Family doctors' consultations with people suffering from chronic pain without objective findings: Which protective practices might they develop in these challenging medical encounters?

Introduction: Consultations with patients suffering from chronic pain without objective findings represent a challenge fo r family doctors (FDs). A mutual lack of understanding may arise, which threatens the doctor-patient relationship and may lead to dissatisfaction of both patient and doctor and to a breakdown of the therapeutic alliance. Objectives: This study aims to investigate FDs' potential protective practices to preserve the doctor-patient relationship during this type of consultation. Method: In the first step of this qualitative research, I carried out a range of 10 se- mi-structured interviews with FDs to explore their reported practices and repre- sentations during consultations with people suffering from chronic pain without objective findings. The interviews' transcripts were integrally analysed with computer-assisted thematic content analysis (QSR NVivo ® ) to highlight the main themes related to the topic in the participants' talk. Results: At this point of the research, two types of FDs' protective practices can be identified: first the use of complementary sources of knowledge in addition to the medical model to provide explanations to patients, second the collaboration with multidisciplinary teams or support gr oups that allow them to share profes- sional expertise and emotional experiences. Conclusion: The findings could be useful to develop ways to improve the follow- up of patients suffering from chronic pain without objective findings and conse- quently the FDs' work satisfaction.

Can Families Resist Managerial and Financial Revolutions? Swiss Family Firms in the Twentieth Century

The aim of this contribution is to highlight the long-term evolution of family capitalism in Switzerland during the twentieth century. We focus on 22 large companies of the machine, electrotechnical and metallurgy (MEM) sector whose boards of directors and general managers have been identified in five benchmark years across the twentieth century, which allows us to distinguish between family-owned and family-controlled firms. Our results show that family firms prevailed until the 1980s and thus contradict the dominance of 'managerial capitalism'. Although we observe a decline of family capitalism during the last decade of the century, the significant remaining presence of family firms in 2000 allows us to relativise the advent of investor capitalism.

p.L1612P, a novel voltage-gated sodium channel Nav1.7 mutation inducing a cold sensitive paroxysmal extreme pain disorder.

BACKGROUND: Mutations in the SCN9A gene cause chronic pain and pain insensitivity syndromes. We aimed to study clinical, genetic, and electrophysiological features of paroxysmal extreme pain disorder (PEPD) caused by a novel SCN9A mutation. METHODS: Description of a 4-generation family suffering from PEPD with clinical, genetic and electrophysiological studies including patch clamp experiments assessing response to drug and temperature. RESULTS: The family was clinically comparable to those reported previously with the exception of a favorable effect of cold exposure and a lack of drug efficacy including with carbamazepine, a proposed treatment for PEPD. A novel p.L1612P mutation in the Nav1.7 voltage-gated sodium channel was found in the four affected family members tested. Electrophysiologically the mutation substantially depolarized the steady-state inactivation curve (V1/2 from -61.8 ± 4.5 mV to -30.9 ± 2.2 mV, n = 4 and 7, P < 0.001), significantly increased ramp current (from 1.8% to 3.4%, n = 10 and 12) and shortened recovery from inactivation (from 7.2 ± 5.6 ms to 2.2 ± 1.5 ms, n = 11 and 10). However, there was no persistent current. Cold exposure reduced peak current and prolonged recovery from inactivation in wild-type and mutated channels. Amitriptyline only slightly corrected the steady-state inactivation shift of the mutated channel, which is consistent with the lack of clinical benefit. CONCLUSIONS: The novel p.L1612P Nav1.7 mutation expands the PEPD spectrum with a unique combination of clinical symptoms and electrophysiological properties. Symptoms are partially responsive to temperature but not to drug therapy. In vitro trials of sodium channel blockers or temperature dependence might help predict treatment efficacy in PEPD.

Techniques for CT and MR, post-processing, radiation

Brain perfusion can be assessed by CT and MR. For CT, two major techniques are used. First, Xenon CT is an equilibrium technique based on a freely diffusible tracer. First pass of iodinated contrast injected intravenously is a second method, more widely available. Both methods are proven to be robust and quantitative, thanks to the linear relationship between contrast concentration and x-ray attenuation. For the CT methods, concern regarding x-ray doses delivered to the patients need to be addressed. MR is also able to assess brain perfusion using the first pass of gadolinium based contrast agent injected intravenously. This method has to be considered as a semi-quantitative because of the non linear relationship between contrast concentration and MR signal changes. Arterial spin labeling is another MR method assessing brain perfusion without injection of contrast. In such case, the blood flow in the carotids is magnetically labelled by an external radiofrequency pulse and observed during its first pass through the brain. Each of this various CT and MR techniques have advantages and limits that will be illustrated and summarized.Learning Objectives:1. To understand and compare the different techniques for brain perfusion imaging.2. To learn about the methods of acquisition and post-processing of brain perfusion by first pass of contrast agent for CT and MR.3. To learn about non contrast MR methods (arterial spin labelling).

The promise of advanced imaging techniques for the detection of hepatitis C virus antigens in the infected liver.

Injection drug use before and after liver transplantation: a retrospective multicenter analysis on incidence and outcome. Clin Transplant 2009 DOI: 10.1111/j.1399-0012.2009.01121.x. Background and aims: Injecting drug use (IDU) before and after liver transplantation (LT) is poorly described. The aim of this study was to quantify relapse and survival in this population and to describe the causes of mortality after LT. Methods: Past injection drug users were identified from the LT listing protocols from four centers in Switzerland and France. Data on survival and relapse were collected and used for uni- and multivariate analysis. Results: Between 1988 and 2006, we identified 59 patients with a past history of IDU. The mean age at transplantation was 42.4 yr and the majority of patients were men (84.7%). The indication for LT was for the vast majority viral cirrhosis accounting for 91.5% of cases, while alcoholic cirrhosis was 5.1%. There were 16.9% of patients who had a substitution therapy before and 6.8% who continued after LT. Two patients (3.4%) relapsed into IDU after LT and died at 18 and 41 months. The mean follow-up was 51 months. Overall survival was 84%, 66%, and 61% at 1, 5, and 10 yr after transplantation. Conclusions: Documented IDU was rare in liver transplanted patients. Past IDU was not associated with poorer survival after LT, and relapse after LT occurred in 3.4%.

Nonredundant Regulation of Rice Arbuscular Mycorrhizal Symbiosis by Two Members of the PHOSPHATE TRANSPORTER1 Gene Family.

Pi acquisition of crops via arbuscular mycorrhizal (AM) symbiosis is becoming increasingly important due to limited high-grade rock Pi reserves and a demand for environmentally sustainable agriculture. Here, we show that 70% of the overall Pi acquired by rice (Oryza sativa) is delivered via the symbiotic route. To better understand this pathway, we combined genetic, molecular, and physiological approaches to determine the specific functions of two symbiosis-specific members of the PHOSPHATE TRANSPORTER1 (PHT1) gene family from rice, ORYsa;PHT1;11 (PT11) and ORYsa;PHT1;13 (PT13). The PT11 lineage of proteins from mono- and dicotyledons is most closely related to homologs from the ancient moss, indicating an early evolutionary origin. By contrast, PT13 arose in the Poaceae, suggesting that grasses acquired a particular strategy for the acquisition of symbiotic Pi. Surprisingly, mutations in either PT11 or PT13 affected the development of the symbiosis, demonstrating that both genes are important for AM symbiosis. For symbiotic Pi uptake, however, only PT11 is necessary and sufficient. Consequently, our results demonstrate that mycorrhizal rice depends on the AM symbiosis to satisfy its Pi demands, which is mediated by a single functional Pi transporter, PT11.

Le médecin de famille de demain [Tomorrow's family doctor].

The profession of family doctor will undergo profound changes in the coming decade due to external, political, demographic and societal developments. Changes will also occur from within the profession affecting its content and its functioning. Other influences, in addition to generational developments (reduced working hours, feminisation, revaluation of the work-life balance), will come from collaboration with new professions, news structures as well as technical and human progress. In this transitional period it is important to uphold core values of family medicine, in particular coordination, continuity of care and the global approach to patients. In training future family doctors we must both prepare them for new skills and roles, and continue to share the core values with them.

Ecologie industrielle de l'aluminium, flux de matières et d'énergie : réalités et enjeux du recyclage

Dans les dernières années du 20ème siècle, l'aluminium a fait l'objet de beaucoup de communications outrancières et divergentes cautionnées par des scientifiques et des organismes faisant autorité. En 1986, la société PECHINEY le décrète perpétuel tel le mouvement « L'aluminium est éternel. Il est recyclable indéfiniment sans que ses propriétés soient altérées », ce qui nous avait alors irrité. Peu de temps après, en 1990, une communication tout aussi outrancière et irritante d'une grande organisation environnementale, le World Wild Fund, décrète que « le recyclage de l'aluminium est la pire menace pour l'environnement. Il doit être abandonné ». C'est ensuite à partir de la fin des années 1990, l'explosion des publications relatives au développement durable, le bien mal nommé. Au développement, synonyme de croissance obligatoire, nous préférons société ou organisation humaine et à durable, mauvaise traduction de l'anglais « sustainable », nous préférons supportable : idéalement, nous aurions souhaité parler de société durable, mais, pour être compris de tous, nous nous sommes limités à parler dorénavant de développement supportable. Pour l'essentiel, ces publications reconnaissent les très graves défauts de la métallurgie extractive de l'aluminium à partir du minerai et aussi les mérites extraordinaires du recyclage de l'aluminium puisqu'il représente moins de 10% de la consommation d'énergie de la métallurgie extractive à partir du minerai (on verra que c'est aussi moins de 10% de la pollution et du capital). C'est précisément sur le recyclage que se fondent les campagnes de promotion de l'emballage boisson, en Suisse en particulier. Cependant, les données concernant le recyclage de l'aluminium publiées par l'industrie de l'aluminium reflètent seulement en partie ces mérites. Dans les années 1970, les taux de croissance de la production recyclée sont devenus plus élevés que ceux de la production électrolytique. Par contre, les taux de recyclage, établis à indicateur identique, sont unanimement tous médiocres comparativement à d'autres matériaux tels le cuivre et le fer. Composante de l'industrie de l'aluminium, le recyclage bénéficie d'une image favorable auprès du grand public, démontrant le succès des campagnes de communication. A l'inverse, à l'intérieur de l'industrie de l'aluminium, c'est une image dévalorisée. Les opinions émises par tous les acteurs, commerçants, techniciens, dirigeants, encore recueillies pendant ce travail, sont les suivantes : métier de chiffonnier, métier misérable, métier peu technique mais très difficile (un recycleur 15 d'aluminium n'a-t-il pas dit que son métier était un métier d'homme alors que celui du recycleur de cuivre était un jeu d'enfant). A notre avis ces opinions appartiennent à un passé révolu qu'elles retraduisent cependant fidèlement car le recyclage est aujourd'hui reconnu comme une contribution majeure au développement supportable de l'aluminium. C'est bien pour cette raison que, en 2000, l'industrie de l'aluminium mondiale a décidé d'abandonner le qualificatif « secondaire » jusque là utilisé pour désigner le métal recyclé. C'est en raison de toutes ces données discordantes et parfois contradictoires qu'a débuté ce travail encouragé par de nombreuses personnalités. Notre engagement a été incontestablement facilité par notre connaissance des savoirs indispensables (métallurgie, économie, statistiques) et surtout notre expérience acquise au cours d'une vie professionnelle menée à l'échelle mondiale dans (recherche et développement, production), pour (recherche, développement, marketing, stratégie) et autour (marketing, stratégie de produits connexes, les ferro-alliages, et concurrents, le fer) de l'industrie de l'aluminium. Notre objectif est de faire la vérité sur le recyclage de l'aluminium, un matériau qui a très largement contribué à faire le 20ème siècle, grâce à une revue critique embrassant tous les aspects de cette activité méconnue ; ainsi il n'y a pas d'histoire du recyclage de l'aluminium alors qu'il est plus que centenaire. Plus qu'une simple compilation, cette revue critique a été conduite comme une enquête scientifique, technique, économique, historique, socio-écologique faisant ressortir les faits principaux ayant marqué l'évolution du recyclage de l'aluminium. Elle conclut sur l'état réel du recyclage, qui se révèle globalement satisfaisant avec ses forces et ses faiblesses, et au-delà du recyclage sur l'adéquation de l'aluminium au développement supportable, adéquation largement insuffisante. C'est pourquoi, elle suggère les thèmes d'études intéressant tous ceux scientifiques, techniciens, historiens, économistes, juristes concernés par une industrie très représentative de notre monde en devenir, un monde où la place de l'aluminium dépendra de son aptitude à satisfaire les critères du développement supportable. ABSTRACT Owing to recycling, the aluminium industry's global energetic and environmental prints are much lower than its ore extractive metallurgy's ones. Likewise, recycling will allow the complete use of the expected avalanche of old scraps, consequently to the dramatic explosion of aluminium consumption since the 50's. The recycling state is characterized by: i) raw materials split in two groups :one, the new scrap, internal and prompt, proportional to semi-finished and finished products quantities, exhibits a fairly good and regular quality. The other, the old scrap, proportional to the finished products arrivïng at their end-of--life, about 22 years later on an average, exhibits a variable quality depending on the collect mode. ii) a poor recycling rate, near by that of steel. The aluminium industry generates too much new internal scrap and doesn't collect all the availa~e old scrap. About 50% of it is not recycled (when steel is recycling about 70% of the old scrap flow). iii) recycling techniques, all based on melting, are well handled in spite of aluminium atiiníty to oxygen and the practical impossibility to purify aluminium from any impurity. Sorting and first collect are critical issues before melting. iv) products and markets of recycled aluminium :New scraps have still been recycled in the production lines from where there are coming (closed loop). Old scraps, mainly those mixed, have been first recycled in different production lines (open loop) :steel deoxidation products followed during the 30's, with the development of the foundry alloys, by foundry pieces of which the main market is the automotive industry. During the 80's, the commercial development of the beverage can in North America has permitted the first old scrap recycling closed loop which is developing. v) an economy with low and erratic margins because the electrolytic aluminium quotation fixes scrap purchasing price and recycled aluminium selling price. vi) an industrial organisation historically based on the scrap group and the loop mode. New scrap is recycled either by the transformation industry itself or by the recycling industry, the remelter, old scrap by the refiner, the other component of the recycling industry. The big companies, the "majors" are often involved in the closed loop recycling and very seldom in the open loop one. To-day, aluminium industry's global energetic and environmental prints are too unbeara~ e and the sustainaЫe development criteria are not fully met. Critical issues for the aluminium industry are to better produce, to better consume and to better recycle in order to become a real sustainaЫe development industry. Specific issues to recycling are a very efficient recycling industry, a "sustainaЫe development" economy, a complete old scrap collect favouring the closed loop. Also, indirectly connected to the recycling, are a very efficient transformation industry generating much less new scrap and a finished products industry delivering only products fulfilling sustainaЫe development criteria.

Valeur ajoutée de la supervision du médecin-assistant par un médecin de famille dans une permanence [Added value of family practitioners' supervision of junior doctors in a walk-in clinic].

The pending workforce crisis in family medicine has triggered various initiatives. This article describes the PMU-FLON walk-in clinic, a project of the Institute of General Medicine University of Lausanne. The working conditions in this clinic are close to that of a family practice. Doctors in training are supervised by family doctors who work part-time in the clinic. The objective is to improve training in the various fields of family medicine, from technical skills (improving optimal use of diagnostic tools), to integrating patients' requests in a more global patient-centered approach. This new educational model allows doctors in training to benefit from the specific approaches of different trainers. It will contribute to promoting quality family medicine in the future.