Qualité des données fournies par la statistique médicale VESKA: le cas de la fracture du fémur proximal. [Quality of data provided by VESKA medical statistics: the case of the fractured proximal femur].

Within the framework of a retrospective study of the incidence of hip fractures in the canton of Vaud (Switzerland), all cases of hip fracture occurring among the resident population in 1986 and treated in the hospitals of the canton were identified from among five different information sources. Relevant data were then extracted from the medical records. At least two sources of information were used to identify cases in each hospital, among them the statistics of the Swiss Hospital Association (VESKA). These statistics were available for 9 of the 18 hospitals in the canton that participated in the study. The number of cases identified from the VESKA statistics was compared to the total number of cases for each hospital. For the 9 hospitals the number of cases in the VESKA statistics was 407, whereas, after having excluded diagnoses that were actually "status after fracture" and double entries, the total for these hospitals was 392, that is 4% less than the VESKA statistics indicate. It is concluded that the VESKA statistics provide a good approximation of the actual number of cases treated in these hospitals, with a tendency to overestimate this number. In order to use these statistics for calculating incidence figures, however, it is imperative that a greater proportion of all hospitals (50% presently in the canton, 35% nationwide) participate in these statistics.

Cost of Illness and Contingent Valuation : Controlling for the Motivations of Expressed Preferences in an Attempt to Avoid Double-Counting

This paper addresses the issue of double counting of health impacts in the context of cost of illness valuation. Double counting occurs when estimates are jointly used, which rely on valuation techniques that overlap. As a solution, we propose to limit the scope of each of the valuation method to a specific range of impacts. In order to limit the contingentvaluation method to the exclusive valuation of intangible costs, we propose a three steps approach : (1) leave the respondents free to valuate the consequences which matter to them, (2) elicit respondent's motivations, (3) control for the influence motivations have on elicited values. This procedure was applied in a Swiss contingent-valuation. An econometric treatment was applied in order to limit the scope of the estimates of the contingent valuation method to intangibles,therefore the possibility to a combination of methods with the risk of double-counting and underestimating costs being kept to a minimum.

Impact of international consensus guidelines on antiviral therapy of chronic hepatitis C patients in Switzerland.

To assess the impact of international consensus conference guidelines on the attitude of Swiss specialists when facing the decision to treat chronic hepatitis C patients. Questionnaires focusing on the personal situation and treatment decisions were mailed to 165 patients who were newly diagnosed with hepatitis C virus (HCV) infection and enrolled into the Swiss Hepatitis C Cohort Study during the years 2002-2004. Survey respondents (n = 86, 52.1%) were comparable to non-respondents with respect to severity of liver disease, history of substance abuse and psychiatric co-morbidities. Seventy percent of survey respondents reported having been offered antiviral treatment. Patients deferred from treatment had less advanced liver fibrosis, were more frequently infected with HCV genotypes 1 or 4 and presented more often with a history of depression. There were no differences regarding age, socio-economic background, alcohol abuse, intravenous drug abuse or methadone treatment when compared with patients to whom treatment was proposed. Ninety percent of eligible patients agreed to undergo treatment. Overall, 54.6% of respondents and 78.3% of those considered eligible had actually received antiviral therapy by 2007. Ninety-five percent of patients reported high satisfaction with their own hepatitis C management. Consistent with latest international consensus guidelines, patients enrolled in the Swiss Hepatitis C Cohort with a history of substance abuse were not withheld antiviral treatment. A multidisciplinary approach is warranted to provide antiviral treatment to patients suffering from depression.

Asthme aigu sévère [Severe acute asthma]

Acute severe asthma is defined by the occurrence of an acute exacerbation resistant to the initial medical treatment, complicated by life-threatening respiratory distress due to severe lung hyperinflation. The conventional therapeutic approach is based on oxygen therapy and on the combined treatment of inhaled beta2-agonists at repeated doses and systemic corticosteroids. Inhaled or systemic magnesium sulfate is also recommended. The unresponsiveness to the initial bronchodilating therapy and the development of respiratory distress requiring intubation significantly increases mortality, due to the complications induced by mechanical ventilation. In these situations, a ventilatory strategy, including controlled hypoventilation with permissive hypercapnia, aiming at preventing lung hyperinflation, is indicated. Non-invasive ventilation may be successful in certain patients and represents an effective alternative to intubation. In ventilated patients, helium-oxygen mixtures can be considered as adjunctive therapies. After having reviewed the basic pathophysiological principles, this article will focus on the current medical treatment and of the modalities of mechanical ventilation in acute severe asthma.

The adolescent with a chronic condition. Part II: healthcare provision.

The treatment and management of chronic conditions during adolescence pose specific issues that need to be appropriately handled by health professionals. In this paper, questions related to disclosure of the diagnosis, the management of adherence to therapy, the need for an interdisciplinary network approach, lifestyles' anticipatory guidance and prevention, and the transition into an adult healthcare setting are reviewed. Special areas such as the issue of life threatening diseases and the ethical aspects of the treatment of chronic conditions are also discussed.

Format of medical order sheet improves security of antibiotics prescription: The experience of an intensive care unit.

OBJECTIVE: To assess whether formatting the medical order sheet has an effect on the accuracy and security of antibiotics prescription. DESIGN: Prospective assessment of antibiotics prescription over time, before and after the intervention, in comparison with a control ward. SETTING: The medical and surgical intensive care unit (ICU) of a university hospital. PATIENTS: All patients hospitalized in the medical or surgical ICU between February 1 and April 30, 1997, and July 1 and August 31, 2000, for whom antibiotics were prescribed. INTERVENTION: Formatting of the medical order sheet in the surgical ICU in 1998. MEASUREMENTS AND MAIN RESULTS: Compliance with the American Society of Hospital Pharmacists' criteria for prescription safety was measured. The proportion of safe orders increased in both units, but the increase was 4.6 times greater in the surgical ICU (66% vs. 74% in the medical ICU and 48% vs. 74% in the surgical ICU). For unsafe orders, the proportion of ambiguous orders decreased by half in the medical ICU (9% vs. 17%) and nearly disappeared in the surgical ICU (1% vs. 30%). The only missing criterion remaining in the surgical ICU was the drug dose unit, which could not be preformatted. The aim of antibiotics prescription (either prophylactic or therapeutic) was indicated only in 51% of the order sheets. CONCLUSIONS: Formatting of the order sheet markedly increased security of antibiotics prescription. These findings must be confirmed in other settings and with different drug classes. Formatting the medical order sheet decreases the potential for prescribing errors before full computerized prescription is available.

Parents and primary care physicians have different views about copying medical letters to parents after paediatric outpatient visits.

AIM: We assessed how satisfied parents were when they received a copy of the letter sent to their primary care physician after their child attended a hospital outpatient clinic and compared their views with those of the primary care physician. METHODS: Anonymised questionnaires were sent to parents, and their primary care physician, after their child had visited a paediatric nephrology unit. RESULTS: We received responses from 112 parents (46%) and 69 primary care physicians (93%). Most parents (97%) were satisfied with the process, 94% thought that the letter was a true reflection of the outpatient consultation and easy to understand, and 55% read it to their child. However, 21% would have preferred a simpler letter. More than a third (37%) of the primary care physicians did not approve of the parents being sent the letter, and 30% felt that the letter was difficult for the parents to understand and should be replaced with a simpler letter. CONCLUSION: Most parents (97%) appreciated receiving a copy of the letter following their child's outpatient clinic visit, and 95% understood its contents. More than half (55%) read the letter to their child. However, 37% of primary care physicians did not approve of the practice.

Vom Finanz- zum Wissenschaftsbetrug : Methode, den Irrungen in der medizinischen Literatur beizukommen [From financial to scientific fraud : Methods to detect discrepancies in the medical literature].

Fraud is as old as Mankind. There are an enormous number of historical documents which show the interaction between truth and untruth; therefore it is not really surprising that the prevalence of publication discrepancies is increasing. More surprising is that new cases especially in the medical field generate such a huge astonishment. In financial mathematics a statistical tool for detection of fraud is known which uses the knowledge of Newcomb and Benford regarding the distribution of natural numbers. This distribution is not equal and lower numbers are more likely to be detected compared to higher ones. In this investigation all numbers contained in the blinded abstracts of the 2009 annual meeting of the Swiss Society of Anesthesia and Resuscitation (SGAR) were recorded and analyzed regarding the distribution. A manipulated abstract was also included in the investigation. The χ(2)-test was used to determine statistical differences between expected and observed counts of numbers. There was also a faked abstract integrated in the investigation. A p<0.05 was considered significant. The distribution of the 1,800 numbers in the 77 submitted abstracts followed Benford's law. The manipulated abstract was detected by statistical means (difference in expected versus observed p<0.05). Statistics cannot prove whether the content is true or not but can give some serious hints to look into the details in such conspicuous material. These are the first results of a test for the distribution of numbers presented in medical research.

The Swiss Systemic lupus erythematosus Cohort Study (SSCS) - cross-sectional analysis of clinical characteristics and treatments across different medical disciplines in Switzerland.

OBJECTIVES: To describe disease characteristics and treatment modalities in a multidisciplinary cohort of systemic lupus erythematosus (SLE) patients in Switzerland. METHODS: Cross-sectional analysis of 255 patients included in the Swiss SLE Cohort and coming from centres specialised in Clinical Immunology, Internal Medicine, Nephrology and Rheumatology. Clinical data were collected with a standardised form. Disease activity was assessed using the Safety of Estrogens in Lupus Erythematosus National Assessment-SLE Disease Activity Index (SELENA-SLEDAI), an integer physician's global assessment score (PGA) ranging from 0 (inactive) to 3 (very active disease) and the erythrocyte sedimentation rate (ESR). The relationship between SLE treatment and activity was assessed by propensity score methods using a mixed-effect logistic regression with a random effect on the contributing centre. RESULTS: Of the 255 patients, 82% were women and 82% were of European ancestry. The mean age at enrolment was 44.8 years and the median SLE duration was 5.2 years. Patients from Rheumatology had a significantly later disease onset. Renal disease was reported in 44% of patients. PGA showed active disease in 49% of patients, median SLEDAI was 4 and median ESR was 14 millimetre/first hour. Prescription rates of anti-malarial drugs ranged from 3% by nephrologists to 76% by rheumatologists. Patients regularly using anti-malarial drugs had significantly lower SELENA-SLEDAI scores and ESR values. CONCLUSION: In our cohort, patients in Rheumatology had a significantly later SLE onset than those in Nephrology. Anti-malarial drugs were mostly prescribed by rheumatologists and internists and less frequently by nephrologists, and appeared to be associated with less active SLE.

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.

Assessment of the capacity to consent to treatment in patients admitted to acute medical wards

RAPPORT DE SYNTHÈSE : Introduction: L'évaluation de la capacité de discernement est importante d'un point de vue légal et éthique dans l'activité médicale quotidienne. Dans cette étude, nous avons évalué attentivement la capacité de discernement chez les patients admis dans un service médical aigu en utilisant l'évaluation du personnel médical, le score spécifique de Silberfeld, le MMSE ainsi que l'évaluation du psychiatre. Méthode : Pendant 3 mois, 195 patients admis dans un service de médecine interne d'un hôpital universitaire ont été inclus et leur capacité de discernement a été évaluée durant les premières 72 heures d'admission. Résultats : Sur les 195 patients, 38 furent incapables de discernement manifestement (patients inconscients ou avec des déficits cognitifs sévères) et 14 furent considérés incapables de discernement par le psychiatre (prévalence de l'incapacité de discernement de 26.7%). La corrélation entre l'évaluation du psychiatre et le questionnaire de Silberfeld fut faible (sensibilité 35.7%, spécificité 91.6%). Les cliniciens expérimentés montrèrent une plus haute corrélation (sensibilité 57.1 %, spécificité 96.5%). L'avis partagé par l'assistant, par le chef de clinique et l'infirmière se révéla le meilleur indicateur de l'évaluation psychiatrique (sensibilité 78.6%, spécificité 94.3%). Conclusion : La prévalence de l'incapacité de discernement chez les patients admis dans un service de médecine interne est élevée. Alors que le questionnaire de Silberfeld et le MMSE ne sont pas indiqués pour évaluer la capacité de discernement dans cette étude, l'évaluation par une équipe médicale multidisciplinaire reflète le mieux l'évaluation du psychiatre.

Missed Opportunities: Evolution of Patients Leaving without Being Seen or against Medical Advice during a Six-Year Period in a Swiss Tertiary Hospital Emergency Department.

Aim. The study aimed at describing the evolution over a 6-year period of patients leaving the emergency department (ED) before being seen ("left without being seen" or LWBS) or against medical advice ("left against medical advice" or LAMA) and at describing their characteristics. Methods. A retrospective database analysis of all adult patients who are admitted to the ED, between 2005 and 2010, and who left before being evaluated or against medical advice, in a tertiary university hospital. Results. During the study period, among the 307,716 patients who were registered in the ED, 1,157 LWBS (0.4%) and 1,853 LAMA (0.9%) patients were identified. These proportions remained stable over the period. The patients had an average age of 38.5 ± 15.9 years for LWBS and 41.9 ± 17.4 years for LAMA. The median time spent in the ED before leaving was 102.4 minutes for the LWBS patients and 226 minutes for LAMA patients. The most frequent reason for LAMA was related to the excessive length of stay. Conclusion. The rates of LWBS and LAMA patients were low and remained stable. The patients shared similar characteristics and reasons for leaving were largely related to the length of stay or waiting time.