Markus Gnädinger

Maintained serum sodium in male ultra-marathoners--the role of fluid intake, vasopressin, and aldosterone in fluid and electrolyte regulation.

Exercise-associated hyponatremia (EAH) is a well know electrolyte disorder in endurance athletes. Although fluid overload is the most like etiology, recent studies, however, argued whether EAH is a disorder of vasopressin secretion. The aims of the present study were to investigate (i) the prevalence of EAH in male ultra-marathoners and (ii) whether fluid intake, aldosterone or vasopressin, as measured by copeptin, were associated with post-race serum sodium concentration ([Na+]). In 50 male ultra-marathoners in a 100 km ultra-marathon, serum [Na+], aldosterone, copeptin, serum and urine osmolality, and body mass were measured pre- and post-race. Fluid intake, renal function parameters and urine excretion were measured. No athlete developed EAH. Copeptin and aldosterone increased; a significant correlation was found between the change in copeptin and the change in serum [Na+], no correlation was found between aldosterone and serum [Na+]. Serum [Na+] increased by 1.6%; body mass decreased by 1.9 kg. The change in serum [Na+] and body mass correlated significantly and negatively. The fluid intake of ~ 0.58 l/h was positively related to the change in body mass and negatively to both post-race serum [Na+] and the change in serum [Na+]. We conclude that serum [Na+] was maintained by both the mechanisms of fluid intake and the hormonal regulation of vasopressin.

Prevalence of exercise-associated hyponatremia in male ultraendurance athletes.

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.

A two year study of verified spider bites in Switzerland and a review of the European spider bite literature

During a two-year study, all spider bites recorded by Swiss primary care physicians were reported to the Swiss Toxicological Information Centre and all collected spiders were identified. A total of 14 verified spider bites were recorded, involving five species from four families: Zoropsis spinimana (five cases), Cheiracanthium punctorium (four cases), Tegenaria atrica (three cases) and one case of Malthonica ferruginea (= Tegenaria ferruginea) (both Agelenidae), and one case of Amaurobius ferox (Amaurobiidae). The bites of all spider species produced relatively mild symptoms. Local symptoms such as moderate to severe pain, circumscribed swelling and redness were the only effects in most cases. Systemic symptoms were rare. There was complete recovery in all cases and all lesions healed completely without further damage or secondary disorders. Following a review of the European spider bite literature, the number of spider species capable of biting humans in Europe is considered to be much larger than could be concluded from this study. Most spider bites are restricted to species living synanthropically, thus promoted by climate and habitat change. The annual frequency of spider bites in Switzerland is estimated at 10-100 bites per million inhabitants, but this is predicted to increase due to the continuous arrival of new alien species, many of which have a high potential to establish in urban areas.

Swiss prospective study on spider bites

Knowledge of spider bites in Central Europe derives mainly from anecdotal case presentations; therefore we aimed to collect cases systematically. From June 2011 to November 2012 we prospectively collected 17 cases of alleged spider bites, and together with two spontaneous notifications later on, our database totaled 19 cases. Among them, eight cases could be verified. The causative species were: Cheiracanthium punctorium (3), Zoropsis spinimana (2), Amaurobius ferox, Tegenaria atrica and Malthonica ferruginea (1 each). Clinical presentation was generally mild, with the exception of Cheiracanthium punctorium, and patients recovered fully without sequelae. In Switzerland, spider bites generally have a benign clinical course, which is characterised by minor effects, with rapid and complete recovery. Since only verified spider bites can be regarded as spider bites, in the case of clinically important arachnidism, the spider should be sent to an expert for identification. Our study may help to diminish spider fear and reassure people who have experienced a bite.

Medication incidents in primary care medicine: a prospective study in the Swiss Sentinel Surveillance Network (Sentinella)

Objectives To describe the type, frequency, seasonal and regional distribution of medication incidents in primary care in Switzerland and to elucidate possible risk factors for medication incidents. Design Prospective surveillance study. Setting Swiss primary healthcare, Swiss Sentinel Surveillance Network. Participants Patients with drug treatment who experienced any erroneous event related to the medication process and interfering with normal treatment course, as judged by their physician. The 180 physicians in the study were general practitioners or paediatricians participating in the Swiss Federal Sentinel reporting system in 2015. Outcomes Primary: medication incidents; secondary: potential risk factors like age, gender, polymedication, morbidity, care-dependency, previous hospitalisation. Results The mean rates of detected medication incidents were 2.07 per general practitioner per year (46.5 per 1 00 000 contacts) and 0.15 per paediatrician per year (2.8 per 1 00 000 contacts), respectively. The following factors were associated with medication incidents (OR, 95% CI): higher age 1.004 per year (1.001; 1.006), care by community nurse 1.458 (1.025; 2.073) and care by an institution 1.802 (1.399; 2.323), chronic conditions 1.052 (1.029; 1.075) per condition, medications 1.052 (1.030; 1.074) per medication, as well as Thurgau Morbidity Index for stage 4: 1.292 (1.004; 1.662), stage 5: 1.420 (1.078; 1.868) and stage 6: 1.680 (1.178; 2.396), respectively. Most cases were linked to an incorrect dosage for a given patient, while prescription of an erroneous medication was the second most common error. Conclusions Medication incidents are common in adult primary care, whereas they rarely occur in paediatrics. Older and multimorbid patients are at a particularly high risk for medication incidents. Reasons for medication incidents are diverse but often seem to be linked to communication problems.

The out-of-focus bias in drug surveillance

PurposeExisting drug safety systems with phase II and III studies and post-marketing surveillance by principle do not allow for the recognition of an important class of adverse drug reactions (ADRs). ADRs that are resistant to being detected reliably may a) appear as if they are age-related chronic diseases, which also manifest themselves in a high degree without drug treatment, b) arise in “old” drugs, c) arise during long-term application, and d) arise with the administration to frail and aged populations.Conclusions“Silent” and multi-factorial health problems evolving from long-term drug treatment must therefore be addressed with a systematic search strategy, as a third track along with the phase II and III studies and spontaneous reporting systems which still exist.

Medication incidents in primary care medicine: protocol of a study by the Swiss Federal Sentinel Reporting System

Background/rationale Patient safety is a major concern in healthcare systems worldwide. Although most safety research has been conducted in the inpatient setting, evidence indicates that medical errors and adverse events are a threat to patients in the primary care setting as well. Since information about the frequency and outcomes of safety incidents in primary care is required, the goals of this study are to describe the type, frequency, seasonal and regional distribution of medication incidents in primary care in Switzerland and to elucidate possible risk factors for medication incidents. Methods and analysis Study design and setting: We will conduct a prospective surveillance study to identify cases of medication incidents among primary care patients in Switzerland over the course of the year 2015. Participants: Patients undergoing drug treatment by 167 general practitioners or paediatricians reporting to the Swiss Federal Sentinel Reporting System. Inclusion criteria: Any erroneous event, as defined by the physician, related to the medication process and interfering with normal treatment course. Exclusion criteria: Lack of treatment effect, adverse drug reactions or drug–drug or drug–disease interactions without detectable treatment error. Primary outcome: Medication incidents. Risk factors: Age, gender, polymedication, morbidity, care dependency, hospitalisation. Statistical Analysis: Descriptive statistics to assess type, frequency, seasonal and regional distribution of medication incidents and logistic regression to assess their association with potential risk factors. Estimated sample size: 500 medication incidents. Limitations: We will take into account under-reporting and selective reporting among others as potential sources of bias or imprecision when interpreting the results. Ethics and dissemination No formal request was necessary because of fully anonymised data. The results will be published in a peer-reviewed journal. Trial registration number NCT0229537.

CIRS-Flash Nr. 1: Morphin-Tropfen in falscher Dosierung

«Im Altersheim betreue ich neu einen Patienten mit schwerster COPD. Er steht unter Dauer-Sauerstofftherapie und erhält für seine Dyspnoe viermal täglich 3 mg Morphin in Tropfenform verordnet. Der Patient hatte früher zu Hause noch die Konzentration 20 mg/ml (2%ige Lösung), d.h. 1 mg/Tropfen, eine Verordnung, die ich wieder erneuere. Im Heim gibt es jedoch nur 10 mg/ml (1%ige Lösung); er erhält somit viermal 6 Tropfen. Später werden von der Apotheke die verlangten 2%igen Tropfen geliefert, und der Pa tient erhält somit irrtümlich 24 statt der gewohnten 12 mg Morphin pro Tag.» Kommentar: Verwechslungen zwischen den 1 und 2%igen Morphinlösungen kommen wohl recht oft vor. Es wäre sinnvoll, nur mit den 2%igen Tropfen zu arbeiten, da ein Tropfen dann immer 1 mg entspricht und die 1%igen Tropfen nicht mehr zu verwenden. Der Fall wurde an die Swissmedic gemeldet. Für Ihren nächsten Fall: www.forum-hausarztmedizin.ch. Herzlichen Dank!

Die peripher venöse Punktion. Teil 2

Das Problem der intravenosen Injektions- resp. Infusionstherapie liegt in der Gewebstoxizitat verschiedener Mittel. Gewebetoxische Injektionen oder Infusionen brauchen bestimmte Vorkehrungen, um die streng intravenose Applikation zu gewahrleisten.

Ponction veineuse périphérique. 2e partie

Le probleme du traitement par injection ou perfusion intraveineuse reside dans la toxicite tissulaire de differents medicaments. Les injections ou perfusions de produits toxiques exigent certaines precautions garantissant l’injection strictement intraveineuse.