[How do Swiss family physicians treat subclinical hypothyroidism?]

Subclinical hypothyroidism is a common condition, and its prevalence increases with age. Currently, guidelines regarding the screening and treatment of subclinical hypothyroidism are controversial. An international survey of general practitioners (GPs), to which Swiss GPs also contributed, showed large inter-country variations in treatment strategies for subclinical hypothyroidism. These differences are mainly explained by the lack of strong evidence for the management of this condition. The European randomized-controlled clinical trial TRUST should help clarify recommendations for screening and thyroxin replacement for the elderly with subclinical hypothyroidism. Working in close collaboration with GPs in Switzerland for the recruitment of patients will ensure that the findings from this study will be applicable to primary care settings.

[General practitioners facing social inequalities in health: which power to act?]

The link between social inequalities and health has been known for many years, as attested by Villermé's work on the "mental and physical status of the working class" (1840). We have more and more insight into the nature of this relationship, which embraces not only material deprivation, but also psychological mechanisms related to social and interpersonal problems. Defining our possible role as physicians to fight against these inequalities has become a public health priority. Instruments and leads, which are now available to help us in our daily practice, are presented here.

[Tomorrow's family doctor]

The profession of family doctor will undergo profound changes in the coming decade due to external, political, demographic and societal developments. Changes will also occur from within the profession affecting its content and its functioning. Other influences, in addition to generational developments (reduced working hours, feminisation, revaluation of the work-life balance), will come from collaboration with new professions, news structures as well as technical and human progress. In this transitional period it is important to uphold core values of family medicine, in particular coordination, continuity of care and the global approach to patients. In training future family doctors we must both prepare them for new skills and roles, and continue to share the core values with them.

[Benefits of using rapid HIV testing at the PMU-FLON walk-in clinic in Lausanne]

Lab tests are frequently used in primary care to guide patient care. This is particularly the case when a severe disorder, or one that will affect patients' initial care, needs to be excluded rapidly. At the PMU-FLON walk-in clinic the use of HIV testing as recommended by the Swiss Office of Public Health was hampered by the delay in obtaining test results. This led us to introduce rapid HIV testing which provides results within 30 minutes. Following the first 250 tests the authors discuss the results as well as the benefits of rapid HIV testing in an urban walk-in clinic.

[Low health literacy: barrier to optimal care]

Health literacy is defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions." Low health literacy mainly affects certain populations at risk limiting access to care, interaction with caregivers and self-management. If there are screening tests, their routine use is not advisable and recommended interventions in practice consist rather to reduce barriers to patient-caregiver communication. It is thus important to include not only population's health literacy but also communication skills of a health system wich tend to become more complex.

[Development, implementation and practical use of a diagnostic score]

In recent years many clinical prediction rules (CPR) have been developed. Before a CPR can be used in clinical practice, different methodical steps are necessary, from the development of the score, the internal and external validation to the impact study. Before using a CPR in daily practice family doctors have to verify how the rules have been developed and whether this has been done in a population similar to the population in which they would use them. The aim of this paper is to describe the development of a CPR, and to discuss advantages and risks related to the use of CPR in order to help family doctors in their choice of scores for use in their daily practice.

[Added value of family practitioners' supervision of junior doctors in a walk-in clinic]

The pending workforce crisis in family medicine has triggered various initiatives. This article describes the PMU-FLON walk-in clinic, a project of the Institute of General Medicine University of Lausanne. The working conditions in this clinic are close to that of a family practice. Doctors in training are supervised by family doctors who work part-time in the clinic. The objective is to improve training in the various fields of family medicine, from technical skills (improving optimal use of diagnostic tools), to integrating patients' requests in a more global patient-centered approach. This new educational model allows doctors in training to benefit from the specific approaches of different trainers. It will contribute to promoting quality family medicine in the future.

[The place of the clinic in primary case--the TOPIC study]

We know very little about the importance of history and physical examination compared to the importance of paraclinical tests in the diagnostic process in primary care. To answer this question, we examined prospectively 672 consecutive patients with chest pain in primary care. We recorded the timing and the clinical characteristics of the most frequent diagnosis. The resort to laboratory or other clinical tests and reference to specialist were influenced by: emergency consultation, potentially life-threatening aetiology, personal characteristics of the general practitioners' (GP) and patients' anxiety. GPs attributed the diagnosis to history and physical examination alone in 66% and to the association of history, physical examination and tests in 31% cases. This, clinical strategy remains the most important factor in the diagnostic process; even when they are insufficient, they allowed to generate hypotheses and guide investigations.

Iron supplementation for unexplained fatigue in non-anaemic women: double blind randomised placebo controlled trial

OBJECTIVE

To determine the subjective response to iron therapy in non-anaemic women with unexplained fatigue.

DESIGN

Double blind randomised placebo controlled trial.

SETTING

Academic primary care centre and eight general practices in western Switzerland.

PARTICIPANTS

144 women aged 18 to 55, assigned to either oral ferrous sulphate (80 mg/day of elemental iron daily; n=75) or placebo (n=69) for four weeks.

MAIN OUTCOME MEASURES

Level of fatigue, measured by a 10 point visual analogue scale.

RESULTS

136 (94%) women completed the study. Most had a low serum ferritin concentration; <or= 20 microg/l in 69 (51%) women. Mean age, haemoglobin concentration, serum ferritin concentration, level of fatigue, depression, and anxiety were similar in both groups at baseline. Both groups were also similar for compliance and dropout rates. The level of fatigue after one month decreased by -1.82/6.37 points (29%) in the iron group compared with -0.85/6.46 points (13%) in the placebo group (difference 0.95 points, 95% confidence interval 0.32 to 1.62; P=0.004). Subgroups analysis showed that only women with ferritin concentrations <or= 50 microg/l improved with oral supplementation.

CONCLUSION

Non-anaemic women with unexplained fatigue may benefit from iron supplementation. The effect may be restricted to women with low or borderline serum ferritin concentrations.

Prevention of acute mastoiditis: fact or fiction?

Acute mastoiditis is the most common complication of acute otitis media (AOM). In recent years routine antibiotic treatment for acute middle ear infections was questioned and even abandoned in some countries. The goal of our study was to investigate the influence of antibiotic treatment on the occurrence and clinical outcome of acute mastoiditis and to analyze the bacteriological findings. A retrospective case record study of 48 patients with 50 episodes of acute mastoiditis hospitalized at our tertiary-care center between 1992 and 1999 was performed. Twenty-three patients (48%) received antibiotic treatment before admission whereas 25 (52%) did not. The group of patients without antibiotic pretreatment were younger (mean, 6 years) than patients with antibiotics (mean, 18 years) and their referral was delayed. The most common isolated single pathogen was Streptococcus pneumoniae. All pneumococci were sensitive to penicillin. Acute mastoiditis may be the first clinical sign of a middle ear infection, especially in very young children. Adequate antibiotic pretreatment cannot invariably prevent the development of acute mastoiditis even in the absence of penicillin resistant pathogens.

[Rhinosurgical concept in management of fronto-basal defects with cerebrospinal rhinorrhea]

BACKGROUND

Cerebrospinal fluid (CSF) leak, with its potential infectious complications remains today a challenge in diagnosis and surgical treatment. With the introduction of endonasal microsurgery, new minimally invasive techniques for the repair of these defects have been pioneered. Nasal approaches to the anterior skull base include external-transfacial as well as endonasal approaches for reconstruction. It is important to have multiple possible approaches for the correction so that the optimal method for the individual pathology may be selected. The purpose of this paper is to clarify the decision process for selecting the safest procedure with the least possible morbidity and functional compromise.

METHOD

In a retrospective study we assessed a group of 69 patients treated from 1988 to 1996. Patient records, CT scans, postoperative clinical follow-up and a questionnaire, sent to the patients, were evaluated. The various external and endonasal approaches are presented and the closure techniques are discussed in detail.

RESULTS

Of the 69 operations, 40 (58%) were external and 29 (42%) were endonasal. There were three failures in the external approach group (4.4%) and no failures in the endonasal group. No major complications in the intraoperative or postoperative course occurred. Of importance, olfaction was retained in 94% of patients in at least one side. The average duration of hospitalization was 6 days.

CONCLUSIONS

Nasal approaches to the anterior skull base for treatment of CSF leaks are highly effective, safe, and cause minimal morbidity. The optimal surgical approach is chosen according to the precise location and extent of the defect. We are now increasing using endonasal microsurgical approaches. The open, transfacial approaches are still indicated for fractures of the posterior wall of the frontal sinus as well as larger multi-fragmented fractures of the anterior skull base.

[Experiences with assessment of frontobasal defects, a diagnostic concept]

BACKGROUND

Cerebrospinal fluid (CSF) rhinorrhea presents not only a therapeutic challenge, but a diagnostic challenge as well. This is especially true in the case of atraumatic spontaneous leakage, which is often only minimal in quantity and can occur intermittently. The purpose of this paper is to compare the current methods of evaluation of CSF Rhinorrhea (beta 2-Transferrin assay, high resolution computed tomography [HRCT], and computotomographic cisternography [CTC]) and develop a diagnostic protocol.

METHOD

A retrospective analysis was performed of 61 patients who underwent operation for CSF rhinorrhea between 1988 and 1996 comparing the method of preoperative diagnosis and intraoperative findings.

RESULTS

beta 2-transferrin-determination in the nasal discharge had a sensitivity of 79% (33/42), HRCT correctly identified the defect in 84% (48/57) of cases, and CTC correctly localized the pathology in 72% (18/25) of the patients.

CONCLUSION

The sensitivity of each CSF rhinorrhea diagnosis method is less than 90%. It is our opinion that with the current level of technology a combined approach is optimal with two or more of the above studies. A diagnosis scheme is presented to manage step by step this challenging and potentially lethal problem.

[Medullary cancer of the thyroid gland]

Thirty-one cases of medullary carcinoma of the thyroid have been studied over the past fifteen years at the University Hospital of the Canton of Vaud, Switzerland (CHUV). Twenty cases were of sporadic nature and eleven presented as part of the familial MEN II syndrome (multiple endocrine neoplasia), one of which showed the classical features of the rare MEN IIb type. It is important to distinguish between the familial and sporadic cases, because membership of the former group implies the investigation of associated endocrinopathies (pheochromocytoma, hyperparathyreoidism) and study of the family tree as the syndrome is autosomal dominant. Medullary carcinoma of the thyroid is a constant feature of the MEN II syndrome and is the cause of premature death in these patients. The familial type should be suspected if the carcinoma appears early in life, is located in the superior pole of the thyroid or is bilateral or multicentric, if the histology shows hyperplasia of the C cells and, of course, if there is a history of surgery for pheochromocytoma or hyperparathyroidism. Although total thyroidecomy is the rule for these familial cases, its role is debatable in sporadic medullary carcinoma of the thyroid. Postoperative follow-up of these patients is based on serum calcitonin determination, as this is an extremely sensitive marker. The ten year survival rate is 50%, with the worst prognosis in MEN IIb type.

Impairment of chemotactic activity of microphages in chronic mucocutaneous candidosis

The chemotactic microphage function in combating and eliminating microorganisms is one of the most important features of the cellular immune system. Using a modified Boyden method we studied in vitro the chemotactic activity of the granulocytes in 5 patients suffering from chronic muco-cutaneous candidosis (CMCC), 3 of the familial and 2 of the non-familial type. To obtain quantitative results comparable to those of a control group, we investigated the granulocytes of 55 clinically and immunologically healthy persons by the same way. So we found, in comparison with the results of the controls, a striking reduction of the chemotactic granulocyte activity in all CMCC patients. This impairment of chemotaxis is apparently due to an inborn defect of the microphages. It is pointed out, however, that a non-specific stimulation of the immune system might be a promising way in the treatment of patients affected by CMCC.