Improvement of antibiotic prescription in outpatient care: a cluster-randomized intervention study using a sentinel surveillance network of physicians.

OBJECTIVES: To assess the effectiveness of implementing guidelines, coupled with individual feedback, on antibiotic prescribing behaviour of primary care physicians in Switzerland. METHODS: One hundred and forty general practices from a representative Swiss sentinel network of primary care physicians participated in this cluster-randomized prospective intervention study. The intervention consisted of providing guidelines on treatment of respiratory tract infections (RTIs) and uncomplicated lower urinary tract infections (UTIs), coupled with sustained, regular feedback on individual antibiotic prescription behaviour during 2 years. The main aims were: (i) to increase the percentage of prescriptions of penicillins for all RTIs treated with antibiotics; (ii) to increase the percentage of trimethoprim/sulfamethoxazole prescriptions for all uncomplicated lower UTIs treated with antibiotics; (iii) to decrease the percentage of quinolone prescriptions for all cases of exacerbated COPD (eCOPD) treated with antibiotics; and (iv) to decrease the proportion of sinusitis and other upper RTIs treated with antibiotics. The study was registered at ClinicalTrials.gov (NCT01358916). RESULTS: While the percentage of antibiotics prescribed for sinusitis or other upper RTIs and the percentage of quinolones prescribed for eCOPD did not differ between the intervention group and the control group, there was a significant increase in the percentage of prescriptions of penicillins for all RTIs treated with antibiotics [57% versus 49%, OR=1.42 (95% CI 1.08-1.89), P=0.01] and in the percentage of trimethoprim/sulfamethoxazole prescriptions for all uncomplicated lower UTIs treated with antibiotics [35% versus 19%, OR=2.16 (95% CI 1.19-3.91), P=0.01] in the intervention group. CONCLUSIONS: In our setting, implementing guidelines, coupled with sustained individual feedback, was not able to reduce the proportion of sinusitis and other upper RTIs treated with antibiotics, but increased the use of recommended antibiotics for RTIs and UTIs, as defined by the guidelines.

The Swiss Early Psychosis Project SWEPP: a national network.

Aim: The study aims to describe the activities of the Swiss Early Psychosis Project (SWEPP) which was founded in 1999 as a national network to further and disseminate knowledge on early psychosis (EP) and to enhance collaboration between healthcare groups. Methods: The present paper is a detailed account of the initiation and the development of the Swiss network. We describe all activities such as the several educational campaigns that were addressed to primary and secondary care groups since the early days. We also provide an overview of the current status of EP services throughout the country. Results: Today, most regions in Switzerland provide specialized EP inpatient and/or outpatient services with a clinical or combined clinical research approach that targets at-risk and/or first-episode populations. Some more recently initiated EP services have been launched as collaborative models between several local or regional psychiatric services. Conclusions: The increasing number of EP services and experts in Switzerland may mirror the catalyzing contribution of the Swiss Early Psychosis Project in this important field of health care. The country's small size and the increasing density of specialized services provide excellent bases for larger-scale networking activities in the future, both in clinical and research areas.

Processus intégratifs et gouvernance clinique dans la psychiatrie institutionnelle [Integration processes and clinical governance in the psychiatric network]

The Swiss Medical Insurance Act (LAMaL) requires the planning of psychiatric care. This necessitates a coordination between the Department of Public Health and the institutional governance. Given the difficulties to draw comparisons between a wide range of systems in a federal country, the Swiss Conference of the State Directors of Health (CDS) proposed as a first step that each canton present some of the key programs they had developed. In the canton Vaud, the implementation of mobile community treatment teams and of an early intervention program for psychosis was chosen. The main challenges faced were to go past traditional divides within the organisation of the Swiss Health system and to conciliate the requirements of public health with the needs of treating teams, in order to promote early intervention in mental health disorders.

La collaboration interprofessionnelle à l'interface des institutions socio-éducative et psychiatrique. Jeux et enjeux de l'intervention auprès de personnes en situation de handicap mental et de troubles psychiques

La prise en charge et le suivi de personnes en situation de handicap mental souffrant de troubles psychiques et se trouvant donc à l'interface des domaines socio:éducatif et psychiatrique, constituent des défis complexes en matière de collaboration interprofessionnelle. Dans le canton de Vaud, les acteurs concernés par ce problème s'efforcent depuis de nombreuses années de créer des réseaux pluridisciplinaires visant un meilleur échange entre professionnels et le développement de compétences et de connaissances permettant d'améliorer le bien:être des bénéficiaires. Ce travail se propose ainsi d'étudier et de questionner ces modalités de travail dans une perspective socioculturelle (Vygotski, 1934/1997), afin d'en comprendre le fonctionnement, d'en éclairer les mécanismes et de fournir des pistes de réflexion aux professionnels. Il repose sur un travail de terrain mené auprès des membres du Dispositif de Collaboration Psychiatrie Handicap Mental (DCPHM) du Département de psychiatrie du CHUV, dont la mission principale est de faciliter la collaboration entre les institutions socio:éducatives et psychiatriques spécialisées dans le suivi des personnes en situation de handicap mental et souffrant de troubles psychiques. Le travail empirique est basé sur une approche qualitative et compréhensive des interactions sociales, et procède par une étude de terrain approfondie. Les données recueillies sont variées : notes de terrain et récolte de documentation, enregistrement de réunions d'équipe au sein du DCPHM et de réunions de réseau, et entretiens de différents types. L'analyse montre que le travail de collaboration qui incombe à l'équipe est constitué d'obstacles qui sont autant d'occasions de développement professionnel et de construction identitaire. Les résultats mettent en lumière des mécanismes discursifs de catégorisation concourant à la fois à la construction des patients comme objets d'activité, et à la construction d'une place qui légitime les interventions de l'équipe dans le paysage socio:éducatif et psychiatrique vaudois et la met au centre de l'arène professionnelle. -- Care and follow:up for people with mental disabilities suffering from psychological disorders : therefore at the interface between the socio:educational and psychiatric fields : represent complex challenges in terms of interprofessional collaboration. In the canton of Vaud, the caregivers involved in this issue have been trying for years to build multidisciplinary networks in order to better exchange between professionals and develop skills and knowledge to improve the recipients' well:being. This work thus proposes to study and question these working methods in a sociocultural perspective (Vygotski, 1934/1997) so as to understand how they operate, highlight inherent mechanisms and provide actionable insights to the professionals. It is based on fieldwork conducted among members of the Dispositif de Collaboration Psychiatrie Handicap Mental (DCPHM), of the Psychiatry Department at the CHUV University Hospital in Lausanne, whose main mission is to facilitate collaboration between the socio:educational and psychiatric institutions specialising in monitoring people presenting with both mental handicap and psychiatric disorder. The empirical work is based on a qualitative and comprehensive approach to social interactions, and conducted based on an in:depth field study. The data collected are varied - field notes and documentation collection, recordings of team meetings within the DCPHM and network meetings, and various types of interviews. The analysis shows that the collaborative work that befalls the team consists of obstacles, all of which provide opportunities for professional development and identity construction. The results highlight discursive strategies of categorisation which contribute both to the construction of the patients as objects of activity and to building a position that legitimates the team's interventions in the socio: educational and psychiatric landscape of canton Vaud and puts it in the centre of the professional arena.

Intervention précoce dans la phase initiale des troubles psychotiques à Lausanne: quels problèmes et quelles solutions [Early intervention for the initial phase of psychotic disorders in Lausanne: what problems and what solutions?]

Schizophrenia has long been considered with pessimism, but the recent interest in the early phase of psychotic disorders has modified this often unjustified perception. Literature has demonstrated the benefit of the development of programs specialised in the treatment of early psychosis, which tend to be developed in many countries. It is however important to match them to local needs as well as to the structure of local health services. This paper reviews elements that justify such a development in Lausanne, Switzerland, and describe its various elements.

Trapping of naive lymphocytes triggers rapid growth and remodeling of the fibroblast network in reactive murine lymph nodes.

Adaptive immunity is initiated in T-cell zones of secondary lymphoid organs. These zones are organized in a rigid 3D network of fibroblastic reticular cells (FRCs) that are a rich cytokine source. In response to lymph-borne antigens, draining lymph nodes (LNs) expand several folds in size, but the fate and role of the FRC network during immune response is not fully understood. Here we show that T-cell responses are accompanied by the rapid activation and growth of FRCs, leading to an expanded but similarly organized network of T-zone FRCs that maintains its vital function for lymphocyte trafficking and survival. In addition, new FRC-rich environments were observed in the expanded medullary cords. FRCs are activated within hours after the onset of inflammation in the periphery. Surprisingly, FRC expansion depends mainly on trapping of naïve lymphocytes that is induced by both migratory and resident dendritic cells. Inflammatory signals are not required as homeostatic T-cell proliferation was sufficient to trigger FRC expansion. Activated lymphocytes are also dispensable for this process, but can enhance the later growth phase. Thus, this study documents the surprising plasticity as well as the complex regulation of FRC networks allowing the rapid LN hyperplasia that is critical for mounting efficient adaptive immunity.