From geriatric service to primary care: a retrospective pharmaceutical analysis of the medical prescription

Introduction The population of elderly persons is increasing andnegative outcomes due to polymedication are frequent. Discrepanciesin information about medication are frequent when older persons aretransitioning from hospital to home, increasing the risk of hospitalreadmission. The aims of this study were a) to determine discrepanciesin medical regimen indicated in two official discharge documents(DS = discharge summary, DP=discharge prescription); b) to characterizethe pharmacotherapy prescribed in older patients dischargedfrom a geriatric service.Materials & Methods Elderly patients (N=230) discharged from thegeriatric service (CHUV, Lausanne) over a 6-month period (January toJune 2009) were selected. Community pharmacists compared DS andDP to identify discrepancies including (a) drugs' name; (b) schedule ofadministration, dosage, frequency, prn prescription, treatment durationand galenic formulation. Beers' criteria were applied to identifypotentially inappropriate drugs and a descriptive analysis of drug costs,prescription profiles and generics were also performed.Results On average, patients were 82 ± 7 years old and stayed23.0 ± 11.6 days in the geriatric service. The delay between the datesof patient's discharge with the DP and the sending of the DS to hisgeneral physician averaged 14.0 ± 7.5 days (range 1-55). The DPhad an average of 10.0 ± 3.3 drugs (range 2-19). 77% of patients hadat least one discrepancy. A drug was missing on the DS in 57.8% ofpatients and 19.6% had a missing prn prescription. Among the 2312drugs prescribed, 3% belonged to Beers' list. They were prescribed to61 patients (26.5%), with 6 patients cumulating two Beers' potentiallyinappropriate drugs in their treatment. Analgesics (85% of thepatients), anticoagulants (80%), mineral supplements (77%), laxatives(52%) and antihypertensives (46%) were the drug classes most frequentlyprescribed. Mean costs of treatment as per DP was160.4 ± 179.4 Euros. Generic prescription represented more than 5%of the costs for 3 therapeutic classes (cholesterol-lowering agents(64%), antihypertensives (50%) and antidepressants (47%)).Discussion & Conclusion The high discrepancy rate between medicationlisted in the DP and the DS highlights a need for safetyimprovement. Potential benefits are expected from reinforced pharmacist-physician collaboration in transition from hospital to primarycare. In addition, even though Beers' criteria are questionable, thedrugs prescribed in this already fragile population, and the potentialopportunities of economical optimizations, are advocating thedevelopment and the scientific evaluation of a structured advancedcollaborative pharmacy practice service. This foresees improvedeffectiveness, safety and efficiency in the medication management ofelderly persons.

Urgences vitales au cabinet médical: implications pour la formation et l'equipement du médecin de premier recours [Life-threatening emergencies at the office: implications for medical education and equipment of the primary care physician].

Every medical practitioner is confronted on a daily basis with emergencies. Among these, life-threatening emergencies can have disastrous consequences in term of morbidity and mortality; 22 cardiac arrests and 10 deaths were reported among the 1,650 Swiss practices during a 5 year period. The occurrence of life-threatening emergencies at the office necessitates, according to the type and place of the practice, the skills of the practitioner and the organization of his practice, the implementation of procedures, equipments (for example room equipped with a defibrillator, respiratory nebulizer, splints, emergency drugs) and specific continuous education programs that should be encouraged and made available to the whole medical corporation.

Instances d'aliénation: portrait du patient tiraillé. 2. Dispositif médical et discours dominants [Instances of alienation: portrait of the torn patient. 2. Medical apparatus and dominant discourses].

The first part of the article focused on the individual mechanisms--body, psyche and relational context--alienating the patient. The second part addresses alienating mechanisms related to the medical apparatus and the dominant discourses produced within and by society. The aim is not to comprehensively list possible mechanisms, but to discuss some of them using illustrative examples.

Causes of health expenditure growth : the predominance of changes in medical practices over population ageing

The increase in total health care expenditures in France can be explained by three distinct factors : the purely demographic effect (namely, the increase in the proportion of elderly people, given that health expenditure is an increasing function of age) ; the changes in morbidity at a given age ; the changes in practices, for a given age and morbidity level (e.g technological progress). The aim of this paper is basically to disentangle, evaluate and interpret the respective effects of these three factors. [Extrait introduction p. 3]

Medical record search engines, using pseudonymised patient identity: an alternative to centralised medical records

Purpose The purpose of our multidisciplinary study was to define a pragmatic and secure alternative to the creation of a national centralised medical record which could gather together the different parts of the medical record of a patient scattered in the different hospitals where he was hospitalised without any risk of breaching confidentiality. Methods We first analyse the reasons for the failure and the dangers of centralisation (i.e. difficulty to define a European patients' identifier, to reach a common standard for the contents of the medical record, for data protection) and then propose an alternative that uses the existing available data on the basis that setting up a safe though imperfect system could be better than continuing a quest for a mythical perfect information system that we have still not found after a search that has lasted two decades. Results We describe the functioning of Medical Record Search Engines (MRSEs), using pseudonymisation of patients' identity. The MRSE will be able to retrieve and to provide upon an MD's request all the available information concerning a patient who has been hospitalised in different hospitals without ever having access to the patient's identity. The drawback of this system is that the medical practitioner then has to read all of the information and to create his own synthesis and eventually to reject extra data. Conclusions Faced with the difficulties and the risks of setting up a centralised medical record system, a system that gathers all of the available information concerning a patient could be of great interest. This low-cost pragmatic alternative which could be developed quickly should be taken into consideration by health authorities.

Quelques abus de la statistique dans la recherche médicale [Various abuses of statistics in medical research].

Statistics has become an indispensable tool in biomedical research. Thanks, in particular, to computer science, the researcher has easy access to elementary "classical" procedures. These are often of a "confirmatory" nature: their aim is to test hypotheses (for example the efficacy of a treatment) prior to experimentation. However, doctors often use them in situations more complex than foreseen, to discover interesting data structures and formulate hypotheses. This inverse process may lead to misuse which increases the number of "statistically proven" results in medical publications. The help of a professional statistician thus becomes necessary. Moreover, good, simple "exploratory" techniques are now available. In addition, medical data contain quite a high percentage of outliers (data that deviate from the majority). With classical methods it is often very difficult (even for a statistician!) to detect them and the reliability of results becomes questionable. New, reliable ("robust") procedures have been the subject of research for the past two decades. Their practical introduction is one of the activities of the Statistics and Data Processing Department of the University of Social and Preventive Medicine, Lausanne.

Clinical and laboratory predictors of imported malaria in an outpatient setting: an aid to medical decision making in returning travellers with fever

Si le tableau clinique évoque une malaria et que le résultat des examens parasitologiques n?est pas disponible ou est négatif, le praticien n?a pas d?information basée sur l?évidence pour savoir s?il doit donner ou non un traitement présomptif. Afin d?identifier les facteurs cliniques et paracliniques prédictifs d?une parasitémie à Plasmodium, nous avons mené une étude prospective chez les voyageurs ou migrants en provenance d?une zone tropicale ou subtropicale et qui consultaient pour de la fièvre. Le questionnaire comprenait 49 items explorant les données démographiques, les caractéristiques du voyage, les éléments de l?anamnèse et de l?examen clinique ainsi que les résultats de laboratoire. 336 sujets avec données complètes ont été recrutés (97 patients atteints de malaria et 239 contrôles avec fièvre et examen parasitologique négatif). L?analyse de régression multivariée a permis d?identifier les facteurs prédictifs de maiaria suivants : prophylaxie inadéquate, sudations, absence de douleur abdominale, température )38"C, mauvais état général, splénomégalie, compte leucocytaire (1 O x 1 03/L, plaquettes ~ 1 5 0 x l 03/L, taux d?hémoglobine <12 g/dL et éosinophiles (5%. La présence d?une splénomégalie avait le coefficient de probabilité positif pour un diagnostic de malaria le plus élevé (1 3.6) ; venait ensuite la présence d?une thrombopénie (1 1 .O). Dans le contexte de la consultation ambulatoire de la Policlinique Médicale Universitaire (prévalence de malaria de 29%), la probabilité post- test d?avoir un examen parasitologique positif était de 85% pour la splénomégalie et de 82% pour la thrombopénie. Même si le seuil thérapeutique n?est pas absolument défini, il semble raisonnable d?envisager un traitement présomptif lorsque la probabilité post- test est >80%. Si le médecin est réticent à administrer un traitement sans documentation parasitologique, il devrait au moins se retenir d?entreprendre d?autres investigations coûteuses, et plutôt répéter l?examen parasitologique après 12-24 heures.

Increasing prehospital emergency medical service interventions for nursing home residents.

QUESTION: In the ageing European population, the proportion of interventions by the emergency medical services (EMS) for elderly patients is increasing, but little is known about the recent trend of EMS interventions in nursing homes. The aim of this analysis was to describe the evolution of the incidence of requests for prehospital EMS interventions for nursing home residents aged 65 years and over between 2004 and 2013. METHODS: A prospective population-based register of routinely collected data for each EMS intervention in the Canton of Vaud. Linear time trends of incidence of requests to the EMS in nursing homes were calculated and stratified by age categories. RESULTS: The number of ambulance interventions in nursing homes for people aged 65 years and over (65+) increased by 68.9% (1124‒1898) between 2004 and 2013. A significant linear increase of the annual incidence of requests to EMS per 1,000 nursing home residents was found for people aged 65-79 (10.2, 95% confidence interval [CI] 6.2-14.2), 80-89 (16.5, 95% CI 14.0-19.0) and over 90 (12.1, 95% CI 5.8-18.4). EMS interventions in nursing home residents who required an emergency physician increased during the same period by 205.6% (from 106 to 324), representing an increase from 2% to 7% of all emergency physician interventions in the Canton. CONCLUSIONS: Our results confirmed an important increase in the incidence of EMS interventions in nursing homes during the last decade, far exceeding the actual increase of the nursing home population during the same period. This evolution represents an important opportunity to reconsider the EMS missions in the context of an ageing society.

Spatially varying selection shapes life history clines among populations of Drosophila melanogaster from sub-Saharan Africa.

Clines in life history traits, presumably driven by spatially varying selection, are widespread. Major latitudinal clines have been observed, for example, in Drosophila melanogaster, an ancestrally tropical insect from Africa that has colonized temperate habitats on multiple continents. Yet, how geographic factors other than latitude, such as altitude or longitude, affect life history in this species remains poorly understood. Moreover, most previous work has been performed on derived European, American and Australian populations, but whether life history also varies predictably with geography in the ancestral Afro-tropical range has not been investigated systematically. Here, we have examined life history variation among populations of D. melanogaster from sub-Saharan Africa. Viability and reproductive diapause did not vary with geography, but body size increased with altitude, latitude and longitude. Early fecundity covaried positively with altitude and latitude, whereas lifespan showed the opposite trend. Examination of genetic variance-covariance matrices revealed geographic differentiation also in trade-off structure, and QST -FST analysis showed that life history differentiation among populations is likely shaped by selection. Together, our results suggest that geographic and/or climatic factors drive adaptive phenotypic differentiation among ancestral African populations and confirm the widely held notion that latitude and altitude represent parallel gradients.

Whole genome sequencing as a means to assess pathogenic mutations in medical genetics and cancer.

The past decade has seen the emergence of next-generation sequencing (NGS) technologies, which have revolutionized the field of human molecular genetics. With NGS, significant portions of the human genome can now be assessed by direct sequence analysis, highlighting normal and pathological variants of our DNA. Recent advances have also allowed the sequencing of complete genomes, by a method referred to as whole genome sequencing (WGS). In this work, we review the use of WGS in medical genetics, with specific emphasis on the benefits and the disadvantages of this technique for detecting genomic alterations leading to Mendelian human diseases and to cancer.

Automated monitoring of medical protocols: a secure and distributed architecture

The control of the right application of medical protocols is a key issue in hospital environments. For the automated monitoring of medical protocols, we need a domain-independent language for their representation and a fully, or semi, autonomous system that understands the protocols and supervises their application. In this paper we describe a specification language and a multi-agent system architecture for monitoring medical protocols. We model medical services in hospital environments as specialized domain agents and interpret a medical protocol as a negotiation process between agents. A medical service can be involved in multiple medical protocols, and so specialized domain agents are independent of negotiation processes and autonomous system agents perform monitoring tasks. We present the detailed architecture of the system agents and of an important domain agent, the database broker agent, that is responsible of obtaining relevant information about the clinical history of patients. We also describe how we tackle the problems of privacy, integrity and authentication during the process of exchanging information between agents.

Medical physicists' implication in radiological diagnostic procedures: results after 1 y of experience.

Since January 2008-de facto 2012-medical physics experts (MPEs) are, by law, to be involved in the optimisation process of radiological diagnostic procedures in Switzerland. Computed tomography, fluoroscopy and nuclear medicine imaging units have been assessed for patient exposure and image quality. Large spreads in clinical practice have been observed. For example, the number of scans per abdominal CT examination went from 1 to 9. Fluoroscopy units showed, for the same device settings, dose rate variations up to a factor of 3 to 7. Quantitative image quality for positron emission tomography (PET)/CT examinations varied significantly depending on the local image reconstruction algorithms. Future work will be focused on promoting team cooperation between MPEs, radiologists and radiographers and on implementing task-oriented objective image quality indicators.