Quelle perception ont les médecins de famille en Suisse de leur rôle dans la prévention et la promotion de la santé? : comprendre les barrières à l'implémentation

Introduction: The importance of health promotion and prevention and the potential of general practitioners (GPs) to conduct individual prevention procedures have been demonstrated in several studies. Clinical recommendations for screening and prevention activities, an important condition for success, are published regularly, but their implementation into daily practice does not necessarily follow. Information is lacking about the actual conditions of how prevention is carried out on a daily basis by Swiss GPs, about their perceptions and needs, their attitudes and the present barriers they face. Such information is essential for the development of new tools and programs targeting better implementation of clinical recommendations for prevention in primary care in Switzerland. Objectives: The objectives of the study were to analyze how Swiss GPs perceive their role in prevention by obtaining information regarding the following issues: What do disease prevention and health promotion mean to them? What are the current incentives and barriers they face? What are their ideas and suggestions to deal with these barriers? What are their needs and expectations regarding prevention guidelines and tools? Methods: We conducted a qualitative research project using focus groups to examine the questions mentioned above. A total of 13 focus groups took place including GPs from eight cantons: five groups in German- speaking Switzerland and eight in French- speaking Switzerland. Each group was composed of 4-11 GPs, making in total 102 participants, who were paid expenses to cover their participation. The sessions were audio-recorded and transcribed verbatim. Data analysis: Content analysis of the transcriptions began by classifying the data according to a typology, the first level of which was developed in line with the structure of the interview guide. This typology was extended by successively regrouping similar statements. Synopsis and interpretation was then performed on each category thus obtained. This research report is based on the results from the French-speaking cantons. Results: Physicians perceive a change in their role as a consequence of changes in society and the health system. They emphasize the importance of a personalized and long lasting relationship between the family doctor and his/her patient; a privileged position allowing them to perform individualized prevention activities, considered to be more effective, as they are appropriate to the specific situation and needs of the patient. They point out their need for training and for better information concerning prevention and health promotion interventions, and stress difficulties arising from the lack of a clear political signal conferring them with a mandate for prevention. -- INTRODUCTION L'importance de la prévention et de la promotion de la santé et le potentiel des médecins de famillea à mettre en oeuvre des mesures individuelles de prévention, de dépistage et de conseils, a été démontrée dans plusieurs études. Régulièrement durant les dernières années, de nombreuses associations médicales ont publié des recommandations cliniques concernant les activités de dépistage et de prévention qui sont une condition essentielle pour le succès, mais ne sont pas forcément appliquées de manière systématique dans la pratique médicale quotidienne. Des contraintes spécifiques contribuent à l'écart entre le désir des médecins de pratiquer une médecine préventive et la réalité d'un cabinet médical. Nous n'avons que peu de données sur les conditions actuelles dans lesquelles la prévention et la promotion de la santé sont réalisées par les médecins de famille suisses dans leur travail quotidien. Des informations précises et représentatives sur leurs perceptions et leurs besoins, leurs attitudes et les contraintes auxquelles ils sont confrontés manquent. Or ces données sont essentielles dans le développement de nouveaux outils et programmes visant une meilleure implémentation des recommandations cliniques dans le domaine de la prévention et la promotion de la santé dans la médecine de famille en Suisse. OBJECTIFS Le développement de concepts pour une prévention systématique ainsi que d'outils adéquats, tout comme l'amélioration des conditions qui permettent une implémentation à grande échelle, implique, avant tout, l'analyse de la perception que les médecins de famille suisses ont de leur rôle dans la prévention. Par conséquent, cette étude a eu pour objectif d'obtenir des informations concernant les questions suivantes : ? Que signifient la prévention et la promotion de la santé pour les médecins de famille suisses ? ? Quelles sont leurs incitations et les barrières rencontrées ? ? Quelles sont leurs idées et leurs suggestions pour faire face à ces contraintes ? ? Quels sont leurs besoins et leurs attentes concernant les outils pour la prévention ? METHODES Nous avons mené un projet de recherche qualitative en utilisant la technique des focus groups pour examiner les questions mentionnées ci-dessus. Une telle technique de collecte de données est particulièrement adaptée à un domaine où l'on connaît mal les perceptions des parties prenantes. Nous avons mené 13 focus groups au total, comprenant des médecins issus de huit cantons: cinq groupes ont eu lieu en Suisse alémanique et huit groupes en Suisse romande. Chaque groupe était composé de 4 à 11 médecins de famille, avec au total 102 participants qui ont été défrayés pour leur participation. Les séances ont été audio-enregistrées et transcrites. ANALYSE DES DONNEES L'analyse du contenu des transcriptions a commencé par la classification des données selon une typologie dont le premier niveau a été développé à partir de la structure de la grille d'entretiens. Cette typologie a été affinée et élargie en regroupant successivement des propos similaires. Une synthèse a été effectuée pour chaque catégorie. Ce rapport est basé sur les résultats de l'analyse des données des cantons francophones. RESULTATS Les médecins perçoivent un changement de leur rôle dans une société et dans un système de santé qui évoluent. Ils soulignent l'importance de la relation personnalisée et durable du médecin de famille avec son patient, atout précieux, qui leur permet de réaliser des activités de prévention individualisées et adaptées à la situation et aux besoins du patient, considérées plus efficaces. Afin de surmonter leur doutes et découragement par rapport aux interventions de prévention, ils pointent la nécessité d'une formation aux nouvelles connaissances en prévention et promotion de la santé et d'une meilleure information aux médecins quant à leur efficacité et importance. Ils montrent le besoin d'un signal clair des politiques par rapport à l'attribution de ce mandat aux médecins de famille et de leur reconnaissance en tant qu'acteur de prévention dans le système de santé.

Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway.

OBJECTIVE: To compare epidural analgesia (EDA) to patient-controlled opioid-based analgesia (PCA) in patients undergoing laparoscopic colorectal surgery. BACKGROUND: EDA is mainstay of multimodal pain management within enhanced recovery pathways [enhanced recovery after surgery (ERAS)]. For laparoscopic colorectal resections, the benefit of epidurals remains debated. Some consider EDA as useful, whereas others perceive epidurals as unnecessary or even deleterious. METHODS: A total of 128 patients undergoing elective laparoscopic colorectal resections were enrolled in a randomized clinical trial comparing EDA versus PCA. Primary end point was medical recovery. Overall complications, hospital stay, perioperative vasopressor requirements, and postoperative pain scores were secondary outcome measures. Analysis was performed according to the intention-to-treat principle. RESULTS: Final analysis included 65 EDA patients and 57 PCA patients. Both groups were similar regarding baseline characteristics. Medical recovery required a median of 5 days (interquartile range [IQR], 3-7.5 days) in EDA patients and 4 days (IQR, 3-6 days) in the PCA group (P = 0.082). PCA patients had significantly less overall complications [19 (33%) vs 35 (54%); P = 0.029] but a similar hospital stay [5 days (IQR, 4-8 days) vs 7 days (IQR, 4.5-12 days); P = 0.434]. Significantly more EDA patients needed vasopressor treatment perioperatively (90% vs 74%, P = 0.018), the day of surgery (27% vs 4%, P < 0.001), and on postoperative day 1 (29% vs 4%, P < 0.001), whereas no difference in postoperative pain scores was noted. CONCLUSIONS: Epidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits. EDA can therefore not be recommended as part of ERAS pathways in laparoscopic colorectal surgery.

Associations of baroreflex sensitivity, heart rate variability, and initial orthostatic hypotension with prenatal and recent postnatal methylmercury exposure in the Seychelles Child Development Study at age 19 years.

BACKGROUND: A few studies have suggested an association between prenatal exposure to methylmercury and decreased heart rate variability (HRV) related to autonomic heart function, but no study has examined this association using baroreflex sensitivity (BRS). In this study we assessed the distribution of BRS and immediate orthostatic hypotension (IOH) in young Seychellois adults and their associations with exposure to prenatal and recent postnatal methylmercury. METHODS: Subjects in the Seychelles Child Development Study (SCDS) main cohort were evaluated at age 19 years. Non-invasive beat-to-beat blood pressure (BP) monitoring (Finapres, Ohmeda) was performed at rest and during active standing in 95 consecutive subjects. Recent postnatal mercury exposure was measured in subjects' hair at the age of 19 years and prenatal exposure in maternal hair grown during pregnancy. BRS was estimated by sequence analysis to identify spontaneous ascending and descending BP ramps. HRV was estimated by the following markers: PNN50 (relative numbers of normal-to-normal intervals which are shorter by more than 50 ms than the immediately following normal-to-normal intervals); rMSSD (root mean of the squared sum of successive interval differences); LF/HF (low frequency/high frequency component ratio); ratio of the mean expiratory/inspiratory RR intervals (EI ratio); and the ratio between the longest RR interval 30 s after active standing and the shortest RR interval at 15 s (Max30/Min15). IOH was estimated by the deepest BP fall within the first 15 s after active standing up. RESULTS: Prenatal MeHg exposures were similar in boys and girls (6.7±4.3, 6.7±3.8 ng/g) but recent postnatal mercury levels were higher in males than females (11.2±5.8 vs 7.9±4.3 ng/g, p=0.003). Markers of autonomic heart rate control were within the normal range (BRS: 24.8±7 ms/mm Hg, PNN50: 24.9±6.8%, rMSSD: 68±22, LF/HF: 0.61±0.28) in both sexes. After standing, 51.4% of subjects had a transient systolic BP drop>40 mm Hg, but only 5.3% reported dizziness or had syncope. Prenatal and recent postnatal MeHg levels, overall, were not associated with BRS, E/I ratio, PNN50, rMSSD, LF/HF ratio, Max30/Min15 ratio, and IOH. CONCLUSIONS: This study provides no support for the hypothesis that prenatal or recent postnatal MeHg exposure from fish consumption is associated with impaired autonomic heart rate control.

Rétablissement postopératoire optimisé, applique aux patients après cystectomie [Enhanced recovery after surgery applied to cystectomy patients].

Enhanced Recovery After Surgery (ERAS) is a multimodal concept combining pre, intra and postoperative evidence-based care elements to reduce surgical stress. ERAS pathways have been shown to significantly reduce morbidity, length of hospital stay and total costs when applied to colorectal surgery. It is therefore considered standard of care in this specialty. There can be no doubt that ERAS principles can be applied also in other major surgeries. However, uncritical application of the guidelines issued from colonic procedures seems inappropriate as the surgical procedures in pelvic cancer surgery differ considerably. This article reports on the first steps of an ERAS project and his introduction in urology.

Réhabilitation améliorée après chirurgie--L'ere de la prise en charge optimale du patient chirurgical [Enhanced Recovery After Surgery--optimal management of the surgical patient].

Enhanced Recovery After Surgery (ERAS) is a multimodal, standardized and evidence-based perioperative care pathway. With ERAS, postoperative complications are significantly lowered, and, as a secondary effect, length of hospital stay and health cost are reduced. The patient recovers better and faster allowing to reduce in addition the workload of healthcare providers. Despite the hospital discharge occurs sooner, there is no increased charge of the outpatient care. ERAS can be safely applied to any patient by a tailored approach. The general practitioner plays an essential role in ERAS by assuring the continuity of the information and the follow-up of the patient.

Meckel-Gruber Syndrome: a population-based study on prevalence, prenatal diagnosis, clinical features, and survival in Europe.

Meckel-Gruber Syndrome is a rare autosomal recessive lethal ciliopathy characterized by the triad of cystic renal dysplasia, occipital encephalocele and postaxial polydactyly. We present the largest population-based epidemiological study to date using data provided by the European Surveillance of Congenital Anomalies (EUROCAT) network. The study population consisted of 191 cases of MKS identified between January 1990 and December 2011 in 34 European registries. The mean prevalence was 2.6 per 100 000 births in a subset of registries with good ascertainment. The prevalence was stable over time, but regional differences were observed. There were 145 (75.9%) terminations of pregnancy after prenatal diagnosis, 13 (6.8%) fetal deaths, 33 (17.3%) live births. In addition to cystic kidneys (97.7%), encephalocele (83.8%) and polydactyly (87.3%), frequent features include other central nervous system anomalies (51.4%), fibrotic/cystic changes of the liver (65.5% of cases with post mortem examination) and orofacial clefts (31.8%). Various other anomalies were present in 64 (37%) patients. As nowadays most patients are detected very early in pregnancy when liver or kidney changes may not yet be developed or may be difficult to assess, none of the anomalies should be considered obligatory for the diagnosis. Most cases (90.2%) are diagnosed prenatally at 14.3±2.6 (range 11-36) gestational weeks and pregnancies are mainly terminated, reducing the number of LB to one-fifth of the total prevalence rate. Early diagnosis is important for timely counseling of affected couples regarding the option of pregnancy termination and prenatal genetic testing in future pregnancies.