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Counseling and pharmacotherapy are smoking cessation interventions whose effectiveness has been widely demonstrated. Different pharmacologic treatment options exist with similar efficacy : notably nicotine replacement therapy, varenicline and bupropion. Providers can promote therapeutic adherence and the chances of successful quitting by involving patients in the choice of medication and incorporating their preferences in the decision process. The concept of shared decision-making is based on an exchange between doctor and patient in medical situations with several reasonable options. Decision aids support this approach by facilitating the transmission of information, communication and patient involvement. Despite opportunities for shared decision-making during the smoking cessation process, few decision aids are available. This article summarizes current knowledge in this field and its application to the process of smoking cessation. Shared decision making in smoking cessation is illustrated by a decision aid created to facilitate the choice between different smoking cessation medications.
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Conducta de Elección/fisiología , Toma de Decisiones Conjunta , Participación del Paciente/métodos , Cese del Hábito de Fumar/métodos , Bupropión/uso terapéutico , Consejo , Humanos , Nicotina/uso terapéutico , Participación del Paciente/psicología , Participación del Paciente/estadística & datos numéricos , Selección de Paciente , Cese del Hábito de Fumar/psicología , Dispositivos para Dejar de Fumar Tabaco , Vareniclina/uso terapéuticoRESUMEN
Essentials The long-term effects of VKORC1 and CYP2C9 variants on clinical outcomes remains unclear. We followed 774 patients ≥65 years with venous thromboembolism for a median duration of 30 months. Patients with CYP2C9 variants are at increased risk of death and non-major bleeding. Patients with genetic variants have a slightly lower anticoagulation quality only. SUMMARY: Background The long-term effect of polymorphisms of the vitamin K-epoxide reductase (VKORC1) and the cytochrome P450 enzyme gene (CYP2C9) on clinical outcomes remains unclear. Objectives We examined the association between CYP2C9/VKORC1 variants and long-term clinical outcomes in a prospective cohort study of elderly patients treated with vitamin K antagonists for venous thromboembolism (VTE). Methods We followed 774 consecutive patients aged ≥ 65 years with acute VTE from nine Swiss hospitals for a median duration of 30 months. The median duration of initial anticoagulant treatment was 9.4 months. The primary outcome was the time to any clinical event (i.e. the composite endpoint of overall mortality, major and non-major bleeding, and recurrent VTE. Results Overall, 604 (78%) patients had a CYP2C9 or VKORC1 variant. Three hundred and thirty-four patients (43.2%) had any clinical event, 119 (15.4%) died, 100 (12.9%) had major and 167 (21.6%) non-major bleeding, and 100 had (12.9%) recurrent VTE. After adjustment, CYP2C9 (but not VKORC1) variants were associated with any clinical event (hazard ratio [HR], 1.34; 95% confidence interval [CI], 1.08-1.66), death (HR, 1.74; 95% CI, 1.19-2.52) and clinically relevant non-major bleeding (sub-hazard ratio [SHR], 1.39; 95% CI, 1.02-1.89), but not with major bleeding (SHR, 1.03; 95% CI, 0.69-1.55) or recurrent VTE (SHR, 0.95; 95% CI, 0.62-1.44). Patients with genetic variants had a slightly lower anticoagulation quality. Conclusions CYP2C9 was associated with long-term overall mortality and non-major bleeding. Although genetic variants were associated with a slightly lower anticoagulation quality, there was no relationship between genetic variants and major bleeding or VTE recurrence.
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Anticoagulantes/uso terapéutico , Coagulación Sanguínea/efectos de los fármacos , Citocromo P-450 CYP2C9/genética , Variantes Farmacogenómicas , Tromboembolia Venosa/tratamiento farmacológico , Vitamina K Epóxido Reductasas/genética , Vitamina K/antagonistas & inhibidores , Factores de Edad , Anciano , Anticoagulantes/efectos adversos , Citocromo P-450 CYP2C9/metabolismo , Femenino , Hemorragia/inducido químicamente , Humanos , Masculino , Farmacogenética , Estudios Prospectivos , Recurrencia , Factores de Riesgo , Suiza , Factores de Tiempo , Resultado del Tratamiento , Tromboembolia Venosa/sangre , Tromboembolia Venosa/genética , Tromboembolia Venosa/mortalidad , Vitamina K Epóxido Reductasas/metabolismoRESUMEN
BACKGROUND: Venous thromboembolism (VTE) and subclinical thyroid dysfunction (SCTD) are both common in elderly patients. SCTD has been related to a hypercoagulable state and an increased thromboembolic risk. However, prospective data on the relationship between SCTD and VTE are lacking. OBJECTIVES: To investigate the relationship between SCTD and recurrent VTE (rVTE), all-cause mortality, and thrombophilic biomarkers. Patients Elderly patients with VTE were studied. METHODS: In a prospective multicenter cohort, thyroid hormones and thrombophilic biomarkers were measured 1 year after acute VTE, as both may be influenced by acute thrombosis. We defined subclinical hypothyroidism (SHypo) as elevated thyroid-stimulating hormone (TSH) levels (4.50-19.99 mIU L(-1) ), and subclinical hyperthyroidism (SHyper) as TSH levels of < 0.45 mIU L(-1) , both with normal free thyroxine levels. Outcomes were incidence of rVTE and overall mortality during follow-up starting after the 1-year blood sampling. RESULTS: Of 561 participants (58% with anticoagulation), 6% had SHypo and 5% had SHyper. After 20.8 months of mean follow-up, 9% developed rVTE and 10% died. The rVTE incidence rate was 7.2 (95% confidence interval [CI] 2.7-19.2) per 100 patient-years in SHypo participants, 0.0 (95% CI 0.0-7.6) in SHyper participants, and 5.9 (95% CI 4.4-7.8) in euthyroid participants. In multivariate analyses, the sub-hazard ratio for rVTE was 0.00 (95% CI 0.00-0.58) in SHyper participants and 1.50 (95% CI 0.52-4.34) in SHypo participants as compared with euthyroid participants, without increased levels of thrombophilic biomarkers. SHyper (hazard ratio [HR] 0.80, 95% CI 0.23-2.81) and SHypo (HR 0.99, 95% CI 0.30-3.29) were not associated with mortality. CONCLUSION: In elderly patients, SHyper may be associated with lower rVTE risks. SHypo showed a non-statistically significant pattern of an association with rVTE, without increased mortality or differences in thrombophilic biomarkers.
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Enfermedades de la Tiroides/complicaciones , Enfermedades de la Tiroides/fisiopatología , Tromboembolia Venosa/complicaciones , Tromboembolia Venosa/fisiopatología , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Coagulación Sanguínea , Femenino , Humanos , Hipertiroidismo/fisiopatología , Hipotiroidismo/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Tromboembolia , Trombofilia/sangre , Trombosis/fisiopatología , Enfermedades de la Tiroides/mortalidad , Glándula Tiroides/fisiopatología , Tirotropina/sangre , Tiroxina/sangre , Resultado del Tratamiento , Tromboembolia Venosa/mortalidadRESUMEN
A group of family physicians in an outpatient clinic in Switzerland prospectively followed scientific literature for ten years. What to remember among the numerous articles retrieved and which paper really changed our practice? If many readings are quickly forgotten, some of them marked our minds and changed our habits. This article is a summary of our efforts to keep the essential tools in clinical practice.
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Medicina Familiar y Comunitaria/tendencias , Medicina Interna/tendencias , Antibacterianos/uso terapéutico , Ensayos Clínicos como Asunto , Quimioterapia/tendencias , Medicina Basada en la Evidencia , HumanosRESUMEN
We are a European academic group of family doctors and we propose a definition of flexibility in family medicine. A review of the literature shows that flexibility and complexity are emerging concepts in the field of family practice. The outcomes of a workshop at the WONCA-Europe congress in 2014 are discussed. The flexibility is a capability of the general practitioner to deal with complex clinical situations in a biomedical and societal changing world. Flexibility is framed by ethics. It could improve the quality of care, be useful against burnout and used in medical research. In conclusion, family medicine should adopt a specific definition of the flexibility describing its specificity, a useful and teachable capacity.
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Medicina Familiar y Comunitaria/organización & administración , Agotamiento Profesional/prevención & control , Humanos , Garantía de la Calidad de Atención de SaludRESUMEN
The Swiss Federal Office of Public Health's (FOPH) updated its recommendations on fat consumption in 2013. The report recommends that maximum 10% of the daily caloric intake should come from saturated fatty acids, and the total fat intake should account for 20-35%. There is no limitation to dietary cholesterol consumption. Recent studies have shown that replacing consumption of saturated fatty acids by unsaturated fatty acids is more beneficial in terms of cardiovascular prevention than a low fat diet. The purpose of this article is to review the FOPH recommendations on dietary fat as well as the current evidence about their cardiovascular benefit, and to provide a translation of these scientific recommendations into clinical advice.
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Grasas de la Dieta/administración & dosificación , Necesidades Nutricionales , Enfermedades Cardiovasculares/prevención & control , Ácidos Grasos/administración & dosificación , Humanos , Salud Pública , SuizaRESUMEN
Cardiac rehabilitation is associated with a reduced risk of recurrence and mortality after an acute coronary syndrome. Cardiac rehabilitation is a multidisciplinary approach which starts during the acute hospital phase, then followed by a four to six weeks home-based or stationary program, in order to maintain long-term lifestyle changes. Despite the important health benefits of cardiac rehabilitation and its cost-effectiveness, only half of the patients in Europe will achieve a cardiovascular prevention program after an acute coronary syndrome. In the French part of Switzerland, one explanation for this low adherence might be the lack of both stationary and home-based program facilities.
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Infarto del Miocardio/rehabilitación , Accesibilidad a los Servicios de Salud , Humanos , Cooperación del Paciente , Prevención Secundaria , SuizaRESUMEN
OBJECTIVE: Whether or not a high risk of falls increases the risk of bleeding in patients receiving anticoagulants remains a matter of debate. METHODS: We conducted a prospective cohort study involving 991 patients ≥ 65 years of age who received anticoagulants for acute venous thromboembolism (VTE) at nine Swiss hospitals between September 2009 and September 2012. The study outcomes were as follows: the time to a first major episode of bleeding; and clinically relevant nonmajor bleeding. We determined the associations between the risk of falls and the time to a first episode of bleeding using competing risk regression, accounting for death as a competing event. We adjusted for known bleeding risk factors and anticoagulation as a time-varying covariate. RESULTS: Four hundred fifty-eight of 991 patients (46%) were at high risk of falls. The mean duration of follow-up was 16.7 months. Patients at high risk of falls had a higher incidence of major bleeding (9.6 vs. 6.6 events/100 patient-years; P = 0.05) and a significantly higher incidence of clinically relevant nonmajor bleeding (16.7 vs. 8.3 events/100 patient-years; P < 0.001) than patients at low risk of falls. After adjustment, a high risk of falls was associated with clinically relevant nonmajor bleeding [subhazard ratio (SHR) = 1.74, 95% confidence interval (CI) = 1.23-2.46], but not with major bleeding (SHR = 1.24, 95% CI = 0.83-1.86). CONCLUSION: In elderly patients who receive anticoagulants because of VTE, a high risk of falls is significantly associated with clinically relevant nonmajor bleeding, but not with major bleeding. Whether or not a high risk of falls is a reason against providing anticoagulation beyond 3 months should be based on patient preferences and the risk of VTE recurrence.
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Accidentes por Caídas , Anticoagulantes/efectos adversos , Hemorragia/epidemiología , Tromboembolia Venosa/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Femenino , Hemorragia/etiología , Humanos , Masculino , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND AND OBJECTIVE: Restless legs syndrome (RLS) is a frequent condition with a prevalence of 5-15% in the general population. Clinical and genetic observations have shown that iron deficiency, highly prevalent among blood donors, can be related to RLS. The objective of this study was to assess the prevalence of RLS in female blood donors 1 week after blood donation. METHODS: One week after blood donation, 291 female blood donors, aged <50 years, self-responded to all four RLS questions defined by the 1995 International RLS study group. Blood donation rate, fatigue, aerobic capacity, menstruation, mood disorder and quality of life were also assessed along with haemoglobin and ferritin blood concentrations. RESULTS: Prevalence of RLS in female blood donors 1 week after blood donation was 6·9% (CI 95% 4·2-10·4%). Female blood donors with RLS had a higher prevalence of hyper-menorrhaea (P = 0·033) and were significantly more tired (P = 0·001). We observed no associations between RLS and number of previous donations (P = 0·409), aerobic capacity (P = 0·476), mood disorder (P = 0·169), quality of life (P = 0·356), haemoglobin (P = 0·087), and serum ferritin level (P = 0·446). CONCLUSION: Restless legs syndrome prevalence in female blood donors is not as important as described in some other studies, which could reassure blood donors. The prevalence of hypermenorrhaea and fatigue is higher in RLS blood donors. Therefore, screening for fatigue and hypermenorrhaea could be considered as these symptoms are associated with RLS in female blood donors.
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Donantes de Sangre/estadística & datos numéricos , Síndrome de las Piernas Inquietas/epidemiología , Adulto , Análisis de Varianza , Anemia Ferropénica/etiología , Anemia Ferropénica/terapia , Femenino , Ferritinas/sangre , Hemoglobinas/metabolismo , Humanos , Persona de Mediana Edad , PrevalenciaRESUMEN
Iron deficiency is generally investigated when faced with anemia, or with symptoms that could be related to iron deficiency without anemia. This simple disorder is easy to treat, provided that the diagnosis is correct. Several biological tests are available, but their interpretation is oftentimes problematic. Pre-analytical factors can interfere with measurements, normal values can change depending on suppliers, and, above all, results from different markers can be contradictory in some clinical situations. The aim of this article is to evaluate how the evolution of scientific knowledge and clinical trials can contribute to a better understanding and greater reliability in the diagnosis of iron deficiency.
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Anemia Ferropénica/diagnóstico , Ferritinas/sangre , Hierro/sangre , Oligoelementos/sangre , Transferrinas/sangre , Alelos , Anemia Ferropénica/sangre , Anemia Ferropénica/genética , Antibacterianos/sangre , Péptidos Catiónicos Antimicrobianos/sangre , Biomarcadores/sangre , Ensayos Clínicos como Asunto , Diagnóstico Diferencial , Recuento de Eritrocitos , Índices de Eritrocitos , Hematócrito , Hemoglobinas/metabolismo , Hepcidinas , Humanos , Mutación , Recuento de Plaquetas , Polimorfismo de Nucleótido Simple , Valor Predictivo de las Pruebas , Ensayos Clínicos Controlados Aleatorios como Asunto , Receptores de Transferrina/sangre , Receptores de Transferrina/genética , Sensibilidad y EspecificidadRESUMEN
Polymorbidity affects an increasing number of patients of all ages as demonstrated by a recent epidemiological study and represents a real challenge for the organization of health care. Appropriate management of polymorbid patients requires an interdisciplinary approach associating generalist and specialist physicians, but also nurses, other health professionals and social workers. An improvement in transition care between the community and the hospital is necessary in both directions. Prioritizing the treatment objectives is essential to allow patient adherence and avoid cumulative drug interactions and adverse effects. Those objectives are difficult to attain in the context of our present health care organization. This paper attempts to identify the difficulties involved in caring for polymorbid patients and propose ways to improve it.
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Enfermedad Crónica/epidemiología , Grupo de Atención al Paciente/organización & administración , Comorbilidad , Manejo de la Enfermedad , Humanos , SuizaRESUMEN
BACKGROUND: The Outpatient Bleeding Risk Index (OBRI) and the Kuijer, RIETE and Kearon scores are clinical prognostic scores for bleeding in patients receiving oral anticoagulants for venous thromboembolism (VTE). We prospectively compared the performance of these scores in elderly patients with VTE. METHODS: In a prospective multicenter Swiss cohort study, we studied 663 patients aged ≥ 65 years with acute VTE. The outcome was a first major bleeding at 90 days. We classified patients into three categories of bleeding risk (low, intermediate and high) according to each score and dichotomized patients as high vs. low or intermediate risk. We calculated the area under the receiver-operating characteristic (ROC) curve, positive predictive values and likelihood ratios for each score. RESULTS: Overall, 28 out of 663 patients (4.2%, 95% confidence interval [CI] 2.8-6.0%) had a first major bleeding within 90 days. According to different scores, the rate of major bleeding varied from 1.9% to 2.1% in low-risk, from 4.2% to 5.0% in intermediate-risk and from 3.1% to 6.6% in high-risk patients. The discriminative power of the scores was poor to moderate, with areas under the ROC curve ranging from 0.49 to 0.60 (P = 0.21). The positive predictive values and positive likelihood ratios were low and varied from 3.1% to 6.6% and from 0.72 to 1.59, respectively. CONCLUSION: In elderly patients with VTE, existing bleeding risk scores do not have sufficient accuracy and power to discriminate between patients with VTE who are at a high risk of short-term major bleeding and those who are not.
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Anticoagulantes/efectos adversos , Técnicas de Apoyo para la Decisión , Hemorragia/inducido químicamente , Tromboembolia Venosa/tratamiento farmacológico , Enfermedad Aguda , Factores de Edad , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Análisis Discriminante , Monitoreo de Drogas/métodos , Femenino , Humanos , Relación Normalizada Internacional , Estimación de Kaplan-Meier , Funciones de Verosimilitud , Modelos Logísticos , Masculino , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Suiza , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Atención a la Salud/historia , Publicaciones Periódicas como Asunto/historia , Atención Primaria de Salud/organización & administración , Aniversarios y Eventos Especiales , Historia del Siglo XIX , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Atención Primaria de Salud/tendencias , SuizaRESUMEN
This article summarizes the different stages of research for the development of medical interventions and their specific characteristics in terms of design, population, resources, importance of results and scientific interest. The emphasis is focused on the two final stages of development, the effectiveness and the impact. An example from our own experience is given to illustrate the reduction of the effect of an intervention against malaria in young children at different stages of the development of the intervention, and the parallel decrease of the recognition by the scientific community of the importance of these results.
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Investigación Biomédica/métodos , Ensayos Clínicos como Asunto/métodos , Malaria/tratamiento farmacológico , Antimaláricos/uso terapéutico , Niño , HumanosRESUMEN
Professionalisation of emergency medicine and triage before most of emergency consultations led to a major reduction in exposure of general practitionners (GP) to vital emergencies, which participates in reduction of their aptitudes to manage such emergencies. The risk for a GP to face a vital emergency is weak nowaday, but did not totaly disappear. Therefore, it seems important for the GPs to maintain the skills required to manage these emergencies properly. These skills would be capacity in recognizing symptoms and signs of alarm (red flags), applying life support, and sorting the patients correctly. These skills will be all the more important in the future, while the role of the GP could be reinforced in response to requirement of increased efficiency.
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Competencia Clínica , Medicina de Emergencia/organización & administración , Médicos Generales/organización & administración , Servicios Médicos de Urgencia/organización & administración , Medicina de Emergencia/educación , Médicos Generales/educación , Médicos Generales/normas , HumanosRESUMEN
Primary care medicine is first in line to meet the necessary changes in our health care system. Innovations in this field pursue three types of objectives: accessibility, quality and continuity of care. The Department of ambulatory care and community medicine of the University of Lausanne (Policlinique médicale universitaire) is committed to this path, emphasizing interprofessional collaboration. The doctor, nurse and medical assistant coordinate their activities to contribute efficiently to meet the needs of patients today and tomorrow. This paper also addresses how our department, as a public and academic institution, might play a major role as a health care network actor. A master degree dissertation in health management has started to identify the critical success factors and the strategic core competencies needed to achieve this development.
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Atención Ambulatoria/organización & administración , Atención a la Salud/organización & administración , Atención Primaria de Salud/organización & administración , Atención Ambulatoria/normas , Continuidad de la Atención al Paciente/normas , Conducta Cooperativa , Atención a la Salud/normas , Accesibilidad a los Servicios de Salud , Necesidades y Demandas de Servicios de Salud , Humanos , Relaciones Interprofesionales , Atención Primaria de Salud/normas , Calidad de la Atención de Salud , SuizaRESUMEN
Should we treat iron deficiency without anemia? The simple fact that the question can be formulated already leads to controversies. During the past years, the development of a new formulation of intravenous iron has helped fuel the controversy. What is the situation in 2012? This article gives a practical point of view on the actual situation and provides indications on the use of new intravenous medications.
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Diseño de Fármacos , Compuestos de Hierro/uso terapéutico , Deficiencias de Hierro , Anemia Ferropénica/tratamiento farmacológico , Humanos , Infusiones Intravenosas , Hierro/administración & dosificación , Compuestos de Hierro/administración & dosificaciónRESUMEN
Lung cancer screening has been the focus of intense interest since the publication in 2011 of the NLST trial (National Lung Screening Trial) showing a mortality reduction in smokers undergoing 3-year screening by chest computed tomography. Although these data appear promising, many issues remain to be resolved, such as high rate of false positive cases, risk of overdiagnosis, optimal intervals between screens, duration of the screening process, feasibility, and cost. Structured screening programs appear crucial to guarantee patient information, technical quality, and multidisciplinary management. Despite these uncertainties, several guidelines already state that screening should be performed in patients at risk, whereas investigators stress that more data are needed. How should the primary care physician deal with individual patients requests? This review provides some clues on this complex issue.
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Neoplasias Pulmonares/diagnóstico , Tamizaje Masivo/métodos , Tomografía Computarizada por Rayos X/métodos , Reacciones Falso Positivas , Humanos , Neoplasias Pulmonares/patología , Médicos de Atención Primaria , Guías de Práctica Clínica como Asunto , Factores de RiesgoRESUMEN
The Framework Convention on Tobacco Control (FCTC) isa global and comprehensive legal framework for reducing demand for tobacco (e.g. price measures; ban on smoking in enclosed places; contents of tobacco products; packaging and labeling; advertising, promotion and sponsorship; liability, tobacco cessation, etc.) and supply (e.g. illicit trade; sales to/by minors, etc.). Adopted in 2003, the FCTC has been ratified by 174 countries so far. Switzerland has signed the treaty in 2004 but ratification will necessitate the implementation of stronger tobacco control measures at the national level. The FCTC is a priority of any strategy to reduce noncommunicable diseases in populations. Broad implementation of the FCTC has the potential to prevent a substantial proportion of the billion of tobacco-related deaths expected in the 21st century.