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Background and Aim: The increasing number of patients requiring emergency care is a challenge and leads to decreased satisfaction of health professionals at emergency departments (EDs). Thus, a Swiss hospital implemented a hospital-associated primary care centre at the ED. The study aim was to investigate changes in job satisfaction of ED staff before and after the implementation of this new service model and to measure hospital GPs' (HGPs) satisfaction at the hospital-associated primary care centre., Method: This study was embedded in a large prospective before-after study over two years. We examined changes in job satisfaction with a questionnaire followed by selected interviews approaching all of the involved 25 ED staff members and 38 HGPs., Results: The new emergency care model increased job satisfaction of ED staff and HGPs in all measured dimensions. The overall job satisfaction of ED employees improved from 76.5 to 83.9 points (visual analogue scale 0-100; difference 7.4 points [95% CI: 1.3 to 13.5, p = 0.02]). 86% of 29 HGPs preferred to provide their out-of-hours service at the new hospital-associated primary care centre., Conclusions: The hospital-associated primary care centre is a promising option to improve job satisfaction of different health professionals in emergency care., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Daptomycin dose is adjusted to body weight and renal function and is usually not guided by therapeutic drug monitoring. Daptomycin plasma concentration measurement was established at our institution in January 2009 and is now increasingly being used. The aim of this study was to describe and characterize variability in daptomycin exposure during routine clinical therapy., Methods: We collected daptomycin plasma concentrations that were measured at our institution during the period January 2009-July 2012. Additional clinical and demographic data and their association with daptomycin exposure were tested by a multilevel linear regression analysis., Results: A total of 332 daptomycin plasma concentrations were determined in 86 patients. Sixty-six percent (n = 218) of all determinations were trough concentrations (Cmin), and 34% (n = 114) were peak concentrations (Cmax). Cmin ranged 2-68 mg/L (median, 16.7 mg/L), and Cmax 20-236 mg/L (median, 66.2 mg/L). A significant positive association of total dose, albumin, creatinine and a significant negative association of dose interval and intermittent hemodialysis with Cmin were found in the regression analysis. Total dose and intensive care unit (ICU) stay were significantly associated with Cmax (P < 0.05). However, only 28% (P < 0.005) of Cmin variability and 8% (P = 0.08) of Cmax variability were explained by the factors included in the analysis., Conclusions: Daptomycin plasma concentrations are often unpredictable as shown by highly variable drug exposure that is only partially explained by dose administered and underlying renal function.

Background: Managing patients with polypharmacy is a challenging issue in primary care. The aim of this study is to determine whether a patient-centered systematic review leads to more appropriate medication use in patients without negatively affecting quality of life and the course of the disease., Methods/design: The trial is a two-armed, double blinded cluster-randomized controlled trial. Primary care physicians (PCPs) will be randomly assigned to the intervention or control group. Physicians in the intervention group undergo training with instruction of the algorithm. The control group is given a lecture on multimorbidity and instructions for collecting data in a usual care manner. PCPs will approach patients aged 60 years or older who are taking 5 or more drugs. The study period is 1 year. The primary outcome measure is the change in the number of drugs 12 months after the algorithm was applied by the PCP during consultation with the patient. Secondary outcomes are: change in the number of drugs immediately after the encounter and 6 months later, reason for a change of the medication, discrepancy in the decision to change between PCP and patient, number of drugs for which the patient is suggesting a change, number of drugs the patient is taking that are not known to the PCP, time consumption of the intervention, disease-specific variables to evaluate the course of the disease(s) for which the patient is being treated , quality of life, barriers against using the algorithm, numbers of drugs readopted due to an unfavorable course of the disease, and numbers of drugs which have been started., Discussion: Answering the four questions of the algorithm requires a weighing-up of risks and benefits and contains a shared-decision-making approach: a prioritization of the treatment goals is necessary. This can only be done in collaboration with the patient. The majority of patients with multimorbidity are treated in the primary care setting. This underlines the significance of our study carried out in this setting: given the high prevalence of adverse drug events in patients with multimorbidity an intervention like ours has a large potential to reduce drug-related morbidity., Trial Registration: ISRCTN16560559 13 November 2014.

The theory of Participatory Discrepancies (or PDs) claims that minute temporal asynchronies (microtiming) in music performance are crucial for prompting bodily entrainment in listeners, which is a fundamental effect of the "groove" experience. Previous research has failed to find evidence to support this theory. The present study tested the influence of varying PD magnitudes on the beat-related body movement behavior of music listeners. 160 participants (79 music experts, 81 non-experts) listened to 12 music clips in either Funk or Swing style. These stimuli were based on two audio recordings (one in each style) of expert drum and bass duo performances. In one series of six clips, the PDs were downscaled from their originally performed magnitude to complete quantization in steps of 20%. In another series of six clips, the PDs were upscaled from their original magnitude to double magnitude in steps of 20%. The intensity of the listeners' beat-related head movement was measured using video-based motion capture technology and Fourier analysis. A mixed-design Four-Factor ANOVA showed that the PD manipulations had a significant effect on the expert listeners' entrainment behavior. The experts moved more when listening to stimuli with PDs that were downscaled by 60% compared to completely quantized stimuli. This finding offers partial support for PD theory: PDs of a certain magnitude do augment entrainment in listeners. But the effect was found to be small to moderately sized, and it affected music expert listeners only.

Rationale: Adherence to recommendations regarding quality of care for chronic obstructive pulmonary disease (COPD) improves outcome of patients. Performance measures (PM) reflect the quality of care but information about documentation of PM in primary care, is scant., Aim: To investigate the documentation of COPD PM in primary care practices of the Canton Zurich., Method: Twelve months retrospective medical chart review with physician of patients diagnosed COPD. PM were assessed by calculating the percentages of documented performance parameters. In addition, PM were compared with a practice running a structured COPD program., Results: Data from 14 practices, total 115 patients, 57% male, mean age 68 (44–93) years, 46% active smokers, median pack-years 56 (range 22–150) were analyzed. Comorbidities were documented in 73%, GOLD grading in 70% (GOLD I 11%, GOLD II 64%, GOLD III 21%, GOLD IV 4%). On average, patients were reported to have 1,4 exacerbations/year. Documentation of PM ranged between 16% (written action plan for exacerbations) and 95% (smoking status). Documentation was identified for smoking cessation advice (74%), influenza vaccination/recommendation (49%), adequate pharmacotherapy (65%), inhalation instruction (57%), pulmonary rehabilitation advice (27%), collaborative care (60%) and proactive follow up (51%). The practice running the COPD program showed significant better documentation for all PM (p<0,01) but for influenza vaccination., Conclusion: In Swiss primary care gaps in documentation and tracking of COPD performance exist. Identifying and bridging these gaps is central for health care quality.

Background.  Although acquired immune deficiency syndrome-associated morbidity has diminished due to excellent viral control, multimorbidity may be increasing among human immunodeficiency virus (HIV)-infected persons compared with the general population. Methods.  We assessed the prevalence of comorbidities and multimorbidity in participants of the Swiss HIV Cohort Study (SHCS) compared with the population-based CoLaus study and the primary care-based FIRE (Family Medicine ICPC-Research using Electronic Medical Records) records. The incidence of the respective endpoints were assessed among SHCS and CoLaus participants. Poisson regression models were adjusted for age, sex, body mass index, and smoking. Results.  Overall, 74 291 participants contributed data to prevalence analyses (3230 HIV-infected; 71 061 controls). In CoLaus, FIRE, and SHCS, multimorbidity was present among 26%, 13%, and 27% of participants. Compared with nonsmoking individuals from CoLaus, the incidence of cardiovascular disease was elevated among smoking individuals but independent of HIV status (HIV-negative smoking: incidence rate ratio [IRR] = 1.7, 95% confidence interval [CI] = 1.2-2.5; HIV-positive smoking: IRR = 1.7, 95% CI = 1.1-2.6; HIV-positive nonsmoking: IRR = 0.79, 95% CI = 0.44-1.4). Compared with nonsmoking HIV-negative persons, multivariable Poisson regression identified associations of HIV infection with hypertension (nonsmoking: IRR = 1.9, 95% CI = 1.5-2.4; smoking: IRR = 2.0, 95% CI = 1.6-2.4), kidney (nonsmoking: IRR = 2.7, 95% CI = 1.9-3.8; smoking: IRR = 2.6, 95% CI = 1.9-3.6), and liver disease (nonsmoking: IRR = 1.8, 95% CI = 1.4-2.4; smoking: IRR = 1.7, 95% CI = 1.4-2.2). No evidence was found for an association of HIV-infection or smoking with diabetes mellitus. Conclusions.  Multimorbidity is more prevalent and incident in HIV-positive compared with HIV-negative individuals. Smoking, but not HIV status, has a strong impact on cardiovascular risk and multimorbidity.

Background: Patients requiring anticoagulation suffer from comorbidities such as hypertension. On the occasion of INR monitoring, general practitioners (GPs) have the opportunity to control for blood pressure (BP). We aimed to evaluate the impact of Vitamin-K Antagonist (VKA) monitoring by GPs on BP control in patients with hypertension., Methods: We cross-sectionally analyzed the database of the Swiss Family Medicine ICPC Research using Electronic Medical Records (FIRE) of 60 general practices in a primary care setting in Switzerland. This database includes 113,335 patients who visited their GP between 2009 and 2013. We identified patients with hypertension based on antihypertensive medication prescribed for ≥ 6 months. We compared patients with VKA for ≥ 3 months and patients without such treatment regarding BP control. We adjusted for age, sex, observation period, number of consultations and comorbidity., Results: We identified 4,412 patients with hypertension and blood pressure recordings in the FIRE database. Among these, 569 (12.9%) were on Phenprocoumon (VKA) and 3,843 (87.1%) had no anticoagulation. Mean systolic and diastolic BP was significantly lower in the VKA group (130.6 ± 14.9 vs 139.8 ± 15.8 and 76.6 ± 7.9 vs 81.3 ± 9.3 mm Hg) (p < 0.001 for both). The difference remained after adjusting for possible confounders. Systolic and diastolic BP were significantly lower in the VKA group, reaching a mean difference of -8.4 mm Hg (95% CI -9.8 to -7.0 mm Hg) and -1.5 mm Hg (95% CI -2.3 to -0.7 mm Hg), respectively (p < 0.001 for both)., Conclusions: In a large sample of hypertensive patients in Switzerland, VKA treatment was independently associated with better systolic and diastolic BP control. The observed effect could be due to better compliance with antihypertensive medication in patients treated with VKA. Therefore, we conclude to be aware of this possible benefit especially in patients with lower expected compliance and with multimorbidity.

Background and Objective: Both comorbidities and physical inactivity have been shown to impair quality of life and contribute to hospital admissions and mortality in chronic obstructive pulmonary disease (COPD) patients. We hypothesized that the comorbid status predicts the level of daily physical activity (PA) in COPD., Methods: In 228 patients with COPD (76% men; median (quartiles) age: 64 (59/69) years; percentage of predicted forced expiratory volume in 1 s (FEV1 % pred): 44 (31/63)), comorbidities were assessed by medical history, clinical interviews, examination and blood analysis. PA level (PAL) was measured by an activity monitor (SenseWear Pro, Bodymedia Inc., Pittsburgh, PA, USA). The association between PAL and comorbidities was investigated by univariate and multivariate regression analysis., Results: Seventy-nine percent of the COPD patients had at least one additional chronic comorbidity, 56% had two or more comorbidities and 35% had three or more comorbidities. In univariate analysis body mass index, the number of pack years and having at least one additional comorbidity was negatively associated with PAL while there was a positive nonlinear association between FEV1 and PAL. The presence of at least one additional comorbidity was independently associated with PAL irrespective of airflow limitation., Conclusions: In this cohort, almost 80% of COPD patients had at least one additional chronic comorbidity. The level of daily PA seems to be significantly impaired by the presence of comorbidities irrespective of the type of comorbidity and independent of the degree of airflow limitation., Clinical Trial Registration: NCT01527773 at http://www.clinicalTrials.gov., (© 2015 Asian Pacific Society of Respirology.)

Rationale, Aim and Objective: To test feasibility and diagnostic accuracy of dermatologist's feedback based on digital images of skin lesions collected in Swiss primary care., Methods: This was a process analysis of a randomized controlled trial, conducted in 2011/2012. 30 of 78 general practitioners (GPs) were randomized to an intervention, which included dermatologist's feedback on digital images of skin lesions. Feedback was categorized into four categories: (1) no further investigation; (2) clinical observation; (3) biopsy; and (4) other. Histologic findings were allocated to the same categories. Feasibility was measured in the perspective of GPs concerning technical handling and of dermatologists as proportion of images usable for feedback. Diagnostic accuracy was measured as proportion of malignant histology of the first three feedback groups. No long-term data was collected., Results: 981 images of skin lesions were collected, two were not eligible due to low quality of images. The majority of GPs (77.8%) reported no problem with the procedure. 207 images were in feedback category 1, 353 in 2, 360 in 3 and 59 in 4. A total of 236 histologic tests were collected. Three cases in category 1 indicated malignancy (1 melanoma). 201 of category 3 received a biopsy, where in 91 (45.3%) malignancy was confirmed., Conclusion: Teledermatology with digital images taken in primary care was feasible from a GP and from a specialist perspective. However, diagnostic appropriateness regarding avoidance of specialist care and possible missed skin cancer raises concerns. These results therefore question a promotion of teledermatology in clinical routine., (© 2015 John Wiley & Sons, Ltd.)

Background: Adequate application of guidelines concerning non-invasive ischemia testing (NIIT) could avoid inappropriate invasive testing in non-emergency situations. Hardly any data exists regarding frequency and appropriateness of diagnostic coronary angiography (CA). The aim of this study was to evaluate the proportion and predictors of patients without NIIT prior to elective purely diagnostic CA without therapeutic intervention., Methods: Retrospective cross-sectional analysis of insurance claims data from 2012 and 2013. Patients <18 years, acute cardiac ischemia and emergency procedures and patients insured in a managed care model were excluded from analysis. The proportion of patients with NIIT procedures (stress-ECG, transthoracic echocardiography, stress echocardiography, scintigraphy, computer tomography, heart MRI) undertaken within two months before diagnostic CA was assessed. Multiple logistic regression analysis was applied to investigate independent determinants for receiving NIIT., Findings: 2714 patients were included for analysis. 37.5% (1018) did not receive any NIIT before CA. When high risk patients (patients having received therapeutic cardiac intervention within one month after or 18 months prior to diagnostic CA, n = 766) were excluded 34.3% (669) did not receive NIIT before CA. High risk status as well as >6 chronic comorbidities were independently associated with a lower proportion of NIIT (p<0.0001, OR 0.607 and p = 0.0041, OR 0.648), when additionally controlled for age, sex, language area, insurance coverage, inpatient treatment, cardiovascular medication and lower number of chronic comorbidities. Age (p<0.05, OR 1.009) and intake of oral antiplatelet therapy (p<0.0001, OR 1.914) were independently associated with a higher proportion of NIIT when controlled for the mentioned cofactors., Conclusions: Our data show that despite the existence of guidelines a substantial overuse of a potentially harmful and inappropriate diagnostic intervention is performed suggesting the need for improvement of diagnostic pathways prior to invasive testing.

Point of care testing (POCT) allows, among others, for efficient care of patients presenting with acute problems to primary care physicians. A combination of clinical information and laboratory results enables physicians to obtain posttest probabilities for the presence or absence of a specific disease. In order to rule in or rule out a disease, the physician has to know both the pretest probability for a disease in a patient as well as the analytical and diagnostic characteristics of the employed test. Pretest probability can be assessed by scores or by personal judgment of the experienced clinician. This article presents the basics of the Bayes theorem together with its clinical applications in acute scenarios in primary health care. These scenarios comprise the use of D-Dimer testing in ruling out venous thromboembolism, rapid testing of group A streptococci in the setting of acute pharyngitis, troponin testing in patients with thoracic pain, c-reactive protein (CRP) testing in patients presenting with acute cough and fever, as well as urine dipstick testing in suspected urinary tract infection. These examples illustrate, that risk stratification before conducting laboratory analysis is of utmost importance in order to obtain valid results for ruling in or ruling out diseases in POCT-settings.

Background: Emergency departments (EDs) are increasingly overcrowded by walk-in patients. However, little is known about health-economic consequences resulting from long waiting times and inefficient use of specialised resources. We have evaluated a quality improvement project of a Swiss urban hospital: In 2009, a triage system and a hospital-associated primary care unit with General Practitioners (H-GP-unit) were implemented beside the conventional hospital ED. This resulted in improved medical service provision with reduced process times and more efficient diagnostic testing. We now report on health-economic effects., Methods: From the hospital perspective, we performed a cost comparison study analysing treatment costs in the old emergency model (ED, only) versus treatment costs in the new emergency model (triage plus ED plus H-GP-unit) from 2007 to 2011. Hospital cost accounting data were applied. All consecutive outpatient emergency contacts were included for 1 month in each follow-up year., Results: The annual number of outpatient emergency contacts increased from n=10 440 (2007; baseline) to n=16 326 (2011; after intervention), reflecting a general trend. In 2007, mean treatment costs per outpatient were €358 (95% CI 342 to 375). Until 2011, costs increased in the ED (€423 (396 to 454)), but considerably decreased in the H-GP-unit (€235 (221 to 250)). Compared with 2007, the annual local budget spent for treatment of 16 326 patients in 2011 showed cost reductions of €417 600 (27 200 to 493 600) after adjustment for increasing patient numbers., Conclusions: From the health-economic point of view, our new service model shows 'dominance' over the old model: While quality of service provision improved (reduced waiting times; more efficient resource use in the H-GP-unit), treatment costs sustainably decreased against the secular trend of increase., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: To describe the prevalence and determinants of potentially inappropriate medication (PIM) use and association with hospitalizations in an elderly managed care population in Switzerland., Methods: Using health care claims data of four health insurers for a sample of managed care patients 65 years of age and older to compare persons on PIM with persons not on PIM. Beers' 2012 and PRISCUS criteria were used to determine the potential inappropriateness of prescribed medications. The sample included 16'490 elderly patients on PIM and 33'178 patients not on PIM in the time period of January 1, 2008 through December 31, 2012. Prevalence estimates are standardized to the population of Switzerland. Associations between PIM and hospitalizations were examined by multivariate Cox regression analyses controlling for possible confounding variables., Results: The estimated prevalence of PIM use in our managed care sample was 22.5%. Logistic regression analysis showed that number of different medications used in the previous year, total costs in the previous year and hospitalization in the previous year all significantly increased the likelihood of receiving PIM. Multiple Cox regression analysis revealed that those on cumulative levels of PIM use acted significantly as a factor related to greater hospitalization rates: the adjusted HR was 1.13 (95% CI 1.07-1.19) for 1 PIM, 1.27 (95% CI 1.19-1.35) for 2 PIM, 1.35 (95% CI 1.22-1.50) for 3 PIM, and 1.63 (95% CI 1.40-1.90) for more than 3 PIM compared to no PIM use., Conclusions: The prevalence of PIM in managed care health plans are widely found but seem to be much lower than rates of non-managed care plans. Furthermore, our study revealed a significant association with adverse outcomes in terms of hospitalizations. These findings stress the need for further development of interventions to decrease drug-related problems and manage patients with multiple chronic conditions.

Background: Specific prevalence data are needed to assess the burden of sexually transmitted infections (STIs) in specific settings where data are scant, such as women seeking early termination of pregnancy (TOP). We aimed to investigate the prevalence of STIs and its determinants in women at risk (e. g. pathological cervical swab) undergoing TOP in a primary care setting in Switzerland., Methods: Cross-sectional study of 620 women seeking abortion counselling at a general practice in Zurich, Switzerland. Patients' characteristics were assessed and in case of pathological cervical swab a PCR-based screening for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG) and Neisseria gonorrhoeae (NG) was initiated to estimate STI prevalence. Bi-and multivariable analysis were used to investigate STI determinants., Results: 585 out of the 620 women presenting for counselling resulted in TOP. 581 (93,7%) cervical specimens were available with 272 having pathological signs (46,8%), thus were considered at risk for STIs. In 192 screened samples 28 STIs (14,6%) (95% CI: 10,3-20,3%) were detected, predominantly CT (17 cases) followed by MG (9 cases) and NG (2 cases). Compared to non-immigrants, immigrants were more likely to have a STI (adjusted OR 2,63; p=0,037) Non-screened women were significantly more often self-payers (31,3%) compared to screened women (8,3%) (p<0,001)., Conclusion: We found a high STI prevalence in women presenting for TOP in a Swiss primary care setting. Women with a migration background seemed to be a vulnerable subgroup. Public health efforts are needed to implement cost-effective screening and case management programmes in this population at risk for STIs.

OBJECTIVE To test whether the implementation of elements of the Chronic Care Model (CCM) via a specially trained practice nurse leads to an improved cardiovascular risk profile among type 2 diabetes patients. RESEARCH DESIGN AND METHODS This cluster randomized controlled trial with primary care physicians as the unit of randomization was conducted in the German part of Switzerland. Three hundred twenty-six type 2 diabetes patients (age >18 years; at least one glycosylated hemoglobin [HbA1c] level of ≥7.0% [53 mmol/mol] in the preceding year) from 30 primary care practices participated. The intervention included implementation of CCM elements and involvement of practice nurses in the care of type 2 diabetes patients. Primary outcome was HbA1c levels. The secondary outcomes were blood pressure (BP), LDL cholesterol, accordance with CCM (assessed by Patient Assessment of Chronic Illness Care [PACIC] questionnaire), and quality of life (assessed by the 36-item short-form health survey [SF-36]). RESULTS After 1 year, HbA1c levels decreased significantly in both groups with no significant difference between groups (-0.05% [-0.60 mmol/mol]; P = 0.708). Among intervention group patients, systolic BP (-3.63; P = 0.050), diastolic BP (-4.01; P < 0.001), LDL cholesterol (-0.21; P = 0.033), and PACIC subscores (P < 0.001 to 0.048) significantly improved compared with control group patients. No differences between groups were shown in the SF-36 subscales. CONCLUSIONS A chronic care approach according to the CCM and involving practice nurses in diabetes care improved the cardiovascular risk profile and is experienced by patients as a better structured care. Our study showed that care according to the CCM can be implemented even in small primary care practices, which still represent the usual structure in most European health care systems.

Polypharmacy increasingly is a problem in the care of polymorbid and elderly people, and affects morbidity and mortality. We adapted an algorithm for systematic deprescribing of medicaments (Good Palliative Geriatric Practice, developed for geriatric patients originally), and performed a practicability and acceptance study with 14 general practitioners and 63 patients with 523 medicaments totally. By the intervention 13% of all medicaments could be changed and 9% stopped, mostly (56%) due to an absence of indication. 75% of patients given a recommendation to change a medicament agreed. Acceptance and practicability of the tool were rated clearly positive by physicians. To study efficacy a randomized-controlled trial with clinical outcomes, long-term follow up and the exploration of patients' views is warranted.

Rationale, Aims and Objectives: The inappropriate use and overcrowding of emergency departments (EDs) by walk-in patients are well-known problems in many countries. The current study aimed to determine whether ambulatory walk-in patients could be treated more efficiently in a new hospital-integrated general practice (HGP) for emergency care services compared to a traditional ED., Methods: We conducted a pre-post comparison before and after the implementation of a new HGP. Participants were walk-in patients attending the ED of a city hospital in Zurich. Main outcome measures were differences in total process time, time intervals between stages of care and diagnostic resources used., Results: The median process time from admission to discharge was 120 minutes in the ED [interquartile range (IQR): 80-165] versus 60 minutes in the HGP (IQR: 40-90) (P < 0.001). The adjusted odds ratio of receiving any additional diagnostics was 1.86 (95% confidence interval 1.06-3.27; P = 0.032) for ED doctors versus general practitioners (GPs) when controlling for patients' age, sex and injury-related medical problems., Conclusion: The HGP is an efficient way to manage walk-in patients with regard to process time and utilization of additional diagnostic resources. The involvement of GPs in the HGPs should be considered as a promising model to overcome the inappropriate use of resources in EDs for walk-in patients who can be treated by ambulatory care., (© 2013 John Wiley & Sons, Ltd.)

Background: Smoking cessation advice is important for reducing the worldwide burden of disease resulting from tobacco smoking. Appropriate risk communication formats improve the success of counselling interventions in primary care., Aims: To test the feasibility and acceptance of a smoking cessation counselling tool with different cardiovascular risk communication formats including graphs, in comparison with the International Primary Care Respiratory Group (IPCRG) 'quit smoking assistance' tool., Methods: GPs were randomised into an intervention group (using our communication tool in addition to the IPCRG sheet) and a control group (using the IPCRG sheet only). We asked participants for socioeconomic data, smoking patterns, understanding of information, motivation, acceptance and feasibility, and measured the duration and frequency of counselling sessions., Results: Twenty-five GPs performed 2.8 counselling sessions per month in the intervention group and 1.7 in the control group (p=0.3) with 114 patients. The median duration of a session was 10 mins (control group 11 mins, p=0.09 for difference). Median patients' motivation for smoking cessation was 7 on a 10-point visual analogue scale with no significant difference before and after the intervention (p=0.2) or between groups (p=0.73 before and p=0.15 after the intervention). Median patients' ratings of motivation, selfconfidence, understanding of information, and satisfaction with the counselling were 3-5 on a 5-point Likert scale, similar to GPs' ratings of acceptance and feasibility, with no significant difference between groups., Conclusions: Among Swiss GPs and patients, both our innovative communication tool and the IPCRG tool were well accepted and both merit further dissemination and application in research.

Objectives/background: The population of people who use drugs (PWUD) has the highest prevalence of hepatitis C virus (HCV) infections in Europe. PWUD are multimorbid patients who are difficult to integrate into existing healthcare systems. In our study, we evaluated the feasibility of providing HCV treatment within opioid maintenance treatment (OMT) programmes offering integrated primary care-based health services under one roof., Methods: We evaluated 66 charts of patients in four outpatient clinics (OMT) with HCV treatment (between 2002 and 2010). Fourteen of the patients were treated with heroin and nine patients had an HIV coinfection. Data on the socioeconomic characteristics and quality of life were assessed. We counted the number of consultations in the clinic to assess how much supportive care the patients needed., Results: Overall, 62% of all patients (41 out of 66) achieved a sustained virological response (SVR). A total of 84% of patients with genotype 3 achieved an SVR. Sixty-four percent of patients treated with heroin achieved an SVR. The majority of patients (71%) used illicit drugs during HCV treatment and over 80% were diagnosed with psychiatric comorbidities. Comparisons of patient characteristics according to SVR or non-SVR showed that a longer duration of OMT, more consultations per week during HCV treatment and poor self-reported physical condition were associated with non-SVR., Conclusion: We conclude that offering HCV treatment in an integrated primary care-based setting with OMT and individualized use of different supporting strategies allows for treatment success rates in the population of PWUD that is comparable to the ones in the population of patients without drug use. Heroin maintenance treatment programmes offer a feasible and safe setting for providing HCV treatment.

Chronic obstructive pulmonary disease (COPD) is associated with increased cardiovascular mortality. Endothelial dysfunction may underpin this association. This cross-sectional study aimed to determine the impact of airflow obstruction, systemic inflammation, oxidative stress, sympathetic activation, hypoxaemia and physical activity on endothelial function in COPD. In stable COPD patients, assessments of endothelial function by flow-mediated dilatation (FMD), cardiovascular risk (Pocock score), airflow obstruction (forced expiratory volume in 1 s (FEV1)), systemic inflammation (high-sensitivity C-reactive protein and interleukin-6), oxidative stress (malondialdehyde), sympathetic activation (baroreflex sensitivity), hypoxaemia (arterial oxygen tension), hypercapnia (arterial carbon dioxide tension (PaCO2)), physical activity (steps per day) and exercise capacity (6-min walking distance) were performed. Associations between FMD and potential determinants were assessed in univariate and multivariate analyses. 106 patients (Global Initiative for Chronic Obstructive Lung Disease stage I/II 35%, stage III 25% and stage IV 40%) were included. In multivariate analysis FEV1 was positively associated with FMD, independent of other significant FMD determinants from univariate analysis (sex, smoking, combined inhaled long-acting β-adrenergic and steroid medication, heart rate, baroreflex sensitivity and PaCO2) and adjusted for potential confounders (cardiovascular risk and age). In addition, the FMD and FEV1 association was modified by physical activity. The findings of this study demonstrate that the severity of airflow obstruction is a significant determinant of endothelial function in patients with COPD. A high level of physical activity seems to have a favourable effect on this association.

Background: Incidence of malignant skin lesions is rising in Switzerland. We wanted to assess the frequency of patients with suspicious skin lesions in daily practice. Furthermore, we asked for diagnostic certainty and the need of further education in skin cancer., Methods: Survey with 1212 GPs in the canton of Zurich, descriptive analysis, regression analysis., Results: Response rate 41,4%. 23,2% of the GPs saw daily/weekly patients with suspicious skin lesions, another 34,8% monthly. 79,0% reported need for further education in skin cancer. This need was lower in urban GPs and in GPs with higher diagnostic certainty., Conclusions: GPs saw relatively often patients with suspicious skin lesions. Despite high diagnostic certainty, there was a clear need for further education in skin cancer.

Background: Switzerland lacks of national guidelines for the initial treatment of an acute coronary syndrome (ACS). ACS is not as frequent in an outpatient setting as in an emergency department; nevertheless, missing an ACS is associated with high morbidity and mortality. We wanted to observe actual infrastructure and performance based on case vignettes in outpatient general practitioners (GPs) and cardiologists (CAs); as a second outcome, we wanted to compare GPs to CAs., Methods: We conducted a postal vignette-based survey to investigate the management of outpatients presenting with acute chest pain by doctors in private practice. The use of troponin and cardiac stress testing for the evaluation of acute chest pain as well as referral practice and use of antiplatelet agents were assessed and compared between GPs and CAs., Results: There were 507 of the 571 respondents (response rate 39.7%) who were CAs (36) or GPs (471) and were included in the analysis. Whereas all CAs were equipped with electrocardiogram (ECG), cardiac stress testing and troponin assays, the majority of GPs had an ECG (97.8%) and applied troponin testing (76.3%), and 38.7% performed cardiac stress testing. The vast majority responded to directly refer a STEMI to the next catheter lab (87.7%), or in the case of a troponin-positive NSTEMI, to an inpatient ward (94.1%) with no difference between GPs and CAs. A majority of the GPs responded to use antiplatelet agents in the case of a STEMI (89.6%) and reported further workup with cardiac stress testing in the case of a troponin-negative acute chest pain (78.7%), which was lower compared to CAs who applied antiplatelet agents and cardiac stress testing in 100% and 97.0%., Conclusions: We could show that international guideline adherence in ACS of GPs is high and GPs perform as well as CAs. Nevertheless there is room for optimization in the antiplatelet therapy and the use of cardiac stress testing in a low-risk population. National guidelines for treatment of an ACS in an outpatient setting are indicated., (© 2012 John Wiley & Sons Ltd.)

This study examined participation and performance trends in the 26.4-km open-water ultra-swim "Marathon Swim in Lake Zurich," Switzerland. A total of 461 athletes (157 women and 304 men) finished the race between 1987 and 2011. The mean age of the finishers during the studied period was 32.0 ± 6.5 years for men and 30.9 ± 7.2 years for women. The mean age of finishers and the age of winners increased significantly across years for both sexes (p < 0.01). The winner times were significantly lower for men (403 ± 43 minutes) compared with women (452 ± 63 minutes) (p < 0.01). In contrast, the mean swimming time of the finishers did not differ between men (530 ± 39 minutes) and women (567 ± 71 minutes) (p > 0.05). The swimming time performance remained stable (p > 0.05) for both sexes across years. A higher age was associated with an increased risk for not finishing the race (odds ratio = 0.93, p = 0.045). Swim time was negatively associated with water temperature in the top 3 swimmers (ß = -9.87, p = 0.025). These results show that open-water ultra-swimming performance of elite swimmers over 26.4 km in a freshwater lake is affected by age, sex, and water temperature. The sex difference in open-water ultra-swimming performance (approximately 11.5%) remained unchanged these last 25 years. It seems unlikely that elite female swimmers will achieve the same performance of elite male swimmers competing in open-water ultra-swimming in water of approximately 20 °C. Anthropometric and physiological characteristics such as skeletal muscle mass and thermoregulation need additional investigations in female and male open-water ultra-swimmers.

The differences in gender- and the age-related changes in triathlon (i.e., swimming, cycling, and running) performances have been previously investigated, but data are missing for duathlon (i.e., running, cycling, and running). We investigated the participation and performance trends and the gender difference and the age-related decline in performance, at the "Powerman Zofingen" long-distance duathlon (10-km run, 150-km cycle, and 30-km run) from 2002 to 2011. During this period, there were 2,236 finishers (272 women and 1,964 men, respectively). Linear regression analyses for the 3 split times, and the total event time, demonstrated that running and cycling times were fairly stable during the last decade for both male and female elite duathletes. The top 10 overall gender differences in times were 16 ± 2, 17 ± 3, 15 ± 3, and 16 ± 5%, for the 10-km run, 150-km cycle, 30-km run and the overall race time, respectively. There was a significant (p < 0.001) age effect for each discipline and for the total race time. The fastest overall race times were achieved between the 25- and 39-year-olds. Female gender and increasing age were associated with increased performance times when additionally controlled for environmental temperatures and race year. There was only a marginal time period effect ranging between 1.3% (first run) and 9.8% (bike split) with 3.3% for overall race time. In accordance with previous observations in triathlons, the age-related decline in the duathlon performance was more pronounced in running than in cycling. Athletes and coaches can use these findings to plan the career in long-distance duathletes with the age of peak performance between 25 and 39 years for both women and men.

Background: Aortic dissection is a life-threatening manifestation of Marfan's syndrome. Preliminary evidence suggests that obstructive sleep apnea (OSA) is associated with aortic disease in Marfan's syndrome., Objectives: To study the effect of OSA on aortic events in Marfan's syndrome., Methods: In patients with Marfan's syndrome, a sleep study was performed at baseline and OSA was defined as >5 events of apnea/hypopnea (A+H) per hour in bed. Operation because of progressive aortic dilatation and death because of aortic rupture were defined as 'aortic events'. Kaplan-Meier survival analyses were used to compare event-free survival in patients with and without OSA. Cox regression models were used to explore the effects of covariates on event-free survival., Results: Data from 44 patients (mean age 37.4 years, 30 females) were available for analysis; 15 patients (34.1%) had OSA. The median follow-up time was 29 (interquartile range 24-36) months. Five patients had an aortic event within the follow-up time. Median event-free survival was 51.6 months. Event-free survival was significantly shorter in patients with OSA compared to patients without OSA (p = 0.012). In univariate analysis, A+H was associated with aortic events [hazard ratio (HR) 1.09, 95% confidence interval (CI) 1.01-1.18, p = 0.023]. Taking the interaction between BMI and A+H into account increased the HR for A+H (HR 1.75, 95% CI 1.003-3.048, p = 0.049). This association was no longer significant when other covariates were forced into the multivariate analysis., Conclusions: These data suggest that aortic event-free survival may be shorter in patients with Marfan's syndrome and OSA compared to patients without OSA, but more data from well-designed studies are needed to prove this association., (Copyright © 2012 S. Karger AG, Basel.)

Background: Published reference values for echocardiographic measurements of right-heart dimensions and function do not stratify for gender and body size. The aim of this study was therefore to assess the impact of gender and biometric characteristics on right-heart dimensions and function., Methods: From the echocardiography database at a tertiary care center, 1,625 subjects (mean age, 44 ± 14 years; 47% men) with normal echocardiographic findings between 2000 and 2009 were identified. Gender differences and association with body surface area were assessed retrospectively for right atrial long-axis and short-axis dimensions, right ventricular short-axis dimension, end-diastolic and end-systolic right ventricular area, right ventricular fractional area change, and tricuspid annular plane systolic excursion. The impact of normal values stratified for gender and body surface area was tested in 24 patients with moderate-sized to large atrial septal defects., Results: All dimensional right-heart measurements were significantly lower in women. Differences became smaller when measurements were indexed for body surface area, but significant differences persisted, particularly for right ventricular end-diastolic area (7.9 ± 1.6 vs 8.7 ± 1.8 cm(2)/m(2), P < .001) and right ventricular end-systolic area (4.0 ± 1.2 vs 4.7 ± 1.4 cm(2)/m(2), P < .001). Fractional area change and tricuspid annular plane systolic excursion indexed to body surface area were significantly higher in women (50 ± 7% vs 46 ± 9% and 14 ± 3 vs 12 ± 2 mm/m(2), respectively, P < .001 for both comparisons). The use of upper reference ranges for end-diastolic right ventricular area stratified for gender and body surface area improved the detection of enlarged right ventricles in patients with moderate-sized to large atrial septal defects (92% vs 54%, P < .007)., Conclusions: Gender and body surface area are important determinants of right ventricular dimensions and systolic function as measured on two-dimensional echocardiography. The investigators thus propose the use of measurements indexed to body surface area, with upper and lower reference ranges stratified for gender., (Copyright © 2012 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

Ultra-marathon running is supposed to increase the parameters of skeletal muscle damage and impair renal function. The purpose of this study was to investigate the effect of branched-chain amino acid supplementation on skeletal muscle damage and renal function during a 100-km ultra-marathon. Twenty-eight athletes were randomly divided into two groups, one group using branched-chain amino acid supplementation (BCAA) and a control group (CON). The athletes in the BCAA group were supplemented with a total of 50 g of an amino acid concentrate including 20 g of BCAA. The intake of energy, antioxidants and parameters of both skeletal muscle damage and renal function were determined. Race time was not different between BCAA and CON when controlled for the personal best time in a 100-km ultra-marathon. Neither the intake of energy and antioxidants nor the parameters of skeletal muscle damage and renal function were different between BCAA and CON. We concluded that BCAA-supplementation before and during a 100-km ultra-marathon had no effect on performance, skeletal muscle damage or renal function.

Unlabelled: Sirolimus has been approved for clinical use in non proliferative and proliferative disorders. It inhibits the mammalian target of rapamycin (mTOR) signaling pathway which is also known to regulate ovarian morphology and function. Preliminary observational data suggest the potential for ovarian toxicity but this issue has not been studied in randomized controlled trials. We reviewed the self-reported occurrence of menstrual cycle disturbances and the appearance of ovarian cysts post hoc in an open label randomized controlled phase II trial conducted at the University Hospital Zürich between March 2006 and March 2010. Adult females with autosomal dominant polycystic kidney disease, an inherited kidney disease not known to affect ovarian morphology and function, were treated with 1.3 to 1.5 mg sirolimus per day for a median of 19 months (N = 21) or standard care (N = 18). Sirolimus increased the risk of both oligoamenorrhea (hazard ratio [HR] 4.3, 95% confidence interval [CI] 1.1 to 29) and ovarian cysts (HR 4.4, CI 1.1 to 26); one patient was cystectomized five months after starting treatment with sirolimus. We also studied mechanisms of sirolimus-associated ovarian toxicity in rats. Sirolimus amplified signaling in rat ovarian follicles through the pro-proliferative phosphatidylinositol 3-kinase pathway. Low dose oral sirolimus increases the risk of menstrual cycle disturbances and ovarian cysts and monitoring of sirolimus-associated ovarian toxicity is warranted and might guide clinical practice with mammalian target of rapamycin inhibitors., Trial Registration: ClinicalTrials.gov NCT00346918.

Background: Traditionally, single-unit red blood cell transfusions were believed to be insufficient to treat anemia, but recent data suggest that they may lead to a safe reduction of transfusion requirements. We tested this hypothesis by changing from a double- to a single-unit red blood cell transfusion policy., Design and Methods: We performed a retrospective cohort study in patients with hematologic malignancies receiving intensive chemotherapy or hematopoietic stem cell transplantation. The major end-points were the reduction in the total number of red blood cell units per therapy cycle and per day of aplasia. The study comprised 139 patients who received 272 therapy cycles. Overall 2212 red blood cell units were administered in 1548 transfusions., Results: During the periods of the double- and single-unit policies, one red blood cell unit was transfused in 25% and 84% of the cases and the median number of red blood cell units per transfusion was two and one, respectively. Single-unit transfusion led to a 25% reduction of red blood cell usage per therapy cycle and 24% per aplasia day, but was not associated with a higher out-patient transfusion frequency. In multivariate analysis, single-unit transfusion resulted in a reduction of 2.7 red blood cell units per treatment cycle (P = 0.001). The pre-transfusion hemoglobin levels were lower during the single-unit period (median 61 g/L versus 64 g/L) and more transfusions were administered to patients with hemoglobin values of 60 gl/L or less (47% versus 26%). There was no evidence of more severe bleeding or more platelet transfusions during the single-unit period and the overall survival was similar in both cohorts., Conclusions: Implementing a single-unit transfusion policy saves 25% of red blood cell units and, thereby, reduces the risks associated with allogeneic blood transfusions.

Introduction: The purpose of the study was to comprehensively evaluate physiologic changes associated with development of high altitude pulmonary edema (HAPE). We tested whether changes in pulmonary function and breathing pattern would herald clinically overt HAPE at an early stage., Methods: In 18 mountaineers, spirometry, diffusing capacity, nitrogen washout, nocturnal ventilation and pulse oximetry were recorded at 490 m and during 3 days after rapid ascent to 4559 m. Findings were compared among subjects developing HAPE and those remaining well (controls)., Results: In 8 subjects subsequently developing radiographically documented HAPE at 4559 m, median FVC declined to 82% of low altitude baseline while closing volume increased to 164% of baseline (P<0.05, both instances). In 10 controls, FVC decreased slightly (to 93% baseline, P<0.05) but significantly less than in subjects with HAPE and closing volume remained unchanged. Sniff nasal pressure was reduced in both subjects with and without subsequent HAPE. During nights at 4559 m, mean nocturnal oxygen saturation dropped to lower values while minute ventilation, the number of periodic breathing cycles and heart rate were higher (60%; 8.6 L/min; 97 cycles/h; 94 beats/min, respectively) in subjects subsequently developing HAPE than in controls (73%; 5.1 L/min; 48 cycles/h; 79 beats/min; P<0.05 vs. HAPE, all instances)., Conclusion: The results comprehensively represent the pattern of physiologic alterations that precede overt HAPE. The changes in lung function are consistent with reduced lung compliance and impaired gas exchange. Pronounced nocturnal hypoxemia, ventilatory control instability and sympathetic stimulation are further signs of subsequent overt HAPE.

Background: Patients with severe thrombocytopenia are at risk for bleeding during insertion of central venous catheters (CVCs). Although most guidelines recommend preprocedural platelet (PLT) transfusions at a threshold of less than 50 × 10(9) /L, there is only weak evidence supporting such recommendations., Study Design and Methods: The current study aimed to establish a safe PLT transfusion trigger in patients with CVC placements. We performed a retrospective single-center analysis of 604 CVC insertions in 193 patients with acute leukemia receiving intensive chemotherapy or stem cell transplantation., Results: A total of 48% of the patients had a bleeding risk during CVC insertions, mostly due to thrombocytopenia. The bleeding incidence was 32% with 96% Grade 1 and 4% Grade 2 bleedings requiring prolonged local compression. There were no Grade 3 to 4 bleedings. Hemoglobin levels were similar before and 24 and 48 hours after the CVC insertion in the bleeding and nonbleeding group and there was no difference in the red blood cell (p = 0.72) and PLT transfusion requirements (p = 0.057) after CVC insertion. In multivariate analysis, only patients with PLT counts of less than 20 × 10(9) /L were at higher risk for bleeding before (p = 0.015) and after preprocedural PLT transfusions (p =0.006) compared to patients with PLT counts of 100 × 10(9) /L or more., Conclusion: CVC placements can safely be performed in patients with PLT counts of 20 × 10(9) /L or more without preprocedural PLT transfusions., (© 2011 American Association of Blood Banks.)

We investigated the associations between selected anthropometric and training characteristics with race time in 84 recreational male long-distance inline skaters at the longest inline marathon in Europe, the 'Inline One-eleven' over 111 km in Switzerland, using bi- and multivariate analysis. The mean (s) race time was 264 (41) min. The bivariate analysis showed that age (r = 0.30), body mass (r = 0.42), body mass index (r = 0.35), circumference of upper arm (r = 0.32), circumference of thigh (r = 0.29), circumference of calf (r = 0.38), skin-fold of thigh (r = 0.22), skin-fold of calf (r = 0.27), the sum of skin-folds (r = 0.43), percent body fat (r = 0.45), duration per training unit in inline skating (r = 0.33), and speed during training (r = -0.46) were significantly and positively correlated to race time. Stepwise multiple regression showed that duration per training unit (P = 0.003), age (P = 0.029) and percent body fat (P = 0.016) were the best correlated with race time. Race time in a long-distance inline race such as the 'Inline One-eleven' over 111 km with a mean race time of ∼260 min might be predicted by the following equation (r(2) = 0.41): Race time (min) = 114.91 + 0:51* (duration per training unit, min) + 0:85* (age, years) +3:78* (body fat, %) for recreational long-distance inline skaters.

Objective: The prevalence of exercise-associated hyponatremia (EAH) has mainly been investigated in marathoners and Ironman triathletes. The aim of this study was to investigate the prevalence of EAH in male ultraendurance athletes in other disciplines, such as ultraswimming, ultracycling, and ultramarathon running., Design: Observational field study., Setting: "Marathon Swim" in Lake Zurich, the "Swiss Cycling Marathon," the "Swiss Bike Masters," the "100-km Lauf Biel," and the "Swiss Jura Marathon.", Participants: Fifteen ultraswimmers, 28 ultra-road cyclists, 37 ultra-mountain bikers, 95 ultramarathoners, and 25 mountain ultramarathoners., Main Outcome Measures: Changes in body mass, plasma sodium, urinary specific gravity, and hematocrit were measured. The athletes recorded their intake of fluids., Results: Two swimmers (13%), 3 road cyclists (10.7%), no mountain bikers (0%), 5 ultramarathoners (5%), and 2 mountain ultramarathoners (8%) developed EAH. In the mountain bikers (r = -0.41) and the 100-km ultramarathoners (r = -0.52), fluid intake was significantly and negatively related to race time. In the mountain ultramarathoners, fluid consumption increased during the race., Conclusions: The prevalence of EAH was no higher in ultraendurance athletes compared with existing reports on marathoners and Ironman triathletes. Of the 200 investigated ultraendurance athletes, 12 finishers (6%) developed EAH., (2011 by Lippincott Williams & Wilkins.)

We investigated in 73 male ultraendurance mountain bikers, with (mean and SD) age 39.1 (8.6) years, weight 74.4 (8.3) kg, height 1.78 (0.07) m, and a body mass index of 23.3 (1.9) kg·m⁻², whether variables of anthropometry, training, or prerace experience were associated with race time using bi and multivariate analysis. Our investigation was conducted at the "Swiss Bike Masters," which covers a distance of 120 km and an altitude of 5,000 m. In the bivariate analysis, body mass index (r = 0.29), circumference of upper arm (r = 0.28), sum of upper body skinfolds (r = 0.38), sum of lower body skinfolds (r = 0.25), sum of 8 skinfolds (r = 0.36), percent body fat (r = 0.41), total cycling kilometers per year (r = -0.47), yearly volume in both mountain bike (r = -0.33) and road cycling (r = -0.52), number of training units per week (r = -0.48), distance per unit in road cycling (r = -0.33), average speed during training in road cycling (r = -0.33), and personal best time in the "Swiss Bike Masters"(r = 0.67) were related to race time. In the multiple linear regression analysis, personal best time in the "Swiss Bike Masters" (p = 0.000), total yearly cycling kilometers (p = 0.004), and yearly training kilometers in road cycling (p = 0.017) were related to race time. When the personal best time was the dependent variable in a separate regression model, total yearly cycling kilometers (p = 0.002) remained the single predictor variable. We concluded that finishing a particular mountain bike ultramarathon does not seem to require a special anthropometry but rather a specific skill and experience for this selective kind of race coupled with a high training volume. For practical use, we concluded that successful athletes in a mountain bike ultramarathon, in a special environment and using sophisticated equipment, need prerace experience coupled with high training volume, rather than any special anthropometry.

The purpose of this study was to investigate in 81 male recreational ultratriathletes (64 finishers and 17 nonfinishers) the relationship of anthropometry, prerace experience, and training with race outcome in a Triple Iron triathlon, using bi and multivariate analyses. In the bivariate analysis, the sum of 8 skinfolds (r = 0.38) and the sum of upper body skinfolds (r = 0.37) were positively related to total race time. None of the anthropometric variables was related to the swim or bike split. Circumference of upper arm (r = 0.42), percent body fat (r = 0.43), the sum of 8 skinfolds (r = 0.47), and the sum of upper body skinfolds (r = 0.45) were positively associated with the time in the run split. None of the training variables was related to total race time or split times. Personal best time in an Ironman triathlon (r = 0.59) and a Triple Iron triathlon (r = 0.82) were positively and highly significantly related to total race time. When all significant variables after bivariate analysis were included in a regression model, personal best time in a Triple Iron triathlon (p < 0.0001) remained the single predictor variable. For practical considerations, athletes with a background as an ultrarunner might have an advantage in successfully finishing a Triple Iron triathlon. However, ultrarunners should also have enough prerace experience in competing in Ironman and Triple Iron triathlons to successfully finish such a race.

We investigated the associations of anthropometry, training, and pre-race experience with race time in 93 recreational male ultra-marathoners (mean age 44.6 years, s = 10.0; body mass 74.0 kg, s = 9.0; height 1.77 m, s = 0.06; body mass index 23.4 kg · m(-2), s = 2.0) in a 100-km ultra-marathon using bivariate and multivariate analysis. In the bivariate analysis, body mass index (r = 0.24), the sum of eight skinfolds (r = 0.55), percent body fat (r = 0.57), weekly running hours (r = -0.29), weekly running kilometres (r = -0.49), running speed during training (r = -0.50), and personal best time in a marathon (r = 0.72) were associated with race time. Results of the multiple regression analysis revealed an independent and negative association of weekly running kilometres and average speed in training with race time, as well as a significant positive association between the sum of eight skinfold thicknesses and race time. There was a significant positive association between 100-km race time and personal best time in a marathon. We conclude that both training and anthropometry were independently associated with race performance. These characteristics remained relevant even when controlling for personal best time in a marathon.

Rationale, Aims and Objectives: To investigate the demand for traditional out-of-hours general practitioner (GP) emergency care in Switzerland including GPs' satisfaction and reasons for encounter (RFE)., Method: During a 2-month period (2009), a questionnaire-based, cross-sectional study was performed in GPs participating in the mandatory out-of-hours service in the city of Zurich, Switzerland. The number and mode of patient contacts were assessed to investigate the demand for GP care in traditional out-of-hours services. GPs and patient characteristics, including RFE according to the International Classification of Primary Care, were noted. Descriptive statistics and non-parametric tests were conducted., Results: Out of the 295 out-of-hours episodes during the study period, 148 (50%) duty periods were documented by a total of 93 GPs (75% men) with a mean (SD) age of 48.0 (6.2) years. The median (interquartile range) number of out-of-hours contacts was 5 (3-8) and the demand for home visits was significantly more common compared with practice and telephone consultations. A total of 112 different RFEs were responsible for the 382 documented patient contacts with fever accounting for the most common complaint (13.9%). Although 80% of GPs agreed to be satisfied overall with their profession as primary care provider, 57.6% among them were dissatisfied with the current out-of-hours service. Inappropriate payment and interference with their daily work in practice were most frequently reported., Conclusions: Our findings indicate that there is still strong patient demand for out-of-hours care with special need for home visits, suggesting that new organizational models such as integrating GPs into emergency care may not be an appropriate approach for all patients. Therefore, the ongoing reorganization of the out-of-hours-service in many health care systems has to be evaluated carefully in order not to miss important patient needs., (© 2010 Blackwell Publishing Ltd.)

We investigated the change in body composition and hydration status in 27 male ultra-runners during a 100 km ultra-run. The athletes drank fluids ad libitum during the run; intake of calories, fluids, and electrolytes during performance were determined. Body mass decreased by 1.9 kg, haematocrit decreased, plasma [Na(+)] remained unchanged, and urinary specific gravity and plasma volume increased. Fluid intake was 0.52 (0.18) L/h and was related to running speed (r = 0.50; p = 0.0081). Δ body mass was associated with total fluid intake during the race (r = 0.49, p = 0.0095). Sodium intake amounted to 425 (478) mg/h and potassium intake to 140 (179) mg/h. Sodium and potassium intake were not related to either postrace concentration or change in plasma concentration. Sodium intake, however, was related to Δ urinary sodium concentration (r = 0.45, p = 0.0227). The increase in plasma volume was significantly and negatively related to both postrace plasma [Na(+)] (r = - 0.42, p = 0.0278) and the postrace potassium-to-sodium ratio in urine (r = - 0.44, p = 0.0218). To conclude, we found no fluid overload in these ultra-runners, the increase in plasma volume was most probably due to a stimulation of the renin-angiotensin-aldosterone system (RAAS) since sodium intake was not related to both the change in plasma [Na(+)] or postrace plasma [Na(+)].

The purpose of this study was to investigate the association between selected skin-fold thicknesses and training variables with a half-marathon race time, for both male and female recreational runners, using bi- and multivariate analysis. In 52 men, two skin-fold thicknesses (abdominal and calf) were significantly and positively correlated with race time; whereas in 15 women, five (pectoral, mid-axilla, subscapular, abdominal, and suprailiac) showed positive and significant relations with total race time. In men, the mean weekly running distance, minimum distance run per week, maximum distance run per week, mean weekly hours of running, number of running training sessions per week, and mean speed of the training sessions were significantly and negatively related to total race time, but not in women. Interaction analyses suggested that race time was more strongly associated with anthropometry in women than men. Race time for the women was independently associated with the sum of eight skin-folds; but for the men, only the mean speed during training sessions was independently associated. Skin-fold thicknesses and training variables in these groups were differently related to race time according to their sex.

Background: Smoking is a well-known risk factor for cardiovascular, lung, and many other diseases. Smoking can induce pulmonary arterial hypertension (PAH) in animal models; PAH is common in smokers with COPD and thereby not correlated with the degree of airway obstruction. The impact of tobacco smoke exposure on the development of PAH in humans is not known., Methods: In a case-control study we assessed smoking and secondhand smoke exposure in all patients with PAH and chronic thromboembolic pulmonary hypertension (CTEPH) seen at our pulmonary hypertension clinic from 2002 until July 2008. Data from patients with PAH were compared with CTEPH and healthy control subjects from the Swiss Health Survey 2007., Results: Ninety-one patients with PAH were compared with 64 patients with CTEPH and 18,747 control subjects (women 58, 36, 10,331, respectively). Tobacco smoking was significantly more common in PAH compared with CTEPH and control subjects. This difference could be attributed to men. Patients with PAH also smoked longer and more heavily compared with patients with CTEPH. In addition, secondhand smoke exposure was significantly longer in nonsmokers with PAH compared with control subjects., Conclusion: Our data indicate that tobacco smoke exposure may be a risk factor for men with PAH. Considering smoking as a risk factor for PAH will have implications in counseling patients and especially their hitherto unaffected relatives. Further research on the pathogenetic role of smoking in PAH is warranted.

Background: Peritoneal dialysis (PD) catheter displacement is a major cause of dysfunction. Various catheter forms have been designed to improve outcome. One of them is based on the classical Tenckhoff catheter, but includes a small tungsten cylinder at the distal end to optimize location and to prevent dislocations. ♢, Methods: In this retrospective study, we analyzed the functionality and complication profile of the self-locating catheter implanted at our center from November 2005 to September 2008 in our PD program. ♢, Results: Data from 27 self-locating catheters implanted in 25 patients (12 women) were obtained. Patients were followed for up to 30 months (median observation time: 13 months), resulting in a cumulative study period of 357 PD months. A total of 22 complications were identified, including 1 episode of peritonitis per 52 patient-months, 1 tunnel infection, and 1 exit-site infection. The "functional catheter failure incidence rate" was approximately 0.01 catheters per month on PD (or approximately 1 catheter loss per 100 PD months). The catheter survival was 93% at 1 year. ♢, Conclusions: The "self-locating" PD catheter demonstrates low rates of catheter migration and dislocations, and good catheter survival.

Background: In autosomal dominant polycystic kidney disease (ADPKD), aberrant activation of the mammalian target of rapamycin (mTOR) pathway is associated with progressive kidney enlargement. The drug sirolimus suppresses mTOR signaling., Methods: In this 18-month, open-label, randomized, controlled trial, we sought to determine whether sirolimus halts the growth in kidney volume among patients with ADPKD. We randomly assigned 100 patients between the ages of 18 and 40 years to receive either sirolimus (target dose, 2 mg daily) or standard care. All patients had an estimated creatinine clearance of at least 70 ml per minute. Serial magnetic resonance imaging was performed to measure the volume of polycystic kidneys. The primary outcome was total kidney volume at 18 months on blinded assessment. Secondary outcomes were the glomerular filtration rate and urinary albumin excretion rate at 18 months., Results: At randomization, the median total kidney volume was 907 cm3 (interquartile range, 577 to 1330) in the sirolimus group and 1003 cm3 (interquartile range, 574 to 1422) in the control group. The median increase over the 18-month period was 99 cm3 (interquartile range, 43 to 173) in the sirolimus group and 97 cm3 (interquartile range, 37 to 181) in the control group. At 18 months, the median total kidney volume in the sirolimus group was 102% of that in the control group (95% confidence interval, 99 to 105; P=0.26). The glomerular filtration rate did not differ significantly between the two groups; however, the urinary albumin excretion rate was higher in the sirolimus group., Conclusions: In adults with ADPKD and early chronic kidney disease, 18 months of treatment with sirolimus did not halt polycystic kidney growth. (Funded by Wyeth and others; ClinicalTrials.gov number, NCT00346918.)

Inter- and intra-judge reliabilities of skinfold measures were investigated in a sample of 27 men and 11 women ultramarathon runners. Two physicians had agreement higher than 90% in field measurements before an ultramarathon race.

Background: Insufficient blood pressure control is a frequent problem despite the existence of effective treatment. Insufficient adherence to self-monitoring as well as to therapy is a common reason. Blood pressure self-measurement at home (Home Blood Pressure Measurement, HBPM) has positive effects on treatment adherence and is helpful in achieving the target blood pressure. Only a few studies have investigated whether adherence to HBPM can be improved through simple measures resulting also in better blood pressure control., Objective: Improvement of self-monitoring and improved blood pressure control by using a new colour-coded blood pressure diary., Primary Outcome: Change in systolic and/or diastolic blood pressure 6 months after using the new colour-coded blood pressure diary.Secondary outcome: Adherence to blood pressure self-measurement (number of measurements/entries)., Methods/design: Randomised controlled study., Population: 138 adult patients in primary care with uncontrolled hypertension despite therapy. The control group uses a conventional blood pressure diary; the intervention group uses the new colour-coded blood pressure diary (green, yellow, red according a traffic light system). EXPECTED RESULTS/CONCLUSION: The visual separation and entries in three colour-coded areas reflecting risk (green: blood pressure in the target range 140/>90 mmHg, red: blood pressure in danger zone > 180 mmHg/>110 mmHg) lead to better self-monitoring compared with the conventional (non-colour-coded) blood pressure booklet. The colour-coded, visualised information supports improved perception (awareness and interpretation) of blood pressure and triggers correct behaviour, in the means of improved adherence to the recommended treatment as well as better communication between patients and doctors resulting in improved blood pressure control., Trial Registration: ClinicalTrials.gov ID NCT01013467.

In 16 female nonprofessional Ironman triathletes, body mass, percent body fat, and skeletal muscle mass were determined before and after an Ironman race in order to detect changes. Selected hematological and urinary variables as well as percent total body water were measured in order to quantify a change in hydration status. Body mass, skeletal muscle mass, percent body fat, and percent body water did not change (p > 0.05). Plasma volume increased significantly by 8.1 (13.7) % (p < 0.05). The significant increase in plasma volume, plasma urea concentration, and urinary specific gravity after the race was associated with a significant fall in hematocrit and plasma sodium concentration (p < 0.05). In contrast to studies of male Ironman triathletes, we could not detect a decrease in body mass in female Ironman triathletes. The statistically insignificant loss of 0.6 kg in body mass was smaller than reported in studies of male athletes.

Background: Utility indices are used in cost-effectiveness analyses as a measure of quality of life reflecting the patient's preference for a given health state on a scale anchored at 0 (corresponding to death) to 1 (perfect health). It is uncertain which utility instruments are most suitable for application in patients with the obstructive sleep apnea syndrome (OSA)., Objectives: To compare utility indices obtained in OSA patients by various instruments., Methods: In 66 untreated OSA patients (median Epworth score 12, apnea/hypopnea index, AHI, 57/h), five different utility instruments were employed. In 34 OSA patients, changes in utility after 4 months of continuous positive airway pressure (CPAP) were retrieved from published SF-36 data., Results: In 66 OSA patients, median (quartiles) utility indices were: standard gamble 0.97 (0.89; 0.99); time trade-off 0.94 (0.81; 0.99); EuroQol questionnaire (EQ-5D) 0.92 (0.83; 1.00); Euro-thermometer visual analog scale 0.80 (0.70; 0.90); SF-36 questionnaire (SF-6D) 0.75 (0.69; 0.85; p < 0.05 SF-6D and Euro-thermometer utility vs. other indices). Different utility indices were poorly correlated among each other and with AHI and Epworth scores. SF-6D utility after 4 months of CPAP had changed by 0.04 (0.02; 0.12, p = 0.026)., Conclusions: Utility indices measured by different instruments vary largely and some indices reflect the impaired quality of life in OSA poorly. Interpretation of cost-effectiveness analyses should account for the utility instrument used., (Copyright 2009 S. Karger AG, Basel.)

We investigated in 11 female ultra-runners during a 100 km ultra-run, the association between fluid intake and prevalence of exercise-associated hyponatremia in a cross-sectional study. Athletes drank ad libitum and recorded their fluid intake. They competed at 8.0 (1.0) km/h and finished within 762 (91) min. Fluid intake was 4.1 (1.3) L during the race, equal to 0.3 (0.1) L/h. Body mass decreased by 1.5 kg (p< 0.01); pre race body mass was related to speed in the race (r = -0.78, p< 0.05); and change (Delta) in body mass was not associated with speed in the race. Change in body mass was positively (r = 0.70; p< 0.05), and Delta urinary specific gravity negatively (r = -0.67; p< 0.05), correlated to Delta percent total body water. Changes in body mass were not related to fluid intake during the race. Fluid intake was not correlated to running speed and showed no association with either Delta percent total body water nor Delta [Na] in plasma. Fluid intake showed no relationship with both Delta haematocrit and Delta plasma volume. No exercise-associated hyponatremia occurred. Female ultra- runners consuming fluids ad libitum during the race experienced no fluid overload, and ad libitum drinking protects against exercise-associated hyponatremia. The reported higher incidence of exercise-associated hyponatremia in women is not really a gender effect but due to women being more prone to overdrink.

The aim of the present study was to assess health related characteristics and reasons for participation on the <>, second, to compare these variables with a representative Swiss Health Survey (SHS). Characteristics of the participants were collected cross-sectionally and afterwards compared with results of the SHS. Response rate was 74.6% (n = 206). Compared to the SHS population smoking rate and alcohol consumption were significantly lower and a doctor's visit within the last 12 months more frequent. Considerable differences in health related characteristics exist between our study and the SHS suggesting a self-selection of healthy people. Thus a potential health gain by this kind of medical prevention program is at least questionable.

Aims: Injection drug users are at high risk for chronic hepatitis C virus infection (CHC). Opioid maintenance treatment (OMT) offers a unique opportunity to screen for CHC. This study proposed the hypothesis that a general practitioner (GP) with special interest in addiction medicine can achieve CHC screening rates comparable to specialized centres and aimed to investigate determinants for a successful CHC case finding in a primary care setting., Design and Participants: Retrospective medical record analysis of 387 patients who received opioid maintenance therapy between 1 January 2002 and 31 May 2008 in a general practice in Zurich, Switzerland., Measurements: Successful CHC assessment was defined as performance of hepatitis C virus (HCV) serology with consecutive polymerase chain reaction-based RNA and genotype recordings. The association between screening success and patient characteristics was assessed using multiple logistic regression. findings: Median (interquartile range) age and duration of OMT of the 387 (268 males) patients was 38.5 (33.6-44.5) years and 34 (11.3-68.0) months, respectively. Fourteen patients (3.6%) denied HCV testing and informed consent about screening was missing in 13 patients (3.4%). In 327 of 360 patients (90.8%) with informed consent a successful CHC assessment has been performed. Screening for HCV antibodies was positive in 136 cases (41.6%) and in 86 of them (63.2%) a CHC was present. The duration of OMT was an independent determinant of a successful CHC assessment., Conclusions: In addicted patients a high CHC assessment rate in a primary care setting in Switzerland is feasible and opioid substitution provides an optimal framework.

Background: We initiated a randomized controlled clinical trial to assess the effect of sirolimus on disease progression in patients affected by autosomal dominant polycystic kidney disease (ADPKD). Here we report the preliminary safety results of the first 6 months of treatment., Method: A total of 25 patients were randomized to sirolimus 2 mg/day and 25 patients to no treatment except standard care. Treatment adherence was monitored electronically. At baseline and at Month 6, laboratory parameters were analysed and the urinary protein profile in 24-h urine collections was determined., Results: Both treatment groups were well balanced for age, sex and renal function. In 94.1 +/- 11.4% of the study days, patients in the sirolimus group were exposed to the drug when assuming a therapeutic efficacy duration of 30 h. At Month 6, the mean sirolimus dose and trough level were 1.28 +/- 0.71 mg/day and 3.8 +/- 1.9 microg/l, respectively. Glomerular (albumin, transferrin, IgG) and tubular (retinol-binding protein, alpha(1)-microglobulin) protein excretion remained unchanged. Glomerular filtration rate also did not change significantly. Haematological parameters were similar in both groups, except for a mild reduction of the mean corpuscular volume of erythrocytes in patients receiving sirolimus. Lipid levels were similar in both groups. Adverse events were transient and mild, and no grade 3 or 4 events occurred. The incidence of infections was similar in the sirolimus group (80%) and the standard group (88%). The most common gastrointestinal adverse events were mucositis (72% in the sirolimus group versus 16% in the standard group, P = 0.0001) and diarrhoea (36% in the sirolimus versus 20% in the standard group, P = 0.345)., Conclusion: Treatment of ADPKD patients with sirolimus with a dose of 1-2 mg/day is safe and does not cause proteinuria or impairment of GFR. Treatment adherence was excellent. (ClinicalTrials.gov number, NCT00346918.).