Apprendre ensemble pourtravailler ensemble: l'education interprofessionnelle, un mythe ou une réalité [Learning together to work together: interprofessional education, a myth or reality?].

This article offers a review of the literature on interprofessional education (EIP), a form of education which brings together members of two or more professions in a joint training. In this course, participants gain knowledge through other professionals and about them. The goal of EIP is to improve collaboration between health professionals and the quality of patient care. The EIP is booming worldwide and seems for from a mere fad. This expansion can be explained by several factors: the increasing importance attributed to the quality of care and patient safety, care changes (aging population and increasing chronic diseases) and the shortage of health professionals. The expectations of the EIP are large, while the evidence supporting its effectiveness is being built.

Loss of ability to work and ability to live independently in Parkinson's disease.

OBJECTIVE: Ability to work and live independently is of particular concern for patients with Parkinson's disease (PD). We studied a series of PD patients able to work or live independently at baseline, and evaluated potential risk factors for two separate outcomes: loss of ability to work and loss of ability to live independently. METHODS: The series comprised 495 PD patients followed prospectively. Ability to work and ability to live independently were based on clinical interview and examination. Cox regression models adjusted for age and disease duration were used to evaluate associations of baseline characteristics with loss of ability to work and loss of ability to live independently. RESULTS: Higher UPDRS dyskinesia score, UPDRS instability score, UPDRS total score, Hoehn and Yahr stage, and presence of intellectual impairment at baseline were all associated with increased risk of future loss of ability to work and loss of ability to live independently (P ≤ 0.0033). Five years after initial visit, for patients ≤70 years of age with a disease duration ≤4 years at initial visit, 88% were still able to work and 90% to live independently. These estimates worsened as age and disease duration at initial visit increased; for patients >70 years of age with a disease duration >4 years, estimates at 5 years were 43% able to work and 57% able to live independently. CONCLUSIONS: The information provided in this study can offer useful information for PD patients in preparing for future ability to perform activities of daily living.

Dynamics of the recruitment of lateral amygdala neurons following successive fear learning to different conditional stimuli

In fear conditioning, an animal learns to associate an unconditioned stimulus (US), such as a shock, and a conditioned stimulus (CS), such as a tone, so that the presentation of the CS alone can trigger conditioned responses. Recent research on the lateral amygdala has shown that following cued fear conditioning, only a subset of higher-excitable neurons are recruited in the memory trace. Their selective deletion after fear conditioning results in a selective erasure of the fearful memory. I hypothesize that the recruitment of highly excitable neurons depends on responsiveness to stimuli, intrinsic excitability and local connectivity. In addition, I hypothesize that neurons recruited for an initial memory also participate in subsequent memories, and that changes in neuronal excitability affect secondary fear learning. To address these hypotheses, I will show that A) a rat can learn to associate two successive short-term fearful memories; B) neuronal populations in the LA are competitively recruited in the memory traces depending on individual neuronal advantages, as well as advantages granted by the local network. By performing two successive cued fear conditioning experiments, I found that rats were able to learn and extinguish the two successive short-term memories, when tested 1 hour after learning for each memory. These rats were equipped with a system of stable extracellular recordings that I developed, which allowed to monitor neuronal activity during fear learning. 233 individual putative pyramidal neurons could modulate their firing rate in response to the conditioned tone (conditioned neurons) and/or non- conditioned tones (generalizing neurons). Out of these recorded putative pyramidal neurons 86 (37%) neurons were conditioned to one or both tones. More precisely, one population of neurons encoded for a shared memory while another group of neurons likely encoded the memories' new features. Notably, in spite of a successful behavioral extinction, the firing rate of those conditioned neurons in response to the conditioned tone remained unchanged throughout memory testing. Furthermore, by analyzing the pre-conditioning characteristics of the conditioned neurons, I determined that it was possible to predict neuronal recruitment based on three factors: 1) initial sensitivity to auditory inputs, with tone-sensitive neurons being more easily recruited than tone- insensitive neurons; 2) baseline excitability levels, with more highly excitable neurons being more likely to become conditioned; and 3) the number of afferent connections received from local neurons, with neurons destined to become conditioned receiving more connections than non-conditioned neurons. - En conditionnement de la peur, un animal apprend à associer un stimulus inconditionnel (SI), tel un choc électrique, et un stimulus conditionné (SC), comme un son, de sorte que la présentation du SC seul suffit pour déclencher des réflexes conditionnés. Des recherches récentes sur l'amygdale latérale (AL) ont montré que, suite au conditionnement à la peur, seul un sous-ensemble de neurones plus excitables sont recrutés pour constituer la trace mnésique. Pour apprendre à associer deux sons au même SI, je fais l'hypothèse que les neurones entrent en compétition afin d'être sélectionnés lors du recrutement pour coder la trace mnésique. Ce recrutement dépendrait d'un part à une activation facilité des neurones ainsi qu'une activation facilité de réseaux de neurones locaux. En outre, je fais l'hypothèse que l'activation de ces réseaux de l'AL, en soi, est suffisante pour induire une mémoire effrayante. Pour répondre à ces hypothèses, je vais montrer que A) selon un processus de mémoire à court terme, un rat peut apprendre à associer deux mémoires effrayantes apprises successivement; B) des populations neuronales dans l'AL sont compétitivement recrutées dans les traces mnésiques en fonction des avantages neuronaux individuels, ainsi que les avantages consentis par le réseau local. En effectuant deux expériences successives de conditionnement à la peur, des rats étaient capables d'apprendre, ainsi que de subir un processus d'extinction, pour les deux souvenirs effrayants. La mesure de l'efficacité du conditionnement à la peur a été effectuée 1 heure après l'apprentissage pour chaque souvenir. Ces rats ont été équipés d'un système d'enregistrements extracellulaires stables que j'ai développé, ce qui a permis de suivre l'activité neuronale pendant l'apprentissage de la peur. 233 neurones pyramidaux individuels pouvaient moduler leur taux d'activité en réponse au son conditionné (neurones conditionnés) et/ou au son non conditionné (neurones généralisant). Sur les 233 neurones pyramidaux putatifs enregistrés 86 (37%) d'entre eux ont été conditionnés à un ou deux tons. Plus précisément, une population de neurones code conjointement pour un souvenir partagé, alors qu'un groupe de neurones différent code pour de nouvelles caractéristiques de nouveaux souvenirs. En particulier, en dépit d'une extinction du comportement réussie, le taux de décharge de ces neurones conditionné en réponse à la tonalité conditionnée est resté inchangée tout au long de la mesure d'apprentissage. En outre, en analysant les caractéristiques de pré-conditionnement des neurones conditionnés, j'ai déterminé qu'il était possible de prévoir le recrutement neuronal basé sur trois facteurs : 1) la sensibilité initiale aux entrées auditives, avec les neurones sensibles aux sons étant plus facilement recrutés que les neurones ne répondant pas aux stimuli auditifs; 2) les niveaux d'excitabilité des neurones, avec les neurones plus facilement excitables étant plus susceptibles d'être conditionnés au son ; et 3) le nombre de connexions reçues, puisque les neurones conditionné reçoivent plus de connexions que les neurones non-conditionnés. Enfin, nous avons constaté qu'il était possible de remplacer de façon satisfaisante le SI lors d'un conditionnement à la peur par des injections bilatérales de bicuculline, un antagoniste des récepteurs de l'acide y-Aminobutirique.

Federalism and Welfare to Work in Switzerland: The Development of Active Social Policies in a Fragmented Welfare State

This article is concerned with the impact that federal structures have on the development of welfare to work or activation policies. More precisely, it argues that the incentives and the risks associated with a division of responsibilities among different jurisdictions may constitute an obstacle to broad reforms that promote labor market participation of nonworking benefit recipients. This argument is illustrated with a case study discussing policy responses to a massive rise in caseloads among social assistance recipients in Switzerland. We conclude that the lack of a fundamental reform was the consequence of the incentives provided by the federal structure of the program. These incentives have both encouraged cost shifting among jurisdictions and discouraged involvement of federal level policy makers in a bigger reform.

Predictors of return to work after a knee injury in patients hospitalized in vocational rehabilitation

Introduction.- Knee injuries are frequent in a young and active population. Most of the patients resume their professional activity but few studies were interested in factors that predict a return to work. The aim of this study is to identify these predictors from a large panel of bio-psychosocial variables. We postulated that the return to work 3 months and 2 years after discharge is mostly predicted by psychosocial variables.Patients and methods.- Prospective study, patients hospitalized for a knee injury. Variables measured: the abbreviated injury score (AIS) for the gravity of the injuries, analog visual scale for the intensity of pain, INTERMED for the bio-psychosocial complexity, SF-36 for the quality of life, HADs for the anxiety/depression symptoms and IKDC score for the knee function. Univariate logistic regressions, adjusted for age and gender, were performed in order to predict return to work.Results.- One hundred and twenty-six patients hospitalized during 8 months after the accident were included into this prospective study. A total of 73 (58%) and 75 (59%) questionnaires were available after 3 months and 2 years, respectively. The SF-36 pain was the sole predictor of return to work at 3 months (odds Ratio 1.06 [1.02-1.10], P = 0.01; for a one point increase) and 2 years (odds Ratio 1.06 [1.02-1.10], P = 0.01). At three months, other factors are SF-36 (physic sub-scale), IKDC score, the presence of a work contract and the presence of litigation. The bio-psychosocial complexity, the presence of depressive symptoms predicts the return to work at two years.Discussion.- Our working hypothesis was partially confirmed: some psychosocial factors (i.e. depressive symptoms, work contract, litigation, INTERMED) predict the return to work but the physical health and the knee function, perceived by the patient, are also correlated. Pain is the sole factor isolated at both times (i.e. 3 months and 2 years) and, consequently, appears a key element in the prediction of the return to work. Some factors are accessible to the rehabilitation program but only if an interdisciplinary approach is performed.

The effect of recalled previous work environment on return to work after a rehabilitation program including vocational aspects for trauma patients.

INTRODUCTION: The aim of the present study was to assess the association between remembered previous work place environment and return to work (RTW) after hospitalisation in a rehabilitation hospital. METHODS: A cohort of 291 orthopedic trauma patients discharged from hospital between 15 December 2004 and 31 December 2005 was included in a study addressing quality of life and work-related questions. Remembered previous work environment was measured by Karasek's 31-item Job Content Questionnaire (JCQ), given to the patients during hospitalisation. Post-hospitalisation work status was assessed 3 months, 1, and 2 years after discharge, using a questionnaire sent to the ex-patients. Logistic regression models were used to test the role of four JCQ variables on RTW at each time point while controlling for relevant confounders. RESULTS: Subjects perceiving a higher physical demand were less likely to return to work 1 year after hospital discharge. Social support at work was positively associated with RTW at all time points. A high job strain appeared to be positively associated with RTW 1 year after rehabilitation, with limitations due to large confidence intervals. CONCLUSIONS: Perceptions of previous work environment may influence the probability of RTW. In a rehabilitation setting, efforts should be made to assess those perceptions and, if needed, interventions to modify them should be applied.

INTERMED predicts non-return to work in an occupational rehabilitation setting for individuals with orthopaedic trauma-Part I

Introduction.- Knowledge of predictors of an unfavourable outcome, e.g. non-return to work after an injury enables to identify patients at risk and to target interventions for modifiable predictors. It has been recently shown that INTERMED; a tool to measure biopsychosocial complexity in four domains (biologic, psychologic, social and care, with a score between 0-60 points) can be useful in this context. The aim of this study was to set up a predictive model for non-return to work using INTERMED in patients in vocational rehabilitation after orthopaedic injury.Patients and methods.- In this longitudinal prospective study, the cohort consisted of 2156 consecutively included inpatients with orthopaedic trauma attending a rehabilitation hospital after a work, traffic or sport related injury. Two years after discharge, a questionnaire regarding return to work was sent (1502 returned their questionnaires). In addition to INTERMED, 18 predictors known at baseline of the rehabilitation were selected based on previous research. A multivariable logistic regression was performed.Results.- In the multivariate model, not-returning to work at 2 years was significantly predicted by the INTERMED: odds-ratio (OR) 1.08 (95% confidence interval, CI [1.06; 1.11]) for a one point increase in scale; by qualified work-status before the injury OR = 0.74, CI (0.54; 0.99), by using French as preferred language OR = 0.60, CI (0.45; 0.80), by upper-extremity injury OR = 1.37, CI (1.03; 1.81), by higher education (> 9 years) OR = 0.74, CI (0.55; 1.00), and by a 10 year increase in age OR = 1.15, CI (1.02; 1.29). The area under the receiver-operator-characteristics curve (ROC)-curve was 0.733 for the full model (INTERMED plus 18 variables).Discussion.- These results confirm that the total score of the INTERMED is a significant predictor for return to work. The full model with 18 predictors combined with the total score of INTERMED has good predictive value. However, the number of variables (19) to measure is high for the use as screening tool in a clinic.

Self perceptions as predictors for return to work 2 years after rehabilitation in orthopedic trauma inpatients.

Purpose This study aimed to identify self-perception variables which may predict return to work (RTW) in orthopedic trauma patients 2 years after rehabilitation. Methods A prospective cohort investigated 1,207 orthopedic trauma inpatients, hospitalised in rehabilitation, clinics at admission, discharge, and 2 years after discharge. Information on potential predictors was obtained from self administered questionnaires. Multiple logistic regression models were applied. Results In the final model, a higher likelihood of RTW was predicted by: better general health and lower pain at admission; health and pain improvements during hospitalisation; lower impact of event (IES-R) avoidance behaviour score; higher IES-R hyperarousal score, higher SF-36 mental score and low perceived severity of the injury. Conclusion RTW is not only predicted by perceived health, pain and severity of the accident at the beginning of a rehabilitation program, but also by the changes in pain and health perceptions observed during hospitalisation.

INTERMED predicts non-return to work in an occupational rehabilitation setting for individuals with orthopaedic trauma-part 2

Introduction.- The model presented in part I (19 predictors) had good predictive values for non-return to work 2 years after vocational rehabilitation for orthopaedic trauma. However, the number of predictors is high for the detection of patients at risk in a clinic. For example, the INTERMED for itself consists of 20 questions and needs 20 minutes to be filled in. For this reason, the aim of this study was to compare the predictive value of different models for the prediction of non-return to work.Patients and methods.- In this longitudinal prospective study, the cohort consisted of 2156 included inpatients with orthopaedic trauma attending a rehabilitation hospital after a work, traffic, sport or leisure related injury. Two years after discharge, 1502 patients returned a questionnaire regarding return to work. We compared the area under the receiver-operator-characteristics curve (ROC) between different models: INTERMED total score, the 4 partial INTERMED scores, the items of the most predictive partial score; with or without confounders.Results.- The ROC for the total score of the INTERMED plus the five confounders of the of the part one (qualified work, speaking French, lesion of upper extremity, education and age) was 0.72. The sole partial INTERMED score to predict return to work was the social sub score. The ROC for the five items of the latter sub score of the INTERMED was 0.69. The ROC for the five items of the social subscale of the INTERMED combined with five predictors was 0.73. This was significantly better than the use of only the five items from INTERMED alone (delta 0.034; 95% CI 0.017 to .050). The model presented in part I (INTERMED total score plus 18 predictors) was not significantly better than the five items INTERMED social score plus five confounders.Discussion.- The use of a model with ten variables (INTERMED social five items plus five confounders) has good predictive value to detect patients not returning to work after vocational rehabilitation after orthopaedic trauma. The parsimony of this model facilitates its use in a clinic for the detection of patients at risk.

The INTERMED questionnaire for predicting return to work after a multidisciplinary rehabilitation program for chronic low back pain.

OBJECTIVES: To evaluate the performance of the INTERMED questionnaire score, alone or combined with other criteria, in predicting return to work after a multidisciplinary rehabilitation program in patients with non-specific chronic low back pain. METHODS: The INTERMED questionnaire is a biopsychosocial assessment and clinical classification tool that separates heterogeneous populations into subgroups according to case complexity. We studied 88 patients with chronic low back pain who followed an intensive multidisciplinary rehabilitation program on an outpatient basis. Before the program, we recorded the INTERMED score, radiological abnormalities, subjective pain severity, and sick leave duration. Associations between these variables and return to full-time work within 3 months after the end of the program were evaluated using one-sided Fisher tests and univariate logistic regression followed by multivariate logistic regression. RESULTS: The univariate analysis showed a significant association between the INTERMED score and return to work (P<0.001; odds ratio, 0.90; 95% confidence interval, 0.86-0.96). In the multivariate analysis, prediction was best when the INTERMED score and sick leave duration were used in combination (P=0.03; odds ratio, 0.48; 95% confidence interval, 0.25-0.93). CONCLUSION: The INTERMED questionnaire is useful for evaluating patients with chronic low back pain. It could be used to improve the selection of patients for intensive multidisciplinary programs, thereby improving the quality of care, while reducing healthcare costs.

Predicting Non Return to Work after Orthopaedic Trauma: The Wallis Occupational Rehabilitation RisK (WORRK) Model.

BACKGROUND: Workers with persistent disabilities after orthopaedic trauma may need occupational rehabilitation. Despite various risk profiles for non-return-to-work (non-RTW), there is no available predictive model. Moreover, injured workers may have various origins (immigrant workers), which may either affect their return to work or their eligibility for research purposes. The aim of this study was to develop and validate a predictive model that estimates the likelihood of non-RTW after occupational rehabilitation using predictors which do not rely on the worker's background. METHODS: Prospective cohort study (3177 participants, native (51%) and immigrant workers (49%)) with two samples: a) Development sample with patients from 2004 to 2007 with Full and Reduced Models, b) External validation of the Reduced Model with patients from 2008 to March 2010. We collected patients' data and biopsychosocial complexity with an observer rated interview (INTERMED). Non-RTW was assessed two years after discharge from the rehabilitation. Discrimination was assessed by the area under the receiver operating curve (AUC) and calibration was evaluated with a calibration plot. The model was reduced with random forests. RESULTS: At 2 years, the non-RTW status was known for 2462 patients (77.5% of the total sample). The prevalence of non-RTW was 50%. The full model (36 items) and the reduced model (19 items) had acceptable discrimination performance (AUC 0.75, 95% CI 0.72 to 0.78 and 0.74, 95% CI 0.71 to 0.76, respectively) and good calibration. For the validation model, the discrimination performance was acceptable (AUC 0.73; 95% CI 0.70 to 0.77) and calibration was also adequate. CONCLUSIONS: Non-RTW may be predicted with a simple model constructed with variables independent of the patient's education and language fluency. This model is useful for all kinds of trauma in order to adjust for case mix and it is applicable to vulnerable populations like immigrant workers.

MetaNetX/MNXref - reconciliation of metabolites and biochemical reactions to bring together genome-scale metabolic networks.

MetaNetX is a repository of genome-scale metabolic networks (GSMNs) and biochemical pathways from a number of major resources imported into a common namespace of chemical compounds, reactions, cellular compartments-namely MNXref-and proteins. The MetaNetX.org website (http://www.metanetx.org/) provides access to these integrated data as well as a variety of tools that allow users to import their own GSMNs, map them to the MNXref reconciliation, and manipulate, compare, analyze, simulate (using flux balance analysis) and export the resulting GSMNs. MNXref and MetaNetX are regularly updated and freely available.