[A physician reflects after 20 years of practice].
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Delivery of Health Care↗
Biomedical subjects
H Stalder
Publications and source records attributed to H Stalder.
[General practice--linear thinking and complexity].
As physicians, we apply and teach linear thinking. This approach permits to dissect the patient's problem to the molecular level and has contributed enormously to the knowledge and progress of medicine. The linear approach is particularly useful in medical education, in quantitative research and helps to resolve simple problems. However, it risks to be rigid. Living beings (such as patients and physicians!) have to be considered as complex systems. A complex system cannot be dissected into its parts without losing its identity. It is dependent on its past and interactions with the outside are often followed by unpredictable reactions. The patient-centred approach in medicine permits the physician, a complex system himself, to integrate the patient's system and to adapt to his reality. It is particularly useful in general medicine.
Family Practice↗
[Quality care in primary care: the importance of patients' reports].
Patients' evaluation of care is an important element of quality of care, especially for patients with chronic conditions. Our objective was to expose physicians in training to a quality improvement program and study how continuity of care could influence patients' experience of care. Physicians in training valued this approach, but deplored no to be actively involved in its planning. They also underlined the importance of keeping physicians' individual results absolutely confidential. Positive patients' reports toward communication and physician-patient relationship were associated with longer duration of follow-up at the medical outpatient clinic. Following this project, several changes have been made to improve aspects of care that were problematic.
Communication↗
[Preparing a drug list for primary care].
To limit drug adverse effects, the use of a limited choice of drugs is desirable. We identified 29 frequent health problems and selected first and second choice medication based on the following criteria: clinical efficacy based on medical evidence or expert consensus, safety profile, and costs. For each substance, adverse effect, contraindication, interaction risk, specific dosing, and safety use during pregnancy and lactation were reviewed. More than seventy substances were identified. This list is available for download at the following address (in French): http://www.hcuge.
Formularies, Hospital as Topic↗
[Sociocultural diversity and medical education].
Global migration patterns have led to increasingly diverse populations, and physicians must learn to work effectively with patients from diverse backgrounds. However, some aspects of medical education may actually reinforce the idea that physicians do not need to take social and cultural differences into consideration in their work. In order to train physicians who are capable of providing quality care to patients from diverse backgrounds, it will be important to integrate the concept of cultural competence into all aspects of medical training, such that it will cease to be perceived as an "optional" aspect of medicine.
Cultural Diversity↗
[Social inequalities and health: experiences of a mobile health care unit in Geneva].
Health care professionals are in contact with patients of all social horizons. Healthcare professionals come into contact with patients from all social backgrounds. Low socio-economic status is a well-known determinant of morbidity and mortality. A mobile community health care unit ("Umsco") was created in Geneva in 1996 with the aim of providing health care to very low-income patients who aren't catered for by the traditional healthcare system in Switzerland. The Mobile Unit's patients are mainly female South American illegal immigrants, but also the city' homeless. This article explains how the Unit functions on a day-to-day basis. We describe socio-demographic characteristics of the patients and their main presenting complaints. We also discuss how health care professionals in general can adapt to the specific needs of socially deprived and vulnerable patients.
Community Health Services↗
[The Geneva experience: the Department of Community Medicine].
The mission of the Department of Community Medicine at the Geneva University Hospitals is to offer the underserved and marginalised populations guaranteed access to the health system and to promote education and research in general and internal medicine (primary care). The activity with a two-fold focus--medical-social and academic--demonstrated by the type of care offered to homeless people and other clandestine groups allows for the achievement of a number of objectives of the Towards Unity for Health programme. However, evidence to date emphasises that such a structure remains fragile.
Community Health Services↗
2-(2-Oxo-1,4-dihydro-2H-quinazolin-3-yl)- and 2-(2,2-dioxo-1,4-dihydro-2H-2lambda6-benzo[1,2,6]thiadiazin-3-yl)-N-hydroxy-acetamides as potent and selective peptide deformylase inhibitors.
Potent, selective, and structurally new inhibitors of the Fe(II) enzyme Escherichia coli peptide deformylase (PDF) were obtained by rational optimization of the weakly binding screening hit (5-chloro-2-oxo-1,4-dihydro-2H-quinazolin-3-yl)-acetic acid hydrazide (1). Three-dimensional structural information, gathered from Ni-PDF complexed with 1, suggested the preparation of two series of related hydroxamic acid analogues, 2-(2-oxo-1,4-dihydro-2H-quinazolin-3-yl)-N-hydroxy-acetamides (A) and 2-(2,2-dioxo-1,4-dihydro-2H-2lambda(6)-benzo[1,2,6]thiadiazin-3-yl)-N-hydroxy-acetamides (B), among which potent PDF inhibitors (37, 42, and 48) were identified. Moreover, two selected compounds, one from each series, 36 and 41, showed good selectivity for PDF over several endoproteases including matrix metalloproteases. However, these compounds showed only weak antibacterial activity.
Amidohydrolases↗
Role of nasopharyngeal culture in antibiotic prescription for patients with common cold or acute sinusitis.
The aim of the present study was to assess the hypothesis that, when present in nasopharyngeal secretions, Streptococcus pneumoniae. Haemophilus influenzae, and Moraxella catarrhalis play a pathogenic role early in the course of an upper respiratory tract infection. Adults with a clinical diagnosis of acute sinusitis or common cold were enrolled. Participants were randomly assigned in a double-blind manner to receive azithromycin 500 mg daily or placebo for 3 days. The effect of treatment on symptom evolution in the predefined subset of patients with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis in their nasopharyngeal secretions was assessed. Of 265 patients enrolled, 132 received placebo and 133 azithromycin. Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis was identified in nasopharyngeal secretions of 77 patients (29%). In this predefined subgroup of patients with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, resolution of symptoms by day 7 occurred in 73% of those treated with azithromycin compared with 47% of those who received placebo (P=0.007). The median time before resolution of symptoms was 5 days in the azithromycin group compared to 7 days in the placebo group. Respiratory complications requiring antibiotic treatment occurred in 19% of patients in the placebo group and in 3% of the azithromycin group (P=0.025). In the remaining 188 patients without Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, resolution of symptoms by day 7 was similar in both groups (69% in the placebo group vs. 64% in the azithromycin group [P=0.75]). Antibiotic treatment is of clinical benefit for patients with acute sinusitis or common cold when Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis is present in nasopharyngeal secretions. This observation provides new insights into the pathogenic role of these bacteria in the early stage of the common cold.
Acute Disease↗
Stress fracture of the cuboid in an 8-year-old boy: a characteristic magnetic resonance imaging diagnosis.
A stress fracture of an 8-year-old boy diagnosed on magnetic resonance (MR) images is presented. Stress fractures of the cuboid are probably more common than previously reported. The diagnosis should be considered even when a history of trauma or chronic overload is absent. The MR appearance of the stress fracture was characteristic.
Child↗
Blood pressure and renal haemodynamic response to salt during the normal menstrual cycle.
The purpose of the present study was to evaluate prospectively blood pressure and the renal haemodynamic response to salt during the normal menstrual cycle. A total of 35 healthy normotensive young women not on oral contraceptives were enrolled; 17 were studied in the follicular phase and 18 in the luteal phase of the menstrual cycle. The women in each group were then randomly allocated to receive a low-sodium (40 mmol/day) or a high-sodium (250 mmol/day) diet for a 7-day period in two consecutive menstrual cycles. At the end of each dietary period, 24 h ambulatory blood pressure, urinary sodium excretion, plasma renin activity, plasma catecholamine levels and renal haemodynamics were measured. Our results show that the blood pressure response to salt is comparable during the luteal and the follicular phases of the normal menstrual cycle and is characterized by a salt-resistant pattern. In the kidney, effective renal plasma flow was significantly greater and the filtration fraction lower (P<0.05) after salt loading in women studied in the luteal phase compared with women investigated in the follicular phase. This study thus demonstrates that the female hormone status does not affect the blood pressure response to sodium in young normotensive women. However, in contrast with systemic haemodynamics, the renal response to salt varies during the normal menstrual cycle, suggesting that female sex hormones play a role (direct or indirect) in the regulation of renal haemodynamics.
Adult↗
[Symptoms and clinical and radiological signs predicting the bacterial origin of acute rhinosinusitis].
A minority of patients with common cold and upper respiratory tract infections have a bacterial infection and may benefit from antibiotic therapy. The present analysis set out to determine whether there were clinical symptoms or signs which could help the clinician to identify a subset of patients with moderate forms of acute rhinosinusitis who are infected with pathogenic bacteria. Detailed clinical history and medical examination were obtained from 265 patients (mean age 35 years, 138 females and 127 males) presenting symptoms of upper respiratory tract infections but no fever above 38 degrees C. The presence of three pathogenic bacteria (S. pneumoniae, H. influenzae or M. catarrhalis) was determined in all patients by culture of nasopharyngeal secretions. Aggravating factors for severity of rhinosinusitis, such as severe nasal obstruction, inferior and/or middle turbinate hypertrophy, oedema of the middle meatus mucosa and septal defects, were not associated with the presence of bacteria. Pathogenic bacteria were found in 77 patients (29%). The clinical signs and symptoms which were significantly associated in a multivariate model with the presence of bacteria included facial pain (p < 0.003), coloured nasal discharge (p < 0.003) and radiological maxillary sinusitis (complete opacity, air-fluid level or mucosal thickening greater than 10 mm) (p < 0.002). This, the best predictive model, had a sensitivity of 69% and a specificity of 64% and therefore could not be used either as a screening tool or as a diagnostic criterion for bacterial rhinosinusitis. We conclude that signs and symptoms of acute rhinosinusitis in patients with a mild to moderate clinical presentation are poor predictors of the presence of bacteria. In agreement with previous studies, culture of nasopharyngeal secretions may identify patients who would benefit from antibiotic treatment. Thus, antibiotic therapy should not be prescribed in the absence of bacteriological evidence.
Adolescent↗
[Evaluation of drug prescription in the primary care clinic in Geneva in 1997].
INTRODUCTION: The analysis of drug prescription in a primary care clinic is a useful tool to evaluate the quality of medical care provided to outpatients. METHODOLOGY: We analysed drug prescriptions of the first consultations with 701 patients attending between May 14 and June 6 1997, and compared this data to previous surveys conducted in 1988, 1991 and 1993. RESULTS AND DISCUSSION: The three most common diagnoses were hypertension, lumbar pain and diabetes. The prescription of non steroidal antiinflammatory drugs (NSAID) increased from 7.1% in 1988 to 20% in 1997. For acute lumbar pain physicians prescribed NSAID to 58% of patients and paracetamol only to 33%. Further, doctors often prescribed muscle relaxants although an additional antalgic effect has not been proven. The prescription of psychotropic drugs decreased from 22.5% in 1988 to 12.7% in 1997. ACE inhibitors and calcium antagonists were the most frequently prescribed antihypertensive drugs. Therefore physicians do not follow the American (JNC VI) and our institutional guidelines, which recommend beta-blockers and diuretics as first line agents.
Acetaminophen↗
Language difficulties in an outpatient clinic in Switzerland.
This small-scale study attempts to examine the languages spoken in medical consultations during a one-month period in an outpatient clinic in Geneva and the ways health professionals use to communicate with their allophone patients, in particular by using interpreters. Patients of foreign origin accounted for 58% of all the consultations during the survey. Of these, 37% were Non-French-speakers (NFS). The four major language groups of NFS were Albanian, Somali, Tamil and Serbo-croat. Qualified interpreters were used in 24% of the consultations, relatives acting as interpreters in 17%, and in the other consultations without anyone interpreting (59%), a common language had to be negotiated: French, English, Italian, Spanish or German. In only 14% of the consultations without interpreters, both patient's and doctors ability to speak a common language was rated as good. Our data suggest that there has been an increasing awareness of the possible language barriers in the medical outpatient clinic. Even if proxy solutions (informal interpreters or the use of a common language) still play an important role, access to an interpreter service has been widely used. This calls for systematic and regular interpreter use, planning the interpreting needs in a timely manner. In the future, training in working with interpreters should become an integral part to the introductory sessions for the junior physicians assigned to the outpatient clinic.
Ambulatory Care Facilities↗
[Rational union between medical sociology and academics].
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Clinical Medicine↗
Radiological maxillary sinusitis in patients with common cold.
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Adult↗