The response of a Swiss university hospital's palliative care consult team to assisted suicide within the institution.

In January 2006 the Centre Hospitalier Universitaire Vaudois (CHUV), a large university hospital in Lausanne, Switzerland, became the first hospital in Switzerland to allow assisted suicide (AS) in exceptional cases within its walls. However, euthanasia is illegal. This decision has posed several ethical and practical dilemmas for the hospital's palliative care consult service. To address these, the team embarked on a formal process of open dialogue amongst its members with the goal of identifying a collective response and position. This process involved meetings every 4 to 6 weeks over the course of 10 months. An iterative process unfolded. One of the principal dilemmas relates to finding a balance between the team's position against AS and the patient's autonomy and the institution's directive. Although all team members expressed opposition to AS, there were mixed opinions as to whether or not the team members should be present during the act if requested so by patients. Some thought this could be misinterpreted as complicity in the act and could send out mixed messages to the public and other health professionals about palliative care. Others felt that the team's commitment to nonabandonment obliged them to be present even if they did not provide the drug or give any advice or assistance. The implications of nonabandonment are explored, as are several other questions such as whether or not the teams are obliged to provide detailed information on AS when requested by patients.

Sudden cardiac death in athletes : the Lausanne recommendations

La mort subite d'origine cardiaque chez les sportifs : les Recommandations de Lausanne Résumé Objectifs : Cette étude collecte les données de la littérature scientifique concernant la mort subite d'origine cardiaque chez les sportifs et a pour but d'aboutir à un protocole d'investigation de préparticipation globalement acceptable, approuvé par la conférence de consensus du Comité International Olympique(CIO), et recommandé par ce dernier. Données cliniques : La mort subite chez les athlètes de moins de 35 ans, engagés dans des sports de compétition,. est un évènement bien connu, dont l'incidence est plus élevée (~2/100000/an) que chez les non-athlètes (2,5 :1). La cause est cardiovasculaire dans plus de 90% des cas. Méthodes : Une revue systématique de la littérature a mis en évidence les causes de mort subite d'origine cardiaque, le sexe, l'âge, les maladies cardiaques sous-jacentes et le type de sport, ainsi que les protocoles d'investigation de préparticipation utilisés. Les méthodes nécessaires pour détecter des anomalies cardiaques préexistantes sont discutées pour formuler un protocole d'investigation de préparticipation pour la commission médicale du CIO. (http://www.olympic.org/uk/organisation/commissions/medical/full_ story_ uk.asp?id=1182) Résultats: 1101 cas de mort subite d'origine cardiaque ont été rapportés (1966-2004) chez des athlètes de moins de 35 ans, 50% présentant des anomalies cardiaques congénitales et des cardiomyopathies et 10% une athérosclérose à début précoce. 40% des athlètes avaient moins de 18 ans, 33% moins de 16 ans ; le rapport femme/homme était de 1/9. La mort subite d'origine cardiaque était reportée dans presque tous les sports ; ceux impliqués le plus fréquemment étaient le football(30%), le basketball(25%), et la course à pied(15%). Les tests de préparticipation étaient de qualité et de contenu variables. La conférence de consensus du CIO a accepté les «Recommandations de Lausanne » proposées, basées sur cette recherche et des opinions d'experts. (http://multimedia.olympic.org/pdf/en_report_886.pdf) Conclusions : La mort subite d'origine cardiaque touche plus souvent qu'attendu les jeunes athlètes et est principalement due à des anomalies cardiaques congénitales préexistantes. Les atteintes athérosclérotiques précoces forment une autre cause importante de décès chez les jeunes adultes. L'acceptation par le CIO de «Recommandations de Lausanne » a permis d'aboutir à un protocole d'investigation de préparticipation globalement acceptable .

The efficacy of a protective cream in a real-world apprentice hairdresser environment.

The object of this study was to compare the protective action of a new barrier cream (Excipial Protect, Spirig Pharma AG, Egerkingen, Switzerland) to its vehicle in the context of hand irritation of apprentice hairdressers caused by repeated shampooing and exposure to hair-care products. This was a double-blind cross-over comparing Excipial Protect (containing aluminium chlorohydrate 5% as active ingredient) against its vehicle alone. The efficacy of the creams was evaluated taking into account: (1) clinical scores by researchers, (2) biometric measurements, (3) subjective opinions of the subjects. An analysis of variance was performed considering order of application, degree of atopy, and reported number of shampoos. We observed very little difference in efficacy between the protective cream and its vehicle. The presence, however, of aluminium chlorhydrate in the protective cream was shown to have a positive effect against work-related irritation. The cosmetic qualities of the creams seemed, to the participants, to be as important as their real protective and hydrating properties, an important factor in compliance issues.

ESPEN Guidelines on Parenteral Nutrition: intensive care.

Nutritional support in the intensive care setting represents a challenge but it is fortunate that its delivery and monitoring can be followed closely. Enteral feeding guidelines have shown the evidence in favor of early delivery and the efficacy of use of the gastrointestinal tract. Parenteral nutrition (PN) represents an alternative or additional approach when other routes are not succeeding (not necessarily having failed completely) or when it is not possible or would be unsafe to use other routes. The main goal of PN is to deliver a nutrient mixture closely related to requirements safely and to avoid complications. This nutritional approach has been a subject of debate over the past decades. PN carries the considerable risk of overfeeding which can be as deleterious as underfeeding. Therefore the authors will present not only the evidence available regarding the indications for PN, its implementation, the energy required, its possible complementary use with enteral nutrition, but also the relative importance of the macro- and micronutrients in the formula proposed for the critically ill patient. Data on long-term survival (expressed as 6 month survival) will also be considered a relevant outcome measure. Since there is a wide range of interpretations regarding the content of PN and great diversity in its practice, our guidance will necessarily reflect these different views. The papers available are very heterogeneous in quality and methodology (amount of calories, nutrients, proportion of nutrients, patients, etc.) and the different meta-analyses have not always taken this into account. Use of exclusive PN or complementary PN can lead to confusion, calorie targets are rarely achieved, and different nutrients continue to be used in different proportions. The present guidelines are the result of the analysis of the available literature, and acknowledging these limitations, our recommendations are intentionally largely expressed as expert opinions.

Le prêt à intérêt dans l'Antiquité préchrétienne : Jérusalem, Athènes, Rome : étude juridique, philosophique et historiographique

Le prêt à intérêt était pratiqué par tous les peuples de l'Antiquité préchrétienne, à l'exception du peuple d'Israël. L'auteur examine d'abord l'interdiction du prêt à intérêt dans l'Ancien Testament. Il expose ensuite la pratique du prêt à intérêt en Grèce, avant de détailler les critiques d'Aristote. Enfin, l'auteur retrace l'évolution du prêt (mutuum) et de la réglementation de l'intérêt à Rome, des origines à Constantin. Il met l'accent sur trois grandes controverses parmi les romanistes modernes (XVIe - XXIe s.) : sur le nexum, sur la centesima et, surtout, sur le mystérieux fenus unciarium, le taux d'intérêt fixé par les Douze Tables, pour lequel l'éventail des interprétations va de 1 à 100 % par an ! L'auteur recense les opinions de plus de 400 juristes et historiens, discute les plus importantes et propose sa conclusion. The loan at interest was used by all the peoples of pre-Christian Antiquity, excepting the people of Israel. The author first focuses on the prohibition of lending at interest in the Old Testament. He then explores the use of loans at interest in Greece before examining Aristotle's criticism. Eventually, the author follows the evolution of loan (mutuum) and interest regulation in Rome, from the origins to Constantine. Three great controversies among modern Roman law scholars (16th - 21th) are considered: nexum, centesima and above all, the mysterious fenus unciarium, the interest rate defined by the Twelve Tables, for which the range of interpretations varies between 1 and 100% per year! The author gives an inventory of more than 400 opinions expressed by jurists and historians, discusses the most important ones and suggests a solution.

Death Caused by Cardioinhibitory Reflex. What experts believe

The danger of neck compression without restriction of the arterial flow remains unresolved in forensic medicine. There is an ongoing debate concerning life endangerment due to the cardioinhibitory reflex. The aim of this study was to determine what forensic medical experts believe and how they deal with this reflex. An anonymous electronic questionnaire was sent to 1429 forensic medical experts all over the world. We asked them about their opinion on the cardioinhibitory reflex, its role in causing death, and what their diagnostic criteria were.A total of 182 questionnaires were returned. The experts who answered were from 32 different countries. Our survey showed that 80.2% of experts believe that the cardioinhibitory reflex can theoretically cause death. In the practical application opinions diverge though. Apparently, the practical application mainly depends on the habit of the individual expert. We observed no consensus on the diagnostic criteria to be used. Given the potentially frequent use of the concept of the cardioinhibitory reflex in forensic practice and its judicial impact it would be important to reach a consensus.

Stellenwert Vertebroplastie/Kyphoplastie in der Behandlung von Wirbelkörperfrakturen. [Place de la vertébroplastie et de la cyphoplastie lors de fracture vertébrale ostéoporotique.]

La fracture vertébrale ostéoporotique est associée à une morbidité et une mortalité élevée. La vertébroplastie a pour but de diminuer les douleurs. La cyphoplastie permet en plus de restaurer la hauteur vertébrale. Ces deux techniques se font avec un risque faible d'effet secondaire immédiat. Cependant elles augmentent à cour et long terme le risque de nouvelle fracture vertébrale, surtout aux niveaux adjacents à la vertébre traitée.

Renforcer la participation politique : une approche évaluative du projet du Bureau lausannois pour les immigrés "Votre Ville, Votre Vie, Votre Voix"

Ce mémoire de recherche a pour thématique la participation politique, dans son acception large. Celle-ci est abordée sous un angle novateur, celui des politiques publiques. Les objectifs sont, d'une part, de déterminer les mécanismes mis en place pour renforcer la participation politique et, d'autre part, d'en évaluer les impacts. L'étude consiste en une étude de cas du projet « Votre Ville, Votre Vie, Votre Voix » développé par le Bureau lausannois pour les immigrés. Plus précisément, deux sortes d'activités menées entre mars et juin 2014 dans le cadre de ce projet ont été sélectionnées pour l'évaluation : une séance d'information sur les droits politiques et des visites d'institutions politiques. Pour ce faire, une dizaine de participants à ces activités ont été interviewés. Les résultats de l'étude mettent en évidence des impacts marqués sur les facteurs de la participation politique liés aux affects ou aux opinions et des impacts moins nets sur la compétence politique et sur les différentes composantes du comportement politique. Ces différents effets ressortent enfin plus clairement chez les interviewés ayant participé aux visites qu'à la séance.

Examination of Heterogeneous Crossing Sequences Between Toner and Rollerball Pen Strokes by Digital Microscopy and 3-D Laser Profilometry

The determination of line crossing sequences between rollerball pens and laser printers presents difficulties that may not be overcome using traditional techniques. This research aimed to study the potential of digital microscopy and 3-D laser profilometry to determine line crossing sequences between a toner and an aqueous ink line. Different paper types, rollerball pens, and writing pressure were tested. Correct opinions of the sequence were given for all case scenarios, using both techniques. When the toner was printed before the ink, a light reflection was observed in all crossing specimens, while this was never observed in the other sequence types. The 3-D laser profilometry, more time-consuming, presented the main advantage of providing quantitative results. The findings confirm the potential of the 3-D laser profilometry and demonstrate the efficiency of digital microscopy as a new technique for determining the sequence of line crossings involving rollerball pen ink and toner. With the mass marketing of laser printers and the popularity of rollerball pens, the determination of line crossing sequences between such instruments is encountered by forensic document examiners. This type of crossing presents difficulties with optical microscopic line crossing techniques involving ballpoint pens or gel pens and toner (1-4). Indeed, the rollerball's aqueous ink penetrates through the toner and is absorbed by the fibers of the paper, leaving the examiner with the impression that the toner is above the ink even when it is not (5). Novotny and Westwood (3) investigated the possibility of determining aqueous ink and toner crossing sequences by microscopic observation of the intersection before and after toner removal. A major disadvantage of their study resides in destruction of the sample by scraping off the toner line to see what was underneath. The aim of this research was to investigate the ways to overcome these difficulties through digital microscopy and three-dimensional (3-D) laser profilometry. The former was used as a technique for the determination of sequences between gel pen and toner printing strokes, but provided less conclusive results than that of an optical stereomicroscope (4). 3-D laser profilometry, which allows one to observe and measure the topography of a surface, has been the subject of a number of recent studies in this area. Berx and De Kinder (6) and Schirripa Spagnolo (7,8) have tested the application of laser profilometry to determine the sequence of intersections of several lines. The results obtained in these studies overcome disadvantages of other methods applied in this area, such as scanning electron microscope or the atomic force microscope. The main advantages of 3-D laser profilometry include the ease of implementation of the technique and its nondestructive nature, which does not require sample preparation (8-10). Moreover, the technique is reproducible and presents a high degree of freedom in the vertical axes (up to 1000 μm). However, when the paper surface presents a given roughness, if the pen impressions alter the paper with a depth similar to the roughness of medium, the results are not always conclusive (8). It becomes difficult in this case to distinguish which characteristics can be imputed to the pen impressions or the quality of the paper surface. This important limitation is assessed by testing different types of paper of variable quality (of different grammage and finishing) and the writing pressure. The authors will therefore assess the limits of 3-D laser profilometry technique and determine whether the method can overcome such constraints. Second, the authors will investigate the use of digital microscopy because it presents a number of advantages: it is efficient, user-friendly, and provides an objective evaluation and interpretation.

Le régime juridique des investissements directs étrangers au Cameroun face à l'impératif du développement

Avant-propos: Selon les données disponibles, le Cameroun, à l'instar de nombreux pays en développement, ne constitue qu'une destination marginale de l'investissement direct étranger (IDE), à l'exception de ceux destinés aux secteurs minier et pétrolier. Déterminer les causes de cette situation peu satisfaisante n'aurait en soi qu'un intérêt théorique si ce pays n'avait pas adopté une réglementation visant à encadrer et à promouvoir ce type d'investissements et n'avait pas, par ailleurs, signé et ratifié divers instruments bilatéraux et multilatéraux se rapportant à cet objet. Ce sont donc des considérations très pratiques qui l'emportent et rendent nécessaire une étude plus détaillée sur le sujet. Ce travail a pour objet l'étude du régime juridique des investissements directs étrangers analysé comme facteur pouvant Favoriser le développement économique et social du Cameroun. Dans ces conditions, il eût été impossible de s'en tenir à l'analyse des seules dispositions ayant trait spécifiquement au régime juridique des investissements d'origine étrangère. L'examen des obstacles et des contraintes ayant un impact aussi bien sur les politiques d'incitation que sur les effets attendus de ce type d'investissement s'est avéré indispensable pour appréhender la question dans sa globalité. Au risque de sacrifier quelque peu l'exigence de concision nécessaire à la rédaction d'une thèse, nous avons donc opté pour un exposé aussi complet que possible des questions avant tout juridiques, mais aussi politiques et économiques, auxquelles peuvent être confrontés, non seulement le juriste averti, mais aussi le praticien ou tout simplement l'étranger désireux d'investir au Cameroun. Pour ce faire, nous avons divisé notre étude en deux parties. Dans la première partie, nous nous efforçons de présenter et d'analyser les normes coutumières, conventionnelles, légales ou contractuelles constitutives du régime juridique des investissements au Cameroun. Et parce que le système juridique camerounais est complexe, et aussi méconnu ou inconnu, il nous a paru indispensable, à chaque fois, d'en rappeler les spécificités de manière à familiariser le lecteur avec les réalités institutionnelles et juridiques du pays qui illustre notre étude. Dans la deuxième partie, nous avons tenté de démontrer la nécessité d'adopter des politiques complémentaires visant à améliorer l'incidence de l'IDE sur le développement en proposant des mesures d'ordre politique et juridique pouvant contribuer à l'amélioration de la compétitivité de l'économie camerounaise, d'une part, et, d'autre part, viser à atténuer les effets néfastes des IDE et des politiques d'incitation. En élargissant ainsi le champ de notre analyse, nous espérons rendre service à la fois aux juristes et aux praticiens, plus sensibles aux solutions concrètes qu'à leur explication doctrinale. C'est ainsi que nous avons mis en commun les connaissances juridiques théoriques et les analyses et opinions émises par différents observateurs des faits économiques et sociaux du Cameroun, conscient qu'en Afrique plus qu'ailleurs, les juristes désireux de faire oeuvre utile ne sauraient s'enfermer dans la tour d'ivoire des Facultés. Nos conclusions, loin de faire l'inventaire de tous les résultats auxquels nous sommes parvenu, se limitent aux enseignements majeurs que nous tirons de notre recherche et aux propositions que nous formulons.

Lecture d'articles médicaux: quelques pièges à éviter [Reading medical articles--what pitfalls to avoid]

Critical reading and careful interpretation of results of the medical literature is a difficult task for primary care physicians. Being aware of common potential pitfalls that may bias results of a study is helpful. Among common pitfalls, odds ratios are often interpreted as relative risks, which overestimate the impact of a risk factor. Randomized controlled trials assessing the effectiveness of a new drug or a new target disease often use surrogate markers instead of clinical events as outcomes. Results of these trials should be considered with caution before using their results for clinical practice. For screening, observational studies often yield potentially biased or conflicting results. As clinical guidelines and expert opinions are often conflicting, primary care physicians should wait for results of large clinical trials in clinical events before changing their practice for screening or new drugs.

Chronic disease management: a qualitative study investigating the barriers, facilitators and incentives perceived by Swiss healthcare stakeholders.

BACKGROUND: Chronic disease management has been implemented for some time in several countries to tackle the increasing burden of chronic diseases. While Switzerland faces the same challenge, such initiatives have only emerged recently in this country. The aim of this study is to assess their feasibility, in terms of barriers, facilitators and incentives to participation. METHODS: To meet our aim, we used qualitative methods involving the collection of opinions of various healthcare stakeholders, by means of 5 focus groups and 33 individual interviews. All the data were recorded and transcribed verbatim. Thematic analysis was then performed and five levels were determined to categorize the data: political, financial, organisational/ structural, professionals and patients. RESULTS: Our results show that, at each level, stakeholders share common opinions towards the feasibility of chronic disease management in Switzerland. They mainly mention barriers linked to the federalist political organization as well as to financing such programs. They also envision difficulties to motivate both patients and healthcare professionals to participate. Nevertheless, their favourable attitudes towards chronic disease management as well as the fact that they are convinced that Switzerland possesses all the resources (financial, structural and human) to develop such programs constitute important facilitators. The implementation of quality and financial incentives could also foster the participation of the actors. CONCLUSIONS: Even if healthcare stakeholders do not have the same role and interest regarding chronic diseases, they express similar opinions on the development of chronic disease management in Switzerland. Their overall positive attitude shows that it could be further implemented if political, financial and organisational barriers are overcome and if incentives are found to face the scepticism and non-motivation of some stakeholders.