Prof. Dr. med. Jörg Leuppi

Unspezifische untere Rückenschmerzen stellen ein komplexes Krankheitsbild dar, von welchen Patienten jeglicher Populationen weltweit betroffen sind. Etwa 5% aller Notfallkonsultationen sind mit Rückenschmerzen assoziiert.

Die Ätiologie sowie die optimale Behandlung dieser Erkrankung ist weiterhin unklar.

Die frühzeitige bildgebende Diagnostik wird aufgrund der hohen finanziellen Kosten und der Strahlenbelastung der Patienten in den ersten 6 Wochen nicht empfohlen, sofern keine Red Flags vorliegen. Ebenso sollte auf eine analgetische Therapie mit Opioiden bei akuter Symptomatik verzichtet werden. Hierbei sind insbesondere die unerwünschten Nebenwirkungen sowie gefährliche Überdosierungen von Bedeutung. Zusätzliche Konsequenzen können längere Arbeitsplatzabsenzen sowie Mehrfachkonsultationen sein. Im Spitalalltag bleibt es jedoch eine Herausforderung, die Diskrepanz zwischen Patientenanforderungen und den Empfehlungen der Guidelines zu meistern.

Wir planen eine retrospektive Single-Center-Beobachtungsstudie. Ziel der Studie ist die Analyse des Rückenschmerzenmanagements anhand von Fallserie-Analysen von Patientinnen und Patienten, welche in den Jahren zwischen 2018 und 2023 auf die Notfallstation mit Rückenschmerzen eingetreten sind. Aus den Erkenntnissen der Studie sollen weitere Massnahmen wie Patientenedukation und Mitarbeiterschulungen entstehen, um so die Versorgung und Sicherheit der Patienten zu verbessern. 

Enhancing Personalized Healthcare and Clinical Research through Interoperable Data Management: A Focus on Symptoms Management

BACKGROUND

In healthcare organizations and hospitals in particular, patient medical data are stored in a multitude of heterogeneous systems and formats. These systems are often not interconnected, and information is not transferred across interfaces. The lack of flexibility and the difficulties involved in current data systems not only impede the quality of health care providers’ work and ability to deliver personalized health care but also limit research opportunities with large amounts of data.

Existing research emphasizes the critical need for interoperability between patient information systems to enhance personalized healthcare and facilitate clinical research (1–3).

To help solve this problem at the Cantonal Hospital of Baselland (KSBL) we have developed a new concept for data selection and extraction based on an innovative approach to data management. We will use the DAWIMED software developed by ID-Berlin (main company) and ID-Suisse (Swiss subsidiary) to enable interoperability between patient information systems and make routine clinical data accessible for clinical research and quality management.

This project aims to use this innovative approach to improve personalized healthcare and clinical research, with a specific focus on symptom management.

The project includes two clinically driven research studies:

1.    Assessment of the Management of Patients Admitted with Dyspnea as Their Chief Complaint

2.    Machine Learning to Predict the Cause of Dyspnea Based on Parameters Available at Admission

RESEARCH STUDIES

1.    Assessment of the Management of Patients Admitted with Dyspnea as Their Chief Complaint

Dyspnea, or shortness of breath, is a prevalent symptom leading to numerous emergency department (ED) visits and hospital admissions. It can result from various conditions, including cardiac and pulmonary diseases, as well as other less common causes. Dyspnea's diverse causes necessitate a comprehensive and prompt assessment using medical history, physical exams, biomarkers, and radiological evaluations. Despite its prevalence, there is limited data on its frequency and causes in Switzerland, and patient data is often fragmented across unstructured paper documents and digital systems. Identifying relevant patient data from mixed formats (paper and digital) is complex and often requires time-consuming manual searches.

The study aims to:

·        Describe the management of patients presenting with dyspnea at the KSBL ED.

·        Assess adherence to the medStandards algorithm for dyspnea management.

Significance: Understanding and improving the management of dyspnea can enhance patient outcomes, reduce in-hospital mortality, and streamline ED processes.

2.    Machine Learning to Predict the Cause of Dyspnea Based on Parameters Available at Admission

Dyspnea has multifactorial causes, ranging from common conditions like respiratory infections and heart failure to rarer causes like anaphylaxis or metabolic disorders. The wide variability in patient demographics, comorbidities, and clinical presentations complicates the diagnostic process. Distinguishing between cardiac and pulmonary causes is particularly difficult due to overlapping symptoms. Accurate and rapid diagnosis is crucial for effective treatment but is often challenging due to the symptom's urgency and diverse etiologies.

The study aims to:

• Identify parameters collected during the initial ED assessment (e.g., symptoms, vital signs, medical history) that predict the underlying cause of dyspnea.
• Develop predictive scores or digital tools to assist physicians in making prompt and accurate diagnoses.

Significance: By leveraging machine learning, the study seeks to enhance diagnostic accuracy, reduce the need for extensive testing, and improve the timeliness and effectiveness of dyspnea management in the ED. This approach can lead to better patient outcomes and more efficient use of resources.

Ziel dieser Studie ist es, ein besseres Verständnis von Risikofaktoren, protektiven Faktoren, Komplikationen, therapeutischem Nutzen verschiedener Behandlungsstrategien, sowie dem generellen Verlauf von COVID-19 von am KSBL hospitalisierten Patienten zu erlangen. Zu diesem Zweck möchten wir eine umfassende Datenbank mit Daten von Patienten, die am Kantonsspital Baselland (KSBL) während der Pandemie aufgrund von COVID-19 hospitalisiert waren anlegen. Diese Datenbank soll als Grundlage für die explorative retrospektive Untersuchung der o.g. Fragestellungen dienen.

Diese Studie ist eine retrospektive single-center Kohortenstudie. Die Studienpopulation wird definiert durch alle aufgrund von COVID-19 am KSBL hospitalisierten Patienten zwischen Januar 2020 und August 2022. Es sollen keine genetischen Daten oder zusätzliches biologisches Material untersucht werden. Diese Daten sollen zunächst deskriptiv zusammengefasst und dann explorativ analysiert werden.

Background: The recent increasing complexity in internal medicine and the concurrent demand for improving quality while cutting down resources represent a major challenge for healthcare providers. Disease-specific clinical guidelines for diagnostic and therapeutic management provide support in this demanding situation. However, according to previous studies, guideline adherence is often poor in clinical practice. Clinical audits are a powerful instrument in the evaluation of guideline adherence and can ultimately improve quality of hospital care.

Objectives: With the QUA-DIT project we seek to identify disease-specific areas of in-hospital management where diagnostic and/or therapeutic guideline-adherence is poor. Furthermore, we plan to investigate the effect of guideline-adherence on patient outcome related quality indicators. By establishing a sustainable quality control program addressing these areas, we intend to lay the foundation for the overall improvement of hospital care.

Methods: The QUA-DIT project consists of seven clinically driven audits in typical acute diagnoses in the department of internal medicine at the Cantonal Hospital Baselland. Recent clinical routine data concerning diagnostic workup, treatment, and other measures of care will be collected and descriptively compared to the established national and international disease-specific guidelines. Ultimately, association of guideline-adherence with quality indicators mortality, length of hospital stay, and rehospitalization will be assessed by multivariable regression models. We expect to include data of 2410 patients into our analyses.

Relevance: Establishing a series of clinical audits with the same methodology and the aim to improve quality in different fields of internal medicine is an innovative approach. Based on the audit findings, we plan to implement several measures to achieve improvement in the evidence-based management of our patients. Being transparent about the results with the intention of publication is a way of creating awareness in the internal medicine community and may serve as a motivation for other hospitals to follow the example. The QUA-DIT project represents a significant step for improvement of the overall healthcare system, and ultimately for the health of the population.

Background

Public health faces the dual challenge of providing optimal care while managing costs, particularly with an aging population and increasing prevalence of chronic conditions. Public hospitals, which often serve older patients with lower socioeconomic status and higher comorbidities, are under pressure to improve quality while reducing costs. Key quality indicators, such as length of hospital stay (LOHS), rehospitalization, and mortality rates, are essential for monitoring and comparing hospital performance.

Aim and Relevance

This research aims to identify predictors of LOHS, rehospitalization, and mortality in patients with pulmonary embolism (PE), chronic obstructive pulmonary disease (COPD), and community-acquired pneumonia (CAP). By understanding these predictors, the project seeks to:

1. Address modifiable factors to develop strategies for improving patient outcomes.
2. Raise awareness among clinicians about non-modifiable risk profiles.
3. Inform the development of better prediction models.
4. Optimize hospital bed management strategies.
5. Provide evidence-based recommendations for policymakers and healthcare providers.

General Conclusions

• PE Cohort Study: The PESI score, diabetes, serum troponin, and NT-proBNP levels are significant predictors for LOHS, mortality, and rehospitalization. These findings highlight the importance of comprehensive risk assessment for PE patients.
• CAP Cohort Study: Factors such as sex, age, qSOFA score, and presence of cancer significantly influence LOHS, rehospitalization, and mortality. Rehabilitation post-discharge plays a crucial role in rehospitalization rates.
• AECOPD Cohort Study: Oxygen supplementation at admission, age, COPD GOLD III/IV, active cancer, and rehabilitation are significant predictors of LOHS and mortality. The study emphasizes the complexity of predicting rehospitalization in AECOPD patients and suggests incorporating disease course variables for better accuracy.

Overall, the findings underscore the significance of disease-specific and broader health system factors in predicting hospital outcomes. The research aims to enhance patient management, discharge planning, and hospital performance, ultimately contributing to improved public healthcare systems for an aging population with complex chronic conditions.

Cough is one of the most common causes for seeking medical advice in general practices. Post-infectious cough is defined as lasting 3 to 8 weeks after an upper respiratory tract infection (URTI). It can be very bothersome, disabling in daily activities with substantial impact on physical and psychosocial health, leading to impaired quality of life (QoL). Recommendations for the management of post-infectious cough in primary care are scarce and incoherent. To provide a wide overview of treatment options for patients with post-infectious cough, we conducted and recently published a systematic review and meta-analysis of randomised clinical trials (RCTs) assessing the patient-relevant benefits and potential harms of available treatments. Only six eligible RCTs assessing different treatment regimens (i.e. inhaled fluticasone propionate, inhaled budesonide, salbutamol plus ipratropium-bromide, montelukast, nociception-opioid-1-receptor agonist, codeine, and gelatine) were identified. None of these RCTs found clear patient-relevant benefits and most had an unclear or high risk of bias.Post-infectious cough is thought to be mediated by inflammatory processes that are also present in exacerbations of asthma or chronic obstructive pulmonary diseases (COPD). There is strong evidence that oral corticosteroids for 5 days provide patient-relevant benefit without relevant harm for these conditions. Our systematic search identified no RCTs evaluating oral corticosteroids for post-infectious cough. Thus, a high quality RCT assessing the benefits and harms of orally administered corticosteroids for post-infectious cough is needed.Aim: To assess whether a 5-day treatment with oral corticosteroids provides patient-relevant benefits by improving the cough-related QoL and reducing the duration and intensity of post-infectious cough in adult primary care patients.Methods: The proposed study is a multicentre, 1:1 randomised, parallel-group, placebo-controlled, superiority trial with blinded patients, general practitioners (GP), and outcome assessors in a primary health care setting. We plan to include 204 patients aged 18 or older seeing their GP for a cough lasting 3 to 8 weeks following an URTI. Any concurrent disease possibly explaining the symptoms, such as pneumonia, asthma, COPD, gastroesophageal reflux disease, allergic rhinitis, or cancer will be ruled out before trial inclusion. Patients will receive oral corticosteroid treatment (equivalent of 40 mg prednisone once daily) for 5 days or placebo for 5 days.The primary outcome is cough-related QoL assessed by the Leicester Cough Questionnaire (LCQ) score 14 days after randomisation. Secondary outcomes are i) cough-related QoL (at day 7, 28, and 3 months), ii) cough-related QoL sub-domains physical, psychological, and social, iii) overall cessation of cough, iv) re-consultations at GP and/or hospitalisations, v) total adverse events (AE), and vi) serious adverse events (SAE). All outcomes will be assessed through follow-up phone calls by study nurses 7, 14, 28 days, and 3 months after randomisation. Clinical follow-up visits with the GP are at the discretion of the patient and the GP.Assumptions for sample size estimation are informed by our systematic review. 204 patients are required to detect a statistically significant minimal clinically important difference of 1.3 of the LCQ score at 14 days (primary outcome; power 80%, two-sided significance level 5%, drop-out-rate 10%). Primary analysis will be done with ANCOVA (analysis of covariance) according to the intention to treat principle. Baseline LCQ scores, duration of cough, age, sex, and smoking status will be covariates.Importance: This will be the first RCT investigating whether oral corticosteroids are beneficial and safe in patients with post-infectious cough, which would have a substantial impact on the well-being and management of these patients in Switzerland and beyond.

Asthma is a chronic respiratory airway disease that affects more than 300 million people worldwide. Severe Asthma (SA) affects around 5-10% of all asthma patients yet accounts for half of the asthma related costs and carries a high burden of disease . Since the introduction of highly targeted treatments (monoclonal antibodies) in 2005, the treatment of severe asthma has been revolutionized. Nowadays, most of the patients with a severe asthma are treated with monoclonal antibodies. However, in Switzerland as in other countries, we have had only a little knowledge about the real-life situation of patients with SA, regarding long-term clinical management and therapeutic outcomes. Recognizing that knowledge gap, multiple countries, including Switzerland, have established national registries observing severe asthma and build up an international network of clinical registries.

The overall aim of this cohort is to gain comprehensive information about severe asthma in Switzerland, with the focus on the following:

• Describing SA Patient characteristics in Switzerland
• Treatment regimens over time
• Clinical course of SA patients over time including changes and influencing factors of asthma related outcomes

Evaluationsforschung zur interdisziplinären Langzeit-Nachsorgesprechstunde im Kantonsspital Baselland und ab 2019 im Inselspital Bern

Childhood cancer treatment is now so successful that over 80% of children diagnosed survive into adulthood, resulting in over 6,000 adult survivors in Switzerland. However, many adult childhood cancer survivors (ACCS) face late effects impacting various organ depending on the oncological treatment they received. Most Swiss ACCS are uninformed about their health risks and lack proper follow-up care.

We established two late effects clinics in Liestal (spring 2017) and Bern (autumn 2019), where ACCS receive follow-up care per the Children's Oncology Group guidelines. Led by internists collaborating with pediatric oncologists, these clinics allow ACCS to complete necessary follow-up exams in a single consultation day and offer annual visits. To gather data on ACCS health, feedback, and quality of life, we started a prospective cohort study in 2017.

Our study aims to describe ACCS health and adapt follow-up care to their needs, hoping to show over time that optimized follow-up can mitigate late effects. We use data from questionnaires and clinical visits to collect information on general health, demographic details, quality of life, psychological health, and follow-up visit feedback. Detailed summaries of the oncological treatments ACCS received are also collected.

Inclusion criteria include all ACCS diagnosed before age 20 and currently aged 18 or above who consent to participate.

Implications for Clinical Care:

We were the first Swiss clinics to use an internist-led follow-up model. Our research has shown positive feedback from ACCS and identified diverse health problems at a young age. We aim to improve follow-up care across Switzerland by encouraging other hospitals to adopt similar models. So far, Luzern has adopted our model, and Baden is starting a similar clinic for young adult cancer survivors."

 

Reduction of corticosteroid use in outpatient treatment of exacerbated COPD – a randomized, double-blind, placebo-controlled, non-inferiority study in an outpatient setting, performed in Northwestern and Central Switzerland and Austria

Background: Chronic obstructive pulmonary disease (COPD) is a major public health issue affecting approximately five to seven percent of the Swiss population. According to current guidelines for the inpatient setting, systemic corticosteroids are most important in the treatment of acute COPD exacerbations and should be given for five to seven days. Several studies suggest that corticosteroids accelerate the recovery of the FEV1 (forced expiratory volume in one second), enhance oxygenation, decrease duration of hospitalization and improve clinical outcome. However, the additional therapeutic benefit on FEV1 recovery appears to be most distinctive in the first three to five days. No data are available on the minimal necessary corticosteroid dose and treatment duration in primary care patients with acutely exacerbated COPD. Given the fact that many patients are treated in an outpatient setting, there is an urgent need to improve evidence about COPD management in this setting. Methods: The proposed study is a prospective, double-blind, randomized controlled trial that is conducted in a primary care setting including an anticipated 470 patients with acutely exacerbated COPD. Participants receive systemic corticosteroid treatment equivalent of 40 mg prednisone daily for either five days (conventional arm, n = 235), or for three days, followed by two days of placebo (experimental arm, n = 235). Antibiotic treatment for seven days is given to all patients with CRP ≥ 50 mg/l, known diagnosis of bronchiectasis, or presenting with Anthonisen Type-I exacerbation. Additional treatment after inclusion are left at the discretion of the treating general pracititioner. Follow-up visits are performed on days three and seven by the treating general practitioners, followed by telephone interviews on das 30, 90 and 180 after inclusion into the study. Primary endpoint is the time to next exacerbation during index exacerbation, or during a six-months follow-up period, whichever occurs first. Discussion: This study is designed to assess whether a three-day course of corticosteroid treatment is not inferior to the current conventional five-day treatment course in outpatients with exacerbated COPD. Depending on the results, this trial might lead to a further reduction of cumulative corticosteroid dose in COPD patients.