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Objectives Laboratory testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has played an important role in the effort to prevent and contain local outbreaks. The aim of this study was to assess the diagnostic accuracy of a new fully automated SARS-CoV-2 laboratory-based antigen assay (CoV2Ag) and to explore the efficiency of a diagnostic algorithm combining antigen and conventional high-throughput molecular assays to address potential future challenges of the SARS-CoV-2 pandemic. Methods One thousand two hundred and twenty four consecutive nasopharyngeal swabs were tested using RT-PCR and CoV2Ag assay. Results The overall sensitivity and specificity of CoV2Ag were 79.1 and 97.8%, respectively. When the analysis was restricted to cases with Ct values ≤30, the sensitivity of the assay improved to 98.1%. Acceptable sensitivity was found when the analysis was limited to patients presenting within one or two to four days of symptom onset (80.5 and 84.8%, respectively). A retrospective analysis of the use of a two-step diagnostic approach combining the CoV2Ag assay and RT-PCR during an acute pandemic phase of 97 days showed a potential reduction in the number of RT-PCR tests by 36.1%, corresponding to savings in reagent costs and technician workload of approximately €8,000 and 10.5 h per day, respectively. Conclusions Our data show that the proposed algorithm represents a valid alternative diagnostic approach to increase testing efficiency during future pandemic phases with high positivity rates (>20%) and elevated numbers of RT-PCR test requests.

A systematic screening of patients with a need for post-acute care is a helpful support for interprofessional discharge planning teams. We aimed to test self-care abilities, measured by the self-care index (SPI) as predictors of post-acute care transfer and to update the existing SPI prediction model. We analysed data from a prospective, observational cohort study conducted at the Kantonsspital Aarau between February and October 2013. We updated the SPI model, adding age and gender using a training and validation data set. Logistic regression models were run on the outcome “transfer to a post-acute care facility” and judged based on their AUC (area under curve), AIC (Akaike information criterion), and BIC (Bayesian information criteria) values. ROC curves (receiver operating characteristic) were derived from the models; and cut-points for the linear predictors of the models were defined (thus defining the new scores). Sensitivities and specificities were calculated. This study included 1372 adult internal medicine in-patients admitted from home, who either returned home or were transferred to a post-acute care institution. The total SPI score was a significant predictor for post-acute care referral (p < 0.001). Including age and gender in the SPI model increased the AUC to 0.85 (training) and 0.84 (validation). An improvement in the AUC by 3% (0.81 [95% CI: 0.77–0.85] to 0.84 [95% CI: 0.80–0.87]), compared to the original SPI was achieved (p = 0.004). The new score reached a sensitivity of 81% and specificity of 74% compared to a sensitivity of 64% and specificity of 84% for the original score. The extended SPI can be used as a tool for individualised discharge organisation of internal medicine patients with higher accuracy.

To externally validate four previously developed severity scores (i.e., CALL, CHOSEN, HA2T2 and ANDC) in patients with COVID-19 hospitalised in a tertiary care centre in Switzerland. This observational analysis included adult patients with a real-time reverse-transcription polymerase chain reaction or rapid-antigen test confirmed severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection hospitalised consecutively at the Cantonal Hospital Aarau from February to December 2020. The primary endpoint was all-cause in-hospital mortality. The secondary endpoint was disease progression, defined as needing invasive ventilation, ICU admission or death. From 399 patients (mean age 66.6 years ± 13.4 SD, 68% males), we had complete data for calculating the CALL, CHOSEN, HA2T2 and ANDC scores in 297, 380, 151 and 124 cases, respectively. Odds ratios for all four scores showed significant associations with mortality. The discriminative power of the HA2T2 score was higher compared to CALL, CHOSEN and ANDC scores [area under the curve (AUC) 0.78 vs. 0.65, 0.69 and 0.66, respectively]. Negative predictive values (NPV) for mortality were high, particularly for the CALL score (≥ 6 points: 100%, ≥ 9 points: 95%). For disease progression, discriminative power was lower, with the CHOSEN score showing the best performance (AUC 0.66). In this external validation study, the four analysed scores had a lower performance compared to the original cohorts regarding prediction of mortality and disease progression. However, all scores were significantly associated with mortality and the NPV of the CALL and CHOSEN scores in particular allowed reliable identification of patients at low risk, making them suitable for outpatient management.

Estimating the probability of readmission following hospitalization using prediction scores can be complex. Quality of life (QoL) may provide an easy and effective alternative. Secondary analysis of the prospective “TRIAGE” cohort. All medical in-patients admitted to a Swiss tertiary care institution (2016–2019) ≥18 years with a length of stay of ≥2 days (23,309 patients) were included. EQ-5D VAS, EQ-5D index, and Barthel index were assessed at a single telephone interview 30-day after admission. Patients lost to follow-up were excluded. Readmission was defined as a non-elective hospital stay at our institution >24 h within 1 year after discharge and assessed using area under the curve (AUC) analysis with adjustment for confounders. 12,842 patients (43% females, median age 68, IQR 55–78) were included. Unadjusted discrimination was modest at 0.59 (95% CI 0.56–0.62) for EQ-5D VAS. Partially adjusted discrimination (for gender) was identical. Additional adjustment for insurance, Charlson comorbidity index, length of stay, and native language increased the AUC to 0.66 (95% CI 0.63–0.69). Results were robust irrespective of time to event (12, 6 or 3 months). A cut-off in the unadjusted model of EQ-5D VAS of 55 could separate cases with a specificity of 80% and a sensitivity of 30%. QoL at day 30 after admission can predict one-year readmission risk with similar precision as more intricate tools. It might help for identification of high-risk patients and the design of tailored prevention strategies.

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) has been linked to thrombotic complications and endothelial dysfunction. We assessed the prognostic implications of endothelial activation through measurement of endothelin-I precursor peptide (proET-1), the stable precursor protein of Endothelin-1, in a well-defined cohort of patients hospitalized with COVID-19.MethodsWe measured proET-1 in 74 consecutively admitted adult patients with confirmed COVID-19 and compared its prognostic accuracy to that of patients with community-acquired pneumonia (n = 876) and viral bronchitis (n = 371) from a previous study by means of logistic regression analysis. The primary endpoint was all-cause 30-day mortality.ResultsOverall, median admission proET-1 levels were lower in COVID-19 patients compared to those with pneumonia and exacerbated bronchitis, respectively (57.0 pmol/l vs. 113.0 pmol/l vs. 96.0 pmol/l, p ConclusionsCompared to other types of pulmonary infection, COVID-19 shows only a mild activation of the endothelium as assessed through measurement of proET-1. Therefore, the high mortality associated with COVID-19 may not be attributed to endothelial dysfunction by the surrogate marker proET-1.

Objectives Midregional pro-adrenomedullin (MR-proADM) is a vasoactive peptide with key roles in reducing vascular hyperpermeability and thereby improving endothelial stability during infection. While MR-proADM is useful for risk stratification in patients with sepsis, clinical data about prediction accuracy in patients with severe acute respiratory syndrome coronavirus 2 disease (COVID-19) is currently missing. Methods We included consecutively adult patients hospitalized for confirmed COVID-19 at a tertiary care center in Switzerland between February and April 2020. We investigated the association of MR-proADM levels with in-hospital mortality in logistic regression and discrimination analyses. Results Of 89 included COVID-19 patients, 19% (n=17) died while in the hospital. Median admission MR-proADM levels (nmol/L) were increased almost 1.5-fold increased in non-survivors compared to survivors (1.3 [interquartile range IQR 1.1–2.3]) vs. 0.8 [IQR 0.7–1.1]) and showed good discrimination (area under the curve 0.78). An increase of 1 nmol/L of admission MR-proADM was independently associated with a more than fivefold increase in in-hospital mortality (adjusted odds ratio of 5.5, 95% confidence interval 1.4–21.4, p=0.015). An admission MR-proADM threshold of 0.93 nmol/L showed the best prognostic accuracy for in-hospital mortality with a sensitivity of 93%, a specificity of 60% and a negative predictive value of 97%. Kinetics of follow-up MR-proADM provided further prognostic information for in-hospital treatment. Conclusions Increased levels of MR-proADM on admission and during hospital stay were independently associated with in-hospital mortality and may allow a better risk stratification, and particularly rule-out of fatal outcome, in COVID-19 patients.

Summary: In phlegmasia cerulea dolens (PCD), immediate diagnosis and prompt treatment is crucial for limb salvage. Aggressive treatment options including venous intervention, thrombolysis and/or surgical thrombectomy should be considered. Due to the lack of data, the most appropriate intervention depends upon etiology of PCD, clinical presentation and patient’s bleeding risk.

BACKGROUND: Several clinical risk scores for unplanned 30-day readmission have been published, but there is a lack of external validation and head-to-head comparison. OBJECTIVE: Retrospective replication of six clinical risk scores (LACE, HOSPITAL, SEMI, RRS, PARA, Tsui et al.)f DESIGN: Models were fitted with the original intercept and beta coefficients as reported. Otherwise, a logistic model was refitted (SEMI and Tsui et al). We performed subgroup analyses on main admission specialty. This report adheres to the TRIPOD statement for reporting of prediction models. PARTICIPANTS: We used our prospective cohort of 15,639 medical patients from a Swiss tertiary care institution from 2016 through 2018. MAIN MEASURES: Thirty-day readmission rate and area under the curve (AUC 0.70 acceptable, > 0.80 excellent) CONCLUSIONS: Among several readmission risk scores, HOSPITAL, PARA, and the score from Tsui et al. showed the best predictive abilities and have high potential to improve patient care. Interventional research is now needed to understand the effects of these scores when used in clinical routine. KEY RESULTS: Among the six risk scores externally validated, calibration of the models was overall poor with overprediction of events, except for the HOSPITAL and the PARA scores. Discriminative abilities (AUC) were as follows: LACE 0.53 (95% CI 0.50–0.56), HOSPITAL 0.73 (95% CI 0.72–0.74), SEMI 0.47 (95% CI 0.46–0.49), RRS 0.64 (95% CI 0.62–0.66), PARA 0.72 (95% CI 0.72–0.74), and the score from Tsui et al. 0.73 (95% CI 0.72–0.75). Performance in subgroups did not differ from the overall performance, except for oncology patients in the PARA score (0.57, 95% CI 0.54–0.60), and nephrology patients in the SEMI index (0.25, 95% CI 0.18–0.31), respectively. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05638-z) contains supplementary material, which is available to authorized users.

ImportanceWhether interprofessional collaboration is effective and safe in decreasing hospital length of stay remains controversial.ObjectiveTo evaluate the outcomes and safety associated with an electronic interprofessional-led discharge planning tool vs standard discharge planning to safely reduce length of stay among medical inpatients with multimorbidity.Design, Setting, and ParticipantsThis multicenter prospective nonrandomized controlled trial used interrupted time series analysis to examine medical acute hospitalizations at 82 hospitals in Switzerland. It was conducted from February 2017 through January 2019. Data analysis was conducted from March 2021 to July 2022.InterventionAfter a 12-month preintervention phase (February 2017 through January 2018), an electronic interprofessional-led discharge planning tool was implemented in February 2018 in 7 intervention hospitals in addition to standard discharge planning.Main Outcomes and MeasuresMixed-effects segmented regression analyses were used to compare monthly changes in trends of length of stay, hospital readmission, in-hospital mortality, and facility discharge after the implementation of the tool with changes in trends among control hospitals.ResultsThere were 54 695 hospitalizations at intervention hospitals, with 27 219 in the preintervention period (median [IQR] age, 72 [59-82] years; 14 400 [52.9%] men) and 27 476 in the intervention phase (median [IQR] age, 72 [59-82] years; 14 448 [52.6%] men) and 438 791 at control hospitals, with 216 261 in the preintervention period (median [IQR] age, 74 [60-83] years; 109 770 [50.8%] men) and 222 530 in the intervention phase (median [IQR] age, 74 [60-83] years; 113 053 [50.8%] men). The mean (SD) length of stay in the preintervention phase was 7.6 (7.1) days for intervention hospitals and 7.5 (7.4) days for control hospitals. During the preintervention phase, population-averaged length of stay decreased by −0.344 hr/mo (95% CI, −0.599 to −0.090 hr/mo) in control hospitals; however, no change in trend was observed among intervention hospitals (−0.034 hr/mo; 95% CI, −0.646 to 0.714 hr/mo; difference in slopes, P = .09). Over the intervention phase (February 2018 through January 2019), length of stay remained unchanged in control hospitals (slope, −0.011 hr/mo; 95% CI, −0.281 to 0.260 hr/mo; change in slope, P = .03), but decreased steadily among intervention hospitals by −0.879 hr/mo (95% CI, −1.607 to −0.150 hr/mo; change in slope, P = .04, difference in slopes, P = .03). Safety analyses showed no change in trends of hospital readmission, in-hospital mortality, or facility discharge over the whole study time.Conclusions and RelevanceIn this nonrandomized controlled trial, the implementation of an electronic interprofessional-led discharge planning tool was associated with a decline in length of stay without an increase in hospital readmission, in-hospital mortality, or facility discharge.Trial Registrationisrctn.org Identifier: ISRCTN83274049

Purpose To externally validate four previously developed severity scores (i.e., CALL, CHOSEN, HA2T2 and ANDC) in patients with COVID-19 hospitalised in a tertiary care centre in Switzerland. Methods This observational analysis included adult patients with a real-time reverse-transcription polymerase chain reaction or rapid-antigen test confirmed severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection hospitalised consecutively at the Cantonal Hospital Aarau from February to December 2020. The primary endpoint was all-cause in-hospital mortality. The secondary endpoint was disease progression, defined as needing invasive ventilation, ICU admission or death. Results From 399 patients (mean age 66.6 years ± 13.4 SD, 68% males), we had complete data for calculating the CALL, CHOSEN, HA2T2 and ANDC scores in 297, 380, 151 and 124 cases, respectively. Odds ratios for all four scores showed significant associations with mortality. The discriminative power of the HA2T2 score was higher compared to CALL, CHOSEN and ANDC scores [area under the curve (AUC) 0.78 vs. 0.65, 0.69 and 0.66, respectively]. Negative predictive values (NPV) for mortality were high, particularly for the CALL score (≥ 6 points: 100%, ≥ 9 points: 95%). For disease progression, discriminative power was lower, with the CHOSEN score showing the best performance (AUC 0.66). Conclusion In this external validation study, the four analysed scores had a lower performance compared to the original cohorts regarding prediction of mortality and disease progression. However, all scores were significantly associated with mortality and the NPV of the CALL and CHOSEN scores in particular allowed reliable identification of patients at low risk, making them suitable for outpatient management. Supplementary Information The online version contains supplementary material available at 10.1007/s15010-021-01728-0.

Estimating the probability of readmission following hospitalization using prediction scores can be complex. Quality of life (QoL) may provide an easy and effective alternative.Secondary analysis of the prospective "TRIAGE" cohort. All medical in-patients admitted to a Swiss tertiary care institution (2016-2019) ≥18 years with a length of stay of ≥2 days (23,309 patients) were included. EQ-5D VAS, EQ-5D index, and Barthel index were assessed at a single telephone interview 30-day after admission. Patients lost to follow-up were excluded. Readmission was defined as a non-elective hospital stay at our institution 24 h within 1 year after discharge and assessed using area under the curve (AUC) analysis with adjustment for confounders.12,842 patients (43% females, median age 68, IQR 55-78) were included. Unadjusted discrimination was modest at 0.59 (95% CI 0.56-0.62) for EQ-5D VAS. Partially adjusted discrimination (for gender) was identical. Additional adjustment for insurance, Charlson comorbidity index, length of stay, and native language increased the AUC to 0.66 (95% CI 0.63-0.69). Results were robust irrespective of time to event (12, 6 or 3 months). A cut-off in the unadjusted model of EQ-5D VAS of 55 could separate cases with a specificity of 80% and a sensitivity of 30%.QoL at day 30 after admission can predict one-year readmission risk with similar precision as more intricate tools. It might help for identification of high-risk patients and the design of tailored prevention strategies.

Lung ultrasound (LUS) has shown promising diagnostic potential in different pulmonary conditions. We evaluated the diagnostic accuracy of LUS for pulmonary COVID-19. In this prospective cohort study at a Swiss tertiary care center, patients hospitalized with suspected COVID-19 were scanned using a 12-zone protocol. Association of a summation score (0–36 points) with the final diagnosis was tested using the area under the receiver operating characteristic curve and sensitivity and specificity at different cutoff points. Of the 49 participants, 11 (22%) were later diagnosed with COVID-19. LUS score showed excellent diagnostic performance, with an odds ratio of 1.30 per point (95% confidence interval [CI], 1.09–1.54, p = 0.003) and an area under the curve of 0.85 (95% CI, 0.71–0.99). At a cutoff of 8/36 points, 10 of 11 participants later diagnosed with COVID-19 were correctly predicted (sensitivity 91%, 95% CI, 59%–100%), and 29 of the 38 who were not diagnosed with COVID-19 were correctly ruled out (specificity 76%, 95% CI, 60%–89%). LUS demonstrated promising discriminatory potential in people hospitalized with suspected COVID-19.

BackgroundActivation of the vasopressin system plays a key role for the maintenance of osmotic, cardiovascular, and stress hormone homeostasis during disease. We investigated levels of copeptin, the C-terminal segment of the vasopressin prohormone, that mirrors the production rate of vasopressin in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).MethodsWe measured levels of copeptin on admission and after days 3/4, 5/6, and 7/8 in 74 consecutive hospitalized adult COVID-19 patients and compared its prognostic accuracy to that of patients with community-acquired pneumonia (n = 876) and acute or chronic bronchitis (n = 371) from a previous study by means of logistic regression analysis. The primary endpoint was all-cause 30-day mortality.ResultsMedian admission copeptin levels in COVID-19 patients were almost 4-fold higher in nonsurvivors compared with survivors (49.4 pmol/L [iterquartile range (IQR) 24.9–68.9 pmol/L] vs 13.5 pmol/L [IQR 7.0–26.7 pmol/L]), resulting in an age- and gender-adjusted odds ratio of 7.0 (95% confidence interval [CI] 1.2–40.3), p < 0.03 for mortality. Higher copeptin levels in nonsurvivors persisted during the short-term follow-up. Compared with the control group patients with acute/chronic bronchitis and pneumonia, COVID-19 patients did not have higher admission copeptin levels.ConclusionsA pronounced activation of the vasopressin system in COVID-19 patients is associated with an adverse clinical course in COVID-19 patients. This finding, however, is not unique to COVID-19 but similar to other types of respiratory infections.

Background Delays in patient discharge can not only lead to deterioration, especially among geriatric patients, but also incorporate unnecessary resources at the hospital level. Many of these delays and their negative impact may be preventable by early focused screening to identify patients at risk for transfer to a post-acute care facility. Early interprofessional discharge planning is crucial in order to fit the appropriate individual discharge destination. While prediction of discharge to a post-acute care facility using post-acute care discharge score, the self-care index, and a combination of both has been shown in a single-center pilot study, an external validation is still missing. Objective This paper outlines the study protocol and methodology currently being used to replicate the previous pilot findings and determine whether the post-acute care discharge score, the self-care index, or the combination of both can reliably identify patients requiring transfer to post-acute care facilities. Methods This study will use prospective data involving all phases of the quasi-experimental study “In-HospiTOOL” conducted at 7 Swiss hospitals in urban and rural areas. During an 18-month period, consecutive adult medical patients admitted to the hospitals through the emergency department will be included. We aim to include 6000 patients based on sample size calculation. These data will enable a prospective external validation of the prediction instruments. Results We expect to gain more insight into the predictive capability of the above-mentioned prediction instruments. This approach will allow us to get important information about the generalizability of the three different models. The study was approved by the institutional review board on November 21, 2016, and funded in May 2020. Expected results are planned to be published in spring 2021. Conclusions This study will provide evidence on prognostic properties, comparative performance, reliability of scoring, and suitability of the instruments for the screening purpose in order to be able to recommend application in clinical practice. International Registered Report Identifier (IRRID) DERR1-10.2196/21447

Objective While evidence on the interface between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the renin-angiotensin-aldosterone-system (RAAS) is accumulating, clinical data on RAAS peptide alteration among coronavirus disease-19 (COVID-19) patients is missing. Design and methods In this exploratory study, we prospectively included adult patients (aged ≥ 18 years) admitted between February 26 and April 30, 2020 to a tertiary care hospital in Switzerland. We assessed the association of an underlying SARS-CoV-2 infection and equilibrium serum levels of RAAS peptides in hospitalized COVID-19 patients 1:1 propensity-score matched with patients suffering from SARS-CoV-2-negative respiratory infections. Subgroup analyses involved stratification for taking RAAS inhibitors. Results COVID-19 patients had about 50% lower equilibrium serum RAAS peptide levels as compared with matched controls (angiotensin I: 31.6 vs 66.8 pmol/L, −52.7% (95%CI: −68.5% to −36.9%); angiotensin II: 37.7 vs 92.5 pmol/L, −59.2% (95%CI: −72.1% to −46.3%); angiotensin (1–5): 3.3 vs 6.6 pmol/L, −49.7% (95%CI: −59.2% to −40.2%); angiotensin (1–7): 4.8 vs 7.6 pmol/L, −64.9% (95%CI: −84.5% to −45.3%)). While the plasma renin activity was lower in COVID-19 patients (88.6 vs 207.9 pmol/L, −58.5% (95%CI: −71.4% to −45.6%)), there was no difference of angiotensin-converting enzyme (ACE) and ACE2 plasma activity between the groups. Subgroup analyses revealed a pronounced RAAS peptide profile depression in COVID-19 patients among those not on RAAS inhibitors. Conclusions As compared with SARS-CoV-2-negative patients, we found a downregulated RAAS in presence of a SARS-CoV-2 infection. Whether the lower levels of the protective angiotensin (1–5) and (1–7) are linked to adverse outcomes in COVID-19 warrants further investigation.

BACKGROUND Delays in patient discharge can not only lead to deterioration, especially among geriatric patients, but also incorporate unnecessary resources at the hospital level. Many of these delays and their negative impact may be preventable by early focused screening to identify patients at risk for transfer to a post-acute care facility. Early interprofessional discharge planning is crucial in order to fit the appropriate individual discharge destination. While prediction of discharge to a post-acute care facility using post-acute care discharge score, the self-care index, and a combination of both has been shown in a single-center pilot study, an external validation is still missing. OBJECTIVE This paper outlines the study protocol and methodology currently being used to replicate the previous pilot findings and determine whether the post-acute care discharge score, the self-care index, or the combination of both can reliably identify patients requiring transfer to post-acute care facilities. METHODS This study will use prospective data involving all phases of the quasi-experimental study “In-HospiTOOL” conducted at 7 Swiss hospitals in urban and rural areas. During an 18-month period, consecutive adult medical patients admitted to the hospitals through the emergency department will be included. We aim to include 6000 patients based on sample size calculation. These data will enable a prospective external validation of the prediction instruments. RESULTS We expect to gain more insight into the predictive capability of the above-mentioned prediction instruments. This approach will allow us to get important information about the generalizability of the three different models. The study was approved by the institutional review board on November 21, 2016, and funded in May 2020. Expected results are planned to be published in spring 2021. CONCLUSIONS This study will provide evidence on prognostic properties, comparative performance, reliability of scoring, and suitability of the instruments for the screening purpose in order to be able to recommend application in clinical practice. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/21447

Aims of the study Clostridioides difficile infection (CDI) is associated with high morbidity, recurrence rates and mortality. We assessed the local epidemiology, treatment outcomes and risk factors for recurrence and mortality. Methods This was a retrospective study of all adult CDI episodes treated in our tertiary care hospital between 2014 and 2016. Patients were followed up for 60 days, with recurrence and death as endpoints. Antibiotic treatment as well as epidemiological, clinical and laboratory parameters were studied using logistic regression analysis. Risk factors for recurrent CDI (age g70 years, haematological malignancy, chronic kidney disease, severe infection, continued antibiotics other than for CDI, proton pump inhibitor / antacid use) and indicators of severe CDI (temperature g38.5dC, leucocytes g15 t 109/l, creatinine increase g1.5 t baseline, albumin l25 g/l) were analysed. We considered episodes with g2 indicators as severe. Results We identified 210 CDI episodes (66 severe) in 191 patients with a median age of 71 years (interquartile range 59n79). Hypervirulent ribotype 027/NAP1/BI accounted for four episodes (2%). Overall, 176, 30 and 4 patients, respectively, received a first, second and third treatment. Metronidazole was used in 94% of the first episodes and in 73% and 50% of the first and second recurrences, respectively. The recurrence rate after the first metronidazole treatment was 20%. Recurrence rates were higher when g2 risk factors were present (25 vs 10%, p = 0.03). The 60-day mortality was 17% (4% attributable to CDI) and increased with the presence of g2 indicators of severe CDI. Conclusions The high 60-day mortality suggests that CDI is a strong indicator of frailty. Metronidazole was associated with low recurrence rates at minimal costs in patients with uncomplicated CDI, but had relevant shortcomings in patients with severe CDI and/or a high risk of recurrence, suggesting that these vulnerable patients might better be treated with oral vancomycin and fidaxomicin, according to the latest guidelines. &nbsp.

Background There is growing evidence that patients with functional decline are at increased risk of readmission, mortality and institutionalization. Instruments to measure the status of self-care could provide important information for efficient care planning. The widely used Self Care Index serves as an indicator for the severity of nursing dependency. To date, no evidence is available on the association of the instrument with rehospitalization, mortality and institutionalization. Objectives To examine the association of functional status measures (Self Care Index on admission, at discharge and functional decline) with 30-day mortality, readmission and institutionalization in hospitalized non-surgical patients. Design Prospective cohort study. Participants We included 4540 emergency medical patients at a single hospital in Switzerland. Methods Primary outcome was 30-day mortality rate; secondary outcomes were 30-day readmission and institutionalization. We analyzed the association of the functional status with the binary endpoints using logistic regression models and C-statistics for discrimination. Results All of the examined measures were significant predictors of overall 30-day mortality; Self Care Index on admission: adj. OR: 0.90 (95% CI: 0.87–0.92); Self Care Index at discharge: adj. OR: 0.86 (95% CI: 0.83–0.88); functional decline: adj. OR: 1.22 (95% CI: 1.14–1.31) and all Self Care Index single items. A combined model (functional status on admission and functional decline during hospitalization) showed a good accuracy with regard to the AUC: adj. AUC: 0.80 (95% CI: 0.74–0.86). Conclusions Several functional measures were associated with 30-day mortality. Self Care Index total score, five single items and a combined model showed the best performance.

Objective. There is limited data on abdominal obesity and the influence of genetics on weight change after ant iretroviral therapy (ART) initiation. We assessed body mass index (BMI) and waist hip ration (WHR) change over time in the Swiss HIV Cohort study (SHCS)., Methods. Mixed-effects models characterizing BMI and WHR change over time in 1090 SHCS participants initiating ART between 2005 and 2015 were developed and used to quantify the influence of demographics, clinical factors, and genetic background., Results. Individuals with CD4 nadir = 200, and 2.8 times more WHR than individuals with >= 100 (P < .001) during the first 1.5 and 2.5 years after ART initiation, respectively. The risk of being overweight or obese after 1.5 years increased with CD4 nadir = 200 (OR, 1.69; 95% CI, 1.26-2.32), persisting after 10 years of ART. The risk of abdominal obesity after 2.5 years increased with CD4 nadir = 100 (OR, 1.35; 95% CI, 1.17-1.54 [in men]; OR, 1.36; 95% CI, 1.18-1.57 [in women]), persisting after 10 years of ART No significant differences were found across antiretroviral drug classes or genetic scores., Conclusions. The risk of general and abdominal obesity increased with CD4 nadir

Background Renal failure is common in patients seeking help in medical emergency departments. Decreased renal function is associated with increased mortality in patients with heart failure or sepsis. In this study, the association between renal function (reflected by estimated glomerular filtration rate (eGFR) at the time of admission) and clinical outcome was evaluated. Methods/Objectives Data was used from a prospective, multi-national, observational cohort of patients treated in three medical emergency departments of tertiary care centers. The eGFR was calculated from the creatinine at the time of admission (using the Chronic Kidney Disease-Epidemiology Collaboration equation,CKD-EPI). Uni- and multivariate regression models were used for eGFR and 30-day mortality, in hospital mortality, length of stay and intensive care unit admission rate. Results 6983 patients were included. The 30-day mortality was 1.8%, 3.5%, 6.9%, 11.1%, 13.6%, and 14.2% in patients with eGFR of above 90, 60–89, 45–59, 30–44, 15–29, and 90 ml/min/1.73m2, 95% CI 2.04 to 6.84, p

Background Whether procalcitonin (PCT)–guided antibiotic management in patients with positive blood cultures is safe remains understudied. We performed a patient-level meta-analysis to investigate effects of PCT-guided antibiotic management in patients with bacteremia. Methods We extracted and analyzed individual data of 523 patients with positive blood cultures included in 13 trials, in which patients were randomly assigned to receive antibiotics based on PCT levels (PCT group) or a control group. The main efficacy endpoint was duration of antibiotic treatment. The main safety endpoint was mortality within 30 days. Results Mean duration of antibiotic therapy was significantly shorter for 253 patients who received PCT-guided treatment than for 270 control patients (–2.86 days [95% confidence interval [CI], –4.88 to –.84]; P = .006). Mortality was similar in both arms (16.6% vs 20.0%; P = .263). In subgroup analyses by type of pathogen, we noted a trend of shorter mean antibiotic durations in the PCT arm for patients infected with gram-positive organisms or Escherichia coli and significantly shorter treatment for subjects with pneumococcal bacteremia. In analysis by site of infection, antibiotic exposure was shortened in PCT subjects with Streptococcus pneumoniae respiratory infection and those with E. coli urogenital infections. Conclusions This meta-analysis of patients with bacteremia receiving PCT-guided antibiotic management demonstrates lower antibiotic exposure without an apparent increase in mortality. Few differences were demonstrated in subgroup analysis stratified by type or site of infection but notable for decreased exposure in patients with pneumococcal pneumonia and E. coli urogenital infections. Fundo Se o manejo antibiótico guiado por procalcitonina (PCT) em pacientes com hemoculturas positivas é seguro permanece pouco estudado. Realizamos uma meta-análise em nível de paciente para investigar os efeitos do manejo antibiótico guiado por PCT em pacientes com bacteremia. Métodos Extraímos e analisamos dados individuais de 523 pacientes com hemoculturas positivas incluídos em 13 ensaios, nos quais os pacientes foram aleatoriamente designados para receber antibióticos com base nos níveis de PCT (grupo PCT) ou um grupo controle. O principal parâmetro de eficácia foi a duração do tratamento com antibióticos. O principal parâmetro de segurança foi a mortalidade em 30 dias. Resultados A duração média da antibioticoterapia foi significativamente menor para 253 pacientes que receberam tratamento guiado por PCT do que para 270 pacientes controle (–2,86 dias [intervalo de confiança de 95% [IC], –4,88 a –,84]; P = 0,006). A mortalidade foi semelhante em ambos os braços (16,6% vs 20,0%; P = 0,263). Em análises de subgrupo por tipo de patógeno, observamos uma tendência de duração média de antibióticos mais curta no braço de PCT para pacientes infectados com organismos gram-positivos ou Escherichia coli e tratamento significativamente mais curto para indivíduos com bacteremia pneumocócica. Na análise por local de infecção, a exposição a antibióticos foi reduzida em indivíduos PCT com infecção respiratória por Streptococcus pneumoniae e naqueles com infecções urogenitais por E. coli. Conclusões Esta meta-análise de pacientes com bacteremia recebendo tratamento antibiótico guiado por PCT demonstra menor exposição a antibióticos sem um aumento aparente na mortalidade. Poucas diferenças foram demonstradas na análise de subgrupos estratificados por tipo ou local de infecção, mas notáveis ​​pela diminuição da exposição em pacientes com pneumonia pneumocócica e infecções urogenitais por E. coli.

Blood cultures (BC) are the gold standard for bacteremia detection despite a relatively low diagnostic yield and high costs. A retrospective study reported high predictive values for BC positivity when combining the clinical Shapiro score with procalcitonin (PCT). Single-center, prospective cohort study between 01/2016 and 02/2017 to validate SPA algorithm, including a modified Shapiro score ≥ 3 points (S) PLUS admission PCT > 0.25 µg/l (P), or presence of overruling safety criteria (A) in patients with systemic inflammatory response syndrome. The diagnostic yield of SPA compared to non-standardized clinical judgment in predicting BC positivity was calculated and results presented as odds ratios (OR) with 95% confidence intervals. Of 1438 patients with BC sampling, 215 (15%) had positive BC which increased to 31% (173/555) in patients fulfilling SP criteria (OR for BC positivity 9.07 [6.34–12.97]). When adding 194 patients with overruling safety criteria (i.e., SPA), OR increased to 11.12 (6.99–17.69), although BC positivity slightly decreased to 26%. With an area under the receiver operating curve of 0.742, SPA indicated better diagnostic performance than its individual components. Positive BC in 689 patients not fulfilling SPA (sampling according to non-standardized clinical judgment) were rare (3%; OR for BC positivity 0.09 [0.06–0.14]). Eight out of 21 missed pathogens were still identified by sampling the primary infection focus. This study validates the high predictive value of SPA for bacteremia, increasing true BC positivity from 15 to 26%. Restricting BC sampling to SPA would have reduced BC sampling by 48%, while still detecting 194/215 organisms (90%), which makes SPA a valuable diagnostic stewardship tool.

Introduction The physical appearance of a physician may influence patientsr perceptions of that physicianrs quality of care. There is a lack of studies investigating whether physician appearance is indeed associated with patient satisfaction and mortality. Methods This observational study included adult medical inpatients treated at a Swiss tertiary care hospital between 2013 and 2016. We investigated associations of gender and physician appearance (hair colour, wearing of glasses) with in-hospital mortality and perceived quality of care, assessed by a telephone interview 30 days after admission. Regression models were adjusted for patient age, patient gender, and the Charlson Comorbidity Index. Results We included 18,259 inpatients treated by 494 different physicians during their hospital stay. We had full information regarding patient-perceived quality of care for 9917 patients. Overall, 860 patients (4.7%) died in the hospital and 1479 (14.9%) reported low satisfaction with their care. After multivariable adjustment, there was no difference in mortality or patient-perceived quality of care whether physicians did or did not wear glasses and whether they were male or female. The hair colour of residents was also not associated with outcomes. However, patients treated by grey-haired attending physicians, compared to those with dark or blond hair, had significantly lower in-hospital mortality (adjusted odds ratio 0.70, 95% confidence interval 0.53n0.92, p = 0.011). Conclusions This analysis suggests that physician gender or appearance has little influence on the quality of care provided to hospitalised medical patients. Whether the small but significant mortality benefit observed for grey-haired attending physicians is possibly confounded by age and physician experience clearly needs further investigation. Nevertheless, our analysis provides empirical evidence that having at least some grey-haired attending physicians in the medical physician team seems to be beneficial for patients, even if patients do not recognise the clear superiority of their care.

Background Elderly patients often need post-acute care after hospital discharge. Involvement of social workers can positively affect the discharge planning process. Aim To investigate the effect of screening patients at risk for post-acute care needs by social workers on time with respect to social workers’ notification, length of stay and delays in discharge compared to usual care. Methods Cluster randomized stepped wedge trial design for five clusters (wards) and two steps (control to intervention) was used. A total of 400 patients (200 per period) with high risk of post-acute care needs (defined as Post-Acute Care Discharge score, PACD ≥ 7) were included. Social workers performed a screening to decide about self-referral to their services (intervention period), which was compared to a highly structured standard SW notification by physicians and nurses (control period). A Generalized Estimating Equations model adjusted the clustering and baseline differences. Results A total of 139 patients were referred to social services (intervention: n = 76; control: n = 63). Time to social workers’ notification was significantly shorter in the intervention period when adjusted for all the differences in baseline (Mdn 1.2 vs 1.7, Beta = -0.73, 95%-CI 1.39 to -0.09). Both the length of stay and the delayed discharge time in nights showed no significant differences (Mdn 10.0 vs 9.1, Beta = -0.12, 95%-CI 0.46 to .22 nights 95%-CI, resp. Mdn 0.0 vs 0.0, Beta = .11, 95%-CI -0.64 to 0.86). Conclusion Screening speeded up social workers’ notification but did not accelerate the discharge processes. The screening by social workers might show process improvement in settings with less structured discharge planning.

AIM OF THE STUDY To compare admission characteristics, predictors and outcomes of patients with confirmed coronavirus disease 2019 (COVID-19) hospitalised in a tertiary care hospital in Switzerland during the first and second waves of the pandemic. METHODS This retrospective observational analysis included adult patients with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection confirmed by a real-time reverse transcriptase polymerase chain reaction (RT-PCR) or rapid antigen test and hospitalised at the Cantonal Hospital Aarau from 26 February to 30 April 2020 (first wave) and from 1 October to 31 December 2020 (second wave). The primary endpoint was all-cause in-hospital mortality. The secondary endpoints were transfer to the intensive care unit (ICU) and length of hospital stay (LOS). RESULTS Overall, 486 patients (mean age 65.9 years ± 14.7 SD, 65% male) were included. Ninety-two patients (19%) died during the hospital stay and 92 patients (19%) were transferred to the ICU. Admission characteristics, including comorbidities and frailty, were similar for patients of the first (n = 100) and second wave (n = 386). However, during the second wave the median time from symptom onset to presentation to the emergency department (ED) was shorter (7 days, interquartile range [IQR] 4–9 vs 8 days, IQR 4–11; p = 0.02). In the second wave, most patients received high-dose glucocorticoid treatment (0% vs 76%, p

Sporopachydermia cereana is a rare yeast found in necrotic cactus tissue, predominantly in the Americas. Infection in humans with clinical data has only been reported in four patients so far, all of whom died, either directly from the pathogen or from other complications of immunosuppression. Treatment of the yeast is complicated by difficulties in identification of the pathogen with conventional diagnostic techniques and by intrinsic resistance to echinocandins. The first patient to survive a disseminated infection with S. cereana is presented herein. The patient had acute myeloid leukemia and was treated successfully with antifungal therapy and subsequently underwent a successful allogeneic hematopoietic stem cell transplantation.

We validated a clinical prediction rule for Legionella based on clinical parameters (dry cough, fever) and laboratory findings (C-reactive protein, lactate dehydrogenase, sodium, platelet counts) in 713 consecutive patients with community-acquired pneumonia. The Legionella Score performed well in estimating the likelihood for Legionella infection and thus may help to direct diagnostic and therapeutic decisions.

Background A comprehensive in-hospital patient management with reasonable and economic resource allocation is arguably the major challenge of health-care systems worldwide, especially in elderly, frail, and polymorbid patients. The need for patient management tools to improve the transition process and allocation of health care resources in routine clinical care particularly for the inpatient setting is obvious. To address these issues, a large prospective trial is warranted. Methods The “Integrative Hospital Treatment in Older patients to benchmark and improve Outcome and Length of stay” (In-HospiTOOL) study is an investigator-initiated, multicenter effectiveness trial to compare the effects of a novel in-hospital management tool on length of hospital stay, readmission rate, quality of care, and other clinical outcomes using a time-series model. The study aims to include approximately 35`000 polymorbid medical patients over an 18-month period, divided in an observation, implementation, and intervention phase. Detailed data on treatment and outcome of polymorbid medical patients during the in-hospital stay and after 30 days will be gathered to investigate differences in resource use, inter-professional collaborations and to establish representative benchmarking data to promote measurement and display of quality of care data across seven Swiss hospitals. The trial will inform whether the “In-HospiTOOL” optimizes inter-professional collaboration and thereby reduces length of hospital stay without harming subjective and objective patient-oriented outcome markers. Discussion Many of the current quality-mirroring tools do not reflect the real need and use of resources, especially in polymorbid and elderly patients. In addition, a validated tool for optimization of patient transition and discharge processes is still missing. The proposed multicenter effectiveness trial has potential to improve interprofessional collaboration and optimizes resource allocation from hospital admission to discharge. The results will enable inter-hospital comparison of transition processes and accomplish a benchmarking for inpatient care quality. Electronic supplementary material The online version of this article (10.1186/s12913-019-4045-x) contains supplementary material, which is available to authorized users.

Background D-dimer measurement improves the rule-out of thromboembolic disease. However, little is known about the risk of false positive results for the diagnosis of thromboembolic disease and its prognostic value. Herein, we investigated factors influencing the accuracy of D-dimer and its prognostic value in a large cohort of emergency department (ED) patients. Methods This is a secondary analysis of a prospective observational single center, cohort study. Consecutive patients, for whom a D-dimer test was requested by the treating physician, were included. Associations of clinical parameters on admission with false positive D-dimer results for the diagnosis of thromboembolic disease were investigated with logistic regression analysis. Results A total of 3301 patients were included, of which 203 (6.1%) had confirmed thromboembolic disease. The negative and positive predictive values of the D-dimer test at the 0.5 mg/L cut-off were 99.9% and 11.4%, respectively. Several factors were associated with positive D-dimer results potentially falsely indicating thromboembolic disease in multivariate analysis including advanced age (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.04–1.05, p Conclusions While D-dimer allows an accurate rule-out of thromboembolic disease, its positive predictive value in routine ED patients is limited and largely influenced by age, comorbidities and acute disease factors. The strong prognostic value of D-dimer in this population warrants further investigation.

We validated a clinical prediction rule for Legionella based on clinical parameters (dry cough, fever) and laboratory findings (C-reactive protein, lactate dehydrogenase, sodium, platelet counts) in 713 consecutive patients with community-acquired pneumonia. The Legionella Score performed well in estimating the likelihood for Legionella infection and thus may help to direct diagnostic and therapeutic decisions.

Background Discriminating Mycoplasma pneumoniae (MP) from Streptococcus pneumoniae (SP) and viral etiologies of community-acquired pneumonia (CAP) is challenging but has important implications regarding empiric antibiotic therapy. We investigated patient parameters upon hospital admission to predict MP infection. Methods All patients hospitalized in a tertiary care hospital between 2013 and 2017 for CAP with a confirmed etiology were analyzed using logistic regression analyses and area under the receiver operator characteristics (ROC) curves (AUC) for associations between demographic, clinical and laboratory features and the causative pathogen. Results We analyzed 568 patients with CAP, including 47 (8%) with MP; 152 (27%) with SP and 369 (65%) with influenza or other viruses. Comparing MP and SP by multivariate logistic regression analysis, younger age (odds ration [OR] 0.56 per 10 years, 95% CI 0.42–0.73), a lower neutrophil/lymphocyte ratio (OR 0.9, 0.82–0.99) and an elevated C-reactive protein/procalcitonin (CRP/PCT) ratio (OR 15.04 [5.23–43.26] for a 400 mg/μg cut-off) independently predicted MP. With a ROC curve AUC of 0.91 (0.80 for the >400 mg/μg cutoff), the CRP/PCT ratio was the strongest predictor of MP vs. SP. The discriminatory value resulted from significantly lower PCT values (p 400 mg/μg cutoff, 2.26–13.64). Conclusions In patients hospitalized with CAP, a high admission CRP/PCT ratio predicts M. pneumoniae infection and may improve empiric management.