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.

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.

[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.

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.

Couples Adjusting to Multimorbidity: A Dyadic Study on Disclosure and Adjustment Disorder Symptoms.

BACKGROUND: Multimorbidity is challenging not only for the patient but also for the romantic partner. Strategies for interpersonal emotion regulation like disclosing to the partner are supposed to play a major role in the psychosocial adjustment to multimorbidity. Research has often focused on disease-related disclosure, even though disclosing thoughts and feelings related to mundane, everyday life occurrences might also play a role in coadjustment. The current dyadic study aimed at investigating the association between these two types of interpersonal regulation strategies and adjustment disorder symptoms, following the new ICD 11 criteria in multimorbid patients and their partners. METHODS: Shortly after being hospitalized due to an acute health crisis, N = 28 multimorbid patients (average age 70 years) and their partners filled in questionnaires on disclosure in the couple, adjustment disorder criteria of the ICD 11 ("preoccupation," "failure to adapt"), and sleep problems. RESULTS: Both patients and their partners did show similarly high levels of preoccupation and failure to adapt indicating adjustment problems to the complex health situation. The adjustment symptoms of both partners correlated between r = 0.22 and 0.45. Regression based on Actor-Partner Interdependence-Models revealed that own mundane disclosure was related to less adjustment symptoms in the patients. Beyond that, a partner effect was observed, revealing a negative association between partners' illness-related disclosure and the patients' level of preoccupation. For the partners, mundane disclosure of the partner was associated with less preoccupation, failure to adapt, and reported sleep problems above and beyond own disclosure reports. Furthermore, there was an actor effect of disease-related disclosure on less sleep problems for the partners. CONCLUSION: These results support an interpersonal view on adjustment processes to physical disease. Disclosure as a way of regulating the relationship and emotional responses might play a relevant role here, which seems to be different for patients and their partners. Further research is needed to shed more light on the differential role of disease-related and mundane everyday disclosure for psychosocial adjustment in couples confronted with health challenges.

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.

Sensitivity for multimorbidity: The role of diagnostic uncertainty of physicians when evaluating multimorbid video case-based vignettes.

BACKGROUND: Multimorbidity can be defined as the co-occurrence of two or more chronic medical conditions in one person. Within the diagnostic process, accurately detecting a multimorbid disease pattern still poses a major challenge for most physicians, and is known as a source of diagnostic uncertainty. OBJECTIVE: We investigated, how sensitive, confident, and accurate physicians are in diagnosing multimorbid versus monomorbid patients. METHODS: We created eight video case-based vignettes, which differed in type of morbidity (multimorbid versus monomorbid), field of medical specialization (somatic versus mental), and relatedness of underlying diseases (causally related versus unrelated). In total, 74 physicians (GPs, residents in an emergency department and psychiatrists) watched three to five randomly allocated video cases and had to generate suspected diagnoses at the end of each of three video sequences. Additionally, participating physicians rated subjective confidence for all mentioned diagnoses and for three sequences per case with the help of confidence profiles. RESULTS: Altogether, physicians made a large number of accurate diagnoses (69%). Nevertheless, the overall number of underdiagnosed multimorbid cases (misses) was significantly higher (71%) than over-diagnosed monomorbid cases (false alarms) (7%). DISCUSSION: According to Signal Detection Theory, GPs and psychiatrists both showed lower detection performance for medical cases that lay beyond their own field of specialization. Remarkably, residents show the highest sensitivity for multimorbid cases with an approximately identically detection performance d' slightly over 1 for both field of medical specialization (somatic and mental). Furthermore, higher uncertainty in diagnosing multimorbid cases is related to lower confidence especially at the beginning of a diagnostic process, as well as to unrelated and therefore probably rare disease pattern. Several limitations of the study and the video case-based vignettes are described within the discussion section. CONCLUSIONS: Physicians have to be sensitized for multimorbidity even more, and have to be taught in the prevalence of existing disease combinations. Communicating uncertainty with other specialists could be helpful when faced with a sometimes "fuzzy" pattern of symptoms.

What makes internal medicine attractive for the millennial generation? A survey of residents in internal medicine in Switzerland.

AIMS: A new generation of physicians, millennials (also known as Generation Y), are entering residency programmes in internal medicine, and these young men and women learn and work in ways that are different from those of past generations. The aim of the present study was to investigate aspects contributing to the attractiveness to young residents of a career in general internal medicine (GIM) compared with medical subspecialties (SUB). METHODS: In a cross-sectional online survey, we included residents working in residency facilities in GIM in German-speaking Switzerland. A total of 1818 junior residents were eligible. We looked for personal preferences, characteristics, and criteria influencing the choice of a career in GIM or SUB. RESULTS: 392 out of 1818 (22%) residents participated in the survey (66% females); they had been in clinical training for 35.5 months on average. 87% of the respondents aspired to a title in GIM, and 29% of these to a SUB title as well. 71% of the women chose GIM and not a SUB vs 58% of the men (p <0.019). GIM residents gave significantly higher ratings to “broad range of expertise,” “flexible work hours” (p = 0.007), “work-life balance”, and “reconciliation of work, family and private life” than residents aiming at a SUB. SUB residents evaluated career-related criteria as significantly more important (p <0.0001). With regard to career motivation, GIM residents and female residents rated extraprofessional concerns significantly higher than SUB residents did (p = 0.019). In contrast, SUB residents showed significantly higher intrinsic motivation than GIM residents (p = 0.025). Only 28.2% of GIM residents had a mentor, compared to 49.6% of SUB residents (p <0.0005). Concerning personal perceptions of the future within the next 5 years, GIM residents attached significantly more importance to part-time work (p = 0.001), whereas SUB residents attached more importance to getting a leading position as a main goal (p = 0.0001). CONCLUSIONS: There are considerable differences between GIM and SUB residents regarding career motivation and their views on working conditions and work-life balance. It is essential to understand the factors that motivate or deter the next generation in order to ensure the attractiveness of the profession of GIM.  .

The Relevance of Vitamin and Iron Deficiency in Patients with Inflammatory Bowel Diseases in Patients of the Swiss IBD Cohort.

Background andAims: Vitamin and iron deficiencies are common in patients with inflammatory bowel disease (IBD) as a result of chronic intestinal inflammation, increase in demand, or dietary restrictions. Here, we assessed the frequency of complications in relation to deficiency of iron, folate acid, and vitamin B12 in patients enrolled in the nationwide Swiss Inflammatory Bowel Disease Cohort Study (SIBDCS). Methods: A total of 2666 patients were included in the study, 1558 with Crohn's disease (CD) and 1108 with ulcerative colitis (UC). Results: Iron deficiency anemia was detected in 19.6% of CD patients and 21.6% of UC patients. In CD patients low BMI and nonsmoker status were positively associated with anemia. In both CD and UC, malabsorption syndrome, defined as failure of the GI tract to absorb 1 or more substances from the diet, was found to be significantly associated with anemia (6.2% and 3.8%, respectively) and current steroid use (40% CD, 52.7% UC). In CD patients with ileal (31.7% vs 20%) and colonic (29.9% vs 25%) disease location folate deficiency was significantly higher than in patients with ileocolonic CD or upper GI involvement. In CD patients, vitamin B12 deficiency was associated with the onset of stenosis and intestinal surgery (42.9% vs 32.8% and 46% vs 33% for patients with versus without B12 deficiency). Conclusion: Our data indicate that due to frequent occurrence of deficiency states, regular monitoring and substitution of vitamins and iron are mandatory and may prevent long-term intestinal and extraintestinal complications in IBD patients.

Risk factors for gallstones and kidney stones in a cohort of patients with inflammatory bowel diseases.

BACKGROUND: Gallstones and kidney stones are known complications of inflammatory bowel diseases (IBD). Risk factors have been insufficiently studied and explanatory studies date back up to 30 years. It remains unclear, whether improved treatment options also influenced risk factors for these complications. OBJECTIVES: Identifying risk factors for gallstones and kidney stones in IBD patients. METHODS: Using data from the Swiss Inflammatory Bowel Disease Cohort Study we assessed associations of diseases characteristics with gallstones and kidney stones in univariate and multivariate logistic regression analyses. RESULTS: Out of 2323 IBD patients, 104 (7.8%) Crohn's disease (CD) and 38 (3.8%) ulcerative colitis (UC) patients were diagnosed with gallstones. Significant risk factors for gallstones were diagnosis of CD, age at diagnosis, disease activity and duration, NSAID intake, extra-intestinal manifestations and intestinal surgery. Kidney stones were described in 61 (4.6%) CD and 30 (3.0%) UC patients. Male gender, disease activity, intestinal surgery, NSAID usage and reduced physical activity were significant risk factors. Hospitalization was associated with gallstones and kidney stones. The presence of gallstones increased the risk for kidney stones (OR 4.87, p<0.001). CONCLUSION: The diagnosis of CD, intestinal surgery, prolonged NSAID use, disease activity and duration and bowel stenosis were significantly associated with cholecystonephrolithiasis in IBD.

Health Behavior Change in Older Adults: Testing the Health Action Process Approach at the Inter- and Intraindividual Level.

BACKGROUND: Health behavior change theories usually claim to be universally and individually applicable. Most research has tested behavior change theories at the interindividual level and within young-to-middle-aged populations. However, associations at the interindividual level can differ substantially from associations at the intraindividual level. This study examines the applicability of the Health Action Process Approach (HAPA) at the inter- and the intraindividual level among older adults. METHODS: Two intensive longitudinal studies examined the HAPA model covering two different health behaviors and two different time spans: Study 1 (physical activity, N = 52 × 6 monthly observations) and Study 2 (medication adherence, N = 64 × 30 daily observations). The HAPA constructs (risk awareness, outcome expectancy, self-efficacy, intention, action planning, action control), and self-reported behaviors were assessed. RESULTS: Overall, at the interindividual level, results of both studies largely confirmed the associations specified by the HAPA. At the intraindividual level, results were less in line with the HAPA. Only action control emerged as consistent predictor of behavior. CONCLUSIONS: This study emphasises the importance of examining health behavior change theories at both, the inter- and the intraindividual level.

Chronic Pain: How Challenging Are DDIs in the Analgesic Treatment of Inpatients with Multiple Chronic Conditions?

BACKGROUND: Chronic pain is common in multimorbid patients. However, little is known about the implications of chronic pain and analgesic treatment on multimorbid patients. This study aimed to assess chronic pain therapy with regard to the interaction potential in a sample of inpatients with multiple chronic conditions. METHODS AND FINDINGS: We conducted a retrospective study with all multimorbid inpatients aged ≥18 years admitted to the Department of Internal Medicine of University Hospital Zurich in 2011 (n = 1,039 patients). Data were extracted from the electronic health records and reviewed. We identified 433 hospitalizations of patients with chronic pain and analyzed their combinations of chronic conditions (multimorbidity). We then classified all analgesic prescriptions according to the World Health Organization (WHO) analgesic ladder. Furthermore, we used a Swiss drug-drug interactions knowledge base to identify potential interactions between opioids and other drug classes, in particular coanalgesics and other concomitant drugs. Chronic pain was present in 38% of patients with multimorbidity. On average, patients with chronic pain were aged 65.7 years and had a mean number of 6.6 diagnoses. Hypertension was the most common chronic condition. Chronic back pain was the most common painful condition. Almost 90% of patients were exposed to polypharmacotherapy. Of the chronic pain patients, 71.1% received opioids for moderate to severe pain, 43.4% received coanalgesics. We identified 3,186 potential drug-drug interactions, with 17% classified between analgesics (without coanalgesics). CONCLUSIONS: Analgesic drugs-related DDIs, in particular opioids, in multimorbid patients are often complex and difficult to assess by using DDI knowledge bases alone. Drug-multimorbidity interactions are not sufficiently investigated and understood. Today, the scientific literature is scarce for chronic pain in combination with multiple coexisting medical conditions and medication regimens. Our work may provide useful information to enable further investigations in multimorbidity research within the scope of potential interactions and chronic pain.

Assessing adherence to multiple medications and in daily life among patients with multimorbidity.

OBJECTIVE: Chronic conditions often require multiple medication intake. However, past research has focused on assessing overall adherence or adherence to a single index medication only. This study explored adherence measures for multiple medication intake, and in daily life, among patients with multiple chronic conditions (i.e. multimorbidity). DESIGN: Eighty-four patients with multimorbidity and multiple-medication regimens completed three monthly panel questionnaires. A randomly assigned subsample additionally completed a 30-day daily diary. MAIN OUTCOME MEASURE: The Non-Adherence Report; a brief self-report measure of adherence to each prescribed medication (NAR-M), and in daily life. We further assessed the Medication Adherence Report Scale (MARS), and a subsample of participants were randomised to electronic adherence monitoring. RESULTS: The NAR-M indicated M = 94.7% adherence at Time 1 (SD = 9.3%). The NAR-M was significantly correlated with the MARS (rt1 = .52, rt2 = .57, and rt3 = .65; p < .001), and in tendency with electronically assessed adherence (rt2 = .45, rt3 = .46, p < .10). Variance components analysis indicated that between-person differences accounted for 10.2% of the variance in NAR-M adherence rates, whereas 22.9% were attributable to medication by person interactions. CONCLUSION: This study highlights the importance and feasibility of studying adherence to multiple medications differentially, and in daily life. Future studies may use these measures to investigate within-person and between-medication differences in adherence.

Prospective and retrospective memory are differentially related to self-rated omission and commission errors in medication adherence in multimorbidity.

We investigated the relations of self-rated omission errors (i.e., forgetting to take one's medication) and commission errors (i.e., unnecessary repetitions of medication intake because of forgetting that it has already been taken) in medication adherence in multimorbidity to prospective and retrospective memory performance. Moreover, we examined whether these relations were moderated by the number of medications that had to be taken. Eighty-four patients with multimorbidity (aged 28-84 years, M = 62.4) reported medication adherence regarding the last seven days and the number of medications they had to take. In addition, we administered psychometric tests on prospective memory (PM) and retrospective memory performance. We found that reported omission errors in medication adherence were related significantly to lower PM performance. This relationship was increased in individuals with a lower number of medications. In comparison, reported commission errors in medication adherence were related significantly to lower retrospective memory performance. This relationship was increased in individuals with a larger number of medications. Present data suggest that omission errors in medication adherence in multimorbidity may reflect primarily PM errors, particularly if few medications have to be taken, while commission errors may reflect mainly retrospective memory failures, especially with a large number of medications that need to be taken as prescribed. From an applied neuropsychological perspective, these results underline the importance of trying to enhance PM and retrospective memory performance in patients with multimorbidity.

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.

[Acute anterior myocardial infarction after rituximab]. / Akuter Vorderwandinfarkt nach Rituximab.

HISTORY: A 36-year-old man with a history of PR3-ANCA positive granulomatosis with polyangiitis presented with chest pain at the emergency department. Due to his underlying disease, he was treated with Rituximab in regular intervals. The last Rituximab infusion was admitted one day before presentation. INVESTIGATION: The ECG showed marked ST elevation in V1-V4. DIAGNOSIS, TREATMENT AND COURSE: After the diagnosis of an acute anterior myocardial infarction, the patient was prepared for acute percutaneous coronary intervention. During transport to the cardiac catheterization laboratory, he suffered a cardiac arrest due to ventricular fibrillation. After successful resuscitation, the cardiac catheterization showed no evidence of relevant coronary stenosis. Because of suspected coronary spasm of left anterior descending artery the therapy was extended with a calcium channel blocker. A single chamber cardiac defibrillator was implanted for secondary prevention. CONCLUSION: Acute coronary syndrome is a possible side effect of rituximab therapy. The reported case emphasizes a correlation between Rituximab therapy and cardiac event.