Le soignant face au patient lombalgique chronique: l'expérience clinique de l'Unité Rachis à l'Hôpital orthopédique [The health professional's approach to chronic lumbago: clinical experience at the Spinal Cord Unit at the orthopedic hospital]

The treatment of back pain patients refers to the biopsychosocial model of care. This model includes illness in patient's personal and relational life. In this context, it is not only the physical symptom of the patient which is focused but also his psychological distress often hidden by algic complain. Clinical interviews conducted with back pain patients have highlighted psychosocial aspects able to influence the relationship between health care user and provider. Taking account of psychosocial aspects implies an interdisciplinary approach that identify and assesses patients' needs through adequate tools. As a result, the different health care providers implied with back pain patients have to collaborate in a structured network.

Patients with non-insulin depending diabetes mellitus and metabolic syndrome are suboptimal treated in swiss primary care.

The prevalence of complicated hypertension is increasing in America and Europe. This survey was undertaken to assess the status quo of primary care management of hypertension in patients with the high-risk comorbid diseases metabolic syndrome (MetS) and/or type 2 diabetes mellitus (non-insulin depending diabetes mellitus (NIDDM)). Data of anti-hypertensive treatment of 4594 Swiss patients were collected over 1 week. We identified patients with exclusively NIDDM (N = 95), MetS (N = 168), and both (N = 768). Target blood pressure (TBP) attainment, frequency of prescribed substance-classes, and correlations to comorbidities/end-organ damages were assessed. In addition, we analyzed the prescription of unfavorable beta-blockers (BB) and high-dose diuretics (Ds). In NIDDM, Ds (61%), angiotensin receptor blockers (ARBs) (40%), and angiotensin converting enzyme inhibitors (ACEIs) (31%) were mostly prescribed, while in MetS, drugs prevalence was Ds (68%), ARBs (48%), and BB (41%). Polypharmacy in patients with MetS correlated with body mass index; older patients (>65 years) were more likely to receive dual-free combinations. TBP was attained in 25.2% of NIDDM and in 28.7% of MetS patients. In general, low-dose Ds use was more prevalent in NIDDM and MetS, however, overall, Ds were used excessively (NIDDM: 61%, MetS: 68%), especially in single-pill combination. Patients with MetS were more likely to receive ARBs, ACEIs, CCBs, and low-dose Ds than BBs and/or high-dose Ds. Physicians recognize DM and MetS as high-risk patients, but select inappropriate drugs. Because the majority of patients may have both, MetS and NIDDM, there is an unmet need to define TBP for this specific population considering the increased risk in comparison to patients with MetS or NIDDM alone.

Se former à l'entretien motivationnel pour aider ses patients à changer: Les étudiants en médecine le confirment [Learning motivational interviewing to help patients change their health-related behaviors: medical students confirm it].

At the Lausanne University, 5th year medical students were trained in Motivational interviewing (MI). Eight hours of training improved their competence in the use of this approach. This experience supports the implementation of MI training in medical schools. Motivational interviewing allows the health professional to actively involve the patient in this behavior change process (drinking, smoking, diet, exercise, medication adherence, etc.), by encouraging reflection and reinforcing personal motivation and resources.

Adherence: the journey of medication taking, are we there yet?

Patient adherence to medications has been an issue challenging healthcare professionals for decades. Adherence rates, causes of non-adherence, barriers and enablers to medication taking, interventions to promote adherence, and the impact of non-adherence on health outcomes, have been extensively studied. In light of this, the area of adherence research has progressed conceptually and practically. This special issue contains a range of articles which focus on different aspects of adherence, from standardising terminology and methods of measurement, to non-adherence in a broad range of patient populations, and to interventions to promote adherence.

Basal insulin and cardiovascular and other outcomes in dysglycemia.

BACKGROUND: The provision of sufficient basal insulin to normalize fasting plasma glucose levels may reduce cardiovascular events, but such a possibility has not been formally tested. METHODS: We randomly assigned 12,537 people (mean age, 63.5 years) with cardiovascular risk factors plus impaired fasting glucose, impaired glucose tolerance, or type 2 diabetes to receive insulin glargine (with a target fasting blood glucose level of ≤95 mg per deciliter [5.3 mmol per liter]) or standard care and to receive n-3 fatty acids or placebo with the use of a 2-by-2 factorial design. The results of the comparison between insulin glargine and standard care are reported here. The coprimary outcomes were nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes and these events plus revascularization or hospitalization for heart failure. Microvascular outcomes, incident diabetes, hypoglycemia, weight, and cancers were also compared between groups. RESULTS: The median follow-up was 6.2 years (interquartile range, 5.8 to 6.7). Rates of incident cardiovascular outcomes were similar in the insulin-glargine and standard-care groups: 2.94 and 2.85 per 100 person-years, respectively, for the first coprimary outcome (hazard ratio, 1.02; 95% confidence interval [CI], 0.94 to 1.11; P=0.63) and 5.52 and 5.28 per 100 person-years, respectively, for the second coprimary outcome (hazard ratio, 1.04; 95% CI, 0.97 to 1.11; P=0.27). New diabetes was diagnosed approximately 3 months after therapy was stopped among 30% versus 35% of 1456 participants without baseline diabetes (odds ratio, 0.80; 95% CI, 0.64 to 1.00; P=0.05). Rates of severe hypoglycemia were 1.00 versus 0.31 per 100 person-years. Median weight increased by 1.6 kg in the insulin-glargine group and fell by 0.5 kg in the standard-care group. There was no significant difference in cancers (hazard ratio, 1.00; 95% CI, 0.88 to 1.13; P=0.97). CONCLUSIONS: When used to target normal fasting plasma glucose levels for more than 6 years, insulin glargine had a neutral effect on cardiovascular outcomes and cancers. Although it reduced new-onset diabetes, insulin glargine also increased hypoglycemia and modestly increased weight. (Funded by Sanofi; ORIGIN ClinicalTrials.gov number, NCT00069784.).

Older people's views of falls-prevention interventions in six European countries.

PURPOSE: Our study identified factors common to a variety of populations and settings that may promote or inhibit uptake and adherence to falls-related interventions. DESIGN AND METHODS: Semistructured interviews to assess perceived advantages and barriers to taking part in falls-related interventions were carried out in six European countries with 69 people aged 68 to 97 years. The sample was selected to include people with very different experiences of participation or nonparticipation in falls-related interventions, but all individuals were asked about interventions that included strength and balance training. RESULTS: Attitudes were similar in all countries and contexts. People were motivated to participate in strength and balance training by a wide range of perceived benefits (interest and enjoyment, improved health, mood, and independence) and not just reduction of falling risk. Participation also was encouraged by a personal invitation from a health practitioner and social approval from family and friends. Barriers to participation included denial of falling risk, the belief that no additional falls-prevention measures were necessary, practical barriers to attendance at groups (e.g., transport, effort, and cost), and a dislike of group activities. IMPLICATIONS: Because many older people reject the idea that they are at risk of falling, the uptake of strength and balance training programs may be promoted more effectively by maximizing and emphasizing their multiple positive benefits for health and well-being. A personal invitation from a health professional to participate is important, and it also may be helpful to provide home-based programs for those who dislike or find it difficult to attend groups.

Role and therapeutic potential of microRNAs in diabetes.

The discovery in mammalian cells of hundreds of small RNA molecules, called microRNAs, with the potential to modulate the expression of the majority of the protein-coding genes has revolutionized many areas of biomedical research, including the diabetes field. MicroRNAs function as translational repressors and are emerging as key regulators of most, if not all, physiological processes. Moreover, alterations in the level or function of microRNAs are associated with an increasing number of diseases. Here, we describe the mechanisms governing the biogenesis and activities of microRNAs. We present evidence for the involvement of microRNAs in diabetes mellitus, by outlining the contribution of these small RNA molecules in the control of pancreatic beta-cell functions and by reviewing recent studies reporting changes in microRNA expression in tissues isolated from diabetes animal models. MicroRNAs hold great potential as therapeutic targets. We describe the strategies developed for the delivery of molecules mimicking or blocking the function of these tiny regulators of gene expression in living animals. In addition, because changes in serum microRNA profiles have been shown to occur in association with different human diseases, we also discuss the potential use of microRNAs as blood biomarkers for prevention and management of diabetes.

Lack of thermogenic response to glucose/insulin infusion in diabetic obese subjects.

The change in energy expenditure consecutive to the infusion of glucose/insulin was examined in 17 non-obese (ten young, seven middle-aged) and 27 diabetic and non-diabetic obese subjects by employing the euglycemic insulin clamp technique in conjunction with continuous indirect calorimetry. The obese subjects were divided into four groups according to their response to a 100-g oral glucose test: group A, normal glucose tolerance; group B, impaired glucose tolerance; group C, diabetes with increased insulin response; group D, diabetes with reduced insulin response. The glucose/insulin infusion provoked an increase in energy expenditure in both young and middle-aged controls (+8.2 +/- 1.3 percent and +5.9 +/- 0.5 percent over the preinfusion baseline respectively), but a lower increase in the non-diabetic obese groups A and B (+4.0 +/- 0.7 percent and +2.0 +/- 1.0 percent over the preinfusion baseline respectively, P less than 0.05 and P less than 0.01 vs young controls). However, in the diabetic obese groups C and D, energy expenditure failed to increase in response to the glucose/insulin infusion (mean change: +0.1 +/- 1.0 percent and -2.0 +/- 1.9 percent (P less than 0.01, vs middle-aged) over the preinfusion baseline respectively). When the glucose-induced thermogenesis (GIT) was related to the glucose uptake--taking into account the hepatic glucose production--the GIT was found to be similarly reduced in the diabetics groups (C and D). The net change in the rate of energy expenditure was found to be significantly correlated with the rate of glucose uptake (r = +0.647, n = 44, P less than 0.001) when all the individuals were pooled. In conclusion, this study shows that the low glucose-induced thermogenesis in obese diabetics during glucose insulin infusion is mainly related to a reduced rate of glucose uptake; in addition, inhibition of gluconeogenesis by the glucose/insulin infusion may also contribute to decrease the thermogenic response.

The required beta cell research for improving treatment of type 2 diabetes.

In healthy individuals, insulin resistance is associated with physiological conditions such as pregnancy or body weight gain and triggers an increase in beta cell number and insulin secretion capacity to preserve normoglycaemia. Failure of this beta cell compensation capacity is a fundamental cause of diabetic hyperglycaemia. Incomplete understanding of the molecular mechanisms controlling the plasticity of adult beta cells mechanisms and how these cells fail during the pathogenesis of diabetes strongly limits the ability to develop new beta cell-specific therapies. Here, current knowledge of the signalling pathways controlling beta cell plasticity is reviewed, and possible directions for future research are discussed.

Diabetes mellitus, a microRNA-related disease?

Diabetes mellitus is a complex disease resulting in altered glucose homeostasis. In both type 1 and type 2 diabetes mellitus, pancreatic β cells cannot secrete appropriate amounts of insulin to regulate blood glucose level. Moreover, in type 2 diabetes mellitus, altered insulin secretion is combined with a resistance of insulin-target tissues, mainly liver, adipose tissue, and skeletal muscle. Both environmental and genetic factors are known to contribute to the development of the disease. Growing evidence indicates that microRNAs (miRNAs), a class of small noncoding RNA molecules, are involved in the pathogenesis of diabetes. miRNAs function as translational repressors and are emerging as important regulators of key biological processes. Here, we review recent studies reporting changes in miRNA expression in tissues isolated from different diabetic animal models. We also describe the role of several miRNAs in pancreatic β cells and insulin-target tissues. Finally, we discuss the possible use of miRNAs as blood biomarkers to prevent diabetes development and as tools for gene-based therapy to treat both type 1 and type 2 diabetes mellitus.

Transition from pediatric to adult health care: expectations of adolescents with chronic disorders and their parents.

The aim of this study was to assess the expectations of adolescents with chronic disorders with regard to transition from pediatric to adult health care and to compare them with the expectations of their parents. A cross-sectional study was carried out including 283 adolescents with chronic disorders, aged 14-25 years (median age, 16.0 years), and not yet transferred to adult health care, and their 318 parents from two university children's hospitals. The majority of adolescents and parents (64%/70%) perceived the ages of 18-19 years and older as the best time to transfer to adult health care. Chronological age and feeling too old to see a pediatrician were reported as the most important decision factors for the transfer while the severity of the disease was not considered important. The most relevant barriers were feeling at ease with the pediatrician (45%/38%), anxiety (20%/24%), and lack of information about the adult specialist and health care (18%/27%). Of the 51% of adolescents with whom the pediatric specialist had spoken about the transfer, 53% of adolescents and 69% of parents preferred a joint transfer meeting with the pediatric and adult specialist, and 24% of these adolescents declared that their health professional had offered this option. In summary, the age preference for adolescents with chronic disorders and their parents to transfer to adult health care was higher than the upper age limits for admission to pediatric health care in many European countries. Anxiety and a lack of information of both adolescents and their parents were among the most important barriers for a smooth and timely transfer according to adolescents and parents.

The Dyadic and Triadic Therapeutic Alliance in Cross-cultural Health Care: The case of Hispanic American Patients

This research project conducted in the Psychology Department of the University of Lausanne (Switzerland) evaluated the therapeutic alliance with Hispanic American Patients. From the patient's perspective, the therapeutic alliance was explored in two types of frameworks: the dyadic and the triadic setting. The dyadic setting is the encounter between a therapist (health professional) and a patient who ideally share the same language. The triadic setting is the encounter of a therapist and a patient who speak different languages, but are able to interact using the help of an interpreter. My specific interest focuses on studying the therapeutic alliance in a cross- cultural setting through a mixed methodology. As part of the quantitative phase, non- parametric tests were used to analyze 55 questionnaires of the Therapeutic Alliance for Migrants - Health Professionals' version (QALM-PS). For the qualitative phase, a thematic analysis was used to analyze 20 transcript interviews. While no differences were found concerning the strength of the therapeutic alliance between the triadic and dyadic settings, results showed that the factors that enrich the therapeutic alliance with migrant patients depend more on an emotional alliance (bond) than on a rational alliance (agreements). Indeed, the positive relationship with the interpreter, and especially with the therapist, relies considerably on human qualities and moral values, bringing the conception of humanity as an important need when meeting foreign patients in health care settings. In addition, the quality of communication, which could be attributed to the type of interpreter in the triadic setting, plays an important role in the establishment of a positive therapeutic relationship. Ce projet de recherche mené au Département de psychologie de l'Université de Lausanne (Suisse) a évalué l'alliance thérapeutique avec les patients hispano-américains. Du point de vue du patient, l'alliance thérapeutique a été étudiée dans deux types de dispositifs: le cadre dyadique et triadique. Le cadre dyadique est la rencontre d'un thérapeute (professionnel de la santé) et d'un patient qui, idéalement, partagent la même langue. Le cadre triadique est la rencontre d'un thérapeute et d'un patient qui parlent différentes langues, mais sont capables d'interagir grâce à l'aide d'un interprète. Mon intérêt porte en particulier sur l'étude de l'alliance thérapeutique dans un cadre interculturel au travers d'une méthodologie mixte. Dans la phase quantitative, des tests non paramétriques ont été utilisés pour les analyses des 55 questionnaires de l'alliance thérapeutique pour les migrants, version - professionnels de la santé (QALM-PS). Pour la phase qualitative, une analyse thématique a été utilisée pour l'analyse des 20 entretiens transcrits. Bien qu'aucune différence n'a été constatée en ce qui concerne la force de l'alliance thérapeutique entre les cadres dyadiques et triadiques, les résultats montrent que les facteurs qui enrichissent l'alliance thérapeutique avec les patients migrants dépendent plus de l'alliance émotionnelle (lien) que sur une alliance rationnelle (accords). En effet, la relation positive avec l'interprète, et en particulier avec le thérapeute, repose en grande partie sur des qualités humaines et des valeurs morales, ce qui porte la conception de l'humanité comme un besoin important lors de la rencontre des patients étrangers dans un cadre de santé. En outre, la qualité de la communication, qui pourrait être attribuée au type d'interprète dans le cadre triadique, joue un rôle important dans l'établissement d'une relation thérapeutique positive.

Public health education in Europe: old and new challenges

The purpose of this article is to discuss some of the current challenges faced by European schools of public health. Perhaps most remarkable on the continent is the diversity, the magnitude, and the rapidity of the developments in public health education since the Second World War. This article discusses its evolution, its main characteristics and the underlying rationale with several examples. Further, it addresses specific aspects of the future development, namely the collaboration of academic schools with practice-oriented institutions, as well as the interactions between the constituent disciplines of public health. The Bologna process on post-graduate education in Europe has had an important impact on the overall design of most schools. There is a willingness to develop public health in each country of the European region and there is a need to develop common strategies to reach high standards in teaching, training and researching in all disciplines related to public health.

Santé en milieu pénitentiaire: vulnérabilité partagée entre détenus et professionnels de la santé [Health in prison: shared vulnerability between detainees and health professionals]

In prison, the health professional has to take the sanitary needs of a temporary of chronically vulnerable population. His practice has to meet laws and recommendations, as well as the field reality and its numerous constraints. This puts him in a "shared vulnerability and stigmatization". He attempts to maintain or restore a health status in a deteriorating environment, at least psychologically. He is in the penitentiary world's eye which he depends upon in many ways to achieve his mandate. His activity is scarcely known and recognised by his peers from whom he can be very out of touch. To ensure a humanistic, efficient and equivalent-of-care practice, the health professional must rely on sound knowledge of general healthcare, ethics, deontology and medical laws. Basic and continuous training is a mainspring, like networking and development of federal recommendations.