Swiss DRGs : patient heterogeneity and hospital payments

In this paper, we analyze the prospective method of paying hospitals when the within-DRG variance is high. To avoid patients dumping, an outlier payment system is implemented. In the APDRG Swiss System, it consists in a mixture of fully prospective payments for low costs patients and partially cost-based system for high cost patients. We show how the optimal policy depends on the degree to which hospitals take patients' interest into account. A fixed-price policy is optimal when the hospital is sufficiently benevolent. When the hospital is weakly benevolent, a mixed policy solving a trade-off between rent extraction, efficiency and dumping deterrence must be preferred. Following Mougeot and Naegelen (2008), we show how the optimal combination of fixed price and partially costbased payment depends on the degree of benevolence of the hospital, the social cost of public funds and the distribution of patients severity. [Authors]

Cutaneous benign mixed tumor (chondroid syringoma) of the eyelid: clinical presentation and management.

PURPOSE: To describe the clinical presentation of cutaneous benign mixed tumor of the eyelid and its management options. METHODS: Periocular cases of cutaneous benign mixed tumor were gathered from members of an oculoplastics specialty Internet discussion group. A total of 9 patients are described in this retrospective, interventional case series. The clinical presentation, histopathology, and management of these lesions is reviewed. RESULTS: Patients were typically asymptomatic, presenting with a slowly enlarging, nontender nodule of 2 to 8 years' duration. The lesions ranged from 4 mm to 17 mm in greatest dimension. Four of the lesions were on the eyelid margin, three in the sub-brow area of the upper eyelid, and two in the central lids. All six cases not involving the brow were fixed to the tarsus; one brow lesion was believed to be adherent to the skin. None of the lesions was associated with significant changes of the overlying epidermis, although one lesion showed overlying pigmentation. All patients underwent excisional biopsy for diagnostic or cosmetic reasons. On histopathologic examination, the tumors were biphasic, with an epithelial component exhibiting apocrine or hair follicle differentiation and a myxoid, adipocytic, chondroid, and/or fibrous stroma. The pathologic diagnoses were all consistent with cutaneous benign mixed tumor (chondroid syringoma, pleomorphic adenoma). Follow-up ranged from 2 weeks to 12 months, although several patients failed to keep scheduled follow-up appointments. No clinical recurrences were identified. CONCLUSIONS: Cutaneous benign mixed tumor may occur in the eyelid, and, although uncommon, should be included in the differential diagnosis of firm, nodular eyelid tumors. The histopathologic features are similar to those seen in this tumor type arising in other areas of the body. Preoperative consideration of this diagnostic possibility may allow the surgeon to plan for complete excision, thereby reducing the possibility of recurrence or malignant transformation.

Integrative taxonomy of the Formica rufa group (Hymenoptera: Formicidae)

RESUME :Les fourmis du groupe Formica rufa, ou fourmis des bois, ainsi appelées en raison de leur préférence pour les écosystèmes forestiers, sont parmi les fourmis les plus fascinantes et les plus étudiées d'Europe. Ces fourmis jouent un rôle clé dans la plupart des forêts dans lesquelles elles vivent et sont considérées comme étant les meilleurs bioindicateurs de ces milieux. Pour ces raisons, les fourmis des bois sont protégées par la loi dans de nombreux pays européens, y compris en Suisse. Cependant, malgré leur protection, ces fourmis sont inscrites sur la liste rouge des espèces menacées dans plusieurs pays d'Europe et il est donc indispensable de bien les connaître afin de mieux les protéger.À l'heure actuelle, on considère que le groupe Formica rufa est composé de six espèces distinctes : F. rufa, F. polyctena, F. lugubris, F. paralugubris, F. aquilonia et F. pratensis. Toutefois, malgré la grande quantité d'études effectuées sur ces espèces, la systématique et l'identification des fourmis des bois sont toujours sujettes à discussion. Ceci est essentiellement dû au fait que ces espèces sont morphologiquement similaires et qu'elles sont parfois capables de s'hybrider ou de former des colonies mixtes.Une des conditions fondamentales pour toute étude en biologie de la conservation est l'identification correcte des espèces à protéger. Avec cette étude, nous désirons donc dénouer les problèmes liés à la systématique des fourmis des bois et analyser la diversité de ces espèces en adoptant une approche multidisciplinaire.Nous avons d'abord étudié la distribution des espèces jumelles F. lugubris et F. paralugubris dans les Álpes italiennes en re-analysant l'une des plus grandes collections de références sur ces espèces, déposée à l'Université de Pavie, Italie, et en récoltant de nouveaux échantillons sur le terrain. Nos analyses ont montré que F, paralugubris, décrite récemment et souvent «oubliée »par les chercheurs, est bien présente dans les Alpes et vit souvent en sympathie avec F. lugubris. Ensuite nous avons développé un outil moléculaire basé sur l'ADN mitochondrial pour une identification rapide et efficace de ces deux espèces. Au vu des bons résultats, nous avons étendu nos analyses génétiques (microsatellites) à toutes les espèces du groupe F. rufa, ce qui nous a permis de montrer que les outils moléculaires sont très efficaces pour identifier ces fourmis. En outre, nos analyses ont mis en évidence la présence d'une nouvelle espèce cryptique (appelée F. lugubris-X) au sein du Parc National Suisse. L'existence d'une nouvelle espèce peut avoir une grande influence sur les projets de conservation en faveur de ces espèces. Nous avons donc décidé de confirmer ce résultat avec des analyses comportementales et des analyses chimiques basées sur les phéromones sexuelles des différentes espèces, y compris F. lugubris-X. Les deux approches confirment nos données génétiques et indiquent que F. lugubris-X représente bel et bien une nouvelle espèce de fourmis des bois dans les Alpes Suisses.Les résultats de cette étude ont une grande importance du point de vue de la biodiversité. En plus, ils livrent aux futurs chercheurs des outils fiables pour l'identification des fourmis des bois et ouvrent de captivantes perspectives pour une meilleure protection de ces insectes et, par conséquent, de nos écosystèmes forestiers. .Abstract :Mound building red wood ants (species of the Formica rufa group) belong to one of the most studied groups of ants in Europe and have fundamental roles and positive effects in forested habitats of the northern hemisphere. In addition, they are considered among the most promising bioindicators of forest ecosystems. Because of their importance, these ants are protected by law in many European countries, including Switzerland. However, despite this protection, they are included on the red list of threatened species edited by the International Union for Conservation of Nature (IUCN) and on the red list of some particular countries like Switzerland. Because of their similar morphology and a high intraspecific variability, the morphological identification of these species can be quite complicated. In addition, they are sometimes able to hybridize or to form mixed colonies. Consequently, the taxonomy of this group of ants has been much debated during the past decades. Based on a phylogenetic study, today the group is considered to count six species in Europe: F. rufa, F. po/yctena, F. lugubris, F. paralugubris, F. aquilonia and F. pratensis. Nevertheless, the taxonomy of the group is often neglected mainly due to the lack of reliable and easy to use identification methods.Considering the importance of correct species assessment in conservation biology, in this study we want to disentangle the taxonomical difficulties within the Formica rufa group and to clarify the diversity of these protected ants, by using an integrative approach.We first analyzed the distribution of .the sibling species F. lugubris and F. paralugubris in the Italian Alps by collecting new samples on the field and by examining one of the major red wood ant collections, which is deposited at the University of Pavia, Italy. After that, we developed a molecular tool based on mitochondria) DNA, which provides a reliable and easy-to-use technique for the identification of F. lugubris and F. paralugubris. Afterwards, we extended the use of molecular markers for species identification to the whole F. rufa group and made a microsatellite analysis. Results confirm that molecular markers are consistent tools for species identification and that the six known species represent six different genetic pools. In addition, genetic data highlighted the existence of a new cryptic species in the Swiss Alps, called Formica lugubris-X.The presence of a new species can have a great influence on future conservation plans in favour of these protected ants and consequently for forested habitats. We therefore completed molecular data by behavioural (pupae recognition) and chemical analyses based on six pheromones of the entire F. rufa group. Both approaches are in accordance to genetic results and confirm that F. lugubris-X really represents a new cryptic species of red wood ant within the Swiss National Park (Eastern Swiss Alps).Results obtained in this study have a great importance in terms of biodiversity. Moreover, they provide important taxonomical information, reliable tools for species identifications and future perspectives for a consequent conservation of red wood ant species.

Sequential therapist interventions and the therapeutic alliance: a pilot study

(from the journal abstract) Scientific interest for the concept of alliance has been maintained and stimulated by repeated findings that a strong alliance is associated with facilitative treatment process and favourable treatment outcome. However, because the alliance is not in itself a therapeutic technique, these findings were unsuccessful in bringing about significant improvements in clinical practice. An essential issue in modern psychotherapeutic research concerns the relation between common factors which are known to explain great variance in empirical results and the specific therapeutic techniques which are the primary basis of clinical training and practice. This pilot study explored sequences in therapist interventions over four sessions of brief psychodynamic investigation. It aims at determining if patterns of interventions can be found during brief psychodynamic investigation and if these patterns can be associated with differences in the therapeutic alliance. Therapist interventions where coded using the Psychodynamic Intervention Rating Scale (PIRS) which enables the classification of each therapist utterance into one of 9 categories of interpretive interventions (defence interpretation, transference interpretation), supportive interventions (question, clarification, association, reflection, supportive strategy) or interventions about the therapeutic frame (work-enhancing statement, contractual arrangement). Data analysis was done using lag sequential analysis, a statistical procedure which identifies contingent relationships in time among a large number of behaviours. The sample includes N = 20 therapist-patient dyads assigned to three groups with: (1) a high and stable alliance profile, (2) a low and stable alliance profile and (3) an improving alliance profile. Results suggest that therapists most often have one single intention when interacting with patients. Large sequences of questions, associations and clarifications were found, which indicate that if a therapist asks a question, clarifies or associates, there is a significant probability that he will continue doing so. A single theme sequence involving frame interventions was also observed. These sequences were found in all three alliance groups. One exception was found for mixed sequences of interpretations and supportive interventions. The simultaneous use of these two interventions was associated with a high or an improving alliance over the course of treatment, but not with a low and stable alliance where only single theme sequences of interpretations were found. In other words, in this last group, therapists were either supportive or interpretative, whereas with high or improving alliance, interpretations were always given along with supportive interventions. This finding provides evidence that examining therapist interpretation individually can only yield incomplete findings. How interpretations were given is important for alliance building. It also suggests that therapists should carefully dose their interpretations and be supportive when necessary in order to build a strong therapeutic alliance. And from a research point of view, to study technical interventions, we must look into dynamic variables such as dosage, the supportive quality of an intervention, and timing. (PsycINFO Database Record (c) 2005 APA, all rights reserved)

In vivo gene transfer into the ocular ciliary muscle mediated by ultrasound and microbubbles.

This study aimed to assess application of ultrasound (US) combined with microbubbles (MB) to transfect the ciliary muscle of rat eyes. Reporter DNA plasmids encoding for Gaussia luciferase, β-galactosidase or the green fluorescent protein (GFP), alone or mixed with 50% Artison MB, were injected into the ciliary muscle, with or without US exposure (US set at 1 MHz, 2 W/cm(2), 50% duty cycle for 2 min). Luciferase activity was measured in ocular fluids at 7 and 30 days after sonoporation. At 1 week, the US+MB treatment showed a significant increase in luminescence compared with control eyes, injected with plasmid only, with or without MB (×2.6), and, reporter proteins were localized in the ciliary muscle by histochemical analysis. At 1 month, a significant decrease in luciferase activity was observed in all groups. A rise in lens and ciliary muscle temperature was measured during the procedure but did not result in any observable or microscopic damages at 1 and 8 days. The feasibility to transfer gene into the ciliary muscle by US and MB suggests that sonoporation may allow intraocular production of proteins for the treatment of inflammatory, angiogenic and/or degenerative retinal diseases.

Contributions of fat and protein to the incretin effect of a mixed meal.

Background: The relative contributions of fat and protein to the incretin effect are still largely unknown.Objective: This study assessed the incretin effects elicited by a mixed meal, and by its fat and protein components alone, with the use of a hyperglycemic clamp combined with oral nutrients.Design: Eight healthy volunteers were studied over 6 h after ingestion of a sandwich containing 1) dried meat, butter, and white bread; 2) dried meat alone; 3) butter alone; or 4) no meal (fasting control). Meals were ingested during a hyperglycemic clamp, and the incretin effect was calculated as the increment in plasma insulin after food intake relative to the concentrations observed during the control study.Results: A significant augmentation of postprandial insulin secretion, independent of plasma glycemia, occurred after ingestion of the mixed nutrients and the lipid component of the mixed meal (203 +/- 20.7% and 167.4 +/- 22.9% of control, respectively; both P < 0.05), whereas the protein component did not induce a significant incretin effect (129.0 +/- 7.9% of control; P = 0.6)Conclusions: Fat ingestion, in an amount typical of a standard meal, increases insulin secretion during physiologic hyperglycemia and thus contributes to the incretin effect. In contrast, ingestion of protein typical of normal meals does not contribute to the augmentation of postprandial insulin secretion. This trial was registered at clinicaltrials.gov as NCT00869453.

Spatial behavior in groups: an agent-based approach

We present an agent-based model with the aim of studying how macro-level dynamics of spatial distances among interacting individuals in a closed space emerge from micro-level dyadic and local interactions. Our agents moved on a lattice (referred to as a room) using a model implemented in a computer program called P-Space in order to minimize their dissatisfaction, defined as a function of the discrepancy between the real distance and the ideal, or desired, distance between agents. Ideal distances evolved in accordance with the agent's personal and social space, which changed throughout the dynamics of the interactions among the agents. In the first set of simulations we studied the effects of the parameters of the function that generated ideal distances, and in a second set we explored how group macrolevel behavior depended on model parameters and other variables. We learned that certain parameter values yielded consistent patterns in the agents' personal and social spaces, which in turn led to avoidance and approaching behaviors in the agents. We also found that the spatial behavior of the group of agents as a whole was influenced by the values of the model parameters, as well as by other variables such as the number of agents. Our work demonstrates that the bottom-up approach is a useful way of explaining macro-level spatial behavior. The proposed model is also shown to be a powerful tool for simulating the spatial behavior of groups of interacting individuals.

Impact of relative size and language on the attitudes between nations and linguistic groups : The case of Switzerland

This study explores the impact of relative size on the intra- and intergroup attitudes of groups who either share a language or have a different language. For that purpose, we examined international attitudes, comparing a small nation, Switzerland, and two larger nations, Germany and France. We found support for the assumption that large neighbouring nations pose a threat to the smaller nation's identity, especially when they are linguistically similar. Consequently, in line with Tajfel's Social Identity Theory (1978), the smaller nation's inhabitants evaluate those of the larger nation less positively, liking them less and perceiving them to be more arrogant than vice versa. By investigating the special case of the French-speaking and the German-speaking Swiss as linguistic groups within their own nation we were able to demonstrate that these groups seek support with the larger-linguistically-similar nation to defend themselves against the more direct in-country threat to their identity. They acknowledge the similarity with the larger nation, yet keep defending their social identity by expressing a dislike for this perceived similarity.

Biomedical risk assessment as an aid for smoking cessation.

BACKGROUND: A possible strategy for increasing smoking cessation rates could be to provide smokers who have contact with healthcare systems with feedback on the biomedical or potential future effects of smoking, e.g. measurement of exhaled carbon monoxide (CO), lung function, or genetic susceptibility to lung cancer. OBJECTIVES: To determine the efficacy of biomedical risk assessment provided in addition to various levels of counselling, as a contributing aid to smoking cessation. SEARCH METHODS: For the most recent update, we searched the Cochrane Collaboration Tobacco Addiction Group Specialized Register in July 2012 for studies added since the last update in 2009. SELECTION CRITERIA: Inclusion criteria were: a randomized controlled trial design; subjects participating in smoking cessation interventions; interventions based on a biomedical test to increase motivation to quit; control groups receiving all other components of intervention; an outcome of smoking cessation rate at least six months after the start of the intervention. DATA COLLECTION AND ANALYSIS: Two assessors independently conducted data extraction on each paper, with disagreements resolved by consensus. Results were expressed as a relative risk (RR) for smoking cessation with 95% confidence intervals (CI). Where appropriate, a pooled effect was estimated using a Mantel-Haenszel fixed-effect method. MAIN RESULTS: We included 15 trials using a variety of biomedical tests. Two pairs of trials had sufficiently similar recruitment, setting and interventions to calculate a pooled effect; there was no evidence that carbon monoxide (CO) measurement in primary care (RR 1.06, 95% CI 0.85 to 1.32) or spirometry in primary care (RR 1.18, 95% CI 0.77 to 1.81) increased cessation rates. We did not pool the other 11 trials due to the presence of substantial clinical heterogeneity. Of the remaining 11 trials, two trials detected statistically significant benefits: one trial in primary care detected a significant benefit of lung age feedback after spirometry (RR 2.12, 95% CI 1.24 to 3.62) and one trial that used ultrasonography of carotid and femoral arteries and photographs of plaques detected a benefit (RR 2.77, 95% CI 1.04 to 7.41) but enrolled a population of light smokers and was judged to be at unclear risk of bias in two domains. Nine further trials did not detect significant effects. One of these tested CO feedback alone and CO combined with genetic susceptibility as two different interventions; none of the three possible comparisons detected significant effects. One trial used CO measurement, one used ultrasonography of carotid arteries and two tested for genetic markers. The four remaining trials used a combination of CO and spirometry feedback in different settings. AUTHORS' CONCLUSIONS: There is little evidence about the effects of most types of biomedical tests for risk assessment on smoking cessation. Of the fifteen included studies, only two detected a significant effect of the intervention. Spirometry combined with an interpretation of the results in terms of 'lung age' had a significant effect in a single good quality trial but the evidence is not optimal. A trial of carotid plaque screening using ultrasound also detected a significant effect, but a second larger study of a similar feedback mechanism did not detect evidence of an effect. Only two pairs of studies were similar enough in terms of recruitment, setting, and intervention to allow meta-analyses; neither of these found evidence of an effect. Mixed quality evidence does not support the hypothesis that other types of biomedical risk assessment increase smoking cessation in comparison to standard treatment. There is insufficient evidence with which to evaluate the hypothesis that multiple types of assessment are more effective than single forms of assessment.

The influence of work context on demand for master's studies: a comparative analysisi between Brasil and Spain

The communication presents the results of an investigation of exploratory and comparative character which objective is to analyze the influence of the actual labour situation into the demand of official master studies in the field of education. The study has been developed in two countries with a very different labour situation: Brasil, country of economic expansion and Spain, in recession due to the actual economic crisis. In that sense, the study provides data for deep thinking about the influence of the constriction or expansion of employment on the behaviour and demand of the students who access master studies and on how the previous formative and labour trajectory affects their expectations, demands and future projects. The working methodology is qualitative and the strategy for data collection the “focus group”. As a first approach, two groups of discussion have been formed with master students. A first one with students from Universidad de Barcelona- España and another one with members of Universidade do Vale do Itajaí- Brasil. Then, we constituted a mixed group of discussion in order to analyze differences and similarities.