«Smarter Medicine»: 5 Interventionen, die in der ambulanten allgemeinen inneren Medizin vermieden werden sollten

Seit 2012 befasst sich die Schweizerische Gesellschaft für Allgemeine Innere Medizin mit der Problematik der Überdiagnostik und Überversorgung in der Medizin. Nun hat sie beschlossen, eine Liste mit fünf Untersuchungen auf dem Gebiet der ambulanten allgemeinen inneren Medizin zusammenzustellen, die ohne oder mit nur geringem Nutzen bei zahlreichen Patienten durchgeführt werden, gleichzeitig jedoch unerwünschte Nebenwirkungen haben können und zum Anstieg der Gesundheitskosten beitragen

Determinants associated with deprivation in multimorbid patients in primary care-A cross-sectional study in Switzerland

Deprivation usually encompasses material, social, and health components. It has been shown to be associated with greater risks of developing chronic health conditions and of worse outcome in multimorbidity. The DipCare questionnaire, an instrument developed and validated in Switzerland for use in primary care, identifies patients subject to potentially higher levels of deprivation. To identifying determinants of the material, social, and health profiles associated with deprivation in a sample of multimorbid, primary care patients, and thus set priorities in screening for deprivation in this population. Secondary analysis from a nationwide cross-sectional study in Switzerland. A random sample of 886 adult patients suffering from at least three chronic health conditions. The outcomes of interest were the patients' levels of deprivation as measured using the DipCare questionnaire. Classification And Regression Tree analysis identified the independent variables that separated the examined population into groups with increasing deprivation scores. Finally, a sensitivity analysis (multivariate regression) confirmed the robustness of our results. Being aged under 64 years old was associated with higher overall, material, and health deprivation; being aged over 77 years old was associated with higher social deprivation. Other variables associated with deprivation were the level of education, marital status, and the presence of depression or chronic pain. Specific profiles, such as being younger, were associated with higher levels of overall, material, and health deprivation in multimorbid patients. In contrast, patients over 77 years old reported higher levels of social deprivation. Furthermore, chronic pain and depression added to the score for health deprivation. It is important that GPs consider the possibility of deprivation in these multimorbid patients and are able to identify it, both in order to encourage treatment adherence and limit any forgoing of care for financial reasons

How do family physicians communicate about cardiovascular risk? Frequencies and determinants of different communication formats

Background: Patients understand information about risk better if it is communicated in numerical or visual formats (e.g. graphs) compared to verbal qualifiers only. How frequently different communication formats are used in clinical primary care settings is unknown. Methods: We collected socioeconomic and patient understanding data using questionnaires and audio-recorded consultations about cardiovascular disease risk. The frequencies of the communication formats were calculated and multivariate regression analysis of associations between communication formats, patient and general practitioner characteristics, and patient subjective understanding was performed. Results: In 73% of 70 consultations, verbal qualifiers were used exclusively to communicate cardiovascular risk, compared to numerical (11%) and visual (16%) formats. Female GPs and female patient's gender were significantly associated with a higher use of verbal formats compared to visual formats (p = 0.001 and p = 0.039, respectively). Patient subjective understanding was significantly higher in visual counseling compared to verbal counseling (p = 0.001). Conclusions: Verbal qualifiers are the most often used communication format, though recommendations favor numerical and visual formats, with visual formats resulting in better understanding than others. Also, gender is associated with the choice of communication format. Barriers against numerical and visual communication formats among GPs and patients should be studied, including gender aspects. Adequate risk communication should be integrated into physicians' education

Sleep deprivation differentially alters the mRNA and protein levels of neurogranin in rat brain.

The mRNA level of the 17-kDa protein neurogranin (NG), a postsynaptic substrate of the protein kinase C, has previously been found to be decreased in rat forebrain after 24-h sleep deprivation (SD). To investigate the functional significance of this finding in various forebrain regions, the effect of 24-h SD on the mRNA level and the protein level of NG was determined in the cerebral cortex, hippocampus, and the total of the remaining subcortical forebrain plus midbrain areas (SFMA) of rats. In these areas, high levels of both NG mRNA and NG protein were detected by in situ hybridization and immunohistochemistry, respectively. NG protein was recognized in brain tissue by newly developed polyclonal antibodies. As determined by RNase protection assays, the level of NG mRNA was decreased in SFMA by 34 +/- 7% (P < 0.05) after 24-h SD, and was not significantly affected in the cerebral cortex and hippocampus. In contrast, on Western blots, the protein concentration of NG was reduced in the cerebral cortex by 37 +/- 7% (P < 0.05) whereas no significant changes were present in other brain areas tested. The results indicate that the mRNA and protein levels of NG are differentially modulated in rat brain by the prolongation of the waking period

Inappropriate use of arthroscopic meniscal surgery in degenerative knee disease

Background and purpose - Current evidence suggests that arthroscopic knee surgery has no added benefit compared with non-surgical management in degenerative meniscal disease. Yet in many countries, arthroscopic partial meniscectomy (APM) remains among the most frequently performed surgeries. This study quantifies and characterizes the dynamics of the current use of knee arthroscopies in Switzerland in a distinctively non-traumatic patient group. Methods - We assessed a non-accident insurance plan of a major Swiss health insurance company for surgery rates of APM, arthroscopic debridement and lavage in patients over the age of 40, comparing the years 2012 and 2015. Claims were analyzed for prevalence of osteoarthritis, related interventions and the association of surgery with insurance status. Results - 648,708 and 647,808 people were examined in 2012 and 2015, respectively. The incidence of APM, debridement, and lavage was 388 per 10(5) person-years in 2012 and 352 per 10(5) person-years in 2015 in non-traumatic patients over the age of 40, consisting mostly of APM (96%). Between years, APM surgery rates changed in patients over the age of 65 (p < 0.001) but was similar in patients aged 40-64. Overall prevalence of osteoarthritis was 25%. Insurance status was independently associated with arthroscopic knee surgery. Interpretation - APM is widely used in non-traumatic patients in Switzerland, which contrasts with current evidence. Many procedures take place in patients with degenerative knee disease. Surgery rates were similar in non-traumatic middle-aged patients between 2012 and 2015. Accordingly, the potential of inappropriate use of APM in non-traumatic patients in Switzerland is high

Characterization and sleep deprivation-induced expression modulation of dendrin, a novel dendritic protein in rat brain neurons.

We report on the characterization of the novel rat brain protein dendrin which is encoded by the brain-specific transcript 464. On immunoblots, two protein variants (81 kD, 89 kD) were identified in cytosolic and membraneous protein fractions. The variants are most abundant in the hippocampus, notably in apical dendrites of CA1 pyramidal cells. Dendritic and perikaryal immunolabelling is apparent in neurons of the cerebral cortex, dentate gyrus, subiculum, amygdala, and preoptic areas. In cortical and hippocampal dendrites, electron-dense immunoreaction is associated with the endoplasmic reticulum, the plasma membrane, and spine heads. An association of dendrin with polyribosomes and the presence of its mRNA in dendrites both provide evidence for dendritic mRNA translation. In the rat forebrain, dendrin expression is altered after an extended period of wakefulness. Twenty-four-hour sleep deprivation decreases the mRNA and protein concentrations of both variants in subcortical forebrain plus midbrain areas by 24 +/- 11% (P < 0.05) and 40 +/- 14% (P < 0.1), respectively, as measured relative to beta-actin mRNA and neural actin. In the cerebral cortex and hippocampus, the relative mRNA level remains unchanged whereas the cortical protein concentration is reduced by 42 +/- 10% (P < 0.05). Thus, dendrin belongs to a new class of dendritic proteins whose expression is differentially modulated by prolonged behavioral activity