Pancreaticoduodenal Artery Pseudoaneurysm Associated with Pancreatic Fibroinflammatory Mass and Duodenal Obstruction.

BACKGROUND When people in their 60s experiences abdominal pain, vomiting, and unexplained weight loss without a history of abdominal surgery, the usual diagnosis is obstruction caused by a neoplastic mass. Nevertheless, in exceptionally rare cases, these symptoms arise from complications linked to a visceral artery aneurysm. CASE REPORT We present a case of a 60-year-old man with immunodeficiency and Sneddon-Wilkinson disease (a rare subcorneal pustular dermatosis), who developed a pancreaticoduodenal aneurysm of uncertain origin, associated with pancreatic mass, retroperitoneal hematoma, and duodenal obstruction. The treatment approach included transcatheter arterial coil embolization with supportive measures such as parenteral nutrition, a nasogastric tube, octreotide administration, and antiemetics. Despite these interventions, persistence gastrointestinal symptoms prompted an endoscopic ultrasound fine-needle aspiration to rule out malignancy. The biopsy confirmed localized fibro-inflammation. Although he was initially considered for a gastro-jejunal bypass, conservative management effectively improved the pancreatic lesion and duodenal obstruction, leading to discontinuation of parenteral nutrition. The patient was able to resume a regular diet 4 weeks after embolization. CONCLUSIONS Pancreaticoduodenal artery aneurysm is a rare visceral aneurysm with multiple etiologies and potentially fatal consequences. We report an unusual case of a pancreaticoduodenal artery aneurysm associated with pancreatic mass and duodenal obstruction. This diagnosis warrants consideration when an immunodeficient patient presents symptoms of abdominal pain and vomiting. Early endovascular embolization, combined with conservative approaches, effectively alleviated the symptoms in our patient.

[Vitamin D intoxication and "milk alkali syndrome"]. / 5 minutes pour apprendre. Intoxication à la vitamine D et « milk alkali syndrome ¼.

A 80-year-old patient treated with calcium bicarbonate for a reflux developed a milk alkali syndrome after a high doses of vitamin D for a conservatively treated heel fracture. The article highlights the milk alkali syndrome as a potential complication of excessive vitamin D supplementation, emphasizing that routine vitamin D testing and supplementation should be limited to specific situations.

Potentially Inappropriate Medication Dispensing in Outpatients: Comparison of Different Measurement Approaches.

Purpose of the Research: This paper aims at comparing different approaches to measure potentially inappropriate medication (PIM) with routinely collected data on prescriptions, patient age institutionalization status (ie in nursing home or in the community). A secondary objective is to measure the rate and prevalence of PIM dispensing and to identify problematic practices in Switzerland. Material and Methods: The studied population includes about 90,000 insured over 17 years old from a Swiss health maintenance organization in 2019 and 2020. We computed and compared the number of PIM per patient for Beers criteria, Priscus list, Laroche, NORGEP and Prescrire approaches. We also created a composite indicator that accounts for the specificities of the Swiss context (adaptation to the Swiss drugs' market, recommendations in force related to sleeping pills, anxiolytics and NSAIDs). We also stratified the analysis per physician, including initiation and cessation of PIM prescription. Results: Our comparison revealed similarities between the approaches, but also that each of them had specific gaps that provides further motivation for the development of a composite approach. PIM rate was particularly high for sleeping pills, anxiolytics, NSAIDs, even when analyses were limited to chronic use. Drugs with anticholinergic effect were also frequently prescribed. Based on our composite indicator, 27% of insured over 64 years old received at least one PIM in 2020, and 8% received more than one. Our analyses also reveal that for sleeping pills and anxiolytics, half of the volume (or prevalence?) occurs in the <65 population. We observed strong variations between physicians and a significant proportion of new users among patients with PIM. Conclusion: Our results show that PIMs prescribing is very frequent in Switzerland and is driven mostly by a few drug categories. There is important physician variation in PIM prescribing that warrants the development of intervention targeted at high PIM-prescribers.

[Check-ups in daily practice: myths and reality]. / Check-up en pratique : mythes et réalités.

Regular general health check-ups in asymptomatic patients seem not impacting important outcomes. As such, it is no longer recommended by the Swiss Society of General Internal Medicine as part of its «smartermedicine¼ campaign. Physicians should focus on a medical follow-up based on risk-appropriate screening, regular evaluation of lifestyle habits, monitoring of bio-psycho-social well-being, regular re-evaluation of medication and vaccinations. Prevention during the medical consultation is thus rethought, based on a relationship of trust between doctor and patient, with an exchange of views on the need for interventions and screenings based only on scientific evidence.

Tel qu'il est couramment pratiqué, le check-up ou bilan de santé annuel n'a pas prouvé de bénéfice sur la mortalité, ni sur les événements cardiovasculaires. Ainsi, il n'est plus recommandé par la Société suisse de médecine interne générale dans le cadre de sa campagne « smartermedicine ¼. Les médecins devraient privilégier un suivi médical basé sur les dépistages recommandés selon le profil de risque, l'évaluation régulière de l'hygiène de vie, le suivi du bien-être biopsychosocial, la réévaluation régulière des médicaments et des vaccinations. La prévention lors de la consultation médicale est ainsi repensée en se basant sur une relation de confiance entre le médecin et le patient, avec un échange sur la nécessité des interventions et des dépistages qui reposent uniquement sur des évidences scientifiques.

Long term anti-SARS-CoV-2 antibody kinetics and correlate of protection against Omicron BA.1/BA.2 infection.

Binding antibody levels against SARS-CoV-2 have shown to be correlates of protection against infection with pre-Omicron lineages. This has been challenged by the emergence of immune-evasive variants, notably the Omicron sublineages, in an evolving immune landscape with high levels of cumulative incidence and vaccination coverage. This in turn limits the use of widely available commercial high-throughput methods to quantify binding antibodies as a tool to monitor protection at the population-level. Here we show that anti-Spike RBD antibody levels, as quantified by the immunoassay used in this study, are an indirect correlate of protection against Omicron BA.1/BA.2 for individuals previously infected by SARS-CoV-2. Leveraging repeated serological measurements between April 2020 and December 2021 on 1083 participants of a population-based cohort in Geneva, Switzerland, and using antibody kinetic modeling, we found up to a three-fold reduction in the hazard of having a documented positive SARS-CoV-2 infection during the Omicron BA.1/BA.2 wave for anti-S antibody levels above 800 IU/mL (HR 0.30, 95% CI 0.22-0.41). However, we did not detect a reduction in hazard among uninfected participants. These results provide reassuring insights into the continued interpretation of SARS-CoV-2 binding antibody measurements as an independent marker of protection at both the individual and population levels.

Comparative Evaluation of the ABC Score to Other Risk Stratification Scales in Managing High-risk Patients Presenting With Acute Upper Gastrointestinal Bleeding.

OBJECTIVE: The ABC risk score identifies patients at high risk of mortality in acute lower and upper gastrointestinal bleeding (UGIB). We aimed to externally validate the ABC score while comparing it to other prognostication scales when assessing UGIB patients at high risk of negative outcomes before endoscopy. METHODS: UGIB patients from a national Canadian registry (REASON) were studied, with mortality prediction as a primary outcome. Secondary endpoints included prognostication of rebleeding, intensive care unit (ICU) admission, ICU and hospitalization lengths of stay (LOS), and a previously proposed composite outcome measure. Univariable and areas under the receiver operating characteristic curve analyses compared discriminatory abilities of the ABC score to the AIMS65, Glasgow Blatchford Scale (GBS), and clinical Rockall score. RESULTS: The REASON registry included 2020 patients [89.4% nonvariceal; mean age (±SD): 66.3±16.4 y; 38.4% female]. Overall mortality, rebleeding, ICU admission, transfusion and composite score rates were 9.9%, 11.4%, 21.1%, 69.0%, and 67.3%, respectively. ICU and hospitalization LOS were 5.4±9.3 and 9.1±11.5 days, respectively. The ABC score displayed superior 30-day mortality prediction [0.78 (0.73; 0.83)] compared with GBS [0.69 (0.63; 0.75)] or clinical Rockall [0.64 (0.58; 0.70)] but not AIMS65 [0.73 (0.67; 0.79)]. Although most scales significantly prognosticated secondary outcomes in the univariable analysis except for ICU LOS, discriminatory abilities on areas under the receiver operating characteristic curve analyses were poor. CONCLUSIONS: ABC and AIMS65 display similar good prediction of mortality. Clinical usefulness in prognosticating secondary outcomes was modest for all scales, limiting their adoptions when informing early management of high-risk UGIB patients.

General health check-ups: To check or not to check? A question of choosing wisely.

In high-income countries, regular general health check-ups are part of the fabric of the health care systems. The hidden concept of general health check-ups, promoted for more than a century, is to identify diseases at a stage at which early intervention can be effective. However, there has been little evidence to support the benefits of such checkups. Choosing wisely (CW) campaigns may represent a tremendous opportunity to eventually shift patients and physicians away from the non-evidence based yet firmly entrenched practice of the general health check-up. As campaign leaders and members of the CW working group of the European Federation of Internal Medicine, we want to join the discussion by giving our perspective based on the best available evidence.

Seroprevalence of anti-SARS-CoV-2 antibodies and cross-variant neutralization capacity after the Omicron BA.2 wave in Geneva, Switzerland: a population-based study.

Background: More than two years into the COVID-19 pandemic, most of the population has developed anti-SARS-CoV-2 antibodies from infection and/or vaccination. However, public health decision-making is hindered by the lack of up-to-date and precise characterization of the immune landscape in the population. Here, we estimated anti-SARS-CoV-2 antibodies seroprevalence and cross-variant neutralization capacity after Omicron became dominant in Geneva, Switzerland. Methods: We conducted a population-based serosurvey between April 29 and June 9, 2022, recruiting children and adults of all ages from age-stratified random samples of the general population of Geneva, Switzerland. We tested for anti-SARS-CoV-2 antibodies using commercial immunoassays targeting either the spike (S) or nucleocapsid (N) protein, and for antibody neutralization capacity against different SARS-CoV-2 variants using a cell-free Spike trimer-ACE2 binding-based surrogate neutralization assay. We estimated seroprevalence and neutralization capacity using a Bayesian modeling framework accounting for the demographics, vaccination, and infection statuses of the Geneva population. Findings: Among the 2521 individuals included in the analysis, the estimated total antibodies seroprevalence was 93.8% (95% CrI 93.1-94.5), including 72.4% (70.0-74.7) for infection-induced antibodies. Estimates of neutralizing antibodies in a representative subsample (N = 1160) ranged from 79.5% (77.1-81.8) against the Alpha variant to 46.7% (43.0-50.4) against the Omicron BA.4/BA.5 subvariants. Despite having high seroprevalence of infection-induced antibodies (76.7% [69.7-83.0] for ages 0-5 years, 90.5% [86.5-94.1] for ages 6-11 years), children aged <12 years had substantially lower neutralizing activity than older participants, particularly against Omicron subvariants. Overall, vaccination was associated with higher neutralizing activity against pre-Omicron variants. Vaccine booster alongside recent infection was associated with higher neutralizing activity against Omicron subvariants. Interpretation: While most of the Geneva population has developed anti-SARS-CoV-2 antibodies through vaccination and/or infection, less than half has neutralizing activity against the currently circulating Omicron BA.5 subvariant. Hybrid immunity obtained through booster vaccination and infection confers the greatest neutralization capacity, including against Omicron. Funding: General Directorate of Health in Geneva canton, Private Foundation of the Geneva University Hospitals, European Commission ("CoVICIS" grant), and a private foundation advised by CARIGEST SA.

[Acute hepatitis as an inaugural presentation of systemic lupus erythematosus]. / Hépatite aiguë comme présentation inaugurale d'un lupus érythémateux systémique.

Systemic lupus erythematosus (SLE) is a complex multiorgan autoimmune disease with varied clinical and laboratory manifestations. Although common in lupus disease, liver test disturbance is rarely seen as a primary manifestation at diagnosis. In this case report, we describe acute hepatitis as the initial presentation of SLE in a young woman.

Le lupus érythémateux systémique (LES) est une maladie autoimmune multiorganique complexe aux manifestations cliniques et biologiques variées. Bien que fréquente au cours de la maladie lupique, une perturbation des tests hépatiques est rarement observée comme manifestation principale au moment du diagnostic. Dans ce cas clinique, nous décrivons une hépatite aiguë comme présentation initiale d'un LES chez une jeune femme.

[Importance of best practice adherence in upper gastrointestinal bleeding]. / 5 minutes pour apprendre - Importance du suivi des directives internationales lors d'hémorragie digestive haute.

Adherence to international guidelines limits the potentially deleterious consequences for patients with upper gastrointestinal bleeding (UGIB). We report the case of 81-year-old patient admitted for UGIB due to a stomach ulcer (Forrest IIb), with a high risk of rebleeding. Antiaggregation was stopped for 8 days which contrasts with international guidelines that recommend stopping treatment only for 3 to 5 days. Fortunately, he did not present any cardiovascular complication during his stay (near miss). In addition, the patient was left fasting for several days, which necessitated parenteral nutrition, resulting in diabetic decompensation and an extended length of stay.

[The use of ultrasound in IBD: an essential tool?] / Échographie dans les maladies inflammatoires chroniques de l'intestin†: nouvel outil indispensable†?

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBD) characterized by an inflammation of the digestive tract wall. Current guidelines recommend a «treat to target¼ management and a "tight control" of the inflammation for an optimal follow-up. Intestinal ultrasound, due to its low cost, its feasibility at bed side, its absence of preparation and its non-invasive character, has proved its place in the diagnosis and the follow-up of IBD. It allows the evaluation of various parameters of the lumen, the intestinal wall, the mesentery, the vascularization as well as complications.

La maladie de Crohn (MC) et la rectocolite hémorragique (RCH) sont des maladies inflammatoires chroniques de l'intestin (MICI) caractérisées par une inflammation de la paroi du tube digestif. Les recommandations de prise en charge suggèrent de viser une cible thérapeutique et de procéder à une évaluation régulière de l'inflammation appelée «â€…contrôle serré ¼ (tight control en anglais). Le but est de proposer une adaptation thérapeutique si la cible n'est pas atteinte (concept du treat-to-target). L'échographie, par son faible coût, sa faisabilité au lit du malade, son absence de préparation colique et son caractère non invasif, a démontré sa place dans le diagnostic et le suivi des MICI. Elle permet d'évaluer divers paramètres de la lumière, de la paroi intestinale, du mésentère, la vascularisation et de rechercher des complications.

Implementing a Multifaceted Intervention among Internal Medicine Residents with Audit and Educative Data Feedback Significantly Reduces Low-Value Care in Hospitalized Patients.

BACKGROUND: The dissemination of recommendations on low-value care alone may not lead to physicians' behavioral changes. The aim of this study was to evaluate whether a multifaceted behavioral intervention among internal medicine residents could reduce low-value care in hospitalized patients. METHODS: A pre-post quality improvement intervention was conducted at the Internal Medicine Division of La Tour hospital (Geneva, Switzerland) from May 2020 to October 2021. The intervention period (3 months) consisted of a multifaceted informational intervention with audits and educative feedback about low-value care. The pre- and post-intervention periods including the same six calendar months were compared in terms of number of blood samples per patient day, prescription rates of benzodiazepines (BZDs) and proton pump inhibitors (PPIs), as well as safety indicators including potentially avoidable readmissions, premature deaths and complications. RESULTS: A total of 3400 patients were included in this study; 1095 (32.2%) and 1155 (34.0%) were, respectively, hospitalized during the pre- and post-intervention periods. Patient characteristics were comparable between the two periods. Only the number of blood tests per patient day and the BZD prescription rate at discharge were significantly reduced in the post-intervention phase (pre: 0.54 ± 0.43 vs. post: 0.49 ± 0.60, p ≤ 0.001; pre: 4.2% vs. post: 1.7%, p = 0.003, respectively). PPI prescription rates remained comparable. Safety indicators analyses revealed no significant differences between the two periods of interest. CONCLUSIONS: Our results demonstrate a modest but statistically significant effect of a multifaceted educative intervention in reducing the number of blood tests and the BZD prescription rate at discharge in hospitalized patients. Limiting low-value services is very challenging and additional long-term interventions are necessary for wider implementation.