Impact of Mediterranean Diet on Lipid Composition in the Colaus-PsyColaus Study.

High adherence to the Mediterranean diet (MD) has been associated with lower incidence of cardiovascular disease, increased HDL-cholesterol levels, and decreased triglycerides (TG), and total and LDL cholesterol levels. We aimed to assess the association of MD adherence at baseline with the lipid profile both cross-sectionally and prospectively in a sample of apparently healthy community-dwelling subjects. We conducted three cross-sectional studies using data from follow-ups 1 (FU1, 2009-2012), 2 (FU2, 2014-2017), and 3 (FU3, 2018-2021) of CoLaus|PsyCoLaus, a population-based sample from Lausanne, Switzerland. Dietary intake was assessed with a food frequency questionnaire. Two MD scores (Trichopoulou and Vormund) were computed, ranging from 0 (low) to 9 (high). In total, LDL and HDL cholesterol and TG were assessed. Incident dyslipidemia was defined as hypolipidemic treatment at FU2 or FU3. Overall, 4249 participants from FU1 (53.7% women, 57.6 ± 10.5 years, Trichopoulou 4.0 ± 1.5, Vormund 4.7 ± 1.9) were included. Neither MD score correlated significantly with the lipid markers and similar results were obtained according to the hypolipidemic status. Among the 3092 untreated FU1 participants with FU2 and FU3 data, 349 (11.3%) developed dyslipidemia by FU2 or FU3. No difference in MD scores was found between participants who developed dyslipidemia and those who did not (4.1 ± 1.5 vs. 4.0 ± 1.5 and 4.8 ± 1.8 vs. 4.8 ± 1.9 for Trichopoulou and Vormund, respectively, p > 0.05). Finally, no associations were found between MD score and lipid changes at 5 or 10 years. Contrary to other studies, adherence to MD at baseline did not show any significant effects on lipid composition/incident dyslipidemia in Colaus|PsyCoLaus participants.

Association between Mediterranean Diet and Type 2 Diabetes: Multiple Cross-Sectional Analyses.

AIM: To assess whether the Mediterranean diet (MD) is associated with lower levels of type 2 diabetes (T2D) in a non-Mediterranean population. METHODS: Cross-sectional analysis of follow-ups 1 (FU1, 2009-2012, n = 4398, 45.7% men, 57.7 ± 10.5 years), 2 (FU2, 2014-2017, n = 3154, 45.0% men, 61.7 ± 9.9 years), and 3 (FU3, 2018-2021, n = 2394, 45.2% men, 65.0 ± 9.6 years) of the Colaus|PsyCoLaus study (Lausanne, Switzerland). Two MD scores (Trichopoulou, noted MD1, and Sofi, noted MD2) were calculated using participants' dietary data. T2D was defined as a fasting plasma glucose ≥7 mmol/L and/or the presence of an antidiabetic drug treatment. RESULTS: Participants with the highest MD adherence had a higher educational level, a lower BMI, were less frequent smokers, presented less frequently with hypertension, and were more frequent alcohol consumers. After multivariable adjustment, no differences were found between participants with and without T2D regarding MD scores: 3.93 ± 0.07 vs. 3.97 ± 0.02; 4.08 ± 0.10 vs. 3.98 ± 0.03, and 3.83 ± 0.11 vs. 3.97 ± 0.03, respectively, for the MD1 score in FU1, FU2, and FU3. In addition, no association was found between adherence to MD and T2D: odds ratio (and 95% confidence interval) for medium and high relative to low adherence to MD1: 0.87 (0.68-1.10) and 0.89 (0.64-1.24) in FU1, 1.04 (0.76-1.42) and 1.07 (0.68-1.67) in FU2, and 0.73 (0.53-1.03) and 0.61 (0.37-1.02) in FU3, respectively. Corresponding results for MD2 were 0.90 (0.70-1.15) and 1.03 (0.69-1.53) in FU1, 1.16 (0.82-1.63) and 1.40 (0.81-2.41) in FU2, and 0.93 (0.65-1.34) and 0.55 (0.28-1.08) in FU3. CONCLUSION: We found no association between Mediterranean diet adherence and T2D in a non-Mediterranean population.

[Artificial Intelligence in internal medicine†: development of a model predicting length of stay for non-elective admissions]. / Intelligence artificielle en médecine interne†: développement d'un modèle prédictif des durées de séjour.

Efficient management of hospitalized patients requires carefully planning each stay by taking into account patients' pathologies and hospital constraints. Therefore, the ability to accurately estimate length of stays allows for better interprofessional tasks coordination, improved patient flow management, and anticipated discharge preparation. This article presents how we built and evaluated a predictive model of length of stay based on clinical data available upon admission to a division of internal medicine. We show that Machine Learning-based approaches can predict lengths of stay with a similar level of accuracy as field experts.

Une prise en charge efficiente des patients nécessite une planification minutieuse des soins en fonction de la pathologie et des contraintes hospitalières. Dans ce contexte, une estimation de la durée de séjour permet de mieux coordonner les tâches interprofessionnelles, de gérer le flux des patients et d'anticiper la préparation à la sortie. Cet article présente la construction et l'évaluation d'un modèle prédictif de la durée de séjour à l'aide de données cliniques présentes à l'admission dans un service de médecine interne universitaire. Nous démontrons que les approches basées sur le Machine Learning sont capables de prédire des durées de séjour avec une performance similaire à celle des professionnels.

[Medical informatics in response to COVID-19 The experience of the Service of Internal Medicine at CHUV]. / Informatique médicale en réponse au Covid-19 - L'expérience du Service de médecine interne du CHUV.

Medical informatics played a decisive role in the management of the health crisis linked to COVID-19, in particular for the support of hospital clinical, governance and communication activities. In this article, we present the experience of CHUV's Internal Medicine Service in these three areas, and analyse some critical points of our information system revealed by the crisis. The development, implementation, and maintenance of new IT tools during the crisis is a challenge. The involvement of medical informatics in the decision-making processes of hospitals and the training of healthcare professionals in this field are essential to strengthen the efficiency of information technologies and the innovation of our healthcare systems.

L'informatique médicale a joué un rôle déterminant dans la gestion de la crise sanitaire liée au Covid-19, notamment pour le support des activités cliniques hospitalières, de gouvernance et de communication. Nous exposons dans cet article l'expérience vécue au sein du Service de médecine interne du CHUV dans ces trois domaines et analysons certains points critiques de notre système d'information révélés par la situation de crise. Le développement, l'implémentation et la maintenance de nouveaux outils informatiques durant la crise constituent un réel défi. L'implication de l'informatique médicale au cœur des processus décisionnels des hôpitaux et la formation des professionnels de santé dans ce domaine sont essentielles pour renforcer l'efficience des technologies de l'information et l'innovation de nos systèmes de santé.

Bios2cor: an R package integrating dynamic and evolutionary correlations to identify functionally important residues in proteins.

SUMMARY: Both dynamic correlations in protein sidechain motions during molecular dynamics (MD) simulations and evolutionary correlations in multiple sequence alignments (MSAs) of homologous proteins may reveal functionally important residues. We developed the R package Bios2cor that provides a unique framework to investigate and, possibly, integrate both analyses. Bios2cor starts with an MSA or an MD trajectory and computes correlation/covariation scores between positions in the MSA or between sidechain dihedral angles or rotamers in the MD trajectory. In addition, Bios2cor provides a variety of tools for the analysis, the visualization and the interpretation of the data. AVAILABILITY AND IMPLEMENTATION: The R package Bios2cor is available from the Comprehensive R Archive Network, at https://CRAN.R-project.org/package=Bios2cor.

[The best time for a medication: how to sweeten the pill ?] / Le bon moment pour un médicament: comment faire passer la pilule ?

Is it worth improving the effectiveness of a treatment by modulating the prescription schedule? Data show that the preferred administration timing depends on biological rhythms. Taking this into consideration can improve efficiency or reduce side effects. Food also plays a role. However, for most medications, setting a schedule that is too strict in relation to meals may not be clinically relevant and can lead to « therapeutic weariness ¼. To ensure effectiveness, tolerance and economy of a treatment, it is more important to ask patients about their habits and to define with them the best schedule.

Comment améliorer l'efficacité d'un traitement en modulant l'horaire de prise ? Différentes données montrent que le moment d'administration préférentiel dépend en partie des rythmes biologiques. En tenir compte peut améliorer l'efficacité ou diminuer les effets indésirables. La nourriture joue également un rôle. Cependant, pour la plupart des médicaments, fixer un horaire trop strict par rapport aux repas n'apporte rien cliniquement et entraîne une « fatigue thérapeutique ¼. Pour garantir l'efficacité, la tolérance et l'économicité d'un traitement, il est plus important d'interroger les patients sur leurs habitudes et de définir avec eux le bon moment de prise.

[Immune-related adverse events of checkpoint inhibitors: an internist/general practitioner's point of view]. / Effets indésirables immunomédiés des inhibiteurs de points de contrôle immunitaire: point de vue de l'interniste.

Immune checkpoint inhibitors have radically changed oncology by significantly improving prognosis and survival of many patients, even at an advanced or metastatic stage. Some patients undergoing immunotherapy develop adverse immune-related events, presenting a toxicity spectrum that can affect any organ, separately or simultaneously, with different intensities depending on the treatment used and patient characteristics. We hereby suggest a diagnostic and therapeutic approach that any internist, general practitioner or emergency doctor should have facing digestive, cardiac and pulmonary toxicities.

Les inhibiteurs de points de contrôle immunitaire (IPCI) ont radicalement changé la prise en charge oncologique en améliorant significativement le pronostic ainsi que la survie de nombreux patients, même à un stade avancé ou métastatique. Une partie des patients traités peuvent développer des effets indésirables immunomédiés avec un spectre de toxicités pouvant atteindre tous les organes, de façon isolée ou simultanée, avec une sévérité et une chronologie variables en fonction du traitement utilisé et des caractéristiques de chaque patient. Nous proposons ici la conduite à tenir du médecin interniste, généraliste ou urgentiste devant les toxicités digestives, cardiaques et pulmonaires.

Deciphering collaborative sidechain motions in proteins during molecular dynamics simulations.

The dynamic structure of proteins is essential for their functions and may include large conformational transitions which can be studied by molecular dynamics (MD) simulations. However, details of these transitions are difficult to automatically track. To facilitate their analysis, we developed two scores of correlation between sidechain dihedral angles. The CIRCULAR and OMES scores are computed from, respectively, dihedral angle values and rotamer distributions. As a case study, we applied our methods to an activation-like transition of the chemokine receptor CXCR4, observed during accelerated MD simulations. The principal component analysis of the correlation matrices was consistent with the networking structure of the top ranking pairs. Both scores identify a set of residues whose "collaborative" sidechain rotamerization immediately preceded or accompanied the conformational transition of CXCR4. Detailed analysis of the sequential order of these rotamerizations suggests that an allosteric mechanism, involving the outward motion of an asparagine residue in transmembrane helix 3, might be a prerequisite to the large scale conformational transition of CXCR4. This case study provides the proof-of-concept that the correlation methods developed here are valuable exploratory techniques to help decipher complex reactional pathways.

Study of passive sampler calibration (Chemcatcher®) for environmental monitoring of organotin compounds: Matrix effect, concentration levels and laboratory vs in situ calibration.

Application of Chemcatcher® to monitor organotin compounds [monobutyltin (MBT), dibutyltin (DBT) and tributlytin (TBT)] in sea water has been little developed. Prior to the measurement of the time-weighted average water concentrations (TWAC), a calibration step is required to determine sampling rates (Rs) which is usually assessed in a flow-through laboratory pilot where experimental conditions are well controlled. This paper investigates the effect of the water matrix (tap water vs real sea water from the harbor of Port Camargue in France) and organotin concentrations on the uptake rates of organotin compounds. Laboratory calibrations provided sampling rates in the range of 66-225 mL.day-1 in high concentration (usually used for laboratory calibrations) and in the range of 30-56 mL.day-1 at low concentrations (environmental range). When the tank is filled with real sea water, sampling rates were found to be in the range of 38-177 mL.day-1. In order to demonstrate the efficiency of Chemcatcher® in real conditions, in situ calibration was done in the harbor of Port Camargue. This calibration has been done in order to replicate environmental conditions: compounds concentrations, hydrodynamic and water matrix effects. To compare the impact of calibration procedures on TWAC determination, Chemcatcher® was deployed in the harbor of Port Camargue and spot sampling was performed to monitor the concentrations of organotins in water throughout the exposure period. Results obtained using the field Rs determined by in situ calibration were more reliable. In this case, TWAC is in agreement with spot sampling concentration.

[Medical students at the bedside of COVID-19 patients†: motivations and challenges]. / Étudiant·e·s en médecine engagé·e·s au chevet des patient·e·s hospitalisé·e·s pour COVID-19 - Motivations et enjeux.

The SARS-CoV-2 pandemic is putting our healthcare system under exceptional pressure, given the number of affected patients. In a context of limited human healthcare resources, senior medical students represent a valuable workforce that can quickly be mobilized for patient care. This is the approach followed in Switzerland and other countries, in several outpatient structures or inpatient services, including the Department of Internal Medicine, of the Lausanne University Hospital (CHUV). In this article, we first give the floor to students who responded to our call. We conclude with important considerations in terms of students' clinical supervision. It is reminded that the involvement of students in the care of COVID-19 patients should only occur on a vo luntary basis.

La pandémie de COVID-19 met notre système de santé sous une pression exceptionnelle, au vu du nombre de patient·e·s atteint·e·s. Dans un contexte de ressources humaines médico-soignantes limitées, les étudiant·e·s en médecine avancé·e·s dans leur cursus représentent un renfort très précieux, rapidement mobilisable auprès des patient·e·s. C'est la démarche suivie en Suisse et ailleurs dans le monde par diverses structures ambulatoires ou services hospitaliers, dont le Service de médecine interne du Centre hospitalier universitaire vaudois (CHUV). Dans cet article, nous donnons tout d'abord la parole aux étudiant·e·s qui ont répondu à notre appel. Nous terminons par des considérations importantes quant à l'accueil et l'accompagnement de ces étudiant·e·s. Il est rappelé que l'engagement d'étudiant·e·s auprès de patient·e·s souffrant de COVID-19 devrait se faire sur une base volontaire uniquement.

[Organizational Impacts and Clinical Challenges of the COVID-19 Pandemic on a Swiss Tertiary Internal Medicine Department]. / Impacts organisationnels et défis cliniques de la pandémie COVID-19 pour un service hospitalier de médecine interne universitaire.

The rapid progression of COVID-19 is an organizational challenge for all hospitals. To secure the patient overflow, the Department internal medicine of the University Hospital of Lausanne increased nurse and medical workforces as well as bed capacity by 65 %, with extraordinary help from other departments. The implemented crisis management stood upon three pillars : a crisis management team, steering documents and internal communication. In this new form, the Department had already taken care of 442 COVID-19 admissions by April 16, 2020. Alongside organizational challenges, clinical issues such as rapid respiratory distress, clinical suspicions with negative PCR and treatment uncertainties in the absence of sufficient evidence were overcome. Despite the peak of the pandemic appearing to have passed, the next phase could be just as complicated.

La progression rapide du COVID-19 constitue un défi organisationnel pour tous les hôpitaux. Pour anticiper un afflux important de patients, le service de médecine interne du CHUV a ainsi augmenté ses forces de travail médico-soignantes et son nombre de lits de 65 % avec un soutien extraordinaire de toute l'institution. Pour opérer ces changements majeurs, l'organisation de crise mise en place s'est appuyée sur trois piliers : une cellule de conduite, des documents de pilotage et une communication interne. Sous cette nouvelle forme, le service a pris en charge 442 hospitalisations COVID-19 jusqu'au 16 avril 2020. Si les enjeux organisationnels ont été majeurs, la gestion des situations complexes, comme les manifestations respiratoires et les multiples incertitudes cliniques diagnostiques et thérapeutiques, ont été également une gageure. Le pic de la pandémie semble passé, mais la prochaine phase pourrait constituer un nouveau défi organisationnel.

Inter-hospital comparison of working time allocation among internal medicine residents using time-motion observations: an innovative benchmarking tool.

OBJECTIVES: The vast majority of residents' working time is spent away from patients. In hospital practice, many factors may influence the resident's working day structure.Using an innovative method, we aimed to compare working time allocation among internal medicine residents using time-motion observations. The first study goal was to describe how the method could be used for inter-hospital comparison. The secondary goal was to learn about specific differences in the resident's working day structure in university and non-university hospital settings. DESIGN: Two separate time-motion studies. Trained peer-observers followed the residents during weekday day shifts with a tablet, able to record 22 different activities and corresponding context (with patient, phone, colleague or computer). SETTING: Internal medicine residencies at a university (May-July 2015) and a non-university (September-October 2016) community hospital. PARTICIPANTS: 28 residents (mean age: 29 years, average postgraduate training: 30 months) at university hospital, 21 residents (mean age: 30 years, average postgraduate training: 17 months) at non-university hospital. OUTCOMES: Time spent with patients and time dedicated to activities directly related to patients; description of main differences of time allocation between hospitals. RESULTS: Cumulatively 1051 hours of observation (566 (university hospital)+486 (non-university hospital)) and 92 day shifts (49+43) were evaluated. Daily working time was 11.5 versus 11.3 hours. A median daily period of 195 min (IQR 179-211, 27.9%) and 116 min (IQR 98-134, 17.2%) (p<0.001) was dedicated to direct patient care, respectively. CONCLUSIONS: We successfully identified differences potentially related to each hospital structure and organisation. Inter-hospital comparisons could help set up interventions aiming to improve workday structure and experience of residents.

[Internal medicine, seen from the mouth]. / La médecine interne vue depuis la bouche.

Many diseases affect the oral cavity. Therefore, the mouth is an organ that internists should observe carefully. Hereafter we present five illustrations of oral semiology that reflect a systemic condition: a strawberry tongue, an ulceration, a labial lesion, a gingival hyperplasia and a gingival hyperpigmentation. Each time, a differential diagnosis is to be considered, potentially allowing the identification of severe diseases.

Un grand nombre de pathologies ont une répercussion sur la sphère buccale. Pour l'interniste, la bouche est par conséquent un organe à observer soigneusement. Nous présentons cinq illustrations de sémiologie buccale qui traduisent une affection systémique : une langue framboisée, une ulcération, une lésion labiale, une hyperplasie gingivale et une hyperpigmentation gingivale. À chaque fois, un diagnostic différentiel doit être évoqué, permettant potentiellement l'identification de maladies sévères.

Medication reconciliation in a Swiss hospital: methods, benefits and pitfalls.

OBJECTIVES: To assess the feasibility and main obstacles to the implementation of a medication reconciliation (MR) process in a Swiss hospital and to develop a standardised method which can be used in similar healthcare systems. METHODS: For this prospective, observational single-centre and single-ward study, a best possible medication history (BPMH) was established by a clinical pharmacist for 147 patients with heart failure based on two sources and a patient interview for each case. Identified discrepancies with medication histories established during emergency service were conveyed to the ward physician. At the end of each hospital stay, the planned discharge treatments were compared with the BPMHs to identify discrepancies and to propose modifications. After a final validation, the comparative treatment plans were distributed. RESULTS: MR was conducted for 120 (82%) patients and the mean time needed was 74 min/patient. At least one discrepancy was identified among 94% of the patients on admission, with 4.1 discrepancies found per patient (mainly omissions). At discharge, 83% of the patients had at least one discrepancy, with 2.3 discrepancies found per patient (mainly unintentional substitutions). The majority (86%) of pharmaceutical interventions to adjust the discharge prescriptions were accepted by the physician. CONCLUSIONS: A standardised method of MR which offers precise definitions of discrepancies and key tools for the process was developed. This method was applicable to most of our cohort and it effectively identified medication discrepancies. Two potential obstacles for its implementation are the time needed for MR and the questionable impact of pharmaceutical interventions on discrepancies.

Evolution of chemokine receptors is driven by mutations in the sodium binding site.

Chemokines and their receptors (members of the GPCR super-family) are involved in a wide variety of physiological processes and diseases; thus, understanding the specificity of the chemokine receptor family could help develop new receptor specific drugs. Here, we explore the evolutionary mechanisms that led to the emergence of the chemokine receptors. Based on GPCR hierarchical classification, we analyzed nested GPCR sets with an eigen decomposition approach of the sequence covariation matrix and determined three key residues whose mutation was crucial for the emergence of the chemokine receptors and their subsequent divergence into homeostatic and inflammatory receptors. These residues are part of the allosteric sodium binding site. Their structural and functional roles were investigated by molecular dynamics simulations of CXCR4 and CCR5 as prototypes of homeostatic and inflammatory chemokine receptors, respectively. This study indicates that the three mutations crucial for the evolution of the chemokine receptors dramatically altered the sodium binding mode. In CXCR4, the sodium ion is tightly bound by four protein atoms and one water molecule. In CCR5, the sodium ion is mobile within the binding pocket and moves between different sites involving from one to three protein atoms and two to five water molecules. Analysis of chemokine receptor evolution reveals that a highly constrained sodium binding site characterized most ancient receptors, and that the constraints were subsequently loosened during the divergence of this receptor family. We discuss the implications of these findings for the evolution of the chemokine receptor functions and mechanisms of action.

Effectiveness of a transition plan at discharge of patients hospitalized with heart failure: a before-and-after study.

AIMS: We evaluated the effectiveness of a multidisciplinary transition plan to reduce early readmission among heart failure patients. METHODS AND RESULTS: We conducted a before-and-after study in a tertiary internal medicine department, comparing 3 years of retrospective data (pre-intervention) and 13 months of prospective data (intervention period). Intervention was the introduction in 2013 of a transition plan performed by a multidisciplinary team. We included all consecutive patients hospitalized with symptomatic heart failure and discharged to home. The outcomes were the fraction of days spent in hospital because of readmission, based on the sum of all days spent in hospital, and the rate of readmission. The same measurements were used for those with potentially avoidable readmissions. Four hundred thirty-one patients were included and compared with 1441 patients in the pre-intervention period. Of the 431 patients, 138 received the transition plan while 293 were non-completers. Neither the fraction of days spent for readmissions nor the rate of readmission decreased during the intervention period. However, non-completers had a higher rate of the fraction of days spent for 30 day readmission (19.2% vs. 16.1%, P = 0.002) and for potentially avoidable readmission (9.8% vs. 13.2%, P = 0.001). The rate of potentially avoidable readmission decreased from 11.3% (before) to 9.9% (non-completers) and 8.7% (completers), reaching the adjusted expected range given by SQLape® (7.7-9.1%). CONCLUSIONS: A transition plan, requiring many resources, could decrease potentially avoidable readmission but shows no benefit on overall readmission. Future research should focus on potentially avoidable readmissions and other indicators such as patient satisfaction, adverse drug events, or adherence.

Meta-analysis of the effectiveness of nursing discharge planning interventions for older inpatients discharged home.

AIM: To determine the effectiveness of nursing discharge planning interventions on health-related outcomes for older inpatients discharged home. BACKGROUND: Inadequate discharge planning for the ageing population poses significant challenges for health services. Effective discharge planning interventions have been examined in several studies, but little information is available on nursing interventions for older people. Despite the research published on the importance of discharge planning, the impact on patient's health outcomes still needs to be evaluated in practice. DESIGN: Systematic review and meta-analysis. DATA SOURCES: A systematic search was undertaken across 13 databases to retrieve published and unpublished studies in English between 2000-2015. REVIEW METHODS: Critical appraisal, data extraction and meta-analysis followed the methodology of the Joanna Briggs Institute. RESULTS: Thirteen studies were included in the review, 2 of 13 were pilot studies and one had a pre-post design. Included studies involved 3,964 participants with a median age of 77 years. Nurse discharge planning did not significantly reduce hospital readmission or quality of life, except readmission was lower across studies conducted in the USA. The overall effect score for nurse discharge planning on length of stay was statistically significant and positive. CONCLUSION: Nursing discharge planning is a complex intervention and difficult to evaluate. Findings suggest that nursing discharge planning for older inpatients discharged home increases the length of stay yet neither reduces readmission rate nor improves quality of life.

Computer usage and task-switching during resident's working day: Disruptive or not?

BACKGROUND: Recent implementation of electronic health records (EHR) has dramatically changed medical ward organization. While residents in general internal medicine use EHR systems half of their working time, whether computer usage impacts residents' workflow remains uncertain. We aimed to observe the frequency of task-switches occurring during resident's work and to assess whether computer usage was associated with task-switching. METHODS: In a large Swiss academic university hospital, we conducted, between May 26 and July 24, 2015 a time-motion study to assess how residents in general internal medicine organize their working day. RESULTS: We observed 49 day and 17 evening shifts of 36 residents, amounting to 697 working hours. During day shifts, residents spent 5.4 hours using a computer (mean total working time: 11.6 hours per day). On average, residents switched 15 times per hour from a task to another. Task-switching peaked between 8:00-9:00 and 16:00-17:00. Task-switching was not associated with resident's characteristics and no association was found between task-switching and extra hours (Spearman r = 0.220, p = 0.137 for day and r = 0.483, p = 0.058 for evening shifts). Computer usage occurred more frequently at the beginning or ends of day shifts and was associated with decreased overall task-switching. CONCLUSION: Task-switching occurs very frequently during resident's working day. Despite the fact that residents used a computer half of their working time, computer usage was associated with decreased task-switching. Whether frequent task-switches and computer usage impact the quality of patient care and resident's work must be evaluated in further studies.

Allocation of Internal Medicine Resident Time in a Swiss Hospital: A Time and Motion Study of Day and Evening Shifts.

BACKGROUND: Little current evidence documents how internal medicine residents spend their time at work, particularly with regard to the proportions of time spent in direct patient care versus using computers. OBJECTIVE: To describe how residents allocate their time during day and evening hospital shifts. DESIGN: Time and motion study. SETTING: Internal medicine residency at a university hospital in Switzerland, May to July 2015. PARTICIPANTS: 36 internal medicine residents with an average of 29 months of postgraduate training. MEASUREMENTS: Trained observers recorded the residents' activities using a tablet-based application. Twenty-two activities were categorized as directly related to patients, indirectly related to patients, communication, academic, nonmedical tasks, and transition. In addition, the presence of a patient or colleague and use of a computer or telephone during each activity was recorded. RESULTS: Residents were observed for a total of 696.7 hours. Day shifts lasted 11.6 hours (1.6 hours more than scheduled). During these shifts, activities indirectly related to patients accounted for 52.4% of the time, and activities directly related to patients accounted for 28.0%. Residents spent an average of 1.7 hours with patients, 5.2 hours using computers, and 13 minutes doing both. Time spent using a computer was scattered throughout the day, with the heaviest use after 6:00 p.m. LIMITATION: The study involved a small sample from 1 institution. CONCLUSION: At this Swiss teaching hospital, internal medicine residents spent more time at work than scheduled. Activities indirectly related to patients predominated, and about half the workday was spent using a computer. PRIMARY FUNDING SOURCE: Information Technology Department and Department of Internal Medicine of Lausanne University Hospital.

Red cell distribution width and mortality in acute heart failure patients with preserved and reduced ejection fraction.

BACKGROUND: Elevated red blood cell distribution width (RDW) is a valid predictor of outcome in acute heart failure (AHF). It is unknown whether elevated RDW remains predictive in AHF patients with either preserved left ventricular ejection fraction (LVEF) ≥50% or reduced LVEF (<50%). METHODS AND RESULTS: Prospective local registry including 402 consecutive hospitalized AHF patients without acute coronary syndrome or need of intensive care. The primary outcome was all-cause mortality (ACM) at 1 year after admission. Demographic and clinical data derive from admission, echocardiographic examinations (n = 269; 67%) from hospitalization. The Cox proportional hazard model including all patients (P < 0.001) was adjusted for age, gender, and RDW quartiles. Independent predictors of 1-year ACM were cardiogenic shock (HR 2.86; CI: 1.3-6.4), male sex (HR 1.9; CI: 1.2-2.9), high RDW quartile (HR 1.66; CI: 1.02-2.8), chronic HF (HR 1.61; CI: 1.05-2.5), valvular heart disease (HR 1.61; CI: 1.09-2.4), increased diastolic blood pressure (HR 1.02 per mmHg; CI: 1.01-1.03), increasing age (HR 1.04 by year; CI: 1.02-1.07), platelet count (HR 1.002 per G/l; CI: 1.0-1.004), systolic blood pressure (HR 0.99 per mmHg; CI: 0.98-0.99), and weight (HR 0.98 per kg; CI: 0.97-0.99). A total of 114 patients (28.4%) died within the first year; ACM of all patients increased with quartiles of rising RDW (χ2 18; P < 0.001). ACM was not different between RDW quartiles of patients with reduced LVEF (n = 153; χ2 6.6; P = 0.084). In AHF with LVEF ≥50% the probability of ACM increased with rising RDW (n = 116; χ2 9.9; P = 0.0195). CONCLUSIONS: High RDW is associated with increased ACM in AHF patients with preserved but not with reduced LVEF in this study population.