L'impact du nouveau financement hospitalier sur les hôpitaux publics : exemple de l'Hôpital du Valais

L'objectif de ce mémoire est d'évaluer les conséquences du nouveau financement hospitalier de la LAMaI sur les hôpitaux publics et plus particulièrement sur l'Hôpital du Valais. Les nouvelles dispositions votées le 21 décembre 2007 par le Parlement ont pour but d'accroître la concurrence entre les hôpitaux et de mettre sur un pied d'égalité les établissements privés et publics. Ce document traite des principales modifications législatives et de leur entrée en vigueur, des nouveautés concernant le calcul des coûts et des tarifs à la charge de l'assurance obligatoire des soins avec l'inclusion des investissements et la nouvelle défmition des frais de formation, de l'introduction des forfaits par pathologie SwissDRG, des problématiques de l'ouverture des frontières cantonales et de la concurrence. Selon les hypothèses retenues, des effets peu importants sont à prévoir en Valais pour l'ouverture des frontières, la liste hospitalière et la répartition du tarif entre assureurs et cantons. Par contre on estime que la prise en compte des investissements augmentera les coûts de l'Hôpital du Valais de 5 à 13% alors les activités d'intérêt général se chiffrent entre 4 et 22 Mio. Les conséquences de l'introduction de la concurrence voulue par le législateur sont plus difficiles à évaluer, car elles dépendent de paramètres encore inconnus tels que le gain espéré et le comportement des parties. Une concurrence par les prix prétéritera les hôpitaux publics si leurs spécificités, telles que les urgences, les soins intensifs et l'obligation d'admission, ne sont pas prises en compte dans la structure tarifaire, le prix ou la planification. Le changement de comportement du patient, des assureurs, des médecins traitants voire des cantons ou des médias constitue également une inconnue qui pourrait avoir de fortes conséquences et contraindre les hôpitaux publics à développer leurs concepts de marketing et de communication. [Auteur, p. 2]

The prognostic value of health-related quality-of-life data in predicting survival in glioblastoma cancer patients: results from an international randomised phase III EORTC Brain Tumour and Radiation Oncology Groups, and NCIC Clinical Trials Group study.

This is one of the few studies that have explored the value of baseline symptoms and health-related quality of life (HRQOL) in predicting survival in brain cancer patients. Baseline HRQOL scores (from the EORTC QLQ-C30 and the Brain Cancer Module (BN 20)) were examined in 490 newly diagnosed glioblastoma cancer patients for the relationship with overall survival by using Cox proportional hazards regression models. Refined techniques as the bootstrap re-sampling procedure and the computation of C-indexes and R(2)-coefficients were used to try and validate the model. Classical analysis controlled for major clinical prognostic factors selected cognitive functioning (P=0.0001), global health status (P=0.0055) and social functioning (P<0.0001) as statistically significant prognostic factors of survival. However, several issues question the validity of these findings. C-indexes and R(2)-coefficients, which are measures of the predictive ability of the models, did not exhibit major improvements when adding selected or all HRQOL scores to clinical factors. While classical techniques lead to positive results, more refined analyses suggest that baseline HRQOL scores add relatively little to clinical factors to predict survival. These results may have implications for future use of HRQOL as a prognostic factor in cancer patients.

Smoking and adolescence: Exploring tobacco consumption and related attitudes in three different age groups in Switzerland

The present study constitutes an investigation of tobacco consumption, related attitudes and individual differences in smoking or non-smoking behaviors in a sample of adolescents of different ages in the French-speaking part of Switzerland. We investigated three school-age groups (7th-grade, 9th-grade, and the second-year of high school) for differences in attitude and social and cognitive dimensions. We present both descriptive and inferential statistics. On an inferential level, we present a binary logistic regression-based model predicting risk of smoking. The resulting model most importantly suggests a strong relationship between smoking and alcohol consumption (both regular and sporadic). We interpret this result in terms of both the impact of the actual campaigns and the cognitive processes associated with adolescence.

CYP3A activity measured by the midazolam test is not related to 3435 C >T polymorphism in the multiple drug resistance transporter gene.

A recent study with 69 Japanese liver transplants treated with tacrolimus found that the MDR13435 C >T polymorphism, but not the MDR12677 G >T polymorphism, was associated with differences in the intestinal expression level of CYP3A4 mRNA. In the present study, over 6 h, we measured the kinetics of a 75 microg oral dose of midazolam, a CYP3A substrate, in 21 healthy subjects genotyped for the MDR13435 C >T and 2677 G >T polymorphism. No statistically significant differences were found in the calculated pharmacokinetic parameters between the three 3435 C >T genotypes (TT, CT and CC group, respectively: Cmax (mean +/- SD: 0.30 +/- 0.08 ng/ml, 0.31 +/- 0.09 ng/ml and 0.31 +/- 0.11 ng/ml; Apparent clearance: 122 +/- 29 l/h, 156 +/- 92 l/h and 111 +/- 35 l/h; t1/2: 1.9 +/- 1.1 h, 1.6 +/- 0.90 h and 1.7 +/- 0.7 h). In addition, the 30-min 1'OH midazolam to midazolam ratio, a marker of CYP3A activity, determined in 74 HIV-positive patients before the introduction of antiretroviral treatment, was not significantly different between the three 3435 C >T genotypes (mean ratio +/- SD: 3.65 +/- 2.24, 4.22 +/- 3.49 and 4.24 +/- 2.03, in the TT, CT and CC groups, respectively). Similarly, no association was found between the MDR12677 G >T polymorphism and CYP3A activity in the healthy subjects or in the HIV-positive patients. The existence of a strong association between the activity of CYP3A and MDR13435 C >T and 2677 G >T polymorphisms appears unlikely, at least in Caucasian populations and/or in the absence of specific environmental factors.

Intellectual outcome in children and adolescents with acute lymphoblastic leukaemia treated with chemotherapy alone: age- and sex-related differences.

One of the most relevant concerns in long-term survivors of paediatric acute lymphoblastic leukaemia (ALL) is the development of neuropsychological sequelae. The majority of the published studies report on patients treated with chemotherapy and prophylactic central nervous system (CNS) irradiation, little is known about the outcome of patients treated with chemotherapy-only regimens. Using the standardised clinical and neuropsychological instruments of the SPOG Late Effects Study, the intellectual performance of 132 paediatric ALL patients treated with chemotherapy only was compared to that of 100 control patients surviving from diverse non-CNS solid tumours. As a group, ALL and solid tumour survivors showed normal and comparable intellectual performances (mean global IQ 104.6 in both groups). The percentage of patients in the borderline range (global IQ between 70 and 85) was comparable and not higher as expected (10% cases and 13% controls, expected 16%). Only 2 (2%) of the former ALL and 1 (1%) of the solid tumour patients were in the range of mental retardation (global IQ&lt;70). Former known risk factors described in children treated with prophylactic CNS irradiation, like a younger age at diagnosis of ALL and female gender, remained valid in chemotherapy-only treated patients. The abandonment of prophylactic CNS irradiation and its replacement by a more intensive systemic and intrathecal chemotherapy led to a reduction, but not the disappearance of late neuropsychological sequelae.

Personality, psychosocial and health-related predictors of quality of life in old age.

OBJECTIVES: Beyond its well-documented association with depressive symptoms across the lifespan, at an individual level, quality of life may be determined by multiple factors: psychosocial characteristics, current physical health and long-term personality traits. METHOD: Quality of life was assessed in two distinct community-based age groups (89 young adults aged 36.2 ± 6.3 and 92 older adults aged 70.4 ± 5.5 years), each group equally including adults with and without acute depressive symptoms. Regression models were applied to explore the association between quality of life assessed with the World Health Organization Quality of Life - Bref (WHOQOL-Bref) and depression severity, education, social support, physical illness, as well as personality dimensions as defined by the Five-Factor Model. RESULTS: In young age, higher quality of life was uniquely associated with lower severity of depressive symptoms. In contrast, in old age, higher quality of life was related to both lower levels of depressive mood and of physical illness. In this age group, a positive association was also found between quality of life and higher levels of Openness to experience and Agreeableness personality dimensions. CONCLUSION: Our data indicated that, in contrast to young cohorts, where acute depression is the main determinant of poor quality of life, physical illness and personality dimensions represent additional independent predictors of this variable in old age. This observation points to the need for concomitant consideration of physical and psychological determinants of quality of life in old age.

Evolution of anaesthesia care and related events between 1996 and 2010 in a developed country

Background: Anaesthesia Databank Switzerland (ADS) is a voluntary data registry introduced in 1996. The goal was to promote quality in anaesthesiology. Methods: Analysis of routinely recorded adverse events. Internal and external benchmark comparisons between anaesthesia departments. Results: In 2010, the database included 2'158'735 anaesthetic procedures. Forty-four anaesthesia departments were participating to the data collection in 2010. Over time, the number of patients in older age groups increased, the largest group being patients aged 50 to 64 years. Over time, the percentage of patients with ASA physical status score 1 decreased while the number of ASA 2 or 3 patients increased. The most frequent co-morbidities were hypertension (21%), smoking (16%), allergy (15%), and obesity (12%). Between 1996 and 2010, 146'459 adverse events were recorded, of which 34% were cardiovascular, 7% respiratory, 39% specific to anaesthesia and 17% nonspecific. The overall proportion of adverse events decreased over time, whatever their severity. Conclusion: The ADS routine data collection contributes to monitoring the trends of anaesthesia care in Switzerland.

Effects of dietary protein type on oxidized cholesterol-induced alteration in age-related modulation of lipid metabolism and indices of immune function in rats.

Exogenous oxidized cholesterol disturbs both lipid metabolism and immune functions. Therefore, it may perturb these modulations with ageing. Effects of the dietary protein type on oxidized cholesterol-induced modulations of age-related changes in lipid metabolism and immune function was examined using differently aged (4 weeks versus 8 months) male Sprague-Dawley rats when casein, soybean protein or milk whey protein isolate (WPI) was the dietary protein source, respectively. The rats were given one of the three proteins in diet containing 0.2% oxidized cholesterols mixture. Soybean protein, as compared with the other two proteins, significantly lowered both the serum thiobarbituric acid reactive substances value and cholesterol, whereas it elevated the ratio of high density lipoprotein-cholesterol/cholesterol in young rats, but not in adult. Moreover, soybean protein, but not casein and WPI, suppressed the elevation of Delta6 desaturation indices of phospholipids in both liver and spleen, particularly in young. On the other hand, WPI, compared to the other two proteins, inhibited the leukotriene B4 production of spleen, irrespective of age. Soybean protein reduced the ratio of CD4(+)/CD8(+) T-cells in splenic lymphocytes. Therefore, the levels of immunoglobulin (Ig)A, IgE and IgG in serum were lowered in rats given soybean protein in both age groups except for IgA in adult, although these observations were not shown in rats given other proteins. Thus, various perturbations of lipid metabolism and immune function caused by oxidized cholesterol were modified depending on the type of dietary protein. The moderation by soybean protein on the change of lipid metabolism seems to be susceptible in young rats whose homeostatic ability is immature. These observations may be exerted through both the promotion of oxidized cholesterol excretion to feces and the change of hormonal release, while WPI may suppress the disturbance of immune function by oxidized cholesterol in both ages. This alleviation may be associated with a large amount of lactoglobulin in WPI. These results thus showed a possibility that oxidized cholesterol-induced perturbations of age-related changes of lipid metabolism and immune function can be moderated by both the selection and combination of dietary protein.

Diagnostic value of soluble CD14 subtype (sCD14-ST) presepsin for the postmortem diagnosis of sepsis-related fatalities.

The first aim of this study was to assess the diagnostic performance of presepsin (sCD14-ST) in postmortem serum from femoral blood compared to procalcitonin (PCT) to detect sepsis-related fatalities. The second aim was to compare sCD14-ST levels found in postmortem serum to the values in pericardial fluid to investigate the usefulness of the latter as an alternative biological fluid. Two study groups were formed, a sepsis-related fatalities group and a control group. Radiology (unenhanced CT scans and postmortem angiographies), autopsies, histology, neuropathology, and toxicology as well as other postmortem biochemistry investigations were performed in all cases. Microbiological investigations on right cardiac blood were carried out exclusively in septic cases. The results of this study indicated that postmortem serum PCT and sCD14-ST levels, individually considered, allowed septic cases to be identified. Even though increases in both PCT and sCD14-ST concentrations were observed in the control cases, coherent PCT and sCD14-ST results in cases with suspected sepsis allowed the diagnosis to be confirmed. Conversely, no relevant correlation was identified between postmortem serum and pericardial fluid sCD14-ST levels in either the septic or control groups.

Pathogenesis-related proteins and the jasmonate signaling pathway

Résumé Etant une importante source d'énergie, les plantes sont constamment attaquées par des pathogènes. Ne pouvant se mouvoir, elles ont développé des systèmes de défense sophistiqués afin de lutter contre ces prédateurs. Parmi ces systèmes, les voies de signalisation mettant en jeu des éliciteurs endog8nes tels que les jasmonates permettent d'induire la production de protéines de défense telles que les protéines dites "liées à la pathogénèse". Les gènes codant pour ces protéines appartiennent à des familles multigéniques. Le premier but de cette thèse est d'évaluer le nombre de ces gènes dans le génome d'Arabidopsis thaliana et d'estimer la part de ce système de défense, dépendant de la voie de signalisation des jasmonates. Nous avons défini un cluster de seulement 1S gènes sur 266, "liés à la pathogénèse", exclusivement régulés par les jasmonates. De multiples membres des familles des lectines de type jacaline et des inhibiteurs de trypsines semblent dépendre du jasmonate. Présente dans tous les systèmes immunitaires des eucaryotes, la famille des défensines est une famille très intéressante. Chez Arabidopsis thaliana, 317 protéines similaires aux défensines ont été définies, cependant seulement 15 défensines (PDF) sont bien annotées. Ces 15 défensines sont séparées en deux groupes dont un semble avoir évolué plus récemment. Le second but de cette thèse est d'étudier ce groupe de défensines à l'aide de la bioinformatique et des techniques de biologie moléculaire (gêne rapporteur, PCR en temps réel). Nous avons montré que ce groupe contenait une défensine acide intéressante, PDF1.5, qui semblait avoir subi une sélection positive. Cette protéine n'avait encore jamais été étudiée. Contrairement à ce que nous pensions, nous avons établi que cette protéine pouvait avoir une activité biologique liée à la défense. Ce travail de thèse a permis de préciser le nombre de gènes "liées à la pathogénèse" induits par la voie des jasmonates et d'apporter des éléments de réponse sur la question de la redondance des gènes de défense. En conclusion, même si de nombreuses familles de gènes intervenant dans la défense sont bien définies chez Arabidopsis, il reste encore de nombreuses études à faire sur chacun de ces membres. Abstract Being an important source of energy, plants are constantly attacked by herbivores and pathogens. As sessile organisms, they have developed sophisticated defense responses to cope with attack. Among these responses, signalling pathways, using endogenous elicitors including jasmonates (JA), allow the plant to induce the production of defense proteins such as pathogenesis-related (PR) proteins. The genes encoding these proteins belong to multigenic families. The first goal of this thesis was to evaluate the number of PR genes in the genome of Arabidopsis thaliana and estimate how much of this plant defense system was dependent on the jasmonate signaling pathway in leaves. Surprisingly a cluster of only 1S genes out of 2ó6 PR genes was exclusively regulated by JA. Multiple members of the jacalin lectin and trypsin inhibitor gene families were shown to be regulated by JA. Present in all eukaryotic immune systems, defensins are an attractive PR family to study. In Arabidopsis thaliana, 317 defensin-related proteins have been found but just 1S defensins (i.e. PDF family) are well annotated. These defensins are split into 2 groups. One of these groups may have appeared and diversified recently. The second goal of this thesis was to study this defensin gene group combining bioinformatic, reporter gene and quantitative PCR techniques. We have shown that this group contains an interesting acidic defensin, PDF1.S, which seems to have undergone positive selection. No information was known on this protein. We have established that this protein may have a biological activity in plant defense. This thesis allowed us to define the number of PR genes induced by the jasmonate pathway and gave initial leads to explain the redundancy of the PR genes in the genome of Arabidopsis. In conclusion, even if many defense gene families are already defined in the Arabidopsis genome, much work remains to be done on individual members.

Gender differences in HIV-positive persons in use of cardiovascular disease-related interventions : D:A:D study

INTRODUCTION: There is a lack of data on potential gender differences in the use of interventions to prevent and treat cardiovascular disease (CVD) in HIV-positive individuals. We investigated whether such differences exist in the D:A:D study. MATERIALS AND METHODS: Follow-up was from 01/02/99 until the earliest of death, 6 months after last visit or 01/02/13. Rates of initiation of lipid-lowering drugs (LLDs), angiotensin-converting enzyme inhibitors (ACEIs), anti-hypertensives and receipt of invasive cardiovascular procedures (ICPs; bypass, angioplasty, endarterectomy) were calculated in those without a myocardial infarction (MI) or stroke at baseline, overall and in groups known to be at higher CVD risk: (i) age >50, (ii) total cholesterol >6.2 mmol/l, (iii) triglyceride >2.3 mmol/l, (iv) hypertension, (v) previous MI, (vi) diabetes, or (vii) predicted 10-year CVD risk >10%. Poisson regression was used to assess whether rates of initiation were higher in men than women, after adjustment for these factors. RESULTS: At enrolment, women (n=13,039; median (interquartile range) 34 (29-40) years) were younger than men (n=36,664, 39 (33-46) years, p=0.001), and were less likely to be current smokers (29% vs. 39%, p=0.0001), to have diabetes (2% vs. 3%, p=0.0001) or to have hypertension (7% vs. 11%, p=0.0001). Of 49,071 individuals without a MI/stroke at enrolment, 0.6% women vs. 2.1% men experienced a MI while 0.8% vs. 1.3% experienced a stroke. Overall, women received ICPs at a rate of 0.07/100 person-years (PYRS) compared to 0.29/100 PYRS in men. Similarly, the rates of initiation of LLDs (1.28 vs. 2.46), anti-hypertensives (1.11 vs. 1.38) and ACEIs (0.82 vs. 1.37) were all significantly lower in women than men (Table 1). As expected, initiation rates of each intervention were higher in the groups determined to be at moderate/high CVD risk; however, within each high-risk group, initiation rates of most interventions (with the exception of anti-hypertensives) were generally lower in women than men. These gender differences persisted after adjustment for potential confounders (Table 1). CONCLUSION: Use of most CVD interventions was lower among women than men in the D:A:D study. Our findings suggest that actions should be taken to ensure that both men and women are monitored for CVD and, if eligible, receive appropriate CVD interventions.

Novel microsatellite loci for Sebaea aurea (Gentianaceae) and cross-amplification in related species.

Premise of the study: Microsatellite loci were developed in Sebaea aurea (Gentianaceae) to investigate the functional role of diplostigmaty (i.e., the presence of additional stigmas along the style). Methods and Results: One hundred seventy-four and 180 microsatellite loci were isolated through 454 shotgun sequencing of genomic and microsatellite-enriched DNA libraries, respectively. Sixteen polymorphic microsatellite loci were characterized, and 12 of them were selected to genotype individuals from two populations. Microsatellite amplification was conducted in two multiplex groups, each containing six microsatellite loci. Cross-species amplification was tested in seven other species of Sebaea. The 12 novel microsatellite loci amplified only in the two most closely related species to S. aurea (i.e., S. ambigua and S. minutiflora) and were also polymorphic in these two species. Conclusions: These results demonstrate the usefulness of this set of newly developed microsatellite loci to investigate the mating system and population genetic structure in S. aurea and related species.

Small vascular and Alzheimer disease-related pathologic determinants of dementia in the oldest-old.

The relative contributions of Alzheimer disease (AD) and vascular lesion burden to the occurrence of cognitive decline are more difficult to define in the oldest-old than they are in younger cohorts. To address this issue, we examined 93 prospectively documented autopsy cases from 90 to 103 years with various degrees of AD lesions, lacunes, and microvascular pathology. Cognitive assessment was performed prospectively using the Clinical Dementia Rating scale. Neuropathologic evaluation included the Braak neurofibrillary tangle (NFT) and β-amyloid (Aβ) protein deposition staging and bilateral semiquantitative assessment of vascular lesions. Statistics included regression models and receiver operating characteristic analyses. Braak NFTs, Aβ deposition, and cortical microinfarcts (CMIs) predicted 30% of Clinical Dementia Rating variability and 49% of the presence of dementia. Braak NFT and CMI thresholds yielded 0.82 sensitivity, 0.91 specificity, and 0.84 correct classification rates for dementia. Using these threshold values, we could distinguish 3 groups of demented cases and propose criteria for neuropathologic definition of mixed dementia, pure vascular dementia, and AD in very old age. Braak NFT staging and severity of CMI allow for defining most of demented cases in the oldest-old. Most importantly, single cutoff scores for these variables that could be used in the future to formulate neuropathologic criteria for mixed dementia in this age group were identified.

Splenic hypereosinophilia in anaphylaxis-related death: different assessments depending on different types of allergens?

The aim of this study was to evaluate splenic eosinophil and mast cell accumulation using pagoda red stain in a series of anaphylaxis-related deaths that underwent medico-legal investigations. Our goal was to assess whether fatal reactions to insect stings, intramuscularly administered antibiotics and intravenously injected contrast media are responsible for specific patterns of eosinophil and mast cell accumulation. Two study groups were prospectively formed, an anaphylaxis-related death group and a control group. Autopsy, histology (haematoxylin-eosin stain, pagoda red stain and immunohistochemistry using anti-tryptase antibodies), toxicology and postmortem biochemistry (beta-tryptase, total IgE and specific IgE) were performed in all cases. All tested parameters (spleen weight, beta-tryptase and total IgE levels as well as eosinophil, mast cell and degranulated mast cell numbers in the spleen) were significantly higher in the anaphylaxis-related death group. No statistically significant differences were observed among the various groups (intramuscular antibiotic injection, intravenous contrast medium administration and stinging insects) in any combination, suggesting that mast cell and eosinophil accumulation in the spleen during anaphylaxis does not have any specific pattern related to the triggering allergen. Despite a lower sensitivity than immunohistochemical staining in discriminating eosinophil and mast cells, pagoda red stain allowed these cells to be identified and could therefore be proposed as a low-cost, first-line diagnostic procedure in those situations where immunohistochemistry is not systematically performed or cannot be carried out.