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Objective Breaking bad news (BBN) is challenging for physicians and patients and specific communication strategies aim to improve these situations. This study evaluates whether an E-learning assignment could improve medical students' accurate recognition of BBN communication techniques. Methods This randomized controlled trial was conducted at the University of Basel. After a lecture on BBN, 4th year medical students were randomized to an intervention receiving an E-learning assignment on BBN or to a control group. Both groups then worked on an examination video and identified previously taught BBN elements shown in a physician-patient interaction. The number of correctly, misclassified and incorrectly identified BBN communication elements as well as missed opportunities were assessed in the examination video. Results We included 160 medical students (55% female). The number of correctly identified BBN elements did not differ between control and intervention group (mean [SD] 3.51 [2.50] versus 3.72 [2.34], p = 0.58). However, the mean number of inappropriate BBN elements was significantly lower in the intervention than in the control group (2.33 [2.57] versus 3.33 [3.39], p = 0.037). Conclusions Use of an E-learning tool reduced inappropriate annotations regarding BBN communication techniques. Practice implications This E-learning might help to further advance communication skills in medical students.

Background A recent study found serum neurofilament light chain (NfL) levels to be strongly associated with poor neurological outcome in patients after cardiac arrest. Our aim was to confirm these findings in an independent validation study and to investigate whether NfL improves the prognostic value of two cardiac arrest-specific risk scores. Methods This prospective, single-center study included 164 consecutive adult after out-of-hospital cardiac arrest (OHCA) patients upon intensive care unit admission. We calculated two clinical risk scores (OHCA, CAHP) and measured NfL on admission within the first 24 h using the single molecule array NF-light® assay. The primary endpoint was neurological outcome at hospital discharge assessed with the cerebral performance category (CPC) score. Results Poor neurological outcome (CPC > 3) was found in 60% (98/164) of patients, with 55% (91/164) dying within 30 days of hospitalization. Compared to patients with favorable outcome, NfL was 14-times higher in patients with poor neurological outcome (685 ± 1787 vs. 49 ± 111 pg/mL), with an adjusted odds ratio of 3.4 (95% CI 2.1 to 5.6, p p p p p Conclusions Admission NfL was a strong outcome predictor and significantly improved two clinical risk scores regarding prognostication of neurological outcome in patients after cardiac arrest. When confirmed in future outcome studies, admission NfL should be considered as a standard laboratory measures in the evaluation of OHCA patients.

Objectives Prior research found the gut microbiota-dependent and pro-atherogenic molecule trimethylamine-N-oxide (TMAO) to be associated with cardiovascular events as well as all-cause mortality in different patient populations with cardiovascular disease. Our aim was to investigate the prognostic value of TMAO regarding clinical outcomes in patients after out-of-hospital cardiac arrest (OHCA). Methods We included consecutive OHCA patients upon intensive care unit admission into this prospective observational study between October 2012 and May 2016. We studied associations of admission serum TMAO with in-hospital mortality (primary endpoint), 90-day mortality and neurological outcome defined by the Cerebral Performance Category (CPC) scale. Results We included 258 OHCA patients of which 44.6% died during hospitalization. Hospital non-survivors showed significantly higher admission TMAO levels (μmol L−1) compared to hospital survivors (median interquartile range (IQR) 13.2 (6.6–34.9) vs. 6.4 (2.9–15.9), p Conclusions In patients after OHCA, TMAO levels were independently associated with in-hospital mortality and other adverse clinical outcomes and may help to improve prognostication for these patients in the future. Whether TMAO levels can be influenced by nutritional interventions should be addressed in future studies.

Key Points Question Are communication interventions at hospital discharge associated with rates of hospital readmission? Findings In this systematic review and meta-analysis including a pooled analysis of 19 randomized clinical trials involving 3953 patients for the primary end point, communication interventions at discharge were significantly associated with lower readmission rates, higher medication adherence, and higher patient satisfaction. Meaning These findings suggest that communication interventions at discharge have the potential to decrease hospital readmissions and improve treatment adherence and patient satisfaction., This systematic review and meta-analysis examines the associations of communication interventions at hospital discharge with readmission rates and other patient-relevant outcomes., Importance Shortcomings in the education of patients at hospital discharge are associated with higher risks for treatment failure and hospital readmission. Whether improving communication at discharge through specific interventions has an association with patient-relevant outcomes remains unclear. Objective To conduct a systematic review and meta-analysis on the association of communication interventions at hospital discharge with readmission rates and other patient-relevant outcomes. Data Sources PubMed, EMBASE, PsycINFO, and CINAHL were systematically searched from the inception of each database to February 28, 2021. Study Selection Randomized clinical trials that randomized patients to receiving a discharge communication intervention or a control group were included. Data Extraction and Synthesis Two independent reviewers extracted data on outcomes and trial and patient characteristics. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Data were pooled using a random-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures The primary outcome was hospital readmission, and secondary outcomes included adherence to treatment regimen, patient satisfaction, mortality, and emergency department reattendance 30 days after hospital discharge. Results We included 60 randomized clinical trials with a total of 16 070 patients for the qualitative synthesis and 19 trials with a total of 3953 patients for the quantitative synthesis of the primary outcome. Of these, 11 trials had low risk of bias, 6 trials had high risk of bias, and 2 trials had unclear risk of bias. Communication interventions at discharge were significantly associated with lower readmission rates (179 of 1959 patients [9.1%] in intervention groups vs 270 of 1994 patients [13.5%] in control groups; RR, 0.69; 95% CI, 0.56-0.84), higher adherence to treatment regimen (1729 of 2009 patients [86.1%] in intervention groups vs 1599 of 2024 patients [79.0%] in control groups; RR, 1.24; 95% CI, 1.13-1.37), and higher patient satisfaction (1187 of 1949 patients [60.9%] in intervention groups vs 991 of 2002 patients [49.5%] in control groups; RR, 1.41; 95% CI, 1.20-1.66). Conclusions and Relevance These findings suggest that communication interventions at discharge are significantly associated with fewer hospital readmissions, higher treatment adherence, and higher patient satisfaction and thus are important to facilitate the transition of care.

OBJECTIVES Recent research suggests that the gender of health care providers may affect their medical performance. This trial investigated (1) the effects of the gender composition of resuscitation teams on leadership behaviour of first responders and (2) the effects of a brief gender-specific instruction on leadership behaviour of female first responders. METHODS This prospective randomised single-blinded trial, carried out between 2008 and 2016, included 364 fourth-year medical students of two Swiss universities. One hundred and eighty-two teams of two students each were confronted with a simulated cardiac arrest, occurring in the presence of a first responder while a second responder is summoned to help. The effect of gender composition was assessed by comparing all possible gender-combinations of first and second responders. The gender-specific instruction focused on the importance of leadership, gender differences in self-esteem and leadership, acknowledgement of unease while leading, professional role, and mission statement to lead was delivered orally for 10 min by a staff physician and tested by randomising female first responders to the intervention group or the control group. The primary outcome, based on ratings of video-recorded performance, was the first responders' percentage contribution to their teams' leadership statements and critical treatment decision making. RESULTS Female first responders contributed significantly less to leadership statements (53% vs. 76%; P = 0.001) and critical decisions (57% vs. 76%; P = 0.018) than male first responders. For critical treatment decisions, this effect was more pronounced (P = 0.007) when the second responder was male. The gender-specific intervention significantly increased female first responder's contribution to leadership statements (P = 0.024) and critical treatment decisions (P = 0.034). CONCLUSIONS Female first responders contributed less to their rescue teams' leadership and critical decision making than their male colleagues. A brief gender-specific leadership instruction was effective in improving female medical students' leadership behaviours.

Objectives To identify early predictors of postictal delirium in adult patients after termination of status epilepticus. Design Retrospective study. Setting ICUs at a Swiss tertiary academic medical center. Patients Status epilepticus patients treated on the ICUs for longer than 24 hours from 2012 to 2018. Interventions None. Methods Primary outcome was postictal delirium during post-status epilepticus treatment defined as an Intensive Care Delirium Screening Checklist greater than or equal to 4. Associations with postictal delirium were secondary outcomes. A time-dependent multivariable Cox proportional hazards model was used to identify risks of postictal delirium. It included variables that differed between patients with and without delirium and established risk factors for delirium (age, sex, number of inserted catheters, illness severity [quantified by the Sequential Organ Failure Assessment and Status Epilepticus Severity Score], neurodegenerative disease, dementia, alcohol/drug consumption, infections, coma during status epilepticus, dose of benzodiazepines, anesthetics, and mechanical ventilation). Measurements and main results Among 224 patients, post-status epilepticus Intensive Care Delirium Screening Checklist was increased in 83% with delirium emerging in 55% with a median duration of 2 days (interquartile range 1-3 d). Among all variables, only the history of alcohol and/or drug consumption was associated with increased hazards for delirium in multivariable analyses (hazard ratio = 3.35; 95% CI, 1.53-7.33). Conclusions Our study provides first exploratory insights into the risks of postictal delirium in adult status epilepticus patients treated in the ICU. Delirium following status epilepticus is frequent, lasting mostly 2-3 days. Our findings that with the exception of a history of alcohol and/or drug consumption, other risk factors of delirium were not found to be associated with a risk of postictal delirium may be related to the limited sample size and the exploratory nature of our study. Further investigations are needed to investigate the role of established risk factors in other status epilepticus cohorts. In the meantime, our results indicate that the risk of delirium should be especially considered in patients with a history of alcohol and/or drug consumption.

Background Although bedside case presentation contributes to patient-centered care through active patient participation in medical discussions, the complexity of medical information and jargon-induced confusion may cause misunderstandings and patient discomfort. Objective To compare bedside versus outside the room patient case presentation regarding patients' knowledge about their medical care. Design Randomized, controlled, parallel-group trial. (ClinicalTrials.gov: NCT03210987). Setting 3 Swiss teaching hospitals. Patients Adult medical patients who were hospitalized. Intervention Patients were randomly assigned to bedside or outside the room case presentation. Measurements The primary endpoint was patients' average knowledge of 3 dimensions of their medical care (each rated on a visual analogue scale from 0 to 100): understanding their disease, the therapeutic approach being used, and further plans for care. Results Compared with patients in the outside the room group (n = 443), those in the bedside presentation group (n = 476) reported similar knowledge about their medical care (mean, 79.5 points [SD, 21.6] vs. 79.4 points [SD, 19.8]; adjusted difference, 0.09 points [95% CI, -2.58 to 2.76 points]; P = 0.95). Also, an objective rating of patient knowledge by the study team was similar for the 2 groups, but the bedside presentation group had higher ratings of confusion about medical jargon and uncertainty caused by team discussions. Bedside ward rounds were more efficient (mean, 11.89 minutes per patient [SD, 4.92] vs. 14.14 minutes per patient [SD, 5.65]; adjusted difference, -2.31 minutes [CI, -2.98 to -1.63 minutes]; P Limitation Only Swiss hospitals and medical patients were included. Conclusion Compared with outside the room case presentation, bedside case presentation was shorter and resulted in similar patient knowledge, but sensitive topics were more often avoided and patient confusion was higher. Physicians presenting at the bedside need to be skilled in the use of medical language to avoid confusion and misunderstandings. Primary funding source Swiss National Foundation (10531C_ 182422).

ObjectiveTo uncover clinical characteristics leading to false outcome prediction of the Status Epilepticus Severity Score (STESS), a validated and broadly used clinical scoring system for outcome prediction in status epilepticus (SE).MethodsFrom 2005 to 2016, adult patients with SE treated at the University Hospital Basel, Switzerland, were included. To assess independent associations of variables differing between patients with false and correct prediction of death (STESS ≥ 3), multivariable logistic regression models were computed using automated selection.ResultsAmong 467 patients, 12% died. The median STESS was 3 (interquartile range 2–4). Regarding prediction of death, the STESS was false-positive in 51% and false-negative in 1%. Patients surviving despite having a STESS ≥3 had less fatal etiologies, less nonconvulsive SE with coma, and lower Charlson Comorbidity Index, Simplified Acute Physiology Score II, and Acute Physiology and Chronic Health Evaluation II scores. In multivariable analyses, odds for survival were high with SE types other than nonconvulsive status with coma and low with an increasing Charlson Comorbidity Index in patients with a STESS ≥ 3 (odds ratio [OR]for survival 4.23, 95% confidence interval [CI] 2.33–9.60; and ORfor survival 0.86, 95% CI 0.75–0.98). In patients with SE types other than nonconvulsive with coma, the STESS was mainly increased because they were frequently older than 65 years and had no seizure history.ConclusionsThe STESS frequently and inadequately predicts death especially in patients with SE other than nonconvulsive with coma and few comorbidities. Clinicians are urged to interpret a STESS ≥3 with caution in such patients.

Objective To characterize a critically ill cohort with status epilepticus (SE) by the illness severity scoring systems SAPS II (Simplified Acute Physiology Score II), APACHE II (Acute Physiology and Chronic Health Evaluation II), and SOFA (Sequential Organ Failure Assessment), and to compare their performance with the STESS (Status Epilepticus Severity Score) for outcome prediction. Methods The prospective cohort study was carried out at the University Hospital Basel, a Swiss tertiary academic medical care center. Consecutive adult SE patients hospitalized in the intensive care units from 2011 to 2016 were included. Illness severity scores and additional clinical data were recorded. Logistic regression models using automated variable selection were applied to identify scores associated with no return to functional and neurological baseline and death. Measures of discrimination and calibration were assessed. Results Among 184 patients, 33% returned to baseline. Median scores of the illness severity scores were within the lowest third of the possible scoring ranges, and all differed significantly between patients with and without return to baseline. The areas under the receiver operating curves for the prediction of no return to baseline and death ranged from 0.64 to 0.73, with the highest value for the STESS predicting no return to baseline. Measures of calibration revealed adequate model fit for all analyses. Among integral components of the scoring systems, only the Glasgow Coma Scale (GCS) differed significantly between patients with and without return to baseline. In multivariable analyses, decreasing GCS and increasing STESS had the strongest associations (odds ratio [OR] = 0.84, 95% confidence interval [CI] = 0.77-0.93 and OR = 1.34, 95% CI = 1.05-1.68, respectively) with no return to baseline independent of all other scoring systems, whereas the APACHE II revealed the strongest association with death (OR = 1.15, 95% CI = 1.06-1.25). Significance Although complex illness severity scoring systems in SE patients facilitate benchmarking and comparisons with other severely ill patient cohorts, they offer no advantages over the STESS and GCS regarding prediction of no return to baseline.

Objective During cardiopulmonary resuscitation (CPR), it remains unclear whether designating an individual person as team leader compared with emergent leadership results in better team performance. Also, the effect of CPR team size on team performance remains understudied. Methods This randomized-controlled trial compared designated versus emergent leadership and size of rescue team (3 vs 6 rescuers) on resuscitation performance. Results We included 90 teams with a total of 408 students. No difference in mean (±SD) hands-on time (seconds) were observed between emergent leadership (106 ± 30) compared to designated leadership (103 ± 27) groups (adjusted difference − 2.97 (95%CI -15.75 to 9.80, p = 0.645), or between smaller (103 ± 30) and larger teams (106 ± 26, adjusted difference 3.53, 95%CI -8.47 to 15.53, p = 0.56). Emergent leadership groups had a shorter time to circulation check and first defibrillation, but the quality of CPR based on arm and shoulder position was lower. No differences in CPR quality measures were observed between smaller and larger teams. Conclusions Within this international US/Swiss trial, leadership designation and larger team size did not improve hands-on time, but emergent leadership teams initiated defibrillation earlier. Improvements in performance may be more likely to be achieved by optimization of emergent leadership than increasing the size of cardiac arrest teams.

BackgroundDue to the dramatic measures accompanying isolation and the general uncertainty and fear associated with COVID-19, patients and relatives may be at high risk for adverse psychological outcomes. Until now there has been limited research focusing on the prevalence of psychological distress and associated factors in COVID-19 patients and their relatives. The objective of our study was to assess psychological distress in COVID-19 patients and their relatives 30 days after hospital discharge.MethodsIn this prospective observational cohort study at two Swiss tertiary-care hospitals we included consecutive adult patients hospitalized between March and June 2020 for a proven COVID-19 and their relatives. Psychological distress was defined as symptoms of anxiety and/or depression measured with the Hospital Anxiety and Depression Scale (HADS), i.e., a score of ≥8 on the depression and/or anxiety subscale. We further evaluated symptoms of post-traumatic stress disorder (PTSD), defined as a score of ≥1.5 on the Impact of Event Scale-Revised (IES-R).ResultsAmong 126 included patients, 24 (19.1%) had psychological distress and 10 (8.7%) had symptoms of PTSD 30 days after hospital discharge. In multivariate logistic regression analyses three factors were independently associated with psychological distress in patients: resilience (OR 0.82; 95%CI 0.71 to 0.94; p = 0.005), high levels of perceived stress (OR 1.21; 95%CI 1.06 to 1.38; p = 0.006) and low frequency of contact with relatives (OR 7.67; 95%CI 1.42 to 41.58; p = 0.018). The model showed good discrimination, with an area under the receiver-operating characteristic curve (AUC) of 0.92. Among 153 relatives, 35 (22.9%) showed symptoms of psychological distress, and 3 (2%) of PTSD. For relatives, resilience was negatively associated (OR 0.85; 95%CI 0.75 to 0.96; p = 0.007), whereas perceived overall burden caused by COVID-19 was positively associated with psychological distress (OR 1.72; 95%CI 1.31 to 2.25; pConclusionA relevant number of COVID-19 patients as well as their relatives exhibited psychological distress 30 days after hospital discharge. These results might aid in development of strategies to prevent psychological distress in COVID-19 patients and their relatives.

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality, yet the prediction of its outcome remains challenging. Serum Acyl Carnitines (ACs), a biomarker of beta-oxidation, have been associated with cardiovascular events. We evaluated the association of different AC species with mortality and neurological outcome in a cohort of OHCA patients.We consecutively included OHCA patients in this prospective observational study upon admission to the intensive care unit. We studied the association of thirty-nine different ACs measured at admission and 30-day mortality (primary endpoint), as well as neurological outcome at hospital discharge (secondary endpoint) using the Cerebral Performance Category scale. Multivariate models were adjusted for age, gender, comorbidities and shock markers.Of 281 included patients, 137 (48.8%) died within 30 days and of the 144 survivors (51.2%), 15 (10.4%) had poor neurological outcome. While several ACs were associated with mortality, AC C2 had the highest prognostic value for mortality (fully-adjusted odds ratio 4.85 (95%CI 1.8 to 13.06, p .01), area under curve (AUC) 0.65) and neurological outcome (fully-adjusted odds ratio 3.96 (95%CI 1.47 to 10.66, p .01), AUC 0.63).ACs are interesting surrogate biomarkers that are associated with mortality and poor neurological outcome in patients after OHCA and may help to improve the understanding of pathophysiological mechanisms and risk stratification.

Background Gender composition, stress and leadership of a resuscitation team influence CPR performance. Whether psychological variables such as self-esteem, motivation and personality traits are associated with resuscitation performance, stress levels and gender of rescuers during a cardiac arrest scenario remains uncertain. Methods We included 108 medical students in this prospective, observational simulator study. We videotaped the resuscitation performance and assessed self-esteem, perceived stress-overload and personality traits using validated questionnaires. In addition, we analysed leadership utterances and ECG data of all participants during the simulation. The primary endpoint was cardiopulmonary resuscitation performance, defined as hands-on time within the first 180 sec. Secondary outcomes included first meaningful measure of resuscitation, leadership statements of group leaders and physiological stress parameters of rescuers. Results Adjusted for group size and leadership designation, mean self-esteem of students was significantly associated with hands-on time (adjusted regression coefficient 7.94 (95%CI 2.61 to 13.27), p

OBJECTIVES Periodic social events may influence the incidence and course of status epilepticus (SE), likely explained by patients' behavioral changes regarding alcohol intake, sleep, and compliance with antiseizure medication. However, data regarding the association between such events and SE are lacking. The aim of this study was to identify and quantify associations between periodic social events and the incidence, etiology, and outcome of SE. METHODS Adult patients who were admitted to a tertiary academic medical care center with SE from 2005 to 2015 were included. Associations between periodic social events (including birthday, Christmas, New Year's Eve, carnival, national holiday) and the number and etiologies of SE over time were calculated using linear and Poisson regression. Logistic regression was applied to identify associations between time from social events and outcome. RESULTS Four hundred nine patients with a median age of 66 years (interquartile range 52-76) were analyzed. The number of total SE events and SE in patients with known epilepsy peaked within 2 weeks following social events and then decreased with each additional day (incidence rate ratio [IRR]per day 0.99, 95% confidence interval [CI] 0.98-0.99; P

Objective Distress screening programs aim to ensure appropriate psychooncological support for cancer patients, but many eligible patients do not use these services. To improve distress management, we need to better understand patients' supportive care needs. In this paper, we report the first key finding from a longitudinal study that focused on patients' intentions to use psychooncological support and its association with distress and uptake of the psychooncology service. Methods We conducted a prospective, observational study in an Oncology Outpatient Clinic and assessed distress, intention to use psychooncological support, and uptake of the psychooncology service by using the Distress Thermometer, a semistructured interview, and hospital records. We analyzed data with a mixed-methods approach. Results Of 333 patients (mean age 61 years; 55% male; 54% Distress Thermometer ≥ 5), 25% intended to use the psychooncology service (yes), 33% were ambivalent (maybe), and 42% reported no intention (no). Overall, 23% had attended the psychooncology service 4 months later. Ambivalent patients reported higher distress than patients with no intention (odds ratio = 1.18, 95% confidence interval [1.06-1.32]) but showed significantly lower uptake behavior than patients with an intention (odds ratio = 14.04, 95% confidence interval [6.74-29.24]). Qualitative analyses revealed that ambivalent patients (maybe) emphasized fears and uncertainties, while patients with clear intentions (yes/no) emphasized knowledge, attitudes, and coping concepts. Conclusions We identified a vulnerable group of ambivalent patients with high distress levels and low uptake behavior. To optimize distress screening programs, we suggest addressing and discussing patients' supportive care needs in routine clinical practice.

OBJECTIVE: A recently published simulation study suggested that women are inferior leaders of cardiopulmonary resuscitation (CPR) efforts. The aim of this study was to compare female and male code leaders in regard to CPR outcomes in a real-world clinical setting. DESIGN: Retrospective cohort review. SETTING: Two academic, urban hospitals in San Diego, California. SUBJECTS: One thousand eighty-two adult inpatients who suffered cardiac arrest and underwent cardiopulmonary resuscitation. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: We analyzed whether physician code leader gender was independently associated with sustained return of spontaneous circulation and survival to discharge, and with markers of quality CPR. Of all arrests, 327 (30.1%) were run by female physician code leaders with 251 (76.8%) obtaining ROSC, and 122 (37.3%) surviving to discharge. Male physicians ran 757 codes obtaining ROSC in 543 (71.7%) with 226 (29.9%) surviving to discharge. When adjusting for variables, female physician code leader gender was independently associated with a higher likelihood of ROSC (OR 1.36 (95% CI [1.01, 1.85], p = 0.049) and survival to discharge (OR 1.53 (95% CI [1.15, 2.02], p

OBJECTIVE: COVID-19 causes psychological distress for patients and their relatives at short term. However, little research addressed the longer-term psychological outcomes in this population. Therefore, we aimed to prospectively assess clinically relevant psychological distress in hospitalized patients with COVID-19 and their relatives 90 days after hospital discharge. METHODS: This exploratory, prospective, observational cohort study included consecutive adult patients hospitalized in two Swiss tertiary-care hospitals between March and June 2020 for confirmed COVID-19 and their relatives. The primary outcome was psychological distress defined as clinically relevant symptoms of anxiety and/or depression measured with the Hospital Anxiety and Depression Scale (HADS) 90 days after discharge. RESULTS: Clinically relevant psychological distress 90 days after hospital discharge was present in 23/108 patients (21.3%) and 22/120 relatives (18.3%). For patients, risk and protective factors associated with clinically relevant psychological distress included sociodemographic, illness-related, psychosocial, and hospital-related factors. A model including these factors showed good discrimination, with an area under the receiver-operating characteristic curve (AUC) of 0.84. For relatives, relevant risk factors were illness-related, psychosocial, and hospital-related factors. Resilience was negatively associated with anxiety and depression in both patients and relatives and regarding PTSD in relatives only. CONCLUSION: COVID-19 is linked to clinically relevant psychological distress in a subgroup of patients and their relatives 90 days after hospitalization. If confirmed in an independent and larger patient cohort, knowledge about these potential risk and protective factors might help to develop preventive strategies.

Aim Neuron-specific enolase (NSE) increases in response to brain injury and is recommended for outcome prediction in cardiac arrest patients. Our aim was to investigate whether NSE measured at different days after a cardiac arrest and its kinetics would improve the prognostic ability of two cardiac arrest specific risk scores. Methods Within this prospective observational study, we included consecutive adult patients after cardiac arrest. We calculated the Out-of-hospital cardiac arrest (OHCA) score and the Cardiac Arrest Hospital Prognosis (CAHP) score upon ICU admission and measured serum NSE upon admission and days 1, 2, 3, 5 and 7. We calculated logistic regression models to study associations of scores and NSE levels with neurological outcome defined by Cerebral Performance Category (CPC) scale and in-hospital death. Results From 336 included patients, 180 (54%) survived until hospital discharge, of which 150 (45%) had a good neurological outcome. NSE at day 3 showed the highest prognostic accuracy (discrimination) for neurological outcome (area under the curve (AUC) 0.89) and in-hospital mortality (AUC 0.88). These results were robust in reclassification statistics and across different subgroups. NSE kinetics with admission levels serving as a baseline did not further improve prognostication. NSE on day 3 significantly improved discrimination of both clinical risk scores (CAHP from AUC 0.81 to 0.91; OHCA from AUC 0.79 to 0.89). Conclusion NSE measured at day 3 significantly improves clinical risk scores for outcome prediction in cardiac arrest patients and may thus add to clinical decision making about escalation or withdrawal of therapy in this vulnerable patient population.

Objective Highly distressed cancer patients often do not use psycho-oncological services (POS). Research on predictors of POS uptake has mainly focused on patient-related variables and less on communication variables, so we examined the link between patient-oncologist communication (ie, talking about psychosocial distress, providing detailed information, and recommending POS) and POS uptake. Methods We conducted a prospective, observational study in an Oncology Outpatient Clinic in Switzerland. Predictors (ie, patient-related variables and patient's reports of the patient-oncologist communication) were assessed via semistructured interviews, and information on outpatient POS uptake was assessed after 4 months. For statistical analysis, a multivariate logistic regression was performed. Results Of 333 participants (mean age 61 years; 55% male; 54% distress thermometer ≥5), 77 (23%) had used POS during a 4-month period. Patients who reported an oncologist-recommended POS (odds ratio [OR] = 6.27, 95% confidence interval [CI] = 3.14-12.85) and those who were not sure if they had received a recommendation (OR = 4.64, 95% CI = 1.83-11.97) were more likely to attend POS than those who reported receiving no recommendation. Talking about psychosocial distress (OR = 0.74, 95% CI = 0.38-1.46) and providing detailed information about POS did not predict POS uptake (OR = 1.06, 95% CI = 0.46-2.38). Conclusions Oncologists' expert recommendations to attend POS were strongly associated with patients' uptake of POS. The central role played by oncologists should be accounted for in stepped psycho-oncological care when POS referral pathways are defined.

Aim Several scores are available to predict mortality and neurological outcome in cardiac arrest patients admitted to the intensive care unit (ICU). The aim of the study was to externally validate the prognostic value of four previously published risk scores. Methods For this observational, single-center study, we prospectively included 349 consecutive adult cardiac arrest patients upon ICU admission. We calculated two cardiac arrest specific risk scores (OHCA and CAHP) and two general severity of illness scores (APACHE II and SAPS II). The primary endpoint was in-hospital mortality. Secondary endpoints were neurological outcome at hospital discharge and 30-day mortality. Results 170 patients (49%) died until hospital discharge. All scores were independently associated with outcomes in logistic regression analysis and showed acceptable discrimination for in-hospital mortality with highest AUCs of the cardiac arrest specific risk scores (OHCA: 0.80 (95%CI 0.75–0.85) and CAHP: 0.84 (95%CI 0.79–0.88) compared to the severity of illness scores (APACHE II: 0.78 (95%CI 0.73–0.83) and SAPS II: 0.77 (95%CI 0.72–0.82). Results were robust in subgroup analysis except for worse performance in elderly patients (>75 years) and patients with respiratory cause of cardiac arrest. Results were similar for 30-days mortality and slightly higher for neurological outcome. Conclusions This study confirms the good prognostic performance of cardiac arrest specific scores to predict mortality and neurological outcomes in cardiac arrest patients. Routine use of OHCA or CAHP score helps to objectively risk stratify these vulnerable patients and thereby may improve therapeutic decisions.

Prognostication of cardiac arrest patients admitted to the intensive care unit (ICU) may influence treatment decision, but remains challenging. We evaluated the incremental usefulness of routine blood markers from different biological pathways for predicting fatal outcome and neurological deficits in cardiac arrest patients.We prospectively included consecutive, adult cardiac arrest patients upon ICU admission. We recorded initial clinical parameters and measured blood markers of cardiac injury/stress (troponin, BNP, CK), inflammation/infection (WBC, CRP, procalcitonin) and shock (lactate, creatinine, urea). The primary and secondary endpoints were all-cause in-hospital mortality and bad neurological outcome defined by the Cerebral Performance Category (CPC) score.Mortality in the 321 included patients was 49% (n = 156). Procalcitonin (adjusted odds ratio 1.84, 95%CI 1.34 to 2.53, p 0.001; AUC 0.73) and lactate (adjusted odds ratio 7.29, 95%CI 3.05 to 17.42, p 0.001; AUC 0.70) were identified as independent prognostic factors for mortality and significantly improved discrimination of a parsimonious clinical model including resuscitation measures (no-flow time, shockable rhythm) and initial vital signs (Glasgow coma scale, respiratory rate) from an AUC of 0.79 to 0.84 (p 0.001). Cardiac markers did not further improve the model. Results for neurological outcome were similar with model improvements by procalcitonin and lactate from AUC 0.83 to 0.87 (p = 0.004).Assessment of routine markers of inflammation/infection and shock provide significant improvements for prognostication of cardiac arrest patients, while cardiac markers did not further improve statistical models. Combination of blood markers and clinical parameters may help to improve initial management decisions in this vulnerable patient population.

BACKGROUND Performance of cardiopulmonary resuscitation (CPR) causes significant mental stress for rescuers, especially if performed by inexperienced individuals. Our aim was to study electrocardiogram (ECG) alterations in rescuers and its association with gender and CPR performance. METHODS We included 126 medical students in this prospective, observational simulator study. Each student was equipped with a 3-lead continuous ECG device tracking the individual electrocardiographic output before, during and after CPR. We analyzed variations in heart rate, heart-rate variability (HRV) and ST- and T-wave morphology. RESULTS Compared to baseline, mean heart rate (bpm) significantly increased during resuscitation and again decreased after resuscitation (from 87 to 97 to 80, p

Aim Whether mental stress negatively impacts team performance during cardio-pulmonary resuscitation (CPR) remains controversial; this may partly be explained by differences in stress measures used in previous studies. Our aim was to compare self-reported, biochemical and physiological stress measures in regard to CPR performance. Methods This prospective, observational study was conducted at the simulator center of the University Hospital Basel, Switzerland. Self-reported (feeling stressed and overwhelmed [stress/overload]), biochemical (plasma cortisol) and physiological (heart rate, heart rate variability) stress measures were assessed in 28 residents (teams of 2) before, during and after resuscitation. Team performance was defined as time to start CPR and hands-on time during the first 180s. Results At baseline, significant negative correlations of heart rate variability with stress/overload and heart rate, as well as positive correlations of heart rate and cortisol were found. During resuscitation, self-reported, biochemical and physiological stress measures did not correlate significantly. There was no association of baseline stress measures with performance. During CPR, stress/overload was significantly associated with time to start CPR (regression coefficient 12.01 (95% CI 0.65, 23.36), p =0.04), while heart rate was negatively associated with time to start CPR (regression coefficient −0.78 (95% CI −1.44, −0.11), p =0.027) and positively with hands-on time (regression coefficient 2.22 (95% CI 0.53, 3.92), p =0.015). Conclusions Self-reported stress (stress/overload) was the only predictor for low CPR performance. Biochemical measures showed no association, and physiological measures (heart rate) showed an inverse association, which may be due to physical activity, limiting its value as a mental stress marker in this acute setting.

Objective Previous studies suggest that red cell distribution width, a measure of erythrocyte size variability, may predict long-term mortality, particularly in cardiovascular disease. Less research has focused on the prognostic utility of red cell distribution width in an acutely hospitalized population. Methods We performed a secondary analysis of prospectively collected data on 74,784 consecutive hospitalized adults with red cell distribution width measured on admission. The primary outcome of interest was in-hospital mortality; a secondary outcome was unplanned transfer to the intensive care unit. We calculated multivariable logistic models adjusted for age, gender, race, and comorbid conditions. Results The overall in-hospital mortality rate was 1.3% (95% confidence interval [CI], 1.2-1.4). As red cell distribution width increased, so did mortality, from 0.2% (lowest red cell distribution width decile) to 4.4% (highest red cell distribution width decile). Unadjusted red cell distribution width significantly discriminated between hospital survivors and nonsurvivors (area under the curve 0.74). In multivariate analyses, for every 1% increment in red cell distribution width at the time of admission, the odds for in-hospital mortality increased by 24% (odds ratio 1.24; 95% CI, 1.20-1.27); findings were robust across comorbidity subgroups. The rate of unplanned intensive care unit transfer was 7.0% (95% CI, 6.8-7.2) and in unadjusted analyses increased more than 2-fold from 4.5% in the lowest to 11.6% in the highest red cell distribution width decile. This relationship was significantly confounded but remained significant in multivariate analysis (odds ratio 1.04 per 1% red cell distribution width increment; 95% CI, 1.03-1.06). Conclusion Red cell distribution width strongly and independently predicted in-hospital mortality in this large cohort of hospitalized patients. It also was associated with acute decompensation among patients on the general ward, but to a lesser degree. The mechanisms underlying these findings are unknown.

Barriers to optimal performance of cardiopulmonary resuscitation may partly relate to human factors, such as stress and specific emotions. The aim of this study was to investigate whether mental stress and different perceived emotions have a negative impact on the performance of rescuers.This prospective, observational study was conducted at the Simulator Center of the University Hospital Basel, Switzerland. A total of 120 medical students (70% female) participated in teams of three. They reported levels of perceived stress, feeling overwhelmed, motivation and specific emotions before, during, and after a simulated resuscitation. The association of stress/overload (index of stress and feeling overwhelmed), motivation, and specific emotions with resuscitation performance defined as hands-on time during the first 180 s after cardiac arrest was investigated.During resuscitation, levels of stress/overload, motivation, and negative emotions were significantly higher as compared to the periods before and after resuscitation. In contrast, positive emotions were highest before and after resuscitation and significantly lower during resuscitation. In general, females reported higher stress/overload and negative emotions, whereas males reported more positive emotions. A multivariate linear regression model showed negative associations of stress/overload (regression coefficient -18.12, 95% CI -30.73, -5.51, p = 0.006) and positive associations of motivation (regression coefficient 13.45, 95% CI 0.95, 25.95, p = 0.036) with resuscitation performance.A simulated cardiac arrest caused substantial perceived stress/overload and negative emotions, particularly in female students, which adversely impacted resuscitation performance. Further studies are required to expand our findings to more experienced medical professionals and investigate whether stress coping strategies improve resuscitation performance.

Leadership is an important predictor of team performance in medical emergencies. There are no data on why some healthcare workers take the lead in emergencies while others do not. Accordingly, the aim of the study was to determine predictors of leadership in a medical emergency.Two hundred thirty-seven medical students in fourth year of medical school participated and filled in a questionnaire assessing knowledge, experience, and personality traits. Students were randomly assigned to 79 groups of three. Each group was confronted with a standardized scenario of a simulated witnessed cardiac arrest. The primary outcome was the predictors of the number of leadership statements during the first 3 minutes of the cardiac arrest.In the first 3 minutes of the cardiac arrest, the participants made a median of five leadership statements (range, 0-22; interquartile range, 2). Thirteen participants (5.5%) made no single leadership statement. Multivariate analysis revealed that male gender (unstandardized coefficient, 1.9; P = 0.01), extraversion (unstandardized coefficient, 0.9; P = 0.02), and agreeableness (unstandardized coefficient, -1.1; P = 0.023) predicted leadership statements. Context knowledge, context experience, and other personality traits had no significant effect on leadership.During the initial phase of a medical emergency, there is a substantial interindividual variation in the amount of leadership. Leadership behavior as assessed by the number of leadership statements is determined by gender and personality and not by knowledge or experience.

The influence of teaching leadership on the performance of rescuers remains unknown. The aim of this study was to compare leadership instruction with a general technical instruction in a high-fidelity simulated cardiopulmonary resuscitation scenario.Prospective, randomized, controlled superiority trial.Simulator Center of the University Hospital Basel in Switzerland.Two-hundred thirty-seven volunteer medical students in teams of three.During a baseline visit, the medical students participated in a video-taped simulated witnessed cardiac arrest. Participants were thereafter randomized to receive instructions focusing either on correct positions of arms and shoulders (technical instruction group) or on leadership and communication to enhance team coordination (leadership instruction group). A follow-up simulation was conducted after 4 mos.The primary outcome was the amount of hands-on time, defined as duration of uninterrupted cardiopulmonary resuscitation in the first 180 secs after the onset of the cardiac arrest (hands-on time) [corrected]. Secondary outcomes were time to start cardiopulmonary resuscitation, total leadership utterances, and technical skills. Outcomes were compared based on videotapes coded by two independent researchers. After a balanced performance at baseline, the leadership instruction group demonstrated a longer hands-on time (120 secs; interquartile range, 98-135 vs. 87 secs; interquartile range, 61-108; p.001), a shorter median time to start cardiopulmonary resuscitation (44 secs; interquartile range, 32-62; vs. 67 secs; interquartile range, 43-79; p = .018), and had more leadership utterances (7; interquartile range, 4-10; vs. 5; interquartile range, 2-8; p = .02) in the follow-up visit. The rate of correct arm and shoulder positions was higher in teams with technical instruction (59%; 19 out of 32; vs. 23%; 7 out of 31; p = .003).Video-assisted leadership and technical instructions after a simulated cardiopulmonary resuscitation scenario showed sustained efficacy after a 4-mo duration. Leadership instructions were superior to technical instructions, with more leadership utterances and better overall cardiopulmonary resuscitation performance.

BACKGROUND: Early diagnosis of postoperative orthopaedic infections is important in order to rapidly initiate adequate antimicrobial therapy. There are currently no reliable diagnostic markers to differentiate infectious from noninfectious causes of postoperative fever. We investigated the value of the serum procalcitonin level in febrile patients after orthopaedic surgery. METHODS: We prospectively evaluated 103 consecutive patients with new onset of fever within ten days after orthopaedic surgery. Fever episodes were classified by two independent investigators who were blinded to procalcitonin results as infectious or noninfectious origin. White blood-cell count, C-reactive protein level, and procalcitonin level were assessed on days 0, 1, and 3 of the postoperative fever. RESULTS: Infection was diagnosed in forty-five (44%) of 103 patients and involved the respiratory tract (eighteen patients), urinary tract (eighteen), joints (four), surgical site (two), bloodstream (two), and soft tissues (one). Unlike C-reactive protein levels and white blood-cell counts, procalcitonin values were significantly higher in patients with infection compared with patients without infection on the day of fever onset (p = 0.04), day 1 (p = 0.07), and day 3 (p = 0.003). Receiver-operating characteristics demonstrated that procalcitonin had the highest diagnostic accuracy, with a value of 0.62, 0.62, and 0.71 on days 0, 1, and 3, respectively. In a multivariate logistic regression analysis, procalcitonin was a significant predictor for postoperative infection on days 0, 1, and 3 of fever with an odds ratio of 2.3 (95% confidence interval, 1.1 to 4.4), 2.3 (95% confidence interval, 1.1 to 5.2), and 3.3 (95% confidence interval, 1.2 to 9.0), respectively. CONCLUSIONS: Serum procalcitonin is a helpful diagnostic marker supporting clinical and microbiological findings for more reliable differentiation of infectious from noninfectious causes of fever after orthopaedic surgery.

Objectives An increasing number of consultations are delivered in group practices, where a stable 1:1 relationship between patient and physician cannot be guaranteed. Therefore, correct documentation of the content of a consultation is crucial to hand over information from one health care professional to the next. Methods We randomly selected 20 interviews from a series of 56 videotaped consultations with patients requesting a general check-up exam in the outpatient department of Internal Medicine at the University Hospital Basel. All patients actively denied having any symptoms or specific health concerns at the time they made their appointment. Videotapes were analysed with the Roter Interaction Analysis System (RIAS). Corresponding physician notes were analysed with a category check-list that contained the information related items from RIAS. Results Interviews contained a total of 9.002 utterances and lasted between 15 and 53 min (mean duration: 37 min). Patient-centred communication (Waiting, Echoing, Mirroring, Summarising) in the videos significantly correlated with the amount of information presented by patients: medical information ( r = .57; p = .009), therapeutic information ( r = .50; p = .03), psychosocial information ( r = .41; p = .07), life style information ( r = .52; p = .02), and with the sum of patient information ( r = .64; p = .003). Even though there was a significant correlation between the amount of information from the video and information in physician's notes in some categories (patient gives medical information; Pearson's r = .45; p = .05, patient gives psychosocial information; Pearson's r = .49; p = .03), an inspection of the regression lines shows that a large extent of patient information is omitted from the charts. Physicians never discussed with patients whether information should be documented in the charts or omitted. Conclusions The use of typical patient-centred techniques increases information gathered from patients. Physicians document only a small percentage of patient information in the charts, their ‘condensing heuristic’ is not shared with patients. Practice implications Patient involvement should be advocated not only to medical decision making but also to the way physicians document the content of a consultation. It is a joint responsibility of patient and health care professional to decide, which information should be kept and thus be communicated to another health care professional in future consultations.

a b s t r a c t Aim: Prognostic uncertainty and surrogate decision-making demands associated with prolonged uncon- sciousness in out-of hospital cardiac arrest (OHCA) patients in the intensive care unit (ICU) may increase post-traumatic stress disorder (PTSD) risk in their relatives. Our aim was to study PTSD frequency and risk factors in relatives of OHCA patients. Methods: In this observational study 101 consecutive eligible adult relatives of OHCA patients were interviewed using validated questionnaires, the "Impact of Event Scale-Revised" to detect PTSD and the "Family-Satisfaction with Care in the ICU" to assess potential PTSD risk factors. Results: PTSD was detected in 40/101 relatives (40%). Multivariate logistic regression identified three significant PTSD predictors (odds ratio, 95% confidence interval): female gender (3.30, 1.08-10.11), his- tory of depression (3.63, 1.02-12.96), family perception of the patient's therapy as insufficient (18.40, 1.52-224.22). Three other predictors were not significantly associated with PTSD (hypothermia treat- ment of the patient (2.86, 0.96-8.48)), delayed delivery of prognostic information by ICU staff (2.11, 0.83-5.38), family-ICU staff conflict (3.61, 0.71-18.40)). A prediction rule including six factors (p < 0.15 each) showed high discrimination (area under the receiver-operating characteristic curve 0.74) with a stepwise increase in risk for PTSD from 0% (no risk factor) to 63% (≥3 risk factors). There was no evidence for effect modification either by survival status or neurological outcome. Conclusion: Relatives of OHCA patients treated in the ICU are at increased risk of PTSD, which can be pre- dicted based on six factors, three ICU-related and potentially at least partly modifiable. Further research is needed to validate our findings and to develop strategies to prevent PTSD in OHCA patients' relatives. © 2014 Elsevier Ireland Ltd. All rights reserved.

QUESTIONS UNDER STUDY: After years of advocating ABC (Airway-Breathing-Circulation), current guidelines of cardiopulmonary resuscitation (CPR) recommend CAB (Circulation-Airway-Breathing). This trial compared ABC with CAB as initial approach to CPR from the arrival of rescuers until the completion of the first resuscitation cycle. METHODS: 108 teams, consisting of two physicians each, were randomized to receive a graphical display of either the ABC algorithm or the CAB algorithm. Subsequently teams had to treat a simulated cardiac arrest. Data analysis was performed using video recordings obtained during simulations. The primary endpoint was the time to completion of the first resuscitation cycle of 30 compressions and two ventilations. RESULTS: The time to execution of the first resuscitation measure was 32 ± 12 seconds in ABC teams and 25 ± 10 seconds in CAB teams (P = 0.002). 18/53 ABC teams (34%) and none of the 55 CAB teams (P = 0.006) applied more than the recommended two initial rescue breaths which caused a longer duration of the first cycle of 30 compressions and two ventilations in ABC teams (31 ± 13 vs.23 ± 6 sec; P = 0.001). Overall, the time to completion of the first resuscitation cycle was longer in ABC teams (63 ± 17 vs. 48 ± 10 sec; P

The Institute of Medicine defines high-quality care as safe, timely, efficient, effective, equitable, and patient centered (1). In the intensive care unit (ICU), patient-centered care includes family-centered care (2–4) since patients are frequently unable to participate in their care due to sedation, delirium, and severity of illness. Measuring the quality of patient-and family-centered care is complex, but many authorities view satisfaction with care as a central outcome measure in this domain (4–6). Although increased attention has recently turned to improving the patient and family centeredness of ICU care, most data suggest that significant opportunities for improvement remain both in the United States (7) and abroad (8, 9). Three areas of this burgeoning subject of inquiry are particularly notable. First, although survivorship has been called the defining problem of 21st century critical care (10), most research aimed at improving the ICU experience has focused on end-of-life care (5, 11–18) rather than the broader population of the critically ill, most of whom survive. Second, a great deal of research has focused on issues relating to individual patient-provider interactions, such as family conferences (9, 11, 12, 14, 15, 18–20), and less has focused on system-level issues that may affect the experience of critical illness but are not part of the individual-level encounter (3, 21–23). Third, no tools exist to guide providers in predicting which families are at high risk of dissatisfaction, or that guide researchers and quality improvement teams in selecting the most important factors on which to focus limited improvement resources. We therefore sought to understand how patient, family, ICU, and provider characteristics were related to the risk of less-than-ideal satisfaction with critical care. We were interested in three primary questions. First, what factors–ascertainable at ICU admission–independently predicted dissatisfaction with the future ICU experience? This clinical prediction rule might be useful in the design of patient-or family-specific interventions to prevent dissatisfaction. Second, we wanted to understand whether patients’ clinical characteristics (both interventions and outcomes) were associated with the risk of dissatisfaction. Finally, we were interested in understanding what aspects of families’ perceptions of specific aspects of the ICU experience were most strongly correlated associated with overall dissatisfaction. These analyses might be useful to ICU directors and administrators in choosing improvement priorities. They might also be hypothesis generating, helping researchers choose promising targets for novel interventions. Together, these analyses might form the basis for the design of future customized interventions–based on patient-level risks and ICU-specific factors–that aim to improve the critical care experience.

Introduction: Recently, red cell distribution width (RDW), a measure of erythrocyte size variability, has been shown to be a prognostic marker in critical illness. The aim of this study was to investigate whether adding RDW has the potential to improve the prognostic performance of the simplified acute physiology score (SAPS) to predict short- and long-term mortality in an independent, large, and unselected population of intensive care unit (ICU) patients. Methods: This observational cohort study includes 17,922 ICU patients with available RDW measurements from different types of ICUs. We modeled the association between RDW and mortality by using multivariable logistic regression, adjusting for demographic factors, comorbidities, hematocrit, and severity of illness by using the SAPS. Results: ICU-, in-hospital-, and 1-year mortality rates in the 17,922 included patients were 7.6% (95% CI, 7.2 to 8.0), 11.2% (95% CI, 10.8 to 11.7), and 25.4% (95% CI, 24.8 to 26.1). RDW was significantly associated with in-hospital mortality (OR per 1% increase in RDW (95%CI)) (1.14 (1.08 to 1.19), P < 0.0001), ICU mortality (1.10 (1.06 to 1.15), P < 0.0001), and 1-year mortality (1.20 (95% CI, 1.14 to 1.26); P < 0.001). Adding RDW to SAPS significantly improved the AUC from 0.746 to 0.774 (P < 0.001) for in-hospital mortality and 0.793 to 0.805 (P < 0.001) for ICU mortality. Significant improvements in classification of SAPS were confirmed in reclassification analyses. Subgroups demonstrated robust results for gender, age categories, SAPS categories, anemia, hematocrit categories, and renal failure. Conclusions: RDW is a promising independent short- and long-term prognostic marker in ICU patients and significantly improves risk stratification of SAPS. Further research is needed the better to understand the pathophysiology underlying these effects., Swiss National Science Foundation (SNF PBBSP3-128266), Universität Basel, National Institute of Biomedical Imaging and Bioengineering (U.S.) (grant R01 EB001659), Robert Wood Johnson Foundation (Physician Faculty Scholars program, grant 66350)

Background Current guidelines for a check-up recommend routine screening not triggered by specific symptoms for some known risk factors and diseases in the general population. Patients' perceptions and expectations regarding a check-up exam may differ from these principles. However, quantitative and qualitative data about the discrepancy between patient- and provider expectations for this type of clinic consultation is lacking. Methods For a year, we prospectively enrolled 66 patients who explicitly requested a "check-up" at our medical outpatient division. All patients actively denied upon prompting having any symptoms or specific health concerns at the time they made their appointment. All consultations were videotaped and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation ("open agendas") and for cues to hidden patient agendas using the Roter interaction analysis system (RIAS). Results All patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients. The remaining 59 patients spontaneously mentioned a mean of 4.2 ± 3.3 symptoms during their first consultation. In 23 patients a total of 31 hidden agendas were revealed. The primary categories for hidden agendas were health concerns, psychosocial concerns and the patient's concept of disease. Conclusions The majority of patients requesting a general check-up tend to be motivated by specific symptoms and health concerns and are not "asymptomatic" patients who primarily come for preventive issues. Furthermore, physicians must be alert for possible hidden agendas, as one in three patients have one or more hidden reasons for requesting a check-up.

Investigators in France have developed a risk score to predict death or poor neurologic outcome after out-of-hospital cardiac arrest. The aim of this study is to externally validate this score in an independent patient population in the United States.Retrospective, observational, cohort study.Patients being admitted to the intensive care unit after out-of-hospital cardiac arrest.Two geographically distinct tertiary care hospitals in the United States.None.The primary end point was poor outcome, defined as either death or a Cerebral Performance Category score of 3-5. The secondary end point was all-cause mortality. Calibration was assessed by comparing the number of expected outcomes based on the logistic model of the French study with observed outcomes within this study using Hosmer-Lemeshow C test (goodness-of-fit). Discrimination was assessed by calculation of the area under the receiver operating characteristic curve. Of a total of 128 patients, 99 (77%) had a poor outcome, including 91 nonsurvivors (71%). The probability of poor neurologic outcome and mortality increased stepwise with increasing out-of-hospital cardiac arrest score. Graphic display of observed against predicted outcomes and goodness-of-fit test indicated good calibration of the score (p = .4). The score showed good discrimination for poor outcome (area under the receiving operating characteristic curve, 0.85; 95% confidence interval, 0.79-0.92) and for mortality (area under the receiving operating characteristic curve, 0.85; 95% confidence interval, 0.78-0.91). In patients with an out-of-hospital cardiac arrest score40 points and60 points, the positive predictive value for poor outcome was 97% and 100%, respectively.This study found good calibration and high discrimination of the out-of-hospital cardiac arrest score in two geographically distinct patient populations in the United States. Particularly, this score had a high positive predictive value and performed well in identifying high-risk patients for poor outcomes.

In an effort to improve upon the traditional sepsis syndrome definitions, the predisposition, infection, response, organ dysfunction (PIRO) model was proposed to better characterize sepsis. The objective of this investigation was to derive and validate a sepsis staging system based on the PIRO concept that risk stratifies patients with suspected infection.Three independent, observational, prospective cohorts were studied. A derivation cohort (n = 2,132) was used to create the PIRO score, identifying independent predictors of mortality. Individual values were assigned to create the weighted integer score for each parameter, yielding the final PIRO score. The prognostic performance was then investigated in independent internal (n = 4,618) and external (n = 1,004) validation cohorts.Two large U.S. tertiary care centers.Patients admitted to the hospital from the emergency department with suspected infection.None.The PIRO staging system was created by combining components of predisposition (age, chronic obstructive pulmonary disease, liver disease, nursing home residency, and malignancy with and without metastasis), infection (pneumonia and cellulitis), response (tachypnea, bandemia, and tachycardia), and organ dysfunction (renal, respiratory, cardiac, metabolic, and hematologic). The derived PIRO score showed stepwise increase in mortality with increasing points and high discriminatory ability with an area under the curve of 0.90 in the derivation cohort, 0.86 in internal validation, and 0.83 in external validation.This study provides evidence-based support for the PIRO approach to sepsis staging. Future efforts may utilize this approach with additional parameters (e.g., genetics and novel biochemical markers) to develop further the PIRO stratification system.

Eur J Clin Invest 2010; 40 (4): 376–381 Abstract Introduction The aim of this study was to investigate time course of procalcitonin (PCT), C-reactive protein (CRP) and white blood cell (WBC) levels in patients with therapeutic hypothermia after cardiac arrest. Methods We retrospectively assessed laboratory and clinical data in a consecutive cohort of patients admitted to the medical intensive-care-unit of the University Hospital in Basel, Switzerland, in whom therapeutic hypothermia was induced because of cardiac arrest between December 2007 and January 2009. Infection was considered based on microbiological evidence (restricted definition) and/or clinical evidence of infection with prescription of antibiotics (extended definition). Results From 34 included patients, 25 had respiratory tract infection based on the clinical judgment and in 18 microbiological cultures turned positive (restricted definition). PCT concentrations were highest on the first day after hypothermia and showed a steady decrease until day 7 without differences in patients with and without presumed infection. CRP concentrations increased to a peak level at days 3–4 followed by a steady decrease; CRP concentrations were higher in patients with clinical diagnosis of infection on day 4 (P = 0·02); and in patients with evidence of bacterial growth in cultures on days 4 and 5 (P = 0·01 and P = 0·006). WBC remained unchanged after hypothermia without differences between patients with and without infection. Conclusion High initial values of PCT and high peak levels after 3–4 days of CRP were found in patients with induction of hypothermia after cardiac arrest. This increase was unspecific and mirrors rather an inflammatory reaction than true underlying infection, limiting the diagnostic potential for early antibiotic stewardship in these patients.

QUESTION UNDER STUDY: There are no data on the preparedness of medical students at the time of their graduation to handle a cardiac arrest. The aim of the present study was to compare the performance in cardiopulmonary resuscitation of medical students at the time of their graduation with that of experienced general practitioners. METHODS: 24 teams consisting of three medical students and 24 teams consisting of three general practitioners were confronted with a scenario of a simulated witnessed cardiac arrest. Analysis was performed post-hoc using video recordings obtained during the simulation. RESULTS: Medical students diagnosed the cardiac arrest as quickly as general practitioners. Medical students were less likely to call for help in the initial phase of the cardiac arrest (14/24 vs 21/24; P = 0.002); had less hands-on time during the first 180 seconds of the arrest (52 +/- 33 sec vs 105 +/- 39 sec; P >0.0001); delayed the first defibrillation (168 +/- 78 vs 116 +/- 46 sec, P >0.007); and showed less directive leadership (4/24 vs 14/24 teams, P >0.007). The technical quality of cardiopulmonary resuscitation provided by medical students was partly better, but for no parameter worse, than that provided by general practitioners. CONCLUSIONS: When confronted with a cardiac arrest, medical students at the time of their graduation substantially delayed evidence-based life-saving measures like defibrillation and provided only half of the resuscitation support provided by experienced general practitioners. Future research should focus on how to best prepare medical students to handle medical emergencies.

Background Cardiopulmonary resuscitation (CPR) causes significant stress for the rescuers which may cause deficiencies in attention and increase distractibility. This may lead to misjudgements of priorities and delays in CPR performance, which may further increase mental stress (vicious cycle). This study assessed the impact of a task-focusing strategy on perceived stress levels and performance during a simulated CPR scenario. Methods This prospective, randomized-controlled trial was conducted at the simulator-center of the University Hospital Basel, Switzerland. A total of 124 volunteer medical students were randomized to receive a 10 minute instruction to cope with stress by loudly posing two task-focusing questions (“what is the patient’s condition?”, “what immediate action is needed?”) when feeling overwhelmed by stress (intervention group) or a control group. The primary outcome was the perceived levels of stress and feeling overwhelmed (stress/overload); secondary outcomes were hands-on time, time to start CPR and number of leadership statements. Results Participants in the intervention group reported significantly less stress/overload levels compared to the control group (mean difference: -0.6 (95% CI −1.3, -0.1), p=0.04). Higher stress/overload was associated with less hands-on time. Leadership statements did not differ between groups, but the number of leadership statements did relate to performance. Hands-on time was longer in the intervention- group, but the difference was not statistically significant (difference 5.5 (95% CI −3.1, 14.2), p=0.2); there were no differences in time to start CPR (difference −1.4 (95% CI −8.4, 5.7), p=0.71). Conclusions A brief stress-coping strategy moderately decreased perceived stress without significantly affecting performance in a simulated CPR. Further studies should investigate more intense interventions for reducing stress. Trial registration NCT01645566