Swiss family physicians and home visits: a 10-year retrospective analysis and typology based on billing data.

INTRODUCTION: In the context of an aging population, homecare visits by family physicians may contribute to maintaining older patients at home; however, home visits by family physicians have decreased in number in the last decade with the emergence of homecare-oriented healthcare services. We aimed to describe the diversity of activities and evolution over time of home visits by Swiss family physicians. METHODS: This was a retrospective observational descriptive study. We used billing data collected by the cantonal trust centre for home visits made by family physicians of the canton of Vaud, Switzerland from 2006 to 2015. We separated billed items into specific categories, including the Tarmed catalogue (Swiss pricing system for medical services), laboratory catalogue, medications, medical material and vaccines. We compared billing patterns between emergency and routine visits. We used discrete mixture models to identify cluster classes of visits, and compare their characteristics. RESULTS: From 2006 to 2015, Vaud family physicians made 451,634 home visits for which they billed a median of 5 items per visit (range 2–95). Most home visits (65%, 293,713) were routine visits consisting of consultation time without additional investigation. We identified four cluster classes of visits comprising routine visits, routine visits with laboratory tests, emergency visits during the day and emergency visits during the night. Routine visits were the main cluster class while emergency home visits were rare. CONCLUSIONS: Family physician home visits are mainly routine visits without additional investigation. Thus, we wonder if a part of this activity could be delegated to other healthcare professionals.

Phosphorous in the environment: characteristics with distribution and effects, removal mechanisms, treatment technologies, and factors affecting recovery as minerals in natural and engineered systems.

Phosphorus (P), an essential element for living cells, is present in different soluble and adsorbed chemical forms found in soil, sediment, and water. Most species are generally immobile and easily adsorbed onto soil particles. However, P is a major concern owing to its serious environmental effects (e.g., eutrophication, scale formation) when found in excess in natural or engineered environments. Commercial chemicals, fertilizers, sewage effluent, animal manure, and agricultural waste are the major sources of P pollution. But there is limited P resources worldwide. Therefore, the fate, effects, and transport of P in association with its removal, treatment, and recycling in natural and engineered systems are important. P removal and recycling technologies utilize different types of physical, biological, and chemical processes. Moreover, P minerals (struvite, vivianite, etc.) can precipitate and form scales in drinking water and wastewater systems. Hence, P minerals (e.g., struvite, vivianite etc.) are problems when left uncontrolled and unmonitored although their recovery is beneficial (e.g., slow release fertilizers, sustainable P sources, soil enhancers). Sources like wastewater, human waste, waste nutrient solution, etc. can be used for P recycling. This review paper extensively summarizes the importance and distribution of P in different environmental compartments, the effects of P in natural and engineered systems, P removal mechanisms through treatment, and recycling technologies specially focusing on various types of phosphate mineral precipitation. In particular, the factors controlling mineral (e.g., struvite and vivianite) precipitation in natural and engineered systems are also discussed.

Home visits made by general practitioners in the canton of Vaud between 2006 and 2015.

AIM OF THE STUDY: Although physicians’ home visits are highly valued by patients, and are among the measures that contribute to maintaining elderly patients at home, their number is decreasing worldwide. We aimed to describe the trends in home visits made by general practitioners (GPs) in the canton of Vaud in Switzerland between 2006 and 2015, and to explore their associated characteristics. METHODS: We retrospectively analysed billing data from family physicians (internists, generalists and practicing physicians) transmitted to the cantonal trust centre between 2006 and 2015. We explored physician and patient characteristics, first over the entire 10-year study period and then averaged by year. To explore factors associated with the number of home visits, we fitted a mixed effect negative binomial regression of the annual number of home visits per physician. RESULTS: Over ten years, 631 physicians billed a total of 451,634 home visits, of which 19.8% (n = 89,966) were emergency visits, and 9.7% (n = 43,915) were over the weekend. Home visits represented 2.5% of all consultations. Although the average annual number of physicians doing home visits remained stable at around 400, the mean annual number of visits per physician decreased from 125 in 2006 to 75 in 2015, resulting in a 40% decline in the absolute number of visits. Male physicians undertook more home visits than their female counterparts did, although the difference diminished over time. Visits to elderly patients (65+) represented 84.2% of the home visits. CONCLUSIONS: Although most physicians in the canton of Vaud continue to visit patients at home, the overall number of home visits is declining. Most home visits consist of routine visits to elderly patients. Physicians’ gender, age and specialty are associated with the number of home visits. In the rapidly evolving context of an ageing population and the development of home care, physicians’ role in home care provision should be revised, taking into account patient expectations and current health system constraints.

Mechanical Signals Inhibit Growth of a Grafted Tumor In Vivo: Proof of Concept.

In the past ten years, many studies have shown that malignant tissue has been "normalized" in vitro using mechanical signals. We apply the principles of physical oncology (or mechanobiology) in vivo to show the effect of a "constraint field" on tumor growth. The human breast cancer cell line, MDA MB 231, admixed with ferric nanoparticles was grafted subcutaneously in Nude mice. The magnetizable particles rapidly surrounded the growing tumor. Two permanent magnets located on either side of the tumor created a gradient of magnetic field. Magnetic energy is transformed into mechanical energy by the particles acting as "bioactuators", applying a constraint field and, by consequence, biomechanical stress to the tumor. This biomechanical treatment was applied 2 hours/day during 21 days, from Day 18 to Day 39 following tumor implantation. The study lasted 74 days. Palpable tumor was measured two times a week. There was a significant in vivo difference between the median volume of treated tumors and untreated controls in the mice measured up to D 74 (D 59 + population): (529 [346; 966] mm3 vs 1334 [256; 2106] mm3; p = 0.015), treated mice having smaller tumors. The difference was not statistically significant in the group of mice measured at least to D 59 (D 59 population). On ex vivo examination, the surface of the tumor mass, measured on histologic sections, was less in the treated group, G1, than in the control groups: G2 (nanoparticles, no magnetic field), G3 (magnetic field, no nanoparticles), G4 (no nanoparticles, no magnetic field) in the D 59 population (Median left surface was significantly lower in G1 (5.6 [3.0; 42.4] mm2, p = 0.005) than in G2 (20.8 [4.9; 34.3]), G3 (16.5 [13.2; 23.2]) and G4 (14.8 [1.8; 55.5]); Median right surface was significantly lower in G1 (4.7 [1.9; 29.2] mm2, p = 0.015) than in G2 (25.0 [5.2; 55.0]), G3 (18.0 [14.6; 35.2]) and G4 (12.5 [1.5; 51.8]). There was no statistically significant difference in the day 59+ population. This is the first demonstration of the effect of stress on tumor growth in vivo suggesting that biomechanical intervention may have a high translational potential as a therapy in locally advanced tumors like pancreatic cancer or primary hepatic carcinoma for which no effective therapy is currently available.

[Home visits by GPs - Considerations in Europe and in Switzerland]. / Visite à domicile par le médecin de famille : état des lieux en Europe et en Suisse.

Home visits are essential for promoting the ability to remain at home and prevent nursing home admissions ; general practitioners play a key role in the development of this specific ambulatory care. Although the frequency of home visits seems to be overall decreasing in recent years, they remain essential, given the expected demographic changes. This is why education on home visits should be introduced in the training of our students during early years. However, there is a gap in literature regarding the optimal number and length of home visits, as well as the kind of groups most likely to benefit from them and thus more research is needed to enlighten these aspects of home visits.

Les visites à domicile (VAD) jouent un rôle primordial dans la promotion du maintien à domicile pour une population de plus en plus âgée ; le médecin de famille est le chef d'orchestre parmi les intervenants dans cette prise en charge. Bien que la fréquence des VAD semble diminuer globalement ces dernières années, celles-ci vont rester essentielles aux soins ambulatoires étant donné les changements démographiques attendus. C'est pourquoi l'enseignement sur les VAD devrait être introduit dans la formation de nos étudiants dès les premières années d'études. D'autre part, notre connaissance sur le nombre optimal et la durée des VAD, ainsi que les groupes de patients les plus susceptibles d'en bénéficier vont demander le développement d'études ciblées à l'avenir.

First off-time treatment prostate-specific antigen kinetics predicts survival in intermittent androgen deprivation for prostate cancer.

BACKGROUND: Prostate-specific antigen (PSA) doubling time is relying on an exponential kinetic pattern. This pattern has never been validated in the setting of intermittent androgen deprivation (IAD). Objective is to analyze the prognostic significance for PCa of recurrent patterns in PSA kinetics in patients undergoing IAD. METHODS: A retrospective study was conducted on 377 patients treated with IAD. On-treatment period (ONTP) consisted of gonadotropin-releasing hormone agonist injections combined with oral androgen receptor antagonist. Off-treatment period (OFTP) began when PSA was lower than 4 ng/ml. ONTP resumed when PSA was higher than 20 ng/ml. PSA values of each OFTP were fitted with three basic patterns: exponential (PSA(t) = λ.e(αt)), linear (PSA(t) = a.t), and power law (PSA(t) = a.t(c)). Univariate and multivariate Cox regression model analyzed predictive factors for oncologic outcomes. RESULTS: Only 45% of the analyzed OFTPs were exponential. Linear and power law PSA kinetics represented 7.5% and 7.7%, respectively. Remaining fraction of analyzed OFTPs (40%) exhibited complex kinetics. Exponential PSA kinetics during the first OFTP was significantly associated with worse oncologic outcome. The estimated 10-year cancer-specific survival (CSS) was 46% for exponential versus 80% for nonexponential PSA kinetics patterns. The corresponding 10-year probability of castration-resistant prostate cancer (CRPC) was 69% and 31% for the two patterns, respectively. Limitations include retrospective design and mixed indications for IAD. CONCLUSION: PSA kinetic fitted with exponential pattern in approximately half of the OFTPs. First OFTP exponential PSA kinetic was associated with a shorter time to CRPC and worse CSS.

Factors associated with failure to return for HIV test results in a free and anonymous screening centre.

Free and anonymous screening centres (CDAG: Centres de Depistage Anononyme et Gratuit) are public facilities set up for HIV infection diagnosis in France. Some people visiting CDAG fail to return for test results and are not informed of their serology. This study aimed to assess factors associated with failure to return for HIV test results. Patients visiting the Fernand-Widal CDAG (Paris) for an HIV test in January-February 2011 were eligible to take part in the study. Data were collected with an anonymous self-administered questionnaire. Factors associated with failure to return were assessed using logistic regression models. Of the 710 participants (participation rate 88%), 46 patients failed to return. Not specifying birthplace and not living in the region of Paris were associated with failure to return. Those who perceived no risk of HIV infection and those who felt they were more at risk than other people were both statistically associated with failure to return. Self-perceived risk seemed to be of chief concern for failure to return for HIV test results and should be considered during pre-test counselling.

[Multidisciplinary consultation meetings: decision-making in palliative chemotherapy]. / Réunion de concertation pluridisciplinaire : comment décider d'une chimiothérapie à visee palliative?

INTRODUCTION: Multidisciplinary consultation meetings provide an opportunity for specialists from different disciplines to engage in formal discussions over diagnostic and therapeutic strategies in oncology. In complex clinical situations, specialists discuss medical decisions collectively, particularly in cases involving palliative chemotherapy. The purpose of this study was to identify the factors considered in multidisciplinary consultation meetings in deciding whether palliative chemotherapy is needed. METHODS: A study was conducted over a three-month period in an adult hematology department in order to identify the criteria used in weekly multidisciplinary consultation meetings to determine whether palliative chemotherapy is required. The study only included patients who were confirmed to be in the palliative phase by all the doctors present at the multidisciplinary consultation meetings. The criteria cover 5 areas related to patient's characteristics, patients'environment, the disease, scientific data and the objectives of palliative chemotherapy. RESULTS: The criteria considered in 100% of cases were related to the disease, the expected benefits of chemotherapy with palliative intent and patients' characteristics. The least important criteria were related to the patients' environment. Scientific data were not discussed during the multidisciplinary consultation meetings. CONCLUSION: The results show that the criteria used to determine whether chemotherapy with palliative intent is required are essentially of a medical nature. However, in palliative situations, factors related to patients' environment must be taken into account. In order to meet this requirement, it may be necessary to increase the participation of paramedical professionals and palliative care teams in multidisciplinary consultation meetings and to promote dialogue and collaboration with doctors and coordinating nurses.

[Polypharmacy and the elderly: neither too much nor too little]. / Polymédication et personne agée: ni trop ni trop peu!

Elderly persons are at high risk of polypharmacy. Polypharmacy has been associated with numerous adverse outcomes, such as poorer quality of life, higher morbidity and mortality. However, deciding to stop or to continue a treatment is a difficult task, which confronts the physician to complex clinical and ethical choices. Such a decision requires a geriatric multidimensional assessment of the patient, an estimation of his or her prognosis, the definition of the goals of care and a careful assessment of the time to benefit of each drug. Diverse methods and tools to support the physician in this process are discussed in this article. However these can not replace a reflexive approach of the physician that integrates the values and representations of the patient with regard to his or her health and end of life, as well as his or her needs, fears and choices.

[Management and follow-up of patients treated with antiretroviral prophylaxis: an evaluation of professional practices]. / Prise en charge et suivi des patients traités par prophylaxie antirétrovirale : évaluation des pratiques professionnelles.

The care management of patients treated for cases of sexual or blood exposure requires stringent clinical and biological follow-up procedures. Despite the provision of information about the importance of regular follow-up, the number of patients dropping out of screening consultations at the Hospital Lariboisière-Fernand Widal (Assistance Publique-Hôpitaux de Paris) has increased. The main purpose of this study is to improve follow-up for patients treated with anti-retroviral prophylaxis following a known sexual or blood exposure. An investigation based on 5 markers of a targeted clinical audit form ("drop-outs" or lost to follow-up, conduct of HIV serology tests, traceability of clinical, biological and compliance monitoring) was carried out. A review of practices was conducted on the basis of an analysis of patient cases over a six-month period, followed by the implementation and evaluation of corrective measures over a two-year period. A significant decline in the number of patients lost to follow-up was observed. The study shows a significant improvement in other markers: serological follow-up, compliance traceability, and clinical and biological monitoring. These results were observed between 2005 and 2007. Two distinctive effects were identified: improvement in patient care management and the quality of care, and the empowerment of actors, thereby ensuring a certain continuity of action. The decline in the rate of lost to follow-up patients and improved monitoring of compliance and iatrogenic risks confirm these effects. The overall approach is incorporated into an evaluation of professional practices.

[Medical education in France and Canada: is there a best system?]. / Formation médicale en France et au Canada. L'un des deux systèmes est-il meilleur que l'autre?

We have compared the conception and organization of medical education systems in France and Canada, taking into consideration key means and processes including the organization of curriculum, the selection of students, certification and licensure. The major objective of this comparison is to illustrate the degree to which the organization of medical education is influenced by the specific history and culture of each country. This is particularly important in an era of increasing internationalization in medical education. In Canada, a federalist orientation means a great deal of freedom for each province to determine its own criteria for medical licensure, and for each faculty of medicine to determine its own selection criteria and curriculum organization. Meanwhile, the evaluation of graduates of medical schools and later of specialties is organized at a national level. France, on the other hand, is much more centrist, and controls the "input" of students to medical schools and the nature of their curriculum. However, France allows each faculty of medicine to deliver a diploma that authorizes physician graduates to practice, without an evaluation of student performance at a national level. We show how the selection and evaluation of students in France are influenced by the French Revolutionary principles of "liberté" and the education of a national "elite", while in Canada the goals of "equity" and the guarantee of a level of "minimum competence" under pin a very different system. In conclusion, we highlight the important of taking into consideration these factors before undertaking reform of educational systems or transferring methods from one country to another.

[Selection of medical students: a process influenced by history and culture]. / Sélection des étudiants en médecine: une procédure influencée par la liberté d'accès aux études et l'égalité des chances.

OBJECTIVES: Every medical school in the world has a procedure for selecting students for medical studies, intended to identify those who are capable of becoming doctors, according to specific expectations. The means of selection, however, vary significantly from one school to another and from one country to another. France has chosen to undertake this selection at the end of the first year of university studies. This method is costly in that it requires medical schools to organize a whole year of curriculum for thousands of students, fewer than 30% of whom will be chosen for further medical studies. It is also counterproductive for students, a significant proportion of whom are not admitted despite above-average results on their examinations. METHODS: This article examines the historical and cultural factors that have led to the current organization. Our study is based on an analysis of government archives dealing with medical education reforms from 1905-1970. RESULTS: We argue that the format of the current selection process is linked to ideas of freedom of access for students and of equal opportunity for admission to medical studies. CONCLUSION: We conclude that for any reform to be acceptable it must take into account the historical and cultural elements (for the most part stemming from the French Revolution) that form the basis of the current system.

[The differential diagnosis of cognitive disorders in general practice: dementia and delirium]. / Le diagnostic différentiel des troubles cognitifs en médecine de premier recours.

Cognitive deficits are frequently encountered in primary care settings, in particular in the elderly. Screening of these deficits is recommended and aims at identifying subjects who are likely to benefit from treatment. In the event of either positive screening or cognitive complaint, further somatic, cognitive, psychopathological, and functional assessment should be performed and possible consequences on family caregivers sought. Laboratory tests and neuro-imaging are often necessary. This multi-dimensional assessment may require the expertise of a memory clinic to distinguish normal aging, mild cognitive impairment, and to identify the different organic and functional aetiologies of the dementia syndrome and delirium.

Country report: medical education in France.

CONTEXT: The last 10 years have represented a period of significant reform within both the health care and education systems in France. In terms of its workforce, France faces a shortage of doctors, particularly in primary care. METHODS: This paper examines the French medical curriculum, student selection, licensure and continuing medical education and discusses the challenges currently facing French medical faculties. RESULTS: The French medical curriculum is defined nationally, with methods adapted at medical school level. There has been some uptake of innovative methods such as problem-based learning, skills-based teaching and performance-based assessment. However, traditional didactic teaching of scientific medicine and the apprenticeship model remain dominant. France uses a unique method of selection, which is the subject of much debate. Following a general year, medical students are subject to a selection examination that permits only a small number to continue studies. Similarly, at the end of medical school, a written test is used to rank students for the purpose of matching to specialty training. France has no national colleges or licensing authorities and thus authorisation to practise rests on the diploma delivered by each faculty of medicine. From 2005, continuing medical education became compulsory for all doctors. It includes the evaluation of medical practice. CONCLUSIONS: French faculties of medicine face several challenges, including: rising numbers of students without a commensurate growth in the number of faculty members; an increasing emphasis on multidisciplinary health care; a drive towards mandatory continuing education and performance-based outcomes, and the development of national selection examinations that are knowledge-based.