How time consuming are general practitioners' home visits? Insights from a cross-sectional study in Switzerland

BACKGROUND

Worldwide, the number of home visits has been decreasing over past decades. Lack of time and long journeys have been reported to hinder general practitioners (GPs) from conducting home visits. In Switzerland also, home visits have declined. Time constraints in a busy GP practice could be one reason. Therefore, the aim of this study was to analyse the time requirements of home visits in Switzerland.

METHODS

A one-year cross-sectional study involving GPs from the Swiss Sentinel Surveillance System (Sentinella) was conducted in 2019. GPs provided basic information on all home visits performed throughout the year and additionally detailed reports of up to 20 consecutive home visits. Univariable and multivariable logistic regression analyses were run to identify factors affecting journey and consultation duration.

RESULTS

In total, 95 GPs conducted 8489 home visits in Switzerland, 1139 of which have been characterised in detail. On average, GPs made 3.4 home visits per week. Average journey and consultation duration were 11.8 and 23.9 minutes, respectively. Prolonged consultations were provided by GPs working part-time (25.1 minutes), in group practice (24.9 minutes) or in urban regions (24.7 minutes). Rural environments and short journey to patient's home were both found to lower the odds of performing a long consultation compared to a short consultation (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.16-0.44 and OR 0.60, 95% CI 0.46-0.77, respectively). Emergency visits (OR 2.20, 95% CI 1.21-4.01), out-of-hours appointments (OR 3.06, 95% CI 2.36-3.97) and day care involvement (OR 2.78, 95% CI 2.13-3.62) increased the odds of having a long consultation. Finally, patients in their 60s had markedly higher odds of receiving long consultations than patients in their 90s (OR 4.13, 95% CI 2.27-7.62), whereas lack of chronic conditions lowered the odds of a long consultation (OR 0.09, 95% CI 0.00-0.43).

CONCLUSION

GPs perform rather few but long home visits, especially for multimorbid patients. GPs working part-time, in group practice or in urban regions devote more time to home visits.

Role distribution and collaboration between specialists and rural general practitioners in long-term chronic care: a qualitative study in Switzerland

INTRODUCTION

This study explores general practitioners' (GPs') and medical specialists' perceptions of role distribution and collaboration in the care of patients with chronic conditions, exemplified by spinal cord injury.

METHODS

Semi-structured interviews with GPs and medical specialists caring for individuals with spinal cord injury in Switzerland. The physicians we interviewed were recruited as part of an intervention study. We used a hybrid framework of inductive and deductive coding to analyse the qualitative data.

RESULTS

Six GPs and six medical specialists agreed to be interviewed. GPs and specialists perceived the role of specialists similarly, namely as an expert and support role for GPs in the case of specialised questions. Specialists' expectations of GP services and what GPs provide differed. Specialists saw the GPs' role as complementary to their own responsibilities, namely as the first contact for patients and gatekeepers to specialised services. GPs saw themselves as care managers and guides with a holistic view of patients, connecting several healthcare professionals. GPs were looking for relations and recognition by getting to know specialists better. Specialists viewed collaboration as somewhat distant and focused on processes and patient pathways. Challenges in collaboration were related to unclear roles and responsibilities in patient care.

CONCLUSION

The expectations for role distribution and responsibilities differ among physicians. Different goals of GPs and specialists for collaboration may jeopardise shared care models. The role distribution should be aligned according to patients' holistic needs to improve collaboration and provide appropriate patient care.

Frequency of home visits where general practitioners are exposed to a problem different from that foreseen - a Swiss cross-sectional study

BACKGROUND

When a home visit is considered, patients' suspected health problems are important for correct triage, the decision for or against the visit and allocation of the visit to a general practitioner (GP) or a nurse practitioner. Misjudgment might lead to suboptimal patient outcomes.

OBJECTIVE

We aimed to evaluate the accuracy of suspected health problems (based on pre-visit assessments) by comparing them with the actual health problems (post-visit assessments) and investigating associated factors.

METHODS

GPs of the Swiss Sentinel Surveillance Network (Sentinella) reported pre-visit and post-visit assessments and patient characteristics for up to 20 consecutive home visits, which they conducted in 2019. Using multivariable logistic regressions, we investigated associations between patient and clinical factors and unconfirmed suspected health problems from pre-visit assessments and unforeseen actual health problems from post-visit assessments.

RESULTS

Overall, 114 GP practices participated. The GPs reported 1496 patient visits with a total of 1789 and 1762 health problems from pre-visit and post-visit assessments, respectively, that were included in the analysis. Musculoskeletal and circulatory problems were the most common in patients receiving home visits. The health problems from pre-visit and post-visit assessments were unconfirmed and unforeseen in15% and 13% of the cases, respectively. Older age (odds ratio [OR] 1.1 in 10-year steps; 95% confidence interval [95% CI] 1.0-1.3) and urgent visits (OR 1.7 compared with regular visits; 95% CI 1.1-2.6) showed a trend for more unforeseen health problems.

CONCLUSION

When home visits were conducted, about one out of seven health problems from pre-visit and post-visit assessments were unconfirmed and unforeseen. Particularly when patients were older or visits were urgent, there were higher odds of unconfirmed and unforeseen health problems.These results should be considered when triaging patients.

Nurse Practitioners in Swiss Family Practices as Potentially Autonomous Providers of Home Visits: An Exploratory Study of Two Cases

In Swiss primary care, general practitioner (GP) home visits have decreased due to impending GP shortages particularly in rural areas. Nurse practitioners (NP) are newly introduced in family practices and could potentially offer home visits to the increasing number of multimorbid elderly. We analysed consultation data from two pilot projects (Practice A and Practice B) with the goal to measure the frequency and patient characteristics of NP consultations both in the practice and on home visits, and to determine the NPs’ autonomy based on the required GP supervision. In Practice A, 17% of all NP consultations were home visits, in Practice B 51%. In both practices, the NPs saw older patients and reported higher autonomy on home visits compared to consultations in the practice. In Practice A, the NP encountered a higher share of multimorbid patients on home visits than in the practice, and the NP’s proportion of autonomously conducted consultations increased from 0% in the first month to 19% after 13 months of GP supervision. In Practice B, the NP was autonomous in about three-quarters of consultations after 2 years on the job. These first cases provide some evidence that NPs could reach a relatively high degree of autonomy and might pose a potential solution for the decreasing numbers of GP home visits to multimorbid elderly in Swiss primary care.

Potentially inappropriate testing for vitamin D deficiency: a cross-sectional study in Switzerland

Background

There is consensus that vitamin D supplementation is often indicated but population-based screening by laboratory testing for vitamin D deficiency is inadequate. Testing should be restricted to people at high risk of severe deficiency. This study describes the current lab testing for vitamin D deficiency in the adult population of Switzerland.

Methods

We assessed Swiss health insurance data (SWICA) for incidence of lab testing for vitamin D levels, comparing the years 2015 and 2018. Claims were analyzed for associations between lab testing and age, sex, medical indications, insurance status and geographic location in multivariable regression analyses. We also estimated the costs of vitamin D testing.

Results

Data from 200,043 and 200,046 persons for 2015 and 2018, respectively, were analyzed. Vitamin D level was tested in 14% of the sample population in 2015 and 20% in 2018. Testing increased by 69% for individuals aged 26–30. Testing was associated with being middle-aged to young senior citizens, female, medical indications (pregnancy, renal disease, osteoporosis, hyperparathyroidism, HIV, glucocorticoid intake), more chronic conditions, having a mandatory insurance with a low deductible, additional insurance coverage, and living in urban areas. We estimate that the total laboratory cost to mandatory insurance was about 90 million Swiss francs in 2018.

Conclusions

Despite recommendations for routine vitamin D supplementation, vitamin D testing of low risk individuals is common and increasing in Switzerland.

Oral corticosteroids for post-infectious cough in adults: study protocol for a double-blind randomized placebo-controlled trial in Swiss family practices (OSPIC trial)

BACKGROUND

Cough is a common reason for patients to visit general practices. So-called post-infectious cough is defined as lasting 3 to 8 weeks after an upper respiratory tract infection. It can be disabling in daily activities, with substantial impact on physical and psychosocial health, leading to impaired quality of life and increased health care costs. Recommendations for the management of post-infectious cough in primary care are scarce and incoherent. A systematic review and meta-analysis of randomized clinical trials (RCT) assessing patient-relevant benefits and potential harms of available treatments identified six eligible RCTs assessing different treatment regimens (i.e. inhaled fluticasone propionate, inhaled budesonide, salbutamol plus ipratropium-bromide, montelukast, nociception-opioid-1-receptor agonist, codeine, gelatine). No RCT found clear patient-relevant benefits and most had an unclear or high risk of bias. Post-infectious cough is thought to be mediated by inflammatory processes that are also present in exacerbations of asthma or chronic obstructive pulmonary diseases for which there is strong evidence that oral corticosteroids provide patient-relevant benefit without relevant harm. We therefore plan to conduct the first RCT evaluating the effectiveness of oral corticosteroids for post-infectious cough.

METHODS

We are conducting a triple-blinded randomized-controlled and multicentred superiority trial in primary health care practices in Switzerland. We will include 204 adult patients who consult their general practitioner (GP) for a cough lasting 3 to 8 weeks following an upper respiratory tract infection. Participants will be randomly allocated to either the 5-day treatment with oral corticosteroids or placebo. The primary outcome is cough-related quality of life assessed by the Leicester Cough Questionnaire score 14 days after randomization. Secondary outcomes include cough-related quality of life at several time points, overall cessation of cough and adverse events.

DISCUSSION

This RCT will provide evidence on whether oral corticosteroids are beneficial and safe in patients with post-infectious cough. Results can have a substantial impact on the well-being and management of these patients in Switzerland and beyond. An evidence-based treatment for this condition may reduce re-consultations with GPs and spending for antitussive drugs, thus possibly having an impact on health care spending.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04232449 . Prospectively registered on 18 January 2020.

Effect of a patient-centred deprescribing procedure in older multimorbid patients in Swiss primary care - A cluster-randomised clinical trial

Background

Management of patients with polypharmacy is challenging, and evidence for beneficial effects of deprescribing interventions is mixed. This study aimed to investigate whether a patient-centred deprescribing intervention of PCPs results in a reduction of polypharmacy, without increasing the number of adverse disease events and reducing the quality of life, among their older multimorbid patients.

Methods

This is a cluster-randomised clinical study among 46 primary care physicians (PCPs) with a 12 months follow-up. We randomised PCPs into an intervention and a control group. They recruited 128 and 206 patients if ≥60 years and taking ≥five drugs for ≥6 months. The intervention consisted of a 2-h training of PCPs, encouraging the use of a validated deprescribing-algorithm including shared-decision-making, in comparison to usual care. The primary outcome was the mean difference in the number of drugs per patient (dpp) between baseline and after 12 months. Additional outcomes focused on patient safety and quality of life (QoL) measures.

Results

Three hundred thirty-four patients, mean [SD] age of 76.2 [8.5] years participated. The mean difference in the number of dpp between baseline and after 12 months was 0.379 in the intervention group (8.02 and 7.64; p = 0.059) and 0.374 in the control group (8.05 and 7.68; p = 0.065). The between-group comparison showed no significant difference at all time points, except for immediately after the intervention (p = 0.002). There were no significant differences concerning patient safety nor QoL measures.

Conclusion

Our straight-forward and patient-centred deprescribing procedure is effective immediately after the intervention, but not after 6 and 12 months. Further research needs to determine the optimal interval of repeated deprescribing interventions for a sustainable effect on polypharmacy at mid- and long-term. Integrating SDM in the deprescribing process is a key factor for success.

Trial registration

Current Controlled Trials, prospectively registered ISRCTN16560559 Date assigned 31/10/2014.

The Prevention of Polypharmacy in Primary Care Patients Trial (4P-RCT).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01870-8.

Patients' experiences with the advanced practice nurse role in Swiss family practices: a qualitative study

Background

Considering shortages of general practitioners (GP) and strategies for improving the quality of health care provision, many countries have implemented interprofessional care models with advanced practice nurses (APN). International evidence suggests that APN care results in high patient satisfaction. In Switzerland, the role is still new, and the patient perspective has not yet been researched. Our aim was therefore to explore patients’ experiences with the APN role in Swiss family practices.

Methods

We conducted 22 semi-structured interviews in four different family practices with patients aged 18 to 97 suffering from minor acute to multiple chronic diseases, and who had at least one consultation with an APN. All interviews were audiotaped, transcribed verbatim, and analysed using qualitative content analysis.

Results

The analysis resulted in five themes: Despite the unfamiliarity, all patients were willing to be consulted by an APN because it was recommended by their GP (1); after several encounters, most participants perceived differences between the APN and the GP consultation in terms of the length and style of the consultations as well as the complexity of their tasks (2); the interviewees emphasised coaching, guidance, care coordination, and GP-assisting tasks as APN core competencies and attributed the characteristics empathetic, trustworthy, and competent to the APN role (3); most patients especially valued home visits and the holistic approach of the APNs, but they also noticed that in certain cases GP supervision was required (4); and due to the close collaboration between the APN and the GP, patients felt safe, well cared for and experienced improvements in physical and psychological well-being as well as in daily activities (5).

Conclusion

Our results suggested that patients value the APNs’ competencies, despite their initial lack of role knowledge. Trust in the GP seemed to be the most important factor for patients’ receptiveness toward the APN role. Overall, patients perceived an added value due to the enlargement of the scope of practice offered by APNs. The patient perspective might provide valuable insights for further APN role implementation in Swiss family practices.

Treating insomnia in Swiss primary care practices: A survey study based on case vignettes

Guidelines recommend cognitive behavioural therapy for insomnia (CBT-I) as first-line treatment for chronic insomnia, but it is not clear how many primary care physicians (PCPs) in Switzerland prescribe this treatment. We created a survey that asked PCPs how they would treat chronic insomnia and how much they knew about CBT-I. The survey included two case vignettes that described patients with chronic insomnia, one with and one without comorbid depression. PCPs also answered general questions about treating chronic insomnia and about CBT-I and CBT-I providers. Of the 820 Swiss PCPs we invited, 395 (48%) completed the survey (mean age 54 years; 70% male); 87% of PCPs prescribed sleep hygiene and 65% phytopharmaceuticals for the patient who had only chronic insomnia; 95% prescribed antidepressants for the patient who had comorbid depression. In each case, 20% of PCPs prescribed benzodiazepines or benzodiazepine receptor agonists, 8% prescribed CBT-I, 68% said they knew little about CBT-I, and 78% did not know a CBT-I provider. In the clinical case vignettes, most PCPs treated chronic insomnia with phytopharmaceuticals and sleep hygiene despite their lack of efficacy, but PCPs rarely prescribed CBT-I, felt they knew little about it, and usually knew no CBT-I providers. PCPs need more information about the benefits of CBT-I and local CBT-I providers and dedicated initiatives to implement CBT-I in order to reduce the number of patients who are prescribed ineffective or potentially harmful medications.

Differences in patient population and service provision between nurse practitioner and general practitioner consultations in Swiss primary care: a case study

Background

Primary care systems around the world have implemented nurse practitioners (NPs) to ensure access to high quality care in times of general practitioner (GP) shortages and changing health care needs of a multimorbid, ageing population. In Switzerland, NPs are currently being introduced, and their exact role is yet to be determined. The aim of this study was to get insight into patient characteristics and services provided in NP consultations compared to GP consultations in Swiss primary care.

Methods

This case study used retrospective observational data from electronic medical records of a family practice with one NP and two GPs. Data on patient-provider encounters were collected between August 2017 and December 2018. We used logistic regression to assess associations between the assignment of the patients to the NP or GP and patient characteristics and delivered services respectively.

Results

Data from 5210 patients participating in 27,811 consultations were analyzed. The average patient age was 44.3 years (SD 22.6), 47.1% of the patients were female and 19.4% multimorbid. 1613 (5.8%) consultations were with the NP, and 26,198 (94.2%) with the two GPs. Patients in NP consultations were more often aged 85+ (OR 3.43; 95%-CI 2.70–4.36), multimorbid (OR 1.37; 95%-CI 1.24–1.51; p < 0.001) and polypharmaceutical (OR 1.28; 95%-CI 1.15–1.42; p < 0.001) in comparison to GP consultations. In NP consultations, vital signs (OR 3.05; 95%-CI 2.72–3.42; p < 0.001) and anthropometric data (OR 1.33; 95%-CI 1.09–1.63; p 0.005) were measured more frequently, and lab tests (OR 1.16; 95%-CI 1.04–1.30; p 0.008) were ordered more often compared to GP consultations, independent of patient characteristics. By contrast, medications (OR 0.35; 95%-CI 0.30–0.41; p < 0.001) were prescribed or changed less frequently in NP consultations.

Conclusions

Quantitative data from pilot projects provide valuable insights into NP tasks and activities in Swiss primary care. Our results provide first indications that NPs might have a focus on and could offer care to the growing number of multimorbid, polypharmaceutical elderly in Swiss primary care.

The use of ultrasound in primary care: longitudinal billing and cross-sectional survey study in Switzerland

Background

Ultrasound imaging is utilized in Swiss primary care; however, little is known regarding the extent to which it is performed. With this study, we aim to (1) provide an overview of ultrasound use by general practitioners (GPs), and (2) determine the clinical indications of ultrasound in Swiss general practice.

Methods

This is a quantitative study, analyzing 15 years of billing data from 213 GPs in Central Switzerland, and cross-sectional survey data completed by 61 GPs attending 26 certification and refresher courses offered by the Swiss Society of Ultrasound in Medicine (SGUM).

Results

According to billing data, 49% of the GPs used ultrasound and provided 130,245 exams to 67,180 patients between 2004 and 2018. Over the years, ultrasound use became more frequent among GPs. Male GPs provide more ultrasound exams than female GPs. Patients that are female, ≥65 years, and multi-morbid had more ultrasound exams compared to males, patients < 65 years, and those with only one morbidity, respectively. GPs provided a mean of 129 ultrasound exams per physician-year. Abdominal ultrasound comprised almost 69% of all exams. According to survey data, indications covered many organ systems and clinical conditions, with abdominal indications being most frequent among them.

Conclusions

The use of ultrasound is high among general practitioners and it covers a wide range of clinical indications. Ultrasound is utilized primarily in the diagnosis of clinical indications of the abdomen, and more often for female than male patients.

Complexity as a factor for task allocation among general practitioners and nurse practitioners: a narrative review

BACKGROUND

General practitioner (GP) shortages and increasing demand for care led to the introduction of nurse practitioners (NPs) to primary care. Many concepts for task sharing among health professionals feature complexity. The aim of this narrative review was to examine how complexity is used as a factor for task allocation between GPs and NPs.

METHODS

According to the PRISMA statement, PubMed and CINAHL were searched systematically, and eligibility criteria were applied to detect literature concerning GPs and NPs in primary care and complexity in the context of task allocation. Relevant information was extracted, and a narrative analysis was performed.

RESULTS

Thirty-seven studies from seven countries were included, comprising quantitative, qualitative, and mixed methods. Complexity was used to describe patients, their needs, and health professionals' tasks. The understanding of the use of complexity as a factor for task allocation between NPs and GPs was based on the patient population (specific vs. unspecific), the setting (specific vs. unspecific), the numbers of health professionals involved (two vs. more than two), and the NP role (distinct model of care vs. no model). Despite similarities in these areas, the tasks which NPs perform range from providing minor to complex care. However, there is a slight trend towards NPs treating socially complex patients and GPs focusing on medically complex cases.

CONCLUSION

Complexity as a concept is prominent in primary care but remains broad and inconsistent as a factor for task allocation between NPs and GPs. This review can be used as a point of reference when practitioners are seeking methods for task allocation in a collaborative primary care setting.

Reduction of corticosteroid use in outpatient treatment of exacerbated COPD - Study protocol for a randomized, double-blind, non-inferiority study, (The RECUT-trial)

Background

Chronic obstructive pulmonary disease (COPD) is a major public health issue affecting approximately 4% to 7% of the Swiss population. According to current inpatient guidelines, systemic corticosteroids are important in the treatment of acute COPD exacerbations and should be given for 5 to 7 days. Several studies suggest that corticosteroids accelerate the recovery of FEV1 (forced expiratory volume in 1 second), enhance oxygenation, decrease the duration of hospitalization, and improve clinical outcomes. However, the additional therapeutic benefit regarding FEV1 recovery appears to be most apparent in the first 3 to 5 days. No data are available on the optimum duration of corticosteroid treatment in primary-care patients with acute COPD exacerbations. Given that many COPD patients are treated as outpatients, there is an urgent need to improve the evidence base on COPD management in this setting. The aim of this study is to investigate whether a 3-day treatment with orally administered corticosteroids is non-inferior to a 5-day treatment in acute exacerbations of COPD in a primary-care setting.

Methods/design

This study is a prospective double-blind randomized controlled trial conducted in a primary-care setting. It is anticipated that 470 patients with acutely exacerbated COPD will be recruited. Participants are randomized to receive systemic corticosteroid treatment of 40 mg prednisone daily for 5 days (conventional arm, n = 235) or for 3 days followed by 2 days of placebo (experimental arm, n = 235). Antibiotic treatment for 7 days is given to all patients with CRP ≥ 50 mg/l, those with a known diagnosis of bronchiectasis, or those presenting with Anthonisen type I exacerbation. Additional treatment after inclusion is left at the discretion of the treating general practitioner. Follow-up visits are performed on days 3 and 7, followed by telephone interviews on days 30, 90, and 180 after inclusion in the study. The primary endpoint is the time to next exacerbation during the 6-month follow-up period.

Discussion

The study is designed to assess whether a 3-day course of corticosteroid treatment is not inferior to the conventional 5-day treatment course in outpatients with exacerbated COPD regarding time to next exacerbation. Depending on the results, this trial may lead to a reduction in the cumulative corticosteroid dose in COPD patients.

Trial registration

ClinicalTrials.gov, NCT02386735. Registered on 12 March 2015.

Decreased mRNA and protein stability of W1282X limits response to modulator therapy

BACKGROUND

Cell-based studies have shown that W1282X generates a truncated protein that can be functionally augmented by modulators. However, modulator treatment of primary cells from individuals who carry two copies of W1282X generates no functional CFTR. To understand the lack of response to modulators, we investigated the effect of W1282X on CFTR RNA transcript levels.

METHODS

qRT-PCR and RNA-seq were performed on primary nasal epithelial (NE) cells of a previously studied individual who is homozygous for W1282X, her carrier parents and control individuals without nonsense variants in CFTR.

RESULTS

CFTR RNA bearing W1282X in NE cells shows a steady-state level of 4.2 ± 0.9% of wild-type (WT) CFTR RNA in the mother and 12.4 ± 1.3% in the father. NMDI14, an inhibitor of nonsense-mediated mRNA decay (NMD), restored W1282X mRNA to almost 50% of WT levels in the parental NE cells. RNA-seq of the NE cells homozygous for W1282X showed that CFTR transcript level was reduced to 1.7% of WT (p-value: 4.6e-3). Negligible truncated CFTR protein was generated by Flp-In 293 cells stably expressing the W1282X EMG even though CFTR transcript was well above levels observed in the parents and proband. Finally, we demonstrated that NMD inhibition improved the stability and response to correctors of W1282X-CFTR protein expressed in the Flp-In-293 cells.

CONCLUSION

These results show that W1282X can cause substantial degradation of CFTR mRNA that has to be addressed before efforts aimed at augmenting CFTR protein function can be effective.

Burden of cardiovascular disease across 29 countries and GPs' decision to treat hypertension in oldest-old

OBJECTIVES

We previously found large variations in general practitioner (GP) hypertension treatment probability in oldest-old (>80 years) between countries. We wanted to explore whether differences in country-specific cardiovascular disease (CVD) burden and life expectancy could explain the differences.

DESIGN

This is a survey study using case-vignettes of oldest-old patients with different comorbidities and blood pressure levels. An ecological multilevel model analysis was performed.

SETTING

GP respondents from European General Practice Research Network (EGPRN) countries, Brazil and New Zeeland.

SUBJECTS

This study included 2543 GPs from 29 countries.

MAIN OUTCOME MEASURES

GP treatment probability to start or not start antihypertensive treatment based on responses to case-vignettes; either low (<50% started treatment) or high (≥50% started treatment). CVD burden is defined as ratio of disability-adjusted life years (DALYs) lost due to ischemic heart disease and/or stroke and total DALYs lost per country; life expectancy at age 60 and prevalence of oldest-old per country.

RESULTS

Of 1947 GPs (76%) responding to all vignettes, 787 (40%) scored high treatment probability and 1160 (60%) scored low. GPs in high CVD burden countries had higher odds of treatment probability (OR 3.70; 95% confidence interval (CI) 3.00-4.57); in countries with low life expectancy at 60, CVD was associated with high treatment probability (OR 2.18, 95% CI 1.12-4.25); but not in countries with high life expectancy (OR 1.06, 95% CI 0.56-1.98).

CONCLUSIONS

GPs' choice to treat/not treat hypertension in oldest-old was explained by differences in country-specific health characteristics. GPs in countries with high CVD burden and low life expectancy at age 60 were most likely to treat hypertension in oldest-old. Key Points  • General practitioners (GPs) are in a clinical dilemma when deciding whether (or not) to treat hypertension in the oldest-old (>80 years of age).  • In this study including 1947 GPs from 29 countries, we found that a high country-specific cardiovascular disease (CVD) burden (i.e. myocardial infarction and/or stroke) was associated with a higher GP treatment probability in patients aged >80 years.  • However, the association was modified by country-specific life expectancy at age 60. While there was a positive association for GPs in countries with a low life expectancy at age 60, there was no association in countries with a high life expectancy at age 60.  • These findings help explaining some of the large variation seen in the decision as to whether or not to treat hypertension in the oldest-old.

Variation in GP decisions on antihypertensive treatment in oldest-old and frail individuals across 29 countries

Background

In oldest-old patients (>80), few trials showed efficacy of treating hypertension and they included mostly the healthiest elderly. The resulting lack of knowledge has led to inconsistent guidelines, mainly based on systolic blood pressure (SBP), cardiovascular disease (CVD) but not on frailty despite the high prevalence in oldest-old. This may lead to variation how General Practitioners (GPs) treat hypertension. Our aim was to investigate treatment variation of GPs in oldest-olds across countries and to identify the role of frailty in that decision.

Methods

Using a survey, we compared treatment decisions in cases of oldest-old varying in SBP, CVD, and frailty. GPs were asked if they would start antihypertensive treatment in each case. In 2016, we invited GPs in Europe, Brazil, Israel, and New Zealand. We compared the percentage of cases that would be treated per countries. A logistic mixed-effects model was used to derive odds ratio (OR) for frailty with 95% confidence intervals (CI), adjusted for SBP, CVD, and GP characteristics (sex, location and prevalence of oldest-old per GP office, and years of experience). The mixed-effects model was used to account for the multiple assessments per GP.

Results

The 29 countries yielded 2543 participating GPs: 52% were female, 51% located in a city, 71% reported a high prevalence of oldest-old in their offices, 38% and had >20 years of experience. Across countries, considerable variation was found in the decision to start antihypertensive treatment in the oldest-old ranging from 34 to 88%. In 24/29 (83%) countries, frailty was associated with GPs’ decision not to start treatment even after adjustment for SBP, CVD, and GP characteristics (OR 0.53, 95%CI 0.48–0.59; ORs per country 0.11–1.78).

Conclusions

Across countries, we found considerable variation in starting antihypertensive medication in oldest-old. The frail oldest-old had an odds ratio of 0.53 of receiving antihypertensive treatment. Future hypertension trials should also include frail patients to acquire evidence on the efficacy of antihypertensive treatment in oldest-old patients with frailty, with the aim to get evidence-based data for clinical decision-making.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0486-4) contains supplementary material, which is available to authorized users.

Vitamin D Deficiency in Unselected Patients from Swiss Primary Care: A Cross-Sectional Study in Two Seasons

Background

As published data on 25-hydroxy-cholecalciferol (25(OH)D) deficiency in primary care settings is scarce, we assessed the prevalence of hypovitaminosis D, potential associations with clinical symptoms, body mass index, age, Vitamin D intake, and skin type in unselected patients from primary care, and the extent of seasonal variations of serum 25(OH)D concentrations.

Methodology/Principal Findings

25(OH)D was measured at the end of summer and/or winter in 1682 consecutive patients from primary care using an enzyme-linked immunosorbant assay. Clinical symptoms were assessed by self-report (visual analogue scale 0 to 10), and vitamin D deficiency was defined as 25(OH)D concentrations < 50 nmol/l. 25(OH)D deficiency was present in 995 (59.2%) patients. 25(OH)D deficient patients reported more intense muscle weakness (visual analogue scale 2.7, 95% confidence interval 2.5 to 2.9) and had a higher body mass index (25.9kg/m², 25.5 to 26.2) than non-deficient patients (2.5, 2.3 to 2.7; and 24.2, 23.9 to 24.5, respectively). 25(OH)D concentrations also weakly correlated with muscle weakness (Spearman’s rho -0.059, 95% confidence interval -0.107 to -0.011) and body mass index (-0.156, -0.202 to -0.108). Self-reported musculoskeletal pain, fatigue, and age were not associated with deficiency, nor with concentrations. Mean 25(OH)D concentrations in patients with vitamin D containing medication were higher (60.6 ± 22.2 nmol/l) than in patients without medication (44.8 ± 19.2 nmol/l, p < 0.0001) but still below the targeted level of 75 nmol/l. Summer and winter 25(OH)D concentrations differed (53.4 ± 19.9 vs. 41.6 ± 19.3nmol/l, p < 0.0001), which was confirmed in a subgroup of 93 patients who were tested in both seasons (p = 0.01).

Conclusion/Significance

Nearly 60% of unselected patients from primary care met the criteria for 25(OH)D deficiency. Self-reported muscle weakness and high body mass index were associated with lower 25(OH)D levels. As expected 25(OH)D concentrations were lower in winter compared to summer.

[A very slow growing ankle swelling in a healthy male]

We describe the case report of a 66-year-old man with a very slow growing ankle tumour caused by a subcutaneous fungal abscess. Phaeoacremonium inflatipes, a member of the Dematiaceae family, was identified by needle puncture and culture of the non-odorous creamy yellow brown fluid. The fungal pseudocyst was surgically removed in toto and no further fungicidal drug therapy was required. Human infections by dematiaceous fungi causes subcutaneous phaeohyphomycosis, a rare, deep fungal infection of the skin and subcutaneous tissues usually acquired through traumatic skin lesions. In addition, systemic infections are reported, predominantly in immunosuppressed individuals.

[Prevalence and symptoms of vitamin D deficiency in general practices]

In 776 primary care patients serum vitamin D level was measured in month of september showing deficiency (<50 nmol/l) in 45,1%, severe deficiency (<30 nmol/l) in 9,8% and serum levels below the recommended target level of 75 nmol/l in 88,9% of cases. Three possible symptoms of vitamin D deficiency were assessed by a visual analogue scale (0-10): fatigue, muscle weakness, and muscle and joint pain. A significant correlation between muscle weakness and degree of vitamin D deficiency was shown (p=0,04), whereas there was no correlation in the two other symptoms. However, patients with vitamin D deficiency more frequently reported fatigue (p=0,02) and muscle weakness (p=0,009) than patients without deficiency did, and no difference was seen concerning muscle and joint pain.

Management and outcome of severely elevated blood pressure in primary care: a prospective observational study

OBJECTIVE

In primary care the management of patients with acute severely elevated blood pressure (BP) is challenging. The aim of the study was to evaluate the initial management and outcome of patients presenting to their general practitioner (GP) with severe high blood pressure.

METHODS

Twenty five general practitioners prospectively identified 164 patients presenting with severely elevated blood pressure (systolic BP >180 mm Hg and/or diastolic BP >110 mm Hg). At baseline, patients were categorised as having a hypertensive emergency, urgency or asymptomatic BP elevation. The therapeutic approach of the GPs was assessed and patient outcome at 12 month follow-up was analysed.

RESULTS

Median age of 164 patents was 71 (range 22 to 97) years, 60 (37%) were male and 107 (65%) had pre-existing hypertension. Mean baseline systolic BP was 198 ± 16 (range 145 to 255) mm Hg, mean baseline diastolic BP was 101 ± 15 (range 60 to 130). In total, 99 (60%) of patients had asymptomatic BP elevation, 50 (31%) had hypertensive urgency, and 15 (9%) had a hypertensive emergency. Only around two thirds (61%) of patients were given immediate blood pressure lowering medication (most frequently calcium antagonists). Ten patients (6%) were immediately admitted to hospital. Systolic and diastolic BP declined significantly (p <0.01) between one and six hours after study inclusion (drop of systolic and diastolic BP, 24 ± 9 and 10 ± 1, respectively) and were significantly lower (p <0.01) at three month follow-up compared to the initial measurement (drop of systolic and diastolic BP, 37 ± 6 and 14 ± 4, respectively). On average systolic BP was still above target values after three months (148 ± 21). During 12 months of follow-up patients with hypertensive emergency, hypertensive urgency, and asymptomatic BP elevation experienced a cardiovascular event in 27% vs. 6% vs. 16%, of cases respectively (p = 0.17).

CONCLUSION

The majority of 164 patients who presented with acutely and severely elevated blood pressure (BP >180 +/or >110 mm Hg) to their GPs was asymptomatic, had pre-existing hypertension and was managed in GP's office unless a hypertensive emergency was present. At three month follow-up mean systolic BP was still above target values.

Integral assessment of pollution in the Suquía River (Córdoba, Argentina) as a contribution to lotic ecosystem restoration programs

The Suquía River lower-middle basin (Córdoba, Argentina) is subject to a strong anthropic impact because it receives pollutants from different sources (industries, wastewaters, heavy traffic, agricultural land use, etc.) We have assessed the degree of watershed degradation of Suquía River lower-middle sections through the analysis of different ecosystem compartments (air, water, riparian soil, sediments and biota), in order to provide useful data to be considered in future river restoration programs. Four study sites were selected along the river (La Calera city, Córdoba city, Corazón de María village and Río Primero city) which were sampled during the low- and high-water flow periods. We analyzed: a) chemical and physical characteristics of water, sediments, and riparian soil; b) heavy metal content of water and sediments, and c) semi-volatile organic compounds in air. Besides, pollutant bioindicators such as fish assemblages, lichens (Usnea amblyoclada), vascular plants (Tradescantia pallida), and microorganisms (fecal coliform and Escherichia coli) were used to further assess the status of the river. All analyzed ecological compartments were affected by water pollution, particularly, fish assemblages, sediments and riparian soils by heavy metal and coliform bacteria. Moreover, we detected a possible contribution of sulfur and a high pollutant content in air that merit further research about other air-water exchanges. Accordingly, we strongly suggest that an action to restore or remediate the anthropic effect on the Suquía River be extended to all possible compartments along the river.

Elevated levels of plasma prekallikrein, high molecular weight kininogen and factor XI in coronary heart disease

Increased levels of hemostatic factors may play a role in the pathogenesis of myocardial infarction by triggering thrombin formation. We measured factor XII (FXII), factor XI (FXI), plasma prekallikrein (PK) and high-molecular-weight kininogen (HK) in 200 patients having survived myocardial infarction for at least 2 months, and in 100 healthy controls. We found significantly elevated levels of FXI clotting activity (FXI:C), HK:C and of the amidolytic activity of PK (PK:Am) among the patients as compared to the controls. Plasma levels of FXI:C, HK:C and PK:Am in the highest quartile were associated with an odds ratio of 1.9 (95% CI: 1.0-3.8), 2.0 (95% CI: 1.0-4.0) and 5.4 (95% CI: 2.6-11.2), respectively, compared to the respective plasma levels in the lowest quartile. After correction for established clinical and laboratory risk factors, the association between PK:Am plasma levels and myocardial infarction remained significant (P=0.0007). Combination of high PK:Am plasma levels and smoking or arterial hypertension, respectively, resulted in a more than additive relative risk for myocardial infarction.

Mortality and morbidity in reoperation comparing to first intervention in coronary revascularization

BACKGROUND

Coronary artery reoperation represents about 20% of coronary artery operations. In this study we compared mortality and morbidity of first intervention and redo operation.

METHODS

EXPERIMENTAL DESIGN

a retrospective study.

SETTINGS

patients who underwent coronary artery reoperations in a University Cardiac Surgery Division in 1991-1994.

PATIENTS

our clinical survey was composed of two groups: group A included 44 consecutive patients (mean age 60+/-7 years, males/females=41/3) who underwent a coronary artery reoperation in the years 1991-1994 at the University Cardiac Surgery Division of Turin; group B included 344 patients (mean age 58+/-8 years, males/females=289/55) randomly selected among those who underwent a first coronary operation in the above indicated period of time and centre. All patients had angina pectoris refractory to maximal medical therapy.

INTERVENTIONS

all patients underwent a coronary artery operation in extracorporeal circulation (ECC), under mild hypothermia (30-32 degrees C), during a single aortic clamp period, with antegrade cold crystalloid cardioplegia (St. Thomas).

MEASURES

comparison of clinical preoperative features, risk factors and postoperative mortality and morbidity between the two groups.

RESULTS

In reoperated patients we observed a greater mean akinesis score (p<0.001) and severe left ventricular dysfunction presence (p=0.014). Reoperation mortality was 11.4% against first operation mortality of 3.2% (p=0.03). Female gender (p=0.03), intra-aortic balloon counterpulsation need (p=0.002), adrenaline use (p=0.004) and low cardiac output syndrome (p=0.007) were all perioperative risk factors in group A.

CONCLUSIONS

Coronary artery reoperation involves a higher mortality and morbidity compared to the first operation, especially related to the reduced left ventricular function which characterises the population that undergoes reoperation.

[Pneumocystis carinii pneumonia in a, until now, healthy 46-year-old HIV-negative man]

A 46-year-old male patient was referred from a peripheral hospital with a 5 days history of high fever, dyspnea and respiratory deterioration. Direct immunofluorescence examination of bronchoalveolar fluid repeatedly showed clusters of Pneumocystis carinii. High-dose sulfamethoxazole-trimethoprim therapy was initiated and the patient recovered promptly during the following days. This otherwise healthy patient's past history was unremarkable in terms of prior infectious diseases. There was no evidence of immunodeficiency and he was not taking medication. Antibodies against HIV-1 were repeatedly negative, as were the assay for p24-antigen, PCR for HIV-DNA and HIV culture. Subpopulations of lymphocytes showed normal values. Analysis of the IgG fractions revealed a decreased subclass 2 fraction. Functional assays showed decreased biological binding capacity of this subclass 2 IgG to polysaccharide antigens. A four-fold increase of cytomegalovirus (CMV) IgG titer suggested a concomitant CMV infection or reactivation. As CMV infection is known to cause transient cellular immunodeficiency, reactivated CMV infection, in concert with IgG subclass 2 deficiency, could be a predisposing factor for P. carinii infection in this patient.

Plasma protein C inhibitor is elevated in survivors of myocardial infarction

Many studies have shown alterations of the hemostatic and fibrinolytic systems in patients with atherosclerotic disease, principally in levels of plasminogen activator inhibitor-1. However, in a large prospective study only fibrinogen, von Willebrand factor antigen, and tissue plasminogen activator antigen were found to be independent risk markers for acute coronary events. The present study evaluated the fibrinolytic system in coronary artery disease, paying particular attention to another inhibitor of fibrinolysis, plasminogen activator inhibitor-3, also called protein C inhibitor (PCI). One hundred fifteen nonanticoagulated male survivors of myocardial infarction were investigated for a range of hemostatic and fibrinolytic parameters that were compared with values in 87 age-matched healthy control male subjects. PCI active antigen was significantly (P < .03) elevated in the myocardial infarction group compared with the control group and was associated with the number of acute coronary events suffered (P = .005) but not with the severity of disease as determined by coronary angiography. Elevated PCI plasma levels can be considered as a risk marker for acute coronary events and might be of particular importance in the pathogenesis of this disease due to the interference of PCI in both the anticoagulant and fibrinolytic systems.

No association of APC resistance with myocardial infarction

Resistance to activated protein C (APC resistance) due to the factor V mutation 506 Arg-->Gln (factor V Leiden) is the most prevalent inherited risk factor for venous thromboembolism. Its association with arterial thromboembolic disease, however, is still controversial. In the present study we found no difference between the prevalence of APC resistance (assessed by the ratio of the aPTT with and without added APC) in 134 non-anticoagulated survivors of myocardial infarction and that in 100 controls of similar age and sex distribution (2.2% and 2.0%, respectively). Patients showed a significantly higher median value for the aPTT ratio than controls (2.85 and 2.66, respectively), a fact we could not explain by our data.

Variations in erythropoiesis and serum ferritin during erythropoietin therapy for anaemia of end-stage renal disease

In order to study the relationship between erythropoiesis and serum ferritin (SF) during erythropoietin (rHuEPO) therapy in the anaemia of end-stage renal disease (ESRD), 19 patients were followed without iron supplementation and at a fixed dose of the drug (40 U/kg). Twelve patients failed to attain the target haemoglobin (Hb) value, 7 of whom due to the appearance of iron deficiency. Erythropoiesis, as measured by the serum transferrin receptor concentration, increased from 12 to 120% of the basal value. This increment was not constantly associated with a proportional rise of Hb or reticulocyte count. SF decreased exponentially from a median value of 221 micrograms/dl (range 42-470) to a median value of 54 micrograms/dl (range 20-172). Halving of the basal SF value (SF-T50) was reached at the 18th-95th day of therapy (median = 43), representing a iron shift of 3.4-11.6 mg/day (median = 5.4). SF-T50 was not correlated with the Hb increase, but with that of erythropoiesis (r = 0.78; p = 0.003). The minimum SF (MSF) value attained was not correlated with the appearance of iron deficiency. The conclusion is that the rate of SF decrease during rHuEPO in ESRD is a reliable measure of iron mobilisation for erythropoiesis, but not for haematologic response. The MSF value reached during therapy is not representative of available iron for erythropoiesis.

[Hypoglycemia and multiple myeloma]

We report the case of a 78-year-old patient with recurrent attacks of severe fasting and late postprandial hypoglycemia, whose plasma showed highly elevated concentrations of immunoreactive insulin evidenced by high titers of spontaneous insulin and proinsulin-binding antibodies. Insulin autoimmune syndrome was diagnosed. Further investigations revealed a multiple myeloma of the kappa-light chain type. The monoclonal insulin-binding antibodies were characterized as IgG2-subclass and were identical with the paraprotein, thereby confirming that the insulin-binding antibodies were in fact produced by the myeloma. Together with initial symptomatic treatment, plasmapheresis was performed repeatedly to reduce the antibody pool. Subsequently octreotide therapy proved successful. The underlying myeloma was treated by chemotherapy.