Acute haematogenous prosthetic joint infection: prospective evaluation of medical and surgical management

The optimum treatment for prosthetic joint infections has not been clearly defined. We report our experience of the management of acute haematogenous prosthetic joint infection (AHPJI) in patients during a 3-year prospective study in nine Spanish hospitals. Fifty patients, of whom 30 (60%) were female, with a median age of 76 years, were diagnosed with AHPJI. The median infection-free period following joint replacement was 4.9 years. Symptoms were acute in all cases. A distant previous infection and/or bacteraemia were identified in 48%. The aetiology was as follows: Staphylococcus aureus, 19; Streptococcus spp., 14; Gram-negative bacilli, 12; anaerobes, two; and mixed infections, three. Thirty-four (68%) patients were treated with a conservative surgical approach (CSA) with implant retention, and 16 had prosthesis removal. At 2-year follow-up, 24 (48%) were cured, seven (14%) had relapsed, seven (14%) had died, five (10%) had persistent infection, five had re-infection, and two had an unknown evolution. Overall, the treatment failure rates were 57.8% in staphylococcal infections and 14.3% in streptococcal infections. There were no failures in patients with Gram-negative bacillary. By multivariate analysis, CSA was the only factor independently associated with treatment failure (OR 11.6; 95% CI 1.29-104.8). We were unable to identify any factors predicting treatment failure in CSA patients, although a Gram-negative bacillary aetiology was a protective factor. These data suggest that although conservative surgery was the only factor independently associated with treatment failure, it could be the first therapeutic choice for the management of Gram-negative bacillary and streptococcal AHPJI, and for some cases with acute S. aureus infections.

Surveillance, health promotion and control of Chagas disease in the Amazon Region - Medical attention in the Brazilian Amazon Region: a proposal

We refer to Oswaldo Cruz’s reports dating from 1913 about the necessities of a healthcare system for the Brazilian Amazon Region and about the journey of Carlos Chagas to 27 locations in this region and the measures that would need to be adopted. We discuss the risks of endemicity of Chagas disease in the Amazon Region. We recommend that epidemiological surveillance of Chagas disease in the Brazilian Amazon Region and Pan-Amazon region should be implemented through continuous monitoring of the human population that lives in the area, their housing, the environment and the presence of triatomines. The monitoring should be performed with periodic seroepidemiological surveys, semi-annual visits to homes by health agents and the training of malaria microscopists and healthcare technicians to identify Trypanosoma cruzi from patients’ samples and T. cruzi infection rates among the triatomines caught. We recommend health promotion and control of Chagas disease through public health policies, especially through sanitary education regarding the risk factors for Chagas disease. Finally, we propose a healthcare system through base hospitals, intermediate-level units in the areas of the Brazilian Amazon Region and air transportation, considering the distances to be covered for medical care.

Adolescents health in Georgia: a national portrait.

The aim of the study was to assess the basic indicators of health of adolescents in Georgia. A self-administered anonymous questionnaire was adapted from the Swiss Survey (SMASH2002), translated into Georgian and other languages mainly used in schools (Russian, Armenian and Azeri). It contained 87 questions. Two-stage cluster sampling was devised. Weight was adjusted. A total of 599 classes were selected. All questionnaires before being processed into the Epidata (www.epidata.dk) were edited. The final data were analysed by SPSS 11.0. General health status was considered as excellent and very good by 34.0+/-0.8% of respondents. 21.5% claimed to never miss the school due to the illness. The frequencies of physical disability and chronic diseases were 8.0% and 5.0% correspondingly. Among health-related problems the most frequent are problems with teeth, headache and acne. 5.9% of girls had some kind of gynecological problems quite often and very often. Performed survey is a first one done among adolescents in Georgia. It gave us basic information for planning and implementation of necessary measures in order to improve the health of adolescents and raise awareness of professionals involved in health care and prevention settings for adolescents. The data can be also used for monitoring of health status of adolescents in Georgia.

Are the health messages in schoolbooks based on scientific evidence? A descriptive study.

BACKGROUND Most textbooks contains messages relating to health. This profuse information requires analysis with regards to the quality of such information. The objective was to identify the scientific evidence on which the health messages in textbooks are based. METHODS The degree of evidence on which such messages are based was identified and the messages were subsequently classified into three categories: Messages with high, medium or low levels of evidence; Messages with an unknown level of evidence; and Messages with no known evidence. RESULTS 844 messages were studied. Of this total, 61% were classified as messages with an unknown level of evidence. Less than 15% fell into the category where the level of evidence was known and less than 6% were classified as possessing high levels of evidence. More than 70% of the messages relating to "Balanced Diets and Malnutrition", "Food Hygiene", "Tobacco", "Sexual behaviour and AIDS" and "Rest and ergonomics" are based on an unknown level of evidence. "Oral health" registered the highest percentage of messages based on a high level of evidence (37.5%), followed by "Pregnancy and newly born infants" (35%). Of the total, 24.6% are not based on any known evidence. Two of the messages appeared to contravene known evidence. CONCLUSION Many of the messages included in school textbooks are not based on scientific evidence. Standards must be established to facilitate the production of texts that include messages that are based on the best available evidence and which can improve children's health more effectively.

Continuity and change in the gender segregation of the medical profession in Britain and France

It is a well established fact that the entry of women into higher-level professional occupations has not resulted in their equal distribution within these occupations. Indeed, the emergence and persistence of horizontal and vertical gender segregation within the professions has been at the heart of the development of a range of alternative theoretical perspectives on both the "feminisation process" and the future of the "professions"more generally. Through an in-depth comparative analysis of the recent changes in the organisation and administration of the medical profession in Britain and France, this paper draws upon statistical data and biographical interviews with male and female general practitioners (GPs) in both countries in order to discuss and review a variety of approaches that have been adopted to explain and analyse the "eminisation" process of higher-level professions. Our conclusions review the theoretical debates in the light of the evidence we have presented. It is argued that, despite important elements of continuity in respect of gendered occupational structuring in both countries, national variations in both professional and domestic gendered architectures lead to different outcomes as far as the extent and patterns of internal occupational segregation are concerned. Both female and male doctors are currently seeking - with some effect - to resist thepressures of medicine on family life.

Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: a 10 yr retrospective study.

BACKGROUND: Prehospital oligoanalgesia is prevalent among trauma victims, even when the emergency medical services team includes a physician. We investigated if not only patients' characteristics but physicians' practice variations contributed to prehospital oligoanalgesia. METHODS: Patient records of conscious adult trauma victims transported by our air rescue helicopter service over 10 yr were reviewed retrospectively. Oligoanalgesia was defined as a numeric rating scale (NRS) >3 at hospital admission. Multilevel logistic regression analysis was used to predict oligoanalgesia, accounting first for patient case-mix, and then physician-level clustering. The intraclass correlation was expressed as the median odds ratio (MOR). RESULTS: A total of 1202 patients and 77 physicians were included in the study. NRS at the scene was 6.9 (1.9). The prevalence of oligoanalgesia was 43%. Physicians had a median of 5.7 yr (inter-quartile range: 4.2-7.5) of post-graduate training and 27% were female. In our multilevel analysis, significant predictors of oligoanalgesia were: no analgesia [odds ratio (OR) 8.8], National Advisory Committee for Aeronautics V on site (OR 4.4), NRS on site (OR 1.5 per additional NRS unit >4), female physician (OR 2.0), and years of post-graduate experience [>4.0 to ≤5.0 (OR 1.3), >3.0 to ≤4.0 (OR 1.6), >2.0 to ≤3.0 (OR 2.6), and ≤2.0 yr (OR 16.7)]. The MOR was 2.6, and was statistically significant. CONCLUSIONS: Physicians' practice variations contributed to oligoanalgesia, a factor often overlooked in analyses of prehospital pain management. Further exploration of the sources of these variations may provide innovative targets for quality improvement programmes to achieve consistent pain relief for trauma victims.

A multidimensional segmentation evaluation for medical image data.

Evaluation of segmentation methods is a crucial aspect in image processing, especially in the medical imaging field, where small differences between segmented regions in the anatomy can be of paramount importance. Usually, segmentation evaluation is based on a measure that depends on the number of segmented voxels inside and outside of some reference regions that are called gold standards. Although some other measures have been also used, in this work we propose a set of new similarity measures, based on different features, such as the location and intensity values of the misclassified voxels, and the connectivity and the boundaries of the segmented data. Using the multidimensional information provided by these measures, we propose a new evaluation method whose results are visualized applying a Principal Component Analysis of the data, obtaining a simplified graphical method to compare different segmentation results. We have carried out an intensive study using several classic segmentation methods applied to a set of MRI simulated data of the brain with several noise and RF inhomogeneity levels, and also to real data, showing that the new measures proposed here and the results that we have obtained from the multidimensional evaluation, improve the robustness of the evaluation and provides better understanding about the difference between segmentation methods.

An electronic portfolio for quantitative assessment of surgical skills in undergraduate medical education.

BACKGROUND We evaluated a newly designed electronic portfolio (e-Portfolio) that provided quantitative evaluation of surgical skills. Medical students at the University of Seville used the e-Portfolio on a voluntary basis for evaluation of their performance in undergraduate surgical subjects. METHODS Our new web-based e-Portfolio was designed to evaluate surgical practical knowledge and skills targets. Students recorded each activity on a form, attached evidence, and added their reflections. Students self-assessed their practical knowledge using qualitative criteria (yes/no), and graded their skills according to complexity (basic/advanced) and participation (observer/assistant/independent). A numerical value was assigned to each activity, and the values of all activities were summated to obtain the total score. The application automatically displayed quantitative feedback. We performed qualitative evaluation of the perceived usefulness of the e-Portfolio and quantitative evaluation of the targets achieved. RESULTS Thirty-seven of 112 students (33%) used the e-Portfolio, of which 87% reported that they understood the methodology of the portfolio. All students reported an improved understanding of their learning objectives resulting from the numerical visualization of progress, all students reported that the quantitative feedback encouraged their learning, and 79% of students felt that their teachers were more available because they were using the e-Portfolio. Only 51.3% of students reported that the reflective aspects of learning were useful. Individual students achieved a maximum of 65% of the total targets and 87% of the skills targets. The mean total score was 345 ± 38 points. For basic skills, 92% of students achieved the maximum score for participation as an independent operator, and all achieved the maximum scores for participation as an observer and assistant. For complex skills, 62% of students achieved the maximum score for participation as an independent operator, and 98% achieved the maximum scores for participation as an observer or assistant. CONCLUSIONS Medical students reported that use of an electronic portfolio that provided quantitative feedback on their progress was useful when the number and complexity of targets were appropriate, but not when the portfolio offered only formative evaluations based on reflection. Students felt that use of the e-Portfolio guided their learning process by indicating knowledge gaps to themselves and teachers.

Endometriosis: alternative methods of medical treatment.

Endometriosis is an inflammatory estrogen-dependent disease defined by the presence of endometrial glands and stroma at extrauterine sites. The main purpose of endometriosis management is alleviating pain associated to the disease. This can be achieved surgically or medically, although in most women a combination of both treatments is required. Long-term medical treatment is usually needed in most women. Unfortunately, in most cases, pain symptoms recur between 6 months and 12 months once treatment is stopped. The authors conducted a literature search for English original articles, related to new medical treatments of endometriosis in humans, including articles published in PubMed, Medline, and the Cochrane Library. Keywords included "endometriosis" matched with "medical treatment", "new treatment", "GnRH antagonists", "Aromatase inhibitors", "selective progesterone receptor modulators", "anti-TNF α", and "anti-angiogenic factors". Hormonal treatments currently available are effective in the relief of pain associated to endometriosis. Among new hormonal drugs, association to aromatase inhibitors could be effective in the treatment of women who do not respond to conventional therapies. GnRH antagonists are expected to be as effective as GnRH agonists, but with easier administration (oral). There is a need to find effective treatments that do not block the ovarian function. For this purpose, antiangiogenic factors could be important components of endometriosis therapy in the future. Upcoming researches and controlled clinical trials should focus on these drugs.

Le mouvement peut-il guérir? : histoire de l'engagement des médecins français dans l'élaboration de l'éducation physique (1741-1888)

Résumé : Cette recherche doctorale analyse l'engagement des médecins français autour de l'éducation physique entre 1741 et 1888. Basé sur un travail prosopographique d'identification des médecins qui ont participé à l'élaboration de l'éducation physique, ce travail repose sur une mise en dialogue de leurs prises de position respectives. Pour réaliser cette enquête, nous avons compulsé un large corpus de sources primaires, composé des ouvrages consacrés à la gymnastique médicale mais aussi une très large portion de la production d'imprimés touchant à l'anatomie, l'hygiène, la thérapeutique, la physiologie, l'orthopédie, etc. Le corpus contient également des articles des principaux dictionnaires médicaux de la période et des principales revues médicales du XIXe siècle. Avec une approche critique de l'historiographie et à partir de ce corpus, nous avons travaillé dans le cadre de contextes définis pour saisir au plus près les logiques sociales et scientifiques amenant les médecins auprès de l'éducation physique. Trois conjonctures successives structurent l'engagement médical. Entre 1741 et 1817, la thèse retrace l'émergence d'un questionnement ; les années 1817-1847 constituent un « moment orthopédique » dans la formulation de la gymnastique ; et finalement entre 1847 et 1888, on observe une diversification des voies de légitimation médicale des exercices du corps. Ces trois moments de l'histoire des « discours gymniques médicaux » proposent un certain nombre de convergences : la prégnance de l'orthopédie, une certaine concentration autour de la santé des corps féminins, l'inclusion dans un « projet hygiéniste » ; mais aussi des divergences et des singularités : relatives à la progressive structuration en cours du champ médical, à l'implication progressive du politique (surtout après 1845/1850), aux transformations des pathologies/doctrines médicales « dominantes », ainsi qu'à l'importance plus ou moins forte de l'une ou l'autre des facettes de l'éducation physique (militaire, athlétique, « médicinale » ou pédagogique). Le processus est aussi celui de l'expérimentation de la curation de certaines pathologies (scolioses, affections nerveuses), dans des configurations idéologiques/scientifiques marquées par la « dégénération » (XVIIIe siècle), l'anatomie pathologique (début du XIXe siècle) et plus tard la « dégénérescence » et les affections nerveuses (après 1850). Dans le cadre d'une dynamique d'inspiration « foucaldienne », ces recommandations évoluent d'une anatomopolitique - caractérisée par un essor de discours empreints d'anatomie au XVIIIe siècle - vers une biopolitique - caractérisée par l'engagement de l'Etat qui fait de la gymnastique une discipline d'enseignement, pensée à des fins hygiéniques dans la seconde moitié du XIXe - où le processus réside en fait dans une biologisation progressive des recommandations pratiques. Observée à l'aune de la formulation médicale de l'éducation physique, la biopolitique n'est pas réalisée dans la seconde moitié du XVIIIe, elle se compose lentement aux marges de l'institution scolaire et des gymnastiques pédagogico-militaires pour constituer un projet thérapeutique et hygiénique plus construit après 1850. Abstract : This dissertation analyzes French doctor's involvement in debates and initiatives concerning physical education between 1741 and 1888. Based on a prosopographic inventory of those physicians who participated in the development of physical education, it explores the variety of their discourses with respect to the practice of physical exercises. This investigation relies on a large selection of primary sources: works devoted to medical gymnastic, but also medical treatises related to anatomy, hygiene, therapeutics, physiology, orthopedics, etc. The sources also include articles from the major medical dictionaries and journals of the nineteenth century. These documents are used to explore the socio-scientific mechanisms that underlay physicians' commitment to physical education. Three chronological periods structure medical engagement in the area of physical education. Between 1741 and 1817 the thesis traces the emergence of a questioning; the years 1817 to 1847 represent an « orthopedic moment » in the development of gymnastics; finally between 1847 and 1888, one witnesses a diversification of the legitimation process between medicine and gymnastics. These three moments in the history of « medical and gymnastic discourses » offer a number of similarities: the weight of orthopedics, the ongoing focus on the health of the female body, and the association of these discourses with a « hygienic project ». But differences also distinguish these periods as the medical field became more structured and new medical doctrines became dominant, with the increasing involvement of politics (especially after 1850), and with the changing weight of priorities within physical education (military, athletic, « medical » or pedagogic). Medical discourses centered on the curing of certain diseases (scoliosis or nervous disorders) are analyzed within an ideological configuration marked by the idea of « degeneration » (in the eighteenth century), « pathological anatomy » (in the early nineteenth century) and later « dégénérescence » associated with nervous disorders (after 1850). The dissertation draws on Foucault's historical epistemology to understand how medical recommendations evolve from an anatomopolitics - characterized by a surge in anatomical discourses - toward a biopolitics - characterized by the commitment of the State to introduce gymnastics for hygienic purposes into schools in the second half of the nineteenth century. This process reveals a progressive "biologization" of practical recommendations. The medical discourses about physical education show that Foucault's biopolitical power is not achieved in the second half of the eighteenth century, but develops slowly at the margins of the school system and of pedagogical and military gymnastic, becoming a veritable hygienic and therapeutic project only after 1850.

Non-medical prescription drug and illicit street drug use among young Swiss men and associated mental health issues.

Non-medical use of prescription drugs (NMUPD) is increasing among the general population, particularly among teenagers and young adults. Although prescription drugs are considered safer than illicit street drugs, NMUPD can lead to detrimental consequences. The aim of the present study was to investigate the relationship between drug use (NMUPD on the one side, illicit street drugs on the other side) with mental health issues and then compare these associations. A representative sample of 5719 young Swiss men aged around 20 years filled in a questionnaire as part of the ongoing baseline Cohort Study on Substance Use Risk Factors (C-SURF). Drug use (16 illicit street drugs and 5 NMUPDs, including sleeping pills, sedatives, pain killers, antidepressants, stimulants) and mental health issues (depression, SF12) were assessed. Simple and multiple linear regressions were employed. In simple regressions, all illicit and prescription drugs were associated with poorer mental health. In multiple regressions, most of the NMUPDs, except for stimulants, were significantly associated with poorer mental health and with depression. On the contrary, the only associations that remained significant between illicit street drugs and mental health involved cannabis. NMUPD is of growing concern not only because of its increasing occurrence, but also because of its association with depression and mental health problems, which is stronger than the association observed between these problems and illicit street drug use, excepted for cannabis. Therefore, NMUPD must be considered in screening for substance use prevention purposes.

"S'il vous plaît docteur, mettez-moi en arrêt"! Certificats médicaux pour raisons psychologiques ["Doctor please, give me a sick leave"!: medical certificates for psychological reasons].

General practitioners are regularly called to evaluate the psychological work capacity of patients. The implicit motivation behind the explicit reason for requesting a sick leave is linked to the subject's history and the way he transfers it in his professional life. An incapacity to work harbours a variety of challenges for the patient, the physician and their relationship. In order to get a better understanding of all the issues at stake, the doctor should understand the significances that represents the work to the patient and the consequences of a sick leave and its associated transference and countertransference issues.