Psychosis with coexisting substance misuse: assessment and management in adults and young people.

This guideline offers best practice advice on the assessment and management of people with psychosis and coexisting substance misuse. Psychosis is a condition that affects a person’s mental state, including their thoughts, mood and behaviour. The symptoms of psychosis are:• hallucinations – hearing voices and sometimes seeing things that are not really there• delusions – having fixed beliefs that are false but which the person believes in completely. Substance misuse is a broad term encompassing, in this guideline, the harmful use of any psychotropic substance, including alcohol and either legal or illicit drugs. Use of such substances is harmful when it has a negative effect on a person’s life, including their physical and mental health, relationships, work, education and finances or leads to offending behaviour.This resource was contributed by The National Documentation Centre on Drug Use.

Open to the users' needs : combining user-centered design, standards and open source software

This case study introduces our continuous work to enhance the virtual classroom in order to provide faculty and students with an environment open to their needs, compliant with learning standards and, therefore compatible with other e-learning environments, and based on open source software. The result is a modulable, sustainable and interoperable learning environment that can be adapted to different teaching and learning situations by incorporating the LMS integrated tools as well as wikis, blogs, forums and Moodle activities among others.

Principes d'evaluation et de prise en charge des patients agés polymorbides: guide a l'intention des cliniciens [Principles for the assessment and management of polymorbid elderly patients: a guide for clinicians].

Providing care to multimorbid older patients is complex, not only because of the coexistence of multiple chronic conditions, but also because of their frequent intrication with psychological and social problems. This article describes a guide for clinicians to assess and manage multimorbid older patients. This guide was adapted from the work of a group of expert US geriatricians. It proposes seven steps: identification of the main problem; identification of patients' preferences; setting of goals of care; estimation of life expectancy; identification of relevant evidence in the literature; revision of the plan of care; and discussion of the options with the patient. The use of this guide is illustrated by a clinical case.

Allergie aux venins d'hyménopteres: nouveautés diagnostiques et prise en charge [Hymenoptera venom allergy: new diagnostic tools and management].

Anaphylactic reactions to hymenoptera venoms are common and, in our latitudes, mainly concern wasps and bees. Recently, molecular biology techniques have contributed to identifying and to sequencing the major allergens of insect venoms and led to the production of recombinant allergens. Assays for specific IgE directed against these recombinant allergens have recently been made available in clinical practice. They provide considerable assistance in identifying the insect responsible for an anaphylactic reaction, in particular when standard tests are positive for both wasp and bee. This article focuses on these new laboratory tests and also reviews the management of patients experiencing an anaphylactic reaction after hymenoptera sting.

Exposition au VIH, à l'hépatite B et C au cabinet médical et à l'hôpital. Prévention et prophylaxie postexpositionnelle [Exposure to HIV, hepatitis B and C in office practice and hospital. Prevention and post-exposure prophylaxis]

Suite à un accident exposant à du sang (piqûre; coupure), provenant d'un patient infecté, le risque d'infection par VIH est d'environ 0,3% et par le virus de l'hépatite C (VHC) d'environ 0,5%. Chez les personnes vaccinées avec une réponse immunitaire adéquate (titre d'anticorps HBs >100 mUI/ml), aucune infection professionnelle par hépatite B n'a été reconnue en Suisse. La plupart des infections par VIH et VHB peuvent être prévenues par un traitement d'urgence et une prophylaxie postexpositionnelle (PEP). Il n'y a actuellement aucune prophylaxie postexpositionnelle pour le VHC. En cas de transmission de VHC, un traitement rapide par peginterféron et ribavirine est à envisager. Chaque hôpital et cabinet médical doivent mettre sur pied un système pour assurer une prise en charge optimale et en urgence des blessures par piqûres ou coupures. Lors de blessures accidentelles avec du sang de patients séropositifs pour le VIH et dans des situations complexes, il est recommandé de consulter un médecin du personnel ou un infectiologue expérimenté. The risk of infection after an occupational needle stick injury with blood from an infected source patient is approximately 0.3% for HIV and 0.5% for hepatitis C virus (HCV). In Switzerland no cases of occupational HBV infection have been recorded in fully vaccinated persons with a documented adequate vaccine response (HBsantibody titer >100 mIU/mL). Most occupational HIV und HBV infections can be prevented by appropriate emergency measures and post-exposure prophylaxis (PEP). No HCV-PEP is currently available. Early therapy with peginterferon and ribavirin should be considered in cases of occupational HCV seroconversion. Every hospital and office practice should establish a system for 24 h/24 h emergency management of occupational needle stick injuries. In the setting of an HIV-seropositive source patient and in complex situations, early consultation with a specialist in occupational medicine or infectious diseases should be considered.

Current concepts and management of glioblastoma.

Glioblastoma is the most common malignant primary brain tumor in adults. Its often rapid clinical course, with many medical and psychosocial challenges, requires a multidisciplinary management. Modern multimodality treatment and care improve patients' life expectancy and quality of life. This review covers major aspects of care of glioblastoma patients with a focus on the management of common symptoms and complications. We aim to provide a guide for clinicians confronted with glioblastoma patients in their everyday practice. Ann Neurol 2011;

Haemorrhage into the pancreatic duct (Hemosuccus pancreaticus): recognition and management.

OBJECTIVE: To highlight the clinical presentation, investigation and treatment of haemorrhage into the pancreatic duct. DESIGN: Retrospective study and review of publications. SETTING: University hospital, Switzerland. SUBJECTS: All 4 cases from 1972 to 1993. INTERVENTIONS: 2 Whipple procedures, 1 resection of the pancreatic head, 1 exploratory laparotomy. Radiological embolisation in one case. MAIN OUTCOME MEASURES: Cessation of haemorrhage and survival. RESULTS: The diagnosis was made preoperatively in three cases by gastroduodenoscopy and arteriography. Operation was the primary treatment in all patients and was effective with low morbidity and no mortality in three of them. Embolisation stopped the haemorrhage in the fourth patient, who was alcoholic and died of progressive liver insufficiency and variceal haemorrhage. CONCLUSIONS: There is no specific indication for haemorrhage into the pancreatic duct. The diagnosis is suggested by endoscopy (absence of a more common cause, or blood in the second part of the duodenum). Arteriography is essential to confirm the site of the bleeding and to attempt embolization. Operation is usually the definitive treatment.

Chylothorax in children: guidelines for diagnosis and management.

STUDY OBJECTIVE: To establish guidelines for the diagnosis and management of chylothorax in children. DESIGN: Retrospective study. PATIENTS: Fifty-one patients with a diagnosis of chylothorax. Twelve patients were excluded because of incomplete data or incorrect diagnosis. The following parameters were analyzed: triglyceride level, total cell number, and lymphocyte percentage; amount of pleural effusion on day of diagnosis, day 5, and day 14; and total time of pleural effusion. Prospectively, the same parameters were analyzed in a control group of 10 patients with pleural drainage. INTERVENTION: Patients with chylothorax were treated primarily with fat-free oral nutrition; if chyle did not stop, total parenteral nutrition with total enteric rest was started. If conservative therapy was not successful, pleurodesis was performed. RESULTS: In children with chylothorax triglyceride, triglyceride content ranged from 0.56 to 26.6 mmol/L; all values except one were > 1.1 mmol/L. In 36 of 39 patients (92%), the cell count was > 1,000 cells/microL. In 33 of 39 patients (85%), lymphocytes were > 90%. In patients without chylothorax triglyceride, triglyceride levels ranged from 0.1 to 0.71 mmol/L (median, 0.38 mmol/L) and cell count was from 20 to 1400 cells/microL (median, 322 cells/microL), with a maximum of 60% lymphocytes. With fat-free nutrition, chyle disappeared in 29 of 39 patients. Five patients died, and five required pleurodesis. CONCLUSIONS: Pleural effusion in children is chyle when it contains > 1.1 mmol/L triglycerides (with oral fat intake) and has a total cell count > or 1,000 cells/microL, with a lymphocyte fraction > 80%. Chylous effusions usually last long; however, after 6 weeks, the majority of the effusions (29 of 39 patients) had ceased. Late surgical interventions reduce the number of thoracotomies substantially, but can lead to very long hospitalization times. Early surgical interventions (after < 3 weeks) lead to a high number of thoracotomies, but certainly reduce hospitalization time.

Interstitial pregnancies' diagnosis and management: an eleven cases series.

PRINCIPLES: Interstitial pregnancy represents 2% of ectopic pregnancies, but it is a highly morbid condition with a 2.5% of maternal mortality. Its diagnostic and therapeutic management remains controversial. The aim of this review is to describe the management of interstitial pregnancy in our institution between 2001 and 2011 and to define some general rules for the clinical practice. METHODS: Single institution retrospective study. RESULTS: Eleven women were treated for interstitial pregnancy. The median age was 33 years and the median gestity was 4. Seven patients had a history of gynaecological surgery and four interstitial pregnancies followed in vitro fertilisation. The diagnosis was made at a median gestational age of seven weeks with a median beta-HCG level of 5,838 U/l. Six of the eleven patients received an initial treatment with intracornual methotrexate, three with intramuscular methotrexate and two with surgery. The median time to beta-HCG resolution was 58 days. Three of the eleven patients needed a second line treatment: two after intramuscular methotrexate and one after intracornual methotrexate. Six patients had further pregnancies and delivered by caesarean section. CONCLUSIONS: A high prevalence of previous ectopic pregnancies, gynaecological surgery and of pregnancies resulting from in vitro fertilisation was observed. The earliness of the diagnosis was the factor that allowed a conservative treatment in most cases. Beta-HCG level follow up was fundamental in allowing a second line therapy but beta-HCG can persist over a long period of time and this must be taken into account due to its possible psychological impact. Intracornual methotrexate seems to be more efficacious than intramuscular methotrexate in our series.

The impact of Economics on health policy and management in Spain

BackgroundDespite the intrinsic value of scientific disciplines, such as Economics, it is appropriate to gauge the impact of its applications on social welfare, or at least Health Economics (HE) case- its influence on health policy and management.MethodsThe three relevant features of knowledge (production, diffusion and application) are analyzed, more from an emic perspective the one used in Anthropology relying on the experience of the members of a culture- than from an etic approach seated on material descriptions and dubious statistics.ResultsThe soundness of the principles and results of HE depends on its disciplinary foundations,whereas its relevance than does not imply translation into practice- is more linked with the problems studied. Important contributions from Economics to the health sphere are recorded.HE in Spain ranks seventh in the world despite the relatively minor HE contents of its clinical and health services research journals.HE has in Spain more presence than influence, having failed to impregnate sufficiently thedaily events.ConclusionsHE knowledge required by a politician, a health manager or a clinician is rather limited; the main impact of HE could be to develop their intuition and awareness.

Endoscopic Approach and Management of Parasellar Lesions

The parasellar region is the location of a wide variety of inflammatory and benign or malignant lesions. A pathological diagnostic strategy may be difficult to establish relying solely on imaging data. Percutaneous biopsy through the foramen ovale using the Hartel technique has been developed for decision-making process. It is an accurate diagnostic tool allowing pathological diagnosis to determine the best treatment strategy. However, in some cases, this procedure may fail or may be inappropriate particularly for anterior parasellar lesions. Over these past decades, endoscopy has been widely developed and promoted in many indications. It represents an interesting alternative approach to parasellar lesions with low morbidity when compared to the classic microscopic sub-temporal extradural approach with or without orbito-zygomatic removal. In this chapter, we describe our experience with the endoscopic approach to parasellar lesions. We propose a complete overview of surgical anatomy and describe methods and results of the technique. We also suggest a model of a decision-making tree for the diagnosis and treatment of parasellar lesions.

Thermal modeling and management in ultrathin chip stack technology

This paper presents a thermal modeling for power management of a new three-dimensional (3-D) thinned dies stacking process. Besides the high concentration of power dissipating sources, which is the direct consequence of the very interesting integration efficiency increase, this new ultra-compact packaging technology can suffer of the poor thermal conductivity (about 700 times smaller than silicon one) of the benzocyclobutene (BCB) used as both adhesive and planarization layers in each level of the stack. Thermal simulation was conducted using three-dimensional (3-D) FEM tool to analyze the specific behaviors in such stacked structure and to optimize the design rules. This study first describes the heat transfer limitation through the vertical path by examining particularly the case of the high dissipating sources under small area. First results of characterization in transient regime by means of dedicated test device mounted in single level structure are presented. For the design optimization, the thermal draining capabilities of a copper grid or full copper plate embedded in the intermediate layer of stacked structure are evaluated as a function of the technological parameters and the physical properties. It is shown an interest for the transverse heat extraction under the buffer devices dissipating most the power and generally localized in the peripheral zone, and for the temperature uniformization, by heat spreading mechanism, in the localized regions where the attachment of the thin die is altered. Finally, all conclusions of this analysis are used for the quantitative projections of the thermal performance of a first demonstrator based on a three-levels stacking structure for space application.

Science, practice and patient needs: the work of the Plinius Maior Society.

The Plinius Maior Society is a European multinational, multidisciplinary group of clinicians and researchers in the alcoholism field, which strives for a comprehensive care concept in the management of alcoholism and alcohol-related problems. The Society, using evidence-based medicine, has developed a set of protocols, in the forms of guidelines, flow-charts, leaflets and booklets, for use as tools in research on and treatment of alcohol dependence, with a view to standardize clinical research procedures and to bridge the gap between the alcoholism researcher, practitioner and patient. These protocols or tools have been subjected to a review process during their preparation, and further comments on their validity will be integrated in their updates. Seven protocols have so far been developed, two of which, 'Guidelines on Evaluation of Treatment of Alcohol Dependence' and 'Detection and Management of Patients with Psychiatric and Alcohol Use Disorders', are aimed at the clinical researcher and specialists, whereas three others [in the form of decision trees (flow-charts)] are aimed at the general practitioner and other primary health care providers. These are entitled 'Alcohol Risk Assessment and Intervention in Primary Care', 'Withdrawal from Alcohol at Home' and 'Brief Intervention in Patients with Alcohol-Related Problems'. The remaining two tools are booklets aimed at the patient, one to support initiatives for detection of drinking problems and primary intervention, namely 'Do you have this Problem? Discuss it with your Doctor!', and the other to assist the patient in relapse prevention after the early stages of treatment, namely 'On the Way to Recovery'. The protocols for the general practitioners and patients have so far been produced in seven European languages, and, as with the Guidelines, feedback from target users will be collected and incorporated in future updates. The Society continually seeks to consider areas of clinical importance for its work and, as it enters the new millennium, it hopes to address and make a significant contribution to the most pressing problem in the management of alcohol dependence, namely relapse.

Prevalence and management of cardiovascular risk factors in Portuguese residents and Portuguese who migrated to Switzerland

Background: there is little information regarding the health status of migrants compared to subjects who remained in their country of origin. The aim was to compare Portuguese living in Porto (Portugal) with Portuguese migrants living in Lausanne (Switzerland). Design: cross-sectional studies conducted in Porto (EpiPorto, n=1150) and Lausanne (CoLaus, n=388) among Portuguese subjects aged between 35 and 65 years. Methods: body mass index, blood pressure, cholesterol and glucose levels were assessed using standardized procedures. Educational level, antihypertensive, hypocholesterolemic and antidiabetic treatments were collected using questionnaires. Results: Portuguese living in Lausanne were younger, more frequently male and had a lower education than Portuguese living in Porto. After multivariate adjustment, Portuguese living in Porto had a higher likelihood of being obese [Odds ratio and 95% confidence interval: 1.40 (1.01-1.94)] or abdominal obese [OR: 1.40 (1.02-1.93)] than Portuguese living in Lausanne. Portuguese living in Porto had a higher likelihood of being hypertensive than Portuguese living in Lausanne [OR: 1.38 (1.01-1.90)], while no differences were found regarding hypertension management and control. Portuguese living in Porto had a higher likelihood of being hypercholesterolemic [OR: 1.40 (1.06-1.85)] and were less likely to be treated [OR: 0.47 (0.27-0.83)] and controlled [OR: 0.47 (0.27-0.83)] than Portuguese living in Lausanne. Finally, no differences were found regarding smoking, prevalence and management of diabetes. Conclusion: Portuguese living in Lausanne, Switzerland, present a better cardiovascular risk profile and tend to be better managed regarding their cardiovascular risk factors than Portuguese living in Porto, Portugal.

Morphogenetic characteristics and management of Tanzania grass

The objective of this work was to evaluate the effect of grazing interval and period of evaluation over tissue turnover in Tanzania grass pastures (Panicum maximum cv. Tanzania) and to ascertain if herbage accumulation rate can be used as a criterion to establish a defoliation schedule for this grass in Southeast of Brazil. A randomized block design with a split-plot arrangement was used. The effect of three grazing intervals was evaluated within seven periods between October 1995 and September 1996. Responses monitored were leaf and stem elongation rates, leaf senescence rate, stem length, and tiller density. Net herbage accumulation rate was calculated using tissue turnover data. The grazing intervals for Tanzania grass should be around 38 days between October and April (spring and early autumn) and 28 days during the reproductive phase of the grass (April/May). Between May and September (late autumn and winter), grazing interval should be around 48 days. Herbage accumulation rate is not a good criterion to establish defoliation time for Tanzania grass. Studies on the effects of stem production in grazing efficiency, animal intake and forage quality are needed to improve Tanzania grass management.