Médecine interne générale ambulatoire: quelques enseignements de la littérature en 2005 [Primary care in general internal medicine: relevant information in 2005]

During the year 2005, the chief residents of the University Medical Outpatient Clinic of Lausanne have done a database of useful articles for daily practice, scientifically validated and with excellent didactic quality, from 10 electronic journals. They have used those selected articles in personal meetings between the chief residents on a regular basis and the possibility to access the database by the junior physicians. Six of these articles concerning different topics (depression, tuberculosis detection, anticoagulation at home, cholinesterase inhibitors, insomnia and therapies, transdermal nitroglycerin and tendinopathies) are presented.

Désir de grossesse après vasectomie: vasovasostomie ou procréation médicalement assistée [New child wish after vasectomy: vasovasostomy or assisted reproductive medicine?].

New child wish after vasectomy: vasovasostomy or assisted reproductive medicine? In the case of a new child wish after vasectomy, there are two options: vaso-vasostomy (VV) or biopsy of the testicle associated with intra-cytoplasmatic sperm injection (ICSI). Both methods are not reimbursed. The VV offers a cumulative pregnancy rate of 28-40%, depending on pre-, intra- and postoperative factors. The age of the female partner and the time after vasectomy are the most important factors. Pregnancy rates after ICSI are 29-41% per transfer. Cumulative pregnancy rates vary between 60-80%. Malformation rates after ICSI in this special collective are not investigated yet, the "general" ICSI-collective differs completely compared to the a priori fertile couples after vasectomy. Couples have to inform themselves about the experience of the doctors and their rate of success in order to minimize the risk of failure.

Bilan préopératoire pour la chirurgie cardio-vasculaire en urgence [Preoperative assessment in emergency cardiovascular surgery].

In the emergency situation, preoperative patient work-up for cardio-vascular surgery is quite different from the elective setting. We have analyzed a consecutive series of 5576 cases out of which 823 underwent emergency procedures (14.8%). The most frequent problems requiring emergent intervention were peripheral vascular (186 cases; 22.6% of the emergent procedure), followed by coronary artery disease (156 cases; 19.0%), thoracic aortic aneurysms (86 cases; 10.4%), abdominal aortic aneurysms (54 cases; 6.6%), congenital heart disease (36 cases: 4.4%), heart and heart lung transplantation (31 cases; 3.8%), problems with cardiac rythm (25 cases: 3.0%), and others (267 cases: 32.4%). Classification by proportion of urgent procedures with reference to elective operations shows a different picture. As a matter of fact transplantations were always emergency procedures (100%), whereas repair of aortic dissections type A and B was an emergency procedure in 81.5%. Emergency thoracic and abdominal aortic aneurysm repair accounted for 30% and 20% respectively and the corresponding proportion for peripheral vascular surgery is 19%. However, emergency surgery for acute coronary ischemia, valvular and congenital heart disease accounted for somewhat less than 10% for each group of these pathologies. Systematic pre-operative diagnostic work-up is a recognized tool for procedure related risk assessment and superior management of diseases. However, hemodynamic instability and other time related events correlated with negative outcome, are the main driving forces for accelerated diagnostic pathways

Wireless E911 Emergency Communications Fund Iowa Homeland Security and Emergency Management Division of the Iowa Department of Public Defense independent auditor's reports, basic financial statements and supplementary information, June 30, 2009.

Audit report on the Wireless E911 Emergency Communication Fund of the Iowa Homeland Security and Emergency Management Division of the Iowa Department of Public Defense for the year ended June 30, 2009

Recherche scientifique en médecine de famille: expériences, barrières et besoins des praticiens [Scientific research in family medicine: practitioners' experience, barriers and needs].

Scientific data from family medicine are relevant for the majority of the population. They are therefore essential from an ethical and public health perspective. We need to promote quality research in family medicine despite methodological, financial and logistic barriers. To highlight the strengths and weaknesses of research in family medicine in the French-speaking part of Switzerland we asked practitioners from this region to share their experience, critics and needs in relation to research. This article summarizes their contribution in light of the international literature.

Prognostication in comatose survivors of cardiac arrest: An advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine.

OBJECTIVES: To review and update the evidence on predictors of poor outcome (death, persistent vegetative state or severe neurological disability) in adult comatose survivors of cardiac arrest, either treated or not treated with controlled temperature, to identify knowledge gaps and to suggest a reliable prognostication strategy. METHODS: GRADE-based systematic review followed by expert consensus achieved using Web-based Delphi methodology, conference calls and face-to-face meetings. Predictors based on clinical examination, electrophysiology, biomarkers and imaging were included. RESULTS AND CONCLUSIONS: Evidence from a total of 73 studies was reviewed. The quality of evidence was low or very low for almost all studies. In patients who are comatose with absent or extensor motor response at ≥72 h from arrest, either treated or not treated with controlled temperature, bilateral absence of either pupillary and corneal reflexes or N20 wave of short-latency somatosensory evoked potentials were identified as the most robust predictors. Early status myoclonus, elevated values of neuron-specific enolase at 48-72 h from arrest, unreactive malignant EEG patterns after rewarming, and presence of diffuse signs of postanoxic injury on either computed tomography or magnetic resonance imaging were identified as useful but less robust predictors. Prolonged observation and repeated assessments should be considered when results of initial assessment are inconclusive. Although no specific combination of predictors is sufficiently supported by available evidence, a multimodal prognostication approach is recommended in all patients.

Support services for vulnerable patients by a multidisciplinary team in an emergency department

Introduction: Individuals with poor social determinants of health aremore likely to receive improper healthcare. Frequent Users (FUs) ofEmergency Departments (ED) (defined as >4 visits in the previous12 months) represent a subgroup of vulnerable patients presentingwith specific medical and social needs. They usually account for highhealthcare costs by overusing the healthcare system. In 2008-2009,FUs accounted for 4% of our ED patients but 17% of all our ED visits.Methods: We conducted a prospective cohort of patients admitted toour ED with vulnerabilities in ≥3 specific domains (somatic or mentaldiseases, risk behaviors, social determinants of health, and healthcareuse). Patients were either directly identified by a multidisciplinary team(two nurses, one social worker, one physician) or referred to that teamby the ED staff during opening hours from July 1st 2010 to April 30th2011.Results: 127 patients were included (67% males), aged 43 years (SD15); 65% were migrants. They had a median of 6 ED visits (interquartilerange (IQR) 8-1) in the previous 12 months, representing a total of 697visits. The most frequently affected domains during the index visit were:71% somatic, 61% psychiatric, 75% risk behaviors, 97% social and84% healthcare use issues. Each case required a median of 234minutes (IQR 300-90) dedicated to assess their outpatient network(99% of the patients), to set up an ambulatory medical follow-up (43%)or a meeting with social services (40%).Conclusions: Vulnerability affected ED patients in more than onedomain. Vulnerable patients have complex needs that were difficult toaddress in the time-pressured ED setting. Although ED consultationoffers immediate access to medical care, EDs are dedicated more foracute short-term somatic care. Caring for a growing number ofvulnerable patients requires a different type of management. Limitedevidence shows that multidisciplinary case-management interventionshave demonstrated positive outcomes in terms of reducing ED useand costs, and improvement of patient's medical and social outcomes.A randomized trial of case-management is underway to confirm theresults of observational studies.

Activity measurements of 18F and 90Y with commercial radionuclide calibrators for nuclear medicine in Switzerland.

The activity of radiopharmaceuticals in nuclear medicine is measured before patient injection with radionuclide calibrators. In Switzerland, the general requirements for quality controls are defined in a federal ordinance and a directive of the Federal Office of Metrology (METAS) which require each instrument to be verified. A set of three gamma sources (Co-57, Cs-137 and Co-60) is used to verify the response of radionuclide calibrators in the gamma energy range of their use. A beta source, a mixture of (90)Sr and (90)Y in secular equilibrium, is used as well. Manufacturers are responsible for the calibration factors. The main goal of the study was to monitor the validity of the calibration factors by using two sources: a (90)Sr/(90)Y source and a (18)F source. The three types of commercial radionuclide calibrators tested do not have a calibration factor for the mixture but only for (90)Y. Activity measurements of a (90)Sr/(90)Y source with the (90)Y calibration factor are performed in order to correct for the extra-contribution of (90)Sr. The value of the correction factor was found to be 1.113 whereas Monte Carlo simulations of the radionuclide calibrators estimate the correction factor to be 1.117. Measurements with (18)F sources in a specific geometry are also performed. Since this radionuclide is widely used in Swiss hospitals equipped with PET and PET-CT, the metrology of the (18)F is very important. The (18)F response normalized to the (137)Cs response shows that the difference with a reference value does not exceed 3% for the three types of radionuclide calibrators.

Analysis of patient physical restraints usage in a Swiss emergency service

Introduction: Emergency services (ES) are often faced with agitated,confused or aggressive patients. Such situations may require physicalrestraint. The prevalence of these measures is poorly documented,concerning 1 to 10% of patients admitted in the ES. The indications forrestraint, the context and the related complications are poorly studied.The emergency service and the security service of our hospital havedocumented physical restraint for several years, using specific protocolsintegrated into the medical records. The study evaluated the magnitudeof the problem, the patient characteristics, and degree of adherence tothe restraint protocol.Methods: Retrospective study of physical restraint used on adultpatients in the ES in 2009. The study included analysis of medical anddemographic characteristics, indications justifying restraint and qualityof restraint documentation. Patients were identified from computerizedES and security service records. The data were supplemented byexamination of patients' medical records.Results: In 2009, according to the security service, 390 patients (1%)were physically restrained in the ES. The ES computerized systemidentified only 196 patients. Most patients were male (62%). The medianage was 40 years (15-98 years; P90 = 80 years). 63 % of the situationsoccurred between 18h00 and 6h00, and most frequently on Saturday(19%). Substance or alcohol abuse was present in 48.7% of cases andacute psychiatric crisis was mentioned in 16.7%. In most cases,restraint was motivated by extreme agitation or auto / hetero-aggressiveviolence. Most patients (68 %) were restrained with upper limb andabdominal restraints. More than three anatomic restraints werenecessary in 52 % of the patients. Intervention of security guards wasrequired in 77% of the cases. 61 restraint protocols (31 %) were missingand 57% of the records were incomplete. In many cases, the protocolsdid not include the signature of the physician (22%) or of the nurse(43.8%). Medical records analysis did not allow reliable estimation ofthe number of restraint-induced complications.Conclusions: Physical restraint is most often motivated by majoragitation and/or secondary to substance abuse. Caregivers regularlycall security guards for help. Restraint documentation is often missing orincomplete, requiring major improvement in education and prescription.

Factors influencing emergency delays in acute stroke management.

Early admission to hospital with minimum delay is a prerequisite for successful management of acute stroke. We sought to determine our local pre- and in-hospital factors influencing this delay. Time from onset of symptoms to admission (admission time) was prospectively documented during a 6-month period (December 2004 to May 2005) in patients consecutively admitted for an acute focal neurological deficit presented at arrival and of presumed vascular origin. Mode of transportation, patient's knowledge and correct recognition of stroke symptoms were assessed. Physicians contacted by the patients or their relatives were interviewed. The influence of referral patterns on in-hospital delays was further evaluated. Overall, 331 patients were included, 249 had an ischaemic and 37 a haemorrhagic stroke. Forty-five patients had a TIA with neurological symptoms subsiding within the first hours after admission. Median admission time was 3 hours 20 minutes. Transportation by ambulance significantly shortened admission delays in comparison with the patient's own means (HR 2.4, 95% CI 1.6-3.7). The only other factor associated with reduced delays was awareness of stroke (HR 1.9, 95% CI 1.3-2.9). Early in-hospital delays, specifically time to request CT-scan and time to call the neurologist, were shorter when the patient was referred by his family or to a lesser extent by an emergency physician than by the family physician (p < 0.04 and p < 0.01, respectively) and were shorter when he was transported by ambulance than by his own means (p < 0.01). Transportation by ambulance and referral by the patient or family significantly improved admission delays and early in-hospital management. Correct recognition of stroke symptoms further contributed to significant shortening of admission time. Educational programmes should take these findings into account.

Forensic intelligence for medicine anti-counterfeiting

Medicine counterfeiting is a crime that has increased in recent years and now involves the whole world. Health and economic repercussions have led pharmaceutical industries and agencies to develop many measures to protect genuine medicines and differentiate them from counterfeits. Detecting counterfeit is chemically relatively simple for the specialists, but much more information can be gained from the analyses in a forensic intelligence perspective. Analytical data can feed criminal investigation and law enforcement by detecting and understanding the criminal phenomenon. Profiling seizures using chemical and packaging data constitutes a strong way to detect organised production and industrialised forms of criminality, and is the focus of this paper. Thirty-three seizures of a commonly counterfeited type of capsule have been studied. The results of the packaging and chemical analyses were gathered within an organised database. Strong linkage was found between the seizures at the different production steps, indicating the presence of a main counterfeit network dominating the market. The interpretation of the links with circumstantial data provided information about the production and the distribution of counterfeits coming from this network. This forensic intelligence perspective has the potential to be generalised to other types of products. This may be the only reliable approach to help the understanding of the organised crime phenomenon behind counterfeiting and to enable efficient strategic and operational decision making in an attempt to dismantle counterfeit network.