Relevé des consultations et des transferts de patients par enquête directe auprès des médecins: méthode d'une enquête, acceptabilité et limites d'interprétation. [Summary of consultations and transfer of patients by a direct survey of physicians: survey methods, acceptability and limits of interpretation].

A survey of medical ambulatory practice was carried out in February-March 1981 in the two Swiss cantons of Vaud and Fribourg (total population: 700,000), in which 205 physicians participated. The methodology used was inspired from the U.S. National Ambulatory Medical Care Survey, the data collection instrument of which was adapted to our conditions; in addition, data were gathered on all referrals prescribed by 154 physicians during two weeks. (The instruments used are presented.) The potential and limits of this type of survey are discussed, as well as the representativity of the participating physicians and of the recorded visits, which are a systematic sample of over 43,000 visits.

La conversion religieuse: un processus créatif

Les récits de conversion religieuse présentent plusieurs traits communs avec les récits de découvertes scientifiques (Aha-Erlebnisse, expériences de eurêka): événement instantané, exceptionnel, inattendu, marquant une rupture par rapport au passé. Or, il s'agit dans les deux cas de reconstructions a posteriori qui ont tendance à survaloriser le caractère instantané d'un événement au détriment du processus organisant la mise en place d'une nouvelle vision du monde. Howard Gruber l'a très bien montré dans son étude consacrée à Charles Darwin. Là où le récit autobiographique, formulé une quarantaine d'années après l'énoncé de la théorie de la sélection naturelle, donne l'impression d'une intuition subite, les carnets de notes, rédigés à l'époque où s'élabore la théorie, permettent de mettre en évidence un processus créatif qui s'étale sur près d'un an et demi. Ce constat peut être étendu aux récits de conversion religieuse. Le cas de Martin Luther en est une excellente illustration. Ce parallèle entre découverte scientifique et conversion religieuse jette un éclairage nouveau sur cette dernière: l'événement inattendu où tout bascule doit être articulé avec un processus psychologique qui le porte et même le décompose sur une durée bien plus longue que ce que la mémoire ne le reconstruit après-coup. Au point qu'il n'est pas exagéré de voir dans le récit d'une conversion religieuse, ne serait-ce que pour une part, l'expression de la créativité d'un sujet qui invente une solution au problème de sa vie.

Indexes and boundaries for "quantitative significance" in statistical decisions.

Boundaries for delta, representing a "quantitatively significant" or "substantively impressive" distinction, have not been established, analogous to the boundary of alpha, usually set at 0.05, for the stochastic or probabilistic component of "statistical significance". To determine what boundaries are being used for the "quantitative" decisions, we reviewed pertinent articles in three general medical journals. For each contrast of two means, contrast of two rates, or correlation coefficient, we noted the investigators' decisions about stochastic significance, stated in P values or confidence intervals, and about quantitative significance, indicated by interpretive comments. The boundaries between impressive and unimpressive distinctions were best formed by a ratio of greater than or equal to 1.2 for the smaller to the larger mean in 546 comparisons, by a standardized increment of greater than or equal to 0.28 and odds ratio of greater than or equal to 2.2 in 392 comparisons of two rates; and by an r value of greater than or equal to 0.32 in 154 correlation coefficients. Additional boundaries were also identified for "substantially" and "highly" significant quantitative distinctions. Although the proposed boundaries should be kept flexible, indexes and boundaries for decisions about "quantitative significance" are particularly useful when a value of delta must be chosen for calculating sample size before the research is done, and when the "statistical significance" of completed research is appraised for its quantitative as well as stochastic components.

Attaining the minimum target of resolution WHA 54.19 for schistosomiasis control in the Rainforest Zone of the state of Pernambuco, Northeastern Brazil

Resolution 19 of the 54th World Health Assembly (WHA-54.19) urged member nations to promote preventive measures, ensure treatment and mobilize resources for control of schistosomiasis and soil-transmitted helminthiases (STH). The minimum target is to attend 75% of all school-age children at risk by year 2010. The Brazilian Ministry of Health (MoH) recommends biennial surveys of whole communities and treatment of the positives through the Schistosomiasis Control Program within the Unified Health System (PCE-SUS). However, by 2004 the PCE-SUS had covered only 8.4% of the 1.2 million residents in the Rainforest Zone of Pernambuco (ZMP). Six of the 43 municipalities still remained unattended. Only three of the municipalities already surveyed reached coverage of 25% or more. At least 154 thousand children in the 7-14 years old range have to be examined (and treated if positive) within the next five years to attend the minimum target of the WHA 54.19 for the ZMP. To make this target feasible, it is suggested that from 2006 to 2010 the PCE-SUS actions should be complemented with school-based diagnosis and treatment, involving health and educational organs as well as community associations to include both children in schools and non-enrolled school-age children.

How the mind constitutes itself through perceptual learning

Most theories of perception assume a rigid relationship between objects of the physical world and the corresponding mental representations. We show by a priori reasoning that this assumption is not fulfilled. We claim instead that all object-representation correspondences have to be learned. However, we cannot learn to perceive all objects that there are in the world. We arrive at these conclusions by a combinatory analysis of a fictive stimulus world and the way to cope with its complexity, which is perceptual learning. We show that successful perceptual learning requires changes in the representational states of the brain that are not derived directly from the constitution of the physical world. The mind constitutes itself through perceptual learning.

Ambulatory gait analysis results after total knee arthroplasty : arguments for mobile or fixed bearing?

Background: Mobile-bearing knee replacements have some theoretical advantages over fixed-bearing devices. However, very few randomized controlled clinical trials have been published to date, and studies showed little clinical and subjective advantages for the mobile-bearing using traditional systems of scoring. The choice of the ideal outcome measure to assess total joint replacement remains a complex issue. However, gait analysis provides objective and quantifying evidences of treatment evaluation. Significant methodological advances are currently made in gait analysis laboratories and ambulatory gait devices are now available. The goal of this study was to provide gait parameters as a new objective method to assess total knee arthroplasty outcome between patients with fixed- and mobile-bearing, using an ambulatory device with minimal sensor configuration. Methods: This randomized controlled double-blind study included to date 31 patients: the gait signatures of 12 patients with mobile-bearing were compared to the gait signatures of 19 patients with fixed-bearing pre-operatively and post-operatively at 6 weeks, 3 months and 6 months. Each participant was asked to perform two walking trials of 30m long at his/her preferred speed and to complete a EQ-5D questionnaire, a WOMAC and Knee Society Score (KSS). Lower limbs rotations were measured by four miniature angular rate sensors mounted respectively, on each shank and thigh. Results: Better relative differences between pre-operative and post-operative 3 months and 6 months KSS (122% vs 34% at 3 months, 138% vs 36% at 6 months) and KSS function (154% vs 8% at 3 months, 183% vs 42% at 6 months) scores were observed for the fixed-bearing compared to the mobile-bearing. The same better improvements for fixed-bearing were also found with the range of knee angles (Affected side: 31% vs -5% at 3 months, 47% vs 5% at 6 months), (Unaffected side: 16% vs 5% at 3 months, 15% vs 6% at 6 months) and peak swing speeds of shank (Affected side: 18% vs -2% at 3 months, 30% vs 4% at 6 months), (Unaffected side: 8% vs -3% at 3 months, 7% vs 4% at 6 months). Conclusions: A new method for a portable system for gait analysis has been developed with very encouraging results regarding the objective outcome of total knee arthroplasty using mobile- and fixed-bearings.

Selection on age at first and at last reproduction in the long-lived Alpine Swift Apus melba

The way an organism spreads its reproduction over time is defined as a life-history trait, and selection is expected to favour life-history traits associated with the highest fitness return. We use a long-term dataset of 277 life histories to investigate the shape and strength of selection acting on the age at first reproduction and at last reproduction in the long-lived Alpine Swift. Both traits were under strong directional selection, but in opposite directions, with selection favouring birds starting their reproductive career early and being able to reproduce for longer. There was also evidence for stabilising selection acting on both traits, suggesting that individuals should nonetheless refrain from reproducing in their first 2 years of life (i.e. when inexperienced), and that reproducing after 7 years of age had little effect on lifetime fitness, probably due to senescence.

The development of the Quality Indicator for Rehabilitative Care (QuIRC): a measure of best practice for facilities for people with longer term mental health problems

BACKGROUND: Despite the progress over recent decades in developing community mental health services internationally, many people still receive treatment and care in institutional settings. Those most likely to reside longest in these facilities have the most complex mental health problems and are at most risk of potential abuses of care and exploitation. This study aimed to develop an international, standardised toolkit to assess the quality of care in longer term hospital and community based mental health units, including the degree to which human rights, social inclusion and autonomy are promoted. METHOD: The domains of care included in the toolkit were identified from a systematic literature review, international expert Delphi exercise, and review of care standards in ten European countries. The draft toolkit comprised 154 questions for unit managers. Inter-rater reliability was tested in 202 units across ten countries at different stages of deinstitutionalisation and development of community mental health services. Exploratory factor analysis was used to corroborate the allocation of items to domains. Feedback from those using the toolkit was collected about its usefulness and ease of completion. RESULTS: The toolkit had excellent inter-rater reliability and few items with narrow spread of response. Unit managers found the content highly relevant and were able to complete it in around 90 minutes. Minimal refinement was required and the final version comprised 145 questions assessing seven domains of care. CONCLUSIONS: Triangulation of qualitative and quantitative evidence directed the development of a robust and comprehensive international quality assessment toolkit for units in highly variable socioeconomic and political contexts

Perinatal Hypoxia Enhances Cyclic Adenosine Monophosphate-mediated BKCa Channel Activation in Adult Murine Pulmonary Artery.

Exposure to perinatal hypoxia results in alteration of the adult pulmonary circulation, which is linked among others to alterations in K channels in pulmonary artery (PA) smooth muscle cells. In particular, large conductance Ca-activated K (BKCa) channels protein expression and activity were increased in adult PA from mice born in hypoxia compared with controls. We evaluated long-term effects of perinatal hypoxia on the cyclic adenosine monophosphate (cAMP)/protein kinase A (PKA) pathway-mediated activation of BKCa channels, using isoproterenol, forskolin, and dibutyryl-cAMP. Whole-cell outward current was higher in pulmonary artery smooth muscle cells from mice born in hypoxia compared with controls. Spontaneous transient outward currents, representative of BKCa activity, were present in a greater proportion in pulmonary artery smooth muscle cells of mice born in hypoxia than in controls. Agonists induced a greater relaxation in PA of mice born in hypoxia compared with controls, and BKCa channels contributed more to the cAMP/PKA-mediated relaxation in case of perinatal hypoxia. In summary, perinatal hypoxia enhanced cAMP-mediated BKCa channels activation in adult murine PA, suggesting that this pathway could be a potential target for modulating adult pulmonary vascular tone after perinatal hypoxia.

Long-term risk of incident type 2 diabetes and measures of overall and regional obesity: the EPIC-InterAct case-cohort study

BACKGROUND Waist circumference (WC) is a simple and reliable measure of fat distribution that may add to the prediction of type 2 diabetes (T2D), but previous studies have been too small to reliably quantify the relative and absolute risk of future diabetes by WC at different levels of body mass index (BMI). METHODS AND FINDINGS The prospective InterAct case-cohort study was conducted in 26 centres in eight European countries and consists of 12,403 incident T2D cases and a stratified subcohort of 16,154 individuals from a total cohort of 340,234 participants with 3.99 million person-years of follow-up. We used Prentice-weighted Cox regression and random effects meta-analysis methods to estimate hazard ratios for T2D. Kaplan-Meier estimates of the cumulative incidence of T2D were calculated. BMI and WC were each independently associated with T2D, with WC being a stronger risk factor in women than in men. Risk increased across groups defined by BMI and WC; compared to low normal weight individuals (BMI 18.5-22.4 kg/m(2)) with a low WC (<94/80 cm in men/women), the hazard ratio of T2D was 22.0 (95% confidence interval 14.3; 33.8) in men and 31.8 (25.2; 40.2) in women with grade 2 obesity (BMI≥35 kg/m(2)) and a high WC (>102/88 cm). Among the large group of overweight individuals, WC measurement was highly informative and facilitated the identification of a subgroup of overweight people with high WC whose 10-y T2D cumulative incidence (men, 70 per 1,000 person-years; women, 44 per 1,000 person-years) was comparable to that of the obese group (50-103 per 1,000 person-years in men and 28-74 per 1,000 person-years in women). CONCLUSIONS WC is independently and strongly associated with T2D, particularly in women, and should be more widely measured for risk stratification. If targeted measurement is necessary for reasons of resource scarcity, measuring WC in overweight individuals may be an effective strategy, since it identifies a high-risk subgroup of individuals who could benefit from individualised preventive action.

Indicateurs de santé dans le domaine ambulatoire.

Sur mandat de l'Office fédéral de la santé publique, l'Institut d'économie et de management de la santé de l'Université de Lausanne a conduit trois premières études visant à valider de nouveaux indicateurs dans le domaine des soins ambulatoires.[Intertitres] Hospitalisations potentiellement évitables. Identification des maladies. Mesure de l'impact des soins sur l'état de santé. [Graphiques] G1. Taux d'hospitalisation potentiellement évitables par région (2005). G2. Indicateurs de performance du système de santé ambulatoire. G3. Scores de guérison, appliqués aux patients souffrant de bronchite chronique et d'asthme.