["White code protocol": model of interprofessional collaboration in the emergency room]. / « Code blanc ¼ : modèle de collaboration interprofessionnelle aux urgences.

Acute agitation is a frequent cause of emergency department's consultation. Managing an agitated patient is complex due to many factors and require from healthcare teams a close interdisciplinary collaboration. Scope of this article is to describe the management of agitated patients in an emergency department and to present an interprofessional medical care protocol (white code protocol), giving also the opinion of principal actors of this healthcare interdisciplinary model.

L'agitation psychomotrice aiguë est fréquente dans les services d'urgences. La prise en charge d'un patient agité s'avère complexe en raison de multiples facteurs et nécessite de la part des intervenants une collaboration interdisciplinaire étroite. Cet article a pour but de synthétiser les principes de prise en charge d'une agitation aiguë dans un service d'urgences et de détailler un protocole interprofessionnel de prise en charge (code blanc), en présentant l'opinion des principaux intervenants de ce modèle interprofessionnel de soins.

Assessment of diagnostic strategies based on risk stratification for aneurysmal subarachnoid hemorrhage: a retrospective chart review.

BACKGROUND AND IMPORTANCE: Current guidelines recommend noncontrast computed tomography (NCCT) followed by lumbar puncture for the diagnosis of subarachnoid hemorrhage (SAH). Alternative strategies, including clinical risk stratification and CT angiography (CTA), are emerging. OBJECTIVE: To evaluate alternative strategies to current guidelines through clinical risk stratification. DESIGN, SETTING AND PARTICIPANTS: Single-site, retrospective observational study of patients with SAH suspicion, from 2011 to 2016. We combined results of each investigation (NCCT, CTA and lumbar puncture) with a clinical risk assessment, including Ottawa score. EXPOSURE: Comparing the current strategy (NCCT ± lumbar puncture if negative CT) to alternative strategies (NCCT + CTA ± lumbar puncture if high clinical risk or negative CT and onset of headache ≥12 h o dds ratio ≥24 h). OUTCOME MEASURE AND ANALYSIS: Main outcome was diagnosis of SAH at hospital discharge. Secondary outcomes were death from all causes and need for invasive procedures at 28 days. We used sensitivity, specificity, positive predictive value and negative predictive value (NPV) to evaluate the diagnostic performance of three strategies. MAIN RESULTS: 310 patients were included. SAH was diagnosed in 8 cases (2.6%), none died and 7 (2.2%) had a surgical procedure. Performances of different strategies were not statistically different. NPVs were 99.7% [95% Confidence interval (CI), 98.2-100%] for strategy 1 and 100% (95% CI, 98.8-100%) for strategies 2 and 3. More than 4000 lumbar punctures are needed to diagnose one SAH when CTA is performed within 24 h of symptoms' onset and absence of high-risk criteria. CONCLUSION: Clinical risk stratification and CTA strategy are well-tolerated and effective for diagnosis of SAH, avoiding systematic use of lumbar puncture.

Predicting Venous Thromboembolic Events in Patients with Coronavirus Disease 2019 Requiring Hospitalization: an Observational Retrospective Study by the COVIDIC Initiative in a Swiss University Hospital.

BACKGROUND: Coronavirus disease 2019 (COVID-19) can result in profound changes in blood coagulation. The aim of the study was to determine the incidence and predictors of venous thromboembolic events (VTE) among patients with COVID-19 requiring hospital admission. Subjects and Methods. We performed a retrospective study at the Lausanne University Hospital with patients admitted because of COVID-19 from February 28 to April 30, 2020. RESULTS: Among 443 patients with COVID-19, VTE was diagnosed in 41 patients (9.3%; 27 pulmonary embolisms, 12 deep vein thrombosis, one pulmonary embolism and deep vein thrombosis, one portal vein thrombosis). VTE was diagnosed already upon admission in 14 (34.1%) patients and 27 (65.9%) during hospital stay (18 in ICU and nine in wards outside the ICU). Multivariate analysis revealed D-dimer value > 3,120 ng/ml (P < 0.001; OR 15.8, 95% CI 4.7-52.9) and duration of 8 days or more from COVID-19 symptoms onset to presentation (P 0.020; OR 4.8, 95% CI 1.3-18.3) to be independently associated with VTE upon admission. D-dimer value ≥ 3,000 ng/l combined with a Wells score for PE ≥ 2 was highly specific (sensitivity 57.1%, specificity 91.6%) in detecting VTE upon admission. Development of VTE during hospitalization was independently associated with D-dimer value > 5,611 ng/ml (P < 0.001; OR 6.3, 95% CI 2.4-16.2) and mechanical ventilation (P < 0.001; OR 5.9, 95% CI 2.3-15.1). CONCLUSIONS: VTE seems to be a common COVID-19 complication upon admission and during hospitalization, especially in ICU. The combination of Wells ≥ 2 score and D - dimer ≥ 3,000 ng/l is a good predictor of VTE at admission.

[How to fight against overtreatment ? Example of neuroleptic prescriptions for acute delirium]. / Comment lutter contre la surmédicalisation à l'hôpital ? - Exemple des neuroleptiques dans l'état confusionnel aigu.

Since 2014, the Swiss Smarter medicine - choosing wisely campaign has established lists of recommendations, with an emphasis on futile treatments and tests where risks may outweigh benefits. Ultimately this initiative aims to develop, disseminate and implement educational programs to improve quality of care. Literature shows a positive impact of this initiative on clinical practice. Hence, we developed several guidelines based on this initiative in our internal medicine department. This article describes the multimodal and interprofessional strategy aiming to reduce neuroleptic prescriptions in acute delirium. After the implementation of this recommendation in our clinical practice, we noted positive effects, both qualitative and quantitative, confirming the potential benefit of such changes.

Depuis 2014, la campagne Smarter Medicine a établi des recommandations, afin de cibler des thérapies ou des examens considérés comme futiles ou représentant un risque plus grand que le bénéfice apporté au patient. In fine, cette initiative vise à développer, diffuser et implémenter des programmes d'éducation permettant une amélioration de la qualité des soins. La littérature montre un impact positif de cette initiative sur les pratiques cliniques. C'est pourquoi, dans notre service de médecine interne, nous avons développé un certain nombre de recommandations basées sur cette initiative. Cet article décrit une intervention multimodale et interprofessionnelle visant à diminuer la prescription des neuroleptiques lors d'états confusionnels aigus et son impact sur les pratiques.

[Organizational Impacts and Clinical Challenges of the COVID-19 Pandemic on a Swiss Tertiary Internal Medicine Department]. / Impacts organisationnels et défis cliniques de la pandémie COVID-19 pour un service hospitalier de médecine interne universitaire.

The rapid progression of COVID-19 is an organizational challenge for all hospitals. To secure the patient overflow, the Department internal medicine of the University Hospital of Lausanne increased nurse and medical workforces as well as bed capacity by 65 %, with extraordinary help from other departments. The implemented crisis management stood upon three pillars : a crisis management team, steering documents and internal communication. In this new form, the Department had already taken care of 442 COVID-19 admissions by April 16, 2020. Alongside organizational challenges, clinical issues such as rapid respiratory distress, clinical suspicions with negative PCR and treatment uncertainties in the absence of sufficient evidence were overcome. Despite the peak of the pandemic appearing to have passed, the next phase could be just as complicated.

La progression rapide du COVID-19 constitue un défi organisationnel pour tous les hôpitaux. Pour anticiper un afflux important de patients, le service de médecine interne du CHUV a ainsi augmenté ses forces de travail médico-soignantes et son nombre de lits de 65 % avec un soutien extraordinaire de toute l'institution. Pour opérer ces changements majeurs, l'organisation de crise mise en place s'est appuyée sur trois piliers : une cellule de conduite, des documents de pilotage et une communication interne. Sous cette nouvelle forme, le service a pris en charge 442 hospitalisations COVID-19 jusqu'au 16 avril 2020. Si les enjeux organisationnels ont été majeurs, la gestion des situations complexes, comme les manifestations respiratoires et les multiples incertitudes cliniques diagnostiques et thérapeutiques, ont été également une gageure. Le pic de la pandémie semble passé, mais la prochaine phase pourrait constituer un nouveau défi organisationnel.

[The internal medicine articles that struck us the most in 2019]. / L'année 2019 mise en perspective par les internistes hospitaliers.

2019 has continued to bring important progress in all areas of internal medicine, impacting our daily practice. From new indications for SGLT2 inhibitors and rivaroxaban, to antibiotic duration for Gram negative bacteriemia, passing by the delay for cardioversion of recent-onset atrial fibrillation or for beginning sacubitril/valsartan after stabilization of a cardiac failure, internal medicine journals are full of novelties. Every year, the chief residents of the CHUV internal medicine ward meet up to share their readings: here is their selection of eleven articles, chosen, summarized and commented for you.

L'année 2019 a vu d'importants progrès dans tous les domaines de la médecine interne, avec un impact important sur notre pratique quotidienne hospitalière. Des nouvelles indications pour les inhibiteurs du SLGT2 et le rivaroxaban, à la durée du traitement des bactériémies à Gram négatif en passant par le délai pour la cardioversion d'une fibrillation auriculaire inaugurale ou celui pour introduire du sacubitril/valsartan après stabilisation d'une insuffisance cardiaque, les nouveautés abondent dans la littérature. Chaque année, les chefs de clinique du Service de médecine interne du Centre Hospitalier Universitaire Vaudois (CHUV) se réunissent pour partager leurs lectures: voici une sélection de onze articles choisis, revus et commentés pour vous.

[Analysis of chest x-rays, a systematic to remember]. / Analyse de la radiographie thoracique, une systématique à rappeler.

The interpretation of chest x-rays, which is part of a comprehensive medical management, requires a specific mastery, this despite the promising performance of artificial intelligence software. Alternatives to this imaging modality exist, particularly ultra-low dose CT (CT-ULD) and thoracic ultrasound (US) in some indications, but they are not a substitute for chest x-rays in clinical routine. Among the rules to be followed, a systematic reading technique is required, in order to reduce the risk of error. In addition, the observational and interpretive capabilities necessary for this task must be exercised, referring to the normal radiographic aspect. The objective of this article is to demonstrate the interpretation of pathological chest x-rays using clinical cases.

L'interprétation des radiographies thoraciques, qui s'intègre dans une prise en charge médicale globale, requiert une maîtrise spécifique, et ce malgré les performances prometteuses des logiciels d'intelligence artificielle. Des alternatives à cette modalité d'imagerie existent, en particulier le CT ultra-faible (low)-dose (CT-ULD) et l'ultrason (US) thoracique dans certaines indications, mais elles ne s'y substituent pas en routine clinique. Parmi les règles à respecter, une technique de lecture systématique est requise afin de réduire le risque d'erreur. De plus, les capacités d'observation et d'interprétation nécessaires à cette tâche doivent être exercées, et ce en référence à l'aspect radiographique normal. Cet article a pour objectif de démontrer l'interprétation de radiographies thoraciques pathologiques à l'aide de cas cliniques.

Pretreatment of skin using an abrasive skin preparation pad, a microneedling device or iontophoresis improves absorption of methyl aminolevulinate in ex vivo human skin.

BACKGROUND: Pretreatment of skin to remove scales/crusts and roughen the surface is essential to enhance the penetration of topically applied methyl aminolevulinate (MAL) prior to photodynamic therapy and to permit daylight to access all parts of the skin lesions. Numerous procedures of skin preparation are currently available. This study compared the in vitro penetration of MAL into ex vivo human skin pretreated with skin preparation pad abrasion or a microneedling device, and evaluated the effectiveness of an iontophoretic device in delivering MAL into ex vivo human skin. METHODS: Human skin samples, obtained from aesthetic surgeries, were used in this study. The thickness of the skin samples ranged between 1.44-2.87mm. Pretreatment of samples was performed with 10 passages of the Ambu® Unilect™ 2121M (Ambu A/S, Denmark) skin preparation pad, 8 rolling repetitions using the microneedling device Dermaroller® HC 902 (Dermaroller GmbH, Germany), or by an iontophoresis device (Feeligreen SA, France) for 1.5h. The effect of these pretreatment procedures on the penetration of MAL into the skin was assessed. RESULTS: Penetration in the total skin, liquid receptor and total penetration was most increased by skin preparation pad treatment, followed by microneedling and iontophoresis. Overall, MAL total penetration was increased up to 103-fold by skin preparation pad treatment, 4-fold by microneedling and 1.8-fold by iontophoresis. CONCLUSIONS: Abrasion with skin preparation pad was shown to be superior to microneedling and iontophoresis for increasing MAL penetration in ex vivo human skin.