La violence ou le traumatisme médical dans une consultation pluridisciplinaire spécialisée [Violence our medical trauma in specialized multidisciplinary consultation].

In this article a particular patient/physician relationship is described and analyzed: The described interaction between patient and physician during a consultative investigation by several specialists differs markedly from the common trustful relation between a patient and his family doctor. In this context the term and phenomenon pain is discussed and the necessity for an understandable, patient-oriented presentation of diagnosis and hypotheses considering the patient's individual bio-psycho-social dimension is stressed. Consequences for student education are mentioned.

Fonctions du plancher pelvien: de la phase expulsive à la consultation du post-partum [Pelvic floor functions: from the beginning of the second phase of labor to the postpartum consultation].

Vaginal delivery can cause lesions of the various pelvic structures responsible for the mechanisms of continence. These lesions may perhaps be prevented in the future by measuring pressure generated during childbirth. Tear of the anal sphincter during childbirth is a marker of a global impairment of the urinary, ano-rectal and sexual pelvic functions in the short and medium term. Persistence of a defect of the anal sphincter is frequent in spite of immediate suture. The correlation between these defects and ano-rectal incontinence are not established in our experience. The quality of the contraction of the sphincter complex and pubo-rectal sling seems to play a more important role in ano-rectal continence after a traumatic childbirth.

Intérêt d'une Consultation spécialisée multidisciplinaire en neuro-urologie et urologie fonctionnelle [Benefit of a specialized multidisciplinary clinic in neuro-urology and functional urology].

Functional disorders encounter for a large amount of the medical activity, including in urology. The decreased quality of life due to lower urinary tract symptoms requires a prompt management, with primary assessment undergone in community. Referral to a specialist is required when simple management has failed, and whenever any of these coexists: hematuria, recurrent urinary infection, and neurological condition. The specialized clinic in neurourology and functional urology aim at further investigating the underlying disorder responsible for the urinary symptoms and preventing urinary tract complications. A multidisciplinary team is the key to accurately assess patients with regards to their bother and handicap, therefore offering the most appropriate conservative, medical or surgical management.

La consultation systémique: une interface entre recherche et clinique

Le but de la consultation systémique est l'évaluation des interactions familiales à des fins cliniques aussi bien qu'à des fins de recherche, avec mise en lumière des ressources aussi bien que des difficultés de la famille. Elle est soit demandée spontanément par les parents soit par le(s) thérapeute(s) qui sui(ven)t la famille. Lors d'une première rencontre, nous proposons d'une part à la famille de faire des jeux familiaux standardisés que nous filmons et d'autre part de poser les questions qui motivent les parents ou thérapeute(s) à nous consulter. Lors d'une deuxième rencontre, un visionnement des films avec la famille (et les thérapeutes) permet une discussion ainsi que l'élaboration de réponses aux questions posées. Après une description de la pratique de la consultation systémique, avec ses objectifs et ses principes, les situations utilisées dans ce contexte sont présentées (comme le Lausanne Trilogue Play). Enfin, une vignette clinique en illustre la richesse et l'utilité, aussi bien pour la recherche que pour la clinique. The aim of the systems consultation is to assess the family interaction in order to enlighten, in a clinical perspective, the resources as well as the difficulties of the family. The family itself or a therapist may request it. During the first session, we propose to the family, on the one hand, to play standardized games which are recorded and, on the other hand, to ask the questions they (or the therapist/s) may have. During the second session, a video feedback takes place to discuss and elaborate on the questions. After a description of the practice of the systems consultation, including aims and principles, the observational situations used in this context will be presented (e.g. the Lausanne Trilogue Play). Finally a case illustration will show its richness and usefulness for research as well as for clinical purposes, in particular as a bridge between research and clinical domains.

Referral patterns and outcomes in noncritically ill patients with hospital-acquired acute kidney injury.

Background and objectives Despite modern treatment, the case fatality rate of hospital-acquired acute kidney injury (HA-AKI) is still high. We retrospectively described the prevalence and the outcome of HA-AKI without nephrology referral (nrHA-AKI) and late referred HA-AKI patients to nephrologists (lrHA-AKI) compared with early referral patients (erHA-AKI) with respect to renal function recovery, renal replacement therapy (RRT) requirement, and in-hospital mortality of HA-AKI. Design, setting, participants, & measurements Noncritically ill patients admitted to the tertiary care academic center of Lausanne, Switzerland, between 2004 and 2008 in the medical and surgical services were included. Acute kidney injury was defined using the Acute Kidney Injury Network (AKIN) classification. Results During 5 years, 4296 patients (4.12% of admissions) experienced 4727 episodes of HA-AKI during their hospital stay. The mean ± SD age of the patients was 61 ± 15 years with a 55% male predominance. There were 958 patients with nrHA-AKI (22.3%) and 2504 patients with lrHA-AKI (58.3%). RRT was required in 31% of the patients with lrHA-AKI compared with 24% of the patients with erHA-AKI. In the multiple risk factor analysis, compared with erHA-AKI, nrHA-AKI and lrHA-AKI were significantly associated with worse renal outcome and higher in-hospital mortality. Conclusions These data suggest that HA-AKI is frequent and the patients with nrHA-AKI or lrHA-AKI are at increased risk for in-hospital morbidity and mortality.

Plus de femmes que d'hommes VIH positifs sont réferees à une consultation d'adhésion thérapeutique [More HIV-positive women are referred to a medication adherence clinic than men].

HIV-positive patients with antiretroviral medication adherence issues are referred to an outpatient adherence clinic. Surprisingly, two-third of referred patients are women although more than 60% of the patients at the Infectious Disease Outpatient service are men. Women seem to be referred because of specific social factors: children at home, black sub-Saharan ethnicity, difficulties in medication and disease management due to stigmatization. Literature is poor and controversial and it is not possible to conclude whether medication adherence varies with gender. However, recent data seem to show that reasons for nonadherence vary according to gender.

L'unité de médecine des violences : une consultation médicolégale assurée par des infirmières

En janvier 2006, l'institut universitaire de médecine légale a ouvert l'unité de médecine des violences qui offre une consultation médicolégale spécialisée dans la prise en charge des adultes victimes de violence. La consultation est assurée par des infirmières dont la formation et la supervision sont conduites par des médecins légistes. Une écoute, un examen clinique en vue d'établir la documentation médicolégale et une orientation sont proposés aux patients.

L'intégration de la sexualité en consultation gynécologique : discordances entre les perceptions des femmes et celles des gynécologues.

Dès les années 2000, l'Office Fédéral de la Santé Publique recommande aux médecins de premier recours, dont les gynécologues, d'aborder activement la sexualité en consultation, en raison notamment de l'augmentation des infections sexuellement transmissibles asymptomatiques (1ST). Dans le même sens, comme le montrent nombre d'études, plus de 70% des patientes souhaiteraient être interrogées au sujet de leur sexualité en consultation gynécologique. Or, il semble que peu de médecins intègrent systématiquement des questions de sexualité dans leur anamnèse. La revue de la littérature relève que les recherches réalisées à ce jour ont été menées principalement à l'aide de questionnaire selon une perspective naturaliste, qui étudie la sexualité de manière décontextualisée et qui la conçoit comme un invariant biologique et par conséquent universel. Notre objectif est de saisir en profondeur les perceptions et le vécu des gynécologues et des femmes, face à l'intégration de la sexualité en consultation gynécologique. Nous avons adopté une perspective critique en psychologie de la santé (Santiago-Delefosse & Chamberlain, 2008 ; Murray, 2004a ; Lyons & Chamberlain, 2006) qui permet de privilégier d'une part, l'étude de la signification que les sujets donnent à la sexualité dans leur contexte socio-historique et, d'autre part, une vision de l'être humain comprenant des dimensions corporelles, psychologiques et sociétales (Santiago-Delefosse, 2011). Pour ce faire, nous avons utilisé un dispositif de méthodes mixtes en deux phases. Dans la première phase, nous avons mené 21 entretiens semi directifs avec des gynécologues hommes et femmes. Puis, nous avons réalisé 3 groupes focalisés (N=16) avec des femmes âgées de 23 à 65 ans. La seconde phase a consisté à créer un questionnaire, élaboré à partir des résultats de la première phase, afin d'élargir l'expérience de l'intégration de la sexualité en consultation, à une population plus diversifiée de femmes (N=421). Les données récoltées par le biais de ces trois méthodes nous ont permis d'esquisser un modèle présentant les processus en jeu dans la situation de non intégration de la sexualité en consultation gynécologique. Celui-ci relève non seulement des lacunes dans le cursus universitaire de médecine en matière de sexualité, mais également d'importantes discordances entre les gynécologues et les femmes interviewés concernant le rôle du gynécologue, la perception de l'intime, la perception d'introduire le sujet de la sexualité en consultation, ainsi que de la définition même de la sexualité. Nos résultats ouvrent sur des perspectives pratiques pour la consultation gynécologique, ainsi que sur des pistes pour des recherches futures dans l'étude de la sexualité, selon une perspective plus intégrative. -- Since the 2000's, the Swiss Federal Office of Public Health recommended primary care physicians, including gynaecologists, to actively address sexuality issues in consultation, namely because of the increasing incidence of Sexually Transmitted Infections (STI). In line with this, studies have shown that more than 70% of patients would like to be asked about their sexuality by their gynaecologist. However, physicians do not take systematically sexual histories from their patients. Literature in the field has highlighted that most research has been restricted to using questionnaires following a naturalist theoretical perspective according to which sexual behaviour is defined as biologically invariant, hence, universal. Our objective is to deepen understand perceptions from gynaecologists and women with regard to the integration of sexuality in consultations. A critical health psychology approach allows us to consider on the one hand sexuality as a construct that is inseparable from a given socio-historical context. On the other hand, this approach takes into consideration an embodied, social and psychological definition of human beings. Therefore, we used a mixed methods design that included two main research steps : First, we conducted 21 semi-structured interviews with male and female gynaecologists. In this phase, we also led 3 focus groups made up of 16 women aged from 21 to 65. Second, a survey was implemented (N= 421) based on findings stemming from the first phase. This allowed us to further analyse experiences on the integration of sexuality and to extend findings to a more diversified population of women. The data analysis allowed us to create a model that highlights the processes involved in the non integration of sexuality during gynaecological consultation. It shows a lack of training in sexology within medical programs. Moreover, it emphasises the mismatches on perceptions between gynaecologists and women concerning the gynaecologist's role ; intimacy, the issue of whether introducing sexuality topics, and finally, on the actual definition of sexuality itself. Our findings open new research perspectives for the study of sexuality by proposing a more integrative approach. They also provide practical and clinical perspectives concerning consultations in gynaecology.

Consultation d'urgence/crise pour couples et families: motifs d'urgence et évaluation du traitement [Couples and families emergency/crisis consultation: emergency patterns and treatment assessment]

Since the opening in 2003 of the Couple & Family Consultation Unit (UCCF) at Prangins Hospital, we have met urgent demands and observed that the suffering systems (i.e., couples and families) couldn't face any waiting period. So in 2007 an Emergency/Crisis Facility was created, based on the hypothesis that there is no contra-indication to systemic emergency care, if one understands and structures both crisis and treatment. We studied the suffering population in demand and the emergency/crisis issues and assessed therapy efficiency. Then we observed that treating suffering systems in emergency does produce therapeutic gain in terms of crisis resolution and patients' satisfaction. Those treatments refer to public health issues, as considered the human, social and financial cost of couples/families dysfunctions.