Correlates of frailty, prediction of functional decline and preventative approaches - selected results from the lausanne cohort 65+ (lc65+) study (Switzerland) (Lausanne) and the longitudinal urban cohort ageing study (Lucas) (Germany)

Overall introduction.- Longitudinal studies have been designed to investigate prospectively, from their beginning, the pathway leading from health to frailty and to disability. Knowledge about determinants of healthy ageing and health behaviour (resources) as well as risks of functional decline is required to propose appropriate preventative interventions. The functional status in older people is important considering clinical outcome in general, healthcare need and mortality. Part I.- Results and interventions from lucas (longitudinal urban cohort ageing study). Authors.- J. Anders, U. Dapp, L. Neumann, F. Pröfener, C. Minder, S. Golgert, A. Daubmann, K. Wegscheider,. W. von Renteln-Kruse Methods.- The LUCAS core project is a longitudinal cohort of urban community-dwelling people 60 years and older, recruited in 2000/2001. Further LUCAS projects are cross-sectional comparative and interventional studies (RCT). Results.- The emphasis will be on geriatric medical care in a population-based approach, discussing different forms of access, too. (Dapp et al. BMC Geriatrics 2012, 12:35; http://www.biomedcentral.com/1471-2318/12/35): - longitudinal data from the LUCAS urban cohort (n = 3.326) will be presented covering 10 years of observation, including the prediction of functional decline, need of nursing care, and mortality by using a self-filling screening tool; - interventions to prevent functional decline do focus on first (pre-clinical) signs of pre-frailty before entering the frailty-cascade ("Active Health Promotion in Old Age", "geriatric mobility centre") or disability ("home visits"). Conclusions.- The LUCAS research consortium was established to study particular aspects of functional competence, its changes with ageing, to detect pre-clinical signs of functional decline, and to address questions on how to maintain functional competence and to prevent adverse outcome in different settings. The multidimensional data base allows the exploration of several further questions. Gait performance was exmined by GAITRite®-System. Supported by the Federal Ministry for Education and Research (BMBF Funding No. 01ET1002A). Part II.- Selected results from the lausanne cohort 65+ (Lc65 + ) Study (Switzerland). Authors.- Prof Santos-Eggimann Brigitte, Dr Seematter-Bagnoud Laurence, Prof Büla Christophe, Dr Rochat Stéphane. Methods.- The Lc65+ cohort was launched in 2004 with the random selection of 3054 eligible individuals aged 65 to 70 (birth year 1934-1938) in the non-institutionalized population of Lausanne (Switzerland). Results.- Information is collected about life course social and health-related events, socio-economics, medical and psychosocial dimensions, lifestyle habits, limitations in activities of daily living, mobility impairments, and falls. Gait performance are objectively measured using body-fixed sensors. Frailty is assessed using Fried's frailty phenotype. Follow-up consists in annual self-completed questionnaires, as well as physical examination and physical and mental performance tests every three years. - Lausanne cohort 65+ (Lc65 + ): design and longitudinal outcomes. The baseline data collection was completed among 1422 participants in 2004-2005 through self-completed questionnaires, face-to-face interviews, physical examination and tests of mental and physical performances. Information about institutionalization, self-reported health services utilization, and death is also assessed. An additional random sample (n = 1525) of 65-70 years old subjects was recruited in 2009 (birth year 1939-1943). - lecture no 4: alcohol intake and gait parameters: prevalent and longitudinal association in the Lc65+ study. The association between alcohol intake and gait performance was investigated.

Automation in clinical bacteriology: what system to choose?

With increased activity and reduced financial and human resources, there is a need for automation in clinical bacteriology. Initial processing of clinical samples includes repetitive and fastidious steps. These tasks are suitable for automation, and several instruments are now available on the market, including the WASP (Copan), Previ-Isola (BioMerieux), Innova (Becton-Dickinson) and Inoqula (KIESTRA) systems. These new instruments allow efficient and accurate inoculation of samples, including four main steps: (i) selecting the appropriate Petri dish; (ii) inoculating the sample; (iii) spreading the inoculum on agar plates to obtain, upon incubation, well-separated bacterial colonies; and (iv) accurate labelling and sorting of each inoculated media. The challenge for clinical bacteriologists is to determine what is the ideal automated system for their own laboratory. Indeed, different solutions will be preferred, according to the number and variety of samples, and to the types of sample that will be processed with the automated system. The final choice is troublesome, because audits proposed by industrials risk being biased towards the solution proposed by their company, and because these automated systems may not be easily tested on site prior to the final decision, owing to the complexity of computer connections between the laboratory information system and the instrument. This article thus summarizes the main parameters that need to be taken into account for choosing the optimal system, and provides some clues to help clinical bacteriologists to make their choice.

Genetic and maternal contributions to offspring viability under different environmental conditions in various salmonids

Summary : Due to anthropogenic impacts and natural fluctuations, fish usually have to cope with constantly changing and often hostile environments. Whereas adult fish have various possibilities to counteract unfavourable environmental conditions, embryos have much fewer options. Besides by their developing immune system, they are protected by the egg envelopes and several immune substances provided by their mothers. In addition to this, they may also adjust their hatching timing in reaction to various risks. However, individuals may vary in their defensive potential. This variation may be either based on their genetics and/or on differential maternal investments and may be dependent on the experienced stress. Nevertheless, in fish, the impact of such parental contributions on embryo and/or juvenile viability is still poorly investigated. The main objective of this thesis was to investigate the importance of paternal (i.e. genetic) and maternal (i.e. genetic + egg investment) contributions to offspring viability under different environmental conditions and at different life stages. In order to investigate this, we used gametes of various salmonids for in vitro fertilisation experiments based on full-factorial breeding designs. The individual studies are summarised in the following chapters: In the first chapter, we tested the effectiveness of the embryonic immune system in Lake whitefish (Coregonus palaea). Namely, we investigated paternal and maternal contributions to the embryos' tolerance to different kinds of pathogen exposure. Additionally, we tested whether an early sub-léthal exposure has a positive or a negative effect on an embryo's susceptibility to later pathogen exposures with the same pathogen. We found that pre-challenged embryos were more susceptible to future challenges. Moreover, pathogen susceptibility was dependent on maternal investments and/or the embryos' own genetics, depending on the challenge level. Chapter 2 summarises a similar study with brown trout (Salmo trutta). In addition to the previously described investigations, we analysed if genetic effects on offspring viability are mediated either by parental MHC genotypes or relatedness based on neutral microsatellite markers, and we tested if males signal their genetic quality either by their body size or their melanin-based skin colouration. We found that embryo survival was lower at higher stress levels and dependent on the embryos' genetics. Addirionally, parents with similar and/or, very common MHC genotypes had higher offspring viabilities. Finally, darker males produced more viable offspring. In the first two chapters we investigated the embryos' defensive potential based on their immune system, i.e. their pathogen tolerance. In chapter 3 we investigate whether hatching timing of Lake whitefìsh (C. palaea) is dependent on parental contributions and/or on pathogen pressure, and whether there are parental-environmental interactions. We found that whitefish embryos hatch earlier under increasing pathogen pressure. Moreover, hatching timing was affected by embryo genetics and/or maternally provided resources, but the magnitude of the effect was dependent on the pathogen. pressure. We also found a significant paternal-environmental interaction, indicating that the hatching efficiency of a certain sib group is dependent on the pathogen environment. Chapter 4 describes an analogous study with brown trout (S. trutta), with similar findings. In the former chapters, we only looked at offspring performance during the embryonic period, and only under semi-natural conditions. In chapter 5 we now test the performance and viability of embryonic and juvenile brown trout (S. trutta) under natural conditions. To measure embryo viability, we put them in brood boxes, buried them in the gravel of a natural river, and analysed survival after several months. To investigate juvenile survival and performance, wé reared embryos under different stress levels in the laboratory and subsequently released the resulting hatchlings in to a closed river section. Juvenile size and survival was then determined one year later. Additionally, we investigated if sires differ in their genetic quality, determined by embryo and juvenile survival as well as juvenile size, and if they signal their quality by either body size or melanin-based body darkness. We found hat juvenile size was dependent on genetic effects and on maternal investment, whereas this was neither the case for embryo nor for juvenile survival. Additionally, we found that offspring of darker males grew larger, and larger juveniles had also an increased survival. Finally, we found acarry-over effect of the early non-lethal challenge: exposing embryos to higher stress levels resulted in smaller juveniles. To evaluate the long-term performance of differently treated groups, mark-recapture studies are inevitable. For this purpose, effective mass-marking techniques are essential. In chapter 6 we tested the suitability of the fluorescent pigment spray marking method for the mass marking of European graylings (Thymallus thymallus), with very promising results. Our in vitro fertilisation studies on whitefish may reveal new insights on potential genetic benefits of mate choice, but the mating system of whitefish under natural conditions is still poorly investigated. In order to study this, we installed underwater cameras at the spawning place of a Coregonus suidteri population, recorded the whole mating period and subsequently analysed the recordings. Confirmations of previous findings as well as exciting new observations are listed and discussed in chapter 7. Dus aux impacts anthropogéniques et aux fluctuations naturelles, les poissons doivent faire face à des environnements en perpétuel changement. Ces changements font que les poissons doivent s'adapter à de nouvelles situations, souvent hostiles pour eux. Les adultes ont différentes possibilités d'échapper à un environnement peu favorable, ce n'est par contre pas le cas des embryons. Les embryons sont protégés d'une part par leur système immunitaire en développement, d'autre part, par la coquille de l'eeuf et différentes substances immunitaires fournies par leur mère. De plus, ils sont capables d'influencer leur propre date d'éclosion en réponse à différents facteurs de stress. Malgré tout, les individus varient dans leur capacité à se défendre. Cette variation peut être basé sur des facteurs génétiques et/ou sur des facteurs maternels, et est dépendante du stress subi. Néanmoins, chez les poissons, l'impact de telles contributions parentales sur la survie d'embryons et/ou juvéniles est peu étudié. L'objectif principal de cette thèse a été d'approfondir les connaissances sur l'importance de la contribution paternelle (c.a.d. génétique) et maternelle (c.a.d. génétique + investissement dans l'oeuf) sur la survie des jeunes dans différentes conditions expérimentales et stades de vie. Pour faire ces analyses, nous avons utilisé des gamètes de divers salmonidés issus de croisements 'full-factorial'. Les différentes expériences sont résumées dans les chapitres suivants: Dans le premier chapitre, nous avons testé l'efficacité du système immunitaire des embryons chez les corégones (Coregonus palea). Plus précisément nous avons étudié la contribution paternelle et maternelle à la tolérance des embryons à différents niveaux de stress pathogène. Nous avons aussi testé, si une première exposition non létale à un pathogène avait un effet positif ou négatif sur la susceptibilité d'un embryon a une deuxième exposition au même pathogène. Nous avons trouvé que des embryons qui avaient été exposés une première fois étaient plus sensibles au pathogène par la suite. Mais aussi que la sensibilité au pathogène était dépendante de l'investissement de la mère et/ou des gènes de l'embryon, dépendamment du niveau de stress. Le deuxième chapitre résume une étude similaire avec des truites (Salmo truffa). Nous avons examiné, si la survie des jeunes variait sous différentes intensités de stress, et si la variance observée était due aux gènes des parents. Nous avons aussi analysé si les effets génétiques sur la survie des juvéniles étaient dus au MHC (Major Histocompatibility Complex) ou au degré de parenté des parents. De plus, nous avons analysé si les mâles signalaient leur qualité génétique par la taille du corps ou par leur coloration noire, due à la mélanine. On a trouvé que la survie des embryons était plus basse quand le niveau de stress était plus haut mais que la variation restait dépendante de la génétique des embryons. De plus, les parents avec des MHC similaires et/ou communs avaient des embryons avec une meilleure survie. Par contre, des parents avec un degré de parenté plus haut produisent des embryons avec une survie plus mauvaise. Finalement nous avons montré que les mâles plus foncés ont des embryons qui survivent mieux, mais que la taille des mâles n'a pas d'influence sur la survie de ces mêmes embryons. Dans les deux premiers chapitres, nous avons étudié le potentiel de défense des embryons basé sur leur système immunitaire, c.a.d. leur tolérance aux pathogènes. Dans le troisième chapitre, nous nous intéressons à la date d'éclosion des corégones (C. palea), pour voir si elle est influencée par les parents ou par la pression des pathogènes, et si il y a une interaction entre ces deux facteurs. Nous avons trouvé que les jeunes naissent plus rapidement lorsque la pression en pathogènes augmente. La date d'éclosion est influencée par la génétique des embryons et/ou l'investissement des parents, mais c'est la magnitude des effets qui est dépendante de la pression du pathogène. Nous avons aussi trouvé une interaction entre l'effet paternel et l'environnement, ce qui indique que la rapidité d'éclosion de certains croisements est dépendante des pathogènes dans l'environnement. Le chapitre 4 décrit une étude analogue avec de truites (S. truffa), avec des résultats sitzimilaires. Dans les précédents chapitres nous nous sommes uniquement concentrés sur les performances des jeunes durant leur stade embryonnaire, et seulement dans des conditions semi naturelles. Dans le chapitre 5 nous testons la performance et la viabilité des embryons et de juvéniles de truites (S. truffa) dans des conditions naturelles. Nous avons trouvé que la taille des juvéniles était dépendante d'effets génétiques et de l'investissement maternel, mais ceci n'était ni les cas pour les survie des embryons et des juvéniles. De plus, nous avons trouvé que les jeunes des mâles plus foncés devenaient plus grands et que les grands ont un meilleur taux de survie. Finalement nous avons trouvé un 'carry-over effect' d'une première exposition non létale à un pathogène: exposer des embryons à des plus hauts niveaux de stress donnait des juvéniles plus petits. Pour évaluer la performance à long terme de groupes traités dé manières différentes, une méthode de marquage-recapture est inévitable. Pour cette raison, des techniques de marquage en masse sont nécessaires. Dans le chapitre 6, nous avons testé l'efficacité de la technique `fluorescent pigment spray marking' pour le marquage en masse de l'Ombre commun (Thymallus thymallus), avec des résultats très prometteurs. Les études de fertilisations in vitro avec les corégones nous donnent une idée du potentiel bénéfice génétique que représente la sélection d'un bon partenaire, même si le système d'accouplement des corégones en milieu naturel reste peu connu. Pour combler cette lacune, nous avons installé des caméras sous-marines autour de la frayère d'une population de corégones (C. suidteri), nous avons enregistré toute la période de reproduction et nous avons analysé les données par la suite. Ainsi, nous avons été capables de confirmer bien des résultats trouvés précédemment, mais aussi de faire de nouvelles observations. Ces résultats sont reportés dans le septième chapitre, où elles sont comparées avec des observations antérieures.

Prediction of 18-month survival in patients with primary myelodysplastic syndrome. A regression model and scoring system based on the combination of chromosome findings and the Bournemouth score.

The predictive potential of six selected factors was assessed in 72 patients with primary myelodysplastic syndrome using univariate and multivariate logistic regression analysis of survival at 18 months. Factors were age (above median of 69 years), dysplastic features in the three myeloid bone marrow cell lineages, presence of chromosome defects, all metaphases abnormal, double or complex chromosome defects (C23), and a Bournemouth score of 2, 3, or 4 (B234). In the multivariate approach, B234 and C23 proved to be significantly associated with a reduction in the survival probability. The similarity of the regression coefficients associated with these two factors means that they have about the same weight. Consequently, the model was simplified by counting the number of factors (0, 1, or 2) present in each patient, thus generating a scoring system called the Lausanne-Bournemouth score (LB score). The LB score combines the well-recognized and easy-to-use Bournemouth score (B score) with the chromosome defect complexity, C23 constituting an additional indicator of patient outcome. The predicted risk of death within 18 months calculated from the model is as follows: 7.1% (confidence interval: 1.7-24.8) for patients with an LB score of 0, 60.1% (44.7-73.8) for an LB score of 1, and 96.8% (84.5-99.4) for an LB score of 2. The scoring system presented here has several interesting features. The LB score may improve the predictive value of the B score, as it is able to recognize two prognostic groups in the intermediate risk category of patients with B scores of 2 or 3. It has also the ability to identify two distinct prognostic subclasses among RAEB and possibly CMML patients. In addition to its above-described usefulness in the prognostic evaluation, the LB score may bring new insights into the understanding of evolution patterns in MDS. We used the combination of the B score and chromosome complexity to define four classes which may be considered four possible states of myelodysplasia and which describe two distinct evolutional pathways.

Temporal and spatial dynamics of benthic invertebrate communities in an alpine glacier-fed alluvial system

Summary The present thesis work focused on the ecology of benthic invertebrates in the proglacial floodplain of the Rhone in the Swiss Alps. The main glacial Rhone River and a smaller glacial tributary, the Mutt River, joined and entered a braiding multi-thread area. A first part concentrated on the disruption of the longitudinal patterns of environmental conditions and benthic invertebrate fauna in the Rhone by its tributary the Mutt. The Mutt had less harsh environmental conditions, higher taxonomic richness and more abundant zoobenthos compared to the Rhone upstream of the confluence. Although the habitat conditions in the main stream were little modified by the tributary, the fauna was richer and more diverse below the confluence. Colonisation from the Mutt induced the occurrence of faunal elements uncommon of glacial streams in the upper Rhone, where water temperature remains below 4°C. Although the glacial Rhone dominated the system with regard to hydrology and certain environmental conditions, the Mutt tributary has to be seen as the faunal driver of the system. The second part of the study concerned the spatio-temporal differentiation of the habitats and the benthic communities along and across the flood plain. No longitudinal differentiation was found. The spatial transversal differentiation of three habitat types with different environmental characteristics was successfully reflected in the spatial variability of benthic assemblages. This typology separated marginal sites of the flood plain, left bank sites under the influence of the Mutt, and the right bank sites under the influence of the Rh6ne. Faunistic spatial differences were emphasized by the quantitative structure of the fauna, richness, abundances and Simpson index of diversity. Seasonal environmental variability was positively related with Simpson index of diversity and the total richness per site. Low flow conditions were the most favourable season for the fauna and November was characterized by low spatial environmental heterogeneity, high spatial heterogeneity of faunal assemblage, maximum taxonomic richness, a particular taxonomic composition, highest abundances, as well as the highest primary food resources. The third part studied the egg development of three species of Ephemeroptera in the laboratory at 1.5 to 7°C and the ecological implications in the field. Species revealed very contrasting development strategies. Baetis alpinus has a synchronous and efficient egg development, which is faster in warmer habitats, enabling it to exploit short periods of favourable conditions in the floodplain. Ecdyonurus picteti has a very long development time slightly decreasing in warmer conditions. The high degree of individual variation suggests a genetic determination of the degree-days demand. Combined with the glacial local conditions, this strategy leads to an extreme delay of hatching and allows it to develop in very unpredictable habitats. Rhithrogena nivata is the second cold adapted species in Ephemeroptera. The incubation duration is long and success largely depends on the timing of hatching and the discharge conditions. This species is able to exploit extremely unstable and cold habitats where other species are limited by low water temperatures. The fourth part dealt with larval development in different habitats of the floodplain. Addition of data on egg development allowed the description of the life histories of the species from oviposition until emergence. Rhithrogena nivata and loyolaea generally have a two-year development, with the first winter passed as eggs and the second one as larvae. Development of Ecdyonurus picteti is difficult to document but appears to be efficient in a harsh and unpredictable environment. Baetis alpinus was studied separately in four habitats of the floodplain system with contrasting thermal regimes. Differences in success and duration of larval development and in growth rates are emphasised. Subvention mechanisms between habitats by migration of young or grown larvae were demonstrated. Development success and persistence of the populations in the system were thus increased. Emergence was synchronised to the detriment of the optimisation of the adult's size and fecundity. These very different development strategies induce a spatial and temporal distribution in the use of food resources and ecological niches. The last part of this work aimed at the synthesis of the characteristics and the ecological features of three distinct compartments of the system that are the upper Rhone, the Mutt and the floodplain. Their particular role as well as their inter-dependence concerning the structure and the dynamics of the benthic communities was emphasised. Résumé Ce travail de thèse est consacré à l'écologie des invertébrés benthiques dans la zone alluviale proglaciaire du Rhône dans les Alpes suisses. Le Rhône, torrent glaciaire principal, reçoit les eaux de la Mutt, affluent glaciaire secondaire, puis pénètre dans une zone de tressage formée de plusieurs bras. La première partie de l'étude se concentre sur la disruption par la Mutt des processus longitudinaux, tant environnementaux que faunistiques, existants dans le Rhône. Les conditions environnementales régnant dans la Mutt sont moins rudes, la richesse taxonomique plus élevée et le zoobenthos plus abondant que dans le Rhône en amont de la confluence. Bien que les conditions environnementales dans le torrent principal soient peu modifiées par l'affluent, la faune s'avère être plus riche et plus diversifiée en aval de la confluence. La colonisation depuis la Mutt permet l'occurrence de taxons inhabituels dans le Rhône en amont de la confluence, où la température de l'eau se maintient en dessous de 4°C. Bien que le Rhône, torrent glaciaire principal, domine le système du point de vu de l'hydrologie et de certains paramètres environnementaux, l'affluent Mutt doit être considéré comme l'élément structurant la faune dans le système. La deuxième partie concerne la différentiation spatiale et temporelle des habitats et des communautés benthiques à travers la plaine alluviale. Aucune différentiation longitudinale n'a été mise en évidence. La différentiation transversale de trois types d'habitats sur la base des caractéristiques environnementales a été confirmée par la variabilité spatiale de la faune. Cette typologie sépare les sites marginaux de la plaine alluviale, ceux sous l'influence de la Mutt (en rive gauche) et ceux sous l'influence du Rhône amont (en rive droite). Les différences spatiales de la faune sont mises en évidence par la structure quantitative de la faune, la richesse, les abondances et l'indice de diversité de Simpson. La variabilité saisonnière du milieu est positivement liée avec l'indice de diversité de Simpson et la richesse totale par site. L'étiage correspond à la période la plus favorable pour la faune et novembre réunit des conditions de faible hétérogénéité spatiale du milieu, de forte hétérogénéité spatiale de la faune, une richesse taxonomique maximale, une composition faunistique particulière, les abondances ainsi que les ressources primaires les plus élevées. La troisième partie est consacrée à l'étude du développement des oeufs de trois espèces d'Ephémères au laboratoire à des températures de 1.5 à 7°C, ainsi qu'aux implications écologiques sur le terrain. Ces espèces présentent des stratégies de développement très contrastées. Baetis alpinus a un développement synchrone et efficace, plus rapide en milieu plus chaud et lui permettant d'exploiter les courtes périodes de conditions favorables. Ecdyonurus picteti présente une durée de développement très longue, diminuant légèrement dans des conditions plus chaudes. L'importante variation interindividuelle suggère un déterminisme génétique de la durée de développement. Cette stratégie, associée aux conditions locales, conduit à un décalage extrême des éclosions et permet à l'espèce de se développer dans des habitats imprévisibles. Rhithrogena nivata est la seconde espèce d'Ephémères présentant une adaptation au froid. L'incubation des oeufs est longue et son succès dépend de la période des éclosions et des conditions hydrologiques. Cette espèce est capable d'exploiter des habitats extrêmement instables et froids, où la température est facteur limitant pour d'autres espèces. La quatrième partie traite du développement larvaire dans différents habitats de la plaine alluviale. Le développement complet est décrit pour les espèces étudiées de la ponte jusqu'à l'émergence. Rhithrogena nivata et loyolaea atteignent généralement le stade adulte en deux ans, le premier hiver étant passé sous forme d'oeuf et le second sous forme de larve. Le développement de Ecdyonurus picteti est difficile à documenter, mais s'avère cependant efficace dans un environnement rude et imprévisible. Baetis alpinus a été étudié séparément dans quatre habitats de la plaine ayant des régimes thermiques contrastés. La réussite et la durée du développement embryonnaire ainsi que les taux de croissance y sont variables. Des mécanismes de subvention entre habitats sont possibles par la migration de larves juvéniles ou plus développées, augmentant ainsi la réussite du développement et le maintien des populations dans le système. L'émergence devient synchrone, au détriment de l'optimisation de la taille et de la fécondité des adultes. Ces stratégies très différentes induisent une distribution spatiale et temporelle dans l'usage des ressources et des niches écologiques. La dernière partie synthétise les caractéristiques écologiques des trois compartiments du système que sont le Rhône amont, la Mutt et la zone alluviale. Leurs rôles particuliers et leurs interdépendances du point de vue de la structure et de la dynamique des communautés benthiques sont mis en avant.

Frequent users of the emergency department in a universal health coverage system : a randomized controlled trial of a case-management intervention

BACKGROUND: Frequent emergency department users represent a small number of patients but account for a large number of emergency department visits. They should be a focus because they are often vulnerable patients with many risk factors affecting their quality of life (QoL). Case management interventions have resulted in a significant decrease in emergency department visits, but association with QoL has not been assessed. One aim of our study was to examine to what extent an interdisciplinary case management intervention, compared to standard emergency care, improved frequent emergency department users' QoL. METHODS: Data are part of a randomized, controlled trial designed to improve frequent emergency department users' QoL and use of health-care resources at the Lausanne University Hospital, Switzerland. In total, 250 frequent emergency department users (≥5 attendances during the previous 12 months; ≥ 18 years of age) were interviewed between May 2012 and July 2013. Following an assessment focused on social characteristics; social, mental, and somatic determinants of health; risk behaviors; health care use; and QoL, participants were randomly assigned to the control or the intervention group (n=125 in each group). The final sample included 194 participants (20 deaths, 36 dropouts, n=96 in the intervention group, n=99 in the control group). Participants in the intervention group received a case management intervention by an interdisciplinary, mobile team in addition to standard emergency care. The case management intervention involved four nurses and a physician who provided counseling and assistance concerning social determinants of health, substance-use disorders, and access to the health-care system. The participants' QoL was evaluated by a study nurse using the WHOQOL-BREF five times during the study (at baseline, and at 2, 5.5, 9, and 12 months). Four of the six WHOQOL dimensions of QoL were retained here: physical health, psychological health, social relationship, and environment, with scores ranging from 0 (low QoL) to 100 (high QoL). A linear, mixed-effects model with participants as a random effect was run to analyze the change in QoL over time. The effects of time, participants' group, and the interaction between time and group were tested. These effects were controlled for sociodemographic characteristics and health-related variables (i.e., age, gender, education, citizenship, marital status, type of financial resources, proficiency in French, somatic and mental health problems, and behaviors at risk).

Accessibility, equity and the sharing of water resources

While the supply of water to dry or arid mountain regions has long been a major challenge, the on-going processes of climatic and socio-economic change currently affecting the hydrosystems of the Alps raise the spectre of renewed pressure on water resources and possible local shortages. In such a context, questions relating to fair distribution of water are all the more sensitive given the tendency to neglect the social dimension of sustainability. The present paper makes both a conceptual and empirical contribution to this debate by analysing a system of distribution that has a long experience of water scarcity management: the community governance models traditionally linked to the irrigation channels, or bisses, typical of the Swiss Alpine canton of Valais. More specifically, we evaluate these models in terms of accessibility and equity, characteristics that we use to operationalize the notion of 'fair distribution'. We examine these dimensions in three case studies with a view to highlighting the limitations of the aforementioned models. Indeed, despite their cooperative and endogenous nature, they tend to not only exclude certain members of the population, but also to reproduce rather than reduce social inequalities within the community. In general, these results challenge the rosy picture generally found in the literature relating to these community governance models.