Problèmes dus aux fistules d'hémodialyse: un réseau régional de prise en charge [Problems related to haemodialysis vascular accesses: a regional network of care]

The number of patients treated by haemodialysis (HD) is continuously increasing. The complications associated with vascular accesses represent the first cause of hospitalisation in these patients. Since 2001 nephrologists, surgeons, angiologists and radiologists at the CHUV are working to develop a multidisciplinary model that includes planning and monitoring of HD accesses. In this setting the echo-Doppler represents an important tool of investigation. Every patient is discussed and decisions are taken during a weekly multidisciplinary meeting. A network has been created with nephrologists of peripheral centres and other specialists. This model allows to centralize investigational information and coordinate patient care while keeping and even developing some investigational activities and treatment in peripheral centres.

Characterization and management of rockslide hazard at Turtle Mountain, Alberta, Canada

In 1903, more than 30 million m3 of rock fell from the east slopes of Turtle Mountain in Alberta, Canada, causing a rock avalanche that killed about 70 people in the town of Frank. The Alberta Government, in response to continuing instabilities at the crest of the mountain, established a sophisticated field laboratory where state-of-the-art monitoring techniques have been installed and tested as part of an early-warning system. In this chapter, we provide an overview of the causes, trigger, and extreme mobility of the landslide. We then present new data relevant to the characterization and detection of the present-day instabilities on Turtle Mountain. Fourteen potential instabilities have been identified through field mapping and remote sensing. Lastly, we provide a detailed review of the different in-situ and remote monitoring systems that have been installed on the mountain. The implications of the new data for the future stability of Turtle Mountain and related landslide runout, and for monitoring strategies and risk management, are discussed.

Reproducibility of diabetes quality of care indicators as reported by patients and physicians.

INTRODUCTION: Self-report of diabetes care has moderate validity and is prone to under- and over-reporting. We assessed reproducibility of a range of processes and outcomes of diabetes care as reported by patients and physicians. METHODS: In a Swiss community-based survey, patients with diabetes and physicians independently reported past 12 months processes of care (HbA1c, lipids, microalbuminuria, blood pressure, weight, foot and eye examinations) and last measured values of HbA1c, height, weight and blood pressure. For dichotomous variables, we assessed reliability by Cohen's kappa and agreement by uniform kappa. For continuous measures, we used Lin's concordance correlation coefficient and limits of agreement, respectively. RESULTS: Mean age of the 210 patients was 65 years; 40% were women, and 51% had diabetes for >10 years. Agreement was good for recommended processes of care such as blood pressure (uniform kappa = 0.94), HbA1c (0.93), weight (0.88) and lipid (0.78), but lower for microalbuminuria, foot and eye examinations (all <0.50). Cohen's kappa values were all low (<0.25). Comparisons of reported continuous variables showed large limits of agreement for height (±6 cm) and weight (8-10 kg) despite high concordance correlation coefficients (0.93 and 0.97). Concordance correlation coefficients were smaller for HbA1c (0.72) and blood pressure (0.5-0.6), with large limits of agreement (±2% and ±25 mmHg). CONCLUSION: While agreement of routine processes of care was good, agreement was less satisfactory for microalbuminuria, foot and eye examinations. Reports of continuous outcomes yielded good reliability but too wide limits of agreement. Quality of care evaluation relying on self-report only should be made cautiously.

Management of slips and its effect on growth and production of 'Pérola' pineapple plants

The lack of good quality planting material has limited the expansion and contributed to yield reduction of the Brazilian pineapple culture. Alternatives of 'Pérola' pineapple slips management were studied aiming at obtaining superior planting material within a shorter time period and making good use of healthy slips of low vigor, that are commonly discarded by growers. Two experiments were carried out at the Experimental Field of Embrapa Cassava & Fruits, Cruz das Almas, Bahia, Brazil, and another one in a commercial plantation in the region of Itaberaba, BA, using blocks or entirely randomized designs with at least four replications. In the first one, the development of slips of different initial sizes (6 to 20 cm long), when grown on mother plants after fruit harvest, was compared with that of slips grown in a nursery after their removal from the mother plants. It became clear that larger slips grow more vigorously and that the removal from the mother plant delays their growth. However, results from the second study showed that those slips grown in nursery had vegetative and agronomic performance similar to that of conventional slips and close to that of plantlets produced from plant stem sections. Independently from the type of planting material used, the larger ones presented a more vigorous growth and produced higher yields. In the third study, it was observed the influence of mineral fertilization, pest control and growth regulator application after fruit harvest on slip development. The treatments applied did not significantly accelerate slip growth. Slips reached 50 cm length and at least 300 g fresh weight within 90 days after fruit harvest, indicating that vigorous plants have enough nutritional storage material for slips development.

Survey of management of first-ever seizures in a hospital based community

Résumé Contexte: Bon nombre d'études épidémiologiques concernant les premières crises comitiales ont été effectuées principalement sur des populations générales. Cependant, les patients admis dans un hôpital peuvent présenter des éléments cliniques différents. Nous avons donc mené une étude prospective auprès de sujets dans une population hospitalière ayant subi une première crise d'épilepsie, afin d'étudier leur pronostic et le rôle des examens complémentaires (examen neurologique, imagerie cérébrale, examens sanguins, EEG) dans le choix de l'administration d'une médication antiépileptique. Méthodes : Sur une période d'une année, nous avons suivi 177 patients adultes, admis consécutivement, ayant présenté une crise d'épilepsie dont l'évaluation aiguë a été effectuée dans notre hôpital. Pendant 6 mois, nous avons pratiqué pour chaque patient un suivi du traitement antiépileptique, des récidives de crises et d'un éventuel décès. Résultats : L'examen neurologique était anormal dans 72.3% des cas, l'imagerie cérébrale dans 54.8% et les examens sanguins dans 57.1%. L'EEG a montré des éléments épileptiformes dans 33.9% des cas. L'étiologie la plus fréquemment représentée était constituée par des intoxications. Un traitement antiépileptique a été prescrit chez 51% des patients. 31.6% des sujets suivis à six mois ont subi une récidive ; la mortalité s'est élevée à 17.8%. Statistiquement, l'imagerie cérébrale, l'EEG et l'examen neurologique étaient des facteurs prédictifs indépendants pour l'administration d'antiépileptiques, et l'imagerie cérébrale le seul facteur associé au pronostic. Conclusions : Les patients évalués en aigu dans un hôpital pour une première crise comitiale présentent un profil médical sous-jacent, qui explique probablement leur mauvais pronostic. L'imagerie cérébrale s'est avérée être le test paraclinique le plus important dans la prévention du traitement et du pronostic. Mots-clés : première crise d'épilepsie, étiologie, pronostic, récidive, médication antiépileptique, population hospitalière Summary Background: Epidemiological studies focusing on first-ever seizures have been carried out mainly on community based populations. However, since hospital populations may display varying clinical features, we prospectively analysed patients with first-ever seizure in a hospital based community to evaluate prognosis and the role of complementary investigations in the decision to administer antiepileptic drugs (AED). Methods: Over one year, we recruited 177 consecutive adult patients with a first seizure acutely evaluated in our hospital. During six months' follow-up data relating to AED treatment, recurrence of seizures and death were collected for each patient. Results:. Neurological examination was abnormal in 72.3%, neuroimaging in 54.8% and biochemical tests in 57.1%. Electroencephalogram (EEG) showed epileptiform features in 33.9%. Toxicity represented the most common aetiology. AED was prescribed in 51% of patients. Seizure recurrence at six months involved 31.6% of patients completing the follow-up; mortality was 17.8%. Statistical analysis showed that brain CT, EEG and neurological examination are independent predictive factors for AED administration, but only CT scan is associated with outcome. Conclusions: Patients evaluated acutely for first- ever seizure in a hospital setting have severe underlying clinical conditions apparently related to their relatively poor prognosis. Neuroimaging represents the most important paraclinical test in predicting both treatment administration and outcome.

Coping with Technology: A Study on Economic Methodology and Strategic Management of Technology

There is a broad consensus among economists that technologicalchange has been a major contributor to the productivity growth and, hence, to the growth of the material welfare in western industrialized countries at least over the last century. Paradoxically, this issue has not been the focal point of theoretical economics. At the same time, we have witnessed the rise of the importance of technological issues at the strategic management level of business firms. Interestingly, the research has not accurately responded to this challenge either. The tension between the overwhelming empirical evidence of the importance of technology and its relative omission in the research offers a challenging target for a methodological endeavor. This study deals with the question of how different theories cope with technology and explain technological change. The focusis at the firm level and the analysis concentrates on metatheoretical issues, except for the last two chapters, which examine the problems of strategic management of technology. Here the aim is to build a new evolutionary-based theoreticalframework to analyze innovation processes at the firm level. The study consistsof ten chapters. Chapter 1 poses the research problem and contrasts the two basic approaches, neoclassical and evolutionary, to be analyzed. Chapter 2 introduces the methodological framework which is based on the methodology of isolation. Methodological and ontoogical commitments of the rival approaches are revealed and basic questions concerning their ways of theorizing are elaborated. Chapters 3-6 deal with the so-called substantive isolative criteria. The aim is to examine how different approaches cope with such critical issues as inherent uncertainty and complexity of innovative activities (cognitive isolations, chapter 3), theboundedness of rationality of innovating agents (behavioral isolations, chapter4), the multidimensional nature of technology (chapter 5), and governance costsrelated to technology (chapter 6). Chapters 7 and 8 put all these things together and look at the explanatory structures used by the neoclassical and evolutionary approaches in the light of substantive isolations. The last two cpahters of the study utilize the methodological framework and tools to appraise different economics-based candidates in the context of strategic management of technology. The aim is to analyze how different approaches answer the fundamental question: How can firms gain competitive advantages through innovations and how can the rents appropriated from successful innovations be sustained? The last chapter introduces a new evolutionary-based technology management framework. Also the largely omitted issues of entrepreneurship are examined.

Prevalence and management of cardiovascular risk factors in Portuguese living in Portugal and Portuguese who migrated to Switzerland.

BACKGROUND: Information regarding the health status of migrants compared to subjects who remain in the country of origin is scarce. We compared the levels and management of the main cardiovascular risk factors between Portuguese living in Porto (Portugal) and Portuguese migrants living in Lausanne (Switzerland). METHODS: Cross-sectional studies conducted in Porto (EPIPorto, 1999 to 2003, n = 1150) and Lausanne (CoLaus, 2003 to 2006, n = 388) among subjects aged 35-65 years. Educational level, medical history and time since migration were collected using structured questionnaires. Body mass index, blood pressure, cholesterol and glucose levels were measured using standardized procedures. RESULTS: Portuguese living in Lausanne were younger, more frequently male and had lower education than Portuguese living in Porto. After multivariate adjustment using Poisson regression, no differences were found between Portuguese living in Porto or in Lausanne: prevalence rate ratio (PRR) and (95% confidence interval) for Portuguese living in Lausanne relative to Portuguese living in Porto: 0.92 (0.71 - 1.18) for current smoking; 0.78 (0.59 - 1.04) for obesity; 0.81 (0.62 - 1.05) for abdominal obesity; 0.82 (0.64 - 1.06) for hypertension; 0.88 (0.75 - 1.04) for hypercholesterolemia and 0.92 (0.49 - 1.73) for diabetes. Treatment and control rates for hypercholesterolemia were higher among Portuguese living in Lausanne: PRR = 1.91 (1.15 - 3.19) and 3.98 (1.59 - 9.99) for treatment and control, respectively. Conversely, no differences were found regarding hypertension treatment and control rates: PRR = 0.98 (0.66 - 1.46) and 0.97 (0.49 - 1.91), respectively, and for treatment rates of diabetes: PRR = 1.51 (0.70 - 3.25). CONCLUSIONS: Portuguese living in Lausanne, Switzerland, present a similar cardiovascular risk profile but tend to be better managed regarding hypercholesterolemia than Portuguese living in Porto, Portugal.

The impact of a register on the management of neonatal cooling in Switzerland.

BACKGROUND: Therapeutic hypothermia following hypoxic ischaemic encephalopathy in term infants was introduced into Switzerland in 2005. Initial documentation of perinatal and resuscitation details was poor and neuromonitoring insufficient. In 2011, a National Asphyxia and Cooling Register was introduced. AIMS: To compare management of cooled infants before and after introduction of the register concerning documentation, neuromonitoring, cooling methods and evaluation of temperature variability between cooling methods. STUDY DESIGN: Data of cooled infants before the register was in place (first time period: 2005-2010) and afterwards (second time period: 2011-2012) was collected with a case report form. RESULTS: 150 infants were cooled during the first time period and 97 during the second time period. Most infants were cooled passively or passively with gel packs during both time periods (82% in 2005-2010 vs 70% in 2011-2012), however more infants were cooled actively during the second time period (18% versus 30%). Overall there was a significant reduction in temperature variability (p < 0.001) comparing the two time periods. A significantly higher proportion of temperature measurements within target temperature range (72% versus 77%, p < 0.001), fewer temperature measurements above (24% versus 7%, p < 0.001) and more temperatures below target range (4% versus 16%, p < 0.001) were recorded during the second time period. Neuromonitoring improved after introduction of the cooling register. CONCLUSION: Management of infants with HIE improved since introducing the register. Temperature variability was reduced, more temperature measurements in the target range and fewer temperature measurements above target range were observed. Neuromonitoring has improved, however imaging should be performed more often.

Vacuum-assisted closure device for the management of infected postpneumonectomy chest cavities.

BACKGROUND: Infected postpneumonectomy chest cavities may be related to chronic postpneumonectomy empyema or arise in rare situations of necrotizing pneumonia with complete lung destruction where pneumonectomy and pleural debridement are required. We evaluated the safety and efficacy of an intrathoracic vacuum-assisted closure device (VAC) for the treatment of infected postpneumonectomy chest cavities. METHOD: A retrospective single institution review of all patients with infected postpneumonectomy chest cavities treated by VAC between 2005 and 2013. Patients underwent surgical debridement of the thoracic cavity, muscle flap closure of the bronchial stump when a fistula was present, and repeated intrathoracic VAC dressings until granulation tissue covered the entire chest cavity. After this, the cavity was obliterated by a Clagett procedure and closed. RESULTS: Twenty-one patients (14 men and 7 women) underwent VAC treatment of their infected postpneumonectomy chest cavity. Twelve patients presented with a chronic postpneumonectomy empyema (10 of them with a bronchopleural fistula) and 9 patients with an empyema occurring in the context of necrotizing pneumonia treated by pneumonectomy. In-hospital mortality was 23%. The median duration of VAC therapy was 23 days (range, 4-61 days) and the median number of VAC changes per patient was 6 (range, 2-14 days). Infection control and successful chest cavity closure was achieved in all surviving patients. One adverse VAC treatment-related event was identified (5%). CONCLUSIONS: The intrathoracic VAC application is a safe and efficient treatment of infected postpneumonectomy chest cavities and allows the preservation of chest wall integrity.

Conservation and management of the Common Quail (Coturnix coturnix) in Europe: past, present and future.

En el presente estudio hacemos una revisión del estado de conservación y las tendencias poblacionales de la codorniz común (Coturnix coturnix) desde 1900 hasta nuestros días. Algunos de los datos de los que disponemos son contradictorios con respecto al estado de la especie, que presenta ciertas características que dificultan el poder proporcionar estimas poblacionales fiables. Datos recientes sugieren claramente, tanto a escala local como a escala transnacional, que las poblaciones atlánticas de codorniz común han permanecido estables en las dos últimas décadas y que la práctica de liberar codornices criadas en granjas (híbridas con la codorniz japonesa, Coturnix japonica) con finalidades cinegéticas, no afectan significativamente a nuestras estimas. Por otra parte, los complejos patrones de desplazamiento de esta especie requieren especial atención. En este sentido, el análisis de recuperaciones de anillas puede aportar información relevante, especialmente de los movimientos nomádicos de codornices a la búsqueda de hábitats adecuados, tras la destrucción de los cultivos invernales de cereales debido a la siega. Así, al desarrollar un modelo de distribución de cría para esta especie, se debe incorporar continuamente información actualizada de los cambios estacionales de hábitat y clima, con el fin de obtener unas predicciones óptimas. En este sentido, por ejemplo, la inclusión de datos quincenales de índices de vegetación en los modelos de distribución ha dado muy buenos resultados. La obtención de predicciones fiables de los cambios de la distribución de la especie y de sus desplazamientos durante la estación de cría puede ser muy útil para un mejor conocimiento del estado de conservación y las tendencias poblacionales de la especie, así como para el diseño de futuras medidas de gestión.

Diagnosis and Management of Upper Tract Urothelial Carcinoma.

While UTUC is relatively uncommon, it has an aggressive natural history and poor prognosis, which has not substantially improved over the past two decades. Nevertheless, continued research has led to the discovery of risk factors improving the prevention and early detection of UTUC. Although RNU remains the standard treatment for localized invasive UTUC, nephron-sparing surgery for selected patients has made considerable progress in the recent years. The stagnation in the prognosis of UTUC over the past two decades highlights the necessity for incorporating multimodal approaches including refinements in systemic chemotherapy and radiotherapy to attain better outcomes for patients with UTUC.

Trends in self-reported prevalence and management of hypertension, hypercholesterolemia and diabetes in Swiss adults between 1992 and 2007

PURPOSE: to assess the trends of prevalence of self-reported cardiovascular risk factors (CV RFs: hypertension, hypercholesterolemia, diabetes) and their management for the period of 1992 to 2007 in Switzerland. METHODS: four health interview surveys conducted between 1992 and 2007 in representative samples of the Swiss population (63,782 subjects overall). Self-reported CV RFs prevalence, treatment and control levels were computed after weighting. Weights were calculated by raking ratio such that the marginal distribution of the weighted totals conforms to the marginal distribution of the target population. Multivariate analysis was conducted using logistic regression. RESULTS: prevalence of all CV RFs increased between 1992 and 2007. Also, the prevalence of self-reported treatment among subjects with CV RFs increased, as confirmed by multivariate analysis: OR for hypolipidemic treatment relative to 1992: 0.64 [0.52-0.78]; 1.39 [1.18-1.65] and 2.00 [1.69-2.36] for 1997, 2002 and 2007, respectively. Still, in 2007, circa 40% of hypertensive, 60% of hypercholesterolemic and 50% of diabetic subjects weren't treated. On the other hand, there is an increase of the prevalence of controlled RFs as reported by treated subjects. This was confirmed by multivariate analysis 12.1 [12.0 - 12.2]; 4.16 [4.1 - 4.23] and 2.85 [2.79 - 2.90] for hypertension, hypercholesterolemia and diabetes, respectively, in 2007, relative to 1992. CONCLUSION: the prevalence of self-reported hypertension, hypercholesterolemia and diabetes increased between 1992 and 2007 in the Swiss population. Despite a good control of treated subjects, still a significant percentage of subjects with CV RFs are not treated.

Pharmacoeconomics of Cyclamen europaeum in the management of Acute Rhinosinusitis

Objective. To carry out a pharmacoeconomic analysis of Cyclamen europaeum (CE) in the management of acute rhinosinusitis (ARS) in Spain using data from the PROSINUS study. Study Design. This was a prospective observational study to compare the effectiveness and cost-effectiveness between therapies including CE vs. other therapies in the management of ARS. Methods. The study was carried out as a secondary analysis of the PROSINUS, combining healthcare resource use, productivity loses, and health outcomes from the observational study with costs representative of the Spanish Health System. Results. CE given as monotherapy appears to be more effective (cure rate) than other monotherapies (15.3% higher, p<0.05) and combination (10.3% higher, p<0.05) therapies. The addition of CE to other single-drug or combination therapies showed a statistically significant improvement in terms of cure rates when adding CE to 2-drug combinations (93.9% vs. 76.5%; p<0.05), and no significant effect when added to combinations of three or more drugs (81.1% vs. 79.8; NS). CE based therapies generally showed lower indirect costs, although only the comparison of CE alone vs. other monotherapies, with a net cost savings of 101 per patient, reached statistical significance (331 vs. 432 , p<0.05). In addition, CE-based therapies show lower cost per cured patient in all comparisons except when CE was used in combination with three or more other drugs. Conclusions. The use of Cyclamen europaeum may be associated to better clinical outcomes at no additional cost for the healthcare system, respect to treatments commonly used for ARS in clinical practice.