Training primary care physicians in shared decision making for colorectal cancer screening : Insights from the first statewide colorectal cancer screening program in Switzerland

Background: The State of Vaud has launched the first population-based, organized, colorectal cancer screening program in Switzerland for the population aged 50 to 69. Each primary care physician (PCP) has been invited to participate in an interactive session preparing them to enroll patients in the screening program. We aimed at testing the impact of an interactive seminar for PCPs on their intention to discuss the options of no screening, screening with the fecal-immunological test (FIT) and colonoscopy. We measured attitude, intentions and knowledge through questionnaires filled by PCPs before and after a 2.5 hour-long interactive seminar. The main outcome was the proportion of physicians foreseeing to offer coloscopy vs FIT on an equal basis. Physicians estimated the proportion of their patients prescribed a fecal occult blood test (FOBT) vs coloscopy over the months before the seminar and after the interactive seminar. We used a clinical vignette to test for knowledge about screening indications. The interactive seminar included powerpoint presentations with quizzes and clickers, an 8-minute video presenting a shared decision making (SDM) consultation around CRC screening and distribution of educational materials such as a SDM decision aid and background epidemiological information.

Communication du risque en médecine des voyages [Risk communication in travel medicine].

Les recommandations en termes de prévention contre la malaria pour les pays à risques modéré à faible diffèrent entre les pays, malgré le fait que les personnes soient exposées à un risque identique dans les pays qu'ils visitent. Pour inclure les voyageurs dans la réflexion, des outils de partage de la décision ont été développés et testés dans cette population. Leur utilisation a montré que la majorité des personnes choisissent de ne pas prendre de chimioprophylaxie en avançant des raisons valides. Le développement d'aides décisionnelles répondant à des critères reconnus est prévu et permettra d'améliorer la pertinence des recommandations. Les aides décisionnelles permettront aussi aux voyageurs de faire un choix de prévention avec les soignants au plus près de leurs valeurs et préférences, tout en respectant les règles de l'éthique médicale. Recommendations for malaria prevention for travelers planning a trip in medium to low risk countries differ between countries, despite the fact that people are exposed to the same risk in the travelled country. Decision aids have been developed and tested in a population of travelers planning a trip in such countries n order to present travelers the various prevention options and involve them in the decision. The use of the decision aid showed that he majority of people choose not to take chemoprophylaxis and that they could motivate their choice with valid reasons. The development of decision aids based on recognized quality criteria is foreseen; these will allow to improving the relevance of the recommendations and enable travelers to choose a prevention option that will be the closest to their values and preferences while following to the principles of medical ethics.

Late mesozoic to neogene radiolarian biostratigraphy and palaeoceanography in the Caribbean and East pacific region

^Raduolarians constitute a good tool for contributing to the biostratigraphy of accreted terranes and in deep-sea sediment sequences. The use of radiolarians is also proven to be valuable as a palaeoceanographic indicator. The present study evaluates radiolarians in three different geological settings, in order to better constrain the age of the sites and to try to understand their palaeoenvironmental situation at different periods, particularly in the Caribbean-Central America area. On the Jarabacoa Block, in Central Dominican Republic, a hundred meters of siliceous mudstones (Pedro Brand section in the Tireo Group) was dated as Turonian- Coniancian in age using radiolarians. A 40Ar-39Ar whole rock age of 75.1±1.1 Ma (Campanian), obtained in a basalt dyke crosscutting the radiolarian bearing rocks, a consistent minimum age for the pelagic-hemipelagic Pedro Brand section. The Jarabacoa Block is considered as the most complete outcrop section of Pacific ocean crust overlain by a first Aptian-Albian phase of Caribbean Large Igneous Province-type activity (CLIP), followed by the development of a Cenomanian-Santonian intraoceanic arc, which is in turn overlain by a late Campanian-Maastrichtian CLIP-phase. The Tireo Group records an episode of pelagic to hemi-pelagic and intermediate to acidic arc-derived sedimentation, previous to the youngest magmatic phase of the CLIP. Thus, the section of Pedro Brand has been interpreted in this study as being part of the intraoceanic arc. In northern Venezuela, a greenish radiolarite section from Siquisique Ophiolite (basalts, gabbros and some associated cherts) in Guaparo Creek has been studied. In previous studies, the Ophiolite unit (Petacas Creek section) has been dated as Bajocian-Bathonian, based on ammonites present in interpillow sediments from basalt blocks. New dating of the present study concluded in an Aptian?-Albian-Cenomanian age for the Guaparo creek section (middle Cretaceous), based on radiolarian assemblage associated to basalts-gabbros rocks of the unit. Previous plagioclase 40Ar-39Ar ages from the Siquisuique Ophiolite may be slightly younger (94-90 Ma.) and may, therefore, represent younger dykes that intruded onto a well-developed sheeted dyke complex of the Siquisique. The geochemistry of these rocks and the palaeotectonic reconstruction of the Caribbean area during this period suggest that these rocks were derived from a mid-ocean ridge with an influence of deep mantle plume. The Siquisique Ophiolite most probably represents a fragment of the proto-Caribbean basin. The Integrated Ocean Drilling Program Expedition 344 drilled a transect across the convergent margin off Costa Rica. Two sites of this expedition were chosen for radiolarian biostratigraphy and palaeoceanographic studies. Both sites (U1381C and U1414A) are located in the incoming Cocos plate, in the eastern Equatorial Pacific. The succession of U1381C yields a Middle Miocene to Pleistocene age, and presents an important hiatus of approximately 10 Ma. The core of U1414A exposes a continuous sequence that deposited during Late Miocene to Pleistocene (radiolarian zones RN6-RN16). The ages were assigned based on radiolarians and correlated with nannofossil zonation and tephra 40Ar-39Ar datation. With those results, and considering the northward movement of the Cocos plate motion (about 7 cm/year), deduction is made that the sites U1381C and U1414A were initially deposited during the Miocene, several hundreds of kilometres from the current location, slightly south of the Equator. This suggests that the faunas of these sites have been subjected to different currents, first influenced by the cold tongue of the South Equatorial Current and followed by the warm Equatorial Countercurrent. At last, coastal upwelling influenced faunas of the Pleistocene. -- Les radiolaires sont considérés comme un outil utile à la biostratigraphie des terrains accrétés et des sédiments profonds. Leur utilité est aussi prouvée comme étant remarquable au niveau des reconstructions paléocéanographiques. La présente étude évalue l'importance et la présence des radiolaires de trois localités géologiquement différentes d'Amérique Centrale-Caraïbes, dans le but d'améliorer les model d'âges et de mieux comprendre la situation paléoenvironnementale à travers le temps. Dans le Bloque de Jarabacoa, au centre de la République Dominicaine, une section de cent mètres (section de Pedro Brand, Groupe de Tireo) a été datée comme faisant partie du Turonien-Santonien, en utilisant les radiolaires. Une datation 40Ar-39Ar sur roche totale de 75±1.1 Ma (Campanien) a été obtenu pour vin dyke traversant les sédiments riches en radiolaires, en cohérence avec l'âge minimum accordé à la section de Pedro Brand. Aux Caraïbes, le Bloque de Jarabacoa est considéré comme l'affleurement le plus complet présentant une succession de croûte océanique d'origine Pacifique recouverte d'une première phase d'activité volcanique de type CLIP (Caribbean Large Igneous Province) d'âge Aptien- Albien, de dépôts d'arc volcanique intra-océanique d'âge Cénomanien-Santonien, puis d'une seconde phase de type CLIP d'âge Campanien-Maastrichtien. Le Groupe de Tireo enregistre un épisode de dépôt pélagiques-hémipélagiques et d'arc volcanique, antérieur à la plus jeune phase de type CLIP. Cette étude place donc la formation de la section de Pedro Brand au moment du développement de l'arc intra-océanique. A Guaparo Creek (nord du Vénézuela), une section de radiolarite verdâtre faisant partie des ophiolites de Siquisique (basaltes, gabbros, cherts) a été étudiée. Dans des études précédentes, sur la localité de Petacas Creek, l'unité ophiolitique a été daté d'âge Bajocien- Bathonien (Jurassique) sur la base d'ammonites trouvées dans des sédiments intercalés entre des laves en coussins. Les nouvelles datations de notre étude, basées sur des assemblages à radiolaires de l'unité à basaltes-gabbros, donnent un âge Aptien?-Albien-Cénomanien (Crétacé moyen). Les âges de l'Ophiolite de Siquisique, précédement calculés par la méthode sur plagioclases, pourraient être légèrement plus jeune (94-90 Ma) et donc représenter des intrusions plus récentes de dykes dans le complexe filonien déjà bien dévelopé. La géochimie de ces roches magmatiques, ainsi que les reconstructions paléotectoniques de la zone Caraïbes durant cette période, suggèrent que ces formations sont dérivées d'une ride médio-océanique associée à l'influence d'un panache mantellique. L'ophiolite de Siquisique représente très probablement un fragment du bassin de proto¬Caraïbe. L'expédition 344 du programme IODP (Integrated Ocean Drilling Program) a eu lieu dans l'optique de forer et dresser une coupe de la marge convergente au large du Costa Rica. Deux sites de cette expédition ont été choisis pour les besoins des études de biostratigraphie et de reconstruction paléocéanographique. Ces deux sites (U1381C et U1414A) sont situés sur la plaque subductante de Cocos, dans la zone Pacifique est-équatoriale. La carotte U1381C expose une séquence s'étalant du Miocène moyen au Pléistocène, et présente un important hiatus d'environ 10 Ma. La carotte U1414A expose une séquence continue s'étalant du Miocène tardif au Pléistocène (zone à radiolaires RN6-RN16). Les âges ont été assignés sur la base des radiolaires et corrélés avec les zones à nanofossiles et les datations 40Ar-39Ar sur téphras. Avec ces résultats, et en considérant le mouvement nord de la plaque de Cocos (environ 7 cm/an), déduction est faite que les deux sites étaient initialement situés, au cours du Miocène, à plusieurs centaines de kilomètres de leur location actuelle, au sud de l'équateur. Cela suggère que les faunes de ces sites ont été sujettes à différents courants; premièrement influencées par la langue froide du SEC (South Equatorial Current), puis par les eaux chaudes du ECC (Equatorial Countercurrent). Pour terminer, les remontées d'eau côtières ont influencées les faunes Pléistocène.

Low statin use in adults hospitalized with acute coronary syndrome.

OBJECTIVE: To assess recommended and actual use of statins in primary prevention of cardiovascular disease (CVD) based on clinical prediction scores in adults who develop their first acute coronary syndrome (ACS). METHOD: Cross-sectional study of 3172 adults without previous CVD hospitalized with ACS at 4 university centers in Switzerland. The number of participants eligible for statins before hospitalization was estimated based on the European Society of Cardiology (ESC) guidelines and compared to the observed number of participants on statins at hospital entry. RESULTS: Overall, 1171 (37%) participants were classified as high-risk (10-year risk of cardiovascular mortality ≥5% or diabetes); 1025 (32%) as intermediate risk (10-year risk <5% but ≥1%); and 976 (31%) as low risk (10-year risk <1%). Before hospitalization, 516 (16%) were on statins; among high-risk participants, only 236 of 1171 (20%) were on statins. If ESC primary prevention guidelines had been fully implemented, an additional 845 high-risk adults (27% of the whole sample) would have been eligible for statins before hospitalization. CONCLUSION: Although statins are recommended for primary prevention in high-risk adults, only one-fifth of them are on statins when hospitalized for a first ACS.

Transcriptional regulator PRDM12 is essential for human pain perception.

Pain perception has evolved as a warning mechanism to alert organisms to tissue damage and dangerous environments. In humans, however, undesirable, excessive or chronic pain is a common and major societal burden for which available medical treatments are currently suboptimal. New therapeutic options have recently been derived from studies of individuals with congenital insensitivity to pain (CIP). Here we identified 10 different homozygous mutations in PRDM12 (encoding PRDI-BF1 and RIZ homology domain-containing protein 12) in subjects with CIP from 11 families. Prdm proteins are a family of epigenetic regulators that control neural specification and neurogenesis. We determined that Prdm12 is expressed in nociceptors and their progenitors and participates in the development of sensory neurons in Xenopus embryos. Moreover, CIP-associated mutants abrogate the histone-modifying potential associated with wild-type Prdm12. Prdm12 emerges as a key factor in the orchestration of sensory neurogenesis and may hold promise as a target for new pain therapeutics.

Prevalence and management of familial hypercholesterolaemia in patients with acute coronary syndromes.

AIMS: We aimed to assess the prevalence and management of clinical familial hypercholesterolaemia (FH) among patients with acute coronary syndrome (ACS). METHODS AND RESULTS: We studied 4778 patients with ACS from a multi-centre cohort study in Switzerland. Based on personal and familial history of premature cardiovascular disease and LDL-cholesterol levels, two validated algorithms for diagnosis of clinical FH were used: the Dutch Lipid Clinic Network algorithm to assess possible (score 3-5 points) or probable/definite FH (>5 points), and the Simon Broome Register algorithm to assess possible FH. At the time of hospitalization for ACS, 1.6% had probable/definite FH [95% confidence interval (CI) 1.3-2.0%, n = 78] and 17.8% possible FH (95% CI 16.8-18.9%, n = 852), respectively, according to the Dutch Lipid Clinic algorithm. The Simon Broome algorithm identified 5.4% (95% CI 4.8-6.1%, n = 259) patients with possible FH. Among 1451 young patients with premature ACS, the Dutch Lipid Clinic algorithm identified 70 (4.8%, 95% CI 3.8-6.1%) patients with probable/definite FH, and 684 (47.1%, 95% CI 44.6-49.7%) patients had possible FH. Excluding patients with secondary causes of dyslipidaemia such as alcohol consumption, acute renal failure, or hyperglycaemia did not change prevalence. One year after ACS, among 69 survivors with probable/definite FH and available follow-up information, 64.7% were using high-dose statins, 69.0% had decreased LDL-cholesterol from at least 50, and 4.6% had LDL-cholesterol ≤1.8 mmol/L. CONCLUSION: A phenotypic diagnosis of possible FH is common in patients hospitalized with ACS, particularly among those with premature ACS. Optimizing long-term lipid treatment of patients with FH after ACS is required.

Programme cantonal vaudois de dépistage du cancer colorectal: information et décision partagée [Shared decision making in the colorectal cancer screening program in the canton of Vaud].

Le programme cantonal vaudois de dépistage du cancer colorectal vise à faciliter ce dépistage pour la population de 50 à 69 ans. Les deux modalités retenues sont la recherche immunologique de sang dans les selles (FIT) et la coloscopie. La décision de réaliser un test de dépistage et la modalité de dépistage s'appuient sur une consultation individuelle avec un médecin de famille. L'assurance de base prend en charge le remboursement. Le programme vaudois permet l'exemption de la franchise pour la consultation médicale d'information et les deux modalités de dépistage, ainsi que pour la coloscopie de confirmation en cas de test FIT positif. La quote-part de 10 % reste à charge des participants. Des outils de communication ont été développés pour faciliter un entretien de décision partagée dans le cadre d'une consultation médicale. The colorectal cancer screening program of the canton of Vaud aims to facilitate screening for this cancer for the population aged 50 to 69 years old. The two screening modalities offered are fecal immunochemical testing (FIT) and colonoscopy. The decision to undergo screening and the screening modality is based on an individual medical encounter with a primary care physician. Both screening modalities are reimbursed through basic health coverage in Switzerland. The participation to the screening program allows the exemption of the deductible for the medical encounter and the chosen screening modality. A copay of 10% is maintained for all costs. Communication tools were developed on the basis of recommendations in the literature to facilitate shared decision-making in a medical encounter.

Dépistage du cancer de la prostate: partager avec le patient les incertitudes [Sharing uncertainties of prostate cancer screening].

The decision of whether our patients should undergo prostate cancer screening with the prostate specifc antigen (PSA) test remains daunting. The role of the primary care doctor is to help men decide between a potential decrease in mortality from a slow evolving but sometimes lethal cancer, and the risk of diagnosing and treating cancers that would have otherwise been indolent and asymptomatic. We can structure our discussions with three steps: choice, option, and decision making. A decision aid, such as the one that we have adapted and simplifed from the Collège des médecins du Québec, can help with this complex decision.

Statines en prévention primaire: comment décider avec le patient [Statins in primary prevention: how to share the decision?].

Long-term treatment of hypercholesterolemia with statins diminishes the risk of cardiovascular events. Statins are recommended in secondary prevention of cardiovascular disease. In the absence of preexisting cardiovascular disease, the decision to start a statin or not is most often made by the general practitioner and his patient. An interactive decision aid, developed by the Mayo Clinic, has just been translated in French and adapted to the Swiss epidemiology of cardiovascular risk factors, with the aim of promoting shared decision-making. This paper reviews the conditions and potential benefits of shared decision-making about statin therapy in primary prevention.

Association between resistin levels and cardiovascular disease events in older adults: The health, aging and body composition study.

OBJECTIVE: Prospective data on the association between resistin levels and cardiovascular disease (CVD) events are sparse with conflicting results. METHODS: We studied 3044 aged 70-79 years from the Health, Aging, and Body Composition Study. CVD events were defined as coronary heart disease (CHD) or stroke events. «Hard » CHD events were defined as CHD death or myocardial infarction. We estimated hazard ratio (HR) and 95% confidence intervals (CI) according to the quartiles of serum resistin concentrations and adjusted for clinical variables, and then further adjusted for metabolic disease (body mass index, fasting plasma glucose, abdominal visceral and subcutaneous adipose tissue, leptin, adiponectin, insulin) and inflammation (C-reactive protein, interleukin-6, tumor necrosis factors-α). RESULTS: During a median follow-up of 10.1 years, 559 patients had « hard » CHD events, 884 CHD events and 1106 CVD Events. Unadjusted incidence rate for CVD events was 36.6 (95% CI 32.1-41.1) per 1000 persons-year in the lowest quartile and 54.0 per 1000 persons-year in the highest quartile (95% CI 48.2-59.8, P for trend < 0.001). In the multivariate models adjusted for clinical variables, HRs for the highest vs. lowest quartile of resistin was 1.52 (95% CI 1.20-1.93, P < 0.001) for « Hard » CHD events, 1.41 (95% CI 1.16-1.70, P = 0.001) for CHD events and 1.35 (95% CI 1.14-1.59, P = 0.002) for CVD events. Further adjustment for metabolic disease slightly reduced the associations while adjustment for inflammation markedly reduced the associations. CONCLUSIONS: In older adults, higher resistin levels are associated with CVD events independently of clinical risk factors and metabolic disease markers, but markedly attenuated by inflammation.

Prognostic value of PCSK9 levels in patients with acute coronary syndromes.

AIMS: Proprotein convertase subtilisin kexin 9 (PCSK9) is an emerging target for the treatment of hypercholesterolaemia, but the clinical utility of PCSK9 levels to guide treatment is unknown. We aimed to prospectively assess the prognostic value of plasma PCSK9 levels in patients with acute coronary syndromes (ACS). METHODS AND RESULTS: Plasma PCSK9 levels were measured in 2030 ACS patients undergoing coronary angiography in a Swiss prospective cohort. At 1 year, the association between PCSK9 tertiles and all-cause death was assessed adjusting for the Global Registry of Acute Coronary Events (GRACE) variables, as well as the achievement of LDL cholesterol targets of <1.8 mmol/L. Patients with higher PCSK9 levels at angiography were more likely to have clinical familial hypercholesterolaemia (rate ratio, RR 1.21, 95% confidence interval, CI 1.09-1.53), be treated with lipid-lowering therapy (RR 1.46, 95% CI 1.30-1.63), present with longer time interval of chest pain (RR 1.29, 95% CI 1.09-1.53) and higher C-reactive protein levels (RR 1.22, 95% CI 1.16-1.30). PCSK9 increased 12-24 h after ACS (374 ± 149 vs. 323 ± 134 ng/mL, P < 0.001). At 1 year follow-up, HRs for upper vs. lower PCSK9-level tertiles were 1.13 (95% CI 0.69-1.85) for all-cause death and remained similar after adjustment for the GRACE score. Patients with higher PCSK9 levels were less likely to reach the recommended LDL cholesterol targets (RR 0.81, 95% CI 0.66-0.99). CONCLUSION: In ACS patients, high initial PCSK9 plasma levels were associated with inflammation in the acute phase and hypercholesterolaemia, but did not predict mortality at 1 year.

Early Modern Persian, Urdu, and English Historiography and the Imagination of Islamic India under British Rule

This paper analyses the early modern transformations of South Asian literary cultures through the production of historiography in Persian, English, and Urdu. In the 18th-19th centuries, South Asian communities experienced and participated in a major restructuring of the languages of the subcontinent. Urdu and English were institutionalized as governmental languages and utilized in new literary productions as Persian was gradually marginalized from the centre of literary and governmental polities. Three interrelated colonial policies reshaped the historical consciousness of South Asia and Britain: the production of new Persian histories commissioned under British patronage, the initiation of Urdu historiography through the translation of Persian and English histories, and the construction of the British history of India written in English. This article explores the historical and social dynamics of these events and situates the origins and evolution of the colonial historiographical project. Major works discussed are the Tārīkh-i Bangālah of Salīm Allāh Munshī (fl. 1763), James Mill's (1773-1836) The History of British India first published in 1817, Mīr Sher ʿAlī Afsos' the Ārāʾish-i mahfil, as well as the production of original Urdu histories such as Muḥammad Zakāʾ-Allāh's (1832-1910) the Tārīkh-i Hindustān.