Paralysie faciale: diagnostic et prise en charge [Diagnosis and management of facial paralysis]

Facial palsy is an unusual pathology that requires standard investigations and management. A clinical overview of the current attitudes is suggested to the general practitioners in order to help them in initiating the adequate investigations and treatment before referring the patient to a specialist.

Cross-coding from the Swiss Disability Insurance listing to the ICIDH.

It has been suggested that converting, via a process of cross-coding, the listing used by the Swiss Disability Insurance (SDI) for their statistics into codes of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) would improve the quality and international comparability of disability statistics for Switzerland. Using two different methods we tested the feasibility of this cross-coding on a consecutive sample of 204 insured persons, examined at one of the medical observation centres of the SDI. Cross-coding is impossible, for all practical purposes, in a proportion varying between 30% and 100%, depending on the method of cross-coding, the level of disablement and the required quality of the resulting codes. Failure is due to lack of validity of the SDI codes: diseases are poorly described, consequences of diseases (disability and handicap, including loss of earning capacity), insufficiently described or not at all. Assessment of disability and handicap would provide necessary information for the SDI. It is concluded that the SDI should promote the use of the ICIDH in Switzerland, especially among medical practitioners whose assessment of work capacity is the key element in the decision to award benefits or propose rehabilitation.

Continuity and change in the gender segregation of the medical profession in Britain and France

It is a well established fact that the entry of women into higher-level professional occupations has not resulted in their equal distribution within these occupations. Indeed, the emergence and persistence of horizontal and vertical gender segregation within the professions has been at the heart of the development of a range of alternative theoretical perspectives on both the "feminisation process" and the future of the "professions"more generally. Through an in-depth comparative analysis of the recent changes in the organisation and administration of the medical profession in Britain and France, this paper draws upon statistical data and biographical interviews with male and female general practitioners (GPs) in both countries in order to discuss and review a variety of approaches that have been adopted to explain and analyse the "eminisation" process of higher-level professions. Our conclusions review the theoretical debates in the light of the evidence we have presented. It is argued that, despite important elements of continuity in respect of gendered occupational structuring in both countries, national variations in both professional and domestic gendered architectures lead to different outcomes as far as the extent and patterns of internal occupational segregation are concerned. Both female and male doctors are currently seeking - with some effect - to resist thepressures of medicine on family life.

Urologie [Urology].

This article intended to general practitioners brings an overview on current diseases in urology such as stone disease, benign prostatic hyperplasia, sexual dysfunction and localized cancers of prostate, bladder and kidney.

Cost-effectiveness analysis of the first-line therapies for nicotine dependence.

BACKGROUND: Nicotine dependence is the major obstacle for smokers who want to quit. Guidelines have identified five effective first-line therapies, four nicotine replacement therapies (NRTs)--gum, patch, nasal spray and inhaler--and bupropion. Studying the extent to which these various treatments are cost-effective requires additional research. OBJECTIVES: To determine cost-effectiveness (CE) ratios of pharmacotherapies for nicotine dependence provided by general practitioners (GPs) during routine visits as an adjunct to cessation counselling. METHODS: We used a Markov model to generate two cohorts of one-pack-a-day smokers: (1) the reference cohort received only cessation counselling from a GP during routine office visits; (2) the second cohort received the same counselling plus an offer to use a pharmacological treatment to help them quit smoking. The effectiveness of adjunctive therapy was expressed in terms of the resultant differential in mortality rate between the two cohorts. Data on the effectiveness of therapies came from meta-analyses, and we used odds ratio for quitting as the measure of effectiveness. The costs of pharmacotherapies were based on the cost of the additional time spent by GPs offering, prescribing and following-up treatment, and on the retail prices of the therapies. We used the third-party-payer perspective. Results are expressed as the incremental cost per life-year saved. RESULTS: The cost per life-year saved for only counselling ranged from Euro 385 to Euro 622 for men and from Euro 468 to Euro 796 for women. The CE ratios for the five pharmacological treatments varied from Euro 1768 to Euro 6879 for men, and from Euro 2146 to Euro 8799 for women. Significant variations in CE ratios among the five treatments were primarily due to differences in retail prices. The most cost-effective treatments were bupropion and the patch, and, then, in descending order, the spray, the inhaler and, lastly, gum. Differences in CE between men and women across treatments were due to the shape of their respective mortality curve. The lowest CE ratio in men was for the 45- to 49-year-old group and for women in the 50- to 54-year-old group. Sensitivity analysis showed that changes in treatment efficacy produced effects only for less-well proven treatments (spray, inhaler, and bupropion) and revealed a strong influence of the discount rate and natural quit rate on the CE of pharmacological treatments. CONCLUSION: The CE of first-line treatments for nicotine dependence varied widely with age and sex and was sensitive to the assumption for the natural quit rate. Bupropion and the nicotine patch were the two most cost-effective treatments.

Le suicidant, sa famille et son médecin

Résumé : Le suicidant, sa famille et son médecin. - Dans une lignée systémique, nous avons à nous demander quelle représentation du suicide ont les suicidants par rapport à l'acte lui-même et par rapport à l'impact que ces mêmes actes ont sur leur famille. D'autre part, il convient de nous interroger sur les représentations que chaque membre de la famille peut construire de l'acte suicidaire lui-même, du sens qu'il revêt pour le jeune et les proches. Notre expérience de psychiatres dans un hôpital général nous amène à nous questionner aussi sur les représentations de cet acte chez les professionnels qui offrent des soins aigus somatiques et qui luttent pour la vie lorsque les patients eux ont opté pour la mort. Ce geste nous envoie un signal fort de perte d'espoir et d'absence de perspectives futures chez les suicidants. Il nous renvoie aussi à la question de la mort chez les médecins formés à lutter pour la vie. L'acte suicidaire est un geste violent qui renvoie aux soignants un sentiment d'impuissance et pour lequel ils se sentent démunis. Nous aborderons dans une première partie l'attitude adoptée dans le service de psychiatrie de liaison à Lausanne. Nous exposerons ensuite quelques pistes de réflexion sur la prise en charge des suicidants dans un effort de compréhension systémique. Une responsabilité majeure éthique et humaine nous incombe.Summary : The suicidal person, his family and his doctor. - In a systemic lineage, we have to ask ourselves what representation of suicide do people with suicidal tendencies have, and what is the impact of suicide on their families and their doctor. On the other hand, it is advisable to ask ourselves what does suicide mean to their relatives. Our practice as psychiatrists in a general hospital leads us also to try and understand the image and impact of suicide on the medical staff who constantly aims at saving lives, while patients opted for death. This act sends us a strong signal of loss of hope and the absence of prospects for suicidal people. It has also a strong emotional impact on health practitioners and frequently makes them feel helpless. It also sends back to us to the question of the image of death among doctors. We will discuss, in a first part, the adopted attitude in the service of liaison psychiatry in Lausanne. We will try and develop then a way of taking care of suicidal patients, their families and the medical staff, attending them in a systemic approach. This is a great ethical and human responsibility to all health practitioners.

Urgences et médecins de premier recours: quelles perspectives? Quelle formation [Emergencies and general practitionners. Which prospects? Which education?].

Professionalisation of emergency medicine and triage before most of emergency consultations led to a major reduction in exposure of general practitionners (GP) to vital emergencies, which participates in reduction of their aptitudes to manage such emergencies. The risk for a GP to face a vital emergency is weak nowaday, but did not totaly disappear. Therefore, it seems important for the GPs to maintain the skills required to manage these emergencies properly. These skills would be capacity in recognizing symptoms and signs of alarm (red flags), applying life support, and sorting the patients correctly. These skills will be all the more important in the future, while the role of the GP could be reinforced in response to requirement of increased efficiency.

"S'il vous plaît docteur, mettez-moi en arrêt"! Certificats médicaux pour raisons psychologiques ["Doctor please, give me a sick leave"!: medical certificates for psychological reasons].

General practitioners are regularly called to evaluate the psychological work capacity of patients. The implicit motivation behind the explicit reason for requesting a sick leave is linked to the subject's history and the way he transfers it in his professional life. An incapacity to work harbours a variety of challenges for the patient, the physician and their relationship. In order to get a better understanding of all the issues at stake, the doctor should understand the significances that represents the work to the patient and the consequences of a sick leave and its associated transference and countertransference issues.

Identification concept and the use of probabilities in forensic odontology--an approach by philosophical discussion.

This paper questions the practitioners' deterministic approach(es) in forensic identification and notes the limits of their conclusions in order to encourage a discussion to question current practices. With this end in view, a hypothetical discussion between an expert in dentistry and an enthusiastic member of a jury, eager to understand the scientific principles of evidence interpretation, is presented. This discussion will lead us to regard any argument aiming at identification as probabilistic.

Support for Seasonal Influenza Vaccination Requirements among US Healthcare Personnel.

Objective. To measure support for seasonal influenza vaccination requirements among US healthcare personnel (HCP) and its associations with attitudes regarding influenza and influenza vaccination and self-reported coverage by existing vaccination requirements. Design. Between June 1 and June 30, 2010, we surveyed a sample of US HCP ([Formula: see text]) recruited using an existing probability-based online research panel of participants representing the US general population as a sampling frame. Setting. General community. Participants. Eligible HCP who (1) reported having worked as medical doctors, health technologists, healthcare support staff, or other health practitioners or who (2) reported having worked in hospitals, ambulatory care facilities, long-term care facilities, or other health-related settings. Methods. We analyzed support for seasonal influenza vaccination requirements for HCP using proportion estimation and multivariable probit models. Results. A total of 57.4% (95% confidence interval, 53.3%-61.5%) of US HCP agreed that HCP should be required to be vaccinated for seasonal influenza. Support for mandatory vaccination was statistically significantly higher among HCP who were subject to employer-based influenza vaccination requirements, who considered influenza to be a serious disease, and who agreed that influenza vaccine was safe and effective. Conclusions. A majority of HCP support influenza vaccination requirements. Moreover, providing HCP with information about the safety of influenza vaccination and communicating that immunization of HCP is a patient safety issue may be important for generating staff support for influenza vaccination requirements.

BrainCheck - a very brief tool to detect incipient cognitive decline: optimized case-finding combining patient- and informant-based data.

INTRODUCTION: Optimal identification of subtle cognitive impairment in the primary care setting requires a very brief tool combining (a) patients' subjective impairments, (b) cognitive testing, and (c) information from informants. The present study developed a new, very quick and easily administered case-finding tool combining these assessments ('BrainCheck') and tested the feasibility and validity of this instrument in two independent studies. METHODS: We developed a case-finding tool comprised of patient-directed (a) questions about memory and depression and (b) clock drawing, and (c) the informant-directed 7-item version of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Feasibility study: 52 general practitioners rated the feasibility and acceptance of the patient-directed tool. Validation study: An independent group of 288 Memory Clinic patients (mean ± SD age = 76.6 ± 7.9, education = 12.0 ± 2.6; 53.8% female) with diagnoses of mild cognitive impairment (n = 80), probable Alzheimer's disease (n = 185), or major depression (n = 23) and 126 demographically matched, cognitively healthy volunteer participants (age = 75.2 ± 8.8, education = 12.5 ± 2.7; 40% female) partook. All patient and healthy control participants were administered the patient-directed tool, and informants of 113 patient and 70 healthy control participants completed the very short IQCODE. RESULTS: Feasibility study: General practitioners rated the patient-directed tool as highly feasible and acceptable. Validation study: A Classification and Regression Tree analysis generated an algorithm to categorize patient-directed data which resulted in a correct classification rate (CCR) of 81.2% (sensitivity = 83.0%, specificity = 79.4%). Critically, the CCR of the combined patient- and informant-directed instruments (BrainCheck) reached nearly 90% (that is 89.4%; sensitivity = 97.4%, specificity = 81.6%). CONCLUSION: A new and very brief instrument for general practitioners, 'BrainCheck', combined three sources of information deemed critical for effective case-finding (that is, patients' subject impairments, cognitive testing, informant information) and resulted in a nearly 90% CCR. Thus, it provides a very efficient and valid tool to aid general practitioners in deciding whether patients with suspected cognitive impairments should be further evaluated or not ('watchful waiting').

L'analyse des renvois régionaux et interrégionaux en pratique médicale ambulatoire. [Analysis of regional and interregional referrals in ambulatory medical practice].

This article examines, in two Swiss cantons, the interdependence from a medical care point of view of various regions (health planning zones in one canton, political districts in the other). The volume and the destination of patient referrals prescribed by physicians in ambulatory practice are analyzed. The available data (on 1609 referrals) were gathered by the practitioners themselves, during a National Ambulatory Medical Care Survey type study in February-March 1981, in which 203 physicians participated. Several indicators are proposed (including an integration coefficient and an attraction coefficient for each zone); they show marked differences among the regions. This dynamic approach, based on the effective behavior of physicians, appears to be of major interest for health planning purposes (as compared with the frequent practice to use mainly parameters in relation with the availability of care services--the "supply"--numbers of professionals and/or health facilities).

Advanced nursing role to improve care among breast cancer patients

Background: Breast cancer is a devastating disease for women as it impacts on their intimate, familial, social life. We study the specificities of breast cancer nurse interventions related to demands of support, information and coordination. Material and Methods: More than 300 patients are treated every year in our institution. From 2006 January to 2008 December, the specialist nurse has reported demands of patients and professionals: 1. Patients' needs related to support, information and coordination of care were collected from consultations with her and from their phone calls on using working days help line 2. Demands of breast cancer specialists and general practitioners related to information and coordination for specific patients were collected from their phone calls. Results: The specialist nurse received 679 phone calls respectively 71.5% from patients and 28.5% from professionals. Data are presented in the following table. Table 1: Evolution of number of patients and professionals demands Patients consultations Patients calls Professionals calls 2006 93 45 32 2007 210 200 40 2008 245 240 122 - Seventy percent (70%) of women asked for information about exams and treatments by phone and in nurse consultation. - Forty percent (40%) of women asked for support after announce of diagnosis. The specialist nurse proposed consultations, 2 to 4 consultations were necessary for women to express emotional distress or psychosocial problem. With this specialised nursing support less than 15% of patients were referred to the psycho-oncologist setting. - Forty percent (40%) of professionals asked support for patients and 60% for information and coordination of care. Conclusion: The interventions of the specialist nurse have improved coordination and quality of care. The increase of professionals' demands showed that it was necessary that a nurse assures continuity of information between hospital and extrahospital structures. The breast cancer nurse empowers patients and helps them to get well by providing support to fulfil specific needs.

Reduction des risques au cabinet du généraliste chez les consommateurs de cocaine: une perspective motivationnelle [Risk reduction among cocaine users: a motivational approach in the GP's office]

Today, cocaine use is a public health issue. Cocaine is a powerfully addictive stimulant drug which use is increasing among some part of the population. After a brief description of the physical and psychological effects of cocaine use, the article presents a motivational way for general practitioners to deal with risk-reduction issues. Based on the Transtheoretical Model of human behavior change and providing clinical examples, the article focuses particularly on the two earliest stages of change: "pre-contemplation" and "contemplation".

Prescription des psychotropes au cabinet médical [Psychotropic drug prescription in general practice].

General practitioners treat patients with psychiatric disorders, for whom they have to evaluate the indication of a psychotropic medication. In addition to the patient's symptoms, the clinician has to take into account transferential and countertransferential elements linked to the prescription. Sociological factors also influence both the patient and the clinician, partly due to the western society's value of performance. Consistent with the bio-psycho-social model of disease, we recommend that the evaluation of the indication of a psychotropic medication includes the patient's symptoms, but also the psychological and sociological factors.