Case management for frequent users of the emergency department: study protocol of a randomised controlled trial.

BACKGROUND: We devised a randomised controlled trial to evaluate the effectiveness and efficiency of an intervention based on case management care for frequent emergency department users. The aim of the intervention is to reduce such patients' emergency department use, to improve their quality of life, and to reduce costs consequent on frequent use. The intervention consists of a combination of comprehensive case management care and standard emergency care. It uses a clinical case management model that is patient-identified, patient-directed, and developed to provide high intensity services. It provides a continuum of hospital- and community-based patient services, which include clinical assessment, outreach referral, and coordination and communication with other service providers. METHODS/DESIGN: We aim to recruit, during the first year of the study, 250 patients who visit the emergency department of the University Hospital of Lausanne, Switzerland. Eligible patients will have visited the emergency department 5 or more times during the previous 12 months. Randomisation of the participants to the intervention or control groups will be computer generated and concealed. The statistician and each patient will be blinded to the patient's allocation. Participants in the intervention group (N = 125), additionally to standard emergency care, will receive case management from a team, 1 (ambulatory care) to 3 (hospitalization) times during their stay and after 1, 3, and 5 months, at their residence, in the hospital or in the ambulatory care setting. In between the consultations provided, the patients will have the opportunity to contact, at any moment, the case management team. Participants in the control group (N = 125) will receive standard emergency care only. Data will be collected at baseline and 2, 5.5, 9, and 12 months later, including: number of emergency department visits, quality of life (EuroQOL and WHOQOL), health services use, and relevant costs. Data on feelings of discrimination and patient's satisfaction will also be collected at the baseline and 12 months later. DISCUSSION: Our study will help to clarify knowledge gaps regarding the positive outcomes (emergency department visits, quality of life, efficiency, and cost-utility) of an intervention based on case management care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01934322.

Analyse comparée de régimes institutionnels de gestion des réseaux urbains de l'eau en station touristique de montagne : les cas de Crans-Montana (Suisse) et de Morzine-Avoriaz (France)

La station touristique représente un espace urbain consacré principalement au tourisme, tout en comprenant également une population résidente permanente. Du point de vue de la gestion des réseaux urbains de l'eau, cette caractéristique induit pour ce type de lieu des usages propres à tout espace urbain mais également des spécificités liées à la forte fluctuation saisonnière de la population résidente ou encore à la présence d'usages particuliers tels que l'irrigation des golfs, la production de neige artificielle ou le thermalisme. Dès lors, la planification de l'approvisionnement est délicate et peu prévisible. Ces difficultés sont renforcées par le fait que les concentrations temporelles de la demande coïncident généralement avec des périodes de stress hydrique notable. Dans le cas de stations balnéaires, les pics de fréquentation interviennent en général durant l'été lorsque la ressource en eau est peu disponible. Le problème est similaire dans les stations touristiques de montagne où l'eau est généralement indisponible car stockée sous forme de neige durant les mois de forte fréquentation. De plus, ces difficultés sont souvent renforcées par la localisation géographique des stations touristiques, fréquemment situées dans des espaces sensibles du point de vue de la ressource en eau, avec des situations de pénuries temporelles, voire structurelles. Ces problématiques propres à la plupart des stations touristiques mènent souvent à de fortes rivalités entre, d'une part, les différents usages touristiques de la ressource, et d'autre part, les usages autochtones et touristiques. Les particularités liées au tourisme tendent ainsi à renforcer les rivalités entre différents types de secteurs d'activité (approvisionnement en eau potable, tourisme, hydroélectricité, enneigement artificiel, irrigation, etc.). Ces différents usages de la ressource mis en concurrence nécessitent dès lors la mise en oeuvre de réglementations structurées à travers des politiques publiques ainsi que des droits de propriété et selon des composantes nationales, régionales et locales ; soit un cadre institutionnel que nous proposons d'appeler Régime Institutionnel de Ressource (RIR) (Knoepfel et al. 2001, 2007). A travers cette thèse de doctorat, nous répondons à différentes questions de recherche. Nous tentons d'abord de comprendre comment ces différents RIR sont-ils mis en oeuvre dans le cadre d'espaces touristiques ? Comment ceux-ci sont-ils concrétisés par les acteurs et quels sont leurs effets en termes de durabilité technique, environnementale, sociale et économique des réseaux urbains de l'eau ? Nous questionnons ensuite les effets du tourisme sur la gestion des infrastructures de réseau à l'échelle de la station touristique et de son bassin versant et nous interrogeons sur les effets du tourisme en termes de gestion des eaux urbaines. Nous portons notre attention sur deux stations touristiques situées dans deux contextes institutionnels différents (Crans-Montana en Suisse et Morzine-Avoriaz en France) et y étudions trois types de régimes institutionnels en particulier : la régie directe (gestion publique), l'affermage (gestion déléguée) et la gestion privée des infrastructures. Les résultats de cette thèse de doctorat indiquent tout d'abord dans quelle mesure le tourisme modifie de façon significative la perception et les modalités de gestion de la ressource en eau et des infrastructures. Ils montrent ensuite que l'espace fonctionnel de la gestion de ces infrastructures correspond rarement aux limites du réseau hydrographique naturel et quelles en sont les implications en termes de durabilité. Enfin, la comparaison de différents régimes institutionnels révèle les forces et les faiblesses de chaque modèle de gestion dans le cas spécifique des stations touristiques et également les différentes solutions adoptées localement pour la mise en oeuvre d'un arrangement institutionnel permettant un usage plus ou moins durable des infrastructures de réseau et du réseau hydrographique naturel. - Tourism resort represents an urban area mainly dedicated to tourism while including at the same time a permanent residential population. From the point of view of urban water networks, this characteristic induces a strong seasonal fluctuation of residential population and involves special water uses such as golf irrigation, production of artificial snow or functioning of thermal baths. Therefore, water supply planning can be tricky and difficult to predict. These difficulties are reinforced by the fact that temporary concentrations of water demand coïncidé generally with periods of water stress. In the case of seaside resorts, frequenting peaks arise in general during summer when water resource is less available. The problem is similar in mountainous tourist resorts where water is generally unavailable as it is stored as snow during months of highest frequenting. Furthermore, these difficulties are often reinforced by resorts' geographical localisations, which are often situated in sensitive areas in terms of temporary or structural water shortages. These problematic issues often lead to strong rivalries between tourists' water uses on the one hand, and between locals and tourists uses on the other hand. Thus, features of tourism tend to reinforce rivalries between different sectors of activity (supply of drinking water, tourism, hydroelectricity, artificial snow, irrigation, etc.). These different and competing water uses need the implementation of rules structured through public policies and property rights and through national, regional and local legal components; We propose to call this framework as an Institutional Resource Regime (IRR) (Knoepfel et al. 2001, 2007, 2009). Through this PhD thesis, we answer different research questions. We firstly aim to understand how those different IRR are implemented within tourism spaces? How do actors materialize them and what are their effects in term of technical, environmental, social and economical sustainability of urban water networks? We then, investigate effects of tourism on water networks infrastructures' management at the scale of the tourist resort and its river basin. We focus our attention on two tourist resorts situated within two different institutional contexts (Crans-Montana, Switzerland and Morzine-Avoriaz, France) and study three types of institutional regime in particular: public, delegated and private management of infrastructures. Results of this PhD thesis indicate firstly how tourism modifies in a significant way the perception and management modalities of water resource and infrastructures. Results also show that functional space of infrastructures management rarely matches with the limits of the natural river basin and indicates what it means in terms of sustainability. Finally, the comparison of different institutional regimes reveals the strengths and weakness of each management model in the specific case of tourist resorts and shows the different solutions in locally implementing an institutional arrangement for a more or less sustainable management of network infrastructures and natural water system.

State power and protected areas: Dynamics and contradictions of forest conservation in Madhya Pradesh, India

The traditionally coercive and state-controlled governance of protected areas for nature conservation in developing countries has in many cases undergone change in the context of widespread decentralization and liberalization. This article examines an emerging "mixed" (coercive, community- and market-oriented) conservation approach in managed-resource protected areas and its effects on state power through a case study on forest protection in the central Indian state of Madhya Pradesh. The findings suggest that imperfect decentralization and partial liberalization resulted in changed forms, rather than uniform loss, of state power. A forest co-management program paradoxically strengthened local capacity and influence of the Forest Department, which generally maintained its territorial and knowledge-based control over forests and timber management. Furthermore, deregulation and reregulation enabled the state to withdraw from uneconomic activities but also implied reduced place-based control of non-timber forest products. Generally, the new policies and programs contributed to the separation of livelihoods and forests in Madhya Pradesh. The article concludes that regulatory, community- and market-based initiatives would need to be better coordinated to lead to more effective nature conservation and positive livelihood outcomes.

Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism.

Background: In haemodynamically stable patients with acute symptomatic pulmonary embolism (PE), studies have not evaluated the usefulness of combining the measurement of cardiac troponin, transthoracic echocardiogram (TTE), and lower extremity complete compression ultrasound (CCUS) testing for predicting the risk of PE-related death. Methods: The study assessed the ability of three diagnostic tests (cardiac troponin I (cTnI), echocardiogram, and CCUS) to prognosticate the primary outcome of PE-related mortality during 30 days of follow-up after a diagnosis of PE by objective testing. Results: Of 591 normotensive patients diagnosed with PE, the primary outcome occurred in 37 patients (6.3%; 95% CI 4.3% to 8.2%). Patients with right ventricular dysfunction (RVD) by TTE and concomitant deep vein thrombosis (DVT) by CCUS had a PE-related mortality of 19.6%, compared with 17.1% of patients with elevated cTnI and concomitant DVT and 15.2% of patients with elevated cTnI and RVD. The use of any two-test strategy had a higher specificity and positive predictive value compared with the use of any test by itself. A combined three-test strategy did not further improve prognostication. For a subgroup analysis of high-risk patients, according to the pulmonary embolism severity index (classes IV and V), positive predictive values of the two-test strategies for PE-related mortality were 25.0%, 24.4% and 20.7%, respectively. Conclusions: In haemodynamically stable patients with acute symptomatic PE, a combination of echocardiography (or troponin testing) and CCUS improved prognostication compared with the use of any test by itself for the identification of those at high risk of PE-related death.

Forensic processing of false identity and travel documents to produce intelligence: a novel approach to assist in fighting organized crime

The production and use of false identity and travel documents in organized crime represent a serious and evolving threat. However, a case-by-case perspective, thus suffering from linkage blindness and a limited analysis capacity, essentially drives the present-day fight against this criminal problem. To assist in overcoming these limitations, a process model was developed using a forensic perspective. It guides the systematic analysis and management of seized false documents to generate forensic intelligence that supports strategic and tactical decision-making in an intelligence-led policing approach. The model is articulated on a three-level architecture that aims to assist in detecting and following-up on general trends, production methods and links between cases or series. Using analyses of a large dataset of counterfeit and forged identity and travel documents, it is possible to illustrate the model, its three levels and their contribution. Examples will point out how the proposed approach assists in detecting emerging trends, in evaluating the black market's degree of structure, in uncovering criminal networks, in monitoring the quality of false documents, and in identifying their weaknesses to orient the conception of more secured travel and identity documents. The process model proposed is thought to have a general application in forensic science and can readily be transposed to other fields of study.

Combined CSL and p53 downregulation promotes cancer-associated fibroblast activation.

Stromal fibroblast senescence has been linked to ageing-associated cancer risk. However, density and proliferation of cancer-associated fibroblasts (CAFs) are frequently increased. Loss or downmodulation of the Notch effector CSL (also known as RBP-Jκ) in dermal fibroblasts is sufficient for CAF activation and ensuing keratinocyte-derived tumours. We report that CSL silencing induces senescence of primary fibroblasts from dermis, oral mucosa, breast and lung. CSL functions in these cells as a direct repressor of multiple senescence- and CAF-effector genes. It also physically interacts with p53, repressing its activity. CSL is downmodulated in stromal fibroblasts of premalignant skin actinic keratosis lesions and squamous cell carcinomas, whereas p53 expression and function are downmodulated only in the latter, with paracrine FGF signalling as the probable culprit. Concomitant loss of CSL and p53 overcomes fibroblast senescence, enhances expression of CAF effectors and promotes stromal and cancer cell expansion. The findings support a CAF activation-stromal co-evolution model under convergent CSL-p53 control.

A multistep process of cancer associated fibroblasts determination under CSL-p53 control

Stromal fibroblast senescence has been linked to the aging-associated increase of tumors. However, in epithelial cancer, density and proliferation of cancer associated fibroblasts (CAF) are frequently increased, rather than decreased. We previously showed that genetic deletion or down-modulation of the canonical Notch effector CSL/RBP-JK in dermal fibroblasts is sufficient for CAF activation with consequent development of keratinocyte-derived tumors. We show here that CSL silencing induces senescence of primary fibroblasts from dermis, oral mucosa, breast and lung. CSL functions in these cells as direct repressor of multiple senescence- and CAF-effector genes. It also physically interacts with p53, repressing its activity. CSL is down-modulated in stromal fibroblasts of premalignant skin actinic keratosis lesions and squamous cell carcinomas (SCC), while p53 gene expression and function is down-modulated only in the latter, with paracrine influences of incipient cancer cells as a likely culprit. Concomitant loss of CSL and p53 overcomes fibroblast senescence, enhances CAF effector gene expression and promotes stromal and cancer cell expansion. The findings support a CAF activation/stromal co-evolution model under convergent CSL/p53 control of likely clinical relevance.

Respecting the deal: Economically sustainable management of open innovation among co-opeting companies

Platforms like eBay allow product seekers and providers to meet and exchange goods. On eBay, consumers can return a product if it does not correspond to expectations; eBay is the third-party firm in charge of assuring that the agreement among seekers and providers will be respected. Who provides the same service for what concerns open innovation, where specifications might not fully defined? This paper describes the business model of an organizational structure to support the elicitation and respect of agreements among agents, who have conflicting interests but that gain from cooperating together. Extending previous studies, our business model takes into account the economic dimensions concerning the needs of knowledge share and mutual control to allow a third-party to sustainably reinforce trust among untrusted partners and to lower their overall relational risk.

Will climate change drive alien invasive plants into areas of high protection value? An improved model-based regional assessment to prioritise the management of invasions.

Species distribution models (SDMs) studies suggest that, without control measures, the distribution of many alien invasive plant species (AIS) will increase under climate and land-use changes. Due to limited resources and large areas colonised by invaders, management and monitoring resources must be prioritised. Choices depend on the conservation value of the invaded areas and can be guided by SDM predictions. Here, we use a hierarchical SDM framework, complemented by connectivity analysis of AIS distributions, to evaluate current and future conflicts between AIS and high conservation value areas. We illustrate the framework with three Australian wattle (Acacia) species and patterns of conservation value in Northern Portugal. Results show that protected areas will likely suffer higher pressure from all three Acacia species under future climatic conditions. Due to this higher predicted conflict in protected areas, management might be prioritised for Acacia dealbata and Acacia melanoxylon. Connectivity of AIS suitable areas inside protected areas is currently lower than across the full study area, but this would change under future environmental conditions. Coupled SDM and connectivity analysis can support resource prioritisation for anticipation and monitoring of AIS impacts. However, further tests of this framework over a wide range of regions and organisms are still required before wide application.

MRI visualized neo-intimal dissection and co-localization of novel apoptotic markers apolipoprotein C-1, ceramide and caspase-3 in a Watanabe hyperlipidemic rabbit model

PURPOSE: Apoptotic arterial wall vascular smooth muscle cell death is known to contribute to plaque vulnerability and rupture. Novel apoptotic markers like apolipoprotein C-I have been implicated in apoptotic human vascular smooth muscle cell death via recruiting a neutral sphingomyelinase (N-SMase)-ceramide pathway. In vivo relevance of these observations in an animal model of plaque rupture has not been shown. METHODS AND RESULTS: Using Watanabe rabbits, we investigated three different groups (group 1, three normal Watanabe rabbits; group 2, six Watanabe rabbits fed with high cholesterol diet for 3 months; group 3, five Watanabe rabbits with similar diet but additional endothelial denudation). We followed progression of atherosclerosis to pharmacologically induced plaque rupture non-invasively using novel 3D magnetic resonance Fast-Field-Echo angiography (TR=7.2, TE=3.6 ms, matrix=512 x 512) and Fast-Spin-Echo vessel wall imaging methods (TR=3 heart beats, TE=10.5 ms, matrix=304 x 304) on 1.5 T MRI. MRI provided excellent image quality with good MRI versus histology vessel wall thickness correlation (r=0.8). In six animals of group 2/3 MRI detected neo-intimal dissection in the abdominal aorta which was accompanied by immuno-histochemical demonstration of concomitant aforementioned novel apoptotic markers, previously implicated in the apoptotic smooth muscle cell death in vitro. CONCLUSIONS: Our studies suggest a potential role for the signal transduction pathway involving apolipoprotein C-I for in vivo apoptosis and atherosclerotic plaque rupture visualized by MRI.

Exposition de l'enfant a des violences domestiques. Un modèle pluridisciplinaire de détection, d'evaluation et de prise en charge [Children's exposure to domestic violence. A multidisciplinary model of detection, assessment and management].

Children psychological abuse is difficult to identify. However, its consequences on child development can be as serious as physical and sexual abuses. It is therefore essential, to implement in our hospitals, structures whose missions are successively to detect victims, evaluate them on somatic and psychological levels, and elaborate a therapy. We propose a model for the achievement of these objectives through collaboration between the Medical Unit of Violence, the Pediatric CAN Team and the Unit of Les Boréales.

MORM--a Petri net based model for assessing OH&S risks in industrial processes: modeling qualitative aspects.

Because of the increase in workplace automation and the diversification of industrial processes, workplaces have become more and more complex. The classical approaches used to address workplace hazard concerns, such as checklists or sequence models, are, therefore, of limited use in such complex systems. Moreover, because of the multifaceted nature of workplaces, the use of single-oriented methods, such as AEA (man oriented), FMEA (system oriented), or HAZOP (process oriented), is not satisfactory. The use of a dynamic modeling approach in order to allow multiple-oriented analyses may constitute an alternative to overcome this limitation. The qualitative modeling aspects of the MORM (man-machine occupational risk modeling) model are discussed in this article. The model, realized on an object-oriented Petri net tool (CO-OPN), has been developed to simulate and analyze industrial processes in an OH&S perspective. The industrial process is modeled as a set of interconnected subnets (state spaces), which describe its constitutive machines. Process-related factors are introduced, in an explicit way, through machine interconnections and flow properties. While man-machine interactions are modeled as triggering events for the state spaces of the machines, the CREAM cognitive behavior model is used in order to establish the relevant triggering events. In the CO-OPN formalism, the model is expressed as a set of interconnected CO-OPN objects defined over data types expressing the measure attached to the flow of entities transiting through the machines. Constraints on the measures assigned to these entities are used to determine the state changes in each machine. Interconnecting machines implies the composition of such flow and consequently the interconnection of the measure constraints. This is reflected by the construction of constraint enrichment hierarchies, which can be used for simulation and analysis optimization in a clear mathematical framework. The use of Petri nets to perform multiple-oriented analysis opens perspectives in the field of industrial risk management. It may significantly reduce the duration of the assessment process. But, most of all, it opens perspectives in the field of risk comparisons and integrated risk management. Moreover, because of the generic nature of the model and tool used, the same concepts and patterns may be used to model a wide range of systems and application fields.

Chronic disease management programmes for adults with asthma (intervention Review)

BACKGROUND: The burden of asthma on patients and healthcare systems is substantial. Interventions have been developed to overcome difficulties in asthma management. These include chronic disease management programmes, which are more than simple patient education, encompassing a set of coherent interventions that centre on the patients' needs, encouraging the co-ordination and integration of health services provided by a variety of healthcare professionals, and emphasising patient self-management as well as patient education. OBJECTIVES: To evaluate the effectiveness of chronic disease management programmes for adults with asthma. SEARCH METHODS: Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, MEDLINE (MEDLINE In-Process and Other Non-Indexed Citations), EMBASE, CINAHL, and PsycINFO were searched up to June 2014. We also handsearched selected journals from 2000 to 2012 and scanned reference lists of relevant reviews. SELECTION CRITERIA: We included individual or cluster-randomised controlled trials, non-randomised controlled trials, and controlled before-after studies comparing chronic disease management programmes with usual care in adults over 16 years of age with a diagnosis of asthma. The chronic disease management programmes had to satisfy at least the following five criteria: an organisational component targeting patients; an organisational component targeting healthcare professionals or the healthcare system, or both; patient education or self-management support, or both; active involvement of two or more healthcare professionals in patient care; a minimum duration of three months. DATA COLLECTION AND ANALYSIS: After an initial screen of the titles, two review authors working independently assessed the studies for eligibility and study quality; they also extracted the data. We contacted authors to obtain missing information and additional data, where necessary. We pooled results using the random-effects model and reported the pooled mean or standardised mean differences (SMDs). MAIN RESULTS: A total of 20 studies including 81,746 patients (median 129.5) were included in this review, with a follow-up ranging from 3 to more than 12 months. Patients' mean age was 42.5 years, 60% were female, and their asthma was mostly rated as moderate to severe. Overall the studies were of moderate to low methodological quality, because of limitations in their design and the wide confidence intervals for certain results.Compared with usual care, chronic disease management programmes resulted in improvements in asthma-specific quality of life (SMD 0.22, 95% confidence interval (CI) 0.08 to 0.37), asthma severity scores (SMD 0.18, 95% CI 0.05 to 0.30), and lung function tests (SMD 0.19, 95% CI 0.09 to 0.30). The data for improvement in self-efficacy scores were inconclusive (SMD 0.51, 95% CI -0.08 to 1.11). Results on hospitalisations and emergency department or unscheduled visits could not be combined in a meta-analysis because the data were too heterogeneous; results from the individual studies were inconclusive overall. Only a few studies reported results on asthma exacerbations, days off work or school, use of an action plan, and patient satisfaction. Meta-analyses could not be performed for these outcomes. AUTHORS' CONCLUSIONS: There is moderate to low quality evidence that chronic disease management programmes for adults with asthma can improve asthma-specific quality of life, asthma severity, and lung function tests. Overall, these results provide encouraging evidence of the potential effectiveness of these programmes in adults with asthma when compared with usual care. However, the optimal composition of asthma chronic disease management programmes and their added value, compared with education or self-management alone that is usually offered to patients with asthma, need further investigation.