Revue médicale suisse
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The care of the frail elderly is characterised by fragmentation and discontinuity within and between sectors, resulting in frequent and inappropriate hospitalisations and premature nursing home placement. Integrated models of care in Europe, and North America have proven to be effective in improving health status, satisfaction and utilisation of resources in the frail elderly. The purpose of this article is to describe these programmes and the community geriatrics unit of Geneva, which provides health care to a frail elderly population in collaboration with other partners in the primary care sector. The main objective of the unit is to enable the frail elderly to stay at home using a multidisciplinary comprehensive geriatric approach and coordinated long-term follow-up.
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Acute aortic dissection (AAD) is uncommon, and associated with high morbidity and mortality rates. Positive or negative likelihood ratios of clinical parameters, ECG and chest x-ray do not allow to rule in or rule out AAD. ⋯ In several studies, D-dimer level within the normal range appears to have a negative predictive value that is low enough to rule out AAD. However, flaws of study design, heterogeneity of D-dimer tests and of their cut-offs (from 100 to 900 microg/l), and the absence of a validated workup strategy are strong arguments against the current use of D-dimer as a unique test to rule out AAD in clinical practice.
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Prescribing a medication for a condition not described in the label approved by national regulatory bodies (in Switzerland, Swissmedic) is called "off-label" prescribing. Unlicensed drug use is common in all fields of medicine and may be encountered in therapeutic guidelines. ⋯ In Switzerland, patients need to be informed that health insurance coverage is not guaranteed with off-label use. The prescribing physician bears the responsibility of off-label use with the possibility of unanticipated risks, and should therefore be prepared for possible malpractice suits.
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Neuropathic pain is challenging to treat, partly because of the systemic side effects of the commonly used medications. Therefore topical analgesics are potentially very usefull. ⋯ However, this option should be evaluated on an individual basis. The efficacy of topical amitriptyline and ketamine is not demonstrated.