Pediatric Moyamoya Presenting as a Subarachnoid Hemorrhage from a Ruptured Anterior Cerebral Artery Aneurysm.

BACKGROUND: The incidence of Moyamoya disease (MMD)-associated intracranial aneurysms ranges from 3% to 14% in adult patients, whereas this complication has rarely been reported in children. CASE DESCRIPTION: We herein report the first case, to our knowledge, of an extremely rare subarachnoid hemorrhage presentation of a child with a ruptured anterior cerebral artery dissecting aneurysm secondary to a newly discovered, unilateral Moyamoya-like pathology. CONCLUSIONS: MMD-associated aneurysms are extremely rare in children, and hemorrhage may be the initial presentation of the disease. Prompt intervention is essential to exclude the ruptured aneurysm that is at risk of rebleeding because of persistent hemodynamic stress

Supply sensitive services in Swiss ambulatory care: An analysis of basic health insurance records for 2003-2007

<p>Abstract</p> <p>Background</p> <p>Swiss ambulatory care is characterized by independent, and primarily practice-based, physicians, receiving fee for service reimbursement. This study analyses supply sensitive services using ambulatory care claims data from mandatory health insurance. A first research question was aimed at the hypothesis that physicians with large patient lists decrease their intensity of services and bill less per patient to health insurance, and vice versa: physicians with smaller patient lists compensate for the lack of patients with additional visits and services. A second research question relates to the fact that several cantons are allowing physicians to directly dispense drugs to patients ('self-dispensation') whereas other cantons restrict such direct sales to emergencies only. This second question was based on the assumption that patterns of rescheduling patients for consultations may differ across channels of dispensing prescription drugs and therefore the hypothesis of different consultation costs in this context was investigated.</p> <p>Methods</p> <p>Complete claims data paid for by mandatory health insurance of all Swiss physicians in own practices were analyzed for the years 2003-2007. Medical specialties were pooled into six main provider types in ambulatory care: primary care, pediatrics, gynecology & obstetrics, psychiatrists, invasive and non-invasive specialists. For each provider type, regression models at the physician level were used to analyze the relationship between the number of patients treated and the total sum of treatment cost reimbursed by mandatory health insurance.</p> <p>Results</p> <p>The results show non-proportional relationships between patient numbers and total sum of treatment cost for all provider types involved implying that treatment costs per patient increase with higher practice size. The related additional costs to the health system are substantial. Regions with self-dispensation had lowest treatment cost for primary care, gynecology, pediatrics and for psychiatrists whereas "prescription only" areas had lowest cost for specialists with non-invasive and invasive activities.</p> <p>Conclusions</p> <p>The results indicate that payment methods for services and for prescription drugs are associated with variations in treatment cost that are unlikely warranted by different medical needs of patients alone. Promoting physician accountability of care by linking reimbursements to quality, not quantity, of services are important policy measures to be considered for health care in Switzerland.</p

Coding of procedures documented by general practitioners in Swedish primary care-an explorative study using two procedure coding systems

<p>Abstract</p> <p>Background</p> <p>Procedures documented by general practitioners in primary care have not been studied in relation to procedure coding systems. We aimed to describe procedures documented by Swedish general practitioners in electronic patient records and to compare them to the Swedish Classification of Health Interventions (KVÅ) and SNOMED CT.</p> <p>Methods</p> <p>Procedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed.</p> <p>Results</p> <p>417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health Interventions category and 4.3% could not be coded with any SNOMED CT concept. 206 procedure-concept/category pairs were assessed as a complete match in SNOMED CT compared to 10 in the Classification of Health Interventions.</p> <p>Conclusions</p> <p>Procedures documented by general practitioners were present in nearly all electronic patient record entries. Almost all procedures could be coded using SNOMED CT.</p> <p>Classification of Health Interventions covered the procedures to a lesser extent and with a much lower degree of concordance. SNOMED CT is a more flexible terminology system that can be used for different purposes for procedure coding in primary care.</p

Bullet-induced synovitis as a cause of secondary osteoarthritis of the hip joint: A case report and review of literature

<p>Abstract</p> <p>Background</p> <p>With increasing prevalence of gunshot injuries we are seeing more patients with retained bullet fragments lodged in their bodies. Embedded lead bullets are usually considered inert after their kinetic energy has dissipated hence these are not removed routinely. However, exposure of any foreign body to synovial fluid may lead to rapid degradation and hence result in systemic absorption, causing local and systemic symptoms. We present the case of a thirty year old man who came to our out patient department with a history of progressive, severe hip pain ten years after a gun shot injury to his right hip.</p> <p>Conclusion</p> <p>The common belief that intraarticular bullets should not be removed has no benefit and may result in unwanted long term complications.</p

The impact of change in a doctor's job position: a five-year cohort study of job satisfaction among Norwegian doctors

<p>Abstract</p> <p>Background</p> <p>Job satisfaction among physicians may be of importance to their individual careers and their work with patients. We lack prospective studies on whether a change in a doctor's job position influences their job satisfaction over a five-year period if we control for other workload factors.</p> <p>Methods</p> <p>A longitudinal national cohort of all physicians who graduated in Norway in 1993 and 1994 was surveyed by postal questionnaire in 2003 (T1) and 2008 (T2). Outcomes were measured with a 10-item job satisfaction scale. Predictor variables in a multiple regression model were: change in job position, reduction in work-home interface stress, reduction in work hours, age, and gender.</p> <p>Results</p> <p>A total of 59% of subjects (306/522) responded at both time points. The mean value of job satisfaction in the total sample increased from 51.6 (SD = 9.0) at T1 to 53.4 (SD = 8.2) at T2 (paired <it>t </it>test, <it>t </it>= 3.8, <it>p </it>< 0.001). The major groups or positions at T1 were senior house officers (45%), chief specialists in hospitals (23%), and general practitioners (17%), and the latter showed the highest levels of job satisfaction. Physicians who changed position during the period (n = 176) experienced an increase in job satisfaction from 49.5 (SD = 8.4) in 2003 to 52.9 (SD = 7.5) in 2008 (paired <it>t </it>test, <it>t </it>= 5.2, <it>p </it>< 0.001). Job satisfaction remained unchanged for physicians who stayed in the same position. There was also an increase in satisfaction among those who changed from positions other than senior house officer at T1 (<it>p </it>< 0.01). The significant adjusted predictor variables in the multiple regression model were the change in position from senior house officer at T1 to any other position (β = 2.83, <it>p </it>< 0.001), any change in job position (from any position except SHO at T1) (β = 4.18, <it>p </it>< 0.01) and reduction in work-home interface stress (β = 1.04, <it>p </it>< 0.001).</p> <p>Conclusions</p> <p>The physicians experienced an increase in job satisfaction over a five-year period, which was predicted by a change in job position and a reduction in work-home stress. This study has implications with respect to career advice for young doctors.</p

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID-19 pandemic

BACKGROUND: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study\u27s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines. METHODS: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation. FINDINGS: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p\u3c0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p\u3c0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile. INTERPRETATION: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction

Hostipitalité, pouvoir et appropriation de l’espace dans l’habitat des réfugiés : le cas des réfugiés syriens au Liban

Avec 80 millions de personnes déracinées à travers le monde, les espaces de refuge sont en train d’émerger comme les transformations urbaines les plus visibles des temps modernes. Ces espaces, dont la fonction première est d’abriter temporairement, servent souvent d’habitat pour les réfugiés pendant des décennies. Cependant, les États hôtes, majoritairement des pays en développement, persistent à accueillir les réfugiés selon des politiques à court-terme. Cet écart génère plusieurs tensions mais se manifeste explicitement dans la conception temporaire des espaces de refuge. Sur le plan théorique, alors que les migrations sont largement documentées, des connaissances limitées existent sur la reproduction de chez-soi. Les théories qui portent sur les espaces de refuge se concentrent surtout sur des enjeux géopolitiques et anthropologiques, négligeant l’espace en soi. Pauvres en nuances, elles classent ces espaces selon des conceptualisations dichotomiques souvent déconnectées du vécu des réfugiés. Cette recherche propose une nouvelle lecture des espaces de refuge à travers les lentilles du pouvoir, de la culture et de l’espace. Elle étudie l’appropriation de ces espaces en se basant sur l’exploration des pratiques sociales, économiques et politiques des réfugiés, de leurs interventions sur l’espace et du lien qu’ils développent avec leurs nouveaux environnements de vie. Elle révèle également l’influence des approches adoptées par la communauté internationale, les gouvernements d’accueil, les organismes humanitaires et les communautés hôtes. L’étude est qualitative exploratoire et adopte la méthode de l’étude de cas multiples. Cette approche permet d’acquérir une compréhension approfondie des perceptions des réfugiés des contextes sociopolitiques et économiques qui caractérisent leur vécu d’une part et de leurs représentations de l’espace d’autre part. Trois typologies d’habitat — deux habitations urbaines, deux campements informels et deux camps organisés — sont étudiées afin d’évaluer l’importance du type de l’espace par rapport à son appropriation. L’étude adopte l’ethnographie comme approche méthodologique complémentaire, dévoilant l’évolution des conditions de vie des réfugiés et la transformation de leurs espaces. Le cas à l’étude est celui des réfugiés syriens au Liban. Submergé par le nombre de réfugiés sur son territoire, le plus grand par nombre d’habitants au monde, le Liban exclut les réfugiés syriens des systèmes institutionnels, économiques et urbains dans le but de réduire leur accès au territoire, de limiter la durée de leur séjour et de prévenir la consolidation matérielle et immatérielle de leurs espaces. Toutefois, huit ans après, les stratégies adoptées par le gouvernement libanais se sont avérées infructueuses : le nombre des réfugiés syriens accueillis est sensiblement le même et leurs espaces se sont pour la plupart ghettoïsés. La thèse propose cinq résultats principaux : 1) l’enjeux central dans l’appropriation des espaces de refuge est un ensemble de géométries de pouvoirs politique, économique et social ; 2) la gouvernance faible de l’État d’accueil fragmente les systèmes traditionnels et permet l’émergence de structures de pouvoir informelles qui contrôlent les réfugiés et leurs espaces ; 3) l’exclusion des réfugiés exacerbe leur vulnérabilité et l’organise au profit de parties prenantes locales influentes. Elle réduit leurs chances d’émigrer et mène souvent à la ghettoïsation de leurs espaces ; 4) la typologie des espaces n’est pas centrale par rapport à leur appropriation ; 5) l’enracinement de l’identité dans le lieu d’origine est une idée basée sur des considérations politiques anti-migratoires. Les espaces de refuges évoluent, selon les opportunités et les défis dans le milieu d’accueil, suivant un continuum entre non-lieux temporaires et lieux de vie socioculturels. En transcendant leur marginalisation et leur homogénéisation, cette recherche dévoile la réalité intime des espaces de refuge. Elle montre que souvent, ils deviennent des chez-soi, lieux de vie quotidiens qui abritent des individus qui forment des groupes sociaux culturellement distincts et économiquement hiérarchisés. D’un point de vue théorique, elle montre que l’accueil des réfugiés est souvent basé sur l’hostipitalité, une hospitalité hostile qui vulnérabilise les réfugiés et facilite leur exploitation. Elle révèle que l’appropriation des espaces de refuge augmente proportionnellement avec l’inclusion institutionnelle et l’autonomisation socioéconomique des réfugiés, concourant à la reproductibilité rhizomique de leur identité individuelle et collective. D'un point de vue pratique, cette recherche démontre que, sous prétexte de raccourcir la durée de l’accueil des réfugiés, les politiques d’accueil sont en réalité adoptées dans l’intérêt économique et politique d’acteurs étatiques et privés. Dans le but d’atteindre une meilleure justice spatiale, elle recommande aux gouvernements d’accueil un changement de paradigme à travers l’adoption de stratégies plus inclusives à l’égard des réfugiés menant à leur autogestion et leur développement et d’approches adaptées à l’usage et à la durée de leurs espaces.With 80 million people uprooted around the world, refuge spaces are coming to be the most visible urban transformations of modern times. These spaces, whose primary function is to shelter, often accommodate refugees for decades. Yet, host states, mostly developing countries, continue to host refugees without adopting comprehensive, long-term strategies for their integration, causing acute political, socio-economic, and humanitarian problems. The lack of a long-term solution is explicitly revealed by the conceptions of refugee spaces, often designed as temporary solutions. From a theoretical perspective, while social scientists and geographers have widely documented the geopolitical and anthropological aspects of forced migrations, they have neglected the concept of space appropriation and the production of place identity in refugee spaces. Indeed, their classification of space/place is often based on dichotomous conceptualizations and differs from refugees’ real-life experience. This research examines refugee spaces through the lenses of power, culture, and space. It provides new evidence on the appropriation of these spaces through refugees’ social, economic, and political practices, their interventions on space, and their perceptions of their new living environment. It also examines the impact of the strategies adopted by the international community, host governments, humanitarian organizations, and local communities. The research method is qualitative and exploratory; it is based on a multiple case study design. This methodological approach provides an in-depth understanding of refugees' perceptions on the socio-political environment undergirding displacement and on their representations of space. Three space typologies — urban dwellings, informal settlements, and organized camps — are studied with the purpose of assessing the relevance of the space-type in relation to its appropriation. The study uses ethnography as a complementary methodological approach, shedding light on the evolution of refugees’ living conditions over time and the transformation of their spaces from a cultural standpoint. It specifically focuses on Syrian refugees in Lebanon, a country which hosts the largest number of refugees per capita in the world. Overwhelmed by the number of refugees hosted, Lebanon excludes Syrian refugees from formal legal, economic, and urban systems, limiting their access to the territory, reducing the duration of their stay, and preventing the tangible and intangible consolidation of their living spaces. Yet, eight years later, the strategies adopted by the Lebanese government have proven unsuccessful: the number of Syrian refugees is roughly the same as at the beginning of the conflict and most of their spaces have been ghettoized. Results show that: 1) complex geometries of political, economic, and social powers determine the appropriation of refugee spaces; 2) weak state authority fragments traditional governance systems which leads to the emergence of informal power structures that control refugees and their spaces; 3) refugees’ exclusion exacerbates their vulnerability, while benefitting local stakeholders, subsequently reducing their chances of emigration and leading to the ghettoization of their living spaces; 4) the typology of spaces is not a major variable in relation to their appropriation; 5) the rooting of identity in the place of origin is an idea based on anti-migration political viewpoints; refugee spaces can evolve along a continuum between temporary non-places and socio-cultural places of life depending on the opportunities and challenges in the host context. Transcending the stigmatization, marginalization, and homogenization of refugee spaces, this research reveals the intimate reality of these spaces. It shows that they often become places of everyday life for refugees who form culturally dissimilar and economically hierarchical social groups. From a theoretical point of view, this research shows that hosting policies are often based on hostipitality, or a hostile form of hospitality which exacerbate refugees’ vulnerability and facilitates their exploitation. It shows that refugees’ appropriation and control of their living spaces increase proportionally with their legal inclusion and their socio-economic empowerment by the host state, inciting the rhizomic reproducibility of their individual and collective identity in their new habitat. From a practical point of view, the research shows that hosting policies adopted on the pretext of shortening the duration of refugees’ settlement are in fact in the interest of state and private actors. With the purpose of achieving spatial justice, the study recommends a change of paradigm in refugee policies with approaches that are more inclusive towards refugees leading to their self-management and their development, and adapted to the use and duration of their living spaces

De l’invisibilité des réfugiés syriens : le rôle des États en France et au Liban

International audienceEn 2015, plus de 1 million de personnes sont entrées illégalement dans l’espace Schengen. La crise migratoire en Europe a débuté dans les années 2010 et s’est amplifiée avec la guerre en Syrie. Onze millions de Syriens ont quitté leurs lieux de vie. Selon les chiffres de l’UNHCR en décembre 2016, 4,8 millions d’entre eux étaient enregistrés dans les pays limitrophes. Où sont-ils aujourd’hui, notamment en France, et dans quelles conditions sont-ils « reçus »