Nouveautés en médecine ambutatoire: dépistage, traitement et iatrogénicité [Innovations in ambulatory care: screening, treatment and iatrogenicity]

Cette année, six études utiles pour la pratique ont été retenues. L'indication à la mammographie entre 40 et 49 ans devrait être évaluée individuellement et en tenant compte des risques/bénéfices de cet examen. Au-delà de 65 ans, un dépistage systématique de la fibrillation auriculaire avec prise de pouls puis ECG (si pouls irrégulier) pourrait être réalisé de manière systématique. Les risques de complications postcolonoscopie existent, particulièrement suite à des biopsies/polypectomies, et ce risque devrait être discuté. Les inhibiteurs de la pompe à protons au long court sont un facteur de risque de fracture de hanche. S'il est important de prendre en charge des pressions artérielles élevées au-delà de 80 ans, il faut être prudent (orthostatisme). Une corticothérapie précoce suite à une paralysie faciale périphérique est efficace. This year we have selected six studies useful for the day to day practice. A mammography in women 40 to 49 years of age should be evaluated taking into account the patient's profile and the possible risks and benefits of this exam. In patients over 65 years of age, a systematic atrial fibrillation screening, with pulse rate measuring then ECG (if irregular beat) should be realised on a regular basis. The risks for complications following colonoscopies do exist, especially after biopsies/polypectomies and this risk should be discussed. Long term proton pump inhibitor treatment is a risk factor for hip fracture. It is important to treat high blood pressure problems in the elderly, but the orthostatic risks should be adressed. A corticoid treatment started quickly for Bell's palsy is efficient

A high proportion of users of low-threshold facilities with needle exchange programmes in Switzerland are currently on methadone treatment: implications for new approaches in harm reduction and care.

BACKGROUND: Increasingly, patients receiving methadone treatment are found in low threshold facilities (LTF), which provide needle exchange programmes in Switzerland. This paper identifies the characteristics of LTF attendees receiving methadone treatment (MT) compared with other LTF attendees (non-MT). METHODS: A national cross-sectional survey was conducted in 2006 over five consecutive days in all LTF (n=25). Attendees were given an anonymous questionnaire, collecting information on socio-demographic indicators, drug consumption, injection, methadone treatment, and self-reported HIV and HCV status. Univariate analysis and logistic regression were performed to compare MT to non-MT. The response rate was 66% (n=1128). RESULTS: MT comprised 57.6% of the sample. In multivariate analysis, factors associated with being on MT were older age (OR: 1.38), being female (OR: 1.60), having one's own accommodation (OR: 1.56), receiving public assistance (OR: 2.29), lifetime injecting (OR: 2.26), HIV-positive status (OR: 2.00), and having consumed cocaine during the past month (OR: 1.37); MT were less likely to have consumed heroin in the past month (OR: 0.76, not significant) and visited LTF less often on a daily basis (OR: 0.59). The number of injections during the past week was not associated with MT. CONCLUSIONS: More LTF attendees were in the MT group, bringing to light an underappreciated LTF clientele with specific needs. The MT group consumption profile may reflect therapeutic failure or deficits in treatment quality and it is necessary to acknowledge this and to strengthen the awareness of LTF personnel about potential needs of MT attendees to meet their therapeutic goals.

Abdominal infections in the intensive care unit: characteristics, treatment and determinants of outcome.

BACKGROUND: Abdominal infections are frequent causes of sepsis and septic shock in the intensive care unit (ICU) and are associated with adverse outcomes. We analyzed the characteristics, treatments and outcome of ICU patients with abdominal infections using data extracted from a one-day point prevalence study, the Extended Prevalence of Infection in the ICU (EPIC) II. METHODS: EPIC II included 13,796 adult patients from 1,265 ICUs in 75 countries. Infection was defined using the International Sepsis Forum criteria. Microbiological analyses were performed locally. Participating ICUs provided patient follow-up until hospital discharge or for 60 days. RESULTS: Of the 7,087 infected patients, 1,392 (19.6%) had an abdominal infection on the study day (60% male, mean age 62 ± 16 years, SAPS II score 39 ± 16, SOFA score 7.6 ± 4.6). Microbiological cultures were positive in 931 (67%) patients, most commonly Gram-negative bacteria (48.0%). Antibiotics were administered to 1366 (98.1%) patients. Patients who had been in the ICU for ≤ 2 days prior to the study day had more Escherichia coli, methicillin-sensitive Staphylococcus aureus and anaerobic isolates, and fewer enterococci than patients who had been in the ICU longer. ICU and hospital mortality rates were 29.4% and 36.3%, respectively. ICU mortality was higher in patients with abdominal infections than in those with other infections (29.4% vs. 24.4%, p < 0.001). In multivariable analysis, hematological malignancy, mechanical ventilation, cirrhosis, need for renal replacement therapy and SAPS II score were independently associated with increased mortality. CONCLUSIONS: The characteristics, microbiology and antibiotic treatment of abdominal infections in critically ill patients are diverse. Mortality in patients with isolated abdominal infections was higher than in those who had other infections.

Trends in prevalence, awareness, treatment and control of hypertension in the Republic of Seychelles (African region) between 1989 and 2013

Objective: We assessed the awareness, treatment and control of hypertension in the Seychelles between 1989 and 2013. In the Seychelles, heath care is free to all inhabitants within a national health system, inclusive all hypertension medications. Design and method: Four surveys were conducted in 1989, 1994, 2004 and 2013 (Seychelles Heart Studies I, II, III and IV) in random samples of the population aged 25-64 (N >1000 and participation rate >75% in each sur acceptance of the program, though no objective index could be calculated. In total, 15% of device measurements were above high normal values and would correspond to either newly diagnosed HNT (second measurement required) or to poorly controlled known HTN. It should be stressed that 53 women without HTN who completed the questionnaire had abnormal BP values, including the 29 women who also contacted the research team. It could be speculated that approximately 2% of women would be first diagnosed with HTN following the completion of the initial phase of the screening program. Conclusions: Hypertension screening in the hair salon setting was proved to be conveniently applicable and well accepted both by owners and by customers and could lead to the new diagnosis of hypertension for 2% of the female clients. Further research is warranted to assess the effectiveness of the program.

Updated Swiss guidelines for the treatment and follow-up of cutaneous melanoma.

Melanoma is the most common lethal cutaneous neoplasm. In order to harmonize treatment and follow-up of melanoma patients, guidelines for the management of melanoma in Switzerland have been inaugurated in 2001. These have been approved by all Swiss medical societies involved in the care of melanoma patients. New data necessitated changes concerning the safety margins (reduction to maximally 2 cm) and modifications of the recommendations of follow-up.

Trends in prevalence, awareness, treatment and control of hypertension in the Republic of Seychelles (African region) between 1989 and 2013 [Poster]

Background: Few data exist on secular trends of high blood pressure (HBP) detection and control in low and middle income countries, particularly in the African region. This study examines trends of HBP over 25 years based on 4 independent population surveys. In the Seychelles, heath care is free to all inhabitants within a national health system, inclusive all HBP medications. Previous studies have shown a transition from traditional to cardiometabolic cardiovascular risk factors in Seychelles. Age adjusted cardiovascular disease mortality rates is high but decreasing over the last two decades.

Treatment and Early Intervention in Psychosis Program (TIPP-Lausanne): implementation of an early intervention programme for psychosis in Switzerland.

AIM: In a survey conducted in the Lausanne catchment area in 2000, we could estimate on the basis of file assessment that first-episode psychosis (FEP) patients had psychotic symptoms for more than 2 years before treatment and that 50% did not attend any outpatient appointment after discharge from hospital. In this paper, we describe the implementation of a specialized programme aimed at improving engagement and quality of treatment for early psychosis patients in the Lausanne catchment area in Switzerland. METHOD: The Treatment and Early Intervention in Psychosis Program-Lausanne is a comprehensive 3-year programme composed of (i) an outpatient clinic based on assertive case management; (ii) a specialized inpatient unit; and (iii) an intensive mobile team, connected for research to the Center for Psychiatric Neuroscience. RESULTS: Eight years after implementation, the programme has included 350 patients with a disengagement rate of 9% over 3 years of treatment. All patients have been assessed prospectively and 90 participated in neurobiological research. Based on this experience, the Health Department funded the implementation of similar programmes in other parts of the state, covering a total population of 540 000 people. CONCLUSION: Programmes for early intervention in psychosis have a major impact on patients' engagement into treatment. While development of mobile teams and assertive case management with specific training are crucial, they do not necessitate massive financial support to be started. Inclusion of a research component is important as well, in terms of service planning and improvement of both quality of care and impact of early intervention strategies.

The impact of penicillinase on cefamandole treatment and prophylaxis of experimental endocarditis due to methicillin-resistant Staphylococcus aureus.

Beta-lactams active against methicillin-resistant Staphylococcus aureus (MRSA) must resist penicillinase hydrolysis and bind penicillin-binding protein 2A (PBP 2A). Cefamandole might share these properties. When tested against 2 isogenic pairs of MRSA that produced or did not produce penicillinase, MICs of cefamandole (8-32 mg/L) were not affected by penicillinase, and cefamandole had a > or =40 times greater PBP 2A affinity than did methicillin. In rats, constant serum levels of 100 mg/L cefamandole successfully treated experimental endocarditis due to penicillinase-negative isolates but failed against penicillinase-producing organisms. This suggested that penicillinase produced in infected vegetations might hydrolyze the drug. Indeed, cefamandole was slowly degraded by penicillinase in vitro. Moreover, its efficacy was restored by combination with sulbactam in vivo. Cefamandole also uniformly prevented MRSA endocarditis in prophylaxis experiments, a setting in which bacteria were not yet clustered in the vegetations. Thus, while cefamandole treatment was limited by penicillinase, the drug was still successful for prophylaxis of experimental MRSA endocarditis.

Santé et besoins en soins des personnes âgées: différences liées au genre [Health status and care giving needs in the elderly: gender related differences].

The health status and need for care differ depending on the gender. The most notable differences are life expectancy, life expectancy in good health and the prevalence of geriatric syndromes or chronic illnesses. Some social health determinants (social isolation or financial precariousness) seem to act as risk factors for vulnerability, mostly amongst old or very old women. Through some examples of differences between men and women in terms of health and caregiving needs, this article tries to heighten the awareness of health professionals to a gender based approach of the elderly patient in order to promote the best possible equity in healthcare.

Névrite vestibulaire: traitement et pronostic [Vestibular neuritis: treatment and prognosis].

Vestibular neuritis is a sudden unilateral peripheral vestibular deficit of unknown origin without associated hearing loss. It is the second cause of peripheral vertigo after Benign Paroxysmal Positional Vertigo (BPPV). The etiology remains unclear and some treatments are still controversial. The prognosis is good. The differential diagnosis of the disease mainly includes an acute vertigo of central origin. This article summarizes the management and prognosis of vestibular neuritis.