Interpretation and use of FRAX in clinical practice.

The introduction of the WHO FRAX® algorithms has facilitated the assessment of fracture risk on the basis of fracture probability. Its use in fracture risk prediction has strengths, but also limitations of which the clinician should be aware and are the focus of this review INTRODUCTION: The International Osteoporosis Foundation (IOF) and the International Society for Clinical Densitometry (ISCD) appointed a joint Task Force to develop resource documents in order to make recommendations on how to improve FRAX and better inform clinicians who use FRAX. The Task Force met in November 2010 for 3 days to discuss these topics which form the focus of this review. METHODS: This study reviews the resource documents and joint position statements of ISCD and IOF. RESULTS: Details on the clinical risk factors currently used in FRAX are provided, and the reasons for the exclusion of others are provided. Recommendations are made for the development of surrogate models where country-specific FRAX models are not available. CONCLUSIONS: The wish list of clinicians for the modulation of FRAX is large, but in many instances, these wishes cannot presently be fulfilled; however, an explanation and understanding of the reasons may be helpful in translating the information provided by FRAX into clinical practice.

Task-shifting in the delivery of hormonal contraceptive methods: Validation of a questionnaire and preliminary results.

Guilbert ER, Morin D, Guilbert AC, Gagnon H, Robitaille J, Richardson M. International Journal of Nursing Practice 2011; 17: 315-321 Task-shifting in the delivery of hormonal contraceptive methods: Validation of a questionnaire and preliminary results In order to palliate the access problem to effective contraceptive methods in Quebec, Canada, as well as to legitimate nurses' practices in family planning, a collaborative agreement was developed that allow nurses, in conjunction with pharmacists, to give hormonal contraceptives to healthy women of reproductive age for a 6 month period. Training in hormonal contraception was offered to targeted nurses before they could begin this practice. A questionnaire, based on Rogers's theory of diffusion of innovations, was elaborated and validated to specifically evaluate this phenomenon. Preliminary results show that the translation of training into practice might be suboptimal. The validated questionnaire can now be used to fully understand the set of factors influencing this new practice.

Joint Official Positions of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX(®). Executive Summary of the 2010 Position Development Conference on Interpretation and use of FRAX® in clinical practice.

The International Society for Clinical Densitometry (ISCD) and the International Osteoporosis Foundation (IOF) convened the FRAX(®) Position Development Conference (PDC) in Bucharest, Romania, on November 14, 2010, following a two-day joint meeting of the ISCD and IOF on the "Interpretation and Use of FRAX(®) in Clinical Practice." These three days of critical discussion and debate, led by a panel of international experts from the ISCD, IOF and dedicated task forces, have clarified a number of important issues pertaining to the interpretation and implementation of FRAX(®) in clinical practice. The Official Positions resulting from the PDC are intended to enhance the quality and clinical utility of fracture risk assessment worldwide. Since the field of skeletal assessment is still evolving rapidly, some clinically important issues addressed at the PDCs are not associated with robust medical evidence. Accordingly, some Official Positions are based largely on expert opinion. Despite limitations inherent in such a process, the ISCD and IOF believe it is important to provide clinicians and technologists with the best distillation of current knowledge in the discipline of bone densitometry and provide an important focus for the scientific community to consider. This report describes the methodology and results of the ISCD-IOF PDC dedicated to FRAX(®).

Explaining rapid transitions in the practice of flood risk management

This article draws on empirical material to reflect on what drives rapid change in flood risk management practice, reflecting wider interest in the way that scientific practices make risk landscapes and a specific focus on extreme events as drivers of rapid change. Such events are commonly referred to as a form of creative destruction, ones that reveal both the composition of socioenvironmental assemblages and provide a creative opportunity to remake those assemblages in alternate ways, therefore rapidly changing policy and practice. Drawing on wider thinking in complexity theory, we argue that what happens between events might be as, if not more, important than the events themselves. We use two empirical examples concerned with flood risk management practice: a rapid shift in the dominant technologies used to map flood risk in the United Kingdom and an experimental approach to public participation tested in two different locations, with dramatically different consequences. Both show that the state of the socioenvironmental assemblage in which the events take place matters as much as the magnitude of the events themselves. The periods between rapid changes are not simply periods of discursive consolidation but involve the ongoing mutation of such assemblages, which could either sensitize or desensitize them to rapid change. Understanding these intervening periods matters as much as the events themselves. If events matter, it is because of the ways in which they might bring into sharp focus the coding or framing of a socioenvironmental assemblage in policy or scientific practice irrespective of whether or not those events evolve the assemblage in subtle or more radical ways.

Inheritance of ductile and brittle structures in the development of large rock slope instabilities: Examples from western Norway

The high density of slope failures in western Norway is due to the steep relief and to the concentration of various structures that followed protracted ductile and brittle tectonics. On the 72 investigated rock slope instabilities, 13 were developed in soft weathered mafic and phyllitic allochthons. Only the intrinsic weakness of such rocks increases the susceptibility to gravitational deformation. In contrast, the gravitational structures in the hard gneisses reactivate prominent ductile or/and brittle fabrics. At 30 rockslides along cataclinal slopes, weak mafic layers of foliation are reactivated as basal planes. Slope-parallel steep foliation forms back-cracks of unstable columns. Folds are specifically present in the Storfjord area, together with a clustering of potential slope failures. Folding increases the probability of having favourably orientated planes with respect to the gravitational forces and the slope. High water pressure is believed to seasonally build up along the shallow-dipping Caledonian detachments and may contribute to destabilization of the rock slope upwards. Regional cataclastic faults localized the gravitational structures at 45 sites. The volume of the slope instabilities tends to increase with the amount of reactivated prominent structures and the spacing of the latter controls the size of instabilities.

Current Molecular Imaging of Spinal Tumors in Clinical Practice.

Energy metabolism measurements in spinal cord tumors, as well as in osseous spinal tumors/metastasis in vivo, are rarely performed only with molecular imaging (MI) by positron emission tomography (PET). This imaging modality developed from a small number of basic clinical science investigations followed by subsequent work that influenced and enhanced the research of others. Apart from precise anatomical localization by coregistration of morphological imaging and quantification, the most intriguing advantage of this imaging is the opportunity to investigate the time course (dynamics) of disease-specific molecular events in the intact organism. Most importantly, MI represents one of the key technologies in translational molecular neuroscience research, helping to develop experimental protocols that may later be applied to human patients. PET may help monitor a patient at the vertebral level after surgery and during adjuvant treatment for recurrent or progressive disease. Common clinical indications for MI of primary or secondary CNS spinal tumors are: (i) tumor diagnosis, (ii) identification of the metabolically active tumor compartments (differentiation of viable tumor tissue from necrosis) and (iii) prediction of treatment response by measurement of tumor perfusion or ischemia. While spinal PET has been used under specific circumstances, a question remains as to whether the magnitude of biochemical alterations observed by MI in CNS tumors in general (specifically spinal tumors) can reveal any prognostic value with respect to survival. MI may be able to better identify early disease and to differentiate benign from malignant lesions than more traditional methods. Moreover, an adequate identification of treatment effectiveness may influence patient management. MI probes could be developed to image the function of targets without disturbing them or as treatment to modify the target's function. MI therefore closes the gap between in vitro and in vivo integrative biology of disease. At the spinal level, MI may help to detect progression or recurrence of metastatic disease after surgical treatment. In cases of nonsurgical treatments such as chemo-, hormone- or radiotherapy, it may better assess biological efficiency than conventional imaging modalities coupled with blood tumor markers. In fact, PET provides a unique possibility to correlate topography and specific metabolic activity, but it requires additional clinical and experimental experience and research to find new indications for primary or secondary spinal tumors.

Segmentation of brain structures in presence of a space-occupying lesion.

Brain deformations induced by space-occupying lesions may result in unpredictable position and shape of functionally important brain structures. The aim of this study is to propose a method for segmentation of brain structures by deformation of a segmented brain atlas in presence of a space-occupying lesion. Our approach is based on an a priori model of lesion growth (MLG) that assumes radial expansion from a seeding point and involves three steps: first, an affine registration bringing the atlas and the patient into global correspondence; then, the seeding of a synthetic tumor into the brain atlas providing a template for the lesion; finally, the deformation of the seeded atlas, combining a method derived from optical flow principles and a model of lesion growth. The method was applied on two meningiomas inducing a pure displacement of the underlying brain structures, and segmentation accuracy of ventricles and basal ganglia was assessed. Results show that the segmented structures were consistent with the patient's anatomy and that the deformation accuracy of surrounding brain structures was highly dependent on the accurate placement of the tumor seeding point. Further improvements of the method will optimize the segmentation accuracy. Visualization of brain structures provides useful information for therapeutic consideration of space-occupying lesions, including surgical, radiosurgical, and radiotherapeutic planning, in order to increase treatment efficiency and prevent neurological damage.

How critical is timing for the diagnosis of influenza in general practice?

Résumé La performance diagnostic des signes et symptômes de la grippe a principalement été étudiée dans le cadre d'études contrôlées avec des critères d'inclusion stricts. Il apparaît nécessaire d'évaluer ces prédicteurs dans le cadre d'une consultation ambulatoire habituelle en tenant compte du délai écoulé entre le début des symptômes et la première consultation ainsi que la situation épidémiologique. Cette étude prospective a été menée à la Policlinique Médicale Universitaire durant l'hiver 1999-2000. Les patients étaient inclus s'ils présentaient un syndrome grippal et si le praticien suspectait une infection à Influenza. Le médecin administrait un questionnaire puis une culture d'un frottis de gorge était réalisée afin de documenter l'infection. 201 patients ont été inclus dans l'étude. 52% avaient une culture positive pour Influenza. En analyse univariée, une température > 37.8° (OR 4.2; 95% CI 2.3-7.7), une durée des symptômes < 48h (OR 3.2; 1.8-5.7), une toux (OR 3.2; 1-10.4) et des myalgies (OR 2.8; 1.0-7.5) étaient associés au diagnostic de grippe. En analyse de régression logistique, le modèle le plus performant qui prédisait la grippe était l'association d'une durée des symptômes <48h, une consultation en début d'épidémie, une température > 37.8° et une toux (sensibilité 79%, spécificité 69%, valeur prédictive positive 67%, une valeur prédictive négative de 73% et aire sous la courbe (ROC) de 0.74). En plus des signes et symptômes prédicteurs de la grippe, le médecin de premier recours devrait prendre en compte dans son jugement la durée des symptômes avant la première consultation et le contexte épidémiologique (début, pic, fin de l'épidémie), car ces deux paramètres modifient considérablement la valeurs des prédicteurs lors de l'évaluation de la probabilité clinique d'un patient d'avoir une infection à Influenza.

Questions et réponses sur l'utilisation du rivaroxaban (Xarelto) dans la pratique [Questions and answers regarding the use of rivaroxaban in daily practice].

Several new oral anticoagulants are now on the Swiss market and the general practitioner faces new challenges regarding the management of these new drugs. This consensus document aims to answer to the most frequently asked questions regarding rivaroxaban and covers different topics such as indications, initiation of treatment, drug-drug interactions and perioperative management.

Molecular neuro-oncology in clinical practice: a new horizon.

Primary brain tumours are heterogeneous in histology, genetics, and outcome. Although WHO's classification of tumours of the CNS has greatly helped to standardise diagnostic criteria worldwide, it does not consider the substantial progress that has been made in the molecular classification of many brain tumours. Recent practice-changing clinical trials have defined a role for routine assessment of MGMT promoter methylation in glioblastomas in elderly people, and 1p and 19q codeletions in anaplastic oligodendroglial tumours. Moreover, large-scale molecular profiling approaches have identified new mutations in gliomas, affecting IDH1, IDH2, H3F3, ATRX, and CIC, which has allowed subclassification of gliomas into distinct molecular subgroups with characteristic features of age, localisation, and outcome. However, these molecular approaches cannot yet predict patients' benefit from therapeutic interventions. Similarly, transcriptome-based classification of medulloblastoma has delineated four variants that might now be candidate diseases in which to explore novel targeted agents.

Methadone maintenance treatment (MMT) in general practice or in specialized centers: profile of patients in the Swiss Canton of Vaud.

We studied profile of patients (n=1782) treated in specialized centers and general practice (GP) enrolled in methadone maintenance treatment (MMT) programs during 2001 in the Swiss Canton of Vaud. We found that GPs treated the majority of patients (76%). Specialized centers treated a higher proportion of patients with uncontrolled intravenous use of cocaine and heroin, and prescribed neuroleptics as concomitant medication three times more frequently than GPs. Patients treated in specialized centers were more likely to undergo screening for HIV, HBV, HCV, and receive complete HBV immunization. In conclusion, specialized centers are more likely to treat severely addicted patients and patients with a poor global assessment (physical, psychiatric, and social).

Cardiac CT: practical approach to integrate appropriate indications in daily practice.

Recent advances in CT technologies had significantly improved the clinical utility of cardiac CT. Major efforts have been made to optimize the image quality, standardize protocols and limit the radiation exposure. Rapid progress in post-processing tools dedicated not only to the coronary artery assessment but also to the cardiac cavities, valves and veins extended applications of cardiac CT. This potential might be however used optimally considering the current appropriate indications for use as well as the current technical imitations. Coronary artery disease and related ischemic cardiomyopathy remain the major applications of cardiac CT and at the same time the most complex one. Integration of a specific knowledge is mandatory for optimal use in this area for asymptomatic as for symptomatic patients, with a specific regards to patient with acute chest pain. This review aimed to propose a practical approach to implement appropriate indications in our routine practice. Emerging indications and future direction are also discussed. Adequate preparation of the patient, training of physicians, and the multidisciplinary interaction between actors are the key of successful implementation of cardiac CT in daily practice.