Adult native septic arthritis: a review of 10 years of experience and lessons for empirical antibiotic therapy.

Objectives To review the epidemiology of native septic arthritis to establish local guidelines for empirical antibiotic therapy as part of an antibiotic stewardship programme. Methods We conducted a 10 year retrospective study based on positive synovial fluid cultures and discharge diagnosis of septic arthritis in adult patients. Microbiology results and medical records were reviewed. Results Between 1999 and 2008, we identified 233 episodes of septic arthritis. The predominant causative pathogens were methicillin-susceptible Staphylococcus aureus (MSSA) and streptococci (respectively, 44.6% and 14.2% of cases). Only 11 cases (4.7%) of methicillin-resistant S. aureus (MRSA) arthritis were diagnosed, among which 5 (45.5%) occurred in known carriers. For large-joint infections, amoxicillin/clavulanate or cefuroxime would have been appropriate in 84.5% of cases. MRSA and Mycobacterium tuberculosis would have been the most frequent pathogens that would not have been covered. In contrast, amoxicillin/clavulanate would have been appropriate for only 75.3% of small-joint infections (82.6% if diabetics are excluded). MRSA and Pseudomonas aeruginosa would have been the main pathogens not covered. Piperacillin/tazobactam would have been appropriate in 93.8% of cases (P < 0.01 versus amoxicillin/clavulanate). This statistically significant advantage is lost after exclusion of diabetics (P = 0.19). Conclusions Amoxicillin/clavulanate or cefuroxime would be adequate for empirical coverage of large-joint septic arthritis in our area. A broad-spectrum antibiotic would be significantly superior for small-joint infections in diabetics. Systematic coverage of MRSA is not justified, but should be considered for known carriers. These recommendations are applicable to our local setting. They might also apply to hospitals sharing the same epidemiology.

Interventions hybrides et malformations cardiaques congénitales [Hybrid procedures in congenital heart disease]

La complexité croissante de la prise en charge des malformations cardiaques congénitales impose des interventions chirurgicales et des cathétérismes cardiaques interventionnels fréquents. Chacune de ces techniques a ces limitations propres. Les interventions hybrides associent les avantages de la chirurgie cardiaque et du cathétérisme interventionnel. Dans notre expérience, les thérapies hybrides permettent de diminuer le temps de circulation extracorporelle, de diminuer la morbidité des interventions chirurgicales, de raccourcir le séjour du patient aux soins intensifs. Pour certaines malformations cardiaques congénitales complexes pour lesquelles il n'existe pas de chirurgie ou de thérapie interventionnelle idéale, les interventions hybrides sont en train de s'imposer comme la prise en charge incontournable. Increasing complexity in management of congenital heart disease imposes more frequent surgeries and interventions. Each technique has its own limitations, which could impair the anticipated result. Hybrid procedures join the advantages of cardiac surgery and interventions, creating a synergy in the management of these patients with cardiac anomalies. In our experience, hybrid procedures shorten cardiopulmonary bypass, reduce morbidity of surgery and reduce duration of stay in the intensive care unit. For some complex congenital heart diseases for which there are no ideal surgical or interventional options, hybrid procedures are becoming increasingly important in their management. Finally hybrid procedures allow surgeons and cardiologist to achieve complex procedures that could not be possible in another way

An international registry on autoinflammatory diseases: the Eurofever experience.

OBJECTIVE: To report on the demographic data from the first 18 months of enrollment to an international registry on autoinflammatory diseases in the context of the Eurofever project. METHODS: A web-based registry collecting baseline and clinical information on autoinflammatory diseases and related conditions is available in the member area of the PRINTO web-site. Anonymised data were collected with standardised forms. RESULTS: 1880 (M:F=916:964) individuals from 67 centers in 31 countries have been entered in the Eurofever registry. Most of the patients (1388; 74%), reside in western Europe, 294 (16%) in the eastern and southern Mediterranean region (Turkey, Israel, North Africa), 106 (6%) in eastern Europe, 54 in Asia, 27 in South America and 11 in Australia. In total 1049 patients with a clinical diagnosis of a monogenic autoinflammatory diseases have been enrolled; genetic analysis was performed in 993 patients (95%): 703 patients have genetically confirmed disease and 197 patients are heterozygous carriers of mutations in genes that are mutated in patients with recessively inherited autoinflammatory diseases. The median diagnosis delay was 7.3 years (range 0.3-76), with a clear reduction in patients born after the identification of the first gene associated with autoinflammatory diseases in 1997. CONCLUSIONS: A shared online registry for patients with autoinflammatory diseases is available and enrollment is ongoing. Currently, there are data available for analysis on clinical presentation, disease course, and response to treatment, and to perform large scale comparative studies between different conditions.

Mothers' experience of their contact with their stillborn infant: an interpretative phenomenological analysis.

BACKGROUND: Guidelines surrounding maternal contact with the stillborn infant have been contradictory over the past thirty years. Most studies have reported that seeing and holding the stillborn baby is associated with fewer anxiety and depressive symptoms among mothers of stillborn babies than not doing so. In contrast, others studies suggest that contact with the stillborn infant can lead to poorer maternal mental health outcomes. There is a lack of research focusing on the maternal experience of this contact. The present study aimed to investigate how mothers describe their experience of spending time with their stillborn baby and how they felt retrospectively about the decision they made to see and hold their baby or not. METHOD: In depth interviews were conducted with twenty-one mothers three months after stillbirth. All mothers had decided to see and the majority to hold their baby. Qualitative analysis of the interview data was performed using Interpretive Phenomenological Analysis. RESULTS: Six superordinate themes were identified: Characteristics of Contact, Physicality; Emotional Experience; Surreal Experience; Finality; and Decision. Having contact with their stillborn infant provided mothers with time to process what had happened, to build memories, and to 'say goodbye', often sharing the experience with partners and other family members. The majority of mothers felt satisfied with their decision to spend time with their stillborn baby. Several mothers talked about their fear of seeing a damaged or dead body. Some mothers experienced strong disbelief and dissociation during the contact. CONCLUSIONS: Results indicate that preparation before contact with the baby, professional support during the contact, and professional follow-up are crucial in order to prevent the development of maternal mental health problems. Fears of seeing a damaged or dead body should be sensitively explored and ways of coping discussed. Even in cases where mothers experienced intense distress during the contact with their stillborn baby, they still described that having had this contact was important and that they had taken the right decision. This indicates a need for giving parents an informed choice by engaging in discussions about the possible benefits and risks of seeing their stillborn baby.

Initial experience with hybrid surgery in congenital heart disease in a single center : P171

Introduction: A hybrid intervention is a joint procedure involving the interventional cardiologist and the cardiac surgeon. At our institution we have opted for this type of approach in congenital heart disease since 2005. We report here our initial experience. Cases: 1. A 3 year old boy with double aortic arch and multiple muscular ventricular septal defects (VSD),was readdressed for pulmonary band (PAB) removal and residual VSD closure after previous palliation. After surgical removal of the PAB, the surgeon provided a minimal transventricular access for placement of a 6mm Amplatzer® muscular VSD occluder by the cardiologist under transoesophageal guidance. The patient was extubated the same day and discharged after 5 days. 2. An 8 year old girl with Williams syndrome was followed for two large VSDs and severe peripheral pulmonary arteries (PA) stenosis. The membranous VSD was closed surgically, the muscular VSD during the same operation by direct placement of a 12 mm Amplatzer® muscular VSD occluder. During rewarming, balloon angioplasty of peripheral PA stenosis was achieved under fluoroscopy. Patient was extubated the following day and discharged after 8 days. 3. A 9 year old boy post tetralogy of Fallot repair had severe distal stenosis of the right ventricular to PA conduit.With patient on partial cardiopulmonary bypass, an incision was made on the conduit and a CP 8 Zig 16 stent placed on the stenosis. The child passed on full bypass and the definitive placement of the stent achieved. The child was extubated at the end of the intervention and discharged after 6 days. 4. A newborn presented at 2 days life with complex aortic arch anatomy: left aortic arch and right descending thoracic aorta perfused directly from a right arterial duct and left PA atresia. The arterial duct was stented with a Genesis XD stent dilated at 7mm. Two days later the cardiac surgeon made banded the right PA. The child was extubated after the operation and discharged a week later. Conclusion: Hybrid approach opens new ways of correction or palliation in congenital heart disease with encouraging results and less morbidity.

Endovascular treatment of symptomatic intracranial arterial stenosis: six-year experience in a single-center series of 42 consecutive patients with acute and mid-term results.

BACKGROUND: The limitations of the medical management of symptomatic intracranial arterial stenosis encourage the development of new therapeutic strategies such as intracranial stenting. OBJECTIVE: To report and analyze the results of a series of 42 patients treated with 3 different endovascular techniques: isolated angioplasty, balloon-expandable coronary stents, and the Wingspan self-expandable intracranial stent system. METHODS: Forty-two patients presenting with symptomatic intracranial arterial stenosis were treated with one of these techniques. Computed tomography angiography was performed 6 months after the procedure, and the clinical neurological statuses were categorized using the modified Rankin Scale and the National Institutes of Health Stroke Scale. RESULTS: A total of 42 lesions were treated: 9 with isolated angioplasty, 14 with balloon-expandable coronary stents, and 19 with Wingspan self-expandable intracranial stents. The mean patient age was 62.9 years, and the mean arterial diameter stenosis was 73.9%. Technical success was achieved in 97.6% of the patients. The overall incidence of procedural complications was 21.4%, and the postoperative permanent morbidity/mortality rate was 7.1%. There were 3 cases of in-stent thrombosis (1 fatal) and 5 cases of asymptomatic restenosis (11.9%), 3 in the isolated angioplasty group and 2 in the Wingspan self-expandable intracranial stent group (mean follow-up 20.4 months). The rate of restenosis was higher in the angioplasty group (33%) than in the coronary (0%) and Wingspan stent (10.5%) groups. CONCLUSION: Endovascular treatment of symptomatic intracranial stenosis has significant overall morbidity and mortality rates. Nevertheless, the very critical natural history of severe refractory lesions and the relatively favorable postoperative evolution suggest that it should be considered the first alternative strategy in cases in which medical therapy has failed.

From dialysis to transplantation, illness experience and patients' concerns about future: A longitudinal qualitative study

Background: Transplantation is the treatment of choice when compared to dialysis. Long-term evolution of patients is rarely comprehensively described. Thirty end-stage renal disease patient's experience of illness was explored from registration for transplantation until twenty-four months after transplantation. Methods: Longitudinal semi-structured interviews were conducted, and qualitative discourse analysis performed. Findings: Before transplantation loss of quality of life (QOL), emotional fragility related to dialysis constraints were reported, and increased with waiting-time. Six months after transplantation, recovered freedom was described but acute rejection, and life-dependency to immunosuppressants generated concerns. After twelve months, long-term survival of the graft, and possible return-to-dialysis were mentioned. After twenty months graft's dysfunction, co-morbidities, immunosuppressants side effects rose concerns even though QOL persisted. Most patients report positive transformations after transplantation, which are related to graft survival and limited co-morbidities. Discussion: As time passes, patients deal with changing illness constraints, and contemplate with anxiety possible new return to dialysis and/or transplantation.

Stage fright: its experience as a problem and coping with it.

PURPOSE AND METHOD: This questionnaire survey of 190 university music students assessed negative feelings of music performance anxiety (MPA) before performing, the experience of stage fright as a problem, and how closely they are associated with each other. The study further investigated whether the experience of stage fright as a problem and negative feelings of MPA predict the coping behavior of the music students. Rarely addressed coping issues were assessed, i.e., self-perceived effectiveness of different coping strategies, knowledge of possible risks and acceptance of substance-based coping strategies, and need for more support.RESULTS: The results show that one-third of the students experienced stage fright as a problem and that this was only moderately correlated with negative feelings of MPA. The experience of stage fright as a problem significantly predicted the frequency of use and the acceptance of medication as a coping strategy. Breathing exercises and self-control techniques were rated as effective as medication. Finally, students expressed a strong need to receive more support (65%) and more information (84%) concerning stage fright.CONCLUSION: Stage fright was experienced as a problem and perceived as having negative career consequences by a considerable percentage of the surveyed students. In addition to a desire for more help and support, the students expressed an openness and willingness to seriously discuss and address the topic of stage fright. This provides a necessary and promising basis for optimal career preparation and, hence, an opportunity to prevent occupational problems in professional musicians. [Authors]

Transsexualisme: enjeux et spécificités liés à la prise en charge d'une demande de réassignation sexuelle [Gender identity disorder: challenges and specificity in the treatment of requests for sexual reassignment].

Gender identity disorder is defined as a permanent desire to relieve one's own sexual features to acquire the sexual features and line to life of the opposite sex. The diagnosis is based on the psychiatric evaluation and treatment on an interdisciplinary approach by endocrinologists, surgeons and psychiatrists, and can be conceptualized into distinct phases: diagnostic evaluation, real life experience, hormonal treatment and surgery. Multiples challenges have to be faced, especially by the psychiatrist who follows the patient during the whole process.

Structured running program for health and performance promotion in hospital employees.

Introduction Our institution (University hospital) is encouraging physical activities for health through various popular sporting events in the city of Lausanne, the biggest of which is a road race of 2, 4, 10 and 20km. Objective To create an efficient and sustainable training program in preparation of the race for a group of motivated hospital employees without any prior experience with structured training and to identifying the benefits and limitations encountered.. Methods Subjects of various fitness levels were recruited by add and agreed to undergo lab and field testing before a 12-week 3 times/week running program, based on maximal aerobic speed (MAS-30/30 sec intervals), running technique exercises and endurance training. The interval session was the only one supervised. Their goal was the 10km (11 subjects) and the 20km (6 subjects). Results A group of 17 subjects (7 male and 10 female), mean age 36.6±7.3 years, VO2max 44.0±5.5 ml/kg/min, filed test interval MAS 15.1±2.4 km/h started the program. 2 were lost because of injury (while skiing). Adherence to interval sessions was excellent, although 3 weekly training sessions proved to be difficult for most of the subjects. Performance in the race was satisfying for all of them, 6/7 subjects having improved their running time from the previous year, the others participated for the first time and 7/8 completed the race satisfyingly, one DNF-ed because of sinusitis. Repeat MAS field test was available for 6 subjects, who improved by 5.9% (p<0.01). Subjectively, all of the participants were very satisfied with improvement, interaction with colleagues from various professions, and with self achievement and confidence. Conclusions Implementation of a structured training program for recreational or non-athletes can be very successful in creating a better self-confidence, a better working environment inside a hospital facility and obviously in improvement of physical fitness and athletic performance. Above all, it can only encourage health institutions to promote the health of their own employees through physical activity, which can allow people to connect through sports. As a result, subjects in this study tend to encourage other employees to be more active and are hungry for more advice and continued offers for physical activities benefiting both them and the institution through better efficiency at work and less absenteeism common to more active people.

Variation in performance in low-volume mammography screening programmes: experience from Switzerland.

BACKGROUND: Reading volume and mammography screening performance appear positively correlated. Quality and effectiveness were compared across low-volume screening programmes targeting relatively small populations and operating under the same decentralised healthcare system. Except for accreditation of 2nd readers (restrictive vs non-restrictive strategy), these organised programmes had similar screening regimen/procedures and duration, which maximises comparability. Variation in performance and its determinants were explored in order to improve mammography practice and optimise screening performance. METHODS: Circa 200,000 screens performed between 1999 and 2006 (4 rounds) in 3 longest standing Swiss cantonal programmes (of Vaud, Geneva and Valais) were assessed. Indicators of quality and effectiveness were assessed according to European standards. Interval cancers were identified through linkage with cancer registries records. RESULTS: Swiss programmes met most European standards of performance with a substantial, favourable cancer stage shift. Up to a two-fold variation occurred for several performance indicators. In subsequent rounds, compared with programmes (Vaud and Geneva) that applied a restrictive selection strategy for 2nd readers, proportions of in situ lesions and of small cancers (≤1cm) were one third lower and halved, respectively, and the proportion of advanced lesions (stage II+) nearly 50% higher in the programme without a restrictive selection strategy. Discrepancy in second-year proportional incidence of interval cancers appears to be multicausal. CONCLUSION: Differences in performance could partly be explained by a selective strategy for second readers and a prior experience in service screening, but not by the levels of opportunistic screening and programme attendance. This study provides clues for enhancing mammography screening performance in low-volume programmes.

Endoscopic repair of laryngotracheoesophageal clefts: experience in 17 cases.

OBJECTIVE: To review the presentation and evaluation of laryngotracheoesophageal clefts as well as their treatment modalities, especially endoscopic closure. STUDY DESIGN: retrospective case series. METHODS: All patients treated for laryngotracheoesophageal clefts in our clinic during the last 15 years were included. Analysis of preoperative data, surgical success and functional outcome was performed. RESULTS: A total of 18 patients were included in our study. Cleft distribution was: type I (n=1), type II (n=3), type IIIa (n=5), type IIIb (n=8) and type IVa (n=1). All clefts were closed endoscopically by CO2 laser repair except for two patients who benfited from open surgery (one type I, one type IIIb). 7 of our 18 patients (39%) experienced a complication necessitating reoperation. Surgical treatment of LTEC allowed cessation of feeding tube assistance and artificial ventilation in 47% and 42% of patients respectively. CONCLUSION: Surgical treatement of laryngotracheoesophageal clefts remains a complex procedure with a high rate of morbidity for high grade clefts. Post-surgical difficulties in feeding and breathing are associated with concomitant congenital anomalies. Endoscopic repair is a successful technique for treating up to grade IIIa laryngeal clefts. Further investigation is needed to assess the best approach for treating longer clefts.