[New developments and perspectives in outpatient general internal medicine]. / Nouveautés et perspectives en médecine interne générale ambulatoire.

Several studies have been published in 2023, in the field of general internal medicine, addressing various aspects of health and covering topics ranging from hormonal treatment of menopause to the management of chronic and acute diseases. A selection of articles was chosen for this update in outpatient general internal medicine, showing recent studies on outpatient care of patients (treatment, follow-up). The summary of articles is supplemented this year by a table of medical recommendations published in 2023, modestly proposed, and covering various areas. These guidelines, most of them from North America, show advances in the care and monitoring of outpatients, and should be interpreted in light of the various recommendations in Switzerland.

En 2023, plusieurs études ont été publiées dans le champ de la médecine interne générale, abordant divers aspects de la santé et couvrant des sujets allant du traitement hormonal de la ménopause à la gestion de maladies chroniques et aiguës. Un bouquet d'articles a été choisi pour cette mise à jour en médecine interne générale ambulatoire, traitant d'études récentes sur la prise en charge en ambulatoire (traitement, suivi) des patientes et patients. Le résumé d'articles est complété d'un tableau de nouvelles recommandations médicales de 2023, humblement proposé, couvrant divers domaines. Ces guidelines, pour la plupart américaines, montrent les avancées dans la prise en charge et le suivi des patientes et patients en ambulatoire, et sont à interpréter à la lumière des différentes recommandations en Suisse.

One-year persistent symptoms and functional impairment in SARS-CoV-2 positive and negative individuals.

BACKGROUND: Persistent symptoms of SARS-CoV-2 are prevalent weeks to months following the infection. To date, it is difficult to disentangle the direct from the indirect effects of SARS-CoV-2, including lockdown, social, and economic factors. OBJECTIVE: The study aims to characterize the prevalence of symptoms, functional capacity, and quality of life at 12 months in outpatient symptomatic individuals tested positive for SARS-CoV-2 compared to individuals tested negative. METHODS: From 23 April to 27 July 2021, outpatient symptomatic individuals tested for SARS-CoV-2 at the Geneva University Hospitals were followed up 12 months after their test date. RESULTS: At 12 months, out of the 1447 participants (mean age 45.2 years, 61.2% women), 33.4% reported residual mild to moderate symptoms following SARS-CoV-2 infection compared to 6.5% in the control group. Symptoms included fatigue (16% vs. 3.1%), dyspnea (8.9% vs. 1.1%), headache (9.8% vs. 1.7%), insomnia (8.9% vs. 2.7%), and difficulty concentrating (7.4% vs. 2.5%). When compared to the control group, 30.5% of SARS-CoV-2 positive individuals reported functional impairment at 12 months versus 6.6%. SARS-CoV-2 infection was associated with the persistence of symptoms (adjusted odds ratio [aOR] 4.1; 2.60-6.83) and functional impairment (aOR 3.54; 2.16-5.80) overall, and in subgroups of women, men, individuals younger than 40 years, those between 40-59 years, and in individuals with no past medical or psychiatric history. CONCLUSION: SARS-CoV-2 infection leads to persistent symptoms over several months, including in young healthy individuals, in addition to the pandemic effects, and potentially more than other common respiratory infections. Symptoms impact functional capacity up to 12 months post infection.

[New guidelines for the management of low back pain in general practice - «Stop pain without drugs¼]. / Nouvelles recommandations de prise en charge des lombalgies communes en cabinet - «Stop pain without drugs¼.

The so-called 4P medicine, preventive, predictive, participatory, and personalized, which places the patient at the center has influenced the latest recommendations for the management of common low back pain. The management of low back pain in the acute, subacute, and chronic phase is currently based on the profile of each patient with their risk factors, their prognosis, and the respect of their preferences, promoting an integrative approach. During the first consultation, it is important to identify factors of moderate to poor prognosis, including kinesiophobia and to search for false beliefs, through a detailed medical history. The non-pharmacological approaches are more effective and have less side effects than the medications. Reassurance and therapeutic education are the first steps in good management of common low back pain.

La médecine dite des 4P, préventive, prédictive, participative et personnalisée, a influencé les dernières recommandations de prise en charge des lombalgies communes. La prise en charge de ces dernières en phases aiguë, subaiguë et chronique se base sur le profil de chaque patient avec ses facteurs de risque, son pronostic et le respect de ses préférences, en valorisant une approche intégrative. Dès la première consultation, il est important d'identifier des facteurs de pronostic moyen à mauvais dont la kinésiophobie et la recherche de fausses croyances grâce à une anamnèse détaillée. Les approches non pharmacologiques sont plus efficaces et ont moins d'effets secondaires que les médicaments. La réassurance et l'éducation thérapeutique sont les ingrédients d'une bonne prise en charge des lombalgies communes.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Viral Load Kinetics in Symptomatic Children, Adolescents, and Adults.

SARS-CoV-2 viral load (VL) can serve as a correlate for infectious virus presence and transmission. Viral shedding kinetics over the first week of illness for symptomatic children (n = 279), adolescents (n = 639), and adults (n = 7109) show VLs compatible with infectious virus presence, with slightly lower VL in children than adults.

Vulnerable patients forgo health care during the first wave of the Covid-19 pandemic.

During the first wave of the Covid-19 pandemic, access to health care was limited, and patients encountered important delays for scheduled appointments and care. Empirical data relying on patients' reports of forgoing health care are scarce. This study investigated Covid-19-related self-reports of forgoing health care in a sample of vulnerable outpatients in Geneva, Switzerland. We collected data from 1167 adult outpatients, including clinically vulnerable patients (with chronic diseases), geriatric patients (involved in a health care network for people aged 60 or older), and socially vulnerable patients (involved in a migrant health program or a mobile outpatient community care center) in June 2020. Data on sociodemographic factors, forgoing health care, and anti-SARS-CoV-2 antibodies were collected. Of the patients, 38.5% reported forgoing health care. Forgoing health care was more frequent for younger patients, women, patients with a low level of education, and patients with a chronic disease (p < .001). There was no significant association between the presence of anti-SARS-CoV-2 antibodies and forgoing health care (p = .983). As the decrease in routine management of patients might have important and unpredictable adverse health consequences, avoiding delayed health care is crucial.

Deep learning diagnostic and risk-stratification pattern detection for COVID-19 in digital lung auscultations: clinical protocol for a case-control and prospective cohort study.

BACKGROUND: Lung auscultation is fundamental to the clinical diagnosis of respiratory disease. However, auscultation is a subjective practice and interpretations vary widely between users. The digitization of auscultation acquisition and interpretation is a particularly promising strategy for diagnosing and monitoring infectious diseases such as Coronavirus-19 disease (COVID-19) where automated analyses could help decentralise care and better inform decision-making in telemedicine. This protocol describes the standardised collection of lung auscultations in COVID-19 triage sites and a deep learning approach to diagnostic and prognostic modelling for future incorporation into an intelligent autonomous stethoscope benchmarked against human expert interpretation. METHODS: A total of 1000 consecutive, patients aged ≥ 16 years and meeting COVID-19 testing criteria will be recruited at screening sites and amongst inpatients of the internal medicine department at the Geneva University Hospitals, starting from October 2020. COVID-19 is diagnosed by RT-PCR on a nasopharyngeal swab and COVID-positive patients are followed up until outcome (i.e., discharge, hospitalisation, intubation and/or death). At inclusion, demographic and clinical data are collected, such as age, sex, medical history, and signs and symptoms of the current episode. Additionally, lung auscultation will be recorded with a digital stethoscope at 6 thoracic sites in each patient. A deep learning algorithm (DeepBreath) using a Convolutional Neural Network (CNN) and Support Vector Machine classifier will be trained on these audio recordings to derive an automated prediction of diagnostic (COVID positive vs negative) and risk stratification categories (mild to severe). The performance of this model will be compared to a human prediction baseline on a random subset of lung sounds, where blinded physicians are asked to classify the audios into the same categories. DISCUSSION: This approach has broad potential to standardise the evaluation of lung auscultation in COVID-19 at various levels of healthcare, especially in the context of decentralised triage and monitoring. TRIAL REGISTRATION: PB_2016-00500, SwissEthics. Registered on 6 April 2020.

[I'm having trouble communicating with my patient at the emergency unit: what tools are available ?] / J'ai de la peine à communiquer avec mon patient aux urgences : quels sont les outils disponibles ?

Today's healthcare systems are increasingly confronted with communication problems between allophone patients and health care staff. Geneva, due to its cosmopolitan character, is at the core of this phenomenon. Several studies attest to the negative effects of the language barrier and its consequences on the quality of care, ethics, safety and financial costs. Different tools, such as semi-professional interpreters or translation applications, make it possible to deal with situations where a lack of communication can be crucial. However, they have many drawbacks. Therefore, the Geneva University Hospitals, in collaboration with the Faculty of Translation and Interpretation, have developed a reliable and innovative tool for the translation of medical language.

Les systèmes de santé actuels sont de plus en plus confrontés à des problèmes de communication entre des patients allophones et le personnel soignant. Genève, du fait de son aspect cosmopolite, est au centre de ce phénomène. Plusieurs études attestent des effets négatifs de la barrière de la langue et ses conséquences sur la qualité des soins, l'éthique, la sécurité et les coûts financiers. Différents outils, comme les interprètes semi-professionnels ou les applications de traduction, permettent de faire face à des situations où un défaut de communication peut s'avérer crucial. Cependant, ils présentent de nombreux inconvénients. Par conséquent, les HUG, en collaboration avec la Faculté de traduction et d'interprétation, ont développé un outil fiable et innovant pour la traduction du langage médical.

Four versus six weeks of antibiotic therapy for osteoarticular infections after implant removal: a randomized trial.

BACKGROUND: The optimal duration of antibiotic therapy for treating orthopaedic implant infections after surgical drainage and complete implant removal is unknown. METHODS: This was a single-centre, unblinded, prospective trial randomizing (1:1) eligible patients to either 4 or 6 weeks of systemic, pathogen-targeted antibiotic therapy. Clinical trial registration number: ClinicalTrials.gov (NCT0362209). RESULTS: We analysed 123 eligible patients (62 in the 4 week antibiotic arm and 61 in the 6 week arm) in the ITT analysis. The patients' median age was 64 years, 75 (61%) were men and 38 (31%) were immunocompromised. The most common types of infection treated included: two-stage exchange procedure for prosthetic joint infection (n = 38); orthopaedic plate infection (44) and infected nail implants (11). The median duration of post-explant intravenous antibiotic therapy was 4 days. Overall, 120 episodes (98%) were cured microbiologically and 116 (94%) clinically after a median follow-up period of 2.2 years. During follow-up, four patients had a clinical recurrence with a pathogen other than the initial causative agent. We noted recurrence of clinical infection in four patients in the 4 week arm and three patients in the 6 week arm (4/62 versus 3/61; χ2 test; P = 0.74); in all cases, this occurred at around 2 months following the end of antibiotic treatment. CONCLUSIONS: We found no statistically significant difference in the rates of clinical or microbiological remission between patients randomized to only 4 compared with 6 weeks of systemic antibiotic therapy after removal of an infected osteoarticular implant.

Patients' time perception in the waiting room of an ambulatory emergency unit: a cross-sectional study.

BACKGROUND: Patient satisfaction has become an increasingly important element in a service-oriented healthcare market. Although satisfaction is influenced by many factors, the waiting time to be seen by medical staff has been shown to be one of the key criteria. However, waiting is not an objective experience and several factors can influence its perception. METHODS: We conducted a questionnaire-based, cross-sectional study among patients attending the emergency unit of a Swiss university hospital in order to explore the key factors influencing wait perception. RESULTS: A total of 509 patients participated in the study. Appropriate assessment of emergency level by caregivers, the feeling of being forgotten, respect of privacy, and lack of information on the exact waiting time were identified as significant variables for wait perception. CONCLUSIONS: Our study confirmed the existence of a 'golden hour' when the patient is willing to wait until the medical encounter. In case the wait cannot be limited, an appropriate assessment of the emergency level by caregivers and avoiding the patients of feeling being forgotten are very important factors to avoid a negative perception of the waiting time before seeing a doctor. TRIAL REGISTRATION: (ID REQ-2016-00555).

[Knowing how to deliver healthcare is now as important as having medical knowledge]. / Savoir délivrer les soins est -désormais aussi important que d'avoir -les -connaissances médicales.

Traditionally, the doctor has focused his efforts on mastering medical knowledge. Given the challenges facing him, the medical institutions and the society, it becomes clear that his concern must also be about how this medical knowledge hits the patients and the general population. Knowing how to deliver our care is now as important as having the medical knowledge ! In this article, we present new models of healthcare delivery that we implemented or plan to implement in Geneva, Switzerland.

Traditionnellement, le médecin a concentré ses efforts sur la maîtrise de la connaissance médicale. Face aux enjeux qui se présentent à lui, aux institutions et à la société, il devient évident que sa préoccupation doit également se porter sur la façon dont cette connaissance médicale atteint les patients et la population en général. Savoir délivrer nos soins est désormais aussi important que d'avoir les connaissances médicales ! Dans cet article, nous présentons des nouveaux modèles de soins de santé que nous avons mis en œuvre ou prévoyons de mettre en œuvre à Genève, en Suisse.

Admission rates in emergency departments in Geneva during tennis broadcasting: a retrospective study.

BACKGROUND: Literature provides mixed results regarding the influence of large-scale sporting events on emergency department attendance. To contribute to the research on the subject, we sought to evaluate whether the broadcasting of major tennis tournaments, one of the most popular sports in Switzerland, has an impact on patient admission rates in emergency units in Geneva including 1) type of match 2) the role of a Swiss player, 3) degree of triage, 4) reason of attendance and 5) age of patients. METHODS: Admission rates between periods with tennis matches regarding the semi-finals and finals of 3 major tennis tournaments were compared to equivalent periods without matches from May 2013 to August 2017. Patient admission data was retrieved retrospectively from administrative databases of two Outpatient Emergency Units in Geneva. Patients' admission rates in periods with and without a tennis match were investigated using a negative binomial regression model with mixed effects. RESULTS: We observed a statistically significant decrease (- 10%, 95% CI -17 to - 2, p = 0.015) in admission rates in periods with a tennis match compared to periods without a tennis match, more pronounced during finals (- 15%, 95% CI -26 to - 3, p = 0.017) than during semi-finals (- 7%, - 16 to 2, p = 0.13). In addition, this effect was more pronounced in patients aged between 26 to 64 years of age, a category representing professionnally active people. No modification in the admission rates was detected in the hours preceding and following the matches, nor in type of consultations (traumatology vs non traumatology related admissions). CONCLUSION: Although modest, the results support the hypothesis that the broadcasting of large-scale sporting events such as tennis matches decreases admission rates in emergency units. Further research is required to explore for a potential causal 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.

[Vaccination of the elderly: how to communicate better]. / Vaccination de la personne âgée : quelques outils pour mieux communiquer.

Elderly people are high risk patients who need specific and tailored monitoring. Prevention is an important part in taking care of their well-being. The utility and efficacy of vaccination against influenza, diphtheria and tetanus are now indisputable for seniors, but coverage is still insufficient. This article will discuss the reasons for insufficient adherence, assuming that the general practitioner or another unit of the health care system has suggested a vaccination plan to the senior patient. With this goal in mind, we explored the various obstacles that may occur during the communication between physician and patient, be it due to old age (sensory loss), linked to cognitive decline or directly in relationship with the myths and beliefs surrounding vaccination, especially the vaccine against influenza.

Les personnes âgées forment une population à risque qui nécessite un suivi spécifique et adapté. La prévention constitue une partie importante de leur prise en charge. L'utilité et l'efficacité de la vaccination contre la grippe (influenza), la diphtérie et le tétanos ne sont plus à démontrer chez les seniors, cependant la couverture reste sous-optimale. Cet article va discuter les raisons d'une adhérence insuffisante, partant du principe qu'un acteur du système de soins a proposé un plan de vaccination à un senior. Pour ce faire, nous explorons les diverses barrières intervenant dans la communication médecin-malade, que ce soit celles liées au vieillissement (troubles sensoriels), au déclin cognitif ou en lien avec les mythes et croyances entourant la vaccination, en mettant l'accent sur le vaccin contre la grippe.

[2015 Update in ambulatory general internal medicine]. / Médecine interne générale ambulatoire.

This article summarizes a selection of recently published clinical and public health articles of interest to primary care physicians. It touches upon the use of new oral anticoagulant in atrial fibrillation, the efficacy of baclofen for alcohol dependence, the pathogen identification in community acquired pneumonia, the accuracy of emergency room diagnosis in patients with ill-defined symptoms, the relationship between sleep and susceptibility to infection, the benefits of smoking cessation and of a new vaccine against zoster in elderly patients and finally the distribution of health literacy in Europe.

Study protocol for assessment of the efficacy of calcium dobesilate versus placebo on SARS-CoV-2 viral load in outpatients with COVID-19 (CADOVID study): a randomised, placebo-controlled, double-blind, monocentric phase II trial.

INTRODUCTION: SARS-CoV-2 mainly infects respiratory endothelial cells, which is facilitated through its spike protein binding to heparan sulphate. Calcium dobesilate (CaD) is a well-established, widely available vasoactive and angioprotective drug interacting with heparan sulphate, with the potential to interfere with the uptake of SARS-CoV-2 by epithelial cells. The CADOVID trial aims to evaluate the efficacy and safety of CaD in reducing the SARS-CoV-2 viral load in non-hospitalised adult patients diagnosed with COVID-19, confirmed by a positive SARS-CoV-2 PCR, including its efficacy to reduce the impact of persistent COVID-19 symptoms. METHODS AND ANALYSIS: This is a randomised, placebo-controlled, double-blind, monocentric phase II trial. Enrolment began in July 2022. A total of 74 adult patients will be randomly allocated to the CaD arm or the placebo group with a 1:1 ratio, respectively. Participants in the intervention arm will receive two capsules of CaD 500 mg two times per day and the placebo arm will receive two matching capsules of mannitol 312.5 mg two times per day, with a treatment period of 7 days for both arms, followed by a 77-day observational period without treatment administration. Participants will be asked to complete secured online questionnaires using their personal smartphone or other electronic device. These include a COVID-19 questionnaire (assessing symptoms, temperature measurement, reporting of concomitant medication and adverse events), a COVID-19 persistent symptoms' questionnaire and the Short Form 12-Item (SF-12) survey. SARS-CoV-2 PCR testing will be performed on nasopharyngeal swabs collected on days 1, 4, 8 and 21. The primary endpoint is the reduction from baseline of SARS-CoV-2 viral load determined by RT-PCR at day 4. ETHICS AND DISSEMINATION: This trial has received approval by the Geneva Regional Research Ethics Committee (2022-00613) and Swissmedic (701339). Dissemination of results will be through presentations at scientific conferences and publication in scientific journals. TRIAL REGISTRATION NUMBER: NCT05305508; Clinicaltrials.gov; Swiss National Clinical Portal Registry (SNCTP 000004938).

[Efficient treatment of breakthrough pain in adults: the importance of timing and medication choice]. / Traiter efficacement la douleur incidente chez l'adulte: donner le bon antalgique au bon moment!

Diagnostic or therapeutic procedures can lead to breakthrough pain. Thanks to a wise choice of analgesic medication started in due time, this type of pain can be avoided or decreased. The therapeutic options of this preventive approach are presented according to the expected breakthrough pain type and intensity. Specific situations are presented through case discussions. The main pharmacokinetic information needed to prescribe the right analgesic at the right time is summarized in a convenient table. When associated to non-pharmacological measures such as empathy, patient positioning and high quality procedures, preventive analgesia provides patients the best possible relief from breakthrough pain.

Communicating in Emergency Settings: BabelDr or Telephone Interpreting?

In this paper, we present a study comparing two mediums that can be used to communicate with allophone patients: a speech-enabled phraselator (BabelDr) and telephone interpreting. To identify the satisfaction provided by these mediums and their pros and cons, we conducted a crossover experiment where doctors and standardized patients completed anamneses and filled in surveys. Our findings suggest that telephone interpreting offers better overall satisfaction, but both mediums presented advantages. Consequently, we argue BabelDr and telephone interpreting can be complementary.

Translating Medical Dialogues into Pictographs: An Approach Using UMLS.

This paper describes a first attempt to map UMLS concepts to pictographs as a resource for translation systems for the medical domain. An evaluation of pictographs from two freely available sets shows that for many concepts no pictograph could be found and that word-based lookup is inadequate for this task.

Use of a Semiautomatic Text Message System to Improve Satisfaction With Wait Time in the Adult Emergency Department: Cross-sectional Survey Study.

BACKGROUND: Many factors influence patient satisfaction during an emergency department (ED) visit, but the perception of wait time plays a central role. A long wait time in the waiting room increases the risk of hospital-acquired infection, as well as the risk of a patient leaving before being seen by a physician, particularly those with a lower level of urgency who may have to wait for a longer time. OBJECTIVE: We aimed to improve the perception of wait time through the implementation of a semiautomatic SMS text message system that allows patients to wait outside the hospital and facilitates the recall of patients closer to the scheduled time of meeting with the physician. METHODS: We performed a cross-sectional survey to evaluate the system using a tailored questionnaire to assess the patient perspective and the Unified Theory of Acceptance and Use of Technology questionnaire for the caregiver perspective. We also monitored the frequency of system use with logs. RESULTS: A total of 110 usable responses were collected (100 patients and 10 caregivers). Findings revealed that 97 of 100 (97%) patients were satisfied, with most patients waiting outside the ED but inside the hospital. The caregiver evaluation showed that it was very easy to use, but the adoption of the system was more problematic because of the perceived additional workload associated with its use. CONCLUSIONS: Although not suitable for all patients, our system allows those who have a low-severity condition to wait outside the waiting room and to be recalled according to the dedicated time defined in the Swiss Emergency Triage Scale. It not only has the potential to reduce the risk of hospital-acquired infection but also can enhance the patient experience; additionally, it was perceived as a real improvement. Further automation of the system needs to be explored to reduce caregiver workload and increase its use.