Assistance au suicide en hôpital de soins aigus: sommes-nous prêts [Physician-assisted suicide in university hospital: are we ready?]

Assisting people to commit suicide has generated a passionate public debate. In exceptional situations, access to this support can be granted to the demanders in a hospital environment. So did the CHUV and the academic hospitals of Geneva draw up a procedure permitting, in principle, the access to an assistance to commit suicide. Two recent clinical situations experienced in the CHUV's Service of internal medicine have created a lot of discussions, doubts and revealed, sometimes, divergent positions. By the light of this clinical cases, we wished to share the perspective of the internist in charge of the ethician, of the chaplain, of the medical director, of the psychiatrist and of the palliative care responsible. Theses complex situations illustrate the deep ambivalence felt by the clinicians confronted to situations which require a multidisciplinary approach.

Flight energetics in relation to sexual differences in the mating behaviour of a mayfly, Siphlonurus aestivalis

Mayflies (Ephemeroptera) are known to have short adult life-spans. Adults are unable to feed, and they utilize reserves stored during their aquatic larval stage. Energy reserves (fat, glycogen, and free sugars) of mature larvae, subimagoes and imagoes of both sexes of Siphlonurus aestivalis Eaton were compared. All the stages of both sexes had low glycogen and free sugar contents, and the only significant change occurred during the transformation of the mature larva to subimago when almost all the reserves of free sugars were used up. Glycogen and free sugars may serve as energy sources permitting individuals to swim and fly out of the water during emergence. Fat made up most of the energy reserves of mature larvae and was the main source of energy used during the final development of both sexes. Young adult males had high fat reserves which they used as a source of energy for their swarming flights. In contrast, females did not seem to use a significant amount of fat for flight. This difference is probably related to the different mating strategies of the sexes in this species. Males perform long flights waiting for females, whereas females perform only brief flights to mate and reproduce.

Changes in running mechanics and spring-mass behaviour during a 5-km time trial.

Research into the biomechanical manifestation of fatigue during exhaustive runs is increasingly popular but additional understanding of the adaptation of the spring-mass behaviour during the course of strenuous, self-paced exercises continues to be a challenge in order to develop optimized training and injury prevention programs. This study investigated continuous changes in running mechanics and spring-mass behaviour during a 5-km run. 12 competitive triathletes performed a 5-km running time trial (mean performance: ̴17 min 30 s) on a 200 m indoor track. Vertical and anterior-posterior ground reaction forces were measured every 200 m by a 5-m long force platform system, and used to determine spring-mass model characteristics. After a fast start, running velocity progressively decreased (- 11.6%; P<0.001) in the middle part of the race before an end spurt in the final 400-600 m. Stride length (- 7.4%; P<0.001) and frequency (- 4.1%; P=0.001) decreased over the 25 laps, while contact time (+ 8.9%; P<0.001) and total stride duration (+ 4.1%; P<0.001) progressively lengthened. Peak vertical forces (- 2.0%; P<0.01) and leg compression (- 4.3%; P<0.05), but not centre of mass vertical displacement (+ 3.2%; P>0.05), decreased with time. As a result, vertical stiffness decreased (- 6.0%; P<0.001) during the run, whereas leg stiffness changes were not significant (+ 1.3%; P>0.05). Spring-mass behaviour progressively changes during a 5-km time trial towards deteriorated vertical stiffness, which alters impact and force production characteristics.

Clinical presentation and outcome in a series of 88 patients with the cblC defect.

The cblC defect is the most common inborn error of vitamin B12 metabolism. Despite therapeutic measures, the long-term outcome is often unsatisfactory. This retrospective multicentre study evaluates clinical, biochemical and genetic findings in 88 cblC patients. The questionnaire designed for the study evaluates clinical and biochemical features at both initial presentation and during follow up. Also the development of severity scores allows investigation of individual disease load, statistical evaluation of parameters between the different age of presentation groups, as well as a search for correlations between clinical endpoints and potential modifying factors. RESULTS: No major differences were found between neonatal and early onset patients so that these groups were combined as an infantile-onset group representing 88 % of all cases. Hypotonia, lethargy, feeding problems and developmental delay were predominant in this group, while late-onset patients frequently presented with psychiatric/behaviour problems and myelopathy. Plasma total homocysteine was higher and methionine lower in infantile-onset patients. Plasma methionine levels correlated with "overall impression" as judged by treating physicians. Physician's impression of patient's well-being correlated with assessed disease load. We confirmed the association between homozygosity for the c.271dupA mutation and infantile-onset but not between homozygosity for c.394C>T and late-onset. Patients were treated with parenteral hydroxocobalamin, betaine, folate/folinic acid and carnitine resulting in improvement of biochemical abnormalities, non-neurological signs and mortality. However the long-term neurological and ophthalmological outcome is not significantly influenced. In summary the survey points to the need for prospective studies in a large cohort using agreed treatment modalities and monitoring criteria.

Hypocretin/orexin in addiction: a mediator of stress-induced reinstatement of cocaine-seeking behaviour

The importance of the lateral hypothalamus in the pursuit of reward has long been recognized. However, the hypothalamic neuronal network involved in the regulation of reward still remains partially unknown. Hypocretins (aka orexins) are neuropeptides synthesized by a few thousand neurons restricted to the lateral hypothalamus and the perifornical area. Compelling evidence indicates that hypocretin neurons receive inputs from sensory and limbic systems and drive hyper-arousal possibly through modulation of stress responses. Major advances have been made in the elucidation of the hypocretin involvement in the regulation of arousal, stress, motivation, and reward seeking, without clearly defining the role of hypocretins in addictionrelated behaviors. We have recently gathered substantial evidence that points to a previously unidentified role for hypocretin-1 in driving relapse for cocaine seeking through activation of brain stress pathways. Meanwhile, several authors published concordant observations rather suggesting a direct activation of the mesolimbic dopamine system. In particular, hypocretin-1 has been shown to be critically involved in cocaine sensitization through the recruitment of NMDA receptors in the ventral tegmental area. Overall, on can conclude from recent findings that activation of hypocretin/orexin neurons plays a critical role in the development of the addiction process, either by contributing to brain sensitization (which is thought to lead to the unmanageable desire for drug intake) or by modulating the brain reward system that, in coordination with brain stress systems, leads to a vulnerable state that may facilitate relapse for drug seeking behavior.

Speed-cohesion trade-offs in collective decision making in ants and the concept of precision in animal behaviour

In decision making, speed-accuracy trade-offs are well known and often inevitable because accuracy depends on being well informed and gathering information takes time. However, trade-offs between speed and cohesion, that is the degree to which a group remains together as a single entity, as a result of their decision making, have been comparatively neglected. We combine theory and experimentation to show that in decision-making systems, speed-cohesion trade-offs are a natural complement to speed-accuracy trade-offs and are therefore of general importance. We then analyse the decision performance of 32 rock ant, Temnothorax albipennis, colonies in experiments in which accuracy of collective decision making was held constant, but time urgency varied. These experiments reveal for the first time an adaptive speed-cohesion trade-off in collective decision making and how this is achieved. In accord with different time constraints, colonies can decide quickly, at the cost of social unity, or they can decide slowly with much greater cohesion. We discuss the similarity between cohesion and the term precision as used in statistics and engineering. This emphasizes the generality of speed versus cohesion/precision trade-offs in decision making and decision implementation in other fields within animal behaviour such as sexually selected motor displays and even certain aspects of birdsong. We also suggest that speed versus precision trade-offs may occur when individuals within a group need to synchronize their activity, and in collective navigation, cooperative hunting and in certain escape behaviours.

Does a mandatory telemedicine call prior to visiting a physician reduce costs or simply attract good risks?

This paper aims to estimate empirically the efficiency of a Swiss telemedicine service introduced in 2003. We used claims' data gathered by a major Swiss health insurer, over a period of 6 years and involving 160 000 insured adults. In Switzerland, health insurance is mandatory, but everyone has the option of choosing between a managed care plan and a fee-for-service plan. This paper focuses on a conventional fee-for-service plan including a mandatory access to a telemedicine service; the insured are obliged to phone this medical call centre before visiting a physician. This type of plan generates much lower average health expenditures than a conventional insurance plan. Reasons for this may include selection, incentive effects or efficiency. In our sample, about 90% of the difference in health expenditure can be explained by selection and incentive effects. The remaining 10% of savings due to the efficiency of the telemedicine service amount to about SFr 150 per year per insured, of which approximately 60% is saved by the insurer and 40% by the insured. Although the efficiency effect is greater than the cost of the plan, the big winners are the insured who not only save monetary and non-monetary costs but also benefit from reduced premiums. Copyright © 2010 John Wiley & Sons, Ltd.

Addressing current treatment challenges in Crohn's disease in real life: A physician's survey.

BACKGROUND: In recent years several trials have addressed treatment challenges in Crohn's disease. Clinical trials however, represent a very special situation. AIMS: To perform a cross-sectional survey among gastroenterologists on the current clinical real life therapeutic approach focussing on the use of biologics. METHODS: A survey including six main questions on clinical management of loss of response, diagnostic evaluation prior to major treatment changes, preference for anti-tumour necrosis factor (TNF) agent, (de-)escalation strategies as well as a basic section regarding personal information was sent by mail to all gastroenterologists in Switzerland (n=318). RESULTS: In total, 120 questionnaires were analysed (response rate 37.7%). 90% of gastroenterologists in Switzerland use a thiopurine as the first step-up strategy (anti-TNF alone 7.5%, combination 2.5%). To address loss of response, most physicians prefer shortening the interval of anti-TNF administration followed by dose increase, switching the biologic and adding a thiopurine. In case of prolonged remission on combination therapy, the thiopurine is stopped first (52.6%) after a mean treatment duration of 15.7 months (biologic first in 41.4%). CONCLUSIONS: Everyday clinical practice in Crohn's disease patients appears to be incongruent with clinical data derived from major trials. Studies investigating reasons underlying these discrepancies are of need to optimize and harmonize treatment.