Advance directives and the impact of timing. A qualitative study with Swiss general practitioners.

PRINCIPLES: Advance directives are seen as an important tool for documenting the wishes of patients who are no longer competent to make decisions in regards to their medical care. Due to their nature, approaching the subject of advance directives with a patient can be difficult for both the medical care provider and the patient. This paper focuses on general practitioners' perspectives regarding the timing at which this discussion should take place, as well as the advantages and disadvantages of the different moments. METHODS: In 2013, 23 semi-structured face-to-face interviews were performed with Swiss general practitioners. Interviews were analysed using qualitative content analysis. RESULTS: In our sample, 23 general practitioners provided different options that they felt were appropriate moments: either (a) when the patient is still healthy, (b) when illness becomes predominant, or (c) when a patient has been transferred to a long-term care facility. Furthermore, general practitioners reported uncertainty and discomfort regarding initiating the discussion. CONCLUSION: The distinct approaches, perspectives and rationales show that there is no well-defined or "right" moment. However, participants often associated advance directives with death. This link caused discomfort and uncertainty, which led to hesitation and delay on the part of general practitioners. Therefore we recommend further training on how to professionally initiate a conversation about advance directives. Furthermore, based on our results and experience, we recommend an early approach with healthy patients paired with later regular updates as it seems to be the most effective way to inform patients about their end-of-life care options.

The European Union in North Korea: Current Realities and Paths for Future Engagement – A Qualitative and Quantitative Study

Malgrat la rellevància estratègica i el paper desestabilitzador de Corea del Nord a la regió econòmicament més dinàmica del món, la UE no compta amb cap estratègia clara per involucrar-se amb aquest país. Combinant tècniques d’anàlisi qualitatives i quantitatives, aquest treball pretén descobrir possibles contradiccions internes que impedeixin la definició d'una política exterior europea coherent i efectiva amb respecte a Corea del Nord, així com discrepàncies entre les percepcions d’actors interns de la UE i les d’actors externs. S'han detectat importants diferències d’expectatives i mancances en termes de coherència, tant entre les visions expressades pels actors interns com entre les opinions d’aquests actors i les dels futurs líders sudcoreans enquestats – diferències que fins i tot afecten la promoció dels drets humans

Aspects juridiques de l'assainissement (cadre, outils et responsabilité) - Aspects pratiques du droit de l'entreprise

Contribution consécutive au séminaire organisé par le CEDIDAC sur le thème Aspects pratiques du droit de l'entreprise, le 3 février 2009

Update on basic and clinical aspects of eosinophilic oesophagitis.

The identification of a distinct syndrome, designated eosinophilic oesophagitis (EoE), with its own clinical and histopathological characteristics, was first described in the early 1990s. Meanwhile intense research has uncovered many molecular, immunological and clinical aspects of this chronic-inflammatory disorder. This article focuses exclusively on basic and clinical insights of EoE gathered during the last few years. Regarding aetiopathogenesis it has become clear that EoE is a food-triggered disease with milk and wheat as the dominant culprit food categories. However, it is still debated whether a disturbed mucosal integrity allowing allergens to cross the mucosal barrier, or changes in wheat and milk manufacturing might induce these inflammatory responses. Furthermore, basic science and clinical studies have accordingly confirmed that a chronic eosinophilic inflammation leads to a remodelling of the oesophagus with micro- and macro-morphological alterations, ending in a strictured oesophagus with impaired function. Fortunately, long-term therapeutic trials, using either topical corticosteroids or dietary allergen avoidance, have demonstrated that this sequela can be prevented or even reversed. This finding is of clinical relevance as it supports the initiation of a consistent anti-inflammatory therapy. Nevertheless, EoE is still an enigmatic disease and the long list of unanswered questions will certainly stimulate further research.

La maladie de Fabry chez l'adulte: aspects cliniques et progrès thérapeutiques [Fabry disease in adulthood: clinical aspects and therapeutic progress].

INTRODUCTION: Fabry disease is an X-linked recessive abnormality of glycosphingolipid metabolism that is due to deficiency of the lysosomal enzyme alpha-galactosidase A. CURRENT KNOWLEDGE AND KEY POINTS: A majority of hemizygous men develop severe multisystemic disease (classic form), dominated by renal failure, progressive neurological and cardiac involvement. Nevertheless, some affected men retain sufficient enzyme activity and long remain asymptomatic (atypical form); their main manifestation is hypertrophic cardiomyopathy. Female heterozygous carriers are usually asymptomatic; 15% of them, however, have severe involvement of one or several organs. Laboratory, histologic and molecular diagnosis identifies 100% of hemizygous and over 80% of heterozygous subjects. FUTURE PROSPECTS AND PROJECTS: With developments in molecular genetics, it is now possible to produce the human recombinant enzyme alpha-galactosidase A. Two recent studies had proven that this therapeutic approach was able to be clinically and histologically effective in men. In addition, the results of a trial of gene therapy in a Fabry gene knocked-out mouse appear promising.

An electronic portfolio for quantitative assessment of surgical skills in undergraduate medical education.

BACKGROUND We evaluated a newly designed electronic portfolio (e-Portfolio) that provided quantitative evaluation of surgical skills. Medical students at the University of Seville used the e-Portfolio on a voluntary basis for evaluation of their performance in undergraduate surgical subjects. METHODS Our new web-based e-Portfolio was designed to evaluate surgical practical knowledge and skills targets. Students recorded each activity on a form, attached evidence, and added their reflections. Students self-assessed their practical knowledge using qualitative criteria (yes/no), and graded their skills according to complexity (basic/advanced) and participation (observer/assistant/independent). A numerical value was assigned to each activity, and the values of all activities were summated to obtain the total score. The application automatically displayed quantitative feedback. We performed qualitative evaluation of the perceived usefulness of the e-Portfolio and quantitative evaluation of the targets achieved. RESULTS Thirty-seven of 112 students (33%) used the e-Portfolio, of which 87% reported that they understood the methodology of the portfolio. All students reported an improved understanding of their learning objectives resulting from the numerical visualization of progress, all students reported that the quantitative feedback encouraged their learning, and 79% of students felt that their teachers were more available because they were using the e-Portfolio. Only 51.3% of students reported that the reflective aspects of learning were useful. Individual students achieved a maximum of 65% of the total targets and 87% of the skills targets. The mean total score was 345 ± 38 points. For basic skills, 92% of students achieved the maximum score for participation as an independent operator, and all achieved the maximum scores for participation as an observer and assistant. For complex skills, 62% of students achieved the maximum score for participation as an independent operator, and 98% achieved the maximum scores for participation as an observer or assistant. CONCLUSIONS Medical students reported that use of an electronic portfolio that provided quantitative feedback on their progress was useful when the number and complexity of targets were appropriate, but not when the portfolio offered only formative evaluations based on reflection. Students felt that use of the e-Portfolio guided their learning process by indicating knowledge gaps to themselves and teachers.

"Quitter le milieu" Une étude sociologique des processus de désaffiliation religieuse du milieu évangélique suisse

La thématique des désaffiliations religieuses du milieu évangélique est le parent pauvre des études faites jusqu'à ce jour sur ce courant religieux. En effet, l'accent est généralement mis sur son développement en termes d'affiliation faisant alors l'impasse sur les pertes qu'il connaît pourtant. De plus, la question des désaffiliations religieuses est un angle d'approche sociologique particulièrement fécond pour étudier les groupes religieux en permettant, entre autres, de cerner plus en profondeur leur identité, les mécanismes qui favorisent leur pérennisation, mais aussi leur rapport à la société environnante. Dans ce travail, qui s'inscrit en sociologie des religions et qui puise autant dans la littérature sur les désaffiliations religieuses que dans celle des désengagements militants, l'analyse s'est focalisée sur les processus de désengagement au niveau microsociologique : quels sont les motifs qui président les désaffiliations, comment se déroulent ces dernières, quels effets ont-elles sur l'individu en termes identitaires et comment sont-elles perçues par ceux qui restent ? Ces principales questions ont permis de (re] questionner des éléments constitutifs de l'engagement évangélique : les processus de socialisation ; la structuration des liens intragroupe développés par le milieu et son rapport à l'extérieur ; son système normatif; son système de représentation du monde et la démarche religieuse qu'il valorise, qui sont autant d'aspects qui jouent un rôle dans les processus de désaffiliation. Plus précisément, ces éléments agissent en tant que mécanismes de rétention tant sociaux que psychologiques compliquant ainsi le désengagement. Cette thèse s'est construite sur dix-sept entretiens semi directifs menés auprès de personnes ayant grandi pour la plupart dans une famille évangélique et qui ont décidé, un jour, de ne plus fréquenter ce milieu religieux. Pour élargir la perspective analytique et pour permettre de comprendre et d'expliquer les processus de désaffiliation en lien avec le groupe quitté, un ensemble de septante-huit entretiens semi directifs et de mille cent questionnaires standardisés de membres d'Eglises évangéliques a été mobilisé. Partant des logiques du désengagement, cette thèse affine les connaissances actuelles sur l'évangélisme dans le contexte de la modernité, grâce à l'éclairage inédit qu'elle lui donne. Elle développe également le champ des connaissances sur les désaffiliations religieuses en lui fournissant un nouvel exemple de cas tout en lui offrant une autre façon de théoriser les sorties de groupes religieux qui valorisent un engagement de type militant. - Religious disaffiliations from the evangelical milieu have not yet been investigated. Indeed, former studies have usually focused on the development of the milieu by looking at conversions. However, it appears that the study of the disaffiliation processes may not only give results on the reasons and experiences of those disaffiliating, but also shed light on the attributes and the development of the evangelical milieu itself. The main goal of this thesis was to fill this gap in the literature. From a microsociological approach, this thesis sought to answer the following central question : Why, how and with what effects do individuals leave the evangelical milieu and how is this phenomenon perceived, interpreted and managed by the individuals who leave the evangelical community and by the members of the evangelical milieu? These questions enabled me to investigate the functioning of the evangelical milieu : its processes of socialization ; internal and external relationships ; normative system ; belief system or its religious engagement. This set of aspects can influence and complicate the processes of disaffiliation. The analysis of religious disaffiliation was based on seventeen qualitative interviews with former members of evangelical chrurches who decided, one day, not to attend an evangelical church anymore and who question more or less strongly the « system of evangelical thought ». Seventy-eight qualitative interviews with members of evangelical free churches and a representative survey with members of evangelical free churches (N = 1100] completed the analysis and inserted the individual disengagement in the « milieu's logics ». This thesis complements and enriches the literature on evangelism as well as on religious disaffiliation in general.

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.

Behavioral aspects of investment fund's markets: are good managers lucky or skilled?

It is generally accepted that financial markets are efficient in the long run a lthough there may be some deviations in the short run. It is also accepted that a good portfolio manager is the one who beats the market persistently along time, this type of manager could not exist if markets were perfectly efficient According to this in a pure efficient market we should find that managers know that they can not beat the market so they would undertake only pure passive management strategies. Assuming a certain degree of inefficiency in the short run, a market may show some managers who tr y to beat the market by undertaking active strategies. From Fama’s efficient markets theory we can state that these active managers may beat the market occasionally although they will not be able to enhance significantly their performance in the long run. On the other hand, in an inefficient market it would be expected to find a higher level of activity related with the higher probability of beating the market. In this paper we follow two objectives: first, we set a basis to analyse the level of efficiency in an asset invest- ment funds market by measuring performance, strategies activity and it’s persistence for a certain group of funds during the period of study. Second, we analyse individual performance persistence in order to determine the existence of skilled managers. The CAPM model is taken as theoretical background and the use of the Sharpe’s ratio as a suitable performance measure in a limited information environment leads to a group performance measurement proposal. The empiri- cal study takes quarterly data from 1999-2007 period, for the whole population of the Spanish asset investment funds market, provided by the CNMV (Comisión Nacional del Mercado de Valores). This period of study has been chosen to ensure a wide enough range of efficient market observation so it would allow us to set a proper basis to compare with the following period. As a result we develop a model that allows us to measure efficiency in a given asset mutual funds market, based on the level of strategy’s activity undertaken by managers. We also observe persistence in individual performance for a certain group of funds

Vitamine D et maladie cardiovasculaire: aspects épidémiologiques. [Vitamin D and cardiovascular disease: epidemiological aspects].

The quasi-ubiquitous distribution of vitamin D receptors in the human tissues and the high prevalence of vitamin D deficiency worldwide have generated much enthusiasm about the opportunity of cardiovascular disease prevention through vitamin D supplementation. However, reported associations between vitamin D and cardiovascular disease present important limitations and are prone to confounding and reverse causation. Results from ongoing randomized clinical trials testing the efficacy of vitamin D supplementation to reduce cardiovascular events will not be available before year 2015. This article reviews the epidemiology of vitamin D and provides a brief overview on the relationship between vitamin D and cardiovascular disease.

Les élites omeyyades en Palmyrène : contribution à l'étude des aspects fonctionnels et économiques des établissements aristocratiques omeyyades du Bilād al-Shām

Cette thèse se présente en deux parties de nature et de propos différents. La première consiste en une présentation synthétique de l'ensemble des travaux archéologiques et études qui ont été menés par l'auteur entre 2002 et 2009 sur la Palmyrène à l'époque omeyyade (41-60 H/661-750 AD): à Palmyre même, à al-Bakhrā' (un établissement de transition entre Antiquité tardive et Islam), à Qaṣr al-Ḥayr al-Sharqī (une ville neuve) et sur plusieurs autres établissements aristocratiques ruraux. La seconde partie regroupe trois essais traitant des aspects formels et fonctionnels des établissements aristocratiques omeyyades du Bilād al-Shām, les fameux «châteaux du désert». Le premier s'attache à définir les différentes composantes des établissements et à proposer une forme de typologie. Leur rôle économique est analysé dans le second. Après une exploitation la plus exhaustive possible des données archéologiques, il est démontré que plus de la moitié d'entre eux avaient une composante dévolue à l'agriculture et que cette dernière était souvent importante. Une majorité des établissements aristocratiques omeyyades a donc eu un rôle économique et, en tant que propriétés foncières, ceux-ci ont été un moyen d'investissement et une source de revenu alternative pour les nouvelles élites islamiques. Ce rôle économique n'était toutefois pas toujours présent et ne permet pas d'expliquer l'émergence d'établissements aristocratiques un peu partout dans les zones steppiques du Bilād al-Shām. Le troisième essai fait donc le point de manière plus générale sur leurs fonctions multiples et montre que ce furent d'abord les lieux de résidence et de vie des nouvelles élites islamiques. Il met enfin l'accent sur leur fonction la plus importante, qui était politique et diplomatique et relevait d'une conception du pouvoir reposant sur la régionalisation et une forme de mobilité, ainsi que sur le poids pris par les grands groupes tribaux arabes.