How to Improve the Use of Proton Pump Inhibitors

Introduction: Proton pump inhibitors (PPI) are one of the most prescribed medications in the world with proven efficacy. However, several studies showed that their use often doesn't respect indications, leading to over-consumption, thus exposing patients to drug interactions and adverse events (for example pneumonias). Interruption of PPIs can induce a rebound phenomenon. This generates costs for health systems.Methods: This is a prospective interventional study performed in two hospitals: La Chaux-de-Fonds (CDF, cases) and Neucha^tel (NE, control) during two six-month periods, comparing use of PPIs before and after intervention. We elaborated recommendations (PPI doses and treatment duration) based on recent medical literature that we summarized on A6 cards and gave out to all prescribing doctors in the hospital of CDF and held a 30-minute information session for the departments of surgery, medicine and anesthesiology in March 2010. Doctors were asked to apply our recommendations as often as possible, leaving space for their own assessment. No information was given to the doctors of the control hospital. The number of PPI tablets that the pharmacy sent to each careunit in both hospitals was counted and adjusted to the number of patientdays from April to September 2009 (before intervention) and April to September 2010 (after intervention). The number of other antacids that were used in both hospitals was counted during the same periods. General practitioners (GP) in the region around CDF received an explanation letter to avoid re-introduction, after discharge from the hospital, of PPI treatment stopped during the stay. The number of gastro-duodenal ulcers and upper digestive hemorrhages was counted from April to December 2009 and the same period in 2010 in both hospitals.Results: In 2010, in the hospital of CDF, the use of PPIs per 100 patient-days decreased by 36% in the surgical and medical departments compared to 2009. In the control hospital the use of PPIs per 100 patient-days increased by 10% in the surgical department and decreased by 5% in the medical department during the same periods. The decrease from 2009 to 2010 of PPI utilization in CDF comparing to NE is statistically significant: p<0.0001. Use of other antacids didn't change, ulcers or digestive hemorrhages decreased slightly from 2009 to 2010 in both hospitals. Conclusions: The study showed that with a very low-cost intervention, it is possible to decrease considerably the use of PPIs in a hospital, without taking any risk for gastro-intestinal complications.

Lasten luvaton tuli – perusasteen oppilaat sytyttelijöinä

Tutkimus lasten ja nuorten luvattomasta tulen käsittelystä perustuu näkemykseen siitä, että ilmiöön voidaan puuttua tehokkaasti interventioin, jos toiminta havaitaan ajoissa. Ilmiötä sävyttää teon salailu ja neutralisaatio eli vähättely. Tulella tehtyjen tuhotöiden lisääntymistä ja muuttumista aggressiivisemmaksi voidaan ennalta ehkäistä ongelman tunnistamisella ja reagoimalla lasten häiriökäytökseen. Lasten ja nuorten luvatonta tulen käyttöä ei ole tutkittu Suomessa aiemmin. Työn ensimmäisessä osiossa tarkastellaan luvattomaan tulen käsittelyyn liittyviä teorioita (esim. Fineman 1980, 1995), kansainvälisiä näkökohtia, teonpiirteitä ja yksilön sisäisiä prosesseja. Lisäksi tarkastellaan perheen, koulun ja ystäväpiirin osuutta ilmiöön, niin sanotun Oregonin mallin mukaisesti (Oregon Treatment Strategies Task Force 1996, 16 – 47). Työn empiirisessä osiossa ilmiötä ja sen ilmenemistä lasten ja nuorten keskuudessa kuvataan oppilaiden, vanhempien ja opettajien näkökulmasta. Tutkimukseen osallistui 661 oppilasta perusasteen toiselta, viidenneltä ja kahdeksannelta luokalta, 341 vanhempaa ja 22 koulun työntekijää. Oppilaiden ja vanhempien aineisto kerättiin survey-tutkimuksella ja opettajat tutkittiin haastattelumenetelmällä. Lasten luvaton tulen käyttö on yleisempää kuin aiemmin on luultu. Vielä viidenteen luokkaan mennessä luvaton tulen käsittely oli yleisempää pojille kuin tytöille, mutta murrosikään tultaessa sukupuolierot vähenivät. Pojista 37 % ja tytöistä 25 % raportoi käsitelleensä tulta luvattomasti. Kaikkiaan kolmasosa oppilaista raportoi leikkineensä tulella. Yleisin tulen sytyttelypaikka oli oma koti tai kodin lähiympäristö, josta tulentekovälineet yleisimmin hankittiin pyytämällä tai ottamalla. Luvattomasti tulta käsitelleet oppilaat olivat häirinneet oppitunteja. Tilastollisesti merkitsevimmin runsasta luvatonta tulen käsittelyä ennusti omien tulentekovälineiden omistaminen ja häiriökäyttäytyminen koulussa. Vanhemmat eivät pitäneet lastensa tulen käyttöä merkittävänä vaarana. Aikuisten suhtautumista lasten luvattomaan tulen käyttöön sävytti tekojen vähättely eli neutralisaatio; vähättelyilmiö oli yhteinen sekä lapsille itselleen, vanhemmille että viranomaisille. Kasvattajilla ei ollut käytössään tehokkaita interventiomenetelmiä ongelman ratkaisemiseen. Viranomaisyhteistyöstä raportoitiin vain vähän. Pelastusviranomaisia ei juurikaan käytetty lasten luvattoman tulen käsittelyn interventiossa. Interventiota sävytti aikuisten käsitysten mukaan tapauskohtaisuus ja sattumanvaraisuus.

Copy number variations and cognitive phenotypes in unselected populations

IMPORTANCE: The association of copy number variations (CNVs), differing numbers of copies of genetic sequence at locations in the genome, with phenotypes such as intellectual disability has been almost exclusively evaluated using clinically ascertained cohorts. The contribution of these genetic variants to cognitive phenotypes in the general population remains unclear. OBJECTIVE: To investigate the clinical features conferred by CNVs associated with known syndromes in adult carriers without clinical preselection and to assess the genome-wide consequences of rare CNVs (frequency ≤0.05%; size ≥250 kilobase pairs [kb]) on carriers' educational attainment and intellectual disability prevalence in the general population. DESIGN, SETTING, AND PARTICIPANTS: The population biobank of Estonia contains 52,000 participants enrolled from 2002 through 2010. General practitioners examined participants and filled out a questionnaire of health- and lifestyle-related questions, as well as reported diagnoses. Copy number variant analysis was conducted on a random sample of 7877 individuals and genotype-phenotype associations with education and disease traits were evaluated. Our results were replicated on a high-functioning group of 993 Estonians and 3 geographically distinct populations in the United Kingdom, the United States, and Italy. MAIN OUTCOMES AND MEASURES: Phenotypes of genomic disorders in the general population, prevalence of autosomal CNVs, and association of these variants with educational attainment (from less than primary school through scientific degree) and prevalence of intellectual disability. RESULTS: Of the 7877 in the Estonian cohort, we identified 56 carriers of CNVs associated with known syndromes. Their phenotypes, including cognitive and psychiatric problems, epilepsy, neuropathies, obesity, and congenital malformations are similar to those described for carriers of identical rearrangements ascertained in clinical cohorts. A genome-wide evaluation of rare autosomal CNVs (frequency, ≤0.05%; ≥250 kb) identified 831 carriers (10.5%) of the screened general population. Eleven of 216 (5.1%) carriers of a deletion of at least 250 kb (odds ratio [OR], 3.16; 95% CI, 1.51-5.98; P = 1.5e-03) and 6 of 102 (5.9%) carriers of a duplication of at least 1 Mb (OR, 3.67; 95% CI, 1.29-8.54; P = .008) had an intellectual disability compared with 114 of 6819 (1.7%) in the Estonian cohort. The mean education attainment was 3.81 (P = 1.06e-04) among 248 (≥250 kb) deletion carriers and 3.69 (P = 5.024e-05) among 115 duplication carriers (≥1 Mb). Of the deletion carriers, 33.5% did not graduate from high school (OR, 1.48; 95% CI, 1.12-1.95; P = .005) and 39.1% of duplication carriers did not graduate high school (OR, 1.89; 95% CI, 1.27-2.8; P = 1.6e-03). Evidence for an association between rare CNVs and lower educational attainment was supported by analyses of cohorts of adults from Italy and the United States and adolescents from the United Kingdom. CONCLUSIONS AND RELEVANCE: Known pathogenic CNVs in unselected, but assumed to be healthy, adult populations may be associated with unrecognized clinical sequelae. Additionally, individually rare but collectively common intermediate-size CNVs may be negatively associated with educational attainment. Replication of these findings in additional population groups is warranted given the potential implications of this observation for genomics research, clinical care, and public health.

Medication incidents in primary care medicine: protocol of a study by the Swiss Federal Sentinel Reporting System.

BACKGROUND/RATIONALE: Patient safety is a major concern in healthcare systems worldwide. Although most safety research has been conducted in the inpatient setting, evidence indicates that medical errors and adverse events are a threat to patients in the primary care setting as well. Since information about the frequency and outcomes of safety incidents in primary care is required, the goals of this study are to describe the type, frequency, seasonal and regional distribution of medication incidents in primary care in Switzerland and to elucidate possible risk factors for medication incidents. Label="METHODS AND ANALYSIS" ="METHODS"/> <AbstractText STUDY DESIGN AND SETTING: We will conduct a prospective surveillance study to identify cases of medication incidents among primary care patients in Switzerland over the course of the year 2015. PARTICIPANTS: Patients undergoing drug treatment by 167 general practitioners or paediatricians reporting to the Swiss Federal Sentinel Reporting System. INCLUSION CRITERIA: Any erroneous event, as defined by the physician, related to the medication process and interfering with normal treatment course. EXCLUSION CRITERIA: Lack of treatment effect, adverse drug reactions or drug-drug or drug-disease interactions without detectable treatment error. PRIMARY OUTCOME: Medication incidents. RISK FACTORS: Age, gender, polymedication, morbidity, care dependency, hospitalisation. STATISTICAL ANALYSIS: Descriptive statistics to assess type, frequency, seasonal and regional distribution of medication incidents and logistic regression to assess their association with potential risk factors. Estimated sample size: 500 medication incidents. LIMITATIONS: We will take into account under-reporting and selective reporting among others as potential sources of bias or imprecision when interpreting the results. ETHICS AND DISSEMINATION: No formal request was necessary because of fully anonymised data. The results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT0229537.

Health care usage among immigrants and native-born elderly populations in eleven European countries: results from SHARE

Differences in health care utilization of immigrants 50 years of age and older relative to the native-born populations in eleven European countries are investigated. Negative binomial and zero-inflated Poisson regression are used to examine differences between immigrants and native-borns in number of doctor visits, visits to general practitioners, and hospital stays using the 2004 Survey of Health, Ageing, and Retirement in Europe database. In the pooled European sample and in some individual countries, older immigrants use from 13 to 20% more health services than native-borns after demographic characteristics are controlled. After controlling for the need for health care, differences between immigrants and native-borns in the use of physicians, but not hospitals, are reduced by about half. These are not changed much with the incorporation of indicators of socioeconomic status and extra insurance coverage. Higher country-level relative expenditures on health, paying physicians a fee-for-service, and physician density are associated with higher usage of physician services among immigrants.

Cost-effectiveness of a community pharmacist intervention in patients with depression: a randomized controlled trial (PRODEFAR study)

Background: Non-adherence to antidepressants generates higher costs for the treatment of depression. Little is known about the cost-effectiveness of pharmacist's interventions aimed at improving adherence to antidepressants. The study aimed to evaluate the cost-effectiveness of a community pharmacist intervention in comparison with usual care in depressed patients initiating treatment with antidepressants in primary care. Methods: Patients were recruited by general practitioners and randomized to community pharmacist intervention (87) that received an educational intervention and usual care (92). Adherence to antidepressants, clinical symptoms, Quality-Adjusted Life-Years (QALYs), use of healthcare services and productivity losses were measured at baseline, 3 and 6 months. Results: There were no significant differences between groups in costs or effects. From a societal perspective, the incremental cost-effectiveness ratio (ICER) for the community pharmacist intervention compared with usual care was 1,866 for extra adherent patient and 9,872 per extra QALY. In terms of remission of depressive symptoms, the usual care dominated the community pharmacist intervention. If willingness to pay (WTP) is 30,000 per extra adherent patient, remission of symptoms or QALYs, the probability of the community pharmacist intervention being cost-effective was 0.71, 0.46 and 0.75, respectively (societal perspective). From a healthcare perspective, the probability of the community pharmacist intervention being cost-effective in terms of adherence, QALYs and remission was of 0.71, 0.76 and 0.46, respectively, if WTP is 30,000. Conclusion: A brief community pharmacist intervention addressed to depressed patients initiating antidepressant treatment showed a probability of being cost-effective of 0.71 and 0.75 in terms of improvement of adherence and QALYs, respectively, when compared to usual care. Regular implementation of the community pharmacist intervention is not recommended.

L'insuffisance rénale chronique: quelle est la diète optimale

The optimal diet for chronic kidney disease (CKD) is an issue frequently brought up by patients and/or their relatives during outpatient visits. For patients without malnutrition who are motivated and supported by an experienced multidisciplinary team, the optimal protein intake of 0,6 g/kg of ideal body weight/day is recommended to halt the progression of CKD. A calorie intake of 30 to 35 kcal/kg of ideal body weight/day is necessary to reduce the risk of malnutrition from a low protein diet and to maintain a neutral nitrogen balance. A low-salt diet, namely 5 to 6 g/d, is useful to optimize the treatment of hypertension associated with CKD and to limit fluid overload. At the advanced stage of CKD, it is also necessary to restrict the intake of phosphorus and sometimes potassium. Given the complexity of optimal renal diet, coordination between general practitioners, nephrologists and dietitians is essential to foster optimal care.

The ADO Index as a Predictor of Two-Year Mortality in General Practice-Based Chronic Obstructive Pulmonary Disease Cohorts.

BACKGROUND: Existing prediction models for mortality in chronic obstructive pulmonary disease (COPD) patients have not yet been validated in primary care, which is where the majority of patients receive care. OBJECTIVES: Our aim was to validate the ADO (age, dyspnoea, airflow obstruction) index as a predictor of 2-year mortality in 2 general practice-based COPD cohorts. METHODS: Six hundred and forty-six patients with COPD with GOLD (Global Initiative for Chronic Obstructive Lung Disease) stages I-IV were enrolled by their general practitioners and followed for 2 years. The ADO regression equation was used to predict a 2-year risk of all-cause mortality in each patient and this risk was compared with the observed 2-year mortality. Discrimination and calibration were assessed as well as the strength of association between the 15-point ADO score and the observed 2-year all-cause mortality. RESULTS: Fifty-two (8.1%) patients died during the 2-year follow-up period. Discrimination with the ADO index was excellent with an area under the curve of 0.78 [95% confidence interval (CI) 0.71-0.84]. Overall, the predicted and observed risks matched well and visual inspection revealed no important differences between them across 10 risk classes (p = 0.68). The odds ratio for death per point increase according to the ADO index was 1.50 (95% CI 1.31-1.71). CONCLUSIONS: The ADO index showed excellent prediction properties in an out-of-population validation carried out in COPD patients from primary care settings. © 2014 S. Karger AG, Basel.

Les vaccins contre le zona : efficacité, sécurité, et rapport coût/bénéfices [Vaccines against Herpes zoster: Effectiveness, safety, and cost/benefit ratio].

CONTEXT: A vaccination against herpes zoster and its complication is available in France since June 2015. Its exact benefit for public health is still controversial and its level of protection is not optimal. All those reasons seem to suggest a low acceptation rate from general practitioners. OBJECTIVE: To evaluate the effectiveness, the safety, and the cost/benefit ratio of the vaccination against herpes zoster in people aged 50 year or over. DOCUMENTARY SOURCE: Systematic review in Medline and PubMed with research by key words: "herpes zoster vaccine", "zoster vaccine" and "post herpetic neuralgia vaccine". SELECTION OF STUDIES: Randomized and observational studies published in English and French language have been selected by two readers. RESULTS: On 1886 articles identified, 62 studies were included in this systematic review of which 21 randomized trials, 21 observational studies, and 17 medico-economic studies concerned the unadjuvanted vaccine. Considered studies showed an effectiveness of 50% against herpes zoster and 60% on post-herpetic neuralgia incidence of the unadjuvanted vaccine. Five randomized controlled studies were identified for the adjuvanted vaccine. The overall effectiveness of this vaccine was > 90% whatever the age of subjects including those over age 70 and 80. The medico-economic studies conducted in many countries have shown that vaccine policies were beneficial in individuals aged 60 years or over. LIMITATION OF THE WORK: Most of data of effectiveness, and tolerance result from 2 large controlled studies only (SPS and ZEST) for the unadjuvanted vaccine and only one for the adjuvanted vaccine. CONCLUSION: Despite controversy and few uncertainties, the vaccine significantly reduces herpes zoster and its complication incidence. In terms of public health objectives, it reduces the burden of the disease and has a positive medico-economic impact. Preliminary data concerning the adjuvanted vaccine, whilst very promising, are still too limited. Up to now, no group of people with particularly high risk of herpes zoster-related complication who will beneficiate the most of the vaccination has been identified yet and only an age criteria has been considered for the recommendation.

Travellers' profile, travel patterns and vaccine practices-a 10-year prospective study in a Swiss Travel Clinic.

BACKGROUND: The travel clinic in Lausanne serves a catchment area of 700 000 of inhabitants and provides pre- and post-travel consultations. This study describes the profile of attendees before departure, their travel patterns and the travel clinic practices in terms of vaccination over time. METHODS: We included all pre-travel first consultation data recorded between November 2002 and December 2012 by a custom-made program DIAMM/G. We analysed client profiles, travel characteristics and vaccinations prescribed over time. RESULTS: Sixty-five thousand and forty-six client-trips were recorded. Fifty-one percent clients were female. Mean age was 32 years. In total, 0.1% were aged <1 year and 0.2% ≥80 years. Forty-six percent of travellers had pre-existing medical conditions. Forty-six percent were travelling to Africa, 35% to Asia, 20% to Latin America and 1% (each) to Oceania and Europe; 19% visited more than one country. India was the most common destination (9.6% of travellers) followed by Thailand (8.6%) and Kenya (6.4%). Seventy-three percent of travellers were planning to travel for ≤ 4 weeks. The main reasons for travel were tourism (75%) and visiting friends and relatives (18%). Sixteen percent were backpackers. Pre-travel advice were sought a median of 29 days before departure. Ninety-nine percent received vaccine(s). The most frequently administered vaccines were hepatitis A (53%), tetanus-diphtheria (46%), yellow fever (39%), poliomyelitis (38%) and typhoid fever (30%). CONCLUSIONS: The profile of travel clinic attendees was younger than the general Swiss population. A significant proportion of travellers received vaccinations that are recommended in the routine national programme. These findings highlight the important role of travel clinics to (i) take care of an age group that has little contact with general practitioners and (ii) update vaccination status. The most commonly prescribed travel-related vaccines were for hepatitis A and yellow fever. The question remains to know whether clients do attend travel clinics because of compulsory vaccinations or because of real travel health concern or both.

Health care utilization among immigrants and native-born populations in 11 European countries. Results from the Survey of Health, Ageing and Retirement in Europe

This study examines health care utilization of immigrants relative to the native-born populations aged 50 years and older in eleven European countries. Methods. We analyzed data from the Survey of Health Aging and Retirement in Europe (SHARE) from 2004 for a sample of 27,444 individuals in 11 European countries. Negative Binomial regression was conducted to examine the difference in number of doctor visits, visits to General Practitioners (GPs), and hospital stays between immigrants and the native-born individuals. Results: We find evidence those immigrants above age 50 use health services on average more than the native-born populations with the same characteristics. Our models show immigrants have between 6% and 27% more expected visits to the doctor, GP or hospital stays when compared to native-born populations in a number of European countries. Discussion: Elderly immigrant populations might be using health services more intensively due to cultural reasons.

Gas collisions and pressure quenching of the photoluminescence of silicon nanopowder grown by plasma-enhanced chemical vapor deposition

The quenching of the photoluminescence of Si nanopowder grown by plasma-enhanced chemical vapor deposition due to pressure was measured for various gases ( H2, O2, N2, He, Ne, Ar, and Kr) and at different temperatures. The characteristic pressure, P0, of the general dependence I(P)=I0exp(-P/P0) is gas and temperature dependent. However, when the number of gas collisions is taken as the variable instead of pressure, then the quenching is the same within a gas family (mono- or diatomic) and it is temperature independent. So it is concluded that the effect depends on the number of gas collisions irrespective of the nature of the gas or its temperature

Implementing a Cancer Fast-track programme between primary and specialised care in Catalonia(Spain): amixed methods study

BACKGROUND: The Cancer Fast-track Programme's aim was to reduce the time that elapsed between well-founded suspicion of breast, colorectal and lung cancer and the start of initial treatment in Catalonia (Spain). We sought to analyse its implementation and overall effectiveness. METHODS: A quantitative analysis of the programme was performed using data generated by the hospitals on the basis of seven fast-track monitoring indicators for the period 2006-2009. In addition, we conducted a qualitative study, based on 83 semistructured interviews with primary and specialised health professionals and health administrators, to obtain their perception of the programme's implementation. RESULTS: About half of all new patients with breast, lung or colorectal cancer were diagnosed via the fast track, though the cancer detection rate declined across the period. Mean time from detection of suspected cancer in primary care to start of initial treatment was 32 days for breast, 30 for colorectal and 37 for lung cancer (2009). Professionals associated with the implementation of the programme showed that general practitioners faced with suspicion of cancer had changed their conduct with the aim of preventing lags. Furthermore, hospitals were found to have pursued three specific implementation strategies (top-down, consensus-based and participatory), which made for the cohesion and sustainability of the circuits. CONCLUSION: The programme has contributed to speeding up diagnostic assessment and treatment of patients with suspicion of cancer, and to clarifying the patient pathway between primary and specialised care.

Cyanoaggregatum brasiliense gen. et sp. nov., a new chroococcal Cyanobacteria from Southern Brazil

The paper proposed Cyanoaggregatum brasiliense, a new genus and species from the plankton of a subtropical brackish coastal lagoon from Rio Grande do Sul State, South Brazil. It differs from all other members of Chroococcales by its characteristic arrangement of cells in irregular groups distributed in a single, flat or slightly curved layer, on irregular rows, slightly distant from each other, forming a mosaic-like pattern slightly below the surface of the mucilaginous colonial envelope. The cell division in one plane perpendicular to the long axis and the lack of pseudo-filaments indicate its classification in the family Synechococcaceae, sub-family Aphanothecoideae. The general characteristics, the diagnostic criteria and the taxonomic position are discussed, and a comparison between Cyanoaggregatum and its most closely related genera is presented. Physical and chemical data on the studied lagoon and geographical distribution are presented.