Audit report on the City of Center Point, Iowa for the year ended June 30, 2013

Audit report on the City of Center Point, Iowa for the year ended June 30, 2013

Médecine interne: le point de vue du chef de clinique [Internal medicine: the point of view of the chief resident].

Clinical practice in internal medicine has fundamentely changed over the last decade. Our knowledge has dramatically improved and we are facing new types of patients. Their number is increasing, they are older and suffer from increasingly complex medical conditions. The society has evolved as well therefore transforming our daily practice. This implies important modifications of our role and new challenges. We must also develop new aspects of our practice such as recognizing our errors, quality of care, quality of education, ethics, new strategies for taking care of the patient all this in parallel with continuous education. Our role as (general practitioner) is of utmost importance since it enables us to keep the "big pictures" in a more and more specialized environment.

A program of nurse algorithm-guided care for adult patients with acute minor illnesses in primary care

Background: Attention to patients with acute minor-illnesses requesting same-day consultation represents a major burden in primary care. The workload is assumed by general practitioners in many countries. A number of reports suggest that care to these patients may be provided, at in least in part, by nurses. However, there is scarce information with respect to the applicability of a program of nurse management for adult patients with acute minor-illnesses in large areas. The aim of this study is to assess the effectiveness of a program of nurse algorithm-guided care for adult patients with acute minor illnesses requesting same-day consultation in primary care in a largely populated area. Methods: A cross-sectional study of all adult patients seeking same day consultation for 16 common acute minor illnesses in a large geographical area with 284 primary care practices. Patients were included in a program of nurse case management using management algorithms. The main outcome measure was case resolution, defined as completion of the algorithm by the nurse without need of referral of the patient to the general practitioner. The secondary outcome measure was return to consultation, defined as requirement of new consultation for the same reason as the first one, in primary care within a 7-day period. Results: During a two year period (April 2009-April 2011), a total of 1,209,669 consultations were performed in the program. Case resolution was achieved by nurses in 62.5% of consultations. The remaining cases were referred to a general practitioner. Resolution rates ranged from 94.2% in patients with burns to 42% in patients with upper respiratory symptoms. None of the 16 minor illnesses had a resolution rate below 40%. Return to consultation during a 7-day period was low, only 4.6%. Conclusions: A program of algorithms-guided care is effective for nurse case management of patients requesting same day consultation for minor illnesses in primary care.

Iterative statistical reconstruction method: A new way to reduce dose in pediatric cardiac CT

Purpose: Although several approaches have been already used to reduce radiation dose, CT doses are still among the high doses in radio-diagnostic. Recently, General Electric introduced a new imaging reconstruction technique, adaptive statistical iterative reconstruction (ASIR), allows to taking into account the statistical fluctuation of noise. The benefits of ASIR method were assessed through classic metrics and the evaluations of cardiac structures by radiologists. Methods and materials: A 64-row CT (MDCT) was employed. Catphan600 phantom acquisitions and 10 routine-dose CT examinations performed at 80 kVp were reconstructed with FBP and with 50% of ASIR. Six radiologists then assessed the visibility of main cardiac structures using the visual grading analysis (VGA) method. Results: On phantoms, for a constant value of SD (25 HU), CTDIvol is divided by 2 (8 mGy to 4 mGy) when 50% of ASIR is used. At constant CTDIvol, MTF medium frequencies were also significantly improved. First results indicated that clinical images reconstructed with ASIR had a better overall image quality compared with conventional reconstruction. This means that at constant image quality the radiation dose can be strongly reduced. Conclusion: The first results of this study shown that the ASIR method improves the image quality on phantoms by decreasing noise and improving resolution with respect to the classical one. Moreover, the benefit obtained is higher at lower doses. In clinical environment, a dose reduction can still be expected on 80 kVp low dose pediatric protocols using 50% of iterative reconstruction. Best ASIR percentage as a function of cardiac structures and detailed protocols will be presented for cardiac examinations.

Increased tender point counts before and after total hip arthroplasty are associated with poorer outcomes but are not individually predictive.

In a prospective study, total hip arthroplasty (THA) patients were assessed preoperatively and postoperatively (n = 95) to determine if tender points (TPs) are associated with poor THA outcomes. Patients with high follow-up TP counts had higher visual analog scale (VAS) for pain and sleep, higher follow-up Western Ontario and McMaster Universities Arthritis Index (pain, stiffness, function), lower Health Assessment Questionnaire, Harris Hip, and Short Form 36 (physical functioning, bodily pain, physical component summary) scores. High follow-up TP were associated with increased pain, pain not relieved by surgery, poor function, and poor sleep. Visual analog scale pain and sleep, Short Form 36 (physical functioning, bodily pain), Western Ontario and McMaster Universities Arthritis Index, Health Assessment Questionnaire, and Harris hip scores improved significantly after THA; TP scores did not. Higher preoperative TP were predictive of higher follow-up TP but were poorly predictive of poor outcome measures after surgery in individual patients, suggesting that preoperative TPs are contraindicative for THA.

Dépistage de l'athérosclérose: point de la situation en 2006. [Screening for atherosclerosis: 2006 update].

In recent years, several screening tests for subclinical atherosclerosis have been developed. The aim of these tests is to be able to better target preventive therapies to patients at high cardiovascular risk. However, the validity of these screening tests has not been well established for wide use in clinical practice. Being aware of these tests results might also enhance patient motivation to change unhealthy behaviors, such as smoking. However, the effectiveness of such strategy has been poorly studied. Early therapy of atherosclerosis has not been shown to improve clinical outcomes yet. Moreover, potential harms of such screening, such as induced anxiety, have been poorly studied. Although promising, such screening should be validated by clinical trials before routine use in clinical practice.

An integer-based score to predict functional outcome in acute ischemic stroke: The ASTRAL score.

OBJECTIVE: To develop and validate a simple, integer-based score to predict functional outcome in acute ischemic stroke (AIS) using variables readily available after emergency room admission. METHODS: Logistic regression was performed in the derivation cohort of previously independent patients with AIS (Acute Stroke Registry and Analysis of Lausanne [ASTRAL]) to identify predictors of unfavorable outcome (3-month modified Rankin Scale score >2). An integer-based point-scoring system for each covariate of the fitted multivariate model was generated by their β-coefficients; the overall score was calculated as the sum of the weighted scores. The model was validated internally using a 2-fold cross-validation technique and externally in 2 independent cohorts (Athens and Vienna Stroke Registries). RESULTS: Age (A), severity of stroke (S) measured by admission NIH Stroke Scale score, stroke onset to admission time (T), range of visual fields (R), acute glucose (A), and level of consciousness (L) were identified as independent predictors of unfavorable outcome in 1,645 patients in ASTRAL. Their β-coefficients were multiplied by 4 and rounded to the closest integer to generate the score. The area under the receiver operating characteristic curve (AUC) of the score in the ASTRAL cohort was 0.850. The score was well calibrated in the derivation (p = 0.43) and validation cohorts (0.22 [Athens, n = 1,659] and 0.49 [Vienna, n = 653]). AUCs were 0.937 (Athens), 0.771 (Vienna), and 0.902 (when pooled). An ASTRAL score of 31 indicates a 50% likelihood of unfavorable outcome. CONCLUSIONS: The ASTRAL score is a simple integer-based score to predict functional outcome using 6 readily available items at hospital admission. It performed well in double external validation and may be a useful tool for clinical practice and stroke research.

Carotid sparing in t1-t2 no glottic cancer using helical tomotherapy

Objective: To study the dosimetric properties and clinical implementation of a carotid dose sparing irradiation protocol using helical Tomotherapy in early stage laryngeal cancer.Materials and Methods: We have developed a simple treatment planning algorithm for carotid sparing. We have compared carotid and critical organ doses and planned target volume (PTV) dose with our standard laryngeal irradiation protocol. Dose constraints were the following: maximum point dose to the carotids <35 Gy, to the spinal cord <30 Gy, and PTV was covered at >95% of the prescribed dose (70 Gy in 2 Gy per fraction). A daily megavoltage CT was done to account for patient movement and anatomy modification. To date, 7 patients have been treated with this protocol in our department.Results: Our early results showed a significant reduction in the carotid dose with an average maximum dose of 35.8 Gy. The average maximum spinal cord dose was 25.8 Gy. PTV was covered without important "hot spots". Average maximum dose in the PTV was 74.1 Gy with an average absolute maximum dose of 75.2 Gy. To date, the clinical outcomes have been excellent.Conclusion: Helical Tomotherapy allows a significant decrease of carotid dose without dangerous spinal cord overdose. There was no important overdose in the PTV that can potentially increase the late complication risks. Daily control imaging brings added security especially when working with such high-dose gradients. We think further studies and longer follow-up are needed to investigate the clinical outcomes such as the local control rate and the vascular late toxicities.

Le projet "SYNAPSY": un point de rencontre entre clinique et neurosciences [The "SYNAPSY" project: where psychiatrists and neuroscientists meet].

The National Center of Competence in Research project "SYNAPSY" aims at identifying certain mechanisms of psychiatric and cognitive disorders, in order to improve the understanding and the genesis of such pathologies, and to promote the development of better diagnostic tools and of new therapeutic approaches. It provides an excellent opportunity for clinical psychiatrists and neuroscientists to develop a synergic mode of collaboration. On the basis of questions stemming from clinical practice and in the frame of patients cohorts, various research projects in neuroscience should lead to progresses that may have a considerable impact on clinical practice.

Reconfigurable Architecture To Estimate The Motion Of An Underwater Vehicle

This work proposes a parallel architecture for a motion estimation algorithm. It is well known that image processing requires a huge amount of computation, mainly at low level processing where the algorithms are dealing with a great numbers of data-pixel. One of the solutions to estimate motions involves detection of the correspondences between two images. Due to its regular processing scheme, parallel implementation of correspondence problem can be an adequate approach to reduce the computation time. This work introduces parallel and real-time implementation of such low-level tasks to be carried out from the moment that the current image is acquired by the camera until the pairs of point-matchings are detected

Evaluation de deux structures à bas seuil de la ville de Lausanne : Le Passage et le Point d'eau

[Table des matières] 1. Méthodes d'évaluation. 2. Le Passage et le Point d'eau. 2.1. Historique et objectifs. 2.2. Etapes de la mise en route. 3.1. Professionnels salariés. 3.2. Bénévoles professionnels. 3.3. Bénévoles d'accueil. 4.1. Activités de la structure. 4.2. Accueil (animations, repas, collations). 4.3. L'offre socio-éducative. 4.4. L'offre sanitaire. 4.5. La distribution du matériel stérile. 5.1. Prestations d'hygiène. 5.2. Soins somatiques. 5.3. Activité sportive. 6.1. Profil des usagers. 6.2. Indicateurs socio-démographiques et d'intégration sociale. 6.3. Etat de santé perçu. 6.4. Fréquentation du réseau (dispositif bas seuil et autre) et de Point d'eau. 7. Consommation de drogues illégales. 8. Fréquentation de la structure. 9.1. Méthodes d'évaluation utilisées. 9.2. Evaluation du Passage et du Point d'eau.

Practice guidelines for evaluation of Fever in returning travelers and migrants.

BACKGROUND: Fever upon return from tropical or subtropical regions can be caused by diseases that are rapidly fatal if left untreated. The differential diagnosis is wide. Physicians often lack the necessary knowledge to appropriately take care of such patients. OBJECTIVE: To develop practice guidelines for the initial evaluation of patients presenting with fever upon return from a tropical or subtropical country in order to reduce delays and potential fatal outcomes and to improve knowledge of physicians. TARGET AUDIENCE: Medical personnel, usually physicians, who see the returning patients, primarily in an ambulatory setting or in an emergency department of a hospital and specialists in internal medicine, infectious diseases, and travel medicine. METHOD: A systematic review of the literature--mainly extracted from the National Library of Medicine database--was performed between May 2000 and April 2001, using the keywords fever and/or travel and/or migrant and/or guidelines. Eventually, 250 articles were reviewed. The relevant elements of evidence were used in combination with expert knowledge to construct an algorithm with arborescence flagging the level of specialization required to deal with each situation. The proposed diagnoses and treatment plans are restricted to tropical or subtropical diseases (nonautochthonous diseases). The decision chart is accompanied with a detailed document that provides for each level of the tree the degree of evidence and the grade of recommendation as well as the key points of debate. PARTICIPANTS AND CONSENSUS PROCESS: Besides the 4 authors (2 specialists in travel/tropical medicine, 1 clinical epidemiologist, and 1 resident physician), a panel of 11 European physicians with different levels of expertise on travel medicine reviewed the guidelines. Thereafter, each point of the proposed recommendations was discussed with 15 experts in travel/tropical medicine from various continents. A final version was produced and submitted for evaluation to all participants. CONCLUSION: Although the quality of evidence was limited by the paucity of clinical studies, these guidelines established with the support of a large and highly experienced panel should help physicians to deal with patients coming back from the Tropics with fever.