The effectiveness of brief alcohol interventions in primary care settings: a systematic review.

Issues. Numerous studies have reported that brief interventions delivered in primary care are effective in reducing excessive drinking. However, much of this work has been criticised for being clinically unrepresentative. This review aimed to assess the effectiveness of brief interventions in primary care and determine if outcomes differ between efficacy and effectiveness trials. Approach. A pre-specified search strategy was used to search all relevant electronic databases up to 2006. We also hand-searched the reference lists of key articles and reviews. We included randomised controlled trials (RCT) involving patients in primary care who were not seeking alcohol treatment and who received brief intervention. Two authors independently abstracted data and assessed trial quality. Random effects meta-analyses, subgroup and sensitivity analyses and meta-regression were conducted. Key Findings. The primary meta-analysis included 22 RCT and evaluated outcomes in over 5800 patients. At 1 year follow up, patients receiving brief intervention had a significant reduction in alcohol consumption compared with controls [mean difference: -38 g week(-1), 95%CI (confidence interval): -54 to -23], although there was substantial heterogeneity between trials (I(2) = 57%). Subgroup analysis confirmed the benefit of brief intervention in men but not in women. Extended intervention was associated with a non-significantly increased reduction in alcohol consumption compared with brief intervention. There was no significant difference in effect sizes for efficacy and effectiveness trials. Conclusions. Brief interventions can reduce alcohol consumption in men, with benefit at a year after intervention, but they are unproven in women for whom there is insufficient research data. Longer counselling has little additional effect over brief intervention. The lack of differences in outcomes between efficacy and effectiveness trials suggests that the current literature is relevant to routine primary care.

Coronary heart disease in primary care: accuracy of medical history and physical findings in patients with chest pain - a study protocol for a systematic review with individual patient data.

BACKGROUND: Chest pain is a common complaint in primary care, with coronary heart disease (CHD) being the most concerning of many potential causes. Systematic reviews on the sensitivity and specificity of symptoms and signs summarize the evidence about which of them are most useful in making a diagnosis. Previous meta-analyses are dominated by studies of patients referred to specialists. Moreover, as the analysis is typically based on study-level data, the statistical analyses in these reviews are limited while meta-analyses based on individual patient data can provide additional information. Our patient-level meta-analysis has three unique aims. First, we strive to determine the diagnostic accuracy of symptoms and signs for myocardial ischemia in primary care. Second, we investigate associations between study- or patient-level characteristics and measures of diagnostic accuracy. Third, we aim to validate existing clinical prediction rules for diagnosing myocardial ischemia in primary care. This article describes the methods of our study and six prospective studies of primary care patients with chest pain. Later articles will describe the main results. METHODS/DESIGN: We will conduct a systematic review and IPD meta-analysis of studies evaluating the diagnostic accuracy of symptoms and signs for diagnosing coronary heart disease in primary care. We will perform bivariate analyses to determine the sensitivity, specificity and likelihood ratios of individual symptoms and signs and multivariate analyses to explore the diagnostic value of an optimal combination of all symptoms and signs based on all data of all studies. We will validate existing clinical prediction rules from each of the included studies by calculating measures of diagnostic accuracy separately by study. DISCUSSION: Our study will face several methodological challenges. First, the number of studies will be limited. Second, the investigators of original studies defined some outcomes and predictors differently. Third, the studies did not collect the same standard clinical data set. Fourth, missing data, varying from partly missing to fully missing, will have to be dealt with.Despite these limitations, we aim to summarize the available evidence regarding the diagnostic accuracy of symptoms and signs for diagnosing CHD in patients presenting with chest pain in primary care. REVIEW REGISTRATION: Centre for Reviews and Dissemination (University of York): CRD42011001170.

Theory of mind tasks and executive functions: A systematic review of group studies in neurology.

A growing number of studies have been addressing the relationship between theory of mind (TOM) and executive functions (EF) in patients with acquired neurological pathology. In order to provide a global overview on the main findings, we conducted a systematic review on group studies where we aimed to (1) evaluate the patterns of impaired and preserved abilities of both TOM and EF in groups of patients with acquired neurological pathology and (2) investigate the existence of particular relations between different EF domains and TOM tasks. The search was conducted in Pubmed/Medline. A total of 24 articles met the inclusion criteria. We considered for analysis classical clinically accepted TOM tasks (first- and second-order false belief stories, the Faux Pas test, Happe's stories, the Mind in the Eyes task, and Cartoon's tasks) and EF domains (updating, shifting, inhibition, and access). The review suggests that (1) EF and TOM appear tightly associated. However, the few dissociations observed suggest they cannot be reduced to a single function; (2) no executive subprocess could be specifically associated with TOM performances; (3) the first-order false belief task and the Happe's story task seem to be less sensitive to neurological pathologies and less associated to EF. Even though the analysis of the reviewed studies demonstrates a close relationship between TOM and EF in patients with acquired neurological pathology, the nature of this relationship must be further investigated. Studies investigating ecological consequences of TOM and EF deficits, and intervention researches may bring further contributions to this question.

Multimodel inference and multimodel averaging in empirical modeling of occupational exposure levels.

Empirical modeling of exposure levels has been popular for identifying exposure determinants in occupational hygiene. Traditional data-driven methods used to choose a model on which to base inferences have typically not accounted for the uncertainty linked to the process of selecting the final model. Several new approaches propose making statistical inferences from a set of plausible models rather than from a single model regarded as 'best'. This paper introduces the multimodel averaging approach described in the monograph by Burnham and Anderson. In their approach, a set of plausible models are defined a priori by taking into account the sample size and previous knowledge of variables influent on exposure levels. The Akaike information criterion is then calculated to evaluate the relative support of the data for each model, expressed as Akaike weight, to be interpreted as the probability of the model being the best approximating model given the model set. The model weights can then be used to rank models, quantify the evidence favoring one over another, perform multimodel prediction, estimate the relative influence of the potential predictors and estimate multimodel-averaged effects of determinants. The whole approach is illustrated with the analysis of a data set of 1500 volatile organic compound exposure levels collected by the Institute for work and health (Lausanne, Switzerland) over 20 years, each concentration having been divided by the relevant Swiss occupational exposure limit and log-transformed before analysis. Multimodel inference represents a promising procedure for modeling exposure levels that incorporates the notion that several models can be supported by the data and permits to evaluate to a certain extent model selection uncertainty, which is seldom mentioned in current practice.

Effectiveness of interventions targeting frequent users of emergency departments: a systematic review

L'article publié de le cadre de cette thèse est intitulé "Effectiveness of interventions targeting frequent users of emergency departments: A systematic review." Il a été publié par les "Annals of Emergency Medicine (AEM)" en juillet 2011. Le titre en français pourrait être: "Efficacité des interventions ciblant les utilisateurs fréquents des services d'urgence: Une revue systématique." Le titre du journal américain pourrait être: "Annales de Médecine d'Urgence". Il s'agit du journal du "Collège Américain des Médecins d'Urgence", en anglais "American College of Emergency Physicians (ACEP)". L'article a été soumis à l'AEM en raison de l'intérêt que ses rédacteurs en chef portent pour le sujet des utilisateurs fréquents des services d'urgence, démontré depuis plus de dix ans par la publication de nombreux articles dans ce domaine. Le facteur d'impact de l'AEM est de surcroît le plus important des journaux d'urgence, assurant ainsi une large diffusion des articles publiés. Lors de sa publication, l'article a été accompagné d'un éditorial signé par le Docteur Maria C. Raven, médecin au Centre Hospitalier de Bellevue à New York, Etats-Unis.¦Contexte et enjeux¦La Direction Générale du Centre Hospitalier Vaudois (CHUV) finance, dans le cadre du plan stratégique 2009-2013, un axe "populations vulnérables". Cet axe est porté en grande partie par des projets développés au sein de la Policinlique Médicale Universitaire et l'Unité des Populations Vulnérables qui prend en charge, enseigne la prise en charge et s'interroge sur la prise en charge des personnes les plus vulnérables. C'est dans ce contexte que nous avons été amenés à réfléchir à l'existence éventuelle de marqueurs de vulnérabilité; l'utilisation fréquente des services d'urgence par certains individus constitue à n'en pas douter l'un de ces marqueurs. Il existe une importante littérature décrivant en détail ces utilisateurs fréquents des services d'urgence, raison pour laquelle nous avons décidé de faire un pas supplémentaire et de nous interroger sur l'efficacité des interventions (quelle qu'elles soient) ciblant cette population particulière. Nous avons ainsi entrepris une revue systématique de la littérature scientifique médicale et sociale pour approfondir cette question, et c'est précisément le résultat de cette recherche qui constitue ce travail de thèse.¦Conclusions et perspectives¦Les utilisateurs fréquents des services d'urgence sont des individus particulièrement vulnérables, et ce aussi bien aux Etats-Unis, qu'en Europe ou en Australie: ils présentent par exemple une mortalité supérieure aux autres utilisateurs des urgences; ils sont également plus à risque de présenter une consommation abusive d'alcool ou de drogues, une maladie mentale, ou une maladie chronique. Ils sont plus souvent sans abri, sans assurance et d'un statut socio-économique bas.¦De nombreuses interventions on été développées pour prendre en charge les utilisateurs fréquents des urgences. Le but de ces interventions est d'une part de réduire la consommation des services d'urgence et d'autre part d'améliorer la santé au sens large de ces patients vulnérables. C'est en ces termes (réduction de la fréquence d'utilisation des services d'urgence et amélioration de la santé) que l'efficacité d'une intervention est mesurée.¦Parmi l'ensemble des interventions étudiées, l'une semble particulièrement efficace pour réduire le nombre de visites aux urgences et améliorer un certain nombre de marqueurs sociaux (accès à un logement ou à une assurance-maladie). Cette intervention est appelée "case management" (ou "gestion de cas", difficile tentative de traduction de ce concept en français), et consiste en une approche multidisciplinaire (médecins, infirmiers, assistants sociaux) fournissant un service individualisé, dans le cadre de l'hôpital et souvent également dans la communauté. L'approche consiste à évaluer les besoins précis du patient, à l'accompagner dans son parcours de soin, à l'orienter si nécessaire et à mettre en place autour de lui un réseau communiquant de manière adaptée.¦Le "case management" ayant montré son efficacité dans la prise en charge des utilisateurs fréquents des services d'urgence, y-compris en termes de coûts, notre conclusion va dans le sens d'encourager les hôpitaux à évaluer l'importance de ce phénomène dans leur propre pratique et à mettre en place des équipes de prise en charge de ces patients, dans le double but de soutenir des patients particulièrement vulnérables et de réduire la consommation des services d'urgence. Suite à la réflexion suscitée par ce travail de thèse, une telle équipe a été mise en place en 2010, dans un cadre de recherche-action, au niveau du CHUV. Ce projet est dirigé par le Dr Patrick Bodenmann, responsable de l'Unité Populations Vulnérables de la Policlinique Médicale Universitaire de Lausanne. Le Dr Bodenmann est également le directeur de cette thèse et le dernier auteur de la revue systématique.

Repeat Gamma Knife surgery for recurrent trigeminal neuralgia: long-term outcomes and systematic review.

Object The purpose of this study was to establish the safety and efficacy of repeat Gamma Knife surgery (GKS) for recurrent trigeminal neuralgia (TN). Methods Using the prospective database of TN patients treated with GKS in Timone University Hospital (Marseille, France), data were analyzed for 737 patients undergoing GKS for TN Type 1 from July 1992 to November 2010. Among the 497 patients with initial pain cessation, 34.4% (157/456 with ≥ 1-year follow-up) experienced at least 1 recurrence. Thirteen patients (1.8%) were considered for a second GKS, proposed only if the patients had good and prolonged initial pain cessation after the first GKS, with no other treatment alternative at the moment of recurrence. As for the first GKS, a single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range 4-14 mm) anterior to the emergence of the nerve (retrogasserian target). A median maximum dose of 90 Gy (range 70-90 Gy) was delivered. Data for 9 patients with at least 1-year followup were analyzed. A systematic review of literature was also performed, and results are compared with those of the Marseille study. Results The median time to retreatment in the Marseille study was 72 months (range 12-125 months) and in the literature it was 17 months (range 3-146 months). In the Marseille study, the median follow-up period was 33.9 months (range 12-96 months), and 8 of 9 patients (88.9%) had initial pain cessation with a median of 6.5 days (range 1-180 days). The actuarial rate for new hypesthesia was 33.3% at 6 months and 50% at 1 year, which remained stable for 7 years. The actuarial probabilities of maintaining pain relief without medication at 6 months and 1 year were 100% and 75%, respectively, and remained stable for 7 years. The systematic review analyzed 20 peer-reviewed studies reporting outcomes for repeat GKS for recurrent TN, with a total of 626 patients. Both the selection of the cases for retreatment and the way of reporting outcomes vary widely among studies, with a median rate for initial pain cessation of 88% (range 60%-100%) and for new hypesthesia of 33% (range 11%-80%). Conclusions Results from the Marseille study raise the question of surgical alternatives after failed GKS for TN. The rates of initial pain cessation and recurrence seem comparable to, or even better than, those of the first GKS, according to different studies, but toxicity is much higher, both in the Marseille study and in the published data. Neither the Marseille study data nor literature data answer the 3 cardinal questions regarding repeat radiosurgery in recurrent TN: which patients to retreat, which target is optimal, and which dose to use.

Systematic evaluation of risk factors for diagnostic delay in inflammatory bowel disease.

The diagnosis of inflammatory bowel disease (IBD), comprising Crohn's disease (CD) and ulcerative colitis (UC), continues to present difficulties due to unspecific symptoms and limited test accuracies. We aimed to determine the diagnostic delay (time from first symptoms to IBD diagnosis) and to identify associated risk factors. A total of 1591 IBD patients (932 CD, 625 UC, 34 indeterminate colitis) from the Swiss IBD cohort study (SIBDCS) were evaluated. The SIBDCS collects data on a large sample of IBD patients from hospitals and private practice across Switzerland through physician and patient questionnaires. The primary outcome measure was diagnostic delay. Diagnostic delay in CD patients was significantly longer compared to UC patients (median 9 versus 4 months, P < 0.001). Seventy-five percent of CD patients were diagnosed within 24 months compared to 12 months for UC and 6 months for IC patients. Multivariate logistic regression identified age <40 years at diagnosis (odds ratio [OR] 2.15, P = 0.010) and ileal disease (OR 1.69, P = 0.025) as independent risk factors for long diagnostic delay in CD (>24 months). In UC patients, nonsteroidal antiinflammatory drug (NSAID intake (OR 1.75, P = 0.093) and male gender (OR 0.59, P = 0.079) were associated with long diagnostic delay (>12 months). Whereas the median delay for diagnosing CD, UC, and IC seems to be acceptable, there exists a long delay in a considerable proportion of CD patients. More public awareness work needs to be done in order to reduce patient and doctor delays in this target population.

Review of Occupational Health Services in the HPSS (PDF 387 KB)

Supporting a Healthy Workforce

Systematic evaluation of risk factors for diagnostic delay in inflammatory bowel

Aim: The diagnosis of inflammatory bowel disease (IBD), comprising Crohn's disease (CD) and ulcerative colitis (UC), continues to present difficulties due to unspecific symptoms and limited test accuracies. We aimed to determine the diagnostic delay (time from first symptoms to IBD diagnosis) and to identify associated risk factors in a national cohort in Switzerland.¦Materials and Methods: A total of 1,591 IBD patients (932 CD, 625 UC, 34 indeterminate colitis) from the Swiss IBD cohort study (SIBDCS) were evaluated. The SIBDCS collects data on a large sample of IBD patients from hospitals and private practice across Switzerland through physician and patient questionnaires. The primary outcome measure was the diagnostic delay.¦Results: Diagnostic delay in CD patients was significantly longer compared to UC patients (median 9 vs. 4 months, P < 0.001). Seventy-five percent of CD patients were diagnosed within 24 months compared to 12 months for UC and 6 months for IC patients. Multivariate logistic regression identified age <40 years at diagnosis (OR 2.15, P = 0.010) and ileal disease (OR 1.69, P = 0.025) as independent risk factors for long diagnostic delay in CD (>24 months). A trend for long diagnostic delay (>12 months) was associated with NSAID intake (OR 1.75, P = 0.093) and male gender (OR 0.59, P = 0.079) in UC patients.¦Conclusions: Whereas the median delay for diagnosing CD, UC, and IC seems to be acceptable, there exists a long delay in a considerable proportion of CD patients. More public awareness work needs to be done in order to reduce patient's and doctor's delay in this target population.