European French-speaking study from the GEMO group on bone metastases management: a special focus on external beam radiotherapy practice survey.

This study seeks to perform a survey of patterns of practice among the different physicians involved in the bone metastases management, with special focus on external beam radiotherapy (EBRT).A questionnaire about bone metastases based on clinical cases and supplemented with general questions, including medical therapies, EBRT and metabolic radiotherapy strategies, surgery, and supportive care approaches, was sent to 4,706 French-speaking physicians in Belgium, France, Luxemburg, and Switzerland.Overall, 644 questionnaires were analyzed. Twenty-eight percent concerned the radiotherapy approach and were judged adequate to respond to the part dedicated to EBRT. Sixty-nine percent of physicians used a total dose irradiation of 30 Gy delivered in ten fractions. A large majority (75%) used two opposed fields prescribed at mid-depth (30%), or with non-equally weighted fields (45%). Seventy percent irradiated also above and below the concerned vertebra. A dosimetry planning treatment was done in 85% and high-energy megavoltage photons were used in 42%. Moreover, 54% physicians used short course radiotherapy in routine.Radiotherapy remains the mainstay of treatment of bone metastases, but there is substantial heterogeneity in clinical practice. Guidelines and treatment protocols are required to improve the treatment quality.

Computerized advice on drug dosage to improve prescribing practice.

BACKGROUND: Maintaining therapeutic concentrations of drugs with a narrow therapeutic window is a complex task. Several computer systems have been designed to help doctors determine optimum drug dosage. Significant improvements in health care could be achieved if computer advice improved health outcomes and could be implemented in routine practice in a cost effective fashion. This is an updated version of an earlier Cochrane systematic review, by Walton et al, published in 2001. OBJECTIVES: To assess whether computerised advice on drug dosage has beneficial effects on the process or outcome of health care. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialized register (June 1996 to December 2006), MEDLINE (1966 to December 2006), EMBASE (1980 to December 2006), hand searched the journal Therapeutic Drug Monitoring (1979 to March 2007) and the Journal of the American Medical Informatics Association (1996 to March 2007) as well as reference lists from primary articles. SELECTION CRITERIA: Randomized controlled trials, controlled trials, controlled before and after studies and interrupted time series analyses of computerized advice on drug dosage were included. The participants were health professionals responsible for patient care. The outcomes were: any objectively measured change in the behaviour of the health care provider (such as changes in the dose of drug used); any change in the health of patients resulting from computerized advice (such as adverse reactions to drugs). DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Twenty-six comparisons (23 articles) were included (as compared to fifteen comparisons in the original review) including a wide range of drugs in inpatient and outpatient settings. Interventions usually targeted doctors although some studies attempted to influence prescriptions by pharmacists and nurses. Although all studies used reliable outcome measures, their quality was generally low. Computerized advice for drug dosage gave significant benefits by:1.increasing the initial dose (standardised mean difference 1.12, 95% CI 0.33 to 1.92)2.increasing serum concentrations (standradised mean difference 1.12, 95% CI 0.43 to 1.82)3.reducing the time to therapeutic stabilisation (standardised mean difference -0.55, 95%CI -1.03 to -0.08)4.reducing the risk of toxic drug level (rate ratio 0.45, 95% CI 0.30 to 0.70)5.reducing the length of hospital stay (standardised mean difference -0.35, 95% CI -0.52 to -0.17). AUTHORS' CONCLUSIONS: This review suggests that computerized advice for drug dosage has some benefits: it increased the initial dose of drug, increased serum drug concentrations and led to a more rapid therapeutic control. It also reduced the risk of toxic drug levels and the length of time spent in the hospital. However, it had no effect on adverse reactions. In addition, there was no evidence to suggest that some decision support technical features (such as its integration into a computer physician order entry system) or aspects of organization of care (such as the setting) could optimise the effect of computerised advice.

Die Hypercholesterinämie in der Allgemeinpraxis: zwei Repräsentativbefragungen in der Schweiz. [Hypercholesterolemia in general practice: 2 representative surveys in Switzerland].

Two representative surveys of general practitioners in 1987 and 1989 showed, that cigarette smoking and high blood pressure are considered the most important risk factors for coronary heart disease. Elevated blood cholesterol level rank third. Between the two surveys no significant changes took place. The blood cholesterol level is usually measured at a check-up visit or in presence of another risk factor. Routine measurement is not common. At what level do Swiss physicians initiate a therapy? The median range in 1989 for a diet therapy was 6.2-6.7 mmol/l (240-260 mg%) for a 30 years old person, and 6.7-7.2 mmol/l for a 60 years old person. Lipid-lowering drugs are used at about 1 mmol/l (40 mg%) higher levels and there is less agreement between the physicians. Within two years the levels of initiating therapy decreased significantly. Differences between the three Swiss language regions (german/french/italian) in initiating therapy can be seen. 90% of the physicians mentioned compliance problems with a diet therapy. In 1989 half of the surveyed doctors experienced insufficient results in both diet and drug treatment. Further, compliance problems and side effects of drug treatment are mentioned. Half of the physicians reported having tested their own cholesterol level in the last 12 months. Older physicians are considerably more conscious of high cholesterol levels than younger.

Teaching cardiac auscultation to trainees in internal medicine and family practice: does it work?

BACKGROUND: The general proficiency in physical diagnostic skills seems to be declining in relation to the development of new technologies. The few studies that have examined this question have invariably used recordings of cardiac events obtained from patients. However, this type of evaluation may not correlate particularly well with bedside skills. Our objectives were 1) To compare the cardiac auscultatory skills of physicians in training with those of experienced cardiologists by using real patients to test bedside diagnostic skills. 2) To evaluate the impact of a five-month bedside cardiac auscultation training program. METHODS: 1) In an academic primary care center, 20 physicians (trainees in internal medicine and family practice) and two skilled academic cardiologists listened to 33 cardiac events in 13 patients directly at bedside and identified the cardiac events by completing an open questionnaire. Heart sounds, murmurs and diagnosis were determined beforehand by an independent skilled cardiologist and were validated by echocardiography. Thirteen primary cardiologic diagnoses were possible.2) Ten of the physicians agreed to participate in a course of 45-minute sessions once a week for 5 months. After the course they listened again to the same patients (pre/post-interventional study). RESULTS: 1) The experts were the most skillful, achieving 69% recognition of heart sounds and murmurs and correct diagnoses in 62% of cases. They also heard all of the diastolic murmurs. The residents heard only 40% of the extra heart sounds and made a correct diagnosis in 24% of cases. 2) After the weekly training sessions, their mean percentage for correct diagnosis was 35% [an increase of 66% (p < 0.05)]. CONCLUSIONS: The level of bedside diagnostic skills in this relatively small group of physicians in training is indeed low, but can be improved by a course focusing on realistic bedside teaching.

Laparoscopic and open colorectal surgery in everyday practice : retrospective study

Résumé Introduction: La plupart des études disponibles sur la chirurgie colorectale par laparoscopie concernent des patients hautement sélectionnés. Le but de cette étude est d'analyser les résultats à court et à long terme de l'ensemble des patients traités dans un service de chirurgie générale. Méthodes: Il s'agit d'une analyse rétrospective d'un registre prospectif interne au service, dans lequel tous les patients consécutifs opérés pour la première fois du colon et du rectum entre mars 1993 et décembre 1997 ont été enregistrés. Les informations concernant le suivi ont été collectées par questionnaire. Résultats: Un total de 187 patients ont été opérés par laparoscopie et 215 patients par chirurgie ouverte durant la période d'étude. Les informations concernant le suivi ont pu être collectées dans 95% des cas avec une évolution de 1-107 mois (médiane 59 mois), respectivement de 1-104 mois (médiane 53 mois). Une conversion fut nécessaire dans 28 cas (15%) mais ceux-ci restent inclus dans le groupe laparoscopie pour l'analyse par intention de traitement. Dans le groupe laparoscopie, les opérations ont duré plus longtemps (205 vs 150 min, p<0.001) mais l'hospitalisation a été plus courte (8 vs 13 jours, p<0.001). La reprise du transit a été plus rapide après laparoscopie, mais uniquement après intervention sur le colon gauche (3 vs 4 jours, p<0.01). Cependant, la sélection préopératoire (nombre plus élevé d'urgences et de patients avec un risque anesthésiologique élevé dans le groupe de la chirurgie ouverte) a été favorable à la laparoscopie. Le taux de complications (global ainsi que pour chaque complication chirurgicale) a été similaire dans les deux groupes, avec un taux global de 20% environ. Conclusions: Malgré une sélection favorable des cas, uniquement très peu d'avantages à la laparoscopie sur la chirurgie ouverte ont pu être observés. Abstract Background: Most studies available on laparoscopic colorectal surgery focus on highly selected patient groups. The aim of the present study was to review short- and long-term outcome of everyday patients treated in a general surgery department. Methods: Retrospective review was carried out of a prospective database of all consecutive patients having undergone primary laparoscopic (LAP) or open colorectal surgery between March 1993 and December 1997. Follow-up data were completed via questionnaire. Results: A total of 187 patients underwent LAP resection and 215 patients underwent open surgery. Follow up was complete in 95% with a median of 59 months (range, 1-107 months) and 53 months (range, 1-104 months), respectively. There were 28 conversions (15%) in the LAP group and these remained in the LAP group in an intention-to-treat analysis. The LAP operations lasted significantly longer for all types of resections (205 vs 150 min, P<0.001) and hospital stay was shorter (8 vs 13 days, P<0.001). Recovery of intestinal function was faster in the LAP group, but only after left-sided procedures (3 vs 4days, P<0.01). However, preoperative patient selection (more emergency operations and patients with higher American Society of Anesthesiologists (ASA) score in the open group) had a major influence on these elements and favours the LAP group. Surprisingly, the overall surgical complication rate (including long-term complications such as wound hernia) was 20% in both groups with rates of individual complications also being comparable in both groups. Conclusion: Despite a patient selection favourable to the laparoscopy group, only little advantage in postoperative outcome could be shown for the minimally invasive over the open approach in the everyday patient.

A health behaviour cross-sectional study of immigrants and non-immigrants in a Swiss urban general-practice setting.

BACKGROUND: Little is known about smoking, unhealthy use of alcohol, and risk behaviours for sexually transmitted diseases (STDs) in immigrants from developed and developing countries. METHOD: We performed a cross-sectional study of 400 patients who consulted an academic emergency care centre at a Swiss university hospital. The odds ratios for having one or more risk behaviours were adjusted for age, gender, and education level. RESULTS: Immigrants from developing countries were less likely to use alcohol in an unhealthy manner (OR = 0.35, 95% CI 0.22-0.57) or practise risk behaviours for STDs (OR = 0.31, 95% CI 0.13-0.74). They were also less likely to have any of the three studied risk behaviours (OR = 2.5, 95% CI 1.5-4.3). DISCUSSION: In addition to the usual determinants, health behaviours are also associated with origin; distinguishing between immigrants from developing and developed countries is useful in clinical settings. Surprisingly, patients from developing countries tend to possess several protective characteristics.

Outpatient prescriptions practice and writing quality in a paediatric university hospital.

BACKGROUND: The writing of prescriptions is an important aspect of medical practice. This activity presents some specific problems given a danger of misinterpretation and dispensing errors in community pharmacies. The objective of this study was to determine the evolution of the prescription practice and writing quality in the outpatient clinics of our paediatric university hospital.¦METHODS: Copies of prescriptions written by physicians were collected from community pharmacies in the region of our hospital for a two-month period in 2005 and 2010. They were analysed according to standard criteria, including both formal and pharmaceutical aspects.¦RESULTS: A total of 597 handwritten prescriptions were reviewed in 2005 and 633 in 2010. They contained 1,456 drug prescriptions in 2005 and 1,348 in 2010. Fifteen drugs accounted for 80% of all prescriptions and the most common drugs were paracetamol and ibuprofen. A higher proportion of drugs were prescribed as International Nonproprietary Names (INN) or generics in 2010 (24.7%) compared with 2005 (20.9%). Of the drug prescriptions examined, 55.5% were incomplete in 2005 and 69.2% in 2010. Moreover in 2005, 3.2% were legible only with difficulty, 22.9% were ambiguous, and 3.0% contained an error. These proportions rose respectively to 5.2%, 27.8%, and 6.8% in 2010.¦CONCLUSION: This study showed that fifteen different drugs represented the majority of prescriptions, and a quarter of them were prescribed as INN or generics in 2010; and that handwritten prescriptions contained numerous omissions and preventable errors. In our hospital computerised prescribing coupled with advanced decision support is eagerly awaited.

Enseignement de recommandations pour la pratique: la prévention et le dépistage [Teaching practice recommendations: prevention and screening].

The aim of this article is to provide guidance to family doctors on how to tutor students about effective screening and primary prevention. Family doctors know their patients and adapt national and international guidelines to their specific context, risk profile, sex and age as well as to the prevalence of the disorders under consideration. Three cases are presented to illustrate guideline use according to the level of evidence (for a 19-year-old man, a 60-year-old woman, and an 80-year-old man). A particular strength of family medicine is that doctors see their patients over the years. Thus they can progressively go through the various prevention strategies, screening, counselling and immunisation, accompanying their patients with precious advice for their health throughout their lifetime.

Paediatric oral peanut challenges: a comparison of practice in London and Western Switzerland.

BACKGROUND: There are guidelines on how to develop a food challenge protocol, but at present there is no gold standard guidance on method, and separate units produce differing protocols. METHODS: We performed a retrospective analysis of 200 patients' data from the paediatric allergy units in Lausanne and Geneva, Western Switzerland, and St Thomas' Hospital (STH), UK. RESULTS: St Thomas' Hospital has a younger cohort with a lower overall mean spIgE (2.36 kU/l vs 8.00 kU/l, P = 0.004). The target peanut protein volumes differed: Switzerland 4.4 g vs STH 8.4 g. Despite this, the dose actually achieved in positive challenges was not significantly different (2.33 g vs 1.49 g, P = 0.16). 26% of challenges reacted at 4 g or more of peanut protein. CONCLUSIONS: The differences in results highlight how the variation in reasoning behind food challenge alters the outcome. Standardization of food challenges would allow easy comparison between hospitals and geographical areas for research purposes.

L'Evidence-based nursing, un levier au changement des pratiques infirmières [Evidence-based nursing, a driver for change in nursing practice].

A urology nursing team examined its perioperative practices in the light of scientific data and implemented updated care practices adapted to this context.This experience favours the development of skills essential for interdisciplinary collaboration drawing on the resources of each profession, to work towards a common goal for the benefit of the patient.