A 64-Year-Old Woman with Chest Pain, Limb Weakness, and Endometrial Cancer

Necrotizing autoimmune myopathy (NAM) is a rare subgroup of idiopathic inflammatory myopathies (IIM). This pathology usually affects proximal limb muscles and in some cases the myocardium. Patients usually display proximal limb weakness. Muscular biopsy is required to confirm the diagnosis. We report the case of a 64-year-old woman with an atypical first presentation of NAM, manifested by chest pain in the context of metastatic endometrial cancer. The diagnosis of NAM was however made when she returned a second time with proximal limb weakness. A treatment with prednisone was then initiated, to which rituximab was rapidly associated, beside a specific chemotherapy

Disseminated tuberculosis presenting with polymorphonuclear effusion and septic shock in an HIV-seropositive patient: a case report

<p>Abstract</p> <p>Introduction</p> <p>Because a substantial number of patients present with few or atypical symptoms, the recognition of tuberculosis remains challenging. Disseminated tuberculosis presenting with septic shock has already been described in some case reports, but, to the best of our knowledge, it has never been associated with polymorphonuclear effusion.</p> <p>Case presentation</p> <p>We describe the case of a 27-year-old man from western Africa who was seropositive for human immunodeficiency virus. He presented with pleural and abdominal polymorphonuclear effusions and quickly developed septic shock due to disseminated <it>Mycobacterium tuberculosis </it>infection leading to multiple organ failure and death.</p> <p>Conclusion</p> <p>In high-risk patients, <it>Mycobacterium tuberculosis </it>infection should be considered even in exceptional clinical presentations, such as septic shock and polymorphonuclear effusions.</p

Therapeutic Drug Monitoring Guides the Management of Crohn's Patients with Secondary Loss of Response to Adalimumab

Background: Managing loss of response (LOR) in Crohn's disase (CD) patients remains challenging. Compelling evidence supports therapeutic drug monitoring (TDM) to guide management in patients on infliximab, but data for other biologics are less robust. We aimed to asses if empiric dose escalation led to improved clinical outcome in addition to TDM-guided optimization in CD patients with LOR to adalimumab (ADA). Methods: Retrospective chart review of patients followed between 2014 and 2016 at McGill IBD Center with index TDM for LOR to ADA was performed. Primary outcomes were composite remission at 3, 6, and 12 months in those with empiric adjustments versus TDM-guided optimization. Results: There were 104 patients (54.8% men) who were included in the study. Of this group, 81 patients (77.9%) had serum level (SL) >= 5 mu g/ml at index TDM with a median value of 12 mu g/ml (IQR 6.1-16.5). There were 10 patients (9.6%) who had undetectable SL with high anti-ADA antibodies and 48 (46.2%) received empiric escalation. TDM led to change in treatment in 58 patients (55.8%). Among them, 28 (48.3%) had discontinued ADA, 12 (21.7%) had addition of immunomodulator or steroid, and 18 (31%) had ADA dose escalation. Empiric dose escalation before TDM-based optimization was not associated with improved outcomes at 3, 6, and 12 months, irrespective of SL levels. Clear SL cutoff associated with composite remission was not identified. Conclusions: Our data do not support empiric dose adjustment beyond that based on the result of the TDM in patients with LOR to ADA. TDM limits unnecessary dose escalation and provides appropriate treatment strategy without compromising clinical outcomes

Clinical presentation, demographics and outcome of Tuberculosis (TB) in a low incidence area: a 4-year study in Geneva, Switzerland

<p>Abstract</p> <p>Background</p> <p>The incidence of tuberculosis (TB) in developed countries has decreased since the 1990s, reflecting worldwide efforts to identify and treat TB according to WHO recommendations. However TB remains an important public health problem in industrialized countries with a high proportion of cases occurring among subjects originating from high prevalence countries. The aim of this study was to describe clinical and social characteristics of patients with TB and their outcome in a low incidence area with a high immigration rate.</p> <p>Methods</p> <p>Four-year retrospective study based on a computerized database and subsequent review of medical records of all patients with TB followed at the outpatient section of the Division of Pulmonary Diseases, Geneva University Hospital, Switzerland.</p> <p>Results</p> <p>252 patients (84% foreigners, 25% asylum seekers) aged 38 ± 19 yrs were studied (11% co-infected with HIV). TB was intrapulmonary (TBP) in 158 cases (63%), extrapulmonary (TBE) in 137 (54%), and both in 43 cases (17%). TBP was smear (S)+/culture (C)+ in 59%, S-/C+ in 37%, S-/C- in 4%. Smoking was significantly associated with cavitary disease.</p> <p>Time from onset of symptoms to diagnosis was 2.1 ± 3.1 months. Initially, 10% were asymptomatic; 35% had no general symptoms. Despite systematic sputum analysis (induced or spontaneous), TBP was confirmed only by bronchoscopy in 38 subjects (24% of TBP). Side effects requiring changes in treatment occurred in 38 cases (11%).</p> <p>Treatment was completed in 210 (83%) patients. In 42 cases, follow up was unsuccessful; causes were: failure (n = 2; 0.8%), defaulters (n = 8; 3%), transfer out (n = 28; 11%) and death (n = 4; 1.6%). Relapse rate was 0.24 per 100 patient-years. Considering S+ TBP only, success rate was 87%.</p> <p>Conclusion</p> <p>TB in our area is predominantly a disease of young foreign-born subjects. Smoking appears as a possible risk factor for cavitary TBP. Time to diagnosis remains long. Compliance to treatment is satisfactory. Success rate for S+ TBP is within WHO objectives.</p

Patients traités pour une tuberculose active: étude rétrospective de 4 ans d'activité du Centre antituberculeux, Service de Pneumologie, Genève

Ce travail analyse les caractéristiques cliniques et sociales des patients traités pour une tuberculose (TB) active ainsi que le taux de succès thérapeutique dans une région (Genève) à faible incidence de tuberculose, mais avec un taux élevé d'immigration. L'examen rétrospectif des dossiers de 252 patients suivis au Centre antituberculeux de Genève (HUG) pour une TB active entre 1999 et 2003 a mis en évidence une proportion élevée de patients immigrés (84% dont 25% de requérants d'asile) reflétant la tendance actuelle dans la plupart des pays d'Europe occidentale. Nous avons également pu montrer qu'il y avait dans cette casuistique une proportion élevée de co-infection avec le VIH (11%), y compris dans la population jeune autochtone. L'évolution des patients traités était favorable dans 87% des cas en se référant aux critères OMS, ce qui est au-dessus de la moyenne européenne et répond aux objectifs de l'OMS

The challenge of implementing <i>less is more</i> medicine in Switzerland

"Less is more" in medicine is an invitation to recognize the potential risks of overuse of medical care that may result in harm rather than in better health. It is indeed necessary to eliminate unnecessary and costly practices by streamlining care without rationing. However, several barriers and challenges for the implementation of less is more medicine have been identified in Switzerland, where overuse is rooted in our culture and demanded by a society that requests certainty at almost any cost. Patients’ high expectations, physician behavior, lack of monitoring and pernicious financial incentives have all indirect negative consequences for medical overuse. Multiple interventions and quality-measurement efforts are necessary to widely implement less is more recommendations. These include financial incentives, patient education, physician behavior change with data feedback, communication training and systems interventions. A quality-oriented approach can be an intellectual challenge but also a real opportunity to promote sustainable medicine

Ten year anniversary of choosing wisely campaigns

© 2022 Published by Elsevier B.V. on behalf of European Federation of Internal MedicineCW campaigns have indeed spread around the world and several medical societies in Europe launched quality driven anti-waste campaigns such as, Smartermedicine in Switzerland, Slow Medicine in Italy, SMART Medicine Initiative in Israel, “Mais Nem Sempre é Melhor” in Portugal and Choosing Wisely in UK, France, Belgium, Romania, Russian Federation and Poland. The campaigns are centered on conversations between clinicians and patients about unnecessary tests, treatments, and procedures that account for up to 20% of all medical costs. These societies published “top-five lists” of low-value medical interventions that should be avoided.info:eu-repo/semantics/publishedVersio

The impact of implementing a psychiatric emergency hotline on the reduction of acute hospitalizations in a Swiss tertiary hospital

Background: Inpatient treatment is not the most beneficial treatment setting for many patients with psychiatric disorders and overcrowding is a recurrent problem for psychiatric hospitals. Therefore, it is important to develop strategies to limit avoidable inpatient treatment. This study sought to evaluate the impact of an emergency hotline that was developed to better manage psychiatric patients, particularly for identifying those requiring a hospital admission.Methods: This pre-post intervention quality improvement study compared changes in the management of psychiatric patients' admission before and after the introduction of an emergency hotline where a specialist in psychiatry examines all inpatient referral from private practitioners. Main outcomes were the change in proportion of hospital admissions after referral from a private practitioner before and within 3 months after the intervention. Secondary outcomes were the average length of hospital stay, proportion of non-voluntary admission, the time required for triage and the impact of the intervention on treatments' costs. Fisher's Exact test was used to test the primary hypothesis of difference in the proportion of hospitalized patients before and after introduction of the emergency hotline. Secondary outcomes were tested with Student's t-test for continuous variables and Fishers's Exact test for proportions.Results: Among 45 admission requests from private practitioners during the 3 months after introduction of the new emergency hotline, 25 (55.6%) were accepted as inpatient treatment, while 20 (44%) were redirected to more appropriate outpatient treatments. There was a highly significant difference from the baseline period during which all 34 requests were accepted (44% vs 100%, p Conclusion: Implementation of an emergency hotline manage by a specialist in psychiatry for admissions to acute psychiatric wards is feasible and simple to use. Importantly, it allows to significantly decrease the proportion of hospitalizations. Additional studies are needed to assess the generalizability of these exploratory results to other health care settings.</p

Infections virales à l'origine des exacerbations de la broncho-pneumopathie chronique obstructive

COPD is a progressive disease whom course is characterized by repeated exacerbations, with a negative impact on quality of life and health costs. Although a causal link between the identification of viruses in the upper respiratory tract and exacerbation is not definitively established, there is growing evidence that viruses are important triggers of exacerbations in more than 50 percent of cases. Yet, neither clinical presentation nor biological markers permit to discriminate between viral and non viral exacerbations