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Metacarpal neck fractures with severe displacement are commonly treated surgically with intramedullary Kirschner wires. We present the results of treatment of fifth metacarpal neck fractures using a light curable intramedullary photodynamic polymer (IlluminOss™, IlluminOss Medical Inc., East Providence, RI, USA). Twenty-nine patients with isolated displaced fifth metacarpal neck fractures were included and followed up for 12–24 weeks. All fractures had radiologically healed after 3 months. In two cases, a secondary loss of reduction was seen, which did not require further correction. During the follow-up period, range of motion of the metacarpophalangeal joint was 89% after 6 weeks and increased to 100% after 3 months compared with the uninjured side. Grip strength improved over time from 61% to 85%. No implant removal was necessary. We conclude that osteosynthesis using an intramedullary photodynamic polymer is a reliable treatment option for displaced fractures of the fifth metacarpal neck. Level of evidence: IV

Aims Heart failure is one of the leading causes of morbidity and mortality worldwide, but little is known on heart failure epidemiology and treatment in primary care. This study described patients with heart failure treated by general practitioners, with focus on drug prescriptions and especially on the only specific treatment for heart failure with reduced ejection fraction, namely sacubitril/valsartan. Methods and results This was a retrospective cross‐sectional study using data from an electronic medical record database of Swiss general practitioners from 2016 to 2019. Multilevel logistic regression was used to find determinants of sacubitril/valsartan prescription; odds ratios (ORs) and 95% confidence intervals (CIs) were reported. We identified 1288 heart failure patients (48.5% women; age: median 85 years, interquartile range 77–90 years) by means of diagnosis code, representing 0.5% of patients consulting a general practitioner during the observation period. About 73.6% received a renin–angiotensin–aldosterone system inhibitor, 67.8% a beta‐blocker, 34.6% a calcium channel blocker, 86.1% a diuretic, and 40.1% another cardiac drug. Sacubitril/valsartan was prescribed in 6% predominantly male patients (OR 2.10, CI 1.25–3.84), of younger age (OR 0.59 per increase in 10 years, CI 0.49–0.71), with diabetes mellitus (OR 1.76, CI 1.07–2.90). The recommended starting dose for sacubitril/valsartan was achieved in 67.1% and the target dose in 28.6% of patients. Conclusions Prevalence of heart failure among patients treated by general practitioners was low. Considering the disease burden and association with multimorbidity, awareness of heart failure in primary care should be increased, with the aim to optimize heart failure therapy.

Aims In some healthcare systems, physicians are allowed to dispense drugs; in others, drug-dispensing is restricted to pharmacists. Whether physician-dispensing affects patient health is unknown. Thus, we aimed to investigate associations between physician-dispensing and clinical and process measurements in patients with selected long-term conditions indicating increased cardiovascular risk. Methods Retrospective cross-sectional study in 2018 based on data from electronic medical records of 22405 patients (73.6% physician-dispensing) in Switzerland with medications for diabetes mellitus, arterial hypertension, or lipid-related disorders. We used multilevel regression models to determine the associations between physician-dispensing and clinical measurements (glycated hemoglobin [HbA1c], systolic blood pressure [sBP], low-density lipoprotein cholesterol [LDL-C]) or process measurements (number of annual clinical measurements, consultations, and drug prescriptions). Results Median (interquartile range) HbA1c value was 6.8% (6.3-7.5) both for the physician-dispensing and pharmacist-dispensing group, sBP was 137 (126-150) and 136 mmHg (126-149), and LDL-C was 2.3 (1.8-3.0) and 2.5 mmol/L (1.9-3.2). After adjustments, the physician-dispensing group had 4% lower LDL-C levels (p = 0.041), 12% more frequent HbA1c measurements (p = 0001), 16% higher annual consultation rates (p < 0.05 for all conditions), and equal number of different drugs, compared to the pharmacist-dispensing group. Conclusions We found no relevant differences in selected clinical measurements between physician- and pharmacist-dispensing, and mixed results in process measurements. Our results do not indicate that one drug-dispensing channel is superior to the other.

Additional file 1: eAppendix 1. Information about the OPTICA trial and the FIRE project. eTable 1. Baseline characteristics of patients in the OPTICA trial compared to other multimorbid patients with polypharmacy in the FIRE database who also were patients of the general practitioners participating in the OPTICA trial. eTable 2. Baseline characteristics of Swiss general practitioners who participated in the Workforce-Study. eFigure 1. FIRE database, FIRE reference cohorts and OPTICA trial participants.

Guidelines recommend initiation of statins depending on cardiovascular risk and low-density lipoprotein cholesterol (LDL-C) levels. In this retrospective cohort study, we aimed to assess guideline concordance of statin treatment decisions and to find determinants of undertreatment in Swiss primary care in the period 2016&ndash, 2019. We drew on electronic medical records of 8060 statin-naive patients (50.0% female, median age 59 years) with available LDL-C levels and cardiovascular risk. Guideline concordance was assessed based on the recommendations of the European Society of Cardiology, and multilevel logistic regression was performed to find determinants of undertreatment. We found that statin treatment was initiated in 10.2% of patients (50.0% female, median age 59 years) during one year of follow up. Treatment decisions were classified as guideline-concordant in 63.0%, as undertreatment in 35.8% and as overtreatment in 1.2%. Among determinants of undertreatment were small deviation from LDL-C treatment thresholds (odds ratio per decrease by 1 mmol/L: 2.09 [95% confidence interval 1.87&ndash, 2.35]), high compared with very high cardiovascular risk (1.64 [1.30&ndash, 2.05]), female sex (1.31 [1.05&ndash, 1.64]), and being treated by older general practitioners (per 10 year decrease: 0.74 [0.61&ndash, 0.90]). In conclusion, undertreatment of patients at high or very high cardiovascular risk was common, but general practitioners considered cardiovascular risk and LDL-C in their treatment decisions.

Mitteilungen des Kunsthistorischen Institutes in Florenz, Bd. 61 Nr. 1 (2019): Mitteilungen des Kunsthistorischen Institutes in Florenz

Background Primary care systems around the world have implemented nurse practitioners (NPs) to ensure access to high quality care in times of general practitioner (GP) shortages and changing health care needs of a multimorbid, ageing population. In Switzerland, NPs are currently being introduced, and their exact role is yet to be determined. The aim of this study was to get insight into patient characteristics and services provided in NP consultations compared to GP consultations in order to appraise whether the NP role meets the political and demographic demands in Swiss primary care.Methods This case study used retrospective observational data from electronic medical records of a family practice with one NP and two GPs. Data on patient-provider encounters were collected between August 2017 and December 2018. We used logistic regression to assess associations between the assignment of the patients to the NP or GP and patient characteristics and delivered services respectively.Results Data from 5,210 patients participating in 27,811 consultations were analyzed. The average patient age was 44.3 years (SD 22.6), 47.1% of the patients were female and 19.4% multimorbid. 1,613 (5.8%) consultations were with the NP, and 26,198 (94.2%) with the two GPs. Patients in NP consultations were more often aged 85+ (OR 3.43; 95%-CI 2.70-4.36), multimorbid (OR 1.37; 95%-CI 1.24-1.51; p Conclusions Quantitative data from pilot projects provide valuable insights into NP tasks and activities in Swiss primary care. Our results provide first indications that NPs might have a focus on and could offer care to the growing number of multimorbid, polypharmaceutical elderly in Swiss primary care. NPs could offer care to the growing number of multimorbid, polypharmaceutical elderly, and might relieve work pressure from the GPs. Hence, the NP role has the potential to meet the current political and demographic demands in Swiss primary care. An extended scope of practice, especially prescription rights, could foster further professional practice and role implementation.

Laboratory tests are frequently ordered by general practitioners (GPs), but little is known about time trends and between-GP variation of their use. In this retrospective longitudinal study, we analyzed over six million consultations by Swiss GPs during the decade 2009&ndash, 2018. For 15 commonly used test types, we defined specific laboratory testing rates (sLTR) as the percentage of consultations involving corresponding laboratory testing requests. Patient age- and sex-adjusted time trends of sLTR were modeled with mixed-effect logistic regression accounting for clustering of patients within GPs. We quantified between-GP variation by means of intraclass correlation coefficients (ICC). Nine out of the 15 laboratory test types considered showed significant temporal increases, most eminently vitamin D (ten-year odds ratio (OR) 1.88, 95% confidence interval (CI) 1.71&ndash, 2.06) and glycated hemoglobin (ten-year OR 1.87, 95% CI 1.82&ndash, 1.92). Test types both subject to substantial increase and high between-GP variation of sLTR were vitamin D (ICC 0.075), glycated hemoglobin (ICC 0.101), C-reactive protein (ICC 0.202), and vitamin B12 (ICC 0.166). Increasing testing frequencies and large between-GP variation of specific test type use pointed at inconsistencies of medical practice and potential overuse.

AIMS Statins decrease the risk of fatal CVD by lowering low-density lipoprotein (LDL) levels. Guidelines suggest that statin treatment strategies should be guided by CV risk, but little is known about statin treatment in Swiss general practice. In this study, we aimed to investigate statin treatment and LDL target achievement rates, including their predictors, in patients treated by Swiss general practitioners (GPs). METHODS Retrospective observational study of statin-treated patients in 2018 using a general practice electronic medical records database. CV risk categories were defined according to the ESC guidelines published in 2016. We used multilevel logistic regression models to find associations between patient and GP demographic factors and LDL target achievement. RESULTS We analysed 11,779 statin-treated patients, of whom 59% were at a high or very high risk of fatal CVD. High-intensity statin treatment was used in 39% of patients, and LDL measurement was performed at least once in 54% of patients. Achievement of LDL target levels across CV risk categories was 36% in very high-risk, 56% in high-risk, and 66% in low-/moderate-risk patients, and generally higher for male patients. CONCLUSIONS Although over half of patients were at a high or very high risk of fatal CVD, the majority did not receive high-intensity statin treatment. Only a third of very high-risk patients achieved LDL target values, and there was a gender gap in LDL target achievement disadvantaging female patients. Results from this study suggest that current treatment may warrant reconsideration in a large proportion of patients treated with statins in Swiss general practice.

Background Gout is the most common form of inflammatory arthritis worldwide and its prevalence is rising. In Switzerland, there are no data available on the characteristics and treatment of gout patients. In this study, we aimed to describe numbers of patients affected by gout and hyperuricaemia and unveil approaches Swiss primary care physicians (PCPs) use for the management. Methods This was a retrospective observational study using electronic medical routine ndata provided from 242 Swiss PCPs. Included were all their patients receiving urate-lowering therapy (ULT), with a diagnostic code for gout or who had a serum uric acid (SUA) measurement. According to their disease status, patients were classified into four subgroups (normal urate, hyperuricaemia, untreated gout, treated gout). For treatment analysis, patients with SUA measurements before and after ULT initiation were included. Comorbidities and risk factors for secondary causes relevant in the context of gout were collected. Outcomes were prevalence of gout and hyperuricaemia, characteristics of patients according to subgroup, number of SUA measurements, levels of SUA and patients who reached the treatment goal of a SUA level l360 mmol/l. Results We assessed 15,808 patients and classified them into the subgroups. This yielded a prevalence of 1.0% for gout and 1.2% for hyperuricaemia. 2642 patients were diagnosed with gout of whom 2420 (91.6%) received a ULT. Overall; 41.3% of patients with a gout treatment had at least one SUA measurement; 15.0% of patients with treated gout had a record of SUA measurements before and after ULT initiation; and 57.5% reached the treatment goal of l360 mmol/l after allopurinol treatment. Conclusion Swiss gout patients received comprehensive treatment, which is reflected in a high number of patients treated with ULT, laboratory tests per person and a high treatment success rate, although there is no systematic approach to the treatment of gout.

Objectives/Interrogation: Post-traumatic, arthritic or degenerative destruction of the midcarpal and radiocarpal joint is difficult to treat. An arthroplasty with a free interposition pyrocarbon implant, Amandys ®, is proposed for the treatment of extensive destruction of midcarpal and radiocarpal[for full text, please go to the a.m. URL], 14th Triennial Congress of the International Federation of Societies for Surgery of the Hand (IFSSH), 11th Triennial Congress of the International Federation of Societies for Hand Therapy (IFSHT), 11th Triennial Congress of the International Federation of Societies for Hand Therapy (IFSHT)

Additional file 1. Definitions of chronic conditions.

supplementary_file_1_1 for Nurse Practitioners in Swiss Family Practices as Potentially Autonomous Providers of Home Visits: An Exploratory Study of Two Cases by Stefan Gysin, Iren Bischofberger, Rahel Meier, Anneke van Vught, Christoph Merlo and Stefan Essig in Home Health Care Management & Practice

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

Background Switzerland is challenged by impending shortages of general practitioners (GPs) in rural areas and decreasing number of GP home visits. In Anglo-Saxon and many other countries, nurse practitioners (NPs) have been implemented and provide high quality, patient-centred home visits autonomously. In Switzerland, the NP role is new and there are currently only a handful of ongoing pilot projects in family practices. Hence, studies are lacking and data collection is challenging as NPs are not yet registered providers who could be identified in billing or health insurance data. Our aims were to gain insights in the frequency of home visits by NPs in Swiss family practices, and to determine their autonomy during visits and consultations based on the required level of GP supervision. Methods We used consultation data from two pilot practices in rural Switzerland. In “Practice A”, the NP was in postgraduate education and data was gathered electronically between August 2017 and 2018. In “Practice B”, the NP had completed her education, and had two years of work experience as a NP when data was collected manually between April and June 2018. We used a coding system based on five levels of GP supervision to identify NP consultations and home visits, and to determine the NPs’ autonomy in each consultation. Results We analysed data from 1375 consultations. The share of home visits in all NP consultations was 17% in Practice A and 51% in Practice B. Both NPs had a higher share of autonomously conducted consultations during home visits than in the office. In Practice A, the proportion of consultations in which the NP was autonomous increased from 0% in the first month of her employment to 19% after 13 months of GP supervision. In Practice B, the NP was autonomous in about three-quarters of her consultations. Conclusions First cases provide some evidence that after completing postgraduate education with clinical supervision by GPs, and few years of practical experience in their role, NPs could reach a relatively high degree of autonomy and might pose a potential solution to the decreasing numbers of GP home visits in Swiss primary care.

Introduction There is only limited and conflicting evidence on the effectiveness of Pay-for-Performance (P4P) programmes, although they might have the potential to improve guideline adherence and quality of care. We therefore aim to test a P4P intervention in Swiss primary care practices focusing on quality indicators (QI) achievement in the treatment of patients with diabetes. Methods and analysis This is a cluster-randomised, two-armed intervention study with the primary care practice as unit of randomisation. The control group will receive bimonthly feedback reports containing last data of blood pressure and glycated haemoglobin (HbA1c) measurements. The intervention group will additionally be informed about a financial incentive for each percentage point improved in QI achievement. Primary outcomes are differences in process (measurement of HbA1c) and clinical QI (blood pressure control) between the two groups. Furthermore, we investigate the effect on non-incentivised QIs and on sustainability of the financial incentives. Swiss primary care practices participating in the FIRE (Family Medicine ICPC Research using Electronic Medical Record) research network are eligible for participation. The FIRE database consists of anonymised structured medical routine data from Swiss primary care practices. According to power calculations, 70 of the general practitioners contributing to the database will be randomised in either of the groups. Ethics and dissemination According to the Local Ethics Committee of the Canton of Zurich, the project does not fall under the scope of the law on human research and therefore no ethical consent is necessary. Results will be published in a peer-reviewed journal. Trial registration number ISRCTN13305645; Pre-results.

Zur Daumenrekonstruktion nach traumatischer Amputation hat sich auch die Kallusdistraktion mittels Distraktionsfixateur etabliert. Die Wahl des geeigneten Verfahrens hangt von der Amputationshohe, dem Alter, Beruf und vom funktionellen Anspruch des Patienten ab. Wir berichten uber unsere Erfahrungen bei 5 Patienten, welche nach traumatischen Daumenamputationen auf Hohe der Basis der Grundphalanx mit einem in unserer Klinik in Zusammenarbeit mit einer spezialisierten Firma (Rotomed AG, Allmenstrasse 4, CH-4512 Bellach, www.rotomed.ch ) entwickelten semi-zirkularen Ringfixateur System behandelt wurden. Bei allen Patienten konnte eine zufriedenstellende Verlangerung von durchschnittlich 26,2 mm erreicht werden. Es traten keine Achsenabweichung oder revisionsbedurftigen Komplikationen auf. Der Hand Michigan Outcome Score betrug durchschnittlich 82,2%.

Background Little guidance is currently available for standardized diagnostic protocols and therapeutic recommendations for bone and joint infections (BJIs) of the hand. Objectives To summarize the available data in the scientific English-language literature on the diagnosis and treatment of native BJIs of the hand. To illustrate these concepts from a narrative point of view in areas where there is lack of evidence. Sources We performed a systematic PubMed and Internet search of studies that investigated hand BJIs in adult patients. Content Few studies have systematically investigated and validated diagnostic concepts, classifications or surgical treatment protocols. Most concepts derive from traditional intra-institutional experience, expert opinions and extrapolations from infections in large joints and long bones. Similarly, there is no uniformly accepted infection definition of BJIs of the hand. The best-documented literature is available for microbiological findings and antibiotic treatment duration in uncomplicated native joint arthritis of the fingers. Retrospective studies and one prospective randomized trial suggest that post-surgical targeted antibiotic therapy of 2 weeks results in a microbiological cure rate of ≥88%. Implications Studies on diagnostic workup and infection definition and classification are urgently needed to compare inter-institutional outcome results and generate guidelines for the best patient care. For uncomplicated pyogenic arthritis of native joints, current evidence suggests that a 2-week course of antibiotic therapy following surgery cures the infection.

To investigate if a trochleoplasty increases knee flexion angles and extensor moments in the gait of patients with patellar instability and to compare postoperative gait to a healthy control group.A bilateral dislocation group (6 patients) and a unilateral dislocation group (14 patients) were treated with bilateral and unilateral trochleoplasty, respectively. Kinematics and kinetics of the lower extremity were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, plug-in-gait, two force plates). The mean of six trials was computed. The gait cycles were compared pre to postoperatively for each group. The gait of the two groups was compared to each other and the gait of a healthy population (54 knees).After trochleoplasty, the knee flexion angles and knee extensor moments only increased in the bilateral dislocation group, whereas the gait pattern of the unilateral dislocation group remained unchanged. Compared to the healthy population, the postoperative gait pattern of the bilateral dislocation group did not differ. In contrast, knee flexion angles and extensor moments of the unilateral dislocation group were still lower.In adolescents with bilateral recurrent patellar dislocations, trochleoplasty of both knees increases knee flexion angles and knee extensor moments comparable to normal gait. Unilateral symptomatic patients undergoing a unilateral trochleoplasty did not achieve normal walking. These findings point out that patellar instability should be considered as a bilateral problem, even in patients with unilateral dislocations.III.