Prévention quaternaire: agir est-il toujours justifié en médecine de famille [Quaternary prevention: is acting always justified in family medicine?].

Quaternary prevention aims to protect the patient or population against overmedicalisation. Quaternary prevention influences all the activities of family medicine by questioning the utility of primary prevention and early diagnosis, identifying the risks of creating new pathological entities and practicing a maximalist medicine. Family doctors can support quaternary prevention by focusing on their patients' priorities and the local resources of an efficient health system.

Family history of cancer and the risk of laryngeal cancer: a case-control study from Italy and Switzerland.

Only limited data is available on the relationship between family history of laryngeal and other neoplasms and laryngeal cancer risk. We investigated the issue using data from a multicentre case-control study conducted in Italy and Switzerland between 1992 and 2009 including 852 cases with histologically confirmed laryngeal cancer and 1970 controls admitted to hospital for acute, non neoplastic conditions. Unconditional logistic regression models adjusted for age, sex, study center, education, tobacco smoking, alcohol drinking and number of siblings were used to estimate the odds ratios (ORs) of laryngeal cancer. The multivariate OR was 2.8 (95% confidence interval [CI], 1.5-5.3) in subjects reporting a first-degree relative with laryngeal cancer, as compared to subjects with no family history. The OR was higher when the relative was diagnosed before 60 years of age (OR = 3.5, 95% CI 1.4-8.8). As compared to subjects without family history, non-smokers, and moderate drinkers, the OR was 37.1 (95% CI 9.9-139.4) for current smokers, heavy drinkers, with family history of laryngeal cancer. Family history of colorectal (OR = 1.5, 95% CI 1.0-2.3) and kidney (OR = 3.8, 95% CI 1.2-12.1) cancer were also associated to an increased risk of laryngeal cancer, while no significant increase in risk was found for family history of cancer at all sites, excluding the larynx (OR = 1.1).

The SLC2 (GLUT) family of membrane transporters.

GLUT proteins are encoded by the SLC2 genes and are members of the major facilitator superfamily of membrane transporters. Fourteen GLUT proteins are expressed in the human and they are categorized into three classes based on sequence similarity. All GLUTs appear to transport hexoses or polyols when expressed ectopically, but the primary physiological substrates for several of the GLUTs remain uncertain. GLUTs 1-5 are the most thoroughly studied and all have well established roles as glucose and/or fructose transporters in various tissues and cell types. The GLUT proteins are comprised of ∼500 amino acid residues, possess a single N-linked oligosaccharide, and have 12 membrane-spanning domains. In this review we briefly describe the major characteristics of the 14 GLUT family members.

Nomenclature of the GLUT/SLC2A family of sugar/polyol transport facilitators.

The recent identification of several additional members of the family of sugar transport facilitators (gene symbol SLC2A, protein symbol GLUT) has created a heterogeneous and, in part, confusing nomenclature. Therefore, this letter provides a summary of the family members and suggests a systematic nomenclature for SLC2A and GLUT symbols.

Patients satisfaction in an academic walk-in centre: a new model of residents training achieved by family doctors.

BACKGROUND: Walk-in centres may improve access to healthcare for some patients, due to their convenient location and extensive opening hours, with no need for an appointment. Herein, we describe and assess a new model of walk-in centre, characterised by care provided by residents and supervision achieved by experienced family doctors. The main aim of the study was to assess patients' satisfaction about the care they received from residents and their supervision by family doctors. The secondary aim was to describe walk-in patients' demographic characteristics and to identify potential associations with satisfaction. METHODS: The study was conducted in the walk-in centre of Lausanne. Patients who consulted between 11th and 31st April were automatically included and received a questionnaire in French. We used a five-point Likert scale, ranging from "not at all satisfied" to "very satisfied", converted from values of 1 to 5. We focused on the satisfaction regarding residents' care and supervision by a family doctor. The former was divided in three categories: "Skills", "Treatment" and "Behaviour". A mean satisfaction score was calculated for each category and a multivariable logistic model was applied in order to identify associations with patients' demographics. RESULTS: The overall response rate was 47% [184/395]. Walk-in patients were more likely to be women (62%), young (median age 31), with a high education level (40% of University degree or equivalent). Patients were "very satisfied" with residents' care, with a median satisfaction score between 4.5 and 5, for each category. Over 90% of patients were "satisfied" or "very satisfied" that a family doctor was involved in the consultation. Age showed the greatest association with satisfaction. CONCLUSION: Patients were highly satisfied with care provided by residents and with the involvement of a family doctor in the consultation. Older age showed the greatest positive association with satisfaction with a positive impact. The high level satisfaction reported by walk-in patients supports this new model of walk-in centre.

Pairing of Vbeta6 with certain Valpha2 family members prevents T cell deletion by Mtv-7 superantigen.

Superantigens (SAg) are proteins of bacterial or viral origin able to activate T cells by forming a trimolecular complex with both MHC class II molecules and the T cell receptor (TCR), leading to clonal deletion of reactive T cells in the thymus. SAg interact with the TCR through the beta chain variable region (Vbeta), but the TCR alpha chain has been shown to have an influence on the T cell reactivity. We have investigated here the role of the TCR alpha chain in the modulation of T cell reactivity to Mtv-7 SAg by comparing the peripheral usage of Valpha2 in Vbeta6(+) (SAg-reactive) and Vbeta8.2(+) (SAg non-reactive) T cells, in either BALB/D2 (Mtv-7(+)) or BALB/c (Mtv-7(-)) mice. The results show, first, that pairing of Vbeta6 with certain Valpha2 family members prevents T cell deletion by Mtv-7 SAg. Second, there is a strikingly different distribution of the Valpha2 family members in CD4 and CD8 populations of Vbeta6 but not of Vbeta8.2 T cells, irrespective of the presence of Mtv-7 SAg. Third, the alpha chain may play a role in the overall stability of the TCR/SAg/MHC complex. Taken together, these results suggest that the Valpha domain contributes to the selective process by its role in the TCR reactivity to SAg/MHC class II complexes, most likely by influencing the orientation of the Vbeta domain in the TCR alphabeta heterodimer.

Vitellogenesis and the vitellogenin gene family.

Vitellogenin is synthesized under estrogen control in the liver, extensively modified, transported to the ovary, and there processed to the yolk proteins lipovitellin and phosvitin. In the frog Xenopus laevis there are at least four distinct but related vitellogenin genes. The two genes A1 and A2 have a 95 percent sequence homology in their messenger RNA coding regions, and contain 33 introns that interrupt the coding region (exons) at homologous positions. Sequences and lengths of analogous introns differ, and many introns contain repetitive DNA elements. The introns in these two genes that have apparently arisen by duplication have diverged extensively by events that include deletions, insertions, and probably duplications. Rapid evolutionary change involving rearrangements and the presence of repeated DNA suggests that the bulk of the sequences within introns may not have any specific function.

On the problematic of reserving and stochastic loss models

Abstract Traditionally, the common reserving methods used by the non-life actuaries are based on the assumption that future claims are going to behave in the same way as they did in the past. There are two main sources of variability in the processus of development of the claims: the variability of the speed with which the claims are settled and the variability between the severity of the claims from different accident years. High changes in these processes will generate distortions in the estimation of the claims reserves. The main objective of this thesis is to provide an indicator which firstly identifies and quantifies these two influences and secondly to determine which model is adequate for a specific situation. Two stochastic models were analysed and the predictive distributions of the future claims were obtained. The main advantage of the stochastic models is that they provide measures of variability of the reserves estimates. The first model (PDM) combines one conjugate family Dirichlet - Multinomial with the Poisson distribution. The second model (NBDM) improves the first one by combining two conjugate families Poisson -Gamma (for distribution of the ultimate amounts) and Dirichlet Multinomial (for distribution of the incremental claims payments). It was found that the second model allows to find the speed variability in the reporting process and development of the claims severity as function of two above mentioned distributions' parameters. These are the shape parameter of the Gamma distribution and the Dirichlet parameter. Depending on the relation between them we can decide on the adequacy of the claims reserve estimation method. The parameters have been estimated by the Methods of Moments and Maximum Likelihood. The results were tested using chosen simulation data and then using real data originating from the three lines of business: Property/Casualty, General Liability, and Accident Insurance. These data include different developments and specificities. The outcome of the thesis shows that when the Dirichlet parameter is greater than the shape parameter of the Gamma, resulting in a model with positive correlation between the past and future claims payments, suggests the Chain-Ladder method as appropriate for the claims reserve estimation. In terms of claims reserves, if the cumulated payments are high the positive correlation will imply high expectations for the future payments resulting in high claims reserves estimates. The negative correlation appears when the Dirichlet parameter is lower than the shape parameter of the Gamma, meaning low expected future payments for the same high observed cumulated payments. This corresponds to the situation when claims are reported rapidly and fewer claims remain expected subsequently. The extreme case appears in the situation when all claims are reported at the same time leading to expectations for the future payments of zero or equal to the aggregated amount of the ultimate paid claims. For this latter case, the Chain-Ladder is not recommended.

The distribution of the dinucleotide CpG and cytosine methylation in the vitellogenin gene family.

Sequence data from regions of five vertebrate vitellogenin genes were used to examine the frequency, distribution, and mutability of the dinucleotide CpG, the preferred modification site for eukaryotic DNA methyltransferases. The observed level of the CpG dinucleotide in all five genes was markedly lower than that expected from the known mononucleotide frequencies. CpG suppression was greater in introns than in exons. CpG-containing codons were found to be avoided in the vitellogenin genes, but not completely despite the redundancy of the genetic code. Frequency and distribution patterns of this dinucleotide varied dramatically among these otherwise closely related genes. Dense clusters of CpG dinucleotides tended to appear in regions of either functional or structural interest (e.g., in the transposon-like Vi-element of Xenopus) and these clusters contained 5-methylcytosine (5 mC). 5 mC is known to undergo deamination to form thymidine, but the extent to which this transition occurs in the heavily methylated genomes of vertebrates and its contribution to CpG suppression are still unclear. Sequence comparison of the methylated vitellogenin gene regions identified C----T and G----A substitutions that were found to occur at relatively high frequencies. The predicted products of CpG deamination, TpG and CpA, were elevated. These findings are consistent with the view that CpG distribution and methylation are interdependent and that deamination of 5 mC plays an important role in promoting evolutionary change at the nucleotide sequence level.

HIV disclosure and nondisclosure among migrant women from sub-Saharan Africa living in Switzerland.

No study to date has focused specifically on the reasons for and against disclosure of HIV-positive status among sub-Saharan migrant women. Thirty HIV-positive women from 11 sub-Saharan countries living in French-speaking Switzerland participated in semi-structured individual interviews. The reasons women reported for disclosure or nondisclosure of their HIV serostatus were classified into three categories: social, medical, and ethical. The women identified the stigma associated with HIV as a major social reason for nondisclosure. However, this study identifies new trends related to disclosure for medical and ethical reasons. Being undetectable played an important role in the life of sub-Saharan migrant women, and analysis revealed their medical reasons for both disclosure and nondisclosure. Disclosure to new sexual partners occurred when women had a more positive perception about HIV and when they believed themselves to be in a long-term relationship. Women reported nondisclosure to family members when they did not need help outside the support provided by the medical and social fields. The results on ethical reasons suggested that challenging stigma was a reason for disclosure. Since the women' perceptions on HIV changed when they came to see it as a chronic disease, disclosure occurred in an attempt to normalize life with HIV in their communities in migration and to challenge racism and discrimination. Our findings can help health providers better understand the communication needs of sub-Saharan migrant women with respect to HIV/AIDS and sexuality and offer them adequate disclosure advice that takes into account migration and gender issues.

A systems perspective on the integrative child psychiatry approach. Discussion of paper: "Working here and now with the individual and family system: A case of a traumatized child"

In this discussion, after a few general comments, I will propose a systems reading of the intervention so elegantly described by Kaija Puura. I will draw parallels between the therapeutic and the family groups as framing-developing systems and formalize the steps taken by the family toward healing under the influence of the therapist's team. En esta discusión, después de algunos comentarios generales, propongo una lectura sistemática de la intervención tan elegantemente descrita por Kaija Puura. Buscaré paralelos entre los grupos terapéuticos y de familia como sistemas de desarrollo enmarcado y formalizaré los pasos tomados por la familia hacia la cicatrización bajo la influencia del equipo del terapista. Après quelques commentaires généraux, je proposerai dans cette discussion une lecture systémique de l'intervention si élégamment décrite par Kaija Puura. J'établirai des parallèles entre les groupes thérapeutiques et familiaux en tant que systèmes d'encadrement-développement et je formaliserai les étapes de guérison franchies par la famille grâce à l'influence de l'équipe thérapeutique. In dieser Diskussion, werde ich nach einigen allgemeineren Aussagen, eine systemische Lesart der von Kaija Puura so eingängig beschriebenen Intervention vorschlagen. Ich werde darin Parallelen zwischen der therapeutischen und Rahmengebenden Familiengruppen ziehen, und die Schritte der Familien hin zu einer Heilung unter dem Einfluss des Therapeutenteams formalisieren.