Multimorbidity in primary care : protocol of a national cross-sectional study in Switzerland.

INTRODUCTION: With the ageing of the population and the general improvement of care, an increasing number of people are living with multiple chronic health conditions or 'multimorbidity'. Multimorbidity often implies multiple medical treatments. As a consequence, the risk of adverse events and the time spent by patients for their treatments increase exponentially. In many cases, treatment guidelines traditionally defined for single conditions are not easily applicable. Primary care for individuals with multimorbidity requires complex patient-centred care and good communication between the patient and the general practitioner (GP). This often includes prioritising among the different chronic conditions. METHODS AND ANALYSIS: The main objectives of this study are to describe the burden related to multimorbidity (disease-related burden and burden of treatment) in primary care and to identify the factors influencing it. Other objectives include evaluating patients' perception of treatment burden and quality of life, assessing factors influencing that perception, and investigating prioritisation in the management of multimorbidity from the perspectives of GPs and patients. For this cross-sectional study, patient enrolment will take place in GP's private practices across Switzerland. A convenient sample of 100 GPs will participate; overall, 1000 patients with at least three chronic health conditions will be enrolled. Data will be collected as paper-based questionnaires for GPs and delayed telephone interview questionnaires for patients. GPs will provide demographic and practice-related data. In addition, each GP will complete a paper-based questionnaire for each patient that they enrol. Each patient will complete a telephone interview questionnaire. ETHICS AND DISSEMINATION: This study has been approved by the research ethics committee of Canton Vaud, Switzerland (Protocol 315/14). The results of the study will be reported in international peer-reviewed journals.

Growth Strategies in Pulp and Paper Industry: An Empirical Investigation on Profitability Effects

This study investigates whether there are differences in profitability of PPI companies based on the growth strategy they have chosen to follow. It is examined whether those companies following organic growth strategy are more profitable than those companies following acquisitive growth strategy. It is also investigated are ones larger than the others, or are ones growing faster than the others. Also, the factors affecting the profitability of acquisitive companies are further examined. The results showed that there actually are differences between the two groups. Organically grown companies were found to be more profitable, smaller and growing slower than acquisitive companies. When it comes to examining only acquisitive companies there could be found factors that better or worsen the profitability of companies. For example targets that the company has bought in developing markets were making them more profitable.

Varastonohjauksen menetelmät ja niiden käyttö osana yrityksen kannattavuuden hallintaa

Tutkielman tavoitteena on tuottaa kohdeyrityksessä tietoa, joka auttaa tunnistamaan ja soveltamaan kannattavuuden parantamiseen vaikuttavia varastonohjauksen menetelmiä ja tukee varastonohjausta koskevaa päätöksentekoa. Varastonohjauksella tarkoitetaan varastoihin sitoutuneen pääoman hallintaa ja materiaalivirtojen ohjausta. Varastonohjauksen ensisijainen tavoite on saavuttaa optimaalinen tasapaino halutun asiakaspalvelutason ja varastonpidosta aiheutuvien kustannusten välillä. Tutkielma toteutettiin tapaustutkimuksena. Aineistona käytettiin kohdeyrityksen sisäisiä tietoja. Varastonohjausperiaatteiden kohdentamiseksi varastonimikkeet luokiteltiin ABC-analyysin avulla, jota täydennettiin kriittisyysanalyysillä. Ohjausmenetelmät määriteltiin luokittain. Varastoilla on merkittävä rooli yrityksen toiminnassa. Niihin sitoutuu pääomaa, joka vaikuttaa yrityksen kannattavuuteen. Nimikkeiden luokittelu ja luokkakohtaisten ohjausmenetelmien ja -periaatteiden määrittely on erittäin tärkeää. Varastotasojen alentamisella ja varaston kiertonopeuden nostamisella on kannattavuutta parantava vaikutus.

Profitability Analysis of Service Contracts of Devices

The objective of this study has been to make a profitability analysis of service contracts for a company in Finland. The purpose has been to see how profitable the contracts are and if there possibly were some things to change or develop in the contracts. Allocation rules of cost accounting, service costs both profitability and management of services have been considered in the theory part. All the service contracts that have been valid at least three last accounting periods have been included in the study. All direct costs relating to the contracts have been collected and indirect costs have been assigned to the contracts. Profitability of the contracts has been calculated over three years. Results have been analyzed according to the key figures the company is controlling. Some suggestions for developments have been given at the end of the study. The study has shown differences between the contracts. Part of them has turned out to be like the profitability aims of the company and part less profitable. The study has shown that many factors have an effect on the profitability of the service contracts.

Prise en charge de la candidose oesophagienne en médecine de premier recours [Management of the esophageal candidiasis by the primary care physician].

La candidose oesophagienne est l'une des infections opportunistes les plus fréquentes chez les patients infectés par le VIH. Ce diagnostic se rencontre également chez des patients sans immunodéficience manifeste. Certains facteurs de risque sont également associés à cette pathologie, tels que les traitements corticoïdes systémiques et inhalés ou les traitements par inhibiteurs de la pompe à protons et les antihistaminiques H2. En l'absence de facteur de risque identifié, un déficit immunitaire primaire devrait être recherché. La prévention de la candidose oesophagienne est basée en premier lieu sur l'identification des facteurs de risque, ainsi qu'un meilleur contrôle de ceux-ci. Cet article présente en détail la physio-pathologie, la clinique et la prise en charge par le médecin de premier recours de la candidose oesophagienne. Nous aborderons également les moyens de prévention de la candidose oesophagienne quand il y a lieu. Esophageal candidiasis is one of the most common opportunistic infections in patients infected by human immunodeficiency virus (HIV). This pathology is also found in patients without overt immunodeficiency. Other risk factors are known to be associated with this disease like inhaled or systemic corticosteroid treatment or proton-pump inhibitors and H2 receptor antagonists. In the absence of identified risk factors, a primary immune deficiency should be sought. Prevention of esophageal candidiasis is based primarily on the identification of risk factors, and a better control of them. This article presents a review of the physiopathology, clinical presentation and management of esophageal candidiasis by primary care physicians. We will also discuss ways of preventing esophageal candidiasis when necessary.

Statines en prévention primaire: comment décider avec le patient [Statins in primary prevention: how to share the decision?].

Long-term treatment of hypercholesterolemia with statins diminishes the risk of cardiovascular events. Statins are recommended in secondary prevention of cardiovascular disease. In the absence of preexisting cardiovascular disease, the decision to start a statin or not is most often made by the general practitioner and his patient. An interactive decision aid, developed by the Mayo Clinic, has just been translated in French and adapted to the Swiss epidemiology of cardiovascular risk factors, with the aim of promoting shared decision-making. This paper reviews the conditions and potential benefits of shared decision-making about statin therapy in primary prevention.

Dual activation of pathways regulated by steroid receptors and peptide growth factors in primary prostate cancer revealed by Factor Analysis of microarray data

Background: We use an approach based on Factor Analysis to analyze datasets generated for transcriptional profiling. The method groups samples into biologically relevant categories, and enables the identification of genes and pathways most significantly associated to each phenotypic group, while allowing for the participation of a given gene in more than one cluster. Genes assigned to each cluster are used for the detection of pathways predominantly activated in that cluster by finding statistically significant associated GO terms. We tested the approach with a published dataset of microarray experiments in yeast. Upon validation with the yeast dataset, we applied the technique to a prostate cancer dataset. Results: Two major pathways are shown to be activated in organ-confined, non-metastatic prostate cancer: those regulated by the androgen receptor and by receptor tyrosine kinases. A number of gene markers (HER3, IQGAP2 and POR1) highlighted by the software and related to the later pathway have been validated experimentally a posteriori on independent samples. Conclusion: Using a new microarray analysis tool followed by a posteriori experimental validation of the results, we have confirmed several putative markers of malignancy associated with peptide growth factor signalling in prostate cancer and revealed others, most notably ERRB3 (HER3). Our study suggest that, in primary prostate cancer, HER3, together or not with HER4, rather than in receptor complexes involving HER2, could play an important role in the biology of these tumors. These results provide new evidence for the role of receptor tyrosine kinases in the establishment and progression of prostate cancer.

Initiation of rivaroxaban in patients with nonvalvular atrial fibrillation at the primary care level: the Swiss Therapy in Atrial Fibrillation for the Regulation of Coagulation (STAR) Study.

BACKGROUND: Rivaroxaban has become an alternative to vitamin-K antagonists (VKA) for stroke prevention in non-valvular atrial fibrillation (AF) patients due to its favourable risk-benefit profile in the restrictive setting of a large randomized trial. However in the primary care setting, physician's motivation to begin with rivaroxaban, treatment satisfaction and the clinical event rate after the initiation of rivaroxaban are not known. METHODS: Prospective data collection by 115 primary care physicians in Switzerland on consecutive nonvalvular AF patients with newly established rivaroxaban anticoagulation with 3-month follow-up. RESULTS: We enrolled 537 patients (73±11years, 57% men) with mean CHADS2 and HAS-BLED-scores of 2.2±1.3 and 2.4±1.1, respectively: 301(56%) were switched from VKA to rivaroxaban (STR-group) and 236(44%) were VKA-naïve (VN-group). Absence of routine coagulation monitoring (68%) and fixed-dose once-daily treatment (58%) were the most frequent criteria for physicians to initiate rivaroxaban. In the STR-group, patient's satisfaction increased from 3.6±1.4 under VKA to 5.5±0.8 points (P<0.001), and overall physician satisfaction from 3.9±1.3 to 5.4±0.9 points (P<0.001) at 3months of rivaroxaban therapy (score from 1 to 6 with higher scores indicating greater satisfaction). In the VN-group, both patient's (5.4±0.9) and physician's satisfaction (5.5±0.7) at follow-up were comparable to the STR-group. During follow-up, 1(0.19%; 95%CI, 0.01-1.03%) ischemic stroke, 2(0.37%; 95%CI, 0.05-1.34%) major non-fatal bleeding and 11(2.05%; 95%CI, 1.03-3.64%) minor bleeding complications occurred. Rivaroxaban was stopped in 30(5.6%) patients, with side effects being the most frequent reason. CONCLUSION: Initiation of rivaroxaban for patients with nonvalvular AF by primary care physicians was associated with a low clinical event rate and with high overall patient's and physician's satisfaction.

Sickness certification in primary care: a survey on views and practices among Swiss physicians.

QUESTIONS UNDER STUDY: Studies from several countries (Scandinavia, United Kingdom) report that general practitioners (GPs) experience problems in sickness certification. Our study explored views of Swiss GPs towards sickness certification, their practice and experience, professional skills and problematic interactions with patients. METHODS: We conducted an online survey among GPs throughout Switzerland, exploring behaviour of physicians, patients and employers with regard to sickness certification; GPs' views about sickness certification; required competences for certifying sickness absence, and approaches to advance their competence. We piloted the questionnaire and disseminated it through the networks of the five Swiss academic institutes for primary care. RESULTS: We received 507 valid responses (response rate 50%). Only 43/507 GPs experienced sickness certification as problematic per se, yet 155/507 experienced problems in sickness certification at least once a week. The 507 GPs identified estimating a long-term prognosis about work capacity (64%), handling conflicts with patients (54%), and determining the reduction of work capacity (42%) as problematic. Over 75% would welcome special training opportunities, e.g., on sickness certifications during residency (93%), in insurance medicine (81%), and conflict management (80%). CONCLUSION: Sickness certification as such does not present a major problem to Swiss GPs, which contrasts with the experience in Scandinavian countries and in the UK. Swiss GPs did identify specific tasks of sickness certification as problematic. Training opportunities on sick-leave certification and insurance medicine in general were welcomed.

"Hit the primary": A paradigm shift in the treatment of metastatic prostate cancer?

Patients with metastatic prostate cancer (PC) represent a heterogeneous group with survival rates varying between 13 and 75 months. The current standard treatment in this setting is hormonal therapy, with or without docetaxel-based chemotherapy. In the era of individualized medicine, however, maximizing treatment options, especially in long-term surviving patients with limited disease burden, is of capital importance. Emerging data, mainly from retrospective surgical series, show survival benefits in men diagnosed with metastatic PC following definitive therapy for the prostate. Whether the irradiation of primary tumor in a metastatic disease might improve the therapeutic ratio in association with systemic treatments remains investigational. In this scenario, modern radiation therapy (RT) can play a significant role owing to its intrinsic capability to act as a more general immune response modifier, as well as to the potentially better toxicity profile compared to surgery. Preclinical data, clinical experience, and challenges in local treatment in de novo metastatic PC are reviewed and discussed.

Quality assessment of primary care for common mental disorders in isolated communities: Taking advantage of health records.

INTRODUCTION: This article is part of a research study on the organization of primary health care (PHC) for mental health in two of Quebec's remote regions. It introduces a methodological approach based on information found in health records, for assessing the quality of PHC offered to people suffering from depression or anxiety disorders. METHODS: Quality indicators were identified from evidence and case studies were reconstructed using data collected in health records over a 2-year observation period. Data collection was developed using a three-step iterative process: (1) feasibility analysis, (2) development of a data collection tool, and (3) application of the data collection method. The adaptation of quality-of-care indicators to remote regions was appraised according to their relevance, measurability and construct validity in this context. RESULTS: As a result of this process, 18 quality indicators were shown to be relevant, measurable and valid for establishing a critical quality appraisal of four recommended dimensions of PHC clinical processes: recognition, assessment, treatment and follow-up. CONCLUSIONS: There is not only an interest in the use of health records to assess the quality of PHC for mental health in remote regions but also a scientific value for the rigorous and meticulous methodological approach developed in this study. From the perspective of stakeholders in the PHC system of care in remote areas, quality indicators are credible and provide potential for transferability to other contexts. This study brings information that has the potential to identify gaps in and implement solutions adapted to the context.

The application of communicative language teaching : a particular case in a polish primary school

L’objectiu d’aquest estudi és examinar si l’Ensenyament Comunicatiu de la Llengua és usat per les mestres quan duen a terme classes d’anglès com a llengua estrangera en una escola de primària polonesa, amb un context educatiu especial. Aquesta recerca qualitativa analitza cinc conjunts principals d’informació relacionats amb l’ensenyament de la llengua estrangera que caracteritzen l’enfocament de l’Ensenyament Comunicatiu de la Llengua i que estan centrats en: el coneixement i les creences dels mestres sobre l’enfocament de l’Ensenyament Comunicatiu de la Llengua; l’ús de la llengua; els aspectes de la llengua anglesa que s’ensenyen; les característiques de les activitats: i el procés d’ensenyament. Per aquest objectiu, s’ha proporcionat un qüestionari a cada mestra d’anglès i s’han portat a terme algunes observacions d’aula per tal de recollir dades, analitzar-les i extreure’n unes conclusions. Els resultats de la investigació mostren que les mestres d’anglès donen bastant suport a l’enfocament de l’Ensenyament Comunicatiu de la Llengua, així com apliquen força sovint els seus trets característics quan porten a terme les classes.

Creating and organizing an "English class" in primary education: The role of teacher talk in the EFL amd CLIL Classes

Catalonia is a bilingual country where the presence of English in the social context is small; the amount of input received by the primary education pupils is very little and this input mainly comes from the English lessons at school. Consequently, this situation combined with the increasing demand for English and the fact that the new generations want to become communicatively competent in English place the role of English teachers in a relevant position. This research project analyses the role of the English teacher talk; in particular, the study focuses on the teacher’s oral productions in foreign language lessons (EFL) and in content-based lessons (CLIL).