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.

Changing paradigms--an update on the multidisciplinary management of malignant glioma.

Treatment of malignant glioma requires a multidisciplinary team. Treatment includes surgery, radiotherapy, and chemotherapy. Recently developed agents have demonstrated activity against recurrent malignant glioma and efficacy if given concurrently with radiotherapy in the upfront setting. Oligodendroglioma with 1p/19q deletions has been recognized as a distinct pathologic entity with particular sensitivity to radiotherapy and chemotherapy. Randomized trials have shown that early neoadjuvant or adjuvant administration of procarbazine, lomustine, and vincristine chemotherapy prolongs disease-free survival; however, it has no impact on overall survival. Temozolomide, a novel alkylating agent, has shown modest activity against recurrent glioma. In combination with radiotherapy in newly diagnosed patients with glioblastoma, temozolomide significantly prolongs survival. Molecular studies have demonstrated that the benefit is mainly observed in patients whose tumors have a methylated methylguanine methyltransferase gene promoter and are thus unable to repair some of the chemotherapy-induced DNA damage. For lower-grade glioma, the use of chemotherapy remains limited to recurrent disease, and first-line administration is the subject of ongoing clinical trials. Irinotecan and agents like gefitinib, erlotinib, and imatinib targeting the epidermal growth factor receptor and platelet-derived growth factor receptor have shown some promise in recurrent malignant glioma. This review summarizes recent developments, focusing on the clinical management of patients in daily neuro-oncology practice.

Nouveautés en médecine interne hospitalière 2007: perspective des chefs de clinique [Highlights 2007 in hospital-based internal medicine: the point of view from the chief residents]

L'année 2007 a été marquée par la publication de plusieurs études internationales concernant directement le quotidien de l'interniste hospitalier. Un résumé de ces travaux ne saurait être qu'un extrait condensé et forcément subjectif d'une croissante et dynamique diversité. Au gré de leurs lectures, de leurs intérêts et de leurs interrogations, les chefs de clinique du Service de médecine interne vous proposent ainsi un parcours original revisitant les thèmes de l'insuffisance cardiaque, du diabète, de l'endocardite, de la BPCO ou de la qualité des soins. Cette variété de sujets illustre à la fois le vaste champ couvert par la médecine interne actuelle, ainsi que les nombreuses incertitudes liées à la pratique médicale moderne basée sur les preuves. In 2007, several international studies brought useful information for the daily work of internists in hospital settings. This summary is of course subjective but reflects the interests and questions of the chief residents of the Department of internal medicine who wrote this article like an original trip in medical literature. This trip will allow you to review some aspects of important fields such as heart failure, diabetes, endocarditis, COPD, and quality of care. Besides the growing diversity of the fields covered by internal medicine, these various topics underline also the uncertainty internists have to face in a practice directed towards evidence.

Note méthodologique sur la collaboration entre praticiens dans le secteur ambulatoire. [Methodologic note on the collaboration between practitioners in the ambulatory care sector].

There are still few studies about the collaboration between ambulatory practitioners (physicians and paramedical services). Nevertheless, the interest seems to be growing for this aspect of health care; it involves indeed basic organisational problems as well as fundamental questions about quality of care and its economic implication. A basic problem is rooted in the inevitable contradiction of the efforts towards a highly qualified-i.e. specialised-care on the one hand and those towards continuity on the other hand.

Nurses, nursing technicians and assistants: who experiences more moral distress?

Objective: To identify the frequency and intensity of moral distress experienced by nurses, technicians and nursing assistants who worked in hospitals in the South of Rio Grande do Sul State. Method: A survey research was conducted with 334 nursing workers from three institutions, through a questionnaire of moral distress. Constructs were validated through factorial analysis and Cronbach’s alpha: lack of competence of the working team, disrespect to the patient’s autonomy, insufficient working conditions and therapeutic obstinacy. Results: With descriptive statistics and analysis of variance, it was found that nurses and nursing assistants have higher perception of moral distress when compared to nursing technicians. Organizational questions and ways of communication influence lower perception of moral distress.Conclusion: Implementation of actions to favor coping, decision making and autonomy exercise from those workers.


Supplemental nursing staff´s experiences at a Spanish hospital: Qualitative phenomenology research

The objective of this study was to describe the Supplemental Nursing Staff´s experiences at different hospital units. A qualitative phenomenological approach was conducted; a purposeful and theoretical sampling was implemented with supplemental nursing staff at Santa Barbara Hospital of Soria (Spain), to gain a more in-depth understanding of the Supplemental Nursing Staff ´s experience. Data were collected by in-depth interviews and through a field notebook. Data were analyzed using the Giorgi proposal. Twenty-one nurses with a mean age of 46 years were included. Three main topics emerged from the data analysis: building the first contact, carving out a niche and establishing interprofessional/interpersonal relationships. We conclude that the experience of hosting the supplemental nursing staff in changing clinical environments is conditioned by various factors. It is necessary for nurses and hospital managers to establish clear objectives with regard to the supplemental nursing staff´s role in the units.

La situación de las mujeres en el mercado laboral en Cataluña y Bélgica

Actualment el paper que desenvolupen dones i homes en el mercat laboral i les seves oportunitats son diferenciades per ambdós, motiu pel qual en las últimes dècades s’ha posat un gran accent en l’elaboració i l’anàlisi d’estadístiques per sexes. Aquest treball es una guia que ens mostra la situació de les dones en el mercat laboral a Catalunya i Bèlgica. D’aquesta forma, cerquem conèixer en quin mercat laboral seria més fàcil trobar un adequat treball per una dona, en aspectes com la taxa d’atur, la jornada laboral, el sector i el salari. Per realitzar aquest treball ens plantegem analitzar la següent hipòtesi: “La situació de la dona en el mercat laboral a Bèlgica, en referència a la taxa d’atur, la jornada laboral, l’elecció del sector y del salari, es millor que en el mercat laboral a Catalunya. Per resoldre aquesta hipòtesis, estudiarem la taxa d’activitat, la taxa d’ocupació i la taxa d’atur a Catalunya i Bèlgica. Aquestes taxes ens permeten quantificar clarament les diferencies existents en el mercat laboral entre homes i dones. A més, realitzarem un anàlisis per conèixer la jornada que predomina a Catalunya i Bèlgica per sexes. Una manifestació de la desigualtat laboral es la distribució dels treballadors en les diverses branques d’activitat i ocupació. Per això, ens hem proposat identificar la distribució dels treballadors per sexe en els diversos sectors econòmics. D’aquesta manera, podrem conèixer la feminització dels sectors. Finalment analitzarem els salaris per sexes, tant a Catalunya com a Bèlgica. Així mateix, podrem esbrinar en quin mercat laboral, si a Catalunya o a Bèlgica, els salaris són més alts. Al mateix temps que realitzem una comparació entre el guany real d’un treballador i el salari mínim interprofessional.

Vision suisse romande de la pratique infirmière avancée [Advanced nursing practice: vision in Switzerland].

To meet the challenges related to the development of health problems taking into account the development of knowledge, several innovations in care are being implemented. Among these, advanced nursing roles and increased interprofessional collaboration are considered as important features in Switzerland. Although the international literature provides benchmarks for advanced roles, it was considered essential to contextualize these in order to promote their application value in Switzerland. Thus, from 79 statements drawn from the literature, 172 participants involved in a two-sequential phases study only kept 29 statements because they considered they were relevant, important and applicable in daily practice. However, it is important to point out that statements which have not been selected at this stage to describe advanced practice cannot be considered irrelevant permanently. Indeed, given the emergence of advanced practice in western Switzerland, it is possible that a statement judged not so relevant at this moment of the development of advanced practice, will be considered as such later on. The master's program in nursing embedded at the University of Lausanne and the University of Applied Sciences Western Switzerland was also examined in the light of these statements. It was concluded that all the objectives of the program are aligned with the competencies statements that were kept.

Une vue globale du secteur ambulatoire: étude structurelle et fonctionnelle dans les cantons de Vaud et Fribourg. [A general view of the ambulatory care sector: Structural and functional study in the cantons of Vaud and Fribourg].

The project "Quantification and qualification of ambulatory health care", financed by the Swiss National Science Foundation and covering the Cantons of Vaud and Fribourg, has two main goals: --a structural study of the elements of the ambulatory care sector. This is done through inventories of the professions concerned (physicians, public health nurses, physiotherapists, pharmacists, medical laboratories), allowing to better characterize the "offer". This inventory work includes the collect and analysis of existing statistical data as well as surveys, by questionnaires sent (from September 1980) to the different professions and by interviews. --a functional study, inspired from the US National Ambulatory Medical Care Survey and from similar studies elsewhere, in order to investigate the modes of practice of various providers, with particular regard to interprofessional collaboration (through studying referrals from the ones to the others). The first months of the project have been used for a methodological research in this regard, centered on the use of systems analysis, and for the elaboration of adequate instruments.

Collaboration entre médecin de famille et psychiatre pour les problèmes de santé mentale [Family physicians and psychiatrists' collaborative care for mental health problems].

The burden of disease linked to mental disorders represents more than one-fifth of years lived with disability in the world. Less than half of people suffering from mental disorders are adequately treated. Three quarter of those who receive treatment are followed by primary care. Collaborative care aims to increase the efficiency of direct general practitioner's treatment. Main components are sustainable and individualized consultation-liaison relationship (1/2 day of psychiatrist by 15 days for 10-15 general practitioners), and support of a clinical case manager for complex situations. Collaboration is bidirectional: early or crisis access to specialist care and long-term followup by general practitioner. This model is a challenge for the doctor-patient dual relationship and requires incentives in a public health perspective.

The development and pilot-testing of a training curriculum in adolescent medicine and health.

PURPOSE: To select and propose a set of knowledge, attitudes, and skills essential for the care of adolescents; to encourage the development of adolescent health multidisciplinary networks; and to set up training programs in as many European countries as possible. METHODS: The curriculum was developed by 16 physicians from 11 European countries with various professional specializations. In line with modern guidelines in medical education, it is a modular, flexible instrument which covers the main teaching areas in the field, such as basic skills (i.e. setting, rights and confidentiality, gender and cultural issues) as well as specific themes (i.e. sexual and reproductive health, eating disorders, chronic conditions). It consists of 17 thematic modules, each containing detailed objectives, learning approaches, examples, and evaluation methods. RESULT: Two international one-week summer schools were used to assess the feasibility and appropriateness of the curriculum. The overall evaluation was good, with most of the items surpassing three on a four-point Likert scale. However, it pointed to several aspects (process and content) which will need to be refined in the future, such as an increase in interactive sessions (role playing), and a better mix of clinical and public health issues.

Comparative study of the LC-MS/MS and UPLC-MS/MS for the multi-residue analysis of quinolones, penicillins and cephalosporins in cow milk, and validation according to the regulation 2002/657/EC

The aim of this study was to develop and validate an analytical method to simultaneously determine European Union-regulated beta-lactams (penicillins and cephalosporins) and quinolones in cow milk. The procedure involves a new solid phase extraction (SPE) to clean-up and pre-concentrate the three series of antibiotics before analysis by liquid chromatography¿tandem mass spectrometry (LC-MS/MS) and ultra-high-performance liquid chromatography¿tandem mass spectrometry (UPLC-MS/MS). LC-MS/MS and UPLC-MS/MS techniques were also compared. The method was validated according to the Directive 2002/657/EC and subsequently applied to 56 samples of raw cow milk supplied by the Laboratori Interprofessional Lleter de Catalunya (ALLIC) (Laboratori Interprofessional Lleter de Catalunya, Control Laboratory Interprofessional of Milk of Catalunya).

La PMU au carrefour des nouveaux chemins du système de santé [Redesigning Swiss ambulatory health care system].

Primary care medicine is first in line to meet the necessary changes in our health care system. Innovations in this field pursue three types of objectives: accessibility, quality and continuity of care. The Department of ambulatory care and community medicine of the University of Lausanne (Policlinique médicale universitaire) is committed to this path, emphasizing interprofessional collaboration. The doctor, nurse and medical assistant coordinate their activities to contribute efficiently to meet the needs of patients today and tomorrow. This paper also addresses how our department, as a public and academic institution, might play a major role as a health care network actor. A master degree dissertation in health management has started to identify the critical success factors and the strategic core competencies needed to achieve this development.