Reliability of panel-based guidelines for colonoscopy: an international comparison.

BACKGROUND: This study examined the reliability of explicit guidelines developed using the RAND-UCLA appropriateness method. METHODS: The appropriateness of over 400 indications for colonoscopy was rated by two multispecialty expert panels (United States and Switzerland). A nine-point scale was used, which was consolidated into three categories of appropriateness: appropriate, uncertain, inappropriate. The distribution of appropriateness ratings between the two panels and the intrapanel and interpanel agreement for categories of appropriateness were calculated for all possible indications. Similar statistics were calculated for a series of 577 primary care patients referred for colonoscopy in Switzerland. RESULTS: Over 80% of all indications (348) could be directly compared. The proportions of indications classified as appropriate, uncertain, or inappropriate were 28.4%, 24.7%, 46.6% and 33.0%, 23.0%, 44.0% for the U.S. and the Swiss panels, respectively. Interpanel agreement was excellent for all the possible indications (kappa value: 0.75) and lower for actual cases (kappa value: 0.51) because of lower agreement for the most frequently encountered indications. CONCLUSIONS: Good agreement between the two sets of criteria was found, pointing to the reliability of the method. Partial disagreement occurred essentially for a few, albeit frequently encountered, indications for use of colonoscopy in cases of uncomplicated lower abdominal pain or constipation.

The INTERNORM project : bridging two worlds of expert- and layknowledge in standardization

This paper presents a pilot project to reinforce participatory practices in standardization. The INTERNORM project is funded by the University of Lausanne, Switzerland. It aims to create an interactive knowledge center based on the sharing of academic skills and the experiences accumulated by the civil society, especially consumer associations, environmental associations and trade unions to strengthen the participatory process of standardization. The first objective of the project is action-oriented: INTERNORM provides a common knowledge pool supporting the participation of civil society actors to international standard-setting activities by bringing them together with academic experts in working groups and by providing logistic and financial support to their participation to meetings of national and international technical committees. The second objective of the project is analytical: the standardization action initiated through INTERNORM provides a research field for a better understanding of the participatory dynamics underpinning international standardization. The paper presents three incentives that explain civil society (non-)involvement in standardization that try to overcome conventional resource-based hypotheses: an operational incentive, related to the use of standards in the selective goods provided by associations to their membership; a thematic incentive, provided by the setting of priorities by strategic committees created in some standardization organization; a rhetorical incentive, related to the discursive resource that civil society concerns offers to the different stakeholders.

Handicap mental et psychiatrie [Mental retardation and psychiatry]

In the canton de Vaud (Switzerland) the psychiatric units devoted to mental retardation have been suppressed during the deinstitutionalization process in the 1970/80s. However, the use of psychiatric hospitalizations has increased these last years. This increase is accompanied by an interdiction of seclusion and restraint outside of the specialized psychiatric unit. A unit of liaison psychiatry has been created as an alternative to psychiatric hospitalization and to assist directly the staff of specialized institutions for people with mental retardation or the family of the patient. The article describes the challenges of liaison psychiatry in this field and the potential benefits of research for the psychiatry of mental retardation.

Evaluation of an online, case-based interactive approach to teaching pathophysiology

Rapport de synthèse : L'article qui fait l'objet de ma thèse évalue une nouvelle approche pédagogique pour l'apprentissage de certains chapitres de physiopathologie. Le dispositif pédagogique se base sur l'alternance d'apprentissage ex-cathedra et de l'utilisation d'un site web comprenant des vignettes cliniques. Lors de la consultation de ces-dernières, l'étudiant est invité à demander des examens de laboratoire dont il pourrait justifier la pertinence selon le cas clinique étudié. La nouveauté du procédé réside dans le fait que, préalablement à son cours ex-cathedra, l'enseignant peut consulter les statistiques de demandes de laboratoire et ainsi orienter son cours selon les éléments mal compris par les étudiants. A la suite du cours ex-cathedra, les étudiants peuvent consulter sur internet la vignette clinique complète avec des explications. A l'issue de tout le cours, une évaluation auprès des étudiants a été conduite. Le procédé a été mis en place durant deux années consécutives et l'article en discute notamment les résultats. Nous avons pu conclure que cette méthode innovatrice d'enseignement amène les étudiants à mieux se préparer pour les cours ex-cathedra tout en permettant à l'enseignant d'identifier plus précisément quelles thématiques étaient difficiles pour les étudiants et donc d'ajuster au mieux son cours. Mon travail de thèse a consisté à créer ce dispositif d'apprentissage, à créer l'application web des vignettes cliniques et à l'implanter durant deux années consécutives. J'ai ensuite analysé les données des évaluations et écrit l'article que j'ai présenté à la revue 'Medical Teacher'. Après quelques corrections et précisions demandées par le comité de lecture, l'article a été accepté et publié. Ce travail a débouché sur une seconde version de l'application web qui est actuellement utilisée lors du module 3.1 de 3è année à l'Ecole de Médecine à Lausanne. Summary : Since the early days of sexual selection, our understanding of the selective forces acting on males and females during reproduction has increased remarkably. However, despite a long tradition of experimental and theoretical work in this field and relentless effort, numerous questions remain unanswered and many results are conflicting. Moreover, the interface between sexual selection and conservation biology has to date received little attention, despite existing evidence for its importance. In the present thesis, I first used an empirical approach to test various sexual selection hypotheses in a population of whitefish of central Switzerland. This precise population is characterized by a high prevalence of gonadal alterations in males. In particular, I challenged the hypothesis that whitefish males displaying peculiar gonadal features are of lower genetic quality than other seemingly normal males. Additionally, I also worked on identifying important determinant of sperm behavior. During a second theoretical part of my work, which is part of a larger project on the evolution of female mate preferences in harvested fish populations, I developed an individual-based simulation model to estimate how different mate discrimination costs affect the demographical behavior of fish populations and the evolutionary trajectories of female mate preferences. This latter work provided me with some insight on a recently published article addressing the importance of sexual selection for harvesting-induced evolution. I built upon this insight in a short perspective paper. In parallel, I let some methodological questions drive my thoughts, and wrote an essay about possible synergies between the biological, the philosophical and the statistical approach to biological questions.

Minimal data requirements for a continuous monitoring of the quality of care using the DRG classification.

The DRG classification provides a useful tool for the evaluation of hospital care. Indicators such as readmissions and mortality rates adjusted for the hospital Casemix could be adopted in Switzerland at the price of minor additions to the hospital discharge record. The additional information required to build patients histories and to identify the deaths occurring after hospital discharge is detailed.

Effects of zoledronate versus placebo on spine bone mineral density and microarchitecture assessed by the trabecular bone score in postmenopausal women with osteoporosis: A three-year study.

The trabecular bone score (TBS) is an index of bone microarchitectural texture calculated from anteroposterior dual-energy X-ray absorptiometry (DXA) scans of the lumbar spine (LS) that predicts fracture risk, independent of bone mineral density (BMD). The aim of this study was to compare the effects of yearly intravenous zoledronate (ZOL) versus placebo (PLB) on LS BMD and TBS in postmenopausal women with osteoporosis. Changes in TBS were assessed in the subset of 107 patients recruited at the Department of Osteoporosis of the University Hospital of Berne, Switzerland, who were included in the HORIZON trial. All subjects received adequate calcium and vitamin D3. In these patients randomly assigned to either ZOL (n = 54) or PLB (n = 53) for 3 years, BMD was measured by DXA and TBS assessed by TBS iNsight (v1.9) at baseline and 6, 12, 24, and 36 months after treatment initiation. Baseline characteristics (mean ± SD) were similar between groups in terms of age, 76.8 ± 5.0 years; body mass index (BMI), 24.5 ± 3.6 kg/m(2) ; TBS, 1.178 ± 0.1 but for LS T-score (ZOL-2.9 ± 1.5 versus PLB-2.1 ± 1.5). Changes in LS BMD were significantly greater with ZOL than with PLB at all time points (p < 0.0001 for all), reaching +9.58% versus +1.38% at month 36. Change in TBS was significantly greater with ZOL than with PLB as of month 24, reaching +1.41 versus-0.49% at month 36; p = 0.031, respectively. LS BMD and TBS were weakly correlated (r = 0.20) and there were no correlations between changes in BMD and TBS from baseline at any visit. In postmenopausal women with osteoporosis, once-yearly intravenous ZOL therapy significantly increased LS BMD relative to PLB over 3 years and TBS as of 2 years. © 2013 American Society for Bone and Mineral Research.

IDENTITÉ, PROJET, CHANGEMENT : DES REPRÉSENTATIONS SOCIALES AUX LEVIERS DE L'ACTION PUBLIQUE. POUR UN MODE DE GOUVERNANCE AXÉ SUR LE DÉVELOPPEMENT TERRITORIAL. ETUDE DE CAS : CANTON DU JURA (SUISSE)

Thirty years after the Canton of Jura entered sovereignty, it has to be admited that the creation of the newly canton did't fullfill the hopes of economic and demografic growth that many could have expected from political independance. Through a plurality of complementary approaches, the research suggest a closer look at, on one hand, the position of the Canton in its territorial context as well as its structure and dynamics and on the other hand, the representations of the territory and its evolution by the social actors. This in order to formulate a set of social demands (of debate, of openness and of overcoming cleavages) which augurs for a new territoriality regime and testify of a requirement of reflexivity toward the state institutions and actions. The analysis allowed to set in evidence the central role of the couple identity-project in the dynamics of change, and to identifiy three main periods in the recent past of the Canton: a period of territorialization, during which grew a strong collective identity, coupled with a major project of society (the creation of the canton of Jura); then followed a period of deterritorialization, with the fragmentation of the collective identity and the lack of a project of society. Then, the third period, with a paradoxical event, the failure in public vote of the the project Jura open Land (Jura Pays ouvert), which was meant to give a second wind to the Canton. We consider this turning point as the start of a new period (of reterritorialization), with an issue linked with the outlines of a renewed "jurassian" identity and the elaboration of a shared territory project.Trente ans après l'entrée en souveraineté, force est de constater que la création du canton du Jura n'a pas permis de répondre aux espérances de développement économique et démographique que l'indépendance politique devait entraîner dans son sillage. Cette recherche se propose, à travers une pluralité d'approches complémentaires, d'examiner d'une part la position du Canton dans son contexte territorial ainsi que sa structure et sa dynamique; d'autre part, les représentations que se font les acteurs du territoire et de son évolution, pour déboucher sur une série de demandes sociales (de débat, d'ouverture et de dépassement des clivages) qui augurent de la transition vers un nouveau régime de territorialité et témoignent d'une exigence de réflexivité envers les institutions et les actions de l'Etat. L'analyse a permis de mettre en évidence le rôle central du couple identité-projet dans la dynamique de changement et d'identifier trois temps forts dans l'évolution récente du Canton, une phase de territorialisation au cours de laquelle s'est constituée une identité forte doublée d'un projet de société majeur, suivie d'une phase de déterritorialisation avec une fragmentation de l'identité collective et l'absence de projet mobilisateur. Enfin, un moment paradoxal, l'échec du projet Jura Pays ouvert, censé redonner un second souffle au Canton, qui amorce une nouvelle étape (de reterritorialisation) avec un questionnement lié aux contours d'une identité jurassienne renouvelée et à l'élaboration d'un projet de territoire partagé.Les ressorts de la production du territoire et de son développement sont analysés à travers le rôle des représentations sociales dans la constitution identitaire et le projet territorial, à l'exemple du canton du Jura. La mise en évidence du rôle central du couple identité-projet dans la dynamique de changement a permis d'identifier trois temps forts dans l'évolution récente du Canton. Une première phase (la création du canton du Jura), au cours de laquelle s'est constituée une identité forte doublée d'un projet de société majeur, suivie d'une phase au cours de laquelle l'identité collective s'est fragmentée en l'absence de projet mobilisateur (la phase de « gestion » de l'Etat). Puis un moment de rupture (l'échec du projet Jura Pays ouvert) et l'amorce d'une transition vers une nouvelle étape, avec un questionnement lié aux contours d'une identité jurassienne renouvelée, à l'élaboration d'un projet de territoire partagé, et à l'action des pouvoirs publics dans un contexte de repositionnement du Canton.

No use for waist-for-height ratio in addition to body mass index to identify children with elevated blood pressure.

Abstract Background. In children, waist-for-height ratio (WHtR) has been proposed to identify subjects at higher risk of cardiovascular diseases. The utility of WHtR to identify children with elevated blood pressure (BP) is unclear. Design. Cross-sectional population-based study of schoolchildren. Methods. Weight, height, waist circumference and BP were measured in all sixth-grade schoolchildren of the canton de Vaud (Switzerland) in 2005/06. WHtR was computed as waist [cm]/height [cm]. Elevated BP was defined according to sex-, age- and height-specific US reference data. The area under the receiver operating characteristic curve (AUC) statistic was computed to compare the ability of body mass index (BMI) z-score and WHtR, alone or in combination, to identify children with elevated BP. Results. 5207 children participated (76% response) [2621 boys, 2586 girls; mean (± SD) age, 12.3 ± 0.5 years; range: 10.1-14.9]. The prevalence of elevated BP was 11%. Mean WHtR was 0.44 ± 0.05 (range: 0.29- 0.77) and 11% had high WHtR (> 0.5). BMI z-score and WHtR were strongly correlated (Spearman correlation coefficient r = 0.76). Both indices were positively associated with elevated BP. AUCs for elevated BP was relatively low for BMI z-score (0.62) or for WHtR (0.62), and was not substantially improved when both indices were considered together (0.63). Conclusions. The ability of BMI z-score or WHtR to identify children aged 10-14 with elevated BP was weak. Adding WHtR did not confer additional discriminative power to BMI alone. These findings do not support the measurement of WHtR in addition to BMI to identify children with elevated BP.

Les gangs en Suisse : délinquance, victimisation et facteurs de risque

Abstract Gang membership constitutes one of the strongest risk factors of delinquency. Research on this topic found that gang members commit more offences in general and are particularly more prone to violent offences than other juveniles. Indeed, they are responsible for approximately 50 to 86% of the total offences perpetrated by juvenile offenders. In Switzerland, as in other European countries, there is a reluctance to use the term of gang to talk about delinquent youth groups. However, this term implies many stereotypes that do not apply to the majority of juvenile American gangs. Thus, it appears that some delinquent youth groups in European countries can be described as gangs. This manifestation of juvenile delinquency is increasingly studied by European researchers, whose studies demonstrate the high level of delinquency committed by gang members. This research assesses the proportion of gangs in Switzerland and their level of involvement in delinquency. Victimization of gang members as well as risk factors of gang membership are also analyzed. For this research, data of two self-reported juvenile delinquency surveys were used, namely the survey of "les jeunes et l'insécurité" and the second wave of the International Self-Reported Delinquency Survey (ISRD-2). The first survey took place in the canton of Vaud among 4'690 teenagers, and the second one was conducted across Switzerland by interviewing 3'648 teenagers aged 12 to 16. The results from the ISRD-2 survey show that 4.6% of young Swiss belong to a gang, whereas this is the case for 6.5% of teenagers in the canton of Vaud. About a third of the gang members ara girls. A strong link between the commission of offences and gang membership was found in both surveys. A teenager who does not belong to a gang commits on average 1.9 offences per year, whereas this number increases to 7.2 offences for teenagers who have delinquent peers and to 16 offences for gang members. The risk of victimization is also stronger for a gang member than for a non-gang member, as it is 4 to 5 times higher for assaults and robberies. International comparisons based on the ISRD-2 survey have been conducted, highlighting the high level of delinquency of gang members and their vulnerability to victimization. Risk factors of gang membership include the influence of accessibility to drugs in the neighbourhoods, the lack of self-control of the teenagers and their consumption of cannabis. Résumé Un des facteurs de risque les plus importants de la délinquance juvénile est l'appartenance à un gang. Les recherches faites sur cette problématique indiquent que les membres de gangs commettent plus de délits et des délits plus violents que les autres jeunes et qu'ils sont responsables d'environ 50 â 86% des actes délinquants perpétrés. En Suisse, tout comme dans d'autres pays européens, une réticence existe à utiliser le terme de gang pour parler des bandes de jeunes délinquants. Pourtant, ce terme implique de nombreux stéréotypes qui ne correspondent toutefois pas à la majorité des gangs américains. Ainsi, il apparaît que certaines bandes de jeunes délinquants présentes dans des pays européens peuvent être qualifiées de gangs. Cette manifestation de ta délinquance juvénile est de plus en plus étudiée par les chercheurs européens qui démontrent également la sur-criminalité de leurs membres. I La présente recherche évalue dans quelle proportion tes membres de gangs existent en Suisse et Quel est leur niveau d'implication dans la délinquance. Leur victimisation ainsi que les facteurs de risque de l'affiliation à de tels groupes y sont également analysés. Pour ce faire, les données de deux enquêtes ont été utilisées, à savoir l'enquête des jeunes et de l'insécurité portant sur 4'690 élèves de 8'? et 9*? année scolaire du canton de Vaud, ainsi que la deuxième vague du sondage de délinquance auto-reportée portant sur 3'648 jeunes suisses ayant entre 12 et 16 ans (ISRD-2 -International Self Reported Delinquency-). Ainsi, 4.6% des jeunes suisses, selon la recherche de l'ISRD-2, et 6.5% des jeunes vaudois, selon l'enquête des jeunes et de l'insécurité, appartiennent à un gang ; un tiers des membres étant de sexe féminin. Un lien fort entre la commission de délits et l'affiliation à un gang a été mis en évidence dans les deux enquêtes. Un adolescent qui ne fait pas partie d'un gang commet en moyenne 1.9 délits par année, un jeune qui a des pairs délinquants en commet en moyenne 7.2, alors que la moyenne annuelle des jeunes qui appartiennent à un gang s'élève à 16. Le risque de devenir victime est également plus important lorsqu'un jeune fait partie de tels groupes, puisqu'il est 4 à 5 fois plus élevé pour les agressions et les brigandages. Des comparaisons internationales, basées sur l'enquête de l'lSRD-2, ont pu être effectuées, mettant en exergue la sur-criminalité des membres de gangs ainsi que leur vulnérabilité face à la victimisation. Des facteurs de risque de l'affiliation è un gang, tels que l'influence de l'accessibilité à la drogue dans les quartiers où habitent les jeunes, le manque d'autocontrôlé de ces derniers ou leur consommation de cannabis ont été relevés

Networking the unemployed : Can policy interventions facilitate access to employment through informal channels ?

It is widely known that informal contacts and networks constitute a major advantage when searching for a job. Unemployed people are likely to benefit from such informal contacts, but building and sustaining a network can be particularly difficult when out of employment. Interventions that allow unemployed people to effectively strengthen their networking capability could as a result be promising. Against this background, this article provides some hints in relation to the direction that such interventions could take. First, on the basis of data collected on a sample of 4,600 newly-unemployed people in the Swiss Canton of Vaud, it looks at the factors that influence jobseekers' decisions to turn to informal contacts for their job search. The article shows that many unemployed people are not making use of their network because they are unaware of the importance of this method. Second, it presents an impact analysis of an innovative intervention designed to raise awareness of the importance of networks which is tested in a randomized controlled trial setting.

Integration of ground-penetrating radar and microgravimetric methods to map shallow caves

Ground-penetrating radar (GPR) and microgravimetric surveys have been conducted in the southern Jura mountains of western Switzerland in order to map subsurface karstic features. The study site, La Grande Rolaz cave, is an extensive system in which many portions have been mapped. By using small station spacing and careful processing for the geophysical data, and by modeling these data with topographic information from within the cave, accurate interpretations have been achieved. The constraints on the interpreted geologic models are better when combining the geophysical methods than when using only one of the methods, despite the general limitations of two-dimensional (2D) profiling. For example, microgravimetry can complement GPR methods for accurately delineating a shallow cave section approximately 10 X 10 mt in size. Conversely, GPR methods can be complementary in determining cavity depths and in verifying the presence of off-line features and numerous areas of small cavities and fractures, which may be difficult to resolve in microgravimetric data.

Case management for frequent users of the emergency department: study protocol of a randomised controlled trial.

BACKGROUND: We devised a randomised controlled trial to evaluate the effectiveness and efficiency of an intervention based on case management care for frequent emergency department users. The aim of the intervention is to reduce such patients' emergency department use, to improve their quality of life, and to reduce costs consequent on frequent use. The intervention consists of a combination of comprehensive case management care and standard emergency care. It uses a clinical case management model that is patient-identified, patient-directed, and developed to provide high intensity services. It provides a continuum of hospital- and community-based patient services, which include clinical assessment, outreach referral, and coordination and communication with other service providers. METHODS/DESIGN: We aim to recruit, during the first year of the study, 250 patients who visit the emergency department of the University Hospital of Lausanne, Switzerland. Eligible patients will have visited the emergency department 5 or more times during the previous 12 months. Randomisation of the participants to the intervention or control groups will be computer generated and concealed. The statistician and each patient will be blinded to the patient's allocation. Participants in the intervention group (N = 125), additionally to standard emergency care, will receive case management from a team, 1 (ambulatory care) to 3 (hospitalization) times during their stay and after 1, 3, and 5 months, at their residence, in the hospital or in the ambulatory care setting. In between the consultations provided, the patients will have the opportunity to contact, at any moment, the case management team. Participants in the control group (N = 125) will receive standard emergency care only. Data will be collected at baseline and 2, 5.5, 9, and 12 months later, including: number of emergency department visits, quality of life (EuroQOL and WHOQOL), health services use, and relevant costs. Data on feelings of discrimination and patient's satisfaction will also be collected at the baseline and 12 months later. DISCUSSION: Our study will help to clarify knowledge gaps regarding the positive outcomes (emergency department visits, quality of life, efficiency, and cost-utility) of an intervention based on case management care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01934322.

A quasi-randomized group trial of a brief alcohol intervention on risky single occasion drinking among secondary school students.

OBJECTIVES: To show the effectiveness of a brief group alcohol intervention. Aims of the intervention were to reduce the frequency of heavy drinking occasions, maximum number of drinks on an occasion and overall weekly consumption. METHODS: A cluster quasi-randomized control trial (intervention n = 338; control n = 330) among 16- to 18-year-old secondary school students in the Swiss Canton of Zürich. Groups homogeneous for heavy drinking occasions (5+/4+ drinks for men/women) consisted of those having medium risk (3-4) or high risk (5+) occasions in the past 30 days. Groups of 8-10 individuals received two 45-min sessions based on motivational interviewing techniques. RESULTS: Borderline significant beneficial effects (p < 0.10) on heavy drinking occasions and alcohol volume were found 6 months later for the medium-risk group only, but not for the high-risk group. None of the effects remained significant after Bonferroni corrections. CONCLUSIONS: Group intervention was ineffective for all at-risk users. The heaviest drinkers may need more intensive treatment. Alternative explanations were iatrogenic effects among the heaviest drinkers, assessment reactivity, or reduction of social desirability bias at follow-up through peer feedback.