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.

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.

Automatic Segmentation of the Eye in 3D Magnetic Resonance Imaging: A Novel Statistical Shape Model for Treatment Planning of Retinoblastoma.

PURPOSE: Proper delineation of ocular anatomy in 3-dimensional (3D) imaging is a big challenge, particularly when developing treatment plans for ocular diseases. Magnetic resonance imaging (MRI) is presently used in clinical practice for diagnosis confirmation and treatment planning for treatment of retinoblastoma in infants, where it serves as a source of information, complementary to the fundus or ultrasonographic imaging. Here we present a framework to fully automatically segment the eye anatomy for MRI based on 3D active shape models (ASM), and we validate the results and present a proof of concept to automatically segment pathological eyes. METHODS AND MATERIALS: Manual and automatic segmentation were performed in 24 images of healthy children's eyes (3.29 ± 2.15 years of age). Imaging was performed using a 3-T MRI scanner. The ASM consists of the lens, the vitreous humor, the sclera, and the cornea. The model was fitted by first automatically detecting the position of the eye center, the lens, and the optic nerve, and then aligning the model and fitting it to the patient. We validated our segmentation method by using a leave-one-out cross-validation. The segmentation results were evaluated by measuring the overlap, using the Dice similarity coefficient (DSC) and the mean distance error. RESULTS: We obtained a DSC of 94.90 ± 2.12% for the sclera and the cornea, 94.72 ± 1.89% for the vitreous humor, and 85.16 ± 4.91% for the lens. The mean distance error was 0.26 ± 0.09 mm. The entire process took 14 seconds on average per eye. CONCLUSION: We provide a reliable and accurate tool that enables clinicians to automatically segment the sclera, the cornea, the vitreous humor, and the lens, using MRI. We additionally present a proof of concept for fully automatically segmenting eye pathology. This tool reduces the time needed for eye shape delineation and thus can help clinicians when planning eye treatment and confirming the extent of the tumor.

A Segmentation Model for Hi-tech Business Markets

Segmentointi on strateginen työkalu, joka tehostaa yrityksen resurssien käyttöä ja siten vaikuttaa kaikkiin asiakkuuksiin liittyviin liiketoimintaprosesseihin. Työn tavoitteena oli muodostaa segmentointimalli (sisältää sekä segmentointiprosessin että kriteerit) yritysinternetmarkkinoille. Työn tuloksia voidaan kuitenkin tulkita ja soveltaa laajemmin korkean teknologian yrityspalvelumarkkinoille. Tämä tutkielma lisää tietämystämme ja tarjoaa uudenlaisen näkemyksen segmentointiin korkean teknologian yrityspalvelumarkkinoilla. Työssä kuvataan korkean teknologian ja yritys- sekä palvelumarkkinoinnin erityispiirteitä ja kuinka nämä tekijät vaikuttavat segmentointimallin. Tutkimuksessa selvitettiin kohdeyrityksen nykyiset segmentointikäytännöt henkilökohtaisin asiantuntijahaastatteluin. Haastatteluiden avulla luotiin kuva nykyisistä lähestymistavoista sekä niiden lähtökohdista, vahvuuksista ja haasteista. Haastatteluiden analysoinnin jälkeen perustettiin projekti segmentoinnin kehittämiseksi. Työ tuloksena luotiin segmentointimalli, joka tarjoaa vankan perustan segmentoinnin kehittämiselle jatkuvana prosessina. Työssä esitetään segmentoinnin integroimista yrityksen asiakkuuksiin liittyviin liiketoimintaprosesseihin, joka usein puuttuu aiemmista töistä, sekä informaationkulun tehostamista segmentoinnin hyödyntämiseksi tehokkaammin. Segmentointi on strateginen työkalu ja vaatii siksi ylemmän johdon tuen ja sitoutumisen. Oikein sovellettuna segmentointi tarjoaa liiketoiminnalle mahdollisuuden merkittäviin etuihin kuten asiakastyytyväisyyden ja kannattavuuden kehittämiseen.

Diagonal ear lobe crease and atherosclerosis: a review of the medical literature and dental implications

In Spain a significant number of individuals die from atherosclerotic disease of the coronary and carotid arteries without having classic risk factors and prodromal symptoms. The diagonal ear lobe crease (DELC) has been characterized in the medical literature as a surrogate marker which can identify high risk patients having occult atherosclerosis. This topic however has not been examined in either the medical or dental literature emanating from Spain. The majority of clinical, angiography and postmortem reports support the premise that DELC is a valuable extravascular physical sign able to distinguish some patients at risk of succumbing to atherosclerosis of the coronary arteries. A minority of studies have however failed to support this hypothesis. More recently reports using B mode ultrasound have also linked DELC to atherosclerosis of the carotid artery and another report has related DELC to the presence of calcified carotid artery atheromas on panoramic radiographs. DELC is readily visible during head and neck cancer screening examinations. In conjunction with the patient"s medical history, vital signs, and panoramic radiograph, the DELC may assist in atherosclerotic risk assessment

Exploring Different Types of Sharing: A Proposed Segmentation of the Market for "Sharing Businesses"

Sharing instead of buying is regaining traction among today's consumers. This study aims at identifying segments of sharing consumers to unearth potentially viable clusters of a consumer behavior that is a market of growing economic relevance. By means of a qualitative study and a survey with a roughly representative sample of 1121 Swiss-German and German consumers, a set of trait-related, motivational, and perceived socioeconomic variables is identified that can be used to group individuals into segments that differ with regard to their approach to sharing. A cluster analysis based on these variables suggests four potential clusters of sharing consumers-sharing idealists, sharing opponents, sharing pragmatists, and sharing normatives. Two sets of testable propositions are derived that can guide further research in this domain and pave the way to a more targeted approach to the growing market of "sharing" businesses.

Segmentation model for small and medium size business sector: Case Oy Compaq Computer Ab

Markkinasegmentointi nousi esiin ensi kerran jo 50-luvulla ja se on ollut siitä lähtien yksi markkinoinnin peruskäsitteistä. Suuri osa segmentointia käsittelevästä tutkimuksesta on kuitenkin keskittynyt kuluttajamarkkinoiden segmentointiin yritys- ja teollisuusmarkkinoiden segmentoinnin jäädessä vähemmälle huomiolle. Tämän tutkimuksen tavoitteena on luoda segmentointimalli teollismarkkinoille tietotekniikan tuotteiden ja palveluiden tarjoajan näkökulmasta. Tarkoituksena on selvittää mahdollistavatko case-yrityksen nykyiset asiakastietokannat tehokkaan segmentoinnin, selvittää sopivat segmentointikriteerit sekä arvioida tulisiko tietokantoja kehittää ja kuinka niitä tulisi kehittää tehokkaamman segmentoinnin mahdollistamiseksi. Tarkoitus on luoda yksi malli eri liiketoimintayksiköille yhteisesti. Näin ollen eri yksiköiden tavoitteet tulee ottaa huomioon eturistiriitojen välttämiseksi. Tutkimusmetodologia on tapaustutkimus. Lähteinä tutkimuksessa käytettiin sekundäärisiä lähteitä sekä primäärejä lähteitä kuten case-yrityksen omia tietokantoja sekä haastatteluita. Tutkimuksen lähtökohtana oli tutkimusongelma: Voiko tietokantoihin perustuvaa segmentointia käyttää kannattavaan asiakassuhdejohtamiseen PK-yritys sektorilla? Tavoitteena on luoda segmentointimalli, joka hyödyntää tietokannoissa olevia tietoja tinkimättä kuitenkaan tehokkaan ja kannattavan segmentoinnin ehdoista. Teoriaosa tutkii segmentointia yleensä painottuen kuitenkin teolliseen markkinasegmentointiin. Tarkoituksena on luoda selkeä kuva erilaisista lähestymistavoista aiheeseen ja syventää näkemystä tärkeimpien teorioiden osalta. Tietokantojen analysointi osoitti selviä puutteita asiakastiedoissa. Peruskontaktitiedot löytyvät mutta segmentointia varten tietoa on erittäin rajoitetusti. Tietojen saantia jälleenmyyjiltä ja tukkureilta tulisi parantaa loppuasiakastietojen saannin takia. Segmentointi nykyisten tietojen varassa perustuu lähinnä sekundäärisiin tietoihin kuten toimialaan ja yrityskokoon. Näitäkään tietoja ei ole saatavilla kaikkien tietokannassa olevien yritysten kohdalta.

Swiss medical centres vary significantly when it comes to outcomes of neonates with a very low gestational age.

AIM: This study quantified the impact of perinatal predictors and medical centre on the outcome of very low-gestational-age neonates (VLGANs) born at <32 completed weeks in Switzerland. METHODS: Using prospectively collected data from a 10-year cohort of VLGANs, we developed logistic regression models for three different time points: delivery, NICU admission and seven days of age. The data predicted survival to discharge without severe neonatal morbidity, such as major brain injury, moderate or severe bronchopulmonary dysplasia, retinopathy of prematurity (≥stage three) or necrotising enterocolitis (≥stage three). RESULTS: From 2002 to 2011, 6892 VLGANs were identified: 5854 (85%) of the live-born infants survived and 84% of the survivors did not have severe neonatal complications. Predictors for adverse outcome at delivery and on NICU admission were low gestational age, low birthweight, male sex, multiple birth, birth defects and lack of antenatal corticosteroids. Proven sepsis was an additional risk factor on day seven of life. The medical centre remained a statistically significant factor at all three time points after adjusting for perinatal predictors. CONCLUSION: After adjusting for perinatal factors, the survival of Swiss VLGANs without severe neonatal morbidity was strongly influenced by the medical centre that treated them.

Publication trends of shared decision making in 15 high impact medical journals: a full-text review with bibliometric analysis.

BACKGROUND: Shared Decision Making (SDM) is increasingly advocated as a model for medical decision making. However, there is still low use of SDM in clinical practice. High impact factor journals might represent an efficient way for its dissemination. We aimed to identify and characterize publication trends of SDM in 15 high impact medical journals. METHODS: We selected the 15 general and internal medicine journals with the highest impact factor publishing original articles, letters and editorials. We retrieved publications from 1996 to 2011 through the full-text search function on each journal website and abstracted bibliometric data. We included publications of any type containing the phrase "shared decision making" or five other variants in their abstract or full text. These were referred to as SDM publications. A polynomial Poisson regression model with logarithmic link function was used to assess the evolution across the period of the number of SDM publications according to publication characteristics. RESULTS: We identified 1285 SDM publications out of 229,179 publications in 15 journals from 1996 to 2011. The absolute number of SDM publications by journal ranged from 2 to 273 over 16 years. SDM publications increased both in absolute and relative numbers per year, from 46 (0.32% relative to all publications from the 15 journals) in 1996 to 165 (1.17%) in 2011. This growth was exponential (P < 0.01). We found fewer research publications (465, 36.2% of all SDM publications) than non-research publications, which included non-systematic reviews, letters, and editorials. The increase of research publications across time was linear. Full-text search retrieved ten times more SDM publications than a similar PubMed search (1285 vs. 119 respectively). CONCLUSION: This review in full-text showed that SDM publications increased exponentially in major medical journals from 1996 to 2011. This growth might reflect an increased dissemination of the SDM concept to the medical community.

Helping medical students to acquire a deeper understanding of truth-telling.

PROBLEM: Truth-telling is an important component of respect for patients' self-determination, but in the context of breaking bad news, it is also a distressing and difficult task. INTERVENTION: We investigated the long-term influence of a simulated patient-based teaching intervention, integrating learning objectives in communication skills and ethics into students' attitudes and concerns regarding truth-telling. We followed two cohorts of medical students from the preclinical third year to their clinical rotations (fifth year). Open-ended responses were analysed to explore medical students' reported difficulties in breaking bad news. CONTEXT: This intervention was implemented during the last preclinical year of a problem-based medical curriculum, in collaboration between the doctor-patient communication and ethics programs. OUTCOME: Over time, concerns such as empathy and truthfulness shifted from a personal to a relational focus. Whereas 'truthfulness' was a concern for the content of the message, 'truth-telling' included concerns on how information was communicated and how realistically it was received. Truth-telling required empathy, adaptation to the patient, and appropriate management of emotions, both for the patient's welfare and for a realistic understanding of the situation. LESSONS LEARNED: Our study confirms that an intervention confronting students with a realistic situation succeeds in making them more aware of the real issues of truth-telling. Medical students deepened their reflection over time, acquiring a deeper understanding of the relational dimension of values such as truth-telling, and honing their view of empathy.

Stereotactic body radiation therapy with helical tomotherapy for medical inoperable early-stage primary and second-primary non-small cell lung neoplasm : one-year outcome and toxicity analysis

Le cancer du poumon est la première cause de mortalité associée au cancer dans le monde. Le traitement curatif des tumeurs pulmonaires non-à-petites-cellules (NSCLC) diagnostiquées à un stade précoce se base sur une approche chirurgicale. Cependant, étant donné les comorbidités liées à la consommation de tabac, dont la bronchopneumopathie chronique occupe la première place, l'éligibilité chirurgicale pour ce type de cancer se trouve fréquemment limitée. Dans ce contexte, l'emploi de la radiothérapie stéréotaxique (SBRT) est une alternative valable chez les patients atteints d'un NSCLC primaire de stade précoce, et qui sont considérés inopérables à cause de leurs comorbidités. Depuis peu seulemement, le spectre de la SBRT a été élargi aux patients atteints d'un deuxième NSCLC primaire (SPLC), faisant suite à un premier NSCLC, traité avec un but curatif. Ils concernent donc des patients ayant déjà subits une intervention chirurgicale au préalable et qui présentent une réserve fonctionnelle pulmonaire extrêmement réduite. Le succès croissant de la SBRT résulte soit d'une efficacité thérapeutique comparables à la chirurgie, soit de sa toxicité qui semble limitée. À notre connaissance, seulement une étude a reporté des issues cliniques de patients affectés par des NSCLC primaires traités par SBRT. Cette dernière a utilisé la tomothérapie comme système d'irradiation (T-SBRT), sur un faible échantillon de patients (n = 27). Concernant l'irradiation des patients présentant des SPLC, la littérature disponible est pauvre et aucune publication a décrit l'utilisation de la T-SBRT. Ces éléments innovants ont donc motivé la rédaction d'un travail de thèse concernant les premières données cliniques de l'expérience faite au CHUV. Du point de vue des effets secondaires, si la pneumonie actinique précoce et tardive survenant au niveau du champ d'irradiation est désormais une complication iatrogène bien connue de la SBRT, une seule étude s'est intéressée à ce sujet dans le cadre de la T-SBRT. De plus, une entité bénigne et transitoire de pneumonie ( ?) a été reconnue depuis peu : la pneumonie organisée radio-induite (OP). Celle-ci semble se chevaucher comme un autre effet iatrogène à l'extérieur du champ d'irradiation. Originellement, cette dernière avait été rapportée dans les suites de la radiothérapie pour les cancer du sein. Elle a été décrite comme étant initialement limitée au champ d'irradiation et successivement pouvant s'étendre dynamiquement en dehors de celui-ci. Nous avons donc supposé que des infiltrats de OP peuvent être présents chez des patients asymptomatiques, et que ce dynamisme pourrait être identifié déjà au sein du champ d'irradiation. Notre étude a démontré que le traitement par T-SBRT garde des issues cliniques très encourageantes, aussi bien pour les tumeurs primaires que pour les SPLC. Entre autre, ce traitement semble avoir une toxicité limitée, et l'existence vraisemblable de la OP, déjà au sein du champ d'irradiation, peut aider les radiologues à différencier les infiltrats radio-induits d'une une récidive tumorale.

Foreign-Medical-School Graduates object to the VISA Qualifiying Examination

To the editor; The Visa Qualifying Examination is a two-day test composed of approximately 950 multiple-choice questions conerneing the basic and clinical sciences....