ABSTRACT
The year 2016 was rich in significant advances in all areas of internal medicine. Many of them have an impact on our daily practice in general internal medicine. From the treatment of NSTEMI in population older than 80, to new sepsis and septic shock criteria to antidotes of new oral anticoagulants, this selection offers to the readers a brief overview of the major advances. The chief residents in the Service of internal medicine of the Lausanne University hospital are pleased to share their readings.
L'année 2016 a été riche en avancées importantes dans tous les domaines de la médecine. L'impact de ces avancées sera palpable dans notre pratique en médecine interne générale. De la prise en charge du NSTEMI (infarctus myocardique sans élévation ST) dans la population des plus de 80 ans, aux nouveaux critères du sepsis et du choc septique, aux antidotes des nouveaux anticoagulants oraux en passant par la déprescription médicamenteuse, les nouveautés dans la littérature ont été abondantes. Chaque année, les chefs de clinique du Service de médecine interne du Centre hospitalier universitaire vaudois (CHUV) se réunissent pour partager leurs lectures. Onze de leurs choix sont ici revus et commentés.
Subject(s)
Hospitals, University/trends , Internal Medicine/trends , Internship and Residency/trends , General Practice/methods , General Practice/trends , Humans , Internal Medicine/methods , Internship and Residency/methodsABSTRACT
BACKGROUND: Granulicatella and Abiotrophia spp. are difficult to detect due to their complex nutritional requirements. Infections with these organisms are associated with high treatment failure rates. We report the first implant-associated infection caused by Granulicatella para-adiacens, which was cured with anti-microbial treatment consisting of anti-biofilm-active rifampin and debridement, exchange of mobile parts and retention of the prosthesis. CASE PRESENTATION: Patient with a history of left hip arthroplasty presented with acute onset of fever, pain and limited range of motion of the left hip. Arthrocentesis of the affected joint yielded purulent fluid and exchange of mobile parts of the prosthesis, but retention of fixed components was performed. Granulicatella para-adiacens grew from preoperative and intraoperative cultures, including sonication fluid of the removed implant. The transesophageal echocardiography showed a vegetation on the mitral valve; the orthopantogram demonstrated a periapical dental abscess. The patient was treated with intravenous penicillin G and gentamicin for 4 weeks, followed by levofloxacin and rifampin for additional 2 months. At discharge and at follow-up 1, 2 and 5 years later, the patient was noted to have a functional, pain-free, and radiologically stable hip prosthesis and the serum C-reactive protein was normal. CONCLUSIONS: Although considered a difficult-to-treat organism, we report a successful treatment of the Granulicatella hip prosthesis infection with prosthesis retention and a prolonged antibiofilm therapy including rifampin. The periapical dental abscess is considered the primary focus of hematogenously infected hip prosthesis, underlining the importance treatment of periodontitis prior to arthroplasty and of proper oral hygiene for prevention of hematogenous infection after arthroplasty.
Subject(s)
Arthroplasty, Replacement, Hip/adverse effects , Gram-Positive Bacterial Infections/diagnostic imaging , Gram-Positive Bacterial Infections/therapy , Prosthesis Retention , Prosthesis-Related Infections/diagnostic imaging , Prosthesis-Related Infections/therapy , Abiotrophia , Aged , Anti-Bacterial Agents/therapeutic use , Debridement/methods , Humans , Male , Prosthesis Retention/methods , Treatment OutcomeABSTRACT
In 2015 a computer-based system of incident reporting was implemented in our hospital. Since then our department has successfully managed this reporting process with a constant interest shown by our staff (1 report / 100 days of hospitalization which equals nearly 2 reports a day). All incidents are analyzed. Some are then chosen for their impact and improvement potential and presented to hospital staff at monthly morbidity and mortality (M&M) conferences or published as clinical cases. This puts emphasis on the reporting process and on suggested practical changes. The current challenge is to transform these ideas into daily improvements and to find the necessary resources to report and analyze the more complex incidents.
Introduite en 2015, la gestion des événements critiques et indésirables recueillis par un système informatisé (application informatique RECI) se poursuit dans notre service, avec un intérêt constant des collaborateurs (1 événement / 100 jours d'hospitalisation, soit presque 2 événements / jour). Tous les événements sont analysés. Quelques-uns, choisis selon leur impact et leur potentiel d'amélioration pratique, sont transmis aux collaborateurs sous forme de colloques morbidité-mortalité (M&M) ou de vignettes cliniques. Ceci permet de valoriser les signalements et de proposer des modifications pratiques. Le défi actuel consiste à transformer ces propositions en actions concrètes et à trouver les ressources nécessaires pour la déclaration et l'analyse des situations les plus compliquées.
Subject(s)
Hospital Information Systems , Medical Errors/statistics & numerical data , Risk Management/methods , Hospitals , Humans , Medical Errors/prevention & control , Personnel, HospitalABSTRACT
BACKGROUND: According to Swiss legislation, do not attempt cardiopulmonary resuscitation (DNACPR) order can be made at any time by patients only, unless the resuscitation is considered as futile, based on the doctors' evaluation. Little is known about how this decision is made, and which are the factors influencing this decision. METHODS: Observational, cross-sectional study was conducted between March and May 2013 on 194 patients hospitalized in the general internal medicine ward of a Swiss hospital. The associations between patients' DNACPR orders and gender, age, marital status, nationality, religion, number and type of comorbidities were assessed. RESULTS: 102 patients (53%) had a DNACPR order: 27% issued by the patient him/herself, 12% by his/her relatives and 61% by the medical team. Patients with a DNACPR order were significantly older: 80.7 ± 10.8 vs. 67.5 ± 15.1 years in the "with" and "without" DNACPR order group, respectively, p < 0.001. Oncologic disease was associated with a DNACPR order issued by the medical team (37.5% vs. 16.9% in the "with" and "without" DNACPR order group, respectively, p < 0.05). Being protestant was associated with a DNACPR order issued by the patient (57.9% vs. 25.9% in the "with" and "without" DNACPR order group, respectively p < 0.01). CONCLUSIONS: Over half of the patients admitted to a general internal medicine ward had a DNACPR order issued within the first 72 h of hospitalization. Older age and oncologic disease were associated with a DNACPR decision by the medical team, while protestant religion was associated with a DNACPR decision by the patient.