The Digital Pen and Paper

Objectives: To evaluate the efficiency and acceptance of digital pen and paper technology for real-time clinical data acquisition.

Methods: A prospective interventional unblinded study involving consecutive patients in two clinical settings during a defined time-frame was proposed. The first trial was designed as a stress test to evaluate acceptance in a workload-intensive environment. Acceptance was assessed using observations and a satisfaction questionnaire. The second trial was intended to determine the reliability of data acquisition in a controlled environment. Reliability was assessed by comparing the performance of the digital pen against scanner analysis and a double human blinded acquisition.

Results: Overall, users were satisfied with the use of the digital pen (median 3 on a Likert-scale (–5, 5)). Without any specific user training, successful data acquisition was greater than 80%. Use of this technology required less adaptation than standard computer devices, and was easy to learn and use. Ergonomic problems shaded the perception of the technology by inducing an increased cognitive load. Digitalized data was missing either because of a bug or due to lack of data validation. The reliability obtained with the digital pen was significantly lower to that obtained with the scanner.

Conclusions: Natural technology such as the digital pen proved to be a good tool in stressful clinical environments without interfering with the normal workload or increasing the time for data acquisition. However, in order to improve quality of data acquisition, designing acquisition forms specifically for the use of digital pens is of paramount importance.

[Emergency medicine: updates 2012]

We review some of the most influential papers from 2012 in the different aspects of emergency medicine, such as prehospital medicine, resuscitation, early diagnosis and timely ED discharge and treatment. In particular, intramuscular benzodiazepines have been shown to be efficient in prehospital status epilepticus, epinephrines usefulness in cardiopulmonary resuscitation has been challenged, colloids have been shown to be deleterious in the treatment of severe sepsis and septic shock, the time window for thrombolysis in acute stroke will probably be extended, acute pyelonephritis treatment duration can be decreased, new D-dimers thresholds for older patients may prevent further diagnosis tests, and hs-Troponin may allow earlier discharge of low coronary risk patients.

[Emergency medicine: updates 2011]

Emergency medicine physicians aim to stabilize or restore vital functions, establish diagnosis, initiate specific treatments and adequately orientate patients. This year, new evidences have improved our knowledge about diagnostic strategy for patients with acute non traumatic headache, treatment of acute atrial fibrillation and outpatient management of acute pulmonary embolism. Reducing injection pain of local anesthetics, reducing irradiation by using alternative diagnostic tools in appendicitis suspicion, and identification of trauma patients who benefit from tranexamic acid administration are other illustrations of the efforts to improve efficacy, safety and comfort in the management of emergency patients.

[Management of acute asthma in the emergency room]

Acute asthma is a frequent occurrence in the emergency room. Early care includes gradation of severity and rapid administration of systemic corticosteroid and bronchodilators. After initial treatment, if the patient has no longer criteria for severe asthma, and no poor outcome risk factor, continuation of treatment at home is a possible option. It requires to schedule a close appointment for medical follow-up, establishment of an asthma treatment plan, prescription of a short course of oral corticosteroids together with a combination of inhaled corticosteroid and long acting beta-2-agonist for longer duration of treatment.

[Critical pathway for community-acquired pneumonia]

A clinical pathway is a methodological tool for standardizing medical practice, improving the quality and efficiency of care delivery, and enhancing the diffusion of evidence-based medicine. Despite the fact that a majority of trials have shown that the use of clinical pathways improves certain specific outcomes such as length of stay or complications, the overall impact of these pathways in the clinical setting has yet to be documented. In the setting of community-acquired pneumonia, a few observational and one large randomized trial have shown positive effects on various outcomes. We describe in this article the clinical pathway for community-acquired pneumonia developed at our institution.

[Emergency medicine: update 2010]

Several scores with predictive value for morbidity or mortality have been published this year. Their current purpose is to improve the direction of admissions and lengths of stay in hospital. Their use permits more directed care, especially for the elderly, and therefore could improve the proper orientation and admission of patients. Also this year, certain procedures are undergoing evaluation, namely: new assays for troponin, and non-contrast CT in the diagnosis of acute appendicitis. Furthermore in the therapeutic realm: the importance of cardiac massage and the advantages of therapeutic hypothermia in cardiac arrest, and the efficacy of oxygen therapy in cluster headache.

[Emergency medicine: update 2009]

Emergency medicine is a cross-discipline characterized by its ability to identify critical threats, as well as its ability to prioritize investigations and identify appropriate treatments. Recent publications have been published on upper gastrointestinal haemorrhage, elbow fracture or brain haemorrhage, to optimize and standardize the investigations. In parallel, conditions such as cardiopulmonary arrest, spontaneous pneumothorax or stroke, benefit from recent therapeutic advances. However, emergency physicians and primary care physicians must remain critical of the numerous medical publications, as evidenced by the contradictory results concerning the interaction between proton pump inhibitors and clopidogrel.

[How urgent is it to decrease high blood pressure?]

Severe hypertension represents a frequent problem for the general practitioner. One has to decide if the blood pressure needs to be decreased immediately (hypertensive emergency), or if the blood pressure maybe progressively decreased in a few hours and normalized in a few days (hypertensive crisis). Thus it is crucial to identify on the basis of the clinical history and a careful physical examination, the patients for whom the arterial blood pressure elevation represents an acute danger for organ damage or a vital threat in the absence of immediate blood pressure control. In the case of hypertensive crisis, oral medication is usually sufficient (slow release or GITS nifedipine, nitroglycerin, labetalol, captopril). The hypertensive emergency sometimes requires an oral medication before the admission to the emergency room, then followed by intravenous drug administration (sodium nitroprussiate, nitroglycerin, labetalol).

[Vertigo: it all revolves around the physical exam]

Dizziness is a common complaint in an emergency department. True vertigo, characterized by subjective sensation of rotation of the subject or of objects around the subject, may be peripheral (85%) or central (15%). Patient's history and physical exam identify the etiology of vertigo in more than 70% of patients. Hallpike test is easily performed and crucial for the diagnosis of benign paroxysmal peripheral vertigo. Central vertigo should be suspected and brain imaging performed in the presence of neurological symptoms, in older patients, or when several risk factors for cerebrovascular disease are present.

[Headache: physical exam or CT?]

The life time prevalence of headache is more than 90% in the general population. The majority of patients presenting to physicians suffer from migraine. A simple clinical predictive score based on five questions will allow clinicians to confirm this diagnosis and will prevent further investigations. In all other circumstances, evidence is not sufficient to develop prediction rules to exclude secondary headache. However, neuroimaging should be performed in patients with a unexplained abnormal finding on the neurological examination.

[Impact of urinary incontinence in community-dwelling women]

Urinary incontinence (UI) is a frequent problem in an aging population and prevalence of urinary incontinence for elderly women may be up to 50% and imposes a huge burden on the health care system comparable to osteoporosis or osteoarthritis. The impact of UI shows clear associations between UI and depression and decline of quality of life comparable to congestive heart failure, major respiratory condition or gastrointestinal tract conditions. Some limited data suggest that UI is also a risk factor for institutionalization and hospitalization. Despite effective treatments, UI is significantly underdiagnosed by clinicians, and underreported by patients. This results in unmet needs for incontinence treatment, in particular for older individuals.

[Lake Geneva Region guidelines on management of adult asthma]

Asthma is a major cause of chronic morbidity throughout the world. In Switzerland, 6.9% of the adult population is suffering from asthma. The standards of treatment are unfortunately not met in most western countries, as well as in Switzerland. We put forward a complete guideline on management of adult asthma, inspired from GINA and BTS guidelines, and adapted to the specific needs of general practitioners working in french part of Switzerland. This guideline reflects a consensus between allergy, lung and emergency specialists, working in the 2 university hospitals of the Lake Geneva Region (HUG and CHUV).

[Should disease management be feared? (2): outpatient care]

Outpatient disease management is a multidisciplinary team intervention for managing complex processes of chronic diseases, in order to improve healthcare quality and decrease process variations. Interventions are based on: (1) evidence-based guidelines; (2) educational programs; (3) close patient follow-up. This can be achieved by telephone follow-up, by outpatient clinic programs, or by homecare visits performed by case managers. For the management of patients with chronic heart failure, disease management programs have resulted in a 25% decrease in hospitalization and in reduced costs. In our Swiss health care system, however, a majority of patients are taken care of by private practitioners; thus, the involvement of these physicians in the development and in the realization of disease management programs will be key to their success.

[Should disease management be feared? (1): hospital care]

The goals of disease management are: (1) an integrated health care delivery system; (2) knowledge-based care; (3) elaborate information systems; (4) continuous quality improvement. In-hospital disease management and, more specifically, critical pathways, establish standardized care plans, set goals and time actions to reach these goals. They can reduce variations in practice patterns and resource utilization without compromising quality of care. Such strategies participate to quality improvement programs in hospitals when they involve and empower all actors of a given process of care, are not imposed from outside, and use sound and rigorous development and evaluation methods.

Die Folgen einer ungenügenden Herdimmunität bei «pädiatrischen» Infektionskrankheiten – Beispiel einer Masernepidemie

Von Januar bis Mitte Februar 2005 wurden dem Kantonsarzt von Genf 15 Fälle von bestätigten Masern gemeldet; verglichen zu einem einzelnen Fall im 2004. Ungewöhnlich an dieser Epidemie war das Alter der betroffenen Personen von 17 bis 44 Jahren. Vier unter ihnen waren Mitarbeiter eines öffentlichen Spitals, die sich nach Kontakt zu einem einzigen, 44-jährigen Patienten ansteckten und die Infektion zum Teil weiter übertrugen. Die Annahme, dass Masern eine pädiatrische Infektion sind, erschwerte die Diagnose. Keiner der betroffenen Erwachsenen war immun nach dem heutigen Stand der Empfehlungen. Trotz vorhandenem Impfplan, behördlichen Empfehlungen, Kostenübernahme durch die Krankenkassen und den guten Impfergebnissen mit den heute zur Verfügung stehenden Vakzinen, ist die freiwillige Durchimpfungsrate in der Schweiz unter Kindern und Erwachsenen zu gering um den Ausbruch von Epidemien zu verhindern. Im Gegensatz zu den Zielen des Bundesamt für Gesundheit (BAG) und der Weltgesundheitsorganisation (WHO) sind wir in der Schweiz aus verschiedenen Gründen noch nicht so weit eine genügend hohe Herdimmunität aufzubauen, um gesundheitliche und volkswirtschaftliche Schäden durch aufflackernde Epidemien zu verhindern.

[Management of asthma attacks in primary care practice]

Most fatal asthma attacks are explained by an underestimation of the severity of the episode and by an underutilization of adequate treatments. The primary care physician should: 1) identify predictors of poor outcome requiring immediate hospital admission, 2) evaluate the severity of the attack, using clinical criteria and peak-flow measurements, and 3) initiate a treatment combining inhaled beta2-agonists and oral steroids. Life threatening asthma attacks warrant immediate hospitalisation as well as severe attacks persisting after initial treatment. Moderate attacks don't usually require referral. Other factors, such as social factors, compliance to treatment, or co-morbid conditions, may warrant hospitalisation.

The digital pen and paper. Evaluation and acceptance of a new data acquisition device in clinical settings

OBJECTIVES

To evaluate the efficiency and acceptance of digital pen and paper technology for real-time clinical data acquisition.

METHODS

A prospective interventional unblinded study involving consecutive patients in two clinical settings during a defined time-frame was proposed. The first trial was designed as a stress test to evaluate acceptance in a workload-intensive environment. Acceptance was assessed using observations and a satisfaction questionnaire. The second trial was intended to determine the reliability of data acquisition in a controlled environment. Reliability was assessed by comparing the performance of the digital pen against scanner analysis and a double human blinded acquisition.

RESULTS

Overall, users were satisfied with the use of the digital pen (median 3 on a Likert-scale (-5, 5)). Without any specific user training, successful data acquisition was greater than 80%. Use of this technology required less adaptation than standard computer devices, and was easy to learn and use. Ergonomic problems shaded the perception of the technology by inducing an increased cognitive load. Digitalized data was missing either because of a bug or due to lack of data validation. The reliability obtained with the digital pen was significantly lower to that obtained with the scanner.

CONCLUSIONS

Natural technology such as the digital pen proved to be a good tool in stressful clinical environments without interfering with the normal workload or increasing the time for data acquisition. However, in order to improve quality of data acquisition, designing acquisition forms specifically for the use of digital pens is of paramount importance.

Detection of mycobacterial nucleic acids by polymerase chain reaction in fixed tissue specimens of patients with human immunodeficiency virus infection. Swiss HIV Cohort Study

A polymerase chain reaction (PCR) method, which amplifies a fragment of the 16S ribosomal RNA (rRNA) gene present in all mycobacterial species, was developed and tested on 84 formalin-fixed paraffin-embedded tissue specimens from 51 patients with human immunodeficiency (HIV) infection. The PCR products were characterized either by sequencing or by hybridization with nonradioactive oligonucleotide probes specific for Mycobacterium tuberculosis complex, M. avium, or M. genavense. Sequencing was successful for 26 samples compared with the 45 samples for probe hybridization. The sensitivity of DNA amplification compared with microscopic examination was 79.5%. A mixed infection was detected with M. genavense for only one patient who was infected with M. tuberculosis complex. In the group of 22 control patients, where no diagnosis of mycobacterial infection was made during life and no acid-fast bacteria were seen during the autopsy, four samples of one patient were positive by hybridization with the M. tuberculosis probe. This patient had a clinical history compatible with tuberculosis. This PCR method may be a powerful tool for the precise diagnosis of mycobacterial infections from histopathologic material, provided that several sections from the same specimen block are tested.

Regression of Kaposi's sarcoma during therapy with HIV-1 protease inhibitors: a prospective pilot study

BACKGROUND

Early studies using HIV protease inhibitors (PI) showed regression of Kaposi's sarcoma (KS) lesions in some patients.

OBJECTIVE

Our purpose was to determine prospectively the influence of PI on HIV-related KS.

METHODS

KS lesions of nine patients with progressive cutaneous disease were prospectively evaluated clinically and by means of epiluminescence microscopy before and during PI therapy. HIV viremia and CD4 cell count were measured in parallel.

RESULTS

All patients experienced reduction or initial stabilization of KS lesions during the first 4 to 8 weeks of HIV-1 PI therapy. After a median follow-up of 7 months and according to AIDS Clinical Trials Groups criteria, six patients had a partial response, two showed stable disease, and in one noncompliant patient KS progressed, requiring chemotherapy. With epiluminescence microscopy, a reduction in skin surface alterations, lesional size, and color intensity was demonstrated in six of nine patients. PI induced a median decrease in viremia of 1.66 log and a median increase in the CD4 count of 49 cells/mm3.

CONCLUSION

In this series, HIV PI therapy reduced or stabilized KS. The efficacy of HIV-1 PI in KS may result from the improvement in cellular immunity. These results suggest the use of PI in AIDS-related KS regardless of the level of CD4 lymphocyte count and HIV viremia.

Neutrophil eccrine hidradenitis in a patient with AIDS

Neutrophilic eccrine hidradenitis (NEH), first described as a rare, transient, and benign complication of various chemotherapy regimens for acute leukemia, has also been observed in other conditions, including three HIV-positive patients and even in otherwise healthy individuals (1-3). A similar histological pattern was described after intradermal bleomycin injections into normal human skin (4). We report the first case of NEH in a hemophilic HIV infected patient treated with stavudine, a new reverse transcriptase inhibitor.

Impact of methicillin resistance on the outcome of patients with bacteremia caused by Staphylococcus aureus

BACKGROUND

Uncertainties remain about the contribution of methicillin resistance to morbidity and mortality associated with bacteremia caused by Staphylococcus aureus.

OBJECTIVE

To assess the impact of methicillin resistance on patient outcome after staphylococcal bacteremia.

METHODS

We investigated a cohort of 145 patients with methicillin-sensitive S aureus bloodstream infection (MSSA BSI) and 39 patients with methicillin-resistant S aureus bloodstream infection (MRSA BSI) and further performed a pairwise-matched (1:1) case-control study. All patients in the University Hospital of Geneva, Geneva, Switzerland, with clinically significant staphylococcal bacteremia between January 1, 1994, and December 31, 1995, were included in the study. For the case-control study, cases were defined as patients with MRSA BSI; control patients with MSSA BSI were selected in a stepwise manner according to the following matching variables: age, sex, number of comorbidities, severity of underlying illness, and prior length of stay in the hospital. Matching was successful for 97% of the cohort.

MAIN OUTCOME MEASURE

The in-hospital mortality after staphylococcal bacteremia.

RESULTS

In the population-based study, the relative hazard of death among patients with MRSA BSI (n = 39, 14 deaths, 36% fatality rate) compared with patients with MSSA BSI (n = 145, 40 deaths, 28% fatality rate) was 1.1 (95% confidence interval, 0.5-2.1), after adjusting for age and length of stay from admission to the onset of bloodstream infection. Following pairwise matching (n = 38), the in-hospital mortality was 34% in both groups (odds ratio, 1.0; 95% confidence interval, 0.4-2.5). Infection was the probable or definite cause of death in 54% of patients with MRSA BSI and 69% of patients with MSSA BSI who died.

CONCLUSION

Methicillin resistance in patients with S aureus bacteremia had no significant impact on patient outcome as measured by in-hospital mortality after adjustment was made for major confounders.

Genetic polymorphism of CCR5 gene and HIV disease: the heterozygous (CCR5/delta ccr5) genotype is neither essential nor sufficient for protection against disease progression. Swiss HIV Cohort

Homozygous (delta ccr5/delta ccr5) and heterozygous (CCR5/delta ccr5) deletions in the beta-chemokine receptor 5 (CCR5) gene, which encodes for the major co-receptor for macrophage-tropic HIV-1 entry, have been implicated in resistance to HIV infection and in protection against disease progression, respectively. The CCR5/delta ccr5 genotype was found more frequently in long-term nonprogressors (LTNP) (31.0%) than in progressors (10.6%, p < 0.0001), in agreement with previous studies. Kaplan-Meier survival analyses showed that a slower progression of disease, i.e. higher proportion of subjects with CD4+ T cell counts > 500/microl (p = 0.0006) and a trend toward a slower progression to AIDS (p = 0.077), was associated with the CCR5/delta ccr5 genotype. However, when LTNP were analyzed separately, no significant differences in CD4+ T cell counts (p = 0.12) and viremia levels (p = 0.65) were observed between the wild-type (69% of LTNP) and the heterozygous (31.0%) genotypes. Therefore, there are other factors which play a major role in determining the status of nonprogression in the majority of LTNP. Furthermore, there was no evidence that the CCR5/delta ccr5 genotype was associated with different rates of disease progression in the group of progressors. Taken together, these results indicate that the CCR5/delta ccr5 genotype is neither essential nor sufficient for protection against the progression of HIV disease.

Antiretroviral therapy: a guide to the most important trials

AIDS and HIV infection have stimulated an unprecedented amount of research. In this review we have selected a few publications illustrating key issues. Viral load monitoring is useful because short-term changes in viremia, caused by antiretroviral treatment, predict long-term outcome. Combination therapy with AZT plus either ddl or ddC produces better results than therapy with AZT only, but the differences are slight and appeared only after several years of follow-up. In contrast, the effect of adding 3TC to AZT-containing regimens was statistically significant after only one year, halving mortality and the incidence of new AIDS-defining opportunistic infection. Adding ritonavir had a similar effect after 20 week's follow-up in far-advanced HIV infection. The most potent regimens combine AZT, 3TC, and either ritonavir or indinavir; in the majority of patients thus treated viremia became undetectable (< 500 copies/ml).