medical center's internal medicine division were examined clinically for dermatoses and quality of life in a prospective, 2-month, single-center study. RESULTS: All patients had several dermatological problems (mean per patient: 13; range: 3-25). There was no relationship between the patient's main medical problem and the number or nature of dermatological conditions. Most patients (84%) requested treatment for their skin condition during hospitalization, especially for xerosis (76%), warts (69%), seborrheic eczema (67%) and onychorrhexis (53%) but not for asymptomatic dermatoses. The impairment in skin-related quality of life was mild but significant, with a mean ± SD Dermatology Life Quality Index of 3 ± 4 (p < 0.001), and global quality of life impairment was severe (p < 0.001). CONCLUSIONS: Inpatients suffered from many different, mostly age-related, skin conditions that remained undiagnosed. When prompted, however, patients requested treatment, particularly for symptomatic dermatological conditions such as xerosis, revealing an unmet need that needs to be addressed by qualified evaluation and care.

Ten-year trends in intoxications and requests for emergency ambulance service.

BACKGROUND: Intoxication, whether from alcohol, drugs, or alcohol and drugs in combination, remains a challenging burden on emergency departments. The increasing alcohol consumption among adolescents and young adults, particularly heavy episodic drinking, and the resulting increase in the use of health care resources for alcohol intoxication has been a widely discussed topic. OBJECTIVE: The aim of our study was to assess and characterize the use of emergency ambulance services that was required as a result of alcohol and drug intoxication in a major metropolitan area. METHODS: We conducted a retrospective, longitudinal study over a 10-year period in the greater metropolitan area of Zurich, Switzerland. The study population included intoxicated patients assessed and initially treated by paramedics of the emergency ambulance service. Data were extracted from the ambulance service reports. The primary outcomes measured were trends over time in the numbers and types of intoxication and trends with respect to gender and age distributions of intoxicated patients. RESULTS: An annual increase of about 5% in the number of intoxicated patients requiring emergency ambulance service was observed over the study period. Alcohol use was present in 73% of the cases. The highest number of cases was among patients 25-44 years of age. The greatest increase in the number of cases over time was among patients under 25 years of age. Women comprised 41% of the patients under 25 years of age but only about 35% of older patients. The number of severe injuries and suicide attempts was small, but the number of suicide attempts increased at a higher rate than the overall number of cases of intoxication. There was a significant increase (17.64% per year on average) in the incidence of aggressive behavior toward paramedics from intoxicated patients, although still small in numbers. CONCLUSIONS: Our findings suggest two main vulnerable groups: young persons under 25 years of age, with a particular focus on women, having the greatest increase over time, and middle-aged men, having the greatest proportion among all cases observed. Intervention efforts should include a high-risk approach to reduce alcohol-related problems. Key words: alcohol intoxication; substance-related disorders; aggression; injuries; emergency medical services.

Validation of a mechanism to balance exercise difficulty in robot-assisted upper-extremity rehabilitation after stroke.

BACKGROUND: The motivation of patients during robot-assisted rehabilitation after neurological disorders that lead to impairments of motor functions is of great importance. Due to the increasing number of patients, increasing medical costs and limited therapeutic resources, clinicians in the future may want patients to practice their movements at home or with reduced supervision during their stay in the clinic. Since people only engage in an activity and are motivated to practice if the outcome matches the effort at which they perform, an augmented feedback application for rehabilitation should take the cognitive and physical deficits of patients into account and incorporate a mechanism that is capable of balancing i.e. adjusting the difficulty of an exercise in an augmented feedback application to the patient's capabilities. METHODS: We propose a computational mechanism based on Fitts' Law that balances i.e. adjusts the difficulty of an exercise for upper-extremity rehabilitation. The proposed mechanism was implemented into an augmented feedback application consisting of three difficulty conditions (easy, balanced, hard). The task of the exercise was to reach random targets on the screen from a starting point within a specified time window. The available time was decreased with increasing condition difficulty. Ten subacute stroke patients were recruited to validate the mechanism through a study. Cognitive and motor functions of patients were assessed using the upper extremity section of the Fugl-Meyer Assessment, the modified Ashworth scale as well as the Addenbrookes cognitive examination-revised. Handedness of patients was obtained using the Edinburgh handedness inventory. Patients' performance during the execution of the exercises was measured twice, once for the paretic and once for the non-paretic arm. Results were compared using a two-way ANOVA. Post hoc analysis was performed using a Tukey HSD with a significance level of p < 0.05. RESULTS: Results show that the mechanism was capable of balancing the difficulty of an exercise to the capabilities of the patients. Medians for both arms show a gradual decrease and significant difference of the number of successful trials with increasing condition difficulty (F(2;60) = 44.623; p < 0.01; η(2) = 0.623) but no significant difference between paretic and non-paretic arm (F(1;60) = 3.768; p = 0.057; η(2) = 0.065). Post hoc analysis revealed that, for both arms, the hard condition significantly differed from the easy condition (p < 0.01). In the non-paretic arm there was an additional significant difference between the balanced and the hard condition (p < 0.01). Reducing the time to reach the target, i.e., increasing the difficulty level, additionally revealed significant differences between conditions for movement speeds (F(2;59) = 6.013; p < 0.01; η(2) = 0.185), without significant differences for hand-closing time (F(2;59) = 2.620; p = 0.082; η(2) = 0.09), reaction time (F(2;59) = 0.978; p = 0.383; η(2) = 0.036) and hand-path ratio (F(2;59) = 0.054; p = 0.947; η(2) = 0.002). The evaluation of a questionnaire further supported the assumption that perceived performance declined with increased effort and increased exercise difficulty leads to frustration. CONCLUSIONS: Our results support that Fitts' Law indeed constitutes a powerful mechanism for task difficulty adaptation and can be incorporated into exercises for upper-extremity rehabilitation.

[Dizziness - What Next?] / Schwindel ­ wie weiter?

Dizziness - What Next? Abstract. Dizziness is a very common symptom with an extensive differential diagnosis that includes both benign and serious conditions. Acute care physicians must be able to distinguish the majority of patients with self-limiting benign complaints from those with serious conditions. Our structured approach is intended to serve as a guide for acute medicine.

Multisensory Home-Monitoring in Individuals With Stable Chronic Obstructive Pulmonary Disease and Asthma: Usability Study of the CAir-Desk.

BACKGROUND: Research integrating multisensory home-monitoring in respiratory disease is scarce. Therefore, we created a novel multisensory home-monitoring device tailored for long-term respiratory disease management (named the CAir-Desk). We hypothesize that recent technological accomplishments can be integrated into a multisensory participant-driven platform. We also believe that this platform could improve chronic disease management and be accessible to large groups at an acceptable cost. OBJECTIVE: This study aimed to report on user adherence and acceptance as well as system functionality of the CAir-Desk in a sample of participants with stable chronic obstructive pulmonary disease (COPD) or asthma. METHODS: We conducted an observational usability study. Participants took part in 4 weeks of home-monitoring with the CAir-Desk. The CAir-Desk recorded data from all participants on symptom burden, physical activity, spirometry, and environmental air quality; data on sputum production, and nocturnal cough were only recorded for participants who experienced symptoms. After the study period, participants reported on their perceptions of the usability of the monitoring device through a purpose-designed questionnaire. We used descriptive statistics and visualizations to display results. RESULTS: Ten participants, 5 with COPD and 5 with asthma took part in this study. They completed symptom burden questionnaires on a median of 96% (25th percentile 14%, 75th percentile 96%), spirometry recordings on 55% (20%, 94%), wrist-worn physical activity recordings on 100% (97%, 100%), arm-worn physical activity recordings on 45% (13%, 63%), nocturnal cough recordings on 34% (9%, 54%), sputum recordings on 5% (3%, 12%), and environmental air quality recordings on 100% (99%, 100%) of the study days. The participants indicated that the measurements consumed a median of 13 (10, 15) min daily, and that they preferred the wrist-worn physical activity monitor to the arm-worn physical activity monitor. CONCLUSIONS: The CAir-Desk showed favorable technical performance and was well-accepted by our sample of participants with stable COPD and asthma. The obtained insights were used in a redesign of the CAir-Desk, which is currently applied in a randomized controlled trial including an interventional program.

The quality of primary care in a country with universal health care coverage.

BACKGROUND: Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage. OBJECTIVE: To assess the quality of preventive care and care for cardiovascular risk factors in a country with universal health care coverage. DESIGN AND PARTICIPANTS: Retrospective cohort of a random sample of 1,002 patients aged 50-80 years followed for 2 years from all Swiss university primary care settings. MAIN MEASURES: We used indicators derived from RAND's Quality Assessment Tools. Each indicator was scored by dividing the number of episodes when recommended care was delivered by the number of times patients were eligible for indicators. Aggregate scores were calculated by taking into account the number of eligible patients for each indicator. KEY RESULTS: Overall, patients (44% women) received 69% of recommended preventive care, but rates differed by indicators. Indicators assessing annual blood pressure and weight measurements (both 95%) were more likely to be met than indicators assessing smoking cessation counseling (72%), breast (40%) and colon cancer screening (35%; all p < 0.001 for comparisons with blood pressure and weight measurements). Eighty-three percent of patients received the recommended care for cardiovascular risk factors, including >75% for hypertension, dyslipidemia and diabetes. However, foot examination was performed only in 50% of patients with diabetes. Prevention indicators were more likely to be met in men (72.2% vs 65.3% in women, p < 0.001) and patients <65 years (70.1% vs 68.0% in those ≥ 65 years, p = 0.047). CONCLUSIONS: Using standardized tools, these adults received 69% of recommended preventive care and 83% of care for cardiovascular risk factors in Switzerland, a country with universal coverage. Prevention indicator rates were lower for women and the elderly, and for cancer screening. Our study helps pave the way for targeted quality improvement initiatives and broader assessment of health care in Continental Europe.