Prescribing practices in German and Swiss psychiatric university and in non-university hospitals : national differences

RÉSUMÉ Il existe dans la pratique de prescription des médicaments de grandes variations entre les hôpitaux. Ces variations sont d'origines multifactorielles, comme par exemple des traditions de prescriptions locales, des considérations pharmato-économiques, la disponibilité d'un médicament, des différences de population, la prévalence d'une maladie, etc. Les études disponibles sur les pratiques de prescription sont souvent réduites à un centre unique, à une région ou à un pays. L'emploi de méthodes et de définitions particulières a jusqu'à pressent limité des comparaisons plus étendues entre les pays et régions. Le but de cette étude est de comparer la pratique de prescription de nouveaux médicaments psychotropes dans des cliniques suisses et allemandes. Cinq hôpitaux psychiatriques ont été sélectionnés, faisant tous partie du projet AMSP, et représentant des cliniques suisses, allemandes, de niveau universitaire ou non. Des données sur 572 patients et 1745 prescriptions ont été collectées durant un jour précis. Les comparaisons ont été ajustées pour l'âge et le sexe. Une différence significative (p <0.001) a été trouvée dans la prescription de nouveaux médicaments antidépresseurs, les cliniciens suisses en donnant en moyenne plus (65.2%) que les allemands (48.3%). Aucune différence significative n'a été démontrée dans la prescription des nouveaux médicaments antipsychotiques atypiques. Il semble en conséquence que les psychiatres suisses ont une propension plus élevée à prescrire des nouveaux médicaments antidépresseurs. Cela semble être dû à des différences de traditions de prescriptions nationales ou régionales. D'autres études sont nécessaires pour investiguer les influences économiques sur la pratique de prescription dans des cliniques suisses et allemandes. SUMMARY Obiective: There are great variations between hospitals in the way drugs are prescribed and these variations may be due to multiple factors such as local prescribing traditions, pharmacoeconomic considerations, drug availability; regional differences of population, disease prevalence etc. Available studies on prescribing habits have, besides studies performed in a unique centre, until now often been restricted to single countries or regions and the comparisons across countries or regions have often been limited by the use of diverse methodologies and definitions. The aim of the present study was to compare drug prescriptions between German and Swiss psychiatric services with regard to their preference of newer psychotropics. Material, method: Five psychiatric hospitals, associated to the AMSP-project, were chosen to represent Swiss and German clinics, university and non-university settings. Data were available from one index day on 572 patients and 1745 prescriptions. The comparisons were adjusted for age and gender. Results: There was a significant difference (p < 0.001) with regard to the prescription of newer antidepressants (NAD), Swiss clinicians giving proportionally more (65.2 %) than the German psychiatrists (48.3 %). No significant difference was, on the other hand, found as to the proportion of atypical antipsychotics, the lack of difference being due to the higher proportion of clozapine among the atypical antipsychotics in Germany. Conclusion: There seems therefore to be a higher propensity for Swiss hospital psychiatrists to prescribe newer antidepressants. This seems to be due to national or regional prescribing traditions. Further studies are needed to investigate the economical influences on antidepressant prescribing in Swiss and German clinics.)

Treatment of status epilepticus: a comparison of phenytoin, valproate, or levetiracetam

Objectives: Phenytoin (PHT), valproic acid (VPA), or levetiracetam (LEV) are commonly used as second-line treatment of status epilepticus (SE), but comparative studies are not available to date.Methods: In our tertiary care hospital, among 279 SE episodes prospectively collected over four years, and occurring in adults, we identified 187 episodes in which PHT, VPA or LEV were prescribed after benzodiazepines. Patients with post-anoxic SE were not included. Demographics, clinical SE features, failure of second-line treatment to control SE, new handicap and mortality at hospital discharge were assessed. Uni- and multivariable statistical analyses were applied to compare the three agents.Results: Each compound was used in about one third of episodes. VPA failed to control SE in 25.4%, PHT in 41.4% and LEV in 48.3% of episodes in which these were prescribed as second-line agents. After adjustment for known SE outcome predictors, LEV failed more often than VPA (OR 2.69; 95% CI 1.19-6.08); in others words, 16.8% (95% CI 6.0-31.4%) of second-line treatment failures could be attributed to prescription for LEV instead of VPA. PHT was statistically not different from the other two compounds. At discharge, second-line treatment did not influence new handicap and mortality, while etiology and severity of the SE episode were robust independent predictors.Conclusions: Even without significant differences on outcome at discharge, LEV seems less efficcacious than VPA to control SE after benzodiazepines. A prospective comparative trial is needed to address this potentially concerning finding. The second interesting finding is that the outcome seems more influenced by the SE characteristics than the treatment.

Confounding factors and genetic polymorphism in the evaluation of individual steroid profiling

In the fight against doping, steroid profiling is a powerful tool to detect drug misuse with endogenous anabolic androgenic steroids. To establish sensitive and reliable models, the factors influencing profiling should be recognised. We performed an extensive literature review of the multiple factors that could influence the quantitative levels and ratios of endogenous steroids in urine matrix. For a comprehensive and scientific evaluation of the urinary steroid profile, it is necessary to define the target analytes as well as testosterone metabolism. The two main confounding factors, that is, endogenous and exogenous factors, are detailed to show the complex process of quantifying the steroid profile within WADA-accredited laboratories. Technical aspects are also discussed as they could have a significant impact on the steroid profile, and thus the steroid module of the athlete biological passport (ABP). The different factors impacting the major components of the steroid profile must be understood to ensure scientifically sound interpretation through the Bayesian model of the ABP. Not only should the statistical data be considered but also the experts in the field must be consulted for successful implementation of the steroidal module.

A model for physical activity, bahaviour and energy expenditure assessment in real-life condition

RésuméL'origine de l'obésité, qui atteint des proportions épidémiques, est complexe. Elle est liée au mode de vie et au comportement des individus par rapport à l'activité physique, expression des choix individuels et de l'interaction avec l'environnement. Les mesures du comportement au niveau de l'activité physique des individus face à leur environnement, la répartition des types d'activité physique, la durée, la fréquence, l'intensité, et la dépense énergétique sont d'une grande importance. Aujourd'hui, il y a un manque de méthodes permettant une évaluation précise et objective de l'activité physique et du comportement des individus. Afin de compléter les recherches relatives à l'activité physique, à l'obésité et à certaines maladies, le premier objectif du travail de thèse était de développer un modèle pour l'identification objective des types d'activité physique dans des conditions de vie réelles et l'estimation de la dépense énergétique basée sur une combinaison de 2 accéléromètres et 1 GPS. Le modèle prend en compte qu'une activité donnée peut être accomplie de différentes façons dans la vie réelle. Les activités quotidiennes ont pu être classées en 8 catégories, de sédentaires à actives, avec une précision de 1 min. La dépense énergétique a pu peut être prédite avec précision par le modèle. Après validation du modèle, le comportement des individus de l'activité physique a été évalué dans une seconde étude. Nous avons émis l'hypothèse que, dans un environnement caractérisé par les pentes, les personnes obèses sont tentées d'éviter les pentes raides et de diminuer la vitesse de marche au cours d'une activité physique spontanée, ainsi que pendant les exercices prescrits et structurés. Nous avons donc caractérisé, par moyen du modèle développé, le comportement des individus obèses dans un environnement vallonné urbain. La façon dont on aborde un environnement valloné dans les déplacements quotidiens devrait également être considérée lors de la prescription de marche supplémentaire afin d'augmenter l'activité physique.SummaryOrigin of obesity, that reached epidemic proportion, is complex and may be linked to different lifestyle and physical activity behaviour. Measurement of physical activity behaviour of individuals towards their environment, the distribution of physical activity in terms of physical activity type, volume, duration, frequency, intensity, and energy expenditure is of great importance. Nowadays, there is a lack of methods for accurate and objective assessment of physical activity and of individuals' physical activity behaviour. In order to complement the research relating physical activity to obesity and related diseases, the first aim of the thesis work was to develop a model for objective identification of physical activity types in real-life condition and energy expenditure based on a combination of 2 accelerometers and 1 GPS device. The model takes into account that a given activity can be achieved in many different ways in real life condition. Daily activities could be classified in 8 categories, as sedentary to active physical activity, within 1 min accuracy, and physical activity patterns determined. The energy expenditure could be predicted accurately with an accuracy below 10%. Furthermore, individuals' physical activity behaviour is expression of individual choices and their interaction with the neighbourhood environment. In a second study, we hypothesized that, in an environment characterized by inclines, obese individuals are tempted to avoid steep positive slopes and to decrease walking speed during spontaneous outdoor physical activity, as well as during prescribed structured bouts of exercise. Finally, we characterized, by mean of the developed model, the physical activity behaviour of obese individuals in a hilly urban environment. Quantifying how one tackles hilly environment or avoids slope in their everyday displacements should be also considered while prescribing extra walking in free-living conditions in order to increase physical activity.

Steroid profiles of professional soccer players: an international comparative study.

BACKGROUND AND OBJECTIVES: Urinary steroid profiling is used in doping controls to detect testosterone abuse. A testosterone over epitestosterone (T/E) ratio exceeding 4.0 is considered as suspicious of testosterone administration, irrespectively of individual heterogeneous factors such as the athlete's ethnicity. A deletion polymorphism in the UGT2B17 gene was demonstrated to account for a significant part of the interindividual variability in the T/E between Caucasians and Asians. Here, the variability of urinary steroid profiles was examined in a widely heterogeneous cohort of professional soccer players. Method: The steroid profile of 57 Africans, 32 Asians, 50 Caucasians and 32 Hispanics was determined by gas chromatography-mass spectrometry. RESULTS: Significant differences have been observed between all ethnic groups. After estimation of the prevalence of the UGT2B17 deletion/deletion genotype (African: 22%; Asian: 81%; Caucasian: 10%; Hispanic: 7%), ethnic-specific thresholds were developed for a specificity of 99% for the T/E (African: 5.6; Asian: 3.8; Caucasian: 5.7; Hispanic: 5.8). Finally, another polymorphism could be hypothesised in Asians based on specific concentration ratio of 5alpha-/5beta-androstane-3alpha,17beta-diol in urine. CONCLUSION: These results demonstrate that a unique and non-specific threshold to evidence testosterone misuse is not fit for purpose. An athlete's endocrinological passport consisting of a longitudinal follow-up together with the ethnicity and/or the genotype would strongly enhance the detection of testosterone abuse. Finally, additional genotyping studies should be undertaken to determine whether the remaining unexplained disparities have an environmental or a genetic origin.

Relationship of imatinib-free plasma levels and target genotype with efficacy and tolerability

Imatinib has revolutionised the treatment of chronic myeloid leukaemia (CML) and gastrointestinal stromal tumours (GIST). Using a nonlinear mixed effects population model, individual estimates of pharmacokinetic parameters were derived and used to estimate imatinib exposure (area under the curve, AUC) in 58 patients. Plasma-free concentration was deduced from a model incorporating plasma levels of alpha(1)-acid glycoprotein. Associations between AUC (or clearance) and response or incidence of side effects were explored by logistic regression analysis. Influence of KIT genotype was also assessed in GIST patients. Both total (in GIST) and free drug exposure (in CML and GIST) correlated with the occurrence and number of side effects (e.g. odds ratio 2.7+/-0.6 for a two-fold free AUC increase in GIST; P<0.001). Higher free AUC also predicted a higher probability of therapeutic response in GIST (odds ratio 2.6+/-1.1; P=0.026) when taking into account tumour KIT genotype (strongest association in patients harbouring exon 9 mutation or wild-type KIT, known to decrease tumour sensitivity towards imatinib). In CML, no straightforward concentration-response relationships were obtained. Our findings represent additional arguments to further evaluate the usefulness of individualizing imatinib prescription based on a therapeutic drug monitoring programme, possibly associated with target genotype profiling of patients.

"Iatrogenicity cascade": doing harm by treating harm?

An electronic survey on substance-induced epileptic crisis was conducted in order to investigate whether doctors, who recognise their own prescription errors, increase their therapeutic aggressiveness, resulting in a so-called "iatrogenicity cascade". Two pairs of clinical vignettes were constructed, in which a patient suffers from iatrogenic (original version) or non-iatrogenic (control version) epileptic crisis. Vignettes were randomised and sent to doctors at the University Hospital of Lausanne, Switzerland, at an interval of 3 weeks. The results of the present survey in the surveyed population of doctors suggest that inappropriate prescription does not increase therapeutic aggressiveness.

Opioid maintenance therapy in Switzerland: an overview of the Swiss IMPROVE study.

BACKGROUND/AIMS: Switzerland's drug policy model has always been unique and progressive, but there is a need to reassess this system in a rapidly changing world. The IMPROVE study was conducted to gain understanding of the attitudes and beliefs towards opioid maintenance therapy (OMT) in Switzerland with regards to quality and access to treatment. To obtain a "real-world" view on OMT, the study approached its goals from two different angles: from the perspectives of the OMT patients and of the physicians who treat patients with maintenance therapy. The IMPROVE study collected a large body of data on OMT in Switzerland. This paper presents a small subset of the dataset, focusing on the research design and methodology, the profile of the participants and the responses to several key questions addressed by the questionnaires. METHODS: IMPROVE was an observational, questionnaire-based cross-sectional study on OMT conducted in Switzerland. Respondents consisted of OMT patients and treating physicians from various regions of the country. Data were collected using questionnaires in German and French. Physicians were interviewed by phone with a computer-based questionnaire. Patients self-completed a paper-based questionnaire at the physicians' offices or OMT treatment centres. RESULTS: A total of 200 physicians and 207 patients participated in the study. Liquid methadone and methadone tablets or capsules were the medications most commonly prescribed by physicians (60% and 20% of patient load, respectively) whereas buprenorphine use was less frequent. Patients (88%) and physicians (83%) were generally satisfied with the OMT currently offered. The current political framework and lack of training or information were cited as determining factors that deter physicians from engaging in OMT. About 31% of OMT physicians interviewed were ≥60 years old, indicating an ageing population. Diversion and misuse were considered a significant problem in Switzerland by 45% of the physicians. CONCLUSION: The subset of IMPROVE data presented gives a present-day, real-life overview of the OMT landscape in Switzerland. It represents a valuable resource for policy makers, key opinion leaders and drug addiction researchers and will be a useful basis for improving the current Swiss OMT model.

Evolution du degré d'activité de la maladie à l'introduction et après 1 an de traitement biologique chez les patients souffrant de polyarthrite rhumatoïde en Suisse

Introduction. - En Suisse, la prescription de produits biologiqueschez les patients souffrant de polyarthrite rhumatoïde (PR) n'est nilimitée à des centres hospitaliers de rhumatologie, ni soumise à desdirectives strictes éditées par les autorités sanitaires sur le type oule nombre de traitements de fond préalables. La notion d'échec auxtraitements de fond n'est pas non plus précisément définie, et enparticulier l'activité de la maladie ne doit pas répondre à des critèresstricts, notamment en terme de valeurs de DAS, et ce contrairementà de nombreux autres pays où l'impact de ces restrictions aété publié récemment (1, 2).Le registre SCQM peut être considéré comme un bon reflet de lapopulation suisse avec PR, aussi bien pour la population suivie pardes centres hospitaliers que par les practiciens en cabinet privé, eton estime qu'environ 30 % des patients avec PR recevant des traitementsbiologiques en Suisse sont inclus dans ce registre.L'objectif primaire de cette étude est de comparer les caractéristiquesdes patients de notre registre à l'initiation et après un an de traitementbiologique avec celles de registres du même type dans des pays avecun accès plus restreint aux traitements biologiques. Les objectifssecondaires sont de comparer les patients traités en milieu hospitalieret ceux pris en charge en cabinet privé, et aussi d'examiner s'il existedes tendances temporelles (avant et après 2005).Patients et Méthodes. - Les données sont extraites du registre suissede PR (SCQM) qui comprend 4 500 patients inclus entre 1997 et2011. 2 715 patients bénéficient d'un traitement biologique, dont2 427 avec des données à l'introduction du traitement : DAS28/VS,DAS28/CRP, HAQ, durée de la maladie, nbre de tttt préalables, comorbidités,etc. Les principales données démographiques sont : âgemoyen 55 ans, 77 % de femmes 72 % FR+, médecins prescripteurs :62 % en cabinet, 21 % en centre hospitaliers et 16 % en centres universitaires.Nous avons calculés les moyennes (+/- écart type) pourdifférents paramètres de l'activité de la maladie.Résultats. - La moyenne du DAS28/VS à l'introduction du traitement(4,4 +/- 1,3) est nettement inférieur aux valeurs publiées pard'autres registres européens ou canadien (5,3 < > 6,6 ; 1,2). Il en ende même pour le HAQ (1 versus 1,4). Les biologiques sont introduitsaprès en moyenne 1,1 +/- 1 DMARD préalable contre > 3 en Suède,au Danemark ou au Canada.Les caractéristiques démographiques, le degré d'activité et les traitementsprodigués sont similaires entre les patients traités encabinet privé ou en milieu hospitalier, hormis pour une proportionmoindre de traitements iv en cabinet (20 % versus 40 %). Après2005, les traitements biologiques sont introduits beaucoup plusprécocemment, avec une durée médiane de maladie avant l'introductionde thérapies biologiques diminuant de 96 à 51 mois. Onnote également une répartition entre les divers produits biologiquesqui se diversifie. Même si les traitements sont introduits à undegré d'activité similaire (DAS28/VS moyen à 4,4 +/- 1,3) onobserve de meilleurs résultats à 1 an avec un DAS moyen à 1 an :3,5 +/- 1,4 avant 2005 contre 3,1 +/- 1,3 après 2005 (p = 0.0001).Conclusion. - Les données du registre suisse des PR (SCQM) suggèrentque, en l'absence de critères restrictifs d'accès aux traitements biologiques,ceux-ci sont prescrits à des scores d'activité de la maladie(DAS et HAQ) inférieurs, et plus précocemement en terme de nombrede DMARD préalables. Cette tendance se confirme dans le temps, etse retrouve aussi bien en milieu hospitalier qu'en cabinet.En terme de résultats, après 2005, plus de 50 % des patients atteignentun bas degré d'activité de la maladie en terme de DAS aprèsun an de traitement, chiffre qui semble justifier ce type de systèmepeu restrictif favorisant certainement une approche thérapeutiqueplus proche des nouveaux paragidmes de traitement avec une stratégiede type « treat to target ».Références[1] Curtis J R et al. Semin Arthritis Rheum. 40:2-14,2009.[2] Pease C, Pope JE, Truong D et al. Semin Arthritis Rheum, December2010.

Cost effectiveness of a new combined immunosuppressive and antiviral regimen on the one-year follow-up of kidney transplant patients.

Background: Medical prescription after organ transplant must prevent both rejection and infectious complications. We assessed the 1-year effectiveness and cost of introducing a new combined regimen in kidney transplantation. Methods: Patients transplanted from January 2000 to March 2003 (Period 1) were compared to patients transplanted from April 2003 to July 2005 (Period 2). In period 1, patients were treated with Basiliximab, Cyclosporin, steroids and Mycophenolate (MMF) or Azathioprine. Prophylaxis with Valacyclovir was prescribed only in CMV D+/R- patients. In period 2, immunosuppressive drugs were Basiliximab, Tacrolimus, steroids and MMF. A 3-month universal CMV prophylaxis with Valganciclovir was used. Medical charts of outpatient visits allowed identifying drug, laboratory and radiological tests use, and hospital information system causes of hospitalisation and length of stay (LOS) over the first year after transplant. Patients with incomplete costs data were excluded. Results: 53 patients were analysed in period 1, and 60 in period 2. CMV serostatus patterns were not significantly different between the 2 periods. Over 12 months, acute rejection decreased from 22 patients (42%) in period 1 to 4 patients (7%) in period 2 (p<0.001), and CMV infection from 25 patients (47%) to 9 patients (15%, p<0.001). Average total rehospitalisation LOS decreased from 28±19 to 20±11 days (p<0.007). Average outpatient visits decreased from 49±10 to 39±8 (p<0.001). Average immunosuppression and CMV prophylaxis costs increased from US$ 18,362±6,546 to 24,637±5,457 (p<0.001), while average graft rejection costs decreased form US$ 4,135±9,164 to 585±2,850 (p=0.005), and average CMV treatment costs from US$ 2,043±5,545 to 91±293 (p=0.008). Average outpatient visits costs decreased from US$ 7,619±1,549 to 6,074±1,043 (p<0.001), and other hospital costs from US$ 3,801±6,519 to 1,196±3,146 (p=0.007). Altogether, average 1-year treatment costs decreased from US$ 35,961±14,916 to 32,584±6,211 (p=0.115). Cost-effectiveness ratios to avoid graft rejection and CMV infection decreased from US$ 61,482±9,292 to 34,911± 1,639 (p=0.006) and US$ 68,070±11,122 to 39,899±2,650 (p=0.015), respectively. Conclusion: The new combined regimen administered in period 2 was significantly more effective. Its additional cost was more than offset by savings linked with complications avoidance.

Participation in a population-based physical activity programme as an aid for smoking cessation: a randomised trial.

OBJECTIVES: Exercise combined with nicotine therapy may help smoking cessation and minimise weight gain after quitting. Low participation in vigorous-intensity physical activity programmes precludes their population-wide applicability. In a randomised controlled trial, we tested whether a population-based moderate-intensity physical activity programme increases quit rates among sedentary smokers receiving nicotine therapy. METHODS: Participants (n=481; 57% male; mean age, 42.2 years (SD 10.1); mean cigarette consumption, 27 (SD 10.2) per day) were offered a nine-week smoking cessation programme consisting of a weekly 15-minute counselling session and the prescription of nicotine replacement therapy. In addition, participants in the physical activity group (n=229) also took part in a programme of moderate-intensity physical activity implemented at the national level, and offering nine weekly 60-minute sessions of physical activity. To ensure equal contact conditions, participants in the control group (n=252) attended weekly 60-minute health behaviour education sessions unrelated to physical activity. The primary outcome was continuous CO-verified smoking abstinence rates at 1-year follow-up. RESULTS: Continuous smoking abstinence rates were high and similar in the physical activity group and the control group at the end of the intervention (47% versus 46%, p=0.81) and at 1-year follow-up (27% versus 29%, p=0.71). The mean weight gain after one year was 4.4 kg and 6.2 kg among sustained quitters of the physical activity and control groups, respectively (p=0.06). CONCLUSION: Participation in a population-based moderate-intensity physical activity programme for 9 weeks in addition to a comprehensive smoking cessation programme did not significantly increase smoking cessation rates. A non-significant reduction in weight gain was observed among participants who quit smoking in the physical activity group. TRIAL REGISTRATION: ClinicalTrials.gov; US National Institutes for Health (available online at http://clinicaltrials.gov/; CLINICAL TRIAL REGISTRATION NUMBER: NCT00521391).

Respecte-t-on les bonnes pratiques de prescriptions des anti-inflammatoires non stéroïdiens en Suisse?

Introduction :¦Les anti-inflammatoires non stéroïdiens (AINS) sont une classe de médicaments fréquemment utilisée. Bien qu'ils soient utiles pour leurs propriétés analgésiques, antipyrétiques et anti-inflammatoires, ils sont à l'origine d'effets indésirables nombreux et potentiellement graves. Neuf recommandations de bonne pratique ont été établies en France en 1994 dans le but de limiter les prescriptions inutiles ou dangereuses. Nous avons examiné ces recommandations, pour savoir si elles sont encore pertinentes, et avons évalué leur suivi en Suisse.¦Méthode :¦La population étudiée consiste en 53 891 patients de plus de 16 ans, suivis en 2005 et 2006, qui ont eu au moins une fois la délivrance d'un AINS (voie non locale).¦Résultats :¦60% des prescriptions d'AINS excèdent 14 jours de traitement standard et 25% des renouvellements de traitement surviennent avant le nombre de jours correspondant à une prescription journalière standard. 2,7% des prescriptions contiennent deux ou plus d'AINS. Un tiers des prescriptions d'AINS sont associées à un protecteur gastrique dans les 3 mois. Cette proportion augmente avec les facteurs de risque des complications gastro-intestinales : l'âge, la prescription d'autres médicaments gastro-toxiques et la dose d'AINS prescrite. Toutefois, moins d'un patient sur deux de plus de 70 ans bénéficie d'un protecteur gastrique. Une prescription d'AINS sur mille concerne une femme au 3ème trimestre de grossesse. La prescription concomitante d'un médicament susceptible d'augmenter la fréquence des événements indésirables des AINS est fréquente : 25% d'anticoagulant ou anti-thrombotique, 30,5% d'inhibiteur de l'enzyme de conversion, diurétique ou antagoniste des récepteurs à l'angiotensine II, et 5,3% de corticothérapie. Ces proportions augmentent avec l'âge. La plupart des taux définis ci-dessus varient en fonction du canton de résidence, après ajustement sur le sexe et l'âge.¦Conclusion:¦Nos résultats suggèrent qu'en Suisse, les AINS sont fréquemment prescrits à doses trop élevées ou pendant une trop longue durée et souvent associés à d'autres médicaments susceptibles d'augmenter le risque d'effets secondaires, et ce particulièrement chez les sujets les plus âgés. La fréquence de prescriptions chez les femmes au 3ème trimestre de grossesse est inférieure à celles publiées ailleurs. Il est probable que les protecteurs gastriques soient sous-utilisés chez les personnes âgées. Les variations inter-cantonales suggèrent que certaines pratiques pourraient être améliorées

Sexual dysfunctions among young men: prevalence and associated factors.

PURPOSE: The purposes of this study are to measure the prevalence of premature ejaculation (PE) and erectile dysfunction (ED) among a population of Swiss young men and to assess which factors are associated with these sexual dysfunctions in this age-group. METHODS: For each condition (PE and ED), we performed separate analyses comparing young men suffering from the condition with those who were not. Groups were compared for substance use (tobacco, alcohol, cannabis, other illegal drugs, and medication without a prescription), self-reported body mass index, sexual orientation, physical activity, professional activity, sexual experience (sexual life length and age at first intercourse), depression status, mental health, and physical health in a bivariate analysis. We then used a log-linear analysis to consider all significant variables simultaneously. RESULTS: Prevalence rates for PE and ED were 11% and 30%, respectively. Poor mental health was the only variable to have a direct association with both conditions after controlling for potential confounders. In addition, PE was directly associated with tobacco, illegal drugs, professional activity, and physical activity, whereas ED was directly linked with medication without a prescription, length of sexual life, and physical health. CONCLUSIONS: In Switzerland, one-third of young men suffer from at least one sexual dysfunction. Multiple health-compromising factors are associated with these dysfunctions. These should act as red flags for health professionals to encourage them to take any opportunity to talk about sexuality with their young male patients.

Jambes lourdes, insuffisance veineuse des membres inférieurs et hormonothérapie substitutive [Heavy legs, venous insufficiency of the legs and hormone substitution therapy]

The effects of estrogens and gestagens on veins and circulation have been studied since prescription of these hormones as oral contraception and description of related thromboembolic events. The identification of different receptors and the description of these receptors in venous walls have helped to understand some hormonal effects. However, the actual knowledge remains insufficient to explain the complexity of the actions of hormones on venous function. The distribution, the density and the receptor types vary with age, gender, hormonal status and vascular bed. Gestagens mainly reduce the tone of venous walls, whereas estrogens have various effects. Between 25% and 50% of European adults and even 80% or more in some risk groups complain about heavy legs, with or without chronic venous insufficiency. The number of women to whom hormonal substitution is or could be prescribed increases along with aging of populations and the better understanding of potential benefits. The need for a better understanding of vascular effects of sexual hormones is growing, since the incidence of chronic venous insufficiency of the legs increases with age. The life prognosis will not be affected by a deterioration of a chronic venous insufficiency. In contrast, the quality of life, morbidity and the cost of treatment will be expected to change. In addition, thromboembolic events have to be considered, as has been shown in recent studies. These findings outline the need for further studies on the relation between hormones and venous function and for some caution when prescribing hormonal substitution.

The interface between oral and systemic health: the need for more collaboration.

The focus of this review is to highlight the need for improved communication between medical and dental professionals in order to deliver more effective care to patients. The need for communication is increasingly required to capitalise on recent advances in the biological sciences and in medicine for the management of patients with chronic diseases. Improvements in longevity have resulted in populations with increasing special oral-care needs, including those who have cancer of the head and neck, those who are immunocompromised due to HIV/AIDS, advanced age, residence in long-term care facilities or the presence of life-long conditions, and those who are receiving long-term prescription medications for chronic conditions (e.g., anti-hypertensives, anticoagulants, immunosuppressants, antidepressants). These medications can cause adverse reactions in the oral cavity, such as xerostomia and ulceration. Patients with xerostomia are at increased risk of tooth decay, periodontal disease and infection. The ideal management of such individuals should involve the collaborative efforts of physicians, nurses, dentists and dental hygienists, thus optimising treatment and minimising secondary complications deriving from the oral cavity.