Is human lactation a particularly efficient process?

The recommended dietary allowances of many expert committees (UK DHSS 1979, FAO/WHO/UNU 1985, USA NRC 1989) have set out the extra energy requirements necessary to support lactation on the basis of an efficiency of 80 per cent for human milk production. The metabolic efficiency of milk synthesis can be derived from the measurements of resting energy expenditure in lactating women and in a matched control group of non-pregnant non-lactating women. The results of the present study in Gambian women, as well as a review of human studies on energy expenditure during lactation performed in different countries, suggest an efficiency of human milk synthesis greater than the value currently used by expert committees. We propose that an average figure of 95 per cent would be more appropriate to calculate the energy cost of human lactation.

Designing phase III or IV trials for vaccines: choosing between individual or cluster randomised trial designs.

The choice of design between individual randomisation, cluster or pseudo-cluster randomisation is often made difficult. Clear methodological guidelines have been given for trials in general practice, but not for vaccine trials. This article proposes a decisional flow-chart to choose the most adapted design for evaluating the effectiveness of a vaccine in large-scale studies. Six criteria have been identified: importance of herd immunity or herd protection, ability to delimit epidemiological units, homogeneity of transmission probability across sub-populations, population's acceptability of randomisation, availability of logistical resources, and estimated sample size. This easy to use decisional method could help sponsors, trial steering committees and ethical committees adopt the most suitable design.

Networks of Coordination : Swiss Business Associations as an Intermediary between Business, Politics and Administration during the 20th Century

Until the 1990's, Switzerland could be classified as either a corporatist, cooperative or coordinated market economy where non-market mechanisms of coordination among economic and political actors were very important. In this respect, Business Interest Associations (BIAs) played a key role. The aim of this paper is to look at the historical evolution of the five main peak Swiss BIAs through network analysis for five assorted dates during the 20th century (1910, 1937, 1957, 1980 and 2000) while relying on a database that includes more than 12,000 people. First, we examine the logic of membership in these associations, which allows us to analyze their position and function within the network of the Swiss economic elite. Until the 1980's, BIAs took part in the emergence and consolidation of a closely meshed national network, which declined during the two last decades of the 20th century. Second, we investigate the logic of influence of these associations by looking at the links they maintained with the political and administrative worlds through their links to the political parties and Parliament, and to the administration via the extra-parliamentary commissions (corporatist bodies). In both cases, the recent dynamic of globalization called into question the traditional role of BIAs.

Les parlementaires suisses entre démocratisation et professionnalisation (1910-2010). Biographie collective des élus fédéraux et réformes du Parlement helvétique

Notre travail de thèse vise à analyser, d'une part, les principales réformes du Parlement fédéral adoptées au cours du 20e siècle et, d'autre part, l'évolution du profil sociographique pour six cohortes d'élus fédéraux (1910, 1937, 1957, 1980, 2000 et 2010), sous l'angle de sa démocratisation et de sa professionnalisation. La thèse comprend trois axes de recherche principaux. Premièrement, nous nous penchons sur les deux réformes institutionnelles censées favoriser la démocratisation du recrutement parlementaire, à savoir l'adoption de la proportionnelle pour l'élection du Conseil national en 1918 et l'introduction du suffrage féminin à l'échelon fédéral en 1971. Nous abordons également les réformes du Parlement visant, depuis les années 1970, à sa revalorisation et à sa professionnalisation. Le deuxième axe porte sur la réalisation d'un portrait collectif des élus fédéraux pour la période 1910-1980, dans le but de vérifier l'impact des réformes des règles électorales (proportionnelle et suffrage féminin) sur le profil des députés et sénateurs. Enfin, dans le troisième axe, nous abordons les transformations du profil socio-professionnel des parlementaires pendant la période plus récente (1980-2010), en lien avec la professionnalisation accrue de l'Assemblée fédérale et les changements des rapports de force partisans. Nos résultats permettent de mettre en évidence plusieurs éléments de continuité (prédominance de la catégories des indépendants, notamment des avocats, des chefs d'entreprise et des agriculteurs, et sous-représentation des salariés du secteur public ; fort ancrage local), ainsi que certains facteurs de rupture (présence accrue des femmes, moindre importance de la carrière militaire). D'autres changements dans le profil sont liés au processus récent de professionnalisation, contesté et inachevé, qui a favorisé néanmoins l'émergence de nouveaux profils sociologiques d'élus, en termes de formation, de profession (apparition du groupe des parlementaires professionnels) et de cumul des mandats économiques et politiques, avec cependant de fortes variations entre les partis et entre les deux Chambres. - Our PhD thesis aims at analysing, on the one hand, the main reforms of the Federal Parliament adopted during the 20th century and, on the other hand, the evolution of sociographical profile for six cohorts of Swiss MPs (1910, 1937, 1957, 1980, 2000 and 2010) in terms of their democratization and professionalization. Our research is composed of three main parts. Firstly, we analyse two institutional reforms which intended to promote the democratization of parliamentary recruitment, namely the adoption of proportional representation (PR) in 1918 for the election of the National Council and the introduction of women's suffrage at the federal level in 1971. We also deal with parliamentary reforms that, since the 1970s, have aimed at reasserting the political status of the Federal Assembly and at professionalizing its members. Secondly, we carry out a collective biography of Swiss MPs during the period 1910-1980, in order to verify the impact of electoral reforms (PR and women's suffrage) on the profiles of deputies and senators. Finally, we discuss the transformation of the MPs' socio-_professional profiles during the recent period (1980-2010) in connection with the increased professionalization of the Federal Assembly and the changes of the power relations within the Parliament. Our results allow us to highlight several elements of continuity (the predominance of self-employed persons, especially lawyers, business managers and farmers, and the underrepresentation of public employees; stronger background in local politics), as well as some factors of discontinuity (increased presence of women and lesser importance of the military career). Other changes of the parliamentarians' profile are related to the recent process of professionalization. Although contested and unfinished, it has promoted new sociological profiles in terms of educational background, profession (growth of the professional parliamentarians) and number of political and economic mandates held simultaneously, however with important variations between parties and between Lower and Upper House.

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.

Blood pressure and LDL-cholesterol targets for prevention of recurrent strokes and cognitive decline in the hypertensive patient: design of the European Society of Hypertension-Chinese Hypertension League Stroke in Hypertension Optimal Treatment randomized trial.

BACKGROUND AND OBJECTIVES: The SBP values to be achieved by antihypertensive therapy in order to maximize reduction of cardiovascular outcomes are unknown; neither is it clear whether in patients with a previous cardiovascular event, the optimal values are lower than in the low-to-moderate risk hypertensive patients, or a more cautious blood pressure (BP) reduction should be obtained. Because of the uncertainty whether 'the lower the better' or the 'J-curve' hypothesis is correct, the European Society of Hypertension and the Chinese Hypertension League have promoted a randomized trial comparing antihypertensive treatment strategies aiming at three different SBP targets in hypertensive patients with a recent stroke or transient ischaemic attack. As the optimal level of low-density lipoprotein cholesterol (LDL-C) level is also unknown in these patients, LDL-C-lowering has been included in the design. PROTOCOL DESIGN: The European Society of Hypertension-Chinese Hypertension League Stroke in Hypertension Optimal Treatment trial is a prospective multinational, randomized trial with a 3 × 2 factorial design comparing: three different SBP targets (1, <145-135; 2, <135-125; 3, <125 mmHg); two different LDL-C targets (target A, 2.8-1.8; target B, <1.8 mmol/l). The trial is to be conducted on 7500 patients aged at least 65 years (2500 in Europe, 5000 in China) with hypertension and a stroke or transient ischaemic attack 1-6 months before randomization. Antihypertensive and statin treatments will be initiated or modified using suitable registered agents chosen by the investigators, in order to maintain patients within the randomized SBP and LDL-C windows. All patients will be followed up every 3 months for BP and every 6 months for LDL-C. Ambulatory BP will be measured yearly. OUTCOMES: Primary outcome is time to stroke (fatal and non-fatal). Important secondary outcomes are: time to first major cardiovascular event; cognitive decline (Montreal Cognitive Assessment) and dementia. All major outcomes will be adjudicated by committees blind to randomized allocation. A Data and Safety Monitoring Board has open access to data and can recommend trial interruption for safety. SAMPLE SIZE CALCULATION: It has been calculated that 925 patients would reach the primary outcome after a mean 4-year follow-up, and this should provide at least 80% power to detect a 25% stroke difference between SBP targets and a 20% difference between LDL-C targets.

Nanotechnology: balancing benefits and risks to public health and the environment : expert paper

Nanotechnology has been heralded as a "revolution" in science, for two reasons: first, because of its revolutionary view of the way in which chemicals and elements, such as gold and silver, behave, compared to traditional scientific understanding of their properties. Second, the impact of these new discoveries, as applied to commerce, can transform the daily life of consumer products ranging from sun tan lotions and cosmetics, food packaging and paints and coatings for cars, housing and fabrics, medicine and thousands of industrial processes.9 Beneficial consumer use of nanotechnologies, already in the stream of commerce, improves coatings on inks and paints in everything from food packaging to cars. Additionally, "Nanomedicine" offers the promise of diagnosis and treatment at the molecular level in order to detect and treat presymptomatic disease,10 or to rebuild neurons in Alzheimer's and Parkinson's disease. There is a possibility that severe complications such as stroke or heart attack may be avoided by means of prophylactic treatment of people at risk, and bone regeneration may keep many people active who never expected rehabilitation. Miniaturisation of diagnostic equipment can also reduce the amount of sampling materials required for testing and medical surveillance. Miraculous developments, that sound like science fiction to those people who eagerly anticipate these medical products, combined with the emerging commercial impact of nanotechnology applications to consumer products will reshape civil society - permanently. Thus, everyone within the jurisdiction of the Council of Europe is an end-user of nanotechnology, even without realising that nanotechnology has touched daily life.

EFNS guidelines on cognitive rehabilitation: report of an EFNS task force.

Disorders of language, spatial perception, attention, memory, calculation and praxis are a frequent consequence of acquired brain damage [in particular, stroke and traumatic brain injury (TBI)] and a major determinant of disability. The rehabilitation of aphasia and, more recently, of other cognitive disorders is an important area of neurological rehabilitation. We report here a review of the available evidence about effectiveness of cognitive rehabilitation. Given the limited number and generally low quality of randomized clinical trials (RCTs) in this area of therapeutic intervention, the Task Force considered, besides the available Cochrane reviews, evidence of lower classes which was critically analysed until a consensus was reached. In particular, we considered evidence from small group or single cases studies including an appropriate statistical evaluation of effect sizes. The general conclusion is that there is evidence to award a grade A, B or C recommendation to some forms of cognitive rehabilitation in patients with neuropsychological deficits in the post-acute stage after a focal brain lesion (stroke, TBI). These include aphasia therapy, rehabilitation of unilateral spatial neglect (ULN), attentional training in the post-acute stage after TBI, the use of electronic memory aids in memory disorders, and the treatment of apraxia with compensatory strategies. There is clearly a need for adequately designed studies in this area, which should take into account specific problems such as patient heterogeneity and treatment standardization.

E-tools for civic education : experiences from the election campaign in Switzerland 2007

Political participation is often very low in Switzerland especially among students and young citizens. In the run-up to the Swiss parliamentary election in October 2007 several online tools and campaigns were developed with the aim to increase not only the level of information about the political programs of parties and candidates, but also the electoral participation of younger citizens. From a practical point of view this paper will describe the development, marketing efforts and the distribution as well as the use of two of these tools : the so-called "Parteienkompass" (party compass) and the "myVote"-tool - an online voting assistance tool based on an issue-matching system comparing policy preferences between voters and candidates on an individual level. We also havea look at similar tools stemming from Voting Advice Applications (VAA) in other countries in Western Europe. The paper closes with the results of an evaluation and an outlook to further developments and on-going projects in the near future in Switzerland.

The INTERNORM Project: Bridging Two Worlds of Expert- and Lay-Knowledge in Standardization

This paper presents a pilot project to reinforce participatory practices in standardization. The INTERNORM project creates an interactive knowledge center based on the sharing of academic skills and 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 providing logistic and financial support to their participation in meetings of national and international technical committees. The second objective is analytical: the standardization action provides a research field for a better understanding of the participatory dynamics underpinning international standardization. This paper presents three incentives that explain civil society (non-)involvement in standardization that 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; and a rhetorical incentive related to the discursive resource that civil society concerns offers to the different stakeholders.

Learning from failure - rationale and design for a study about discontinuation of randomized trials (DISCO study).

BACKGROUND: Randomized controlled trials (RCTs) may be discontinued because of apparent harm, benefit, or futility. Other RCTs are discontinued early because of insufficient recruitment. Trial discontinuation has ethical implications, because participants consent on the premise of contributing to new medical knowledge, Research Ethics Committees (RECs) spend considerable effort reviewing study protocols, and limited resources for conducting research are wasted. Currently, little is known regarding the frequency and characteristics of discontinued RCTs. METHODS/DESIGN: Our aims are, first, to determine the prevalence of RCT discontinuation for specific reasons; second, to determine whether the risk of RCT discontinuation for specific reasons differs between investigator- and industry-initiated RCTs; third, to identify risk factors for RCT discontinuation due to insufficient recruitment; fourth, to determine at what stage RCTs are discontinued; and fifth, to examine the publication history of discontinued RCTs.We are currently assembling a multicenter cohort of RCTs based on protocols approved between 2000 and 2002/3 by 6 RECs in Switzerland, Germany, and Canada. We are extracting data on RCT characteristics and planned recruitment for all included protocols. Completion and publication status is determined using information from correspondence between investigators and RECs, publications identified through literature searches, or by contacting the investigators. We will use multivariable regression models to identify risk factors for trial discontinuation due to insufficient recruitment. We aim to include over 1000 RCTs of which an anticipated 150 will have been discontinued due to insufficient recruitment. DISCUSSION: Our study will provide insights into the prevalence and characteristics of RCTs that were discontinued. Effective recruitment strategies and the anticipation of problems are key issues in the planning and evaluation of trials by investigators, Clinical Trial Units, RECs and funding agencies. Identification and modification of barriers to successful study completion at an early stage could help to reduce the risk of trial discontinuation, save limited resources, and enable RCTs to better meet their ethical requirements.

'Do not attempt resuscitation' and 'cardiopulmonary resuscitation' in an inpatient setting: factors influencing physicians' decisions in Switzerland.

OBJECTIVE: To determine the prevalence of cardiopulmonary resuscitation (CPR) and do-not-attempt-resuscitation (DNAR) orders, to define factors associated with CPR/DNAR orders and to explore how physicians make and document these decisions. METHODS: We prospectively reviewed CPR/DNAR forms of 1,446 patients admitted to the General Internal Medicine Department of the Geneva University Hospitals, a tertiary-care teaching hospital in Switzerland. We additionally administered a face-to-face survey to residents in charge of 206 patients including DNAR and CPR orders, with or without patient inclusion. RESULTS: 21.2% of the patients had a DNAR order, 61.7% a CPR order and 17.1% had neither. The two main factors associated with DNAR orders were a worse prognosis and/or a worse quality of life. Others factors were an older age, cancer and psychiatric diagnoses, and the absence of decision-making capacity. Residents gave four major justifications for DNAR orders: important comorbid conditions (34%), the patients' or their family's resuscitation preferences (18%), the patients' age (14.2%), and the absence of decision-making capacity (8%). Residents who wrote DNAR orders were more experienced. In many of the DNAR or CPR forms (19.8 and 16%, respectively), the order was written using a variety of formulations. For 24% of the residents, the distinction between the resuscitation order and the care objective was not clear. 38% of the residents found the resuscitation form useful. CONCLUSION: Patients' prognosis and quality of life were the two main independent factors associated with CPR/DNAR orders. However, in the majority of cases, residents evaluated prognosis only intuitively, and quality of life without involving the patients. The distinction between CPR/DNAR orders and the care objectives was not always clear. Specific training regarding CPR/DNAR orders is necessary to improve the CPR/DNAR decision process used by physicians.

A pipeline approach with spatial information for segmenting multiple sclerosis lesions on brain magnetic resonance imaging

Background: Conventional magnetic resonance imaging (MRI) techniques are highly sensitive to detect multiple sclerosis (MS) plaques, enabling a quantitative assessment of inflammatory activity and lesion load. In quantitative analyses of focal lesions, manual or semi-automated segmentations have been widely used to compute the total number of lesions and the total lesion volume. These techniques, however, are both challenging and time-consuming, being also prone to intra-observer and inter-observer variability.Aim: To develop an automated approach to segment brain tissues and MS lesions from brain MRI images. The goal is to reduce the user interaction and to provide an objective tool that eliminates the inter- and intra-observer variability.Methods: Based on the recent methods developed by Souplet et al. and de Boer et al., we propose a novel pipeline which includes the following steps: bias correction, skull stripping, atlas registration, tissue classification, and lesion segmentation. After the initial pre-processing steps, a MRI scan is automatically segmented into 4 classes: white matter (WM), grey matter (GM), cerebrospinal fluid (CSF) and partial volume. An expectation maximisation method which fits a multivariate Gaussian mixture model to T1-w, T2-w and PD-w images is used for this purpose. Based on the obtained tissue masks and using the estimated GM mean and variance, we apply an intensity threshold to the FLAIR image, which provides the lesion segmentation. With the aim of improving this initial result, spatial information coming from the neighbouring tissue labels is used to refine the final lesion segmentation.Results:The experimental evaluation was performed using real data sets of 1.5T and the corresponding ground truth annotations provided by expert radiologists. The following values were obtained: 64% of true positive (TP) fraction, 80% of false positive (FP) fraction, and an average surface distance of 7.89 mm. The results of our approach were quantitatively compared to our implementations of the works of Souplet et al. and de Boer et al., obtaining higher TP and lower FP values.Conclusion: Promising MS lesion segmentation results have been obtained in terms of TP. However, the high number of FP which is still a well-known problem of all the automated MS lesion segmentation approaches has to be improved in order to use them for the standard clinical practice. Our future work will focus on tackling this issue.

Vers une gestion de la nature en termes d'action publique : analyse d'une dynamique d'appropriation des ressources végétales à Tobré, Nord Bénin

Cette étude se fonde sur des recherches ethnographiques menées autour de la mise en oeuvre d'une politique publique de gestion de la nature à Tobré, une région baatonu au Bénin. L'étude se place dans une dynamique d'appropriation des ressources naturelles en rapport avec l'entrée en jeu de multiples acteurs publics et privés dans l'arène locale de gestion de la nature. En effet, ces acteurs ont acquis ces dernières années de l'expérience et de l'efficacité à la faveur des changements institutionnels et politiques et s'incluent davantage dans le processus de décision au point de suppléer l'Etat dans les actions qui étaient ses prérogatives. L'étude met en lumière les rapports de conflits, de compétitions, de concurrence ou de compromis autour des enjeux sociaux, politiques et économiques de protection de la nature. Elle décrit et analyse les formes d'interactions entre les différents acteurs individuels, collectifs et institutionnels, afin de voir en quoi ces interactions participent du processus de mobilisation d'acteurs locaux et de confrontation de vision, qui finalement définit et oriente les politiques locales de protection de la nature. Pour atteindre cet objectif, l'étude mobilise des apports théoriques de plusieurs disciplines, notamment de la socio- anthropologie du développement, de l'histoire et de la sociologie politique. Elle repose également sur des données empiriques collectées à partir d'une combinaison d'outils techniques, des entretiens et des observations jusqu'au dépouillement de presse et des études de cas. Les principaux résultats montrent que les acteurs locaux, particulièrement les comités de gestion sont parvenus à inscrire la gestion des ressources naturelles dans l'espace public à travers les débats dans les médias, les forums, les marches de protestation, etc. De fait, ils ont été capables d'influer sur le processus de définition et de mise en oeuvre des politiques locales de protection de la nature et donc de reconfigurer l'arène locale de gestion des ressources naturelles. Ce qui amène l'Etat et ses services déconcentrés, en premier lieu les services des Eaux et Forêts et la mairie à pactiser avec ces différents comités, sans pour autant perdre de leur notoriété. Au contraire, ils participent de la gouvernance de l'ensemble des actions et permettent de mettre en place des formes de gestion négociée. - This is an ethnographic research on the implementation of a public policy for the management of natural resources in Tobre, a baatonu village in Benin. The study focuses on the dynamic of natural resources ownership in a context of multiple stakeholders in the public and private sectors. In recent years, these stakeholders have become more experienced and efficient as a result of several institutional and policy changes. The stakeholders are more involved in the decision making process to the point that they can complement the role of the State in natural resources management. This study highlights the conflicts, competition, or compromise associated with the social, political and economic constraints of nature conservation. The interactions between individual, collective and institutional stakeholders were analyzed, to understand their role in the process of mobilizing local stakeholders and confronting their visions. This process ultimately defines and guides local policies on the management of nature. To achieve this goal, this study combined theoretical approaches from developmental socio-anthropology, history and political sociology with empirical data collected using interviews, observations, newspapers analysis and case studies. The results show that local stakeholders, particularly the management committees, were successful at introducing the need for sustainable natural resource management in the mainstream public discourse through the media, forums, and demonstrations. They were able to influence the process of identifying and implementing local policies on nature conservancy. This has encouraged the State, through its forestry services, and the district mayors to collaborate with these committees in the shared governance of natural resources.

Unequal Representation of Age Groups in Switzerland

The representation of age groups is becoming an increasingly discussed topic in Swiss politics. In this study, we explore inequalities in the descriptive and substantive representation of various age groups and find that despite important disparities in descriptive representation, the policy preferences of various age groups are relatively equally represented in the lower house of the Swiss parliament. Our analysis thus suggests that even if it is gaining visibility, the age cleavage is not central for parliamentary representation in Switzerland.