Screening for acquired cystic kidney disease: A decision analytic perspective

Screening for acquired cystic kidney disease: A decision analytic perspective. Acquired cystic kidney disease (ACKD) increases the risk of renal malignancy, and many authors suggest routine screening of dialysis patients for ACKD and renal tumors. However, they have defined neither the target population, the optimal screening strategy, the magnitude of its benefit, nor its risk. We used decision analysis to evaluate strategies of performing either computed tomography (CT) or ultrasound every three years on all dialysis patients and annually on patients found to have cysts. We compared these strategies to a strategy of seeking cysts and cancer only if these are clinically suspected. The baseline analysis shows that both CT and ultrasound may decrease cancer deaths by half for patients with a life expectancy of 25 years. Screening for ACKD offers these patients as much as a 1.6 year gain in life expectancy. However, for the majority of patients beginning renal replacement therapy, age or comorbid disease substantially limits life expectancy. For such patients, the gain in life expectancy from an ACKD screening program is measured in days. Sensitivity analyses show that the benefit of screening depends on the rate of malignant transformation, which needs better definition. The gain in life expectancy does not appear to be large enough to justify an ACKD screening program for the entire ESRD population. However, for the youngest and healthiest patients, a screening program would be of benefit. The magnitude of this benefit is uncertain, because the analysis was consistently biased in favor of the screening strategies

Age and quality of in-hospital care of patients with heart failure

Background: Elderly patients may be at risk of suboptimal care. Thus, the relationship between age and quality of care for patients hospitalized for heart failure was examined. Methods: A cross-sectional study based on retrospective chart review was performed among a random sample of patients hospitalized between 1996 and 1998 in the general internal medicine wards, with a principal diagnosis of congestive heart failure, and discharged alive. Explicit criteria of quality of care, grouped into three scores, were used: admission work-up (admission score); evaluation and treatment during the stay (evaluation and treatment score); and readiness for discharge (discharge score). The associations between age and quality of care scores were analysed using linear regression models. Results: Charts of 371 patients were reviewed. Mean age was 75.7 (±11.1) years and 52% were men. There was no relationship between age and admission or readiness for discharge scores. The evaluation and treatment score decreased with age: compared with patients less than 70 years old, the score was lower by −2.6% (95% CI: −7.1 to 1.9) for patients aged 70 to 79, by −8.7% (95% CI: −13.0 to −4.3) for patients aged 80 to 89, and by −19.0% (95% CI: −26.6 to −11.5) for patients aged 90 and over. After adjustment for possible confounders, this relationship was not significantly modified. Conclusions: In patients hospitalized for congestive heart failure, older age was not associated with lower quality of care scores except for evaluation and treatment. Whether this is detrimental to elderly patients remains to be evaluate

Predictors of inappropriate hospital days in a department of internal medicine

Background This study aimed to identify predictors of inappropriate hospital days in a deparUnent of internal medicine, as a basis for quality improvement interventions. Methods The appropriateness of 5665 hospital days contributed by 500 patients admitted to the Department of Internal Medicine, Geneva University Hospitals, Switzerland, was assessed by means of the Appropriateness Evaluation Protocol. Predictor variables included patient's age and sex, manner of admission and discharge, and characteristics of hospital days (weekend, holiday, sequence). Results Overall, 15% of hospital admissions and 28% of hospital days were rated as inappropriate. In multivariate models, inappropriate hospital days were more frequent among patients whose admission was inappropriate (odds ratio [OR] = 5.3, 95% CI: 3.1-8.4) and among older patients (80-95 years: OR = 3.6. 95% CI: 1.7-7.0, versus <50 years). The likelihood of inappropriateness also increased with each subsequent hospital day, culminating on the day of discharge, regardless of the total length of stay. Conclusions This study identified both the admission and the discharge processes as important sources of inappropriate hospital use in a department of internal medicine. The oldest patients were also at high risk of remaining in the hospital inappropriately. Surprisingly, long hospital stays did not generate a higher proportion of inappropriate days than short hospital stays. This information proved useful in developing interventions to improve the hospitalization proces

Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest

The objective of this study was to identify the key elements used by prehospital emergency physicians (EP) to decide whether or not to attempt advanced life support (ALS) in asystolic out-of-hospital cardiac arrest (OHCA). From 1 January 2009 to 1 January 2017, all adult victims of asystolic OHCA in Geneva, Switzerland, were retrospectively included. Patients with signs of “obvious death” or with a Do-Not-Attempt-Resuscitation order were excluded. Patients were categorized as having received ALS if this was mentioned in the medical record, or, failing that, if at least one dose of adrenaline had been administered during cardiopulmonary resuscitation (CPR). Prognostic factors known at the time of EP's decision were included in a multivariable logistic regression model. Included were 784 patients. Factors favourably influencing the decision to provide ALS were witnessed OHCA (OR = 2.14, 95% CI: 1.43–3.20) and bystander CPR (OR = 4.10, 95% CI: 2.28–7.39). Traumatic aetiology (OR = 0.04, 95% CI: 0.02–0.08), age &gt; 80 years (OR = 0.14, 95% CI: 0.09–0.24) and a Charlson comorbidity index greater than 5 (OR = 0.12, 95% CI: 0.06–0.27) were the factors most strongly associated with the decision not to attempt ALS. Factors influencing the EP's decision to attempt ALS in asystolic OHCA are the relatively young age of the patients, few comorbidities, presumed medical aetiology, witnessed OHCA and bystander CPR

Complete remission of pure white cell aplasia associated with thymoma, autoimmune thyroiditis and type 1 diabetes

Pure white cell aplasia (PWCA) is a rare disorder of unknown origin, often associated with thymoma, characterized by selective neutropenia or pure agranulocytosis, and absence of granulocyte precursors in the bone marrow, but with normal erythroblasts and megakaryocytes. We report a case of PWCA associated with thymoma. Unusual findings in this case report included simultaneous presence of autoimmune thyroiditis, type 1 diabetes, anti-striated muscle antibodies, and the presence in the peripheral blood of CD8+ T cells that expressed a homogeneous naive phenotype. Neutrophil count became normal on immunosuppressive therapy after thymectomy

Evaluation of quality improvement interventions to reduce inappropriate hospital use

Objectives. To assess the impact of process analyses and modifications on inappropriate hospital use. Design. Pre-post comparison of inappropriate hospital use after process modifications. Setting. The Department of Internal Medicine of the Geneva University Hospitals, Switzerland. Participants. A random sample of 498 patients. Interventions. Two processes of care (i.e. non-urgent admissions and transfer to a rehabilitation hospital), which influenced inappropriate hospital use, were identified and modified. The impact of these modifications was then assessed. Main outcome measures. The proportion of inappropriate hospital admissions and inappropriate hospital days. Results. As a baseline assessment before quality improvement interventions, the appropriateness of hospital use (admissions and hospital days) was evaluated using the Appropriateness Evaluation Protocol (AEP) in a sample of 500 patients (5665 days). After modification of the two processes through a quality improvement program, inappropriate hospital use was reassessed in a sample of 498 patients (6095 days). Inappropriate hospital admissions decreased from 15 to 9% (P = 0.002) and inappropriate hospital days from 28 to 25% (P = 0.12). Conclusion. Using the AEP as a criterion, the quality improvement interventions significantly reduced inappropriate hospital use due to the process of non-urgent admissions, but the reduction of inappropriate hospital days specifically attributed to the transfer to the rehabilitation hospital did not reach statistical significanc

Evolution of Bystander Intention to Perform Resuscitation Since Last Training: Web-Based Survey

Background: Victims of out-of-hospital cardiac arrest (OHCA) have higher survival rates and more favorable neurological outcomes when basic life support (BLS) maneuvers are initiated quickly after collapse. Although more than half of OHCAs are witnessed, BLS is infrequently provided, thereby worsening the survival and neurological prognoses of OHCA victims. According to the theory of planned behavior, the probability of executing an action is strongly linked to the intention of performing it. This intention is determined by three distinct dimensions: attitude, subjective normative beliefs, and control beliefs. We hypothesized that there could be a decrease in one or more of these dimensions even shortly after the last BLS training session.Objective: The aim of this study was to measure the variation of the three dimensions of the intention to perform resuscitation according to the time elapsed since the last first-aid course.Methods: Between January and April 2019, the two largest companies delivering first-aid courses in the region of Geneva, Switzerland sent invitation emails on our behalf to people who had followed a first-aid course between January 2014 and December 2018. Participants were asked to answer a set of 17 psychometric questions based on a 4-point Likert scale (“I don’t agree,” “I partially agree,” “I agree,” and “I totally agree”) designed to assess the three dimensions of the intention to perform resuscitation. The primary outcome was the difference in each of these dimensions between participants who had followed a first-aid course less than 6 months before taking the questionnaire and those who took the questionnaire more than 6 months and up to 5 years after following such a course. Secondary outcomes were the change in each dimension using cutoffs at 1 year and 2 years, and the change regarding each individual question using cutoffs at 6 months, 1 year, and 2 years. Univariate and multivariable linear regression were used for analyses.Results: A total of 204 surveys (76%) were analyzed. After adjustment, control beliefs was the only dimension that was significantly lower in participants who took the questionnaire more than 6 months after their last BLS course (P&lt;.001). Resisting diffusion of responsibility, a key element of subjective normative beliefs, was also less likely in this group (P=.001). By contrast, members of this group were less afraid of disease transmission (P=.03). However, fear of legal action was higher in this group (P=.02).Conclusions: Control beliefs already show a significant decrease 6 months after the last first-aid course. Short interventions should be designed to restore this dimension to its immediate postcourse state. This could enhance the provision of BLS maneuvers in cases of OHCA. </sec

Differences in Basic Life Support Knowledge Between Junior Medical Students and Lay People: Web-Based Questionnaire Study

Background: Early cardiopulmonary resuscitation and prompt defibrillation markedly increase the survival rate in the event of out-of-hospital cardiac arrest (OHCA). As future health care professionals, medical students should be trained to efficiently manage an unexpectedly encountered OHCA. Objective: Our aim was to assess basic life support (BLS) knowledge in junior medical students at the University of Geneva Faculty of Medicine (UGFM) and to compare it with that of the general population. Methods: Junior UGFM students and lay people who had registered for BLS classes given by a Red Cross–affiliated center were sent invitation links to complete a web-based questionnaire. The primary outcome was the between-group difference in a 10-question score regarding cardiopulmonary resuscitation knowledge. Secondary outcomes were the differences in the rate of correct answers for each individual question, the level of self-assessed confidence in the ability to perform resuscitation, and a 6-question score, “essential BLS knowledge,” which only contains key elements of the chain of survival. Continuous variables were first analyzed using the Student t test, then by multivariable linear regression. Fisher exact test was used for between-groups comparison of binary variables. Results: The mean score was higher in medical students than in lay people for both the 10-question score (mean 5.8, SD 1.7 vs mean 4.2, SD 1.7; P Conclusions: Although junior medical students were more knowledgeable than lay people regarding BLS procedures, the proportion of correct answers was low in both groups, and changes in BLS education policy should be considered.</p