Solothurner Spitäler

Ultrasound-assisted catheter-directed thrombolysis (USAT) with recombinant tissue-type plasminogen activator (rt-PA) is widely used as a reperfusion approach for acute pulmonary embolism (PE). The fibrinolytic effector protease plasmin is known to be a potent activator of the complement system. The aim of this study was to better characterize the extent of complement activation during USAT, and its relationship with the fibrinolytic system. In this single-center cohort study of USAT for PE, pulmonary-arterial hemodynamic measurements were performed, and plasma samples obtained from 35 patients before treatment start and at 6 h (during infusion of rt-PA). Hemostatic properties were evaluated with thromboelastometry and assessment of fibrinolytic markers. In addition, levels of the complement components C3a, C4a, C5a, soluble C5b-9 (sC5b-9), Ba, Bb, factor H and factor I at these time points were determined. Several complement components, including the anaphylatoxin C3a, showed a reduction during USAT. We found a positive correlation of the plasmin-antiplasmin complex (plap complex) with factor H, yet a negative correlation with both Ba and Bb, C5a and sC5b-9. The potent plasmin-inhibitor, α2-antiplasmin, displayed a positive correlation with Ba and Bb, factor I and factor H. In addition, the anaphylatoxin C5a negatively, and Ba positively predicted treatment responsiveness to USAT. In conclusion, in the setting of acute PE and reperfusion therapy with USAT, there appears to be a competing effect between plasmin-mediated complement activation and a reduction of the inflammatory trigger by resolution of obstruction and ischemia. Complement activation in PE is downregulated during USAT, an effect exceeding the complement-activating properties of plasmin.

Emergency physicians (EPs) are particularly susceptible to burnout because of the high-stress environment in which they operate, characterized by rapid decision-making, long shifts, and limited resources. This review aims to explore the prevalence and contributing factors to burnout among EPs and to describe different interventions to mitigate this issue. The most used tool to measure burnout is the Maslach Burnout Inventory (MBI), which evaluates emotional exhaustion, depersonalization, and personal accomplishment. Various studies identified both organizational and individual risk factors contributing to high burnout rates, exceeding 70% in some regions. Key organizational factors include increased workload, poor collegial relationships, and work-life conflict, while individual factors involve maladaptive coping strategies. This paper emphasizes the importance of personal and system resilience, defined as the ability to manage stress and thrive under hardship, in combating burnout. It highlights the Stanford Model of Professional Fulfillment, which focuses on cultivating a culture of wellness, enhancing practice efficiency, and fostering personal resilience through self-care and peer support. According to our literature review, proposed interventions include improving shift length and scheduling, managing workload, and reducing bureaucratic tasks. These measures aim to create a supportive environment that prioritizes clinician well-being and enhances job satisfaction. Recognizing the need for a multifaceted approach, this paper suggests combining organizational changes with individual support strategies to effectively reduce burnout rates. This paper underscores the necessity for systemic changes in EM settings to ensure sustainable healthcare delivery and improved outcomes for both patients and healthcare professionals. Implementing these strategies can lead to a more resilient workforce, capable of providing high-quality care while maintaining personal well-being.

Teaching in the operating room represents the cornerstone of surgical education. While residents need to perform enough basic procedures to gain independence, their impact on outcomes remains debated. We conducted a retrospective study using a Swiss national registry between 2009 and 2019. Patients who underwent laparoscopic cholecystectomy were identified. Baseline characteristics were analyzed, and a propensity score was constructed using age, gender, American Society of Anesthesiologists (ASA) classification, workday status, operation setting, and surgical indication. Patients were then matched in a 2:1 ratio (non-teaching vs. teaching), and surgical outcomes were assessed. The primary outcome was safety, defined by the incidence and severity of postoperative complications. We included 34,080 cholecystectomies in our analysis. After propensity-score matching, 7038 interventions used for surgical teaching were compared to 14,076 performed by board-certified surgeons. Mean cohort age was 53 years, and 7.7% of patients had an ASA>II. Our analysis found comparable safety outcomes in regard to frequency (1.5 vs. 1.6%, p = 0.5) and severity (Clavien-Dindo ≥IIIa: 42.0 vs. 42.7%, p = 0.8) of postoperative complications. The teaching group had a longer mean operating time (85 ± 38 vs. 73 ± 44 minutes, p < 0.001), while the mean postoperative LOS was comparable between groups (3.70 ± 5.64 days). Multivariate regression analysis identified older age, ASA ≥III, weekend days, and urgent setting as independent negative predictors of teaching. Teaching residents a common surgical procedure, such as cholecystectomy appears safe, with equally low complication rates and severity, despite longer operative times.

The outcome of orthopaedic and trauma surgery depends to a considerable extent on the surgeon's skills and level of training. Practical exercises are an essential pillar of a comprehensive training concept to improve surgical skills. A novel Digitally Enhanced Hands-on Surgical Training (DEHST) platform was introduced to train relevant practical skills in a safe and radiation-free environment. DEHST is a modular, transportable, cost-effective surgical skills training platform and features a proportionally reduced model of a simulated intraoperative image intensifier with an artificial X-ray engine simulating radiation-free X-ray images. A DEHST training module was developed to overcome the lack of training capabilities for the challenging task of freehand distal interlocking of intramedullary nails. The aim of this study was to evaluate the proficiency level of novices in distal intramedullary nail interlocking achieved through training with DEHST. Ten novices (group DEHST) underwent five DEHST training sessions (approximately one hour in total). Surgical performance metrics such as the time taken, number of X-rays, accuracy of nail hole roundness, and success rates were obtained during a simulated distal interlocking operation using a real image intensifier and a real tibia nail in an artificial bone model. Outcomes were compared with surgical performance of novices without DEHST training (group novices, n=10) and against surgical experts (group expert, n=10) performing the same simulated operation. The DEHST group achieved a higher success rate (90% vs. 60%) and significant better performance in terms of time (414.7 s vs. 623.4 s, p = 0.041), hole roundness (95.0% vs. 80.8%, p &lt; 0.001) compared to the novice group. A comparable performance to the expert group was observed for the number of X-rays (26.0 vs. 22.5, p = 0.281), and accuracy of hole roundness (95.0% vs 93.3%, p = 0.087). However, the participants in the DEHST group needed significantly longer time compared to the experts (414.7 s vs. 256.1 s, p = 0.001), and additionally, one participant (10%) failed to hit the nail hole with the drill bit, while 100% of the expert group were successful. DEHST has shown to be a useful tool to improve the proficiency level of novices and to train relevant practical surgical skills needed for distal interlocking of intramedullary nails. However, further investigations are needed to demonstrate the performance under the conditions of a real operation.

In addition to the treatment recommendations published by the Special Interest Group (SIG) "Mental Health" (formerly "Sleep Psychiatry") of the Swiss Society for Sleep Research, Sleep Medicine and Chronobiology (SGSSC), the following article focusses on cognitive behavioural therapy for insomnia (CBT-I), its evidence, implementation and application, including in shift work, patients on medication, older people, various formats and non-pharmacological alternatives. Chronic insomnia is a disorder characterised by hyperarousal rather than sleep deprivation. The most effective treatment is bedtime restriction. This can be accompanied by increased daytime sleepiness and concentration deficits, which can be challenging. Furthermore, it is a challenge to find activities for the time that becomes available. The number of therapy places is still insufficient. However, it has been shown that CBT-I is also effective in shortened formats, digitally or when carried out by other professional groups.

BackgroundSarcopenia, characterized by loss of muscle mass, reduced strength, and increasing frailty, is common in older adults and is often the result of underlying diseases such as advanced stages of heart failure (HF). Protein intake is crucial for maintaining muscle mass and strength. However, older adults typically consume less protein compared to younger individuals. It has recently been shown that the time of the first refrigerator opening in the morning, indicated by a door sensor, may be correlated with frailty in older individuals living alone.ObjectiveThe aim of this study is to determine whether the time of the first refrigerator opening in the morning can serve as a potential indicator of protein intake in older patients (age ≥70 years) after hospitalization for HF decompensation over a period of 6 months.MethodsThis is a substudy of a prospective interventional cohort study that aims to identify changes in digital biomarkers derived from an ambient sensor system, which may support the early detection of HF decompensation. In this substudy, the frequency and timing of refrigerator door openings in participants’ homes will be measured. To assess associations between protein intake and refrigerator openings, dietary intake will be evaluated using 24-hour dietary recalls at 3 different timepoints: at 1, 3, and 6 months after hospital discharge. All 24-hour dietary recalls will be conducted by trained dietitians in face-to-face interviews on weekdays. The primary outcome of this study will be the correlation between protein intake and the time (in minutes after midnight) of the first refrigerator door opening at each of the 3 assessment points.ResultsThe study is currently in the data collection phase. Recruitment began in February 2024. Data analysis will begin after all data have been collected. As of manuscript submission, 12 patients have been recruited. Results are expected to be published by the end of 2025.ConclusionsConsidering that protein-rich foods are typically stored in the refrigerator, the relationship between frailty and refrigerator usage may be a relevant indicator for nutritional assessment, particularly regarding protein intake. In addition, sarcopenia and frailty may also be linked to protein distribution across meals. This study will explore whether monitoring refrigerator openings can serve as a simple method for identifying increased risk of frailty and sarcopenia. Early detection through such monitoring could facilitate timely interventions and potentially reduce the risk of these conditions.Trial RegistrationClinicalTrials.gov NCT06126848; https://clinicaltrials.gov/study/NCT06126848International Registered Report Identifier (IRRID)DERR1-10.2196/66299

Neurogastroenterology disorders, also known as "Disorders of Gut-Brain Interaction" are gastrointestinal disorders that comprise a wide range of symptoms such as dysphagia, chest pain, heartburn, abdominal pain, nausea and vomiting, bloating, constipation, diarrhea or stool discharge. Scarcity of recognition, knowledge and training leading to the underdiagnosis of these conditions is associated with increased referrals to gastroenterologists or emergency room visits, along with a dramatic rise in healthcare costs and impaired quality of life. Despite advances in endoscopy and radiology, motility and pH impedance procedures remain the cornerstone of an accurate "Disorders of Gut-Brain Interaction" diagnosis, but these procedures need to be performed by well-trained personnel in a dedicated motility unit, with high-performance equipment. The primary motility procedures include high-resolution esophageal manometry and pH monitoring for esophageal function, high-resolution anorectal manometry and balloon expulsion tests for anorectal function, as well as hydrogen/methane breath tests for identifying dysbiosis and food intolerances. The purpose of this article is to highlight the importance of establishing a Neurogastroenterology and Motility Unit, and to provide an up-to-date overview on the main issues encountered when setting up a motility laboratory in the community or academic practice, including considerations for personnel training, equipment, and commonly performed motility procedures and their clinical usefulness.

BackgroundPostoperative acute kidney injury (PO-AKI) remains common after surgery. Although risk prediction models for PO-AKI exist, it is still unknown which intraoperative regime in terms of fluid and norepinephrine administration is beneficial for a specific patient. We thus aim to investigate the potential of uplift modeling—a framework combining causal inference and machine learning—in identifying patients for which certain fluid and norepinephrine regimes result in a PO-AKI-free recovery.MethodsData from a prospectively maintained cystectomy database at a single tertiary center (N = 1,482, period 2000–2020) were used. Total intraoperative fluid balance (TIFB) and norepinephrine (NE) administration were dichotomized into a high TIFB/low NE and a low TIFB/high NE regime. Primary outcome was PO-AKI. Confounding was addressed with inverse probability of treatment weighting. Uplift was defined as the difference in likelihood of no PO-AKI with a high TIFB/low NE versus low TIFB/high NE treatment regime. We modeled uplift using logistic regression and random forests as outcome models. Model performance was evaluated with the area under the Qini curve (AUQC).ResultsThe uplift models demonstrated a higher ability (AUQC: 0.30, 95%-CI: 0.26–0.30) compared to a random sorting strategy (0.06, 95%-CI: 0.02–0.06) or a traditional prediction model (AUQC: 0.06, 95%-CI: 0.03–0.06) for PO-AKI in sorting patients according to the expected treatment benefit from either a high TIFB / low NE or a low TIFB / high NE regime. The performance of the uplift models is robust with respect to the fluid-NE dichotomization.ConclusionUplift modeling provides a clinically relevant step toward personalized medicine by considering the incremental benefit of an alternative treatment versus a control treatment on a patient’s outcome, thus moving from a predictive toward a prescriptive risk assessment. We demonstrated the overall higher clinical utility of an uplift modeling approach compared to a prediction model of baseline PO-AKI risk in sorting patients according to the expected treatment benefit from either a high total intraoperative fluid balance / low norepinephrine regime or a low total intraoperative fluid balance / high norepinephrine regime with respect to postoperative acute kidney injury.

Abstract Background The main complications after ulna shaft fracture fixation are non-union and implant irritation. Standard 3.5-mm locking compression plates can cause soft tissue irritation, often requiring implant removal. Using two smaller orthogonal plates has been proposed as an alternative to address these issues. Aims The aim of this study is to compare the biomechanical properties of a single 3.5-mm locking compression plate versus double-plating using one 2.5-mm and one 2.0-mm matrix mandible plate in a human ulna shaft fracture model. Methods Eight pairs human ulnar specimens with a standardized 10 mm comminuted fracture gap were pairwise assigned for instrumentation with either double plating using a 2.5-mm and a 2.0-mm mandible plate placed posteriorly under the flexor muscles and laterally under the extensor muscles, or with a single 3.5-mm plate placed posteriorly. All constructs underwent biomechanical testing for axial, torsional, and bending stiffness, which was followed by cyclic torsional loading to failure. Interfragmentary movements were monitored by means of optical motion tracking. Results There were no significant differences between double-plating and single-plating techniques in axial stiffness (464.6±424.0 N/mm vs. 754.2±575.2 N/mm; p=0.335), torsional stiffness in supination (0.330±0.072 Nm/° vs. 0.403±0.066 Nm/°; p=0.462) or pronation (0.330±0.071 Nm/° vs. 0.406±0.068 Nm/°; p=0.307), medio-lateral bending stiffness (1.40±0.61 Nm/° vs. 0.97±0.45 Nm/°; p=0.522), and antero-posterior bending stiffness (0.80±0.01 Nm/° vs. 0.85±0.18 Nm/°; p=0.143). Double-plating showed a higher angular displacement rate during cyclic torsional loading (p=0.03), but no significant difference in shear displacement across the fracture gap (p=0.324). Cycles until failure (5° angular deformation) were 1366±685 for double-plating and 2024±958 for single plating. Both constructs failed due to bone breakage at the most distal screw. Conclusion The double-plate construct provides comparable fixation to single plating, with similar stiffness and shear displacement. Clinical trials are needed to confirm if thinner implants reduce irritation and removal rates.