Le Soutien psychiatrique Intensif dans le Milieu (SIM) à Lausanne: un projet pilote [Intensive Psychiatric Support at the Setting in Lausanne: a pilot project]

While the hospital remains an important element of the psychiatric health-care system, the fact that it is always the best place to treat acute psychotic episodes is still debated. After a brief review of the literature relative to the main existing community care models, the authors describe the development in the Department Universitaire de Psychiatrie Adulte (DUPA), of an alternative to hospitalisation for patient going through a severe acute psychiatric episode. They present three clinical situations and the aims of the research project, which will follow this pilot phase.

Etudes Coût-efficacité: ce que devraient retenir les médecins [Cost-effectiveness analyses: what doctors should know]

The resources of our heath care system are limited. Choices in the attribution of resources are necessary to ensure its stability. A cost-effectiveness analysis compares the effects of one health intervention to another, taking into account the costs (including the saved costs) and the saved life years, adjusted for the quality of life (cost-utility). Cost-effectiveness analyses should take the societal perspective and the studied intervention should be compared to a relevant intervention actually in use. Physicians, at the interface between patients and payers, are in an ideal position to interpret, or even perform cost-effectiveness analysis, and to promote the interventions that are most effective and that have a reasonable cost.

Possible synergism of physical exercise and ghrelin-agonists in patients with cachexia associated with chronic heart failure.

The occurrence of cachexia of multifactorial etiology in chronic heart failure (CHF) is a common and underestimated condition that usually leads to poor outcome and low survival rates, with high direct and indirect costs for the Health Care System. Recently, a consensus definition on cachexia has been reached, leading to a growing interest by the scientific community in this condition, which characterizes the last phase of many chronic diseases (i.e., cancer, acquired immunodeficiency syndrome). The etiology of cachexia is multifactorial and the underlying pathophysiological mechanisms are essentially the following: anorexia and malnourishment; immune overactivity and systemic inflammation; and endocrine disorders (anabolic/catabolic imbalance and resistance to growth hormone). In this paper, we review the main pathophysiological mechanisms underlying CHF cachexia, focusing also on the broad spectrum of actions of ghrelin and ghrelin agonists, and their possible use in combination with physical exercise to contrast CHF cachexia.

Dépistage et intervention brève par internet pour la consommation d'alcool a risque: www.alcooquizz.ch [Web-based screening and brief intervention for unhealthy alcohol use: www.alcooquizz.ch].

Many individuals with unhealthy alcohol use have few or no contact with the health care system and are therefore unlikely to receive information or a brief intervention from a health care professional. Consequently, many Internet-based interventions have been developed. These interventions can reach a large population. We present in this report www.alcooquizz.ch, a website providing tailored feedback and information on alcohol use and its consequences. In six months and a half, more than 15000 individuals visited the website. It appropriately targets individuals with unhealthy alcohol use and users' satisfaction was high. Internet is a valuable option to provide health related information and secondary prevention interventions for unhealthy alcohol use.

Gériatrie [What's new in geriatric medicine]

Several studies clarified the role of different interventions such as vitamine D replacement, denosumab treatment, and vertebroplasty in the prevention and management of falls and fractures. A trial tested the effectiveness of pharmaceutical assistance at the time of discharge, emphasizing the potential benefits for the patients and the health care system. Syncopal episodes frequently lead to hospital admission. A retrospective study evaluated the diagnostic yield of different tests and emphasized the importance to actively seek orthostatic hypotension in older patients. Finally, advances remain modest in the field of dementias.

Unplanned nursing home short stay : elderly patients characteristics and 3-month outcomes.

Background: Nursing home short stays (NHSS) in the canton of Vaud have been introduced for respite care purpose. However, a growing number of older patients are urgently admitted from home (within 24h) or directly after hospital discharge (58% of all admissions in 2010). NHSS appears therefore as an increasingly important component of the health care system, but the characteristics of admitted patients have not been previously described. A better knowledge would contribute to identify specific care needs and enhance their care. Objectives: 1) To describe the characteristics of patients admitted in unplanned NHSS ( after hospital stay or urgently from home); 2) To determine living disposition 3-month after NHSS discharge. Method: Over a 18-month period, elderly patients with unplanned NHSS admission to 2 facilities in Lausanne were identified. Demographic, social, health, and functional data, as well as main reason for admission were collected. Death and place of living at 3-months were collected using the administrative database. Results: Overall, 114 patients (mean age 83.1 ± 6.2 years, 77% women, 84% living alone) were assessed, 80% being admitted from hospital. Mean score in Lawton's instrumental ADL before NHSS admission was 4.6 ± 2.5 and 69% of the patients were home care recipients (median number of weekly visits: 5 ± 3). Patients reported going out 4.2 ± 1.3 times/week and 56% reported at least one fall over the past year. Among the 91 patients coming from the hospital, main reason for admission was injury/limb immobilization (58%), recuperation (13%) and functional impairment in basic ADL (10%). Mean score at Katz's Basic ADL at admission was 3.7 ± 1.9. Overall, 90% of patients were identified with gait and balance impairment, 78% with cognitive impairment and 70% with polypharmacy (>6 different drugs). At 3-month after NHSS discharge (N = 92), 72% patients were living at home, 16% had been admitted to long term care, and 6% died. Among patients living at home at follow-up, 11% had been readmitted to hospital during the follow-up period. Conclusion: Older patients with unplanned NHSS admission show a high prevalence of functional, mobility, and cognitive impairments, as well as other geriatric syndromes. Specific measures should be considered during these stays to prevent further functional decline and, possibly, hospital readmission. Patients admitted with basic ADLs impairment might be candidate for higher levels of care (rehabilitation).

Antiretroviral adherence program in HIV patients: a feasibility study in the Swiss HIV Cohort Study.

Objective To evaluate the feasibility of a comprehensive, interdisciplinary adherence program aimed at HIV patients. Setting Two centers of the Swiss HIV Cohort Study: Lausanne and Basel. Method 6-month, pilot, quasi-experimental, 2-arm design (control and intervention). Patients starting a first or second combined antiretroviral therapy line were invited to participate in the study. Patients entering the intervention arm were proposed a multifactorial intervention along with an electronic drug monitor. It consisted of a maximum of six 30-min sessions with the interventionist coinciding with routine HIV check-up. The sessions relied on individualized semi-structured motivational interviews. Patients in the control arm used directly blinded EDM and did not participate in motivational interviews. Main outcome measures Rate of patients' acceptance to take part in the HIV-adherence program and rate of patients' retention in this program assessed in both intervention and control groups. Persistence, execution and adherence. Results The study was feasible in one center but not in the other one. Hence, the control group previously planned in Basel was recruited in Lausanne. Inclusion rate was 84% (n = 21) in the intervention versus 52% (n = 11) in the control group (P = 0.027). Retention rate was 91% in the intervention versus 82% in the control group (P = ns). Regarding adherence, execution was high in both groups (97 vs. 95%). Interestingly, the statistical model showed that adherence decreased more quickly in the control versus the intervention group (interaction group × time P < 0.0001). Conclusion The encountered difficulties rely on the implementation, i.e., on the program and the health care system levels rather than on the patient level. Implementation needs to be evaluated further; to be feasible a new adherence program needs to fit into the daily routine of the centre and has to be supported by all trained healthcare providers. However, this study shows that patients' adherence behavior evolved differently in both groups; it decreased more quickly over time in the control than in the intervention group. RCTs are eventually needed to assess the clinical impact of such an adherence program and to verify whether skilled pharmacists can ensure continuity of care for HIV outpatients.

Exploring the implementation of a medication adherence programme by community pharmacists: a qualitative study

BACKGROUND: Medication adherence has been identified as an important factor for clinical success. Twenty-four Swiss community pharmacists participated in the implementation of an adherence support programme for patients with hypertension, diabetes mellitus and/or dyslipidemia. The programme combined tailored consultations with patients about medication taking (expected at an average of one intervention per month) and the delivery of each drug in an electronic monitoring system (MEMS6?). OBJECTIVE: To explore pharmacists' perceptions and experiences with implementation of the medication adherence programme and to clarify why only seven patients were enrolled in total. SETTING: Community pharmacies in French-speaking Switzerland. METHOD: Individual in-depth interviews were audio-recorded, with 20 of the pharmacists who participated in the adherence programme. These were transcribed verbatim, coded and thematically analysed. Process quality was ensured by using an audit trail detailing the development of codes and themes; furthermore, each step in the coding and analysis was verified by a second, experienced qualitative researcher. MAIN OUTCOME MEASURE: Community pharmacists' experiences and perceptions of the determining factors influencing the implementation of the adherence programme. RESULTS: Four major barriers were identified: (1) poor communication with patients resulting in insufficient promotion of the programme; (2) insufficient collaboration with physicians; (3) difficulty in integrating the programme into pharmacy organisation; and (4) insufficient pharmacist motivation. This was related to the remuneration perceived as insufficient and to the absence of clear strategic thinking about the pharmacist position in the health care system. One major facilitator of the programme's implementation was pre-existing collaboration with physicians. CONCLUSION: A wide range of barriers was identified. The implementation of medication adherence programmes in Swiss community pharmacies would benefit from an extended training aimed at developing communication and change management skills. Individualised onsite support addressing relevant barriers would also be necessary throughout the implementation process.

A case of acute retinal pigment epithelitis: spectral domain optical coherence tomography time course and physiopathologic hypothesis.

PURPOSE: To report the time course of retinal morphologic changes in a patient with acute retinal pigment epithelitis (ARPE) using spectral domain optical coherence tomography (SD-OCT). METHODS: A 30-year old man was referred for blurred vision of his right eye after five days that appeared suddenly 15 days after recovery from a flu-like syndrome. SD-OCT was performed immediately, followed by fluorescein and infracyanine angiography at eight days and then at three weeks. RESULTS: At presentation, a bubble of sub-macular deposit was observed on the right macula with central golden micronodules in a honeycomb pattern. SD-OCT showed an "anterior dislocation" of all the retinal layers up to the inner/outer segment (IS/OS) line and irregular deposits at the OS level together with thickening of the retinal pigment epithelial (RPE) layer. As visual acuity increased, eight days later, the OCT showed reduction of the sub-retinal deposits and an abnormal hyperflectivity of the sub-retinal and RPE layers was observed. The patient showed a positive serology for picornavirus. DISCUSSION: The acute SD-OCT sections of this patient with ARPE were compared with histological sections of a 35 day old Royal College of Surgeons rat. Similar findings could be observed, with preservation of the IS/OS line and accumulation of debris at the OS level, suggesting that ARPE symptoms could result from a transient phagocytic dysfunction of the RPE at the fovea, inducing reversible accumulation of undigested OS. Picornaviruses comprising enterovirus and coxsachievirus described as being associated with acute chorioretinitis. In this case, it was responsible for ARPE. CONCLUSION: We hypothesize that ARPE syndrome results from a transient dysfunction of RPE, which can occur as a post viral reaction.

Chiasmatic infiltration secondary to late malignant transformation of retinoma.

PURPOSE: To report the lethal course of malignant transformation of retinoma in an adult. METHODS: Case report. A 40-year-old patient presented with retinoma in his right eye and retinoblastoma in his left eye. Enucleation was recommended but refused and the patient received whole eye radiotherapy elsewhere. Five years later he presented again, with temporal hemianopsia of the left eye secondary to chiasmatic invasion. RESULTS: Diagnosis of retinoblastoma infiltration was confirmed by stereotactic biopsy of the chiasmatic lesion. Treatment with intravenous and intrathecal chemotherapy led to partial remission, and was followed by stereotactic irradiation of the chiasmatic mass and right optic nerve. The left eye was enucleated. Death occurred one year later due to cerebrospinal fluid metastases. CONCLUSION: Extraocular extension of retinoblastoma diagnosed in adulthood has never, to our knowledge, been reported. This case stresses the importance of lifelong retinoma monitoring and the necessity for radical treatment in the event of malignant transformation.

How to identify and recruit nurses to a survey 14 and 24 years after graduation in a context of scarce data : lessons learnt from the 2012 nurses at work pilot study on nurses' career paths

Nursing workforce data are scarce in Switzerland, with no active national registry of nurses. The worldwide nursing shortage is also affecting Switzerland, so that evidence-based results of the nurses at work project on career paths and retention are needed as part of the health care system stewardship; nurses at work is a retrospective cohort study of nurses who graduated in Swiss nursing schools in the last 30 years. Results of the pilot study are presented here (process and feasibility). The objectives are (1) to determine the size and structure of the potential target population by approaching two test-cohorts of nursing graduates (1988 and 1998); (2) to test methods of identifying and reaching them 14 and 24 years after graduation; (3) to compute participation rates, and identify recruitment and participation biases.

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Summary and conclusion: One of the main challenges facing the Swiss health care system remains continued fragmentation as a consequence of the federal structure and the division of responsibilities. This constitutes a major barrier for the implementation of a nationwide public health strategy and a more rational organization of health care. Much of the health reform agenda during the past decade was driven by cost-containment efforts. Despite the absence of a national regulatory framework targeting prevention and care of chronic diseases, national strategies and programmes have been developed within a growing recognition of the need to address chronic disease in the health care system. In addition, several small-scale pilot and preliminary structured care programmes have been implemented in selected localities. The latter are however still too few and limited in scope to cover the needs of the majority of patients with chronic diseases residing in Switzerland. Given the continued high satisfaction with the system among health care users, of around 80%, pressure to actually initiate larger scale changes might not yet be sufficiently strong.

Impact of case management on frequent users quality of life : a randomized controlled trial

BACKGROUND: Frequent emergency department users represent a small number of patients but account for a large number of emergency department visits. They should be a focus because they are often vulnerable patients with many risk factors affecting their quality of life (QoL). Case management interventions have resulted in a significant decrease in emergency department visits, but association with QoL has not been assessed. One aim of our study was to examine to what extent an interdisciplinary case management intervention, compared to standard emergency care, improved frequent emergency department users' QoL. METHODS: Data are part of a randomized, controlled trial designed to improve frequent emergency department users' QoL and use of health-care resources at the Lausanne University Hospital, Switzerland. In total, 250 frequent emergency department users (≥5 attendances during the previous 12 months; ≥ 18 years of age) were interviewed between May 2012 and July 2013. Following an assessment focused on social characteristics; social, mental, and somatic determinants of health; risk behaviors; health care use; and QoL, participants were randomly assigned to the control or the intervention group (n=125 in each group). The final sample included 194 participants (20 deaths, 36 dropouts, n=96 in the intervention group, n=99 in the control group). Participants in the intervention group received a case management intervention by an interdisciplinary, mobile team in addition to standard emergency care. The case management intervention involved four nurses and a physician who provided counseling and assistance concerning social determinants of health, substance-use disorders, and access to the health-care system.

Impact of case management on frequent users' quality of life : a randomized, controlled trial (FM 286)

Introduction: Frequent emergency department (ED) users are often vulnerable patients with many risk factors affecting their quality of life (QoL). The aim of this study was to examine to what extent a case management intervention improved frequent ED users' QoL. Methods: Data were part of a randomized, controlled trial designed to improve frequent ED users' QoL at the Lausanne University Hospital. A total of 194 frequent ED users (≥ 5 attendances during the previous 12 months; ≥ 18 years of age) were randomly assigned to the control or the intervention group. Participants in the intervention group received a case management intervention (i.e. counseling and assistance concerning social determinants of health, substance-use disorders, and access to the health-care system). QoL was evaluated using the WHOQOL-BREF at baseline and twelve months later. Four dimensions of QoL were retained: physical health, psychological health, social relationship, and environment, with scores ranging from 0 (low QoL) to 100 (high QoL).

Diverse set of Turing nanopatterns coat corneae across insect lineages.

Nipple-like nanostructures covering the corneal surfaces of moths, butterflies, and Drosophila have been studied by electron and atomic force microscopy, and their antireflective properties have been described. In contrast, corneal nanostructures of the majority of other insect orders have either been unexamined or examined by methods that did not allow precise morphological characterization. Here we provide a comprehensive analysis of corneal surfaces in 23 insect orders, revealing a rich diversity of insect corneal nanocoatings. These nanocoatings are categorized into four major morphological patterns and various transitions between them, many, to our knowledge, never described before. Remarkably, this unexpectedly diverse range of the corneal nanostructures replicates the complete set of Turing patterns, thus likely being a result of processes similar to those modeled by Alan Turing in his famous reaction-diffusion system. These findings reveal a beautiful diversity of insect corneal nanostructures and shed light on their molecular origin and evolutionary diversification. They may also be the first-ever biological example of Turing nanopatterns.