[New method to regulate unscheduled urgent care : the ODISSEE interactive self-triage platform]

The regulation of the unscheduled care takes part of the different methods engaged to better organize the global demand for unscheduled urgent care among the different levels of care. Indeed, the first level of care equally with the emergency departments are facing major patient inflows often exceeding their available resources. Technological advances in healthcare and spreading of medical information reveal themselves as precursors of new adaptive strategies and daily challenges. The creation of an interactive app for patients self-triage through the different levels of care involves those different concepts. We created a new interactive platform, the ODISSEE mobile application (Outil Décisionnel et Informatif des Structures de Soins Efficientes Existantes), to allow patient's self-triage to the best level of care. The protocols used were directly based on a previously validated tool with a 5-year experience in our institution, the SALOMON algorithm (Système Algorithmique Liégeois d'Orientation pour la Médecine Omnipraticienne Nocturne). Establishment of interactive self-triage platform to guide patients to the best level of care could potentially be a promising tool to improve the regulation of unscheduled urgent care.

[SALOMON, a collaboration model between primary and secondary care for nocturnal emergency calls]

Facing the aging of primary care practitioners and their still increasing duties, we implemented a new and original solution to maintain the continuity of primary care in the area surrounding of our university hospital. Thereby, we created a new model of nurse telephone triage for the regulation of out-of-hours primary care calls, the SALOMON algorithm ("Système Algorithmique Liégeois d'Orientation pour la Médecine Omnipraticienne Nocturne"). Following the nurse telephone triage and the assessment of the illness severity, the patient is referred to four potential orientations : Emergency Medical Services (EMS), Emergency Department Referred Consultation (EDRC), Primary Care Physician Home visit (PCPH) and Primary Care Physician Delayed visit (PCPD). In this article, we aim to describe the SALOMON model and present a 12-month feasibility study in order to determine the safety of the tool. We can also notice nurse and general practitioner satisfaction about this approach with a positive impact on the global primary care out-of-hour organization. Currently, SALOMON seems to be full of promise. Further investigations on a larger cohort are needed to determine more precisely the reliability of the algorithm.

[Hemorrhagic moyamoya disease]

Moyamoya disease is a rare cerebral vasculopathy. Disease onset is mainly sudden presenting as an ischemic stroke but also sometimes as a brain hemorraghe. Cerebral angiography is the gold standard to confirm the diagnosis. Different therapeutic approaches have been described such as conservative management or endoscopic and surgical approaches. We report the case of a young patient who was diagnosed with a brain hemorraghe following a sudden loss of consciousness.

[Diagnosis of cannabinoid hyperemesis : update on the cannabis-shower syndrome]

Sometimes, the emergency department is confronted with cases of repetitive vomiting and abdominal pain without organic causes. These patients come back again and again for this problem. All diagnostic tests are systematically negative. A well conducted history taking reveals a chronic cannabis addiction and the disappearance of symptomatology by taking hot showers. This presentation is pathognomonic of the cannabinoid hyperemesis syndrome.

[Medical regulation and rescue chains; the issue of primary-secondary transfers. The Belgian model and its application in the province of Liege]

Medical regulation represents an essential tool for emergency medical assistance. Even if it is essentially based on a 1964 law, our medical regulation is constantly evolving to meet the present needs and to follow the medical and technological advances. In this article, we shall outline its major components and evoke some long-awaited developments in the field of public health.

[A case of autoinjection of vaseline under penis skin]

We report the case of a 24-year-old rumanian patient who came to the emergency department complaining of glans penis pain and tight phimosis; he claimed to have undergone an injection of vaseline under penis skin. We review the literature on various nonmedical practices of penile foreign body injection to enlarge and thicken the penis.

Intraoperative consultation in digestive surgery. A consecutive series of 800 frozen sections

AIM

To assess indications and quality of frozen sections in digestive surgery.

PATIENTS AND METHODS

All the frozen sections from the department of digestive surgery from Amiens hospital performed between 01/07/2006 and 01/07/2010 were assessed. Assessment of frozen section forms, reading of pathology reports, and reviewing of frozen section slides were performed.

RESULTS

Eight hundred frozen sections were performed in 349 patients. From one to 14 surgical specimens were sent for frozen section (mean 2.3). Frozen sections were performed in 77% of the cases for cancer surgery (n=268), most of the time pancreatic surgery (28.4%) and liver surgery (24.6%). Frozen sections were performed in 69% of the cases for diagnosis, in 29% of the cases to assess surgical margins and in 2% of the cases to assess if tissue specimen was appropriate for pathological diagnosis. Frozen sections were sent all days of the week (except Saturday and Sunday), during all the year, between 8 H 30 and 17 H 15. Thirty-seven percent of the cases were sent between 12 H and 14 H. Response time was 15 minutes (3 to 57 minutes). Rate of differed diagnoses was 2%. Rate of discordant diagnoses was 3.4%.

CONCLUSION

Frozen section is a rapid and accurate tool in digestive surgery. Local adjustment of the organization of the Pathology Department could enhance the rapidity and the quality of pathology diagnoses.

[Hemolytic uremic syndrome with an atypical presentation]

The hemolytic uremic syndrome (HUS) is rare and of guarded prognosis in adults. It expresses a renal thrombotic microangiopathy. We report the case of a young patient whose clinical presentation and exploration make a diagnosis of HUS likely. The atypical presentation provides an opportunity not only to discuss all diagnostic elements based on recent pathophysiological hypotheses, but also to highlight recommendations for the management of this severe disease.

[How I treat... paracetamol poisoning]

Drug self-poisoning is a common cause of admission in ED. Among various incriminated substances, paracetamol is often implicated and presents a severe toxicity. We briefly describe the epidemiology and physiopathology of paracetamol self-poisoning. We then clarify the diagnostic elements, thresholds of toxicity, indications for treatment and different available therapeutic guidelines.

[The question of secondary medical transfer in Belgium: the experience conducted at the University Hospital Center of Liège]

Evaluation of the aid of an emergency mobile unit to transfer monitorized patients to a University hospital, in the political context of regional care network offering highly qualified but restricted tertiary area centres, and an open prospective study conducted over the 5 first months in 2006. The call regulation was assessed by the emergency physician of the transfer team and all missions were concluded with an evaluating report. An amount of 197 requests were taken into account from which 80 % were addressed between 8 am and 8 pm. The mean average time interval for missions was 59 minutes (base to base) and the distance covered was 20.7 km as a mean. In essence, indications for medical secondary transfer regarded patients in need for acute coronary care (42.6%), specific intensive care (26.4%) and neurosurgical interventions (19.3%). We noted that endotracheal intubation occurred in only one case. Mortality during such a transfer activity was absent. Medical transfer unit allows the development of specific high qualified network resources owing to the secondary addressee of patients. However, the weak incidence of complication questions the practice of systematic medical accompanying during such transfers.

[Coronary dissection and non-penetrating chest trauma]

The occurrence of an acute myocardial infarction after non-penetrating chest trauma is an extremely rare complication. We report a case of dissection of the left anterior descending artery in a 43 year old man after being punched in the chest. Using data from a literature search relish revealed 76 cases; we review the characteristics of the pathology and its incidence. We also characterize its etiology, anatomy and path physiology. We then consider the diagnostic and therapeutic implications.

[Clinical case of the month. Acute methanol intoxication]

We report a fatal methanol intoxication and discuss its physiopathology, diagnosis and treatment.

[Gitelman syndrome: a rare cause of hypokalemia]

We report a case of hypokaliemia whose origin is a urinary potassium loss associated with syndrome of Gitelman. The syndrome of Gitelman is a rare familiar autosomal recessive nephropathy. We will discuss the pathophysiology of this syndrome and differential diagnoses.

[Diagnosis of primary hyperparathyroidism: role of scintigraphy]

We report a case of hyperparathyroidism whose diagnosis was suspected by a clinical history and confirmed by routine laboratory tests. Scintigraphy has permitted to localize a focalized lesion corresponding to an adenoma endocrinopathy. The new developments of this imaging technique will be discussed further. Some aspects of physiopathology will be briefly considered and a therapeutic algorithm will be proposed.

Loss of the Y chromosome in bone marrow cells: results on 1907 consecutive cases of leukaemia and preleukaemia

Loss of the Y chromosome with a resulting 45, X0 karyotype is observed in normal bone marrow cells of elderly males but also in haematological malignancies. Whether Y loss in neoplastic cells is related to the process seen in normal ageing or is part of the carcinogenic process is unknown. The present study concerns the cytogenetic data from 1907 consecutive leukaemic or preleukaemic male patients with special regard to the presence or absence of the Y chromosome. Sixty-five patients (3.4%) had a 45, X-Y clone in their bone marrow (BM) cells. Loss of Y was rare below the age of 50 but increased in older patients, reaching 25% of the men over 80. Sixteen patients (0.08%) had more than 90% X0 cells in their BM. A correlation between Y loss and leukaemia could be established in seven cases, three of which were acute myeloid leukaemia M2 subtype where -Y is known to be a secondary event. In three other cases, -Y was part of a complex karyotype. Only one patient exhibited a 45, X0 karyotype, with no other rearrangement, that could be positively correlated with the neoplastic process.

[The collective unconscious: from image to symbol]

With the help of clinical examples, the author tries to show how the therapeutic process works in Jung's theory of Unconscious: in the course of transference, the Unconscious generates Images which are coming from the Archetypes of Collective Unconscious. The interpretation of these Images and dreamer's associations trough transference, leads the patient to elaborate Symbols as carriers of a new sense for himself.

[C.G. Jung's analytic psychology. Proposal of an approach to the depressive patient]

With aid of the clinical situation of a depressed patient, the author explains the therapeutic approach of analytical psychology of C.G. Jung. The main idea is the fact that depression carries a sense for the patient. The psychological energy, apparently lost, is invested in the unconscious and is given back when the symbols are understood within the study of the dreams and during the transference process.