Physiopathologie et prévention des infections liées aux accès vasculaires [Pathophysiology and prevention of intravascular catheter-related infection]

Les infections liées aux accès vasculaires sont à l'origine d'une proportion importante des infections nosocomiales. Elles comprennent leur colonisation par des micro-organismes, les infections du site d'insertion et les bactériémies et fongémies qui leur sont associées ou attribuées. Une bactériémie complique l'insertion de 3 à 5 % des voies veineuses, correspondant à une incidence de 2 à 14 épisodes pour 1000 jourcathéters. Cette proportion ne représente toutefois que la partie visible de l'iceberg puisque la plupart des épisodes de sepsis clinique sans foyer infectieux associé sont également considérés comme liés aux accès vasculaires. Après un rappel de leur physiopathologie, cet article passe en revue les éléments importants pour leur prévention, y compris ceux concernant l'utilisation de cathéters imprégnés de désinfectants ou d'antibiotiques. Pour terminer, nous discutons en détail les stratégies préventives globales. Fondées sur la prise en compte d'un ensemble d'éléments spécifiques, ces approches sont centrées sur l'éducation du personnel au respect des règles d'hygiène de base et sur l'introduction de recommandations précises pour l'insertion et l'utilisation des accès vasculaires.

Prévention quaternaire: agir est-il toujours justifié en médecine de famille [Quaternary prevention: is acting always justified in family medicine?].

Quaternary prevention aims to protect the patient or population against overmedicalisation. Quaternary prevention influences all the activities of family medicine by questioning the utility of primary prevention and early diagnosis, identifying the risks of creating new pathological entities and practicing a maximalist medicine. Family doctors can support quaternary prevention by focusing on their patients' priorities and the local resources of an efficient health system.

Pédiatrie 4. Comment traiter la fièvre de l'enfant en 2013 avec un peu d'évidence [How to treat pediatric fever in 2013 with little evidence-based?].

Treatment of pediatric fever is based on two main molecules, paracetamol and ibuprofen. Fever should be treated when associated with discomfort. The two molecules have almost similar efficacy and safety. Monotherapy should be preferred to a combined or alternating treatment. Antipyretics do not seem to prevent febrile seizures.

Interpretation of primary care physicians' attitude regarding rotavirus immunisation using diffusion of innovation theories.

To evaluate primary care physicians' attitude towards implementation of rotavirus (RV) immunisation into the Swiss immunisation schedule, an eight-question internet-based questionnaire was sent to the 3799 subscribers of InfoVac, a nationwide web-based expert network on immunisation issues, which reaches >95% of paediatricians and smaller proportions of other primary care physicians. Five demographic variables were also inquired. Descriptive statistics and multivariate analyses for the main outcome "acceptance of routine RV immunisation" and other variables were performed. Diffusion of innovation theory was used for data assessment. Nine-hundred seventy-seven questionnaires were returned (26%). Fifty percent of participants were paediatricians. Routine RV immunisation was supported by 146 participants (15%; so called early adopters), dismissed by 620 (64%), leaving 211 (21%) undecided. However, when asked whether they would recommend RV vaccination to parents if it were officially recommended by the federal authorities and reimbursed, 467 (48.5%; so called early majority) agreed to recommend RV immunisation. Multivariate analysis revealed that physicians who would immunise their own child (OR: 5.1; 95% CI: 4.1-6.3), hospital-based physicians (OR: 1.6; 95% CI: 1.1-2.3) and physicians from the French (OR: 1.6; 95% CI: 1.2-2.3) and Italian speaking areas of Switzerland (OR: 2.5; 95% CI: 1.1-5.8) were more likely to support RV immunisation. Diffusion of innovation theory predicts a >80% implementation if approximately 50% of a given population support an innovation. Introduction of RV immunisation in Switzerland is likely to be successful, if (i) the federal authorities issue an official recommendation and (ii) costs are covered by basic health care insurance.

Fluoride supplements (tablets, drops, lozenges or chewing gums) for preventing dental caries in children.

BACKGROUND: Dietary fluoride supplements were first introduced to provide systemic fluoride in areas where water fluoridation is not available. Since 1990, the use of fluoride supplements in caries prevention has been re-evaluated in several countries. OBJECTIVES: To evaluate the efficacy of fluoride supplements for preventing dental caries in children. SEARCH METHODS: We searched the Cochrane Oral Health Group's Trials Register (to 12 October 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE via OVID (1950 to 12 October 2011), EMBASE via OVID (1980 to 12 October 2011), WHOLIS/PAHO/MEDCARIB/LILACS/BBO via BIREME (1982 to 12 October 2011), and Current Controlled Trials (to 12 October 2011). We handsearched reference lists of articles and contacted selected authors. SELECTION CRITERIA: We included randomised or quasi-randomised controlled trials comparing, with minimum follow-up of 2 years, fluoride supplements (tablets, drops, lozenges) with no fluoride supplement or with other preventive measures such as topical fluorides in children less than 16 years of age at the start. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces (DMFS). DATA COLLECTION AND ANALYSIS: Two review authors, independently and in duplicate, assessed the eligibility of studies for inclusion, and carried out risk of bias assessment and data extraction. In the event of disagreement, we sought consensus and consulted a third review author. We contacted trial authors for missing information. We used the prevented fraction (PF) as a metric for evaluating the efficacy of the intervention. The PF is defined as the mean caries increment in controls minus mean caries increment in the treated group divided by mean caries increment in controls. We conducted random-effects meta-analyses when data could be pooled. We assessed heterogeneity in the results of the studies by examining forest plots and by using formal tests for homogeneity. We recorded adverse effects (fluorosis) when the studies provided relevant data. MAIN RESULTS: We included 11 studies in the review involving 7196 children.In permanent teeth, when fluoride supplements were compared with no fluoride supplement (three studies), the use of fluoride supplements was associated with a 24% (95% confidence interval (CI) 16 to 33%) reduction in decayed, missing and filled surfaces (D(M)FS). The effect of fluoride supplements was unclear on deciduous or primary teeth. In one study, no caries-inhibiting effect was observed on deciduous teeth while in another study, the use of fluoride supplements was associated with a substantial reduction in caries increment.When fluoride supplements were compared with topical fluorides or with other preventive measures, there was no differential effect on permanent or deciduous teeth.The review found limited information on the adverse effects associated with the use of fluoride supplements. AUTHORS' CONCLUSIONS: This review suggests that the use of fluoride supplements is associated with a reduction in caries increment when compared with no fluoride supplement in permanent teeth. The effect of fluoride supplements was unclear on deciduous teeth. When compared with the administration of topical fluorides, no differential effect was observed. We rated 10 trials as being at unclear risk of bias and one at high risk of bias, and therefore the trials provide weak evidence about the efficacy of fluoride supplements.

Epidemiologie und Prävention des Hautmelanoms in der Schweiz: Update 2010. [Epidemiology and prevention of melanoma in Switzerland: 2010 update]

Zusammenfassung] Die Inzidenz des malignen Melanoms steigt seit über 50 Jahren bei der weißen Bevölkerung stark an. Die Schweiz ist mit ungefähr 1900 neu diagnostizierten Fällen pro Jahr das am stärksten betroffene Land Europas (16/100 000 Welt-standardisierte Rate). In letzter Zeit sind regionale Unterschiede mit höherer Inzidenz in den Westschweizer Kantonen festzustellen. Änderungen in Wissen und Verhalten der Schweizer Bevölkerung gegenüber dem Schutz vor Sonnenexposition bestehen noch zu wenig lange und sind zu bescheiden, als dass sie schon einen Einfluss auf die Inzidenz hätten haben können. Dank der seit 20 Jahren betriebenen Früherfassung sind Überlebensrate und Anteil an dünnen Melanomen gestiegen, allerdings bei gleichbleibender Inzidenz dicker Läsionen. Die Mortalität aufgrund des malignen Melanoms ist neuerdings rückläufig, vor allem bei den Frauen. Werden die gegenwärtigen Präventionsbemühungen weitergeführt, dürften sich bald noch mehr Erfolge zeigen. [Abstract] The incidence of cutaneous malignant melanoma has steadily increased in Caucasian populations over the last decades. With around 1900 new cases each year, Switzerland has one of the highest melanoma rates in Europe (16/100 000 world-standardised rate). Regional differences are emerging within Switzerland, with a higher incidence in the western (French-speaking) region. Observed changes in sun protection attitudes and knowledge in the Swiss population have yet no impact on the incidence trend. Early detection, carried out since the mid 1980s in Switzerland, has led to a substantial increase in survival and rates of thin melanoma, without material change in rates of thick melanoma. Mortality from melanoma has recently decreased, earlier in women than men. The efficacy of prevention campaigns should soon become more blatant if current efforts persist.

Blood pressure and LDL-cholesterol targets for prevention of recurrent strokes and cognitive decline in the hypertensive patient: design of the European Society of Hypertension-Chinese Hypertension League Stroke in Hypertension Optimal Treatment randomized trial.

BACKGROUND AND OBJECTIVES: The SBP values to be achieved by antihypertensive therapy in order to maximize reduction of cardiovascular outcomes are unknown; neither is it clear whether in patients with a previous cardiovascular event, the optimal values are lower than in the low-to-moderate risk hypertensive patients, or a more cautious blood pressure (BP) reduction should be obtained. Because of the uncertainty whether 'the lower the better' or the 'J-curve' hypothesis is correct, the European Society of Hypertension and the Chinese Hypertension League have promoted a randomized trial comparing antihypertensive treatment strategies aiming at three different SBP targets in hypertensive patients with a recent stroke or transient ischaemic attack. As the optimal level of low-density lipoprotein cholesterol (LDL-C) level is also unknown in these patients, LDL-C-lowering has been included in the design. PROTOCOL DESIGN: The European Society of Hypertension-Chinese Hypertension League Stroke in Hypertension Optimal Treatment trial is a prospective multinational, randomized trial with a 3 × 2 factorial design comparing: three different SBP targets (1, <145-135; 2, <135-125; 3, <125 mmHg); two different LDL-C targets (target A, 2.8-1.8; target B, <1.8 mmol/l). The trial is to be conducted on 7500 patients aged at least 65 years (2500 in Europe, 5000 in China) with hypertension and a stroke or transient ischaemic attack 1-6 months before randomization. Antihypertensive and statin treatments will be initiated or modified using suitable registered agents chosen by the investigators, in order to maintain patients within the randomized SBP and LDL-C windows. All patients will be followed up every 3 months for BP and every 6 months for LDL-C. Ambulatory BP will be measured yearly. OUTCOMES: Primary outcome is time to stroke (fatal and non-fatal). Important secondary outcomes are: time to first major cardiovascular event; cognitive decline (Montreal Cognitive Assessment) and dementia. All major outcomes will be adjudicated by committees blind to randomized allocation. A Data and Safety Monitoring Board has open access to data and can recommend trial interruption for safety. SAMPLE SIZE CALCULATION: It has been calculated that 925 patients would reach the primary outcome after a mean 4-year follow-up, and this should provide at least 80% power to detect a 25% stroke difference between SBP targets and a 20% difference between LDL-C targets.

A systems perspective on the integrative child psychiatry approach. Discussion of paper: "Working here and now with the individual and family system: A case of a traumatized child"

In this discussion, after a few general comments, I will propose a systems reading of the intervention so elegantly described by Kaija Puura. I will draw parallels between the therapeutic and the family groups as framing-developing systems and formalize the steps taken by the family toward healing under the influence of the therapist's team. En esta discusión, después de algunos comentarios generales, propongo una lectura sistemática de la intervención tan elegantemente descrita por Kaija Puura. Buscaré paralelos entre los grupos terapéuticos y de familia como sistemas de desarrollo enmarcado y formalizaré los pasos tomados por la familia hacia la cicatrización bajo la influencia del equipo del terapista. Après quelques commentaires généraux, je proposerai dans cette discussion une lecture systémique de l'intervention si élégamment décrite par Kaija Puura. J'établirai des parallèles entre les groupes thérapeutiques et familiaux en tant que systèmes d'encadrement-développement et je formaliserai les étapes de guérison franchies par la famille grâce à l'influence de l'équipe thérapeutique. In dieser Diskussion, werde ich nach einigen allgemeineren Aussagen, eine systemische Lesart der von Kaija Puura so eingängig beschriebenen Intervention vorschlagen. Ich werde darin Parallelen zwischen der therapeutischen und Rahmengebenden Familiengruppen ziehen, und die Schritte der Familien hin zu einer Heilung unter dem Einfluss des Therapeutenteams formalisieren.

Does this child have a foreign body aspiration?

Context: Foreign body aspiration (FbA) is a serious problem in children. Accurate clinical and radiographic diagnosis is important because missed or delayed diagnosis can result in respiratory difficulties ranging from life-treatening airway obstruction to chronic wheezing or recurrent pneumonia. Bronchoscopy also has risks and accurate clinical and radiographc diagnosis can support the decision of bronchoscopy. Objective: To rewiev the diagnostic accuracy of clinical presentation (CP) and pulmonary radiograph (PR) for the diagnosis of FbA. There is no previous rewievMethods: A search of Medline is conducted for articles containing data regarding CP and PR signes of FbA. Calculation of likelihood ratios (LR) and pre and post test probability using Bayes theorem were performed for all signs of CP and PR. Inclusion criteria: Articles containing prospective data regarding CP and PR of FbA. Exclusion criteria: Retrospectives studies. Articles containing incomplete data for calculation of LR. Results: Five prospectives studies are included with a total of 585 patients. Prevalence of FbA is 63% in children suspected of FbA. If CP is normal, probability of FbA is 25% and if PR is normal, probability is 14%. If CP is pathologic, probability of FbA is 69-76% with presence of cough (LR = 1.32) or dyspnea (LR = 1.84) or localized crackles (LR = 1.5). Probability is 81-88% if cyanosis (LR = 4.8) or decreased breaths sounds (LR = 4.3) or asymetric auscultation (LR = 2.9) or localized wheezing (LR = 2.5) are present. When CP is anormal and PR show mediatinal shift (LR = 100), pneumomediatin (LR = 100), radio opaque foreign body (LR = 100), lobar distention (LR = 4), atelectasis (LR = 2.5), inspiratory/expiratory abnormal (LR = 7), the probability of FbA is 96-100%. If CP is normal and PR is abnormal the probability is 40-100%. If CP is abnormal and PR is normal the probability is 55-75%. Conclusions: This rewiev of prospective studies demonstrates the importance of CP and PR and an algorithm can be proposed. When CP is abnormal with or without PR pathologic, the probability of FbA is high and bronchoscopy is indicated. When CP and PR are normal the probability of FbA is low and bronchoscopy is not necessary immediatly, observation should be proposed. This approach should be validated with prospective study.

Obesity in Switzerland: a critical assessment of prevalence in children and adults.

The objective was to analyze the situation in Switzerland regarding the prevalence of overweight or obesity in children, adolescents and adults. The data were compared with France, an adjacent much larger country. The results showed that there is a definitive lack of objective information in Switzerland on the prevalence of obesity at different ages. As in other European studies, the fact that many national surveys are classically based on subject interviews (self-reported weights and heights rather than measured values) implies that the overweight/obesity prevalence is largely underestimated in adulthood. For example, in a recent Swiss epidemiological study, the prevalence of obesity (BMI greater than 30 kg/m(2)) averaged 6-7% in young men and women (25-34 y), the prevalence being underestimated by a factor of two to three when body weight was self-reported rather than measured. This phenomenon has already been observed in previous European studies. It is concluded that National Surveys based on telephone interviews generally produce biased obesity prevalence results, although the direction of the changes in prevalence of obesity and its evolution with repeated surveys using strict standardized methodology may be evaluated correctly. Therefore, these surveys should be complemented by large-scale epidemiological studies (based on measured anthropomeric variables rather than declared) covering the different linguistic areas of Switzerland. An epidemiological body weight (BMI) monitoring surveillance system, using a harmonized methodology among European countries, would help to accurately assess differences in obesity prevalence across Europe without methodological bias. It will permit monitoring of the dynamic evolution of obesity prevalence as well as the development of appropriate strategies (taking into account the specificity of each country) for obesity prevention and treatment.