Qualité des soins ambulatoires : opinion des patients infectés par le VIH

Ce travail décrit une étude, qui a visé à évaluer la performance d'un questionnaire de satisfaction en développement, destiné à mesurer l'opinion de patients infectés par le VIH suivis ambulatoirement. 1. Problématique. 1.1. La qualité des soins, une définition. 1.2. L'opinion des patients : comment la mesurer ? Le questionnaire, les questionnaires existants, le focus groups, description de la technique. 2. Patients et méthodes. 2.1. Critères d'inclusion et d'exclusion. 2.2. Les envois et les rappels. 2.3. Stabilité test-retest. 2.4. Le recrutement. 3. Résultats. 3.1. Acceptabilité du questionnaire : participation. 3.2. Représentativité de l'échantillon. 3.3. Scores par dimension. 3. 4. Evaluation de la validité du questionnaire, convergence des items par dimension et cohérence interne. 3.5. Les questions issues du questionnaire SF-36. 4. Discussion. 4.1. Coping et méthodes alternatives. 4.2. Impact sur les service d'une enquête sur la qualité des soins. 5.1. Le questionnaire de satisfaction élaboré. 5.2. Les différents questionnaires des Hospices : patients hospitalisés et ambulatoires. 5.3. Formulaire d'information de l'enquête par questionnaire. 5.4. Formulaire de consentement à l'enquête. 5.5. Lettre d'accompagnement du questionnaire. 5.6. Profil socio-démographique et résultats complets par item.

Evaluation globale et prise en charge gériatriques: quel intérêt ?: revue Cochrane pour le praticien.

Cet article présente les résultats de la revue systématique: Ellis G, Whitehead MA, O'Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD006211. PMID: 21735403.

Inventory and description of disease management programs in Switzerland

Background: Disease management, a system of coordinated health care interventions for populations with chronic diseases in which patient self-care is a key aspect, has been shown to be effective for several conditions. Little is known on the supply of disease management programs in Switzerland. Objectives: To systematically search, record and evaluate data on existing disease management programs in Switzerland. Methods: Programs met our operational definition of disease management if their interventions targeted a chronic disease, included a multidisciplinary team and lasted at least 6 months. To find existing programs, we searched Swiss official websites, Swiss web-pages using Google, medical electronic database (Medline), and checked references from selected documents. We also contacted personally known individuals, those identified as possibly working in the field, individuals working in major Swiss health insurance companies and people recommended by previously contacted persons (snow ball strategy). We developed an extraction grid and collected information pertaining to the following 8 domains: patient population, intervention recipient, intervention content, delivery personnel, method of communication, intensity and complexity, environment and clinical outcomes (measures?). Results: We identified 8 programs fulfilling our operational definition of disease management. Programs targeted patients with diabetes, hypertension, heart failure, obesity, alcohol dependence, psychiatric disorders or breast cancer, and were mainly directed towards patients. The interventions were multifaceted and included education in almost all cases. Half of the programs included regularly scheduled follow-up, by phone in 3 instances. Healthcare professionals involved were physicians, nurses, case managers, social workers, psychologists and dietitians. None fulfilled the 6 criteria established by the Disease Management Association of America. Conclusions: Our study shows that disease management programs, in a country with universal health insurance coverage and little incentive to develop new healthcare strategies, are scarce, although we may have missed existing programs. Nonetheless, those already implemented are very interesting and rather comprehensive. Appropriate evaluation of these programs should be performed in order to build upon them and try to design a generic disease management framework suited to the Swiss healthcare system.

Stress au travail et santé : situation chez les indépendants : synthèse et recommandations

Dans le cadre de l'activité professionnelle, des facteurs de stress d'ordre psychologique, social, et liés à l'organisation du travail, peuvent induire des réponses physiologiques et comportementales impliquées dans la survenue de pathologies comme les maladies cardiovasculaires, les troubles de la santé mentale et les troubles musculosquelettiques.Le Régime social des indépendants (RSI) a sollicité l'Inserm afin de disposer d'un bilan des connaissances sur le stress d'origine professionnelle chez les travailleurs indépendants et ses répercussions sur la santé.Regroupant à la fois des compétences en biologie, psychologie, sociologie et économie de la santé, cette expertise collective présente les modèles et les mécanismes explicatifs mettant en relation le stress au travail et les principales pathologies.Les stratégies de prévention individuelle et collective qui se développent dans le milieu des travailleurs salariés peuvent-elles être adaptées aux travailleurs indépendants ? [Ed.]

Treatment of chronic hepatitis c in 3 patients with hcv-induced severe thrombocytopenia

BACKGROUND: Thrombocytopenia has been described in HCV infection even in the absence of cirrhosis and splenomegaly. Different mechanisms have been proposed, including immunemediated platelet (plt) destruction. Here, we report on the treatment of 3 patients with HCV-HIV coinfection and HCVinduced severe thrombocytopenia. PATIENTS AND TREATMENT: All patients had an infection with HCV genotype 3, an intermediate fibrosis stage (Metavir F2 or F3), HIV infection controlled by antiretroviral combination therapy, and severe, steroid-refractory thrombocytopenia. Pegylated interferon-α2a (PEG-IFN-α2a) was started at 45 or 90 μg per week and doses were rapidly increased in the following, while ribavirin (RBV) was prescribed at standard doses. Treatment was pursued for 48 weeks. Two patients received intravenous immunoglobulins (IVIG) during the first weeks of PEG-IFN-α2a and RBV combination therapy. RESULTS: A significant increase in plt counts (from 17, 39 and 37 G/l, respectively, to > 100 G/l) was observed in the 3 patients while they experienced a virological response. Thrombocytopenia relapsed in one patient together with a relapse of chronic hepatitis C. The other 2 patients achieved a sustained virological response (SVR), with normal plt counts at follow-up in one and persistent mild thrombocytopenia in the other. CONCLUSIONS: Carefully titrated PEG-IFN-α2a and RBV combination therapy may be performed safely in this difficult-totreat patient population, with close monitoring and eventually concomitant IVIG during the first weeks. SVR can lead to normalization or significant improvement of plt counts, suggesting a causative role of HCV in this condition.

Come curare l'obesità nei bambini: revisione Cochrane per il medico di famiglia.

Cet article présente les résultats de la revue systématique: Oude Luttikhuis H, Baur L, Jansen H, et al. Interventions for treating obesity in children. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD001872. DOI: 10.1002/14651858.CD001872.pub2. PMID: 19160202.

Genetic variability of the mTOR pathway and prostate cancer risk in the European Prospective Investigation on Cancer (EPIC)

The mTOR (mammalian target of rapamycin) signal transduction pathway integrates various signals, regulating ribosome biogenesis and protein synthesis as a function of available energy and amino acids, and assuring an appropriate coupling of cellular proliferation with increases in cell size. In addition, recent evidence has pointed to an interplay between the mTOR and p53 pathways. We investigated the genetic variability of 67 key genes in the mTOR pathway and in genes of the p53 pathway which interact with mTOR. We tested the association of 1,084 tagging SNPs with prostate cancer risk in a study of 815 prostate cancer cases and 1,266 controls nested within the European Prospective Investigation into Cancer and Nutrition (EPIC). We chose the SNPs (n = 11) with the strongest association with risk (p<0.01) and sought to replicate their association in an additional series of 838 prostate cancer cases and 943 controls from EPIC. In the joint analysis of first and second phase two SNPs of the PRKCI gene showed an association with risk of prostate cancer (ORallele = 0.85, 95% CI 0.78–0.94, p = 1.3×10−3 for rs546950 and ORallele = 0.84, 95% CI 0.76–0.93, p = 5.6×10−4 for rs4955720). We confirmed this in a meta-analysis using as replication set the data from the second phase of our study jointly with the first phase of the Cancer Genetic Markers of Susceptibility (CGEMS) project. In conclusion, we found an association with prostate cancer risk for two SNPs belonging to PRKCI, a gene which is frequently overexpressed in various neoplasms, including prostate cancer.

Inventory and perspectives of chronic disease management programs in Switzerland: an exploratory survey.

OBJECTIVE: To describe chronic disease management programs active in Switzerland in 2007, using an exploratory survey. METHODS: We searched the internet (Swiss official websites and Swiss web-pages, using Google), a medical electronic database (Medline), reference lists of pertinent articles, and contacted key informants. Programs met our operational definition of chronic disease management if their interventions targeted a chronic disease, included a multidisciplinary team (>/=2 healthcare professionals), lasted at least six months, and had already been implemented and were active in December 2007. We developed an extraction grid and collected data pertaining to eight domains (patient population, intervention recipient, intervention content, delivery personnel, method of communication, intensity and complexity, environment, clinical outcomes). RESULTS: We identified seven programs fulfilling our operational definition of chronic disease management. Programs targeted patients with diabetes, hypertension, heart failure, obesity, psychosis and breast cancer. Interventions were multifaceted; all included education and half considered planned follow-ups. The recipients of the interventions were patients, and healthcare professionals involved were physicians, nurses, social workers, psychologists and case managers of various backgrounds. CONCLUSIONS: In Switzerland, a country with universal healthcare insurance coverage and little incentive to develop new healthcare strategies, chronic disease management programs are scarce. For future developments, appropriate evaluations of existing programs, involvement of all healthcare stakeholders, strong leadership and political will are, at least, desirable.