[2014 update in general internal medicine]. / Médecine interne générale ambulatoire.

This article comments 9 original publications from year 2014 of interest for the primary care physician in the outpatient setting. The impact of diet such as nut consumption on health outcomes and mortality is developped, and the importance of dietary changes while taking statins is reminded. Red flags in low back pain and their predictive value are re-evaluated. An association between benzodiazepine use and Alzheimer dementia seems probable. New treatments for alcohol abuse, restless legs syndrome and type 2 diabetes are discussed. Finally, ß-bloquers' effects on respiratory function in asthmatic patients are beeing reexamined.

A comparison of the spatial dependence of body mass index among adults and children in a Swiss general population.

BACKGROUND: Body mass index (BMI) may cluster in space among adults and be spatially dependent. Whether BMI clusters among children and how age-specific BMI clusters are related remains unknown. We aimed to identify and compare the spatial dependence of BMI in adults and children in a Swiss general population, taking into account the area's income level. METHODS: Geo-referenced data from the Bus Santé study (adults, n=6663) and Geneva School Health Service (children, n=3601) were used. We implemented global (Moran's I) and local (local indicators of spatial association (LISA)) indices of spatial autocorrelation to investigate the spatial dependence of BMI in adults (35-74 years) and children (6-7 years). Weight and height were measured using standardized procedures. Five spatial autocorrelation classes (LISA clusters) were defined including the high-high BMI class (high BMI participant's BMI value correlated with high BMI-neighbors' mean BMI values). The spatial distributions of clusters were compared between adults and children with and without adjustment for area's income level. RESULTS: In both adults and children, BMI was clearly not distributed at random across the State of Geneva. Both adults' and children's BMIs were associated with the mean BMI of their neighborhood. We found that the clusters of higher BMI in adults and children are located in close, yet different, areas of the state. Significant clusters of high versus low BMIs were clearly identified in both adults and children. Area's income level was associated with children's BMI clusters. CONCLUSIONS: BMI clusters show a specific spatial dependence in adults and children from the general population. Using a fine-scale spatial analytic approach, we identified life course-specific clusters that could guide tailored interventions.

[How should we organize health care for multimorbidity patients?]. / Quelle organisation des soins pour le patient polymorbide?

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.

[What is new in ambulatory internal medicine in 2012?]. / Nouveautés 2012 en médecine interne générale ambulatoire.

Ten articles published in 2012 and of interest for the practice of ambulatory general internal medicine are reviewed in this paper. Topics of public health issues, such as the association between sleep disorders and prediabetes, the association between prediabetes and stroke, and the harmful effects of prolonged sitting are tackled. Other focuses include hepatitis C screening, abdominal aortic aneurysm screening and prostatic cancer screening. Therapeutic aspects are reviewed, such as the management of nongonococcal urethritis, the treatment of iron deficiency without anemia and the substitution of subclinical hypothyroidism. Finally a new study about aspirin and cancer prevention is discussed.

High prevalence of forgoing healthcare for economic reasons in Switzerland: a population-based study in a region with universal health insurance coverage.

OBJECTIVE: To investigate the determinants and the 4-year evolution of the forgoing of healthcare for economic reasons in Switzerland. METHOD: Population-based survey (2007-2010) of a representative sample aged 35-74 years in the Canton of Geneva, Switzerland. Healthcare forgone, socioeconomic and insurance status, marital status, and presence of dependent children were assessed using standardized methods. RESULTS: A total of 2601 subjects were included in the analyses. Of the subjects, 13.8% (358/2601) reported having forgone healthcare for economic reasons, with the percentage varying from 3.7% in the group with a monthly income ≥ 13,000 CHF (1CHF ≈ 1$) to 30.9% in the group with a monthly income <3000 CHF. In subjects with a monthly income <3000 CHF, the percentage who had forgone healthcare increased from 22.5% in 2007/8 to 34.7% in 2010 (P trend=0.2). Forgoing healthcare for economic reasons was associated with lower income, female gender, smoking status, lower job position, having dependent children, being divorced and single, paying a higher deductible, and receiving a premium subsidy. CONCLUSION: In a Swiss region with universal health insurance coverage, the reported prevalence of forgoing healthcare for economic reasons was high and greatly dependent on socioeconomic factors. Our data suggested an increasing trend among participants with the lowest income.

[Clinical itinerary for heart failure: a program designed by primary care practitioners in Geneva]. / Itinéraire clinique pour l'insuffisance cardiaque: un programme conçu par des médecins de premier recours genevois.

Episodes of heart failure impact on patients' quality of life as well as their morbidity and mortality. This article describes a series of interventions designed by a group of primary care practitioners in Geneva. Some interventions aim to improve patients' autonomy in identifying the first signs of heart failure to act immediately. Others focus on patients' motivation to adopt appropriate behaviours (physical activity, etc.). And finally others have the objective to improve coordination between ambulatory and hospital care, as well as the transmission of clinical information. The implementation of these interventions highlights the need for individualised objectives of care in complex cases where patients have several co-morbidities and/or complicated social situations. In these situations an interdisciplinary approach is also essential.

[What was new in ambulatory general internal medicine in 2011?]. / Nouveautés 2011 en médecine interne générale ambulatoire.

This review of articles published in 2011 covers a large spectrum of topics that are of interest for the practice of general internal medicine and of primary care. Authors discuss public health issues, such as sleep disorders and their relationship with subsequent weight disorders, and the benefits of commercial weight reduction programs. Clinical topics, such as the management of victims of sexual violence and screening strategies for lung cancer, streptococcal pharyngitis, functional bowel disorders and hypertension in ambulatory settings are also reviewed. Besides, authors cover therapeutic issues, such as the treatment of hand arthritis with chondroitin sulfate and the management of plantar warts with salicylic acids and cryotherapy.

[Urban health: the irremediable urbanization of life and medicine]. / Urban health: l'irrémédiable urbanisation de la vie et de la médecine.

Since 2007, the number of people living in cities exceeds that of rural areas. Thus, cities and their organizations have a major influence on all spheres of human life, especially health. This influence may generate inequality, suffering and disease, but also represent an opportunity for health and well-being. This paper introduces the concept of urban health, particularly in terms of primary care medicine and presents solutions that encompass a wide field (politics, urban planning, social inequality, education). Improving urban health requires collaboration of medical with non-medical actors, in order to become of development (re-) urban structure and promotes the health of all.

PP108. Post-partum evaluation of the blood pressure and the kidney function in pre-eclamptic women.

INTRODUCTION: Recent data have shown that preeclampsia is not just a disease of pregnancy that resolves with delivery. Preeclampsia may be considered a 'risk marker' for later-life diseases, including cardiovascular and renal diseases and the metabolic syndrome. OBJECTIVES: We aimed a longitudinal prospective study to analyze the renal abnormalities in the post-partum. METHODS: We studied 127 post-preeclamptic women at 6 weeks post-partum. Twenty-four hour urine collection, ambulatory blood pressure and renal function were evaluated. RESULTS: The mean age (±SD) was 32±6years, BMI was 29.4±5.7, the race distribution was Caucasian 69%, Hispanic 14%, Black 12% and Orient 5%. Ten % were active smokers, 10% have been suffering from gestational diabetes. The mean duration of the pregnancy was 36 weeks 3/7±4. Our results show that the prevalence of hypertension defined by office blood pressure ⩾140/90 mmHg or ongoing antihypertensive treatment was 35%. The daytime ambulatory blood pressure (ABPM) was 122±16/85±11 mmHg, heart rate 84±8, and 111±20/75±11 mmHg at nighttime.Sixteen % had a daytime ABPM ⩾135/85mmHg corresponding to the definition of ambulatory hypertension. Ultrasensitive CRP was 4.9±5.1mg/ml, of them 31% had a frank elevation of the CRP >4. The glomerular filtration rate evaluated by the Gault-Cockroft equation showed a hyperfiltration with a mean value of 150±42ml/min. Eleven% had a decreased GFR < 90 ml/min. Microalbumine/creatinine ratio measured in the urine spot was 7 ±4. Mean microalbuminuria was 225±529mg/d measured on the 24h urine collection.Urine 24h Na excretion rate was 204±48 mmol/d. CONCLUSION: In conclusion, after the post-partum period, women having suffered from a pre-eclampsia display many cardiovascular risk factors with a high prevalence of hypertension, microalbuminuria, renal hyperfiltration and elevated CRP. These women should be carefully screened, and sub-groups with the higher risk have to be targeted for prevention and treatment, and close follow-up.

[When D-dimers within normal limits do not equate to normal D-dimers]. / Lorsque des D-dimères dans la norme ne sont pas égaux à des D-dimères normaux.

Pulmonary embolism is a difficult diagnosis that may be missed because of an aspecific clinical presentation. Being the most accurate to confirm or exclude the disease is a matter of concern, as effective treatment exists and a possibly fatal outcome without it. Scores and guidelines can help us. However, they cannot replace clinical sense. What are the options when laboratory results put us on the wrong track, such as in a patient with a clinical presentation suggestive of a pulmonary embolism, but whose D-dimers are within the normal range?

Metabolic syndrome and short-term and long-term heart rate variability in elderly free of clinical cardiovascular disease: the PROOF study.

OBJECTIVE: Autonomic nervous system (ANS) activity decrease has been associated with a higher risk of sudden cardiovascular and cerebrovascular disease. Thus, we explored the relationship between ANS control of the cardiovascular system and metabolic syndrome. METHODS: We analyzed the relationship with both short-term and long-term heart rate variability (HRV) and metabolic syndrome in the cross-sectional PROgnostic indicator OF cardiovascular and cerebrovascular events (PROOF) cohort study of 1,011 elderly subjects recruited amongst the inhabitants of the city of Saint Etienne, France, aged 65.6 ± 0.8 years at the inclusion date. Physical examination included measurements of height, weight, systolic and diastolic blood pressure, waist circumference, and biological parameters. HRV variables were measured over 5-min, nighttime, and 24-h periods using Holter monitoring. RESULTS: After adjustment for current type 2 diabetes, depression, and smoking, we found that metabolic syndrome status, high-density lipoprotein cholesterol (HDL-C), and waist circumference were significantly (p < 0.05) associated with total power, very-low frequency, low-frequency/high-frequency (LF/HF) ratio, and normalized LF. HDL-C and metabolic syndrome status were significantly associated with decreased long-term HRV variables. Both nighttime and 24-h HRV showed closer associations with metabolic syndrome than did short-term HRV (5-min). Metabolic syndrome severity was associated with a decrease in both the long-term and short-term HRV variables. CONCLUSIONS: ANS control alteration of the cardiovascular system was more pronounced when evaluated by long-term than short-term HRV recordings, particularly in women.

Undocumented migrants in Switzerland: geographical origin versus legal status as risk factor for tuberculosis.

Undocumented migrants, meaning migrants without a legal residency permit, come to Geneva from countries with high tuberculosis (TB) incidence. We estimate here whether being undocumented is a determinant of TB, independently of origin. Cross-sectional study including undocumented migrants in a TB screening program in 2002; results were compared to 12,904 age and frequency matched participants in a general TB screening program conducted at various workplaces in Geneva, Switzerland from 1992 to 2002. A total of 206 undocumented migrants (36% male, 64% female, mean age 37.8 years (SD 11.8), 82.5% from Latin America) participated in the TB screening program. Compared to legal residents, undocumented migrants had an adjusted OR for TB-related fibrotic signs of 1.7 (95% CI 0.8;3.7). The OR of TB-related fibrotic signs for Latin American (vs. other) origin was 2.7 (95% CI 1.6;4.7) among legal residents and 5.5 (95% CI 2.8;10.8) among undocumented migrants. Chest X-ray screening identified a higher proportion of TB-related fibrotic signs among Latin Americans, independently of their residency status.

[Interpretation of 24h ambulatory blood pressure monitoring by primary care physicians]. / Lecture de la mesure ambulatoire de la pression artérielle (MAPA) par le médecin de premier recours.

Comparatively to office blood pressure measurement, 24h ambulatory blood pressure monitoring (ABPM) provides a more accurate evaluation of the patient's blood pressure and of the burden of the arterial pressure in real life. This measurement is better correlated with cardiovascular risk, with hypertension-related organ damage and its changes with treatment, than does office blood pressure. It allows diagnosis of white coat and masked hypertension, and of alteration in blood pressure's circadian rhythm. This article aims to summarise ABPM's indications, to point out its advantages and give some key practical messages to realize and properly interpret this exam.