Déclaration et traitement des événements indésirables en médecine interne [Incident-reporting electronic-based system in internal medicine].

How to recognize, announce and analyze incidents in internal medicine units is a daily challenge that is taught to all hospital staff. It allows suggesting useful improvements for patients, as well as for the medical department and the institution. Here is presented the assessment made in the CHUV internal medicine department one year after the beginning of the institutional procedure which promotes an open process regarding communication and risk management. The department of internal medicine underlines the importance of feedback to the reporters, ensures the staff of regular follow-up concerning the measures being taken and offers to external reporters such as general practioners the possibility of using this reporting system too.

L'année 2014 mise en perspective par les internistes hospitaliers [What is new in 2014 for the specialist in hospital internal medicine? The point of view of university hospital chief residents].

The year 2014 was rich in significant advances in all areas of internal medicine. Many of them have an impact on our daily practice and on the way we manage one problem or another. From the use of the ultrasound for the diagnosis of pneumonia to the choice of the site of venous access and the type of line, and the increasing complexity of choosing an oral anticoagulant agent, this selection offers to the readers a brief overview of the major advances. The chief residents in the Service of internal medicine of the Lausanne University hospital are pleased to share their readings.

NLRP12 is a neutrophil-specific, negative regulator of in vitro cell migration but does not modulate LPS- or infection-induced NF-κB or ERK signalling.

NOD-like receptors (NLR) are a family of cytosolic pattern recognition receptors that include many key drivers of innate immune responses. NLRP12 is an emerging member of the NLR family that is closely related to the well-known inflammasome scaffold, NLRP3. Since its discovery, various functions have been proposed for NLRP12, including the positive regulation of dendritic cell (DC) and neutrophil migration and the inhibition of NF-κB and ERK signalling in DC and macrophages. We show here that NLRP12 is poorly expressed in murine macrophages and DC, but is strongly expressed in neutrophils. Using myeloid cells from WT and Nlrp12(-/)(-) mice, we show that, contrary to previous reports, NLRP12 does not suppress LPS- or infection-induced NF-κB or ERK activation in myeloid cells, and is not required for DC migration in vitro. Surprisingly, we found that Nlrp12 deficiency caused increased rather than decreased neutrophil migration towards the chemokine CXCL1 and the neutrophil parasite Leishmania major, revealing NLRP12 as a negative regulator of directed neutrophil migration under these conditions.

Challenges to patient-centred care in a general internal medicine context: findings from an exploratory study

Introduction. If we are to promote more patient-centred approaches in care delivery, we have to better characterize the situations in which being patient-centred is difficult to achieve. Data from professionals in health and social care are important because they are the people charged with operationalizing patient-centred care (PCC) in their daily practice. However, empirical accounts from frontline care providers are still lacking, and it is important to gather experiences not only from doctors but also from the other care providers. Indeed, experiences from different professions can help inform our understanding of patient care, which is expected to be both patient-centred and collaborative. Methods. This study was based on the following research question: What factors make the provision of PCC difficult to achieve? Sample and setting. A purposeful sampling technique was used, allowing for a series of choices about the participants and their professional affiliation. Because patient-centredness is the focus, 3 professions appeared to be of special interest: general internists, nurses and social workers. The study was undertaken in the General Internal Medicine Division of a teaching hospital located in a North American context. Data Collection. To answer the research question, a methodological approach based on a theory called phenomenology was chosen. Accordingly, semi-structured interviews were used since they generate understanding of the meanings different individuals have of their lived world. Interviews with 8 physicians, 10 nurses and 10 social workers were eventually conducted. Data analysis. An inductive thematic analysis was employed to make sense of the interview data. Results. The thematic analysis allowed identifying various types of challenges to PCC. Although most of the challenges were perceived by all three groups of professionals, they were perceived to a different degree across the professions, which likely reflected the scope of practice of each profession. The challenges and their distribution across the professions are illustrated in Table 1. Examples of challenges are provided in Table 2. Discussion. There is a tension between what is supposed to be done - what stands in the philosophy of patient -centredness - and what is currently done - the real life with all the challenges to PCC. According to some participants' accounts, PCC clearly risks becoming a mere illusion for health care professionals on which too great pressures are imposed.

Posterior migration of lumbar disc herniation - imaging dilemma due to contrast contraindication: a case report

Disc herniation with posterior epidural migration is a rare and often symptomatic entity. Multiple are the natural barriers that prevent this pattern of migration. Enhanced magnetic resonance imaging is the diagnostic modality of choice in these cases. The diagnostic dilemma in this case was the contraindication to the use of contrast since the patient was known to have chronic renal failure.

Health Migration Policies and Ethical Controversies: the Case of African Nurses in the UK

The United Kingdom (UK) for last few decades has been faced with a growing need for health personnel and has therefore attracted professionals, particularly overseas nurses. The country has been characterised by a historical migration policy favourable to the recruitment of foreign health staff. However, in the context of deep shortage and high level of diseases and health system weakness, the international health professional recruitment from Sub Saharan Africa has created unprecedented ethical controversies which have pushed the UK to the centre of discussions because of its liberal policies towards international recruitment that have been considered as aggressive. While the 'brain drain' controversy is well known, less attention has been devoted to the specific international health migration controversy and the pivotal role of the UK in the diffusion of ethical code of practice. Using mainly the perspective of the policy analysis of controversy (Roe 1994) and the analysis of discourses (de Haas 2008), our paper comes back respectively to the nature of the controversy and the pivotal role of the UK. It also analyses how the implementation of UK ethical policies - Code of Practice, banned countries list of recruitment, restrictive immigration policies - have been considered as inefficient and unethical in their contents and their targets.

Complete internal audit of a mammography service in a reference institution for breast imaging

Objective Undertaking of a complete audit of the service of mammography, as recommended by BI-RADS®, in a private reference institution for breast cancer diagnosis in the city of São Paulo, SP, Brazil, and comparison of results with those recommended by the literature. Materials and Methods Retrospective, analytical and cross-sectional study including 8,000 patients submitted to mammography in the period between April 2010 and March 2011, whose results were subjected to an internal audit. The patients were followed-up until December 2012. Results The radiological classification of 7,249 screening mammograms, according to BI-RADS, was the following: category 0 (1.43%), 1 (7.82%), 2 (80.76%), 3 (8.35%), 4 (1.46%), 5 (0.15%) and 6 (0.03%). The breast cancer detection ratio was 4.8 cases per 1,000 mammograms. Ductal carcinoma in situ was found in 22.8% of cases. Positive predictive values for categories 3, 4 and 5 were 1.3%, 41.3% and 100%, respectively. In the present study, the sensitivity of the method was 97.1% and specificity, 97.4%. Conclusion The complete internal audit of a service of mammography is essential to evaluate the quality of such service, which reflects on an early breast cancer detection and reduction of mortality rates.

High expression levels of macrophage migration inhibitory factor sustain the innate immune responses of neonates.

The vulnerability to infection of newborns is associated with a limited ability to mount efficient immune responses. High concentrations of adenosine and prostaglandins in the fetal and neonatal circulation hamper the antimicrobial responses of newborn immune cells. However, the existence of mechanisms counterbalancing neonatal immunosuppression has not been investigated. Remarkably, circulating levels of macrophage migration inhibitory factor (MIF), a proinflammatory immunoregulatory cytokine expressed constitutively, were 10-fold higher in newborns than in children and adults. Newborn monocytes expressed high levels of MIF and released MIF upon stimulation with Escherichia coli and group B Streptococcus, the leading pathogens of early-onset neonatal sepsis. Inhibition of MIF activity or MIF expression reduced microbial product-induced phosphorylation of p38 and ERK1/2 mitogen-activated protein kinases and secretion of cytokines. Recombinant MIF used at newborn, but not adult, concentrations counterregulated adenosine and prostaglandin E2-mediated inhibition of ERK1/2 activation and TNF production in newborn monocytes exposed to E. coli. In agreement with the concept that once infection is established high levels of MIF are detrimental to the host, treatment with a small molecule inhibitor of MIF reduced systemic inflammatory response, bacterial proliferation, and mortality of septic newborn mice. Altogether, these data provide a mechanistic explanation for how newborns may cope with an immunosuppressive environment to maintain a certain threshold of innate defenses. However, the same defense mechanisms may be at the expense of the host in conditions of severe infection, suggesting that MIF could represent a potential attractive target for immune-modulating adjunctive therapies for neonatal sepsis.

Migration et compétence sanitaire : constats et exemple de l'Hôpital de l'enfance à Lausanne

[...] L'objectif de ce travail est d'exposer les notions de "compétence sanitaire" (Health Literacy) et d' "autonomisation" (Empowerment) dans un contexte de prise en charge pédiatrique des enfants de migrants. Nous sommes convaincus que ces deux concepts émergeants dans le domaine de la santé et appliqués au contexte migratoire constituent, sur les plans économiques et de management, des éléments qui peuvent mener à terme à : i) une réduction mesurable des coûts de la santé et ii) une porte d'entrée efficace dans un processus d'intégration - dont l'importance est reconnue sur le plan économique - des migrants dans leur pays d'accueil. Tout au long de ce travail, il apparaîtra comme évident que des données propres à la prise en charge sanitaire pédiatrique des enfants de migrants font actuellement souvent défaut, a fortiori l'application des concepts de compétence sanitaire et d'autonomisation pour cette part de la société. Nous le percevons comme une opportunité de mettre en place les conditions cadres pour combler ce vide. Nous poserons tout d'abord le cadre de ce mémoire au travers de la présentation des concepts de compétence sanitaire et d'autonomisation, en mettant en avant leurs aspects économiques dans les systèmes de santé actuels, en particulier en Suisse. Nous présenterons dans les chapitres 2 et 3 d'une part des données concernant l'état de santé de la population migrante en Suisse et d'autre part la stratégie mise en place au niveau fédéral dans le domaine " migration et santé 2008-2013 ". Le chapitre 4 nous permettra de présenter un "case study" que nous avons intégré à notre travail afin d'apporter des éléments plus concrets aux notions théoriques abordées dans ce mémoire. Nous avons choisi de nous concentrer sur l'Hôpital de l'Enfance de Lausanne (HEL) parce que l'HEL nous semble présenter un cas de structure hospitalière qui fait un effort remarquable de prise en charge médico-psycho-sociale des enfants de migrants. Le chapitre 5, en conclusion, aura pour objectif principal de soutenir que l'inclusion d'une dimension de management/gestion de la santé (représenté ici par l'autonomisation et la compétence sanitaire) introduirait une valeur ajoutée remarquable à l'effort constructif consenti sur le plan médico-social décrit au chapitre précédent. [Auteure, p. 4-5]

Essays on the Economics of Conflict and Migration

Les conflits civils sont des événements dramatiques qui poussent les individus hors de leurs pays d'origine. Mais si l'émigration était elle-même une force pacificatrice? Dans les deux premiers chapitres, je me suis intéressée à l'impact de l'émigration sur l'incidence des conflits civils dans les pays d'origine. Tout d'abord, je construis un modèle théorique d'équilibre général, dans lequel le niveau de conflit d'équilibre est déterminé par la ratio de combattants dans l'économie. Dans ce modèle, l'émigration décourage les conflits en réduisant les gains d'une rébellion, tout en augmentant le coût d'opportunité des combats. La principale prédiction du modèle est que le conflit diminue avec le niveau du salaire étranger net des coûts de migration. Dans le deuxième chapitre, je teste cette prédiction empiriquement. En utilisant une variable instrumentale, je démontre que l'émigration vers les pays développés diminue l'incidence de guerres civiles dans les pays d'origine. Ces résultats prouvent qu'en ouvrant leurs frontières, les pays d'accueil pourraient contribuer à sauver des vies, aussi bien celles des migrants que celles des habitants restés dans leur pays. De plus, les conflits civils tendent à détruire des sociétés en traumatisant les personnes touchées, augmentant ainsi le risque des conflits futurs. Afin de mieux comprendre ce cercle vicieux et de pouvoir y remédier, le troisième chapitre détermine si les enfants ayant vécu la guerre ont une tendance à être plus violent que des co-nationaux nés après la guerre. L'analyse se concentre sur les demandeurs d'asile en Suisse : Cette population est intéressante puisque l'allocation des demandeurs d'asile entre cantons est aléatoire, ce qui prévient le choix d'un canton avec un taux de criminalité plus élevé. Les résultats démontrent un effet de traumatisme causé par la guerre augmentant ainsi le risque de criminalité dans la vie adulte. Cependant, l'analyse de politiques publiques montre que la mise en place de politiques judicieuses permet d'éviter les conséquences de l'exposition à la guerre. En particulier, en offrant aux nouveaux arrivants l'accès au marché de travail ainsi que des perspectives à long-terme, la Suisse peut éliminer complètement l'effet du traumatisme sur la criminalité.

The internal wave field in Sau reservoir : Observation and modeling of a third vertical mode

Water withdrawal from Mediterranean reservoirs in summer is usually very high. Because of this, stratification is often continuous and far from the typical two-layered structure, favoring the excitation of higher vertical modes. The analysis of wind, temperature, and current data from Sau reservoir (Spain) shows that the third vertical mode of the internal seiche (baroclinic mode) dominated the internal wave field at the beginning of September 2003. We used a continuous stratification two-dimensional model to calculate the period and velocity distribution of the various modes of the internal seiche, and we calculated that the period of the third vertical mode is ;24 h, which coincides with the period of the dominating winds. As a result of the resonance between the third mode and the wind, the other oscillation modes were not excited during this period

The seasonal evolution of high vertical–mode internal waves in a deep reservoir

The causal mechanism and seasonal evolution of the internal wave field in a deep, warm, monomictic reservoirare examined through the analysis of field observations and numerical techniques. The study period extends fromthe onset of thermal stratification in the spring until midsummer in 2005. During this time, wind forcing wasperiodic, with a period of 24 h (typical of land–sea breezes), and the thermal structure in the lake wascharacterized by the presence of a shallow surface layer overlying a thick metalimnion, typical of small to mediumsized reservoirs with deep outtakes. Basin-scale internal seiches of high vertical mode (ranging from mode V3 toV5) were observed in the metalimnion. The structure of the dominant modes of oscillation changed asstratification evolved on seasonal timescales, but in all cases, their periods were close to that of the local windforcing (i.e., 24 h), suggesting a resonant response. Nonresonant oscillatory modes of type V1 and V2 becamedominant after large frontal events, which disrupted the diurnal periodicity of the wind forcing