Essential steps in the development, implementation, evaluation and quality assurance of the written part of the Swiss federal licensing examination for human medicine.

Purpose: This report describes the essential steps in the development, implementation, evaluation and quality assurance of the written part of the Swiss Federal Licensing Examination for Human Medicine (FLE) and the insights gained since its introduction in 2011. Methods: Based on existing scientific evidence, international expertise, and experience gained from previous examinations, the FLE is developed by experts from all five medical faculties in Switzerland with the support of the Institute for Medical Education and is held simultaneously at five locations. The exam organisers document and review every examination held and continuously optimise the processes; they have summarised the results in this report. Results: The essential steps comprise the development, revision and translation of questions; construction of the exam and production of materials; candidate preparation; implementation and analysis. The quality assurance measures consist of guideline coherence in the development of the questions and implementation of the exam, revision processes, construction of the exam based on the national blueprint, multiphase review of the translations and exam material, and statistical analysis of the exam and the comments from candidates. The intensive collaboration, especially on the part of representatives from all the participating faculties and a central coordination unit, which provides methodological support throughout and oversees the analysis of the exam, has proven successful. Successfully completed examinations and reliable results in the eleven examinations so far implemented represent the outcomes of the quality assurance measures. Significant insights in recent years are the importance of appreciating the work of those involved and the central organisation of exam development, thus ensuring the long-term success of the process. Conclusion: Common guidelines and workshops, quality assurance measures accompanied by the continuous improvement of all processes, and appreciation of everyone involved, are essential to carrying out such an examination at a high-quality level in the long term.

Increased hospital treatment volume of splenic injury predicts higher rates of successful non-operative management and reduces hospital length of stay: a Swiss Trauma Registry analysis.

PURPOSE: First time analysis of the epidemiology, management and outcomes of patients with splenic injuries in Switzerland. This study aims to assess the effect of hospital treatment volume on successful non-operative management (NOM) in splenic injuries. METHODS: A multicentric registry-based study including all patients with splenic injuries entered into the Swiss Trauma Registry from 2015 to 2018 was conducted. Patients were stratified according to the hospitals treatment volume of splenic injuries. Primary outcome was the rate of successful NOM. RESULTS: During the 4-year study period, 652 patients with splenic injury were included in the study. Median age of the study population was 42 (IQR 27-59) years, and median ISS was 26 (20-34). The overall rate of successful NOM was 86.5%. Median HLOS was 13 (8-21) days. In-hospital mortality was 7.2% (n = 47). The mean number of patients with splenic injuries per center and year was 14. Five out of 12 Level I trauma centers treating more patients than the mean (≥ 15/year) were defined as high-volume centers. Multivariable analysis adjusting for differences in baseline and injury characteristics revealed treatment in a high-volume center as an independent predictor for successful NOM (OR 2.15, 95% CI 1.28-3.60, p = 0.004) and shorter HLOS (RC - 2.39, 95% CI - 4.91/- 0.48, p = 0.017), however, not for reduced in-hospital mortality (OR 0.92, 95% CI 0.39-2.18, p = 0.845). CONCLUSION: Higher hospital treatment volume was associated with a higher rate of NOM and shorter HLOS, but not lower mortality. These results constitute the basis for further quality improvement in the care of splenic injury patients within the trauma system in Switzerland.

Severe penetrating trauma in Switzerland: first analysis of the Swiss Trauma Registry (STR).

PURPOSE: The purpose of this study was to examine the epidemiology, demographics, injury characteristics and outcomes of patients who presented to Swiss trauma centers following severe penetrating trauma. METHODS: Swiss Trauma Registry (STR)-cohort analysis including patients with severe (ISS ≥ 16 or AIS head ≥ 3) penetrating trauma between 2017 and 2019. Primary outcome was mortality. Secondary outcomes were hospital and intensive care unit (ICU) length of stay (LOS), and prehospital times. RESULTS: During the 3-year study period, 134 (1.6% of entire STR) patients with severe penetrating trauma were identified [64 (48%) gunshot wounds (GSW), 70 (52%) stab wounds (SW)]. Median age was 40.5 (IQR 29.0-59.0) and 82.8% were male. Mortality rate was 50% for GSW; 9% for SW. Overall, prehospital time [incident to arrival emergency department (ED)] was 65 (IQR 45-94) minutes. The median number of patients admitted for a severe GSW/SW per center and year was 2 (range 0-14). Of 64 patients who sustained a GSW, 42 (65.6%) were self-inflicted. Mortality in self-inflicted GSW reached 66.7%, with the head being severely injured in 78.6%. The 67 patients with severe isolated torso GSW/SW had an ISS of 20 (IQR 16-26) and a mortality of 15%. Multivariable analysis identified severe chest trauma, ED Glasgow Coma Scale ≤ 8, age, self-infliction, massive blood transfusion and ISS as independent predictors for mortality. CONCLUSION: Severe penetrating trauma is very rare in Switzerland. Mortality ranges from 9% in SW to 67% in self-inflicted GSW. Particularly in the setting of GSW/SW to the torso, reduction in prehospital time may further improve patient outcomes.

Traumatic Hip Joint and Thigh Injuries - an Analysis of NHF Reporting Data from 2016-2019 Using the NHF Statistics API.

BACKGROUND: The hip joint is one of the most important joints in the human body. Although its multiaxial movements account for many benefits, they also render the hip one of the most hard-working joints. Injuries to the hip joint and thigh often occur as a result of a fall. According to epidemiologic data, such falls are most frequent in the elderly, particularly in osteoporosis sufferers. MATERIAL AND METHODS: The "Services" component of the Statistics API version 1.0 provided by the National Health Fund (NHF) was used in order to evaluate the number of hospitalizations due to hip joint and thigh injuries. Information on the number of patients was obtained in a number of stages. The first stage involved determination of hip and thigh injuries as the main diagnosis. Then, the billing products which made possible settlement for hospitalization of patients with the selected diagnoses were chosen. The last stage consisted in the extraction of relevant medical data sets from the "Services" component of the NHF Sta-tistics API, which made possible this analysis. RESULTS: According to the NHF reporting data, over the four-year period of interest there were approx. 42,000 hospitalizations per year. The most frequent causes of hospitalization were fractures of the neck of the femur (S72.0) and trochanteric fractures (S72.1), accounting for approx. 48% and 36% of all hospital stays, respectively. CONCLUSIONS: 1. Hip injuries constitute a significant health problem in Poland (approx. 42,000 hospitalizations per year). 2. The most frequent causes of hospitalization are injuries in the form of fractures of the neck of the femur or trochanteric fractures (corresponding to the ICD-10 codes S72.0 and S72.1, respectively). 3. It appears advisable to develop a tool to enable medical service providers to adjust their services to patients' changing needs. This tool could em-ploy open-access data on injuries published in the NHF Statistics API.

Major trauma during COVID-19 in a level 1 trauma centre in Switzerland - a cohort study comparing the years 2020 and 2019.

INTRODUCTION: The COVID-19 pandemic and the associated restrictions may have modified the activities of the Swiss population and thus altered trauma patterns. MATERIALS AND PATIENTS: All adult patients with major trauma admitted to our institution in 2019 and 2020 were assessed using the Injury Severity Score (ISS), by body region involved, type of injury, age, admission to an intensive care unit and 30-day mortality. RESULTS: In 2020, 454 patients with major trauma were admitted to our institution, 17% fewer than in the previous year. The drop in the number of major trauma patients proceeded with and overlapped both the first and second peaks in incidence of the pandemic and the associated restrictions. The median ISS was higher in 2020 (25, interquartile range [IQR] 17-26.5) than in 2019 (22, IQR 16-26, p = 0.04). There were no significant differences in body region involved, type of injury or age (p >0.05). In 2020, a higher percentage of patients were admitted to an intensive care unit (86.5% vs 77.7%, p <0.001) and died within 30 days (8.8% vs 5.0%, p = 0.015). The 30-day mortality was higher in 2020 than in 2019, with an odds ratio of 1.80 (95% confidence interval 1.04-3.10, p= 0.036) after adjustment for the following potential confounders: ISS, age, gender and type of injury. CONCLUSION: In the first year of the COVID-19 pandemic, fewer patients with major trauma were admitted to our institution. However, the patients admitted were more severely injured and more often died within 30 days. Understanding the differences in injury patterns and admissions in major trauma patients under special conditions - such as a pandemic - could help to allocate rare resources adequately.

Traumatic Knee Injuries in 2016-2019 - an Analysis of Newly Diagnosed Patients Based on NHF Data Reporting.

BACKGROUND: Traumatic musculoskeletal injuries are more and more frequently regarded as an important health, social and economic problem. According to WHO statistics, injuries are a major present-day health problem. The main aim of the study is to identify the number of new patients who sustained knee structure injuries during a year and to classify them based on data on services provided under National Health Fund agreements. MATERIAL AND METHODS: Information on the number of patients with a knee injury was obtained in a three stage process. First an inventory of relevant diagnoses was determined. Then, the National Health Fund data from 2016-2019 was queried in accordance with the adopted methodology and assumptions. The analysis was based on the report submitted by the NHF in response to the query. RESULTS: According to the NHF reporting data, knee injuries affect approx. 244,000 people per year. There are slightly more men (approx. 52%) than women (48%). People aged 11-20 years constitute the most numerous group of patients with knee injuries, with approx. 41,342 cases per year. The most frequently reported diagnoses in both groups were S80.0 Contusion of knee (approx. 30%), S83.6 Sprain and tear of other and unspecified parts of knee (approx. 21%) and M23.8 Other internal derangements of knee (approx. 9%). According to available data, the overall rate of knee injuries in 2019 was 6.4 per 1000 population. CONCLUSIONS: 1. Knee injuries pose a major health problem. In Poland, according to the reporting data, approx. 244,000 knee injuries occur every year. 2. Knee injuries are more common among men than women, and people aged 11-20 years constitute the most numerous group of patients. 3. The National Health Fund reporting data is a very valuable source of information on the magnitude of the problem of injuries.

Traumatic Knee Injuries: Analysis of Reporting Data from the Period 2016-2018 Using API Interface of Polish National Health Fund Statistics.

BACKGROUND: According to WHO statistics, injuries are among the main causes of contemporary health problems. Injury statistics have been showing a continuing upward trend over years. This is due to numerous factors, such as technological progress, increased life expectancy, change of lifestyle, growing popularity of sports and changes in working conditions. The structures affected by injuries within the knee joint include the ligaments, menisci, articular cartilage and patellar retinacula, with the most common injuries being those to the ligamentous apparatus and menisci. The main objective of this paper is to determine the number of patients hospitalised due to a primary knee injury. MATERIAL AND METHODS: Determination of the number of patients hospitalised due to a primary knee injury was performed using the API Interface of National Health Fund (NFZ) Statistics-Benefits Version 1.0. The process of acquiring information on the number of patients consisted of four stages: preparation of a list of primary diagnoses according to ICD-10 classification, analysis of the ordinances of the President of NFZ concerning the conclusion and implementation of contracts on hospital treatment to select products that could be used to bill hospitalisation of patients with selected types of diagnosis, generating medical data using the API Interface of National Health Fund Statistics-Benefits and analysis of reporting data obtained. RESULTS: According to data reported to NFZ, a total of 101,773 patients were hospitalised due to traumatic knee injuries over the period of three years (2016-2018), which gives an average of ca. 34,000 patients annually. CONCLUSIONS: 1. Knee injuries represent a very serious health problem in Poland. 2. Knee injuries most frequently affect the ligaments and menisci. 3. It seems necessary to develop a complete nation-wide database with up-to-date information on injuries in Poland that would enable providers to adapt medical services to the current needs of the patients.

Possibilities for Quality Assessment of Health Services in Therapeutic Rehabilitation.

The main goal of therapeutic rehabilitation is to provide services that develop, maintain or restore mobility and functionality to the fullest extent possible throughout the patient's life. This process should involve setting real goals both for the person who has mobility and functionality impairment as well as in the records of relevant therapeutic programme objectives. In evaluating this process, quality indicators can be used as 'tools' and they may also be used as parameters for quantitative characterization of healthcare processes and outcomes. The purpose of this paper is to systematise existing knowledge about quality in healthcare in the context of therapeutic rehabilitation, presenting a possible assessment of the level and degree of completion of goals through quality indicators.

Evaluation of Local Cryotherapy after Anterior Cruciate Ligament Reconstruction. Critical Review of the Literature.

BACKGROUND: At a time of innovative medical technologies development, it is paramount that medical services be evaluated with regard to their effectiveness. Research in physical medicine and rehabilitation, as well as the specialty itself, is relatively young; however, the number of publications in the field has recently been increasing. The main aim of this article is to evaluate the effectiveness of cryotherapy, including local cryostimulation, after anterior cruciate ligament reconstruction. MATERIAL AND METHODS: The present paper reviews scientific publications extracted from the Medline Embase, Cochra-ne Library, and PEDro databases according to a pre-designed search strategy. The review analysed publications where the authors indicated cryotherapy as an intervention in patients after ACL reconstruction and the study endpoints referred to analgesic or anti-oedema effects. RESULTS: As a result of selection, 16 publications were chosen for the analysis, including 1 meta-analysis, 2 systematic reviews and 13 RCTs. Only the results of randomised studies are presented. Endpoints referring to analgesic effects were present in all of the studies in the analysis, while endpoints referring to anti-oedema effects were present in five studies. Statistically significant results constituted 62% of the results for analgesic effects and 60% for anti-oedema effects. CONCLUSIONS: 1. The currently limited evidence from randomised studies is not sufficient to draw final conclusions on the effectiveness of cryotherapy in patients after anterior cruciate ligament reconstruction. 2. It seems that cryotherapy can serve as an adjunct analgesic treatment in the early period after arthroscopic ACL reconstruction, while there is no notable improvement in patients after this procedure in reducing oedema.

Endoscopic management of duodenal fistula in a patient operated after abdominal injury.

Post-traumatic duodenal injuries constitute a relatively rare group among this type of lesions reported in the abdominal structures. In the vast majority of cases, a post-traumatic duodenal injury is accompanied by damage to other important organs. The surgical management of duodenum injuries poses a high risk of life-threatening complications with duodenal fistula among the most common. In some cases, the combination of basic and advanced surgical procedures and intensive conservative treatment is insufficient to treat the complication. The progress in endoscopic techniques and the application of modern instruments have allowed for the use of these procedures to manage gastrointestinal injuries of various aetiology. The aim of the study is to present an effective endoscopic occlusion of post-traumatic duodenal fistula.

Novel Structurally Related Flavones Augment Cell Death Induced by rhsTRAIL.

TRAIL (tumor necrosis factor-related apoptosis-inducing ligand) was identified as a powerful activator of apoptosis in tumor cells and one of the most promising candidates for cancer therapy with no toxicity against normal tissues. However, many tumor cells are resistant to TRAIL-induced apoptosis. The aim of this work was to analyze the improvement of the anticancer effect of rhsTRAIL (recombinant human soluble TRAIL) by nine flavones: 5-Hydroxyflavone, 6-Hydroxyflavone, 7-Hydroxyflavone and their new synthetic derivatives 5-acetoxyflavone, 5-butyryloxyflavone, 6-acetoxyflavone, 6-butyryloxyflavone, 7-acetoxyflavone and 7-butyryloxyflavone. We examined the cytotoxic and apoptotic effects of rhsTRAIL enhanced by novel structurally-related flavones on SW480 and SW620 colon cancer cells using the3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide test, the lactate dehydrogenase assay and annexin V-FITC fluorescence staining. We observed a slight difference in the activities of the flavones that was dependent on their chemical structure. Our study indicates that all nine flavones significantly augment cell death by rhsTRAIL (cytotoxicity range 36.8 ± 1.7%-91.4 ± 1.7%; apoptosis increase of 33.0 ± 0.7%-78.5 ± 0.9%). Our study demonstrates the potential use of tested flavones in TRAIL-based anticancer therapy and prevention.

Allergic rhinitis, bronchial asthma and other allergies in patients with Alzheimer's disease: unnoticed issue.

INTRODUCTION: Allergic diseases are becoming more prevalent in elderly patients. Allergic diseases have been observed in patients with Alzheimer's disease (AD). The prevalence of atopic bronchial asthma, allergic rhinitis and atopic dermatitis was analyzed in such elderly Polish population. AIM: Analysis of the presence of allergic diseases in the patients with AD in Poland, including asthma, allergic rhinoconjunctivitis and atopic dermatitis. MATERIAL AND METHODS: The recruitment of subjects with AD was conducted at 6 sites representative of Polish rural and urban areas, and 1060 subjects with a mean age of 69.2 ±5.1 years were screened. Medical examinations, an original questionnaire, skin prick testing for common aeroallergens and appropriate serum-specific IgE assays were performed. RESULTS: Probable atopy was diagnosed in 234 (22.1%) analyzed patients, including 127 women (21.5% of women) and 234 men (22.8% of men). The average prevalence associated with age and sex in this population for bronchial asthma was 2.9%, atopic dermatitis/eczema was 0.6%, seasonal allergic rhinitis was 6.6%, perennial allergic rhinitis was 11.1% and polymorphous atopic disease was 4.4%. The most frequent positive results were recorded for the following allergens: mixed grass, Dermatophagoides pteronyssinus, Dermatophagoides farinae and Alternaria. CONCLUSIONS: One-fifth of diagnosed patients with AD have allergic disease requiring treatment.

The effect of allergen-specific immunotherapy on offspring.

BACKGROUND: The incidence of allergic diseases has increased worldwide. Thus, there is a need for effective primary prevention of allergies. OBJECTIVE: The aim of the present study was to examine how allergen-specific immunotherapy (ASIT) affects the development of allergies in the generation of children whose parents were subjected to this method of treatment. METHODS: A total of 194 children with at least one parent with allergy subjected to ASIT were enrolled. These patients were compared with control individuals without ASIT. Their risk of allergy, based on medical history, examination, allergy skin-prick tests, serum total immunoglobulin E and specific immunoglobulin E concentrations was assessed. RESULTS: The children of parents subjected to immunotherapy showed significantly reduced clinical symptoms of allergic disease. The odds ratios (OR) of any allergic disease and asthma were significantly lower in children with one or both parents with allergy after ASIT compared with the children with parents with allergy and without ASIT: OR 0.73 (95% confidence interval [CI], 0.59-0.86) versus OR 1.85 (95% CI, 1.73-2.2) for any allergic disease and OR 0.63 (95% CI, 0.53-0.79) versus OR 1.36 (95% CI, 1.22-1.67) for asthma. CONCLUSION: The phenomenon of reducing the risk of allergies in children whose parents were desensitized might be important in the primary prevention of allergies.

Asthma, COPD and comorbidities in elderly people.

UNLABELLED: Co-morbidities are a significant problem in the elderly population but are rarely presented and analyzed for interdependencies among the various coexisting chronic diseases. OBJECTIVE: The aim of this study was to present a profile of comorbidities in elderly patients with and without asthma and COPD. METHODS: Respondents were recruited at 20 sites in Poland. Stratified random sampling from patient databases resulted in 15,973 patients older than 60 years of age. A retrospective analysis of medical history and ICD-10 codes was performed. In addition, patients underwent a spirometry test with a bronchial reversibility test and were administered questionnaires on the prevalence of chronic diseases by doctors. RESULTS: The study population consisted of 1023 asthmatic patients, 1084 patients with COPD and 1076 control subjects without any signs of bronchoconstriction and with correct spirometry. Patients with asthma exhibited a similar distribution of cardiovascular and metabolic co-morbidities as the control group. However, asthmatic patients had a higher prevalence of arterial hypertension and depression with an odds ratio (OR) = 1.48 (95% CI: 1.38-1.62) and OR = 1.52 (95% CI: 1.44-1.68), respectively. Coronary disease (OR = 2.12; 95% CI: 1.97-2.33), cor pulmonale (OR = 3.1; 95% CI: 2.87-3.22) and heart failure (OR = 2.71; 95% CI: 2.64-3.11) were predominantly observed in patients with COPD. Patients with severe asthma exhibited a greater predisposition to cardiovascular and neuropsychiatric diseases. CONCLUSION: Asthma coexisted frequently with arterial hypertension and depression in elderly patients. Patients with COPD have a more exaggerated profile of coexisting diseases, specifically cardiovascular problems.

Interventional Laser-assisted Extraction of an Infected Trapped Ventriculoatrial Shunt Based on Techniques for Pacemaker Lead Explantation.

We present a case of successful interventional laser-assisted extraction of an endovascularly trapped long-term implanted ventriculoatrial shunt in a patient with shunt-associated septicemia. This approach is based on modified techniques for explantation of pacemaker leads and might be considered an additional option for extraction of otherwise nonremovable trapped endovascular catheters in experienced centers.

Breast ultrasound scans - surgeons' expectations.

Recent years have witnessed a dynamic development of mammary gland imaging techniques, particularly ultrasonography and magnetic resonance imaging. A challenge related to these studies is the increase in the precision of the anatomical assessment of breast, particularly for early detection of subclinical lesions, performance of ultrasound- guided biopsy procedures, and accurate preoperative location of pathological lesions so as to optimize the surgical treatment. Ultrasound imaging is a primary and baseline diagnostic procedure the patient with suspected pathological lesions within breast is referred to by the surgeon. Lesions visualized in ultrasound scans are classified according to the BI-RADS US assessment categories. The successive categories (2 through 6) encompass individual pathological lesions, estimating the risk of malignancy and provide guidelines for further diagnostic and therapeutic management. This article described the important aspects of ultrasonographic imaging of focal lesions within the breasts as significant from the standpoint of surgical treatment of patients falling within BI-RADS US categories 3, 4, 5, and 6. Attention is drawn to the importance of ultrasound scans in the assessment of axillary fossa lymph nodes before the decision regarding the surgical treatment.

The relationship between autoimmunity and specific immunotherapy for allergic diseases.

The aim of this study was to perform a 20-year post-specific immunotherapy (SIT) observational evaluation for an assessment of any manifestations of autoimmune disease or the appearance of autoantibodies in serum. In total, 1,888 patients (902 women and 986 men) were observed. The mean age of the patients was 34.1 ± 12.4 y at the start of the prospective observation after finishing SIT. New incidences of autoimmune disease and/or the presence of autoantibodies in serum were monitored. The SIT group was compared with control groups consisting of allergic patients who had very received SIT and with non-allergic subjects. There were no significant differences in the autoimmune disease prevalence between the allergic patients with or without SIT. However, significantly higher prevalence of 4 different autoimmune diseases (AID) were observed in the non-allergic patients during the same period. Additionally, the incidence of 8 different autoantibodies was significantly higher in non-allergic patients than in control subjects. Hashimoto disease was the most common autoimmune disease observed. The results of this long-term observational study indicated a lack of a significant prevalence of new instances of autoimmune disease during 20 y of observation post-SIT and at a rate lower than that of non-allergic control subjects, suggesting that SIT is safe in this regard in the long term.

Laser extraction of a trapped infected port catheter in a child using existing experience from pacemaker and ICD lead removal.

A 9-year-old girl presented with systemic infection related to a Port-a-Cath system (PAC); therefore, the urgent removal of the PAC was indicated. However, the catheter was trapped and not extractable by conventional means. Using existing comprehensive experience in the removal of pacemaker and implantable cardioverter defibrillator leads, the entrapped PAC was successfully extracted by laser technique, thus avoiding open heart surgery.

[Preoperative analysis of vital lung capacity in female patients with flattened thyrotoxicosis]. / Przedoperacyjna ocena pojemnosci zyciowej pluc u kobiet z nadczynnoscia tarczycy w stadium eutyreozy.

Unbalanced hyperthyroidism leads to the feeling of dyspnea and to the decrease of vital lung capacity. Efficacious treatment of thyrotoxicosis relieves mentioned disorders and brings normalization of ventilation parameters. The main issue of this research was the analysis of vital lung capacity in female patients with properly treated hyperthyroidism and comparison of values of these parameters among patients with balanced thyrotoxicosis, non-toxic goitre and with non-thyroid disorders. Research was conducted on 300 randomized female-patients (ASA I, II), aged 18 to 47 with surgically treated hyperthyroidism, non-toxic goitre or non-thyroid disorders. Vital lung capacity (VLC) was analyzed as absolute values and as a percent of predicted values. Statistical analysis revealed that patients in specified groups did not differ in age, weight and frequency of belonging to both ASA categories. Vital lung capacity and percent of predicted values were not significantly different in all groups. Vital lung capacity of female-patients with balanced hyperthyroidism did not differ significantly from vital lung capacity of patients with non-toxic goitre and non-thyroid disorders.