Associations between primary care practice type and patient-reported access.

BACKGROUND: We recently defined a global typology of primary care (PC) in Switzerland using a mixed inductive/deductive approach to construct latent, composite variables that summarize variance between practices. Now we explore associations between the primary variable that describes the comprehensiveness of services and patient-perceived access to PC in Switzerland. METHODS: Cross-sectional surveys were administered to physicians from the Swiss PC Active Monitoring (SPAM) network and their patients. The primary outcomes were patient responses to: "Was it easy to get the appointment?", "The opening hours are too restricted" and "In the past 12 months, did you postpone or abstain from a visit to this doctor or another GP when you needed one?" Multivariate, multilevel analyses with stepwise regression were used to assess associations between practice type (practices with a broader range of services have higher scores) and perceived access, controlling for patient characteristics. RESULTS: One hundred and ninety nine of 200 PC physicians in the network completed the questionnaire. Of 2628 patients approached after a physician visit, 1791 accepted (participation = 76%), with 9 patients at each practice. No association was observed between comprehensiveness of services and difficulty getting an appointment. When controlling for patient factors, there was a weak association between higher scores for comprehensiveness of services and patients reporting that the opening hours are too restricted (p = 0.05), though this was no longer significant after controlling for language area. Greater comprehensiveness of services was associated with fewer patients needing to postpone visits (OR 0.93, 95%CI 0.88-0.99, p = 0.03). CONCLUSIONS: Though fewer patients report needing to postpone visits at practices with more comprehensive offering of services, there is limited evidence of associations between patient-reported access and a global typology of Swiss primary care.

[Ten years of literature review in general internal medicine--a first assessment]. / Dix ans de revue de la littérature en médecine interne générale--un premier bilan.

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.

[Acute schistosomiasis: lessons learned from a cohort of 42 exposed travelers]. / Schistosomiase aiguë au retour de voyage. Enseignements tirés d'une cohorte de 42 voyageurs exposés.

Acute schistosomiasis is a regularly encountered disease in travelers. Because of the temporal delay, its unspecific presentation and the spontaneous resolution, acute schistosomiasis can easily remain unrecognized by physicians who are not familiar with tropical pathologies. In December 2011, a female traveler was admitted to the hospital with undetermined fever after having returned from Madagascar where she bathed in fresh water. Acute schistosomiasis was diagnosed and infection was suspected among other travelers of her group. Seroconversion was confirmed among 78% of participants. This article intends to clarify the preventive and diagnostic strategies based on the lessons learned from this cluster of 42 travelers exposed to schistosomiasis.

[Vulnerable older patients in primary care how to identify them? Which ressources to mobilize? ]. / Patients âgées vulnérables au cabinet: comment les identifier et quelles ressources mobiliser?

Trust is essential to foster and preserve a long-term relationship between primary care physicians and their patients suffering from chronic diseases. However, this relation remains insufficient to successfully manage more complex situations, such as those of older patients with multiple diseases and disability. For the primary care physician, a significant limitation is the time required to plan and coordinate interventions supplied by different health and social care providers. This article describes a structured approach to support primary care physicians in this difficult task and help them to identify vulnerable older patients requiring to mobilize and coordinate health and social care resources. Current and future resources available to family physicians to complete this challenging task are further described.

[Efficacy is good, impact is great]. / L'efficacité c'est bien, l'impact c'est top!

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.

Infection prevention and control measures in practices of the Swiss sentinel network during seasonal influenza epidemics.

BACKGROUND: There are limited data on the transmission of influenza in the context of primary care practices, despite the fact that a significant proportion of the population consult their primary care physician for an influenza-like illness every year. AIM: To describe the use of influenza prevention and control methods in private practices of the Swiss sentinel network. METHODS: This online cross-sectional survey collected data about infection prevention and control measures in the 166 private practices of the Swiss sentinel surveillance network during the 2018-2019 influenza season. Questions pertained to the practice setting, infection prevention and control recommendations, influenza vaccination status of the physicians and their staff, adhesion to hand hygiene, and mask wearing. FINDINGS: Among the 122 practices that answered (response rate 73.5%), 90.2% of the responding physicians had been vaccinated themselves, and 46.7% (56/120) estimated that their staff vaccination coverage was >60%, although it was offered to employees in all practices. Most practices (N=68, 55.7%) had no specific recommendations for their staff concerning mask wearing. Most physicians reported washing or disinfecting their hands before examining a patient (N=91, 74.6%), after examination (N=110, 90.2%) and before a medical procedure (N=112, 91.8%). However, this rate was lower for arrival at the practice (N=78, 63.9%) and leaving the practice (N=83, 68.0%). CONCLUSION: Most physicians in the Swiss sentinel surveillance network have been vaccinated themselves. However, the vaccination rates among their staff are low, despite vaccine availability. Hand hygiene measures were also suboptimal. These results warrant further efforts to implement infection prevention and control measures in the ambulatory setting.

[Lymphoepithelial cysts of the parotid gland: a pathology linked to HIV infection]. / Les kystes lymphoépithéliaux de la glande parotide: une pathologie liée à l'infection VIH.

We review the various lesions encountered in the parotid gland associated with HIV infection and propose guidelines for the management of a chronic parotid swelling in this setting. Lymphoepithelial cysts is the main diagnosis of parotid masses presented by HIV positive patients. This benign condition is diagnosed on cytology and the treatment is usually conservative. Patients with a diagnosis of lymphoepithelial cysts should be tested for HIV.

[Pre- and post-exposure rabies prophylaxis: who to vaccinate and how?]. / Prophytaxie pre- et postexpositionnelle de la rage: qui vacciner et comment?

Switzerland is rabies free since 1996 (except bats). However sporadic cases in animals (imported dogs and local bats essentially) may occur from time to time. The disease is always fatal, which implies special attention when someone gets bitten or scratched by a wild or unknown animal, not only in a country with a high endemicity, but also in Switzerland. In this article, we will explore in detail the modalites of application of pre- and post-exposure prophylaxis following the publication of new recommandations from the Public Health authorites of Switzerland.

Kinetic study of the Ca2+ pump in erythrocytes from essential hypertensive patients.

Ca2+ pump kinetics were investigated in erythrocytes from 22 essential hypertensive patients and 20 normotensive controls (under initial-rate and steady-state conditions, using Sr2+ as a Ca2+ analogue). The mean value of the apparent dissociation constant for total internal Ca2+ (KCa) was slightly but significantly increased in the hypertensive population (73 +/- 7 versus 55 +/- 3 mumol/l cells, mean +/- s.e.m., P = 0.042 Mann-Whitney U-test). The statistical analysis showed that this was due to six essential hypertensives who exhibited a dissociation constant for Ca2+ that was higher than the upper 95% normal confidence limit (KCa = 116 +/- 7 mumol/l cells), and abnormally high maximal pump rates (7.7 +/- 0.6 versus 5.0 +/- 0.2 mmol/l cells per h in normotensives, P less than 0.001). In addition, the apparent dissociation constant for Ca2+ was inversely correlated with plasma renin activity, although the correlation was only borderline (P = 0.076). In the remaining 16 hypertensive patients, all kinetic parameters of the Ca2+ pump were within the normal range. Finally, a simultaneous study of Na+ transport kinetics suggested that erythrocyte Ca2+ and Na+ transport abnormalities were independent phenomena. Our results do not support the concept that primary hypertension (as a whole entity) is associated with a ubiquitous defect in the plasma membrane Ca2+ pump. However, in some essential hypertensive patients (about 25%) the erythrocyte Ca2+ pump exhibited an apparent decreased affinity for internal Ca2+. A similar defect in vascular smooth muscle may induce a delayed Ca2+ extrusion after the opening of Ca2+ channels, a disturbance likely to be translated into increased vascular reactivity.

High sensitivity of the Na+, K+-pump of human red blood cells to genins of cardiac glycosides.

1. Four different cardiac glycosides (ouabain, digitoxin, digoxin and gitoxin) and their corresponding genins were tested on Na+, K+-pump fluxes measured under steady-state and initial rate conditions (non equilibrium conditions) in human and rat erythrocytes and in mouse macrophages. 2. In human red cells, Na+, K+-pump fluxes exhibited up to 8 fold higher sensitivity to genins than to glycosides. In addition genins, but not the corresponding glycosides, exhibited double reactivity with regard to the erythrocyte Na+, K+-pump (with the exception of gitoxigenin). A weak reactivity component was similar to the one of the corresponding glycosides (IC50 of about 10(-6) M) and a high reactivity component exhibited IC50 values varying from 0.1 to 0.5 X 10(-6) M for digitoxigenin and ouabagenin respectively. 3. In contrast with human red cells, the initial rate of Na+, K+-pump fluxes in rat erythrocytes and mouse macrophages was less sensitive to genins than to the corresponding cardiac glycosides. 4. Dihydroouabain was 3, 10 and 75 times less active than ouabain in inhibiting the initial rate of Na+, K+-pump fluxes in human and rat erythrocytes and in mouse macrophages respectively. 5. In conclusion, Na+, K+-pump fluxes measured under initial rate conditions in human erythrocytes exhibit an unusually high sensitivity to genins of cardiac glycosides. This property probably results from the fast binding rate constants of genins and the slow association rates of glycosides to human red cells.

Opposite effects of cell growth factors and cicletanine sulfate on the sodium-independent [Cl-/HCO3-] exchange in cultured vascular smooth muscle.

Cicletanine sulfate was tested on bicarbonate-dependent pHi changes in cultured vascular smooth muscle (A10 line). Cicletanine sulfate exhibited double reactivity with regard to the cell alkalinization induced by bicarbonate uptake. The analysis of 11 concentration-response curves revealed a high reactivity component (IC50 approximately 3.5 x 10(-8) mol/L) and a weak reactivity component (IC50 approximately 4 x 10(-4) ml/L). Regarding the cell acidification induced by bicarbonate extrusion, cicletanine sulfate exhibited a single high reactivity component (IC50 = 5.9 +/- 2.9 x 10(-7) mol/l; mean +/- SD, n = 7). The high and weak reactivity sites were both sensitive to DIDS. Analysis of the data strongly suggested that the highly reactive site corresponds to a sodium-independent (Cl-/HCO3-] exchanger, which catalyzes net bicarbonate efflux, and the weak-reactivity site corresponds to the inwardly directed sodium-dependent [Cl-/HCO3-] exchanger. Three cell growth factors--epidermal growth factor, arginine-vasopressin, and insulin--were able to stimulate the sodium-independent [Cl-/HCO3-] exchanger in A10 cells. Finally, cicletanine sulfate (30 mumol/L) partially inhibited serum-dependent A10 cell growth. In conclusion, cicletanine sulfate and cell growth factors exert opposite effects (inhibition and stimulation, respectively) on the sodium-independent [Cl-/HCO3-] exchanger in cultured vascular smooth muscle. The effect of cicletanine sulfate on the sodium-independent [Cl-/HCO3-] exchanger may account for the ability of cicletanine to favorably alter vascular pathology in spontaneously hypertensive rat (SHR) models.

[Na+, K+, Cl-]-cotransport function and dysfunction in different forms of primary hypertension.

We investigated the effect of an increase in cell Na+ content on outward and inward unidirectional fluxes catalyzed by the [Na+, K+, Cl-]-cotransport system in human erythrocytes (incubated in Li-Rb media). Erythrocytes with low Na+ content exhibited an uncoupled K+ efflux. The increase in cell Na+ content resulted in a more marked stimulation of outward Na+, K+ than of inward Li+, Rb+ cotransport fluxes (with stoichiometries not very different from one-to-one). These results suggest that in human erythrocytes and in nonepithelial cells with small but outwardly directed electrochemical Cl- gradients, the [Na+, K+, Cl-]-cotransport system may behave as a "second pump" by using the extra energy supplied by an additional net [K+, Cl-] efflux. The [Na+, K+, Cl-]-cotransport system (of vascular cells and/or noradrenergic endings) may play two different roles in primary hypertension: (a) "defective second pump" in some essential hypertensive patients with decreased cotransport affinity for internal Na+ and (b) "compensatory second pump" in other forms of primary hypertension where abnormalities in the Na+, K+ pump or in other ion transport systems may predispose the cell to a defective extrusion of excess cell Na+ content.

Action of azelastine on intracellular Ca2+ in cultured airway smooth muscle.

Azelastine, a novel antiasthmatic/antiallergic agent, was tested for Ca2+ antagonistic properties in cultured rabbit airway smooth muscle, vascular smooth muscle and cardiocytes. In airway smooth muscle cells, the basal cytosolic free calcium content was 195 +/- 72 nM (mean +/- S.D., n = 18). These basal values were decreased by azelastine with an IC50 value of 1.1 +/- 0.3 x 10(-4) M. Endothelin-1 (10(-7) M) induced a rapid increase in free cytosolic calcium up to 806 +/- 314 nM, which returned to normal levels in 3-5 min. This was fully blocked by azelastine in a concentration-dependent manner, with an IC50 value of 6.7 +/- 2.9 x 10(-5) M. Moreover, azelastine fully blocked histamine-induced calcium mobilization (IC50 = 7 x 10(-5) M). In cultured vascular smooth muscle cells and cardiocytes, azelastine was unable to decrease the basal cytosolic free calcium content or inhibit agonist-induced calcium mobilization. Therefore, at therapeutic levels, a specific, mild inhibition of calcium mobilization in airway smooth muscle may be one component of the antiasthmatic action of azelastine.

Erythrocyte ion transport as indicator of sensitivity to antihypertensive drugs.

Multiple ion transport defects have been characterized in red blood cell membranes from essential hypertensive patients. These seem to be biochemical markers of at least three different types of essential hypertension. A first type is characterized by low pump, low cotransport fluxes in erythrocytes. These hypertensive patients are apparently identical to the salt-sensitive, low-renin hypertensive patients, in whom low pump and cotransport seem to result from the presence of circulating endogenous ouabain-like and bumetanide-like factors. These hypertensive patients are sensitive to diuretic drugs and to vaso-relaxants with salidiuretic activity, as expected from a reduction in plasma volume and circulating levels of endogenous ion transport inhibitors. A second type of essential hypertension is characterized by increased red cell Na+:Li+ countertransport and [Na+, K+, Cl-] cotransport. These hypertensive patients tend to present normal or high plasma renin activity, disorders in lipid metabolism, and left ventricular hypertrophy. Hypertensive patients belonging to this group seem to be resistant to diuretic drugs but sensitive to vasorelaxants. A third type of essential hypertension is characterized by both high membrane sodium leak and high [Na+, K+, Cl-] cotransport in erythrocytes. Hypertensive patients in this group are resistant to diuretics, angiotensin-converting enzyme (ACE) inhibitors, calcium antagonists, and centrally acting drugs.

[Antihypertensive effects of captopril, hydrochlorothiazide, alone or in combination, with different categories of essential hypertensive patients]. / Effet antihypertenseur du captopril, de l'hydrochlorothiazide, seuls ou en association, chez différentes catégories de malades hypertendus essentiels.

30 male essential hypertensive patients were submitted to a "washout" of 8 days and at D (0) divided into two groups receiving 25 mg/day of Hydrochlorothiazide or 50 mg/day of Captopril. At D (45) the treatment was crossed, at D (90) all the patients received both drugs and at D (135) the treatment was stopped. According to the antihypertensive response, the patients were divided into: (i) R: responders, PAS (systolic arterial pressure) less than or equal to 140 mmHg and PAD (diastolic) less than or equal to 90 mmHg, ii) M: moderate responders, 140 less than PAS less than or equal to 160 mmHg and/or 90 less than PAD less than or equal to 100 mmHg and (iii) F: therapeutic failure, PAS greater than 160 mmHg and/or PAD greater than 100. A parallel study was carried out in erythrocytes. At D (0), 40 ml of blood were drawn and the hypertensive patients were classified in: (i) (+)NaT patients, 19 patients having one or more of the following erythrocyte abnormalities: increased Na+: Li+ counter-transport, increased Na+ leak, decreased affinity of the Na+, K+-pump and/or Na+, K+ cotransport system for internal Na+ and (ii) (-)NaT patients, 11 patients without the above erythrocyte abnormalities. During monotherapy treatment (with captopril or hydrochlorothiazide) 8 out of 11 (-)NaT patients normalized blood pressure (responders) against only 5 out of 19 (+)NaT patients (p less than 0.05, chi 2 test).(ABSTRACT TRUNCATED AT 250 WORDS)

[Decrease in the regulatory capacity of the calcium pump in a subgroup of essential hypertensive patients]. / Diminution de la capacité régulatrice de la pompe à calcium dans un sous-groupe de malades hypertendus essentiels.

We developed a new flux technique, useful for the clinical investigation of Ca2+ pump kinetics in intact erythrocytes. The initial rate of Sr2+ efflux (mediated by the Ca2+ pump) was studied as a function of steady state erythrocyte Sr2+ and Ca2+ contents in 22 Caucasian essential hypertensive patients (8 females, 14 males), aged 39-66 years (mean 51) and compared with 20 normotensive control subjects (10 females, 10 males), aged 22-57 years (mean 41). Kinetic analysis of the data (by using a two-sites model) allowed the determination of the apparent dissociation constants for internal Ca2+ (KCa) and for internal Sr2+ (KSr) and the maximal rate of Sr2+ efflux (Vmax). Mean values of these kinetic parameters were slightly increased in the hypertensive population. However, only the increase in KCa reached statistical significance (73 +/- 7 vs 55 +/- 3 mumol/l.cells, Mann-Whitney U test; p = 0.042). Individual analysis of the data showed that 6 essential hypertensives had a KCa higher than the upper normal limit (95 p. 100 confidence limit) of the normotensive group. In addition, mean values of Vmax and KSr were also significantly higher in these six essential hypertensives. In conclusion, about 25 p. 100 of the hypertensive patients had a decreased apparent affinity of the Ca2+ pump for internal Ca2+, which appears to be compensated (in the basal state) by an increased maximal pump rate. A similar abnormality in vascular smooth muscle cells may induce increased contractility by transitory cell Ca2+ retention after the opening of Ca2+ channels.

Endogenous lignans--a potential endogenous digitalis.

Lignans are natural products formed by oxidative dimerization of monomeric phenols. A few were recently discovered in human and animal urine, semen and blood plasma but their role has never been assessed. We investigated the actions of mammalian lignans obtained by total synthesis or extracted from the urine of pregnant women, on the Na+K+-pump in human red cells. Some of the tested lignans (enterolactone, prestegane B and 3-O-methylenterolactone) inhibited the Na+K+-pump activity with IC50 ranging from 5 to 9 X 10(-4) mol/l. The IC50 for ouabain (7 X 10(-7) mol/l) was not modified by addition of lignans suggesting a non-competitive inhibition.