Membranoproliferative glomerulonephritis after intravitreal vascular growth factor inhibitor injections: A case report and review of the literature.

Systemic administration of agents that inhibit vascular endothelial growth factor (VEGF) and therefore vascular proliferation is often used to treat various cancers. However, these agents are associated with a number of side effects, including proteinuria and renal injury. Intravitreal injection of anti-VEGF agents has become the cornerstone of macular disease treatment. Since these agents cross the blood-retina barrier and enter the circulation, systemic side effects have been reported. We report the novel case of a 57-year-old patient who presented with macular oedema secondary to central retinal vein occlusion, underwent three monthly loading-dose injections with the anti-VEGF agent ranibizumab, and 2 weeks after the second injection presented with biopsy-verified membranoproliferative glomerulonephritis. Twelve weeks after presenting with renal failure and 10 weeks after his last anti-VEGF injection, the patient demonstrated spontaneous recovery of his kidney function. The patient had a history that promoted renal fragility, including hypertension, liver transplantation 6 years earlier for alcohol-related cirrhosis and new-onset diabetes mellitus after transplant. Our literature review and case suggest that although adverse renal events after intravitreal anti-VEGF injections are very rare, ophthalmologists and nephrologists should be aware of this risk.

[Urticaria : updates of a chronic condition]. / Urticaire : nouveautés et chronicité.

Urticaria is a frequent disease and exist in an acute or chronic form. The pathophysiology, focused on mast cells and histamine among other mediators, is an active research field but still poorly understood. The medical care focus on the avoidance of triggers and aggravating factors. The recommended drug therapy has not changed. The acknowledgment of chronic urticaria as a chronic disease is essential according to the last international recommendations. Acknowledging the disease morbidity and consequences, in a private, social or professional environment, allows better medical care for patients. The latter should get support on the long term, thanks to multiple diagnostic and therapeutic guidance tools.

L'urticaire est une maladie fréquente pouvant être aiguë ou chronique. Sa physiopathologie, centrée sur les mastocytes et de multiples médiateurs dont l'histamine, fait l'objet de nombreuses recherches mais reste encore mal connue. La prise en charge se concentre sur l'éviction des facteurs déclencheurs et aggravants. Les traitements médicamenteux recommandés n'ont pas changé. La reconnaissance de l'urticaire chronique en tant que maladie chronique est centrale dans les dernières recommandations internationales. La reconnaissance de la morbidité et des conséquences de la maladie, dans les cadres privé, social ou professionnel, permet une meilleure prise en charge des patient-es. Ces dernier-ères devront être accompagné-e-s sur le long terme, grâce à plusieurs outils diagnostiques et d'accompagnement thérapeutique.

[Pilot project for a Medical Home in Geneva]. / Projet pilote de maison de santé à Genève.

The aging of the population and the increase in chronic diseases are overloading our healthcare system, with complex patients requiring more care. To meet their needs and keep them at home, interprofessional team management is necessary. The Directorate of Health of the Canton of Geneva issued a call for tenders to set up Medical Homes. We responded, were selected and have been building its various components over the past two years: identification of complex patients, setting up coordinated teams, the shared care plan, coordination with the medical assistant and the financing system. The preliminary results show its success, yet specific project management skills and financial resources are needed.

Le vieillissement de la population et l'augmentation des maladies chroniques surchargent notre système de santé, les patients complexes demandant plus de soins. Pour répondre à leurs besoins et les maintenir à domicile, une prise en charge en équipe interprofessionnelle est nécessaire. La Direction générale de la santé du canton de Genève a fait un appel d'offres pour mettre en place des maisons de santé (MdS). Nous y avons répondu et construisons depuis deux ans ses différents composants : l'identification des patients complexes, la mise en place d'équipes coordonnées, le plan de soins partagé, la coordination avec l'assistante médicale et le système de financement. Si les résultats démontrent l'intérêt de la MdS, des compétences spécifiques en gestion de projet et des ressources financières restent nécessaires.

[Management of chronic heart failure: updates and implications for the primary care physician]. / Prise en charge de l'insuffisance cardiaque chronique - Nouveautés et implications pour le médecin de premier recours.

The latest recommendations of the European Society of Cardiology on chronic heart failure published in 2021 propose several new concepts. The main changes include a revision of the classification but most importantly modifications in the therapeutic management, especially concerning the first-line treatment of heart failure with reduced ejection fraction. Since heart failure affects approximately 2% of the general population, these new recommendations will have a definite impact on the practice of primary care physicians. Integrating these changes into heart failure management is essential to improve the prognosis, symptoms and the quality of life of patients. This article presents the most significant changes and their implications for primary care physicians.

Les recommandations de la Société européenne de cardiologie sur l'insuffisance cardiaque chronique, parues en 2021, proposent plusieurs nouveaux concepts. On relève comme changements principaux une révision de la classification ainsi que des modifications dans la prise en charge thérapeutique, notamment concernant le traitement de première ligne de l'insuffisance cardiaque (IC) à fraction d'éjection réduite. L'IC touchant environ 2% de la population générale, ces nouvelles recommandations auront un impact certain sur la pratique clinique des médecins de premier recours. Intégrer ces nouveautés dans la prise en charge est essentiel afin d'améliorer le pronostic, les symptômes et la qualité de vie des patients. Cet article présente ces modifications majeures et leurs implications pour la pratique de premiers recours.

The impact of chronic disease management on primary care doctors in Switzerland: a qualitative study.

BACKGROUND: Patient-centeredness and therapeutic relationship are widely explored as a means to address the challenge of chronic disease and multi-morbidity management, however research focusing on the perspective of doctors is still rare. In this study, we aimed to explore the impact of the patient's chronic disease(s) on their healthcare provider. METHODS: A qualitative approach was taken using semi-structured interviews with general practitioners working in outpatient clinics either in individual practices or in a hospital setting in Geneva, Switzerland. Codes were developed through an iterative process and using grounded theory an inductive coding scheme was performed to identify the key themes. Throughout the analysis process the research team reviewed the analysis and refined the coding scheme. RESULTS: Twenty interviews, 10 in each practice type, allowed for saturation to be reached. The following themes relevant to the impact of managing chronic diseases emerge around the issue of feeling powerless as a doctor; facing the patient's socio-economic context; guidelines versus the reality of the patient; time; and taking on the patient's burden. Primary care practitioners face an emotional burden linked with their powerlessness and work conditions, but also with the empathetic bond with their patients and their circumstances. Doctors seem poorly prepared for this emotional strain. The health system is also not facilitating this with time constraints and guidelines unsuitable for the patient's reality. CONCLUSIONS: Chronic disease and multi-morbidity management is a challenge for healthcare providers. This has its roots in patient characteristics, the overall health system and healthcare providers themselves. Structural changes need to be implemented at different levels: medical education; health systems; adapted guidelines; leading to an overall environment that favors the development of the therapeutic relationship.

[Ambulatory emergencies and Tarmed on 2018]. / Urgences ambulatoires et Tarmed 2018.

The practice of consulting with emergency medical centers without an appointment as an alternative to visiting one's doctor has been steadily increasing in Switzerland. Fully integrated in the Swiss health system and attending without appointment to late hours, these establishments can deal with a wide variety of medical and surgical emergencies. However, considered first recourse medical centers, they apply billing rates based on those of general practitioner offices. With the 2018 overhaul of the Tarmed, the billing of some services provided in an emergency center become intricate, particularly those involving time-consuming care or extended observation.

Le recours à la consultation d'urgence, ou sans rendez-vous, est en constante augmentation dans le paysage médical suisse. Les centres d'urgences sont des partenaires du système de santé qui accueillent sans rendez-vous et sur des horaires étendus des urgences médico-chirurgicales variées. Ils sont affiliés à la médecine de premier recours et la tarification des prestations se base sur celle d'un cabinet de médecine générale. Avec la révision du Tarmed 2018 et ses limitations, la facturation de certaines prestations délivrées dans un centre d'urgences ambulatoires devient problématique, en particulier pour les cas nécessitant des soins longs ou une surveillance prolongée.

Partnerships in global health and collaborative governance: lessons learnt from the Division of Tropical and Humanitarian Medicine at the Geneva University Hospitals.

BACKGROUND: In 2007 the "Crisp Report" on international partnerships increased interest in Northern countries on the way their links with Southern partners operated. Since its establishment in 2007 the Division of Tropical and Humanitarian Medicine at the Geneva University Hospitals has developed a variety of partnerships. Frameworks to assess these partnerships are needed and recent attention in the field of public management on collaborative governance may provide a useful approach for analyzing international collaborations. METHODS: Projects of the Division of Tropical and Humanitarian Medicine were analyzed by collaborators within the Division using the model proposed by Emerson and colleagues for collaborative governance, which comprises different components that assess the collaborative process. RESULTS: International projects within the Division of Tropical and Humanitarian Medicine can be divided into four categories: Human resource development; Humanitarian response; Neglected Tropical Diseases and Noncommunicable diseases. For each of these projects there was a clear leader from the Division of Tropical and Humanitarian Medicine as well as a local counterpart. These individuals were seen as leaders both due to their role in establishing the collaboration as well as their technical expertise. Across these projects the actual partners vary greatly. This diversity means a wide range of contributions to the collaboration, but also complexity in managing different interests. A common definition of the collaborative aims in each of the projects is both a formal and informal process. Legal, financial and administrative aspects of the collaboration are the formal elements. These can be a challenge based on different administrative requirements. Friendship is part of the informal aspects and helps contribute to a relationship that is not exclusively professional. CONCLUSION: Using collaborative governance allows the complexity of managing partnerships to be presented. The framework used highlights the process of establishing collaborations, which is an element often negated by other more traditional models used in international partnerships. Applying the framework to the projects of the Division of Tropical and Humanitarian Medicine highlights the importance of shared values and interests, credibility of partners, formal and informal methods of management as well as friendship.

[Materializing interdisciplinary outpatient management of complex situations]. / Concrétiser la prise en charge interdisciplinaire ambulatoire de la complexité.

Patient management is becoming increasingly complex, particularly because of the growing prevalence ofchronic diseases and ageing populations. The Swiss health care system is fragmented and struggles to coordinate care provided by professionals from multiple disciplines or working for different institutions. Models to improve health care of complex situations are available that particularly advocate a coordinated team approach. This article presents an action-research designed to empower health professionals to manage complex situations in outpatient settings by means of this type of approach. Health professionals - good practice leaders in the medical and nursing fields in the Geneva Canton (Switzerland) - explored complex management situations, as well as facilitating components and obstacles. A team approach is essential to manage all of the patient's issues, to take the patient's priorities into account, and to work on a joint care plan. The legitimate role of each member of this team is highlighted, together with new roles for existing practices: informing and motivating the patient, highlighting and supporting care givers, coordination by nurses. The creation of such teams, and implementation of these roles involve new processes, which require financing of coordination as well as development of new methods of interdisciplinary management, particularly novel information technology tools.

Beyond the virus: Ensuring continuity of care for people with diabetes during COVID-19.

The current COVID-19 pandemic is a major concern for the diabetes community. A meta-analysis in China found that the proportions of people with COVID-19 and diabetes was 9.7% and that having diabetes resulted in a two-fold increased risk of having a severe case. Global guidance on confinement measures for the prevention of COVID-19 have a particular emphasis on vulnerable populations which include people with diabetes. These recommendations are coherent to avoid the spread of SARSCoV-2 infection, but are in contradiction with comprehensive diabetes care, which requires regular patient-provider interactions for patient education, prescriptions and possible management of complications or mental health. Moreover, confinement drives risk for unhealthy diets, decreased physical activity, mental health related concerns, in parallel to delayed care-seeking due to fear of contracting COVID-19. Another weakness in the current COVID-19 response is the focus on hospital care which overlooks the importance of Primary Care in guaranteeing continuity of care. Ensuring the availability of insulin, other medicines, self-monitoring and diagnostic tools is another challenge. These are all global concerns for the diabetes community, as well as for those suffering from other chronic conditions. Undoubtedly, the global priority is to contain the spread and impact of COVID-19. However, health systems still need to meet the needs of the entire population, including individuals with diabetes. Clear guidance for preparedness, crisis and post-crisis management of diabetes and chronic diseases during mass disruptions to health systems are lacking. Therefore, in parallel to the epidemic response efforts to ensure existing healthcare services keep running should be supported to avoid health consequences that might be worse than the epidemic itself. This includes targeted messaging for people with diabetes and vulnerable populations with regards to possible risk of infection as well as their disease-related management; continued support via telephone, video conferencing or even home visits; ensuring access to insulin and other medicines and supplies both nationally and individually; and most importantly, preparing for the future.

[General internal medicine: review of year 2009 from the ambulatory perspective (1)]. / Nouveautés en médecine interne générale ambulatoire (1).

Staff physicians of the Division of Primary care medicine of the University Hospitals of Geneva selected 9 articles published in year 2009 based on that they either brought new insights into the handling of current medical problems or that they broadened current knowledge of complex situations in the ambulatory care setting. Their field covers medication treatment for depression, neuropathic pain, facial palsy, osteoporosis, congestive heart failure, as well as during pregnancy. Updates on cardiovascular prevention, on screening of alcohol abuse and on the impact of social determinants on health are also provided.

[Interprofessional training: a key component of integrated care]. / Formation interprofessionnelle: une exigence pour une approche intégrée des soins?

The aging of the population and the rising prevalence of chronic diseases mandate improved collaboration among different health professionals. Interprofessional training is one way to improve it, because it encourages health professionals to learn with, from and about one another and respects the integrity and contribution of each profession. Few medical or health professional schools develop such dimensions in their curricula, while postgraduate and continuous training seldom offer such opportunities. Institutional and political commitment may significantly contribute to the development of such dimensions in medical and other health profession education. Having a same mission, sharing responsibility for the team success, defining clear member roles and task, and communicating on a routine basis represent other key factors of success.

Mechanical Modeling of a Keratoconic Cornea.

PURPOSE: We created a laboratory model of a cornea that was subjected to various pressures and thermal and mechanical factors to better understand the genesis of keratoconus deformation. METHODS: A steel base allowed for fixation of circular multilaminated patches of araldite (10 cm in diameter, 5 mm thick) in which the corneal anatomy was modeled. The model was plunged into a steam room (374°F/3 bars of pressure for 1 h) to ensure thermal homogeneity and was subjected to pressure using compressed air. Three models were assessed: a fault-free model with no lesion (model 1), and 2 models with a defect. The first of the defective models (model 2) had an external crack-type lesion (1 cm long; 1 mm deep). The second defective model (model 3) had one quarter thinned down using abrasive sandpaper (thickness reduced by 30%-40%). RESULTS: For model 1, which represented a healthy cornea, homogeneous modification was noted when examined under polarized light. In model 2, no excessive deformation was noticed, but there were stress lines at the edge of the lesion. Model 3 had a deformity, similar to keratoconic deformation. CONCLUSIONS: Our findings suggest that the disease progresses under environmental stresses, but only when there is an initial defect, and especially when there is a thinning down defect. This thinning down defect may be induced by continual eye rubbing.

Development of youth friendly family medicine services in Bosnia and Herzegovina: protocol for a cluster randomized controlled trial.

BACKGROUND: Young people face many barriers in accessing health services that are responsive to their needs. The World Health Organization has led a call to develop services that address these barriers, i.e. youth-friendly health services. Addressing the needs of young people is one of the priorities of Foundation fami, an organisation working in collaboration with the Swiss Federal Department of Development and Cooperation and Geneva University Hospitals to develop quality family medicine services in Bosnia and Herzegovina. This paper describes the design of a trial to assess the effectiveness of a multifaceted intervention involving family medicine teams (primary care doctors and nurses) to improve the youth-friendliness of family medicine services in Bosnia and Herzegovina. METHODS/DESIGN: This is a stratified cluster randomised trial with a repeated cross-sectional design involving 59 health services in 10 municipalities of the canton of Zenica in Bosnia and Herzegovina. Municipalities were the unit of randomisation: five municipalities were randomised to the intervention arm and five to a wait-list control arm. Family medicine teams in the intervention arm were invited to participate in an interactive training program about youth-friendly service principles and change processes within their service. The primary outcome was the youth-friendliness of the primary care service measured using the YFHS-WHO + questionnaire, a validated tool which young people aged 15 to 24 years complete following a family medicine consultation. A total of 600 young people aged 15 to 24 years were invited to participate and complete the YFHS-WHO + questionnaire: 300 (30 per municipality) at baseline, and 300 at follow-up, three to five months after the training program. DISCUSSION: The results of this trial should provide much awaited evidence about the development of youth-friendly primary care services and inform their further development both in Bosnia and Herzegovina and worldwide. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry_ ACTRN12610000142033.

YFHS-WHO+ Questionnaire: validation of a measure of youth-friendly primary care services.

PURPOSE: To develop and validate a research tool to measure the youth friendliness of primary care services from a client's perspective. METHODS: The questionnaire was initially developed in English, but as it was to be used in Bosnia and Herzegovina (BiH), it was validated in the language of this country. Items were adapted from two sources: a reproductive health services quality improvement questionnaire from the World Health Organization, and an Australian survey used to assess youth-friendly primary care services. An English-speaking international panel reviewed the list of items for face validity. After translation-back translation, the questionnaire was pretested with adolescent patients from a family practice in BiH. The stability and construct validation were then conducted with 60 young people from six different health services in BiH. Items for the final questionnaire were selected using item response theory. RESULTS: The validation and item response analysis led to a 49-item tool. Test-retest stability at 1 week was excellent (mean κ: .93). Construct validation was supported by the fact that services with the highest and the lowest scores on the questionnaire were also those that had many and few, respectively, youth-friendly characteristics, as assessed by experts, on a predefined evaluation grid. Services seeing a higher proportion of adolescents also had higher scores on the questionnaire. CONCLUSIONS: This study supports the validity of the YFHS-WHO+ questionnaire for assessing the level of youth friendliness of family medicine services for research purposes. Further validations in English and French will allow wider use of this tool in the future.

Chronic disease management in Sub-Saharan Africa: whose business is it?

Public health specialists and clinicians alike agree that Humanity faces a global pandemic of chronic diseases in the 21(st) century. In this article we discuss the implications of this pandemic on another global issue, the health workforce. Because both issues are particularly acute in Sub-Saharan Africa (SSA), we will focus on this region and use Cameroon as a case in point. We first gauge the epidemic of chronic conditions in SSA. We then discuss the implications of chronic conditions for the reshaping of health systems and the health workforce. We conclude by making a strong case for the building up and strengthening the health workforce, insisting on the crucial role of nurses, their training, and involvement in chronic disease management.