Science, practice and patient needs: the work of the Plinius Maior Society.

The Plinius Maior Society is a European multinational, multidisciplinary group of clinicians and researchers in the alcoholism field, which strives for a comprehensive care concept in the management of alcoholism and alcohol-related problems. The Society, using evidence-based medicine, has developed a set of protocols, in the forms of guidelines, flow-charts, leaflets and booklets, for use as tools in research on and treatment of alcohol dependence, with a view to standardize clinical research procedures and to bridge the gap between the alcoholism researcher, practitioner and patient. These protocols or tools have been subjected to a review process during their preparation, and further comments on their validity will be integrated in their updates. Seven protocols have so far been developed, two of which, 'Guidelines on Evaluation of Treatment of Alcohol Dependence' and 'Detection and Management of Patients with Psychiatric and Alcohol Use Disorders', are aimed at the clinical researcher and specialists, whereas three others [in the form of decision trees (flow-charts)] are aimed at the general practitioner and other primary health care providers. These are entitled 'Alcohol Risk Assessment and Intervention in Primary Care', 'Withdrawal from Alcohol at Home' and 'Brief Intervention in Patients with Alcohol-Related Problems'. The remaining two tools are booklets aimed at the patient, one to support initiatives for detection of drinking problems and primary intervention, namely 'Do you have this Problem? Discuss it with your Doctor!', and the other to assist the patient in relapse prevention after the early stages of treatment, namely 'On the Way to Recovery'. The protocols for the general practitioners and patients have so far been produced in seven European languages, and, as with the Guidelines, feedback from target users will be collected and incorporated in future updates. The Society continually seeks to consider areas of clinical importance for its work and, as it enters the new millennium, it hopes to address and make a significant contribution to the most pressing problem in the management of alcohol dependence, namely relapse.

Frequency and determinants of using pharmacological enhancement in the clinical practice of in-hospital stroke rehabilitation.

Background: Pharmacological enhancement in stroke rehabilitation (PESR) is promising. Data about its use in clinical practice are missing. Methods: In a prospective, explorative study of four rehabilitation centers, we systematically observed the frequency and determinants of using PESR in consecutive patients. PESR was defined as using agents potentially enhancing post-stroke recovery exclusively to aid rehabilitation without an established indication. Results: 257 (55.4%) of 464 patients had agents potentially enhancing recovery. Selective serotonin reuptake inhibitors (SSRI) (n = 125, 26.9%), levodopa (n = 114, 24.6%), serotonin-noradrenaline reuptake inhibitors (SNRI) (n = 52, 11.2%), and acetylcholinesterase inhibitors (n = 48, 10.3%) were used most often. SSRI in 102/125 patients and SNRI in 46/52 patients were mostly used for accompanying depressive symptoms. 159 (34.3%) patients had PESR (without an otherwise established indication). In PESR patients, levodopa (n = 102, 64.1%) was used most commonly. PESR was primarily used for aphasia (36.5%) and paresis (25.2%). PESR patients did not differ from non-PESR patients in age, gender and stroke type. However, the utilization rates of PESR differed significantly across centers (2, 4, 38 and 55%). Conclusion: SSRI and SNRI were predominately used for accompanying depression, while levodopa was nearly exclusively used to aid stroke rehabilitation in the absence of an otherwise established indication. The differences in utilization rates for PESR between centers suggest therapeutic uncertainty and indicate the need for additional studies.

Joint Official Positions of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX(®). Executive Summary of the 2010 Position Development Conference on Interpretation and use of FRAX® in clinical practice.

The International Society for Clinical Densitometry (ISCD) and the International Osteoporosis Foundation (IOF) convened the FRAX(®) Position Development Conference (PDC) in Bucharest, Romania, on November 14, 2010, following a two-day joint meeting of the ISCD and IOF on the "Interpretation and Use of FRAX(®) in Clinical Practice." These three days of critical discussion and debate, led by a panel of international experts from the ISCD, IOF and dedicated task forces, have clarified a number of important issues pertaining to the interpretation and implementation of FRAX(®) in clinical practice. The Official Positions resulting from the PDC are intended to enhance the quality and clinical utility of fracture risk assessment worldwide. Since the field of skeletal assessment is still evolving rapidly, some clinically important issues addressed at the PDCs are not associated with robust medical evidence. Accordingly, some Official Positions are based largely on expert opinion. Despite limitations inherent in such a process, the ISCD and IOF believe it is important to provide clinicians and technologists with the best distillation of current knowledge in the discipline of bone densitometry and provide an important focus for the scientific community to consider. This report describes the methodology and results of the ISCD-IOF PDC dedicated to FRAX(®).

Small farmers of the Florida Province (Bolivia) : Reciprocity in Practice

Peasant societies are often seen by neoliberal or Marxist theorists as passive subjects of political-economic transformations occurring at a higher level, only surviving through acculturation to market requirements. By analyzing agricultural work organization in highland communities and a local system of water management called Acuerdos Reciprocos por el Agua (Reciprocal Agreements for Water), developed in 2003 by the Natura Bolivia foundation in Florida Province in Bolivia, we show that, contrary to this perception, traditional reciprocal norms still play an essential role in decision making. This suggests the agency of rural societies and the resilience of traditional reciprocity-based norms in mountain regions.

The social disembedding of business theory and practice. A (neo-)institutional analysis of the homo economicus and corporate social responsibility, and the inherent responsibility of business scholars

Aim Structure of the Thesis In the first article, I focus on the context in which the Homo Economicus was constructed - i.e., the conception of economic actors as fully rational, informed, egocentric, and profit-maximizing. I argue that the Homo Economicus theory was developed in a specific societal context with specific (partly tacit) values and norms. These norms have implicitly influenced the behavior of economic actors and have framed the interpretation of the Homo Economicus. Different factors however have weakened this implicit influence of the broader societal values and norms on economic actors. The result is an unbridled interpretation and application of the values and norms of the Homo Economicus in the business environment, and perhaps also in the broader society. In the second article, I show that the morality of many economic actors relies on isomorphism, i.e., the attempt to fit into the group by adopting the moral norms surrounding them. In consequence, if the norms prevailing in a specific group or context (such as a specific region or a specific industry) change, it can be expected that actors with an 'isomorphism morality' will also adapt their ethical thinking and their behavior -for the 'better' or for the 'worse'. The article further describes the process through which corporations could emancipate from the ethical norms prevailing in the broader society, and therefore develop an institution with specific norms and values. These norms mainly rely on mainstream business theories praising the economic actor's self-interest and neglecting moral reasoning. Moreover, because of isomorphism morality, many economic actors have changed their perception of ethics, and have abandoned the values prevailing in the broader society in order to adopt those of the economic theory. Finally, isomorphism morality also implies that these economic actors will change their morality again if the institutional context changes. The third article highlights the role and responsibility of business scholars in promoting a systematic reflection and self-critique of the business system and develops alternative models to fill the moral void of the business institution and its inherent legitimacy crisis. Indeed, the current business institution relies on assumptions such as scientific neutrality and specialization, which seem at least partly challenged by two factors. First, self-fulfilling prophecy provides scholars with an important (even if sometimes undesired) normative influence over practical life. Second, the increasing complexity of today's (socio-political) world and interactions between the different elements constituting our society question the strong specialization of science. For instance, economic theories are not unrelated to psychology or sociology, and economic actors influence socio-political structures and processes, e.g., through lobbying (Dobbs, 2006; Rondinelli, 2002), or through marketing which changes not only the way we consume, but more generally tries to instill a specific lifestyle (Cova, 2004; M. K. Hogg & Michell, 1996; McCracken, 1988; Muniz & O'Guinn, 2001). In consequence, business scholars are key actors in shaping both tomorrow's economic world and its broader context. A greater awareness of this influence might be a first step toward an increased feeling of civic responsibility and accountability for the models and theories developed or taught in business schools.

Sensitivity to Change of the Ultrasound synovitis SONAR Score in RA Patients: Results of the Scqm Cohort

Background/Purpose: Since the end of 2009, an ultrasound scoring call SONAR has been implemented for RA patients as a routine tool in the SCQM registry (Swiss Clinical Quality Management registry for rheumatic diseases). A cross-sectional evaluation of patients with active disease and clinical remission according to the DAS28ESR and the novel ACR/EULAR remission criteria from 2010 clearly indicated a good correlational external validity of synovial pathologies with clinical disease activity in RA (2012 EULAR meeting. Objective: of this study was to evaluate the sensitivity to change of B-mode and Power-Doppler scores in a longitudinal perspective along with the changes in DAS28ESR in two consecutive visits among the patients included in the SCQM registry Methods: All patients who had at least two SONAR scores and simultaneous DAS28ESR evaluations between December 2009 and June 2012 were included in this study. The data came from 20 different operators working mostly in hospitals but also in private practices, who had received a previous teaching over 3 days in a reference center. The SONAR score includes a semi-quantitative B mode and Power-Doppler evaluation of 22 joints from 0 to 3, maximum 66 points for each score. The selection of these 22 joints was done in analogy to a 28 joint count and further restricted to joint regions with published standard ultrasound images. Both elbows and wrist joints were dynamically scanned from the dorsal and the knee joints from a longitudinal suprapatellar view in flexion and in joint extension. The bilateral evaluation of the second to fifth metacarpophalangeal and proximal interphalangeal joints was done from a palmar view in full extension, and the Power-Doppler scoring from a dorsal view with hand and finger position in best relaxation. Results: From the 657 RA patients with at least one score performed, 128 RA patients with 2 or more consultations of DAS28ESR, and a complete SONAR data set could be included. The mean (SD) time between the two evaluations was 9.6 months (54). The mean (SD) DAS28ESR was: 3.5 (1.3) at the first visit and was significantly lower (mean 3.0, SD.2.0, p:_0.0001) at the second visit. The mean (SD) of the total B mode was 12 (9.5) at baseline and 9.6 (7.6) at follow-up (p_0.0004). The Power-Doppler score at entry was 2.9 (5.7) and 1.9 (3.6), at the second visit, p _0.0001. The Pearson r correlation between change in DAS28ESR and the B mode was 0.44 (95% CI: 0.29, 0.57, p_ 0.0001),and 0.35 (95% CI: 0.16, 0.50, p _ 0.0002) for the Power-Doppler score,. Clinical relevant change in DAS (_1.1) was associated with a change of total B mode score _3 in 23/32 patients and a change a Doppler score _0.5 in 19/26. Conclusion: This study confirms that the SONAR score is sensitive to change and provides a complementary method of assessing RA disease activity to the DAS that could be very useful in daily practice.

Stress ulcer prophylaxis in non-critically ill patients: a prospective evaluation of the practice in a surgical ward

Introduction The benefit of stress ulcer prophylaxis (SUP) in noncriticallyill patients has not been proved. Over-prescription of SUP isnot devoided of risks (i.e. drug-drug interactions, adverse events).This prospective study aimed to evaluate the use of proton pumpinhibitors (PPIs) for SUP in a visceral surgery ward.Materials & Methods Data collection was performed prospectivelyduring a 8-week period on patients hospitalized in a visceral surgeryward (58 beds). Patients with a PPI prescription for the treatment ofulcers, gastroesophageal reflux disease, esophagitis or epigastralgiawere excluded as well as patients hospitalized twice during the studyperiod. The American Society of Health-System Pharmacists guidelineson SUP were used to assess the appropriateness of de novo PPIprescriptions.Results Among 255 patients in the study, 138 (54.1%) received aprophylaxis with PPI, of which 86 (62.3%) were de novo PPI prescriptions.93.5% of patients received esomeprazole (according to thehospital drug formulary) mainly orally at 40 mg qd. 79.1% of patientshad no risk factors for SUP. 17.9% and 3.0% had one and two riskfactors, respectively. 95% of the patients with PPI were not hospitalizedin the intensive care unit (ICU) before their stay in the visceralsurgery ward. At discharge, PPI therapy was continued in 34.2% ofpatients with a de novo PPI prescription.Discussion & Conclusion This study highlights the over-utilizationof PPIs in non-ICU patients and the inappropriate continuation of PPIprescriptions at discharge. The PPI dosage prescribed for prophylaxiswas probably too high compared with the data of the literature.Treatment recommendations for SUP are needed to restrict PPIuse for justified indications.

Directives pratiques de la Société européenne d'hypertension sur la mesure de la pression artérielle à domicile [Practice guidelines of the European Society of Hypertension for home blood pressure measurement].

Self-measurement of blood pressure at home is increasingly used in the diagnostic and therapeutic approach of hypertension. This technique allows multiple measurements of blood pressure away from the clinical setting, making it possible to improve the evaluation of cardiovascular risk. Recently new guidelines on the use of self-measured blood pressure have been made available by the European Society of Hypertension, as summarized in the present paper.

Patterns of practice of regional nodal irradiation in breast cancer: results of the European Organization for Research and Treatment of Cancer (EORTC) NOdal Radiotherapy (NORA) survey.

BACKGROUND: Predicting outcome of breast cancer (BC) patients based on sentinel lymph node (SLN) status without axillary lymph node dissection (ALND) is an area of uncertainty. It influences the decision-making for regional nodal irradiation (RNI). The aim of the NORA (NOdal RAdiotherapy) survey was to examine the patterns of RNI. METHODS: A web-questionnaire, including several clinical scenarios, was distributed to 88 EORTC-affiliated centers. Responses were received between July 2013 and January 2014. RESULTS: A total of 84 responses were analyzed. While three-dimensional (3D) radiotherapy (RT) planning is carried out in 81 (96%) centers, nodal areas are delineated in only 51 (61%) centers. Only 14 (17%) centers routinely link internal mammary chain (IMC) and supraclavicular node (SCN) RT indications. In patients undergoing total mastectomy (TM) with ALND, SCN-RT is recommend by 5 (6%), 53 (63%) and 51 (61%) centers for patients with pN0(i+), pN(mi) and pN1, respectively. Extra-capsular extension (ECE) is the main factor influencing decision-making RNI after breast conserving surgery (BCS) and TM. After primary systemic therapy (PST), 49 (58%) centers take into account nodal fibrotic changes in ypN0 patients for RNI indications. In ypN0 patients with inner/central tumors, 23 (27%) centers indicate SCN-RT and IMC-RT. In ypN1 patients, SCN-RT is delivered by less than half of the centers in patients with ypN(i+) and ypN(mi). Twenty-one (25%) of the centers recommend ALN-RT in patients with ypN(mi) or 1-2N+ after ALND. Seventy-five (90%) centers state that age is not considered a limiting factor for RNI. CONCLUSION: The NORA survey is unique in evaluating the impact of SLNB/ALND status on adjuvant RNI decision-making and volumes after BCS/TM with or without PST. ALN-RT is often indicated in pN1 patients, particularly in the case of ECE. Besides the ongoing NSABP-B51/RTOG and ALLIANCE trials, NORA could help to design future specific RNI trials in the SLNB era without ALND in patients receiving or not PST.

Establishment of a Representative Practice-based Research Network (PBRN) for the Monitoring of Primary Care in Switzerland.

Data are urgently needed to better understand processes of care in Swiss primary care (PC). A total of 2027 PC physicians, stratified by canton, were invited to participate in the Swiss Primary care Active Monitoring network, of whom 200 accepted to join. There were no significant differences between participants and a random sample drawn from the same physician databases based on sex, year of obtaining medical school diploma, or location. The Swiss Primary care Active Monitoring network represents the first large-scale, nationally representative practice-based research network in Switzerland and will provide a unique opportunity to better understand the functioning of Swiss PC.

Neurology and psychiatry: waking up to opportunities of sleep. : State of the art and clinical/research priorities for the next decade.

In recent years, evidence has emerged for a bidirectional relationship between sleep and neurological and psychiatric disorders. First, sleep-wake disorders (SWDs) are very common and may be the first/main manifestation of underlying neurological and psychiatric disorders. Secondly, SWDs may represent an independent risk factor for neuropsychiatric morbidities. Thirdly, sleep-wake function (SWF) may influence the course and outcome of neurological and psychiatric disorders. This review summarizes the most important research and clinical findings in the fields of neuropsychiatric sleep and circadian research and medicine, and discusses the promise they bear for the next decade. The findings herein summarize discussions conducted in a workshop with 26 European experts in these fields, and formulate specific future priorities for clinical practice and translational research. More generally, the conclusion emerging from this workshop is the recognition of a tremendous opportunity offered by our knowledge of SWF and SWDs that has unfortunately not yet entered as an important key factor in clinical practice, particularly in Europe. Strengthening pre-graduate and postgraduate teaching, creating academic multidisciplinary sleep-wake centres and simplifying diagnostic approaches of SWDs coupled with targeted treatment strategies yield enormous clinical benefits for these diseases.