Chronic disease management: a qualitative study investigating the barriers, facilitators and incentives perceived by Swiss healthcare stakeholders.

BACKGROUND: Chronic disease management has been implemented for some time in several countries to tackle the increasing burden of chronic diseases. While Switzerland faces the same challenge, such initiatives have only emerged recently in this country. The aim of this study is to assess their feasibility, in terms of barriers, facilitators and incentives to participation. METHODS: To meet our aim, we used qualitative methods involving the collection of opinions of various healthcare stakeholders, by means of 5 focus groups and 33 individual interviews. All the data were recorded and transcribed verbatim. Thematic analysis was then performed and five levels were determined to categorize the data: political, financial, organisational/ structural, professionals and patients. RESULTS: Our results show that, at each level, stakeholders share common opinions towards the feasibility of chronic disease management in Switzerland. They mainly mention barriers linked to the federalist political organization as well as to financing such programs. They also envision difficulties to motivate both patients and healthcare professionals to participate. Nevertheless, their favourable attitudes towards chronic disease management as well as the fact that they are convinced that Switzerland possesses all the resources (financial, structural and human) to develop such programs constitute important facilitators. The implementation of quality and financial incentives could also foster the participation of the actors. CONCLUSIONS: Even if healthcare stakeholders do not have the same role and interest regarding chronic diseases, they express similar opinions on the development of chronic disease management in Switzerland. Their overall positive attitude shows that it could be further implemented if political, financial and organisational barriers are overcome and if incentives are found to face the scepticism and non-motivation of some stakeholders.

French Swiss physicians' attitude toward palliative sedation: Influence of prognosis and type of suffering.

OBJECTIVE: Palliative sedation is a last resort medical act aimed at relieving intolerable suffering induced by intractable symptoms in patients at the end-of-life. This act is generally accepted as being medically indicated under certain circumstances. A controversy remains in the literature as to its ethical validity. There is a certain vagueness in the literature regarding the legitimacy of palliative sedation in cases of non-physical refractory symptoms, especially "existential suffering." This pilot study aims to measure the influence of two independent variables (short/long prognosis and physical/existential suffering) on the physicians' attitudes toward palliative sedation (dependent variable). METHODS: We used a 2 × 2 experimental design as described by Blondeau et al. Four clinical vignettes were developed (vignette 1: short prognosis/existential suffering; vignette 2: long prognosis/existential suffering; vignette 3: short prognosis/physical suffering; vignette 4: long prognosis/physical suffering). Each vignette presented a terminally ill patient with a summary description of his physical and psychological condition, medication, and family situation. The respondents' attitude towards sedation was assessed with a six-point Likert scale. A total of 240 vignettes were sent to selected Swiss physicians. RESULTS: 74 vignettes were completed (36%). The means scores for attitudes were 2.62 ± 2.06 (v1), 1.88 ± 1.54 (v2), 4.54 ± 1.67 (v3), and 4.75 ± 1.71 (v4). General linear model analyses indicated that only the type of suffering had a significant impact on the attitude towards sedation (F = 33.92, df = 1, p = 0.000). Significance of the results: The French Swiss physicians' attitude toward palliative sedation is more favorable in case of physical suffering than in existential suffering. These results are in line with those found in the study of Blondeau et al. with Canadian physicians and will be discussed in light of the arguments given by physicians to explain their decisions.

Identificação de resistência genética do cacaueiro à podridão-parda

O objetivo deste trabalho foi comparar métodos de caracterização da resistência do cacaueiro (Theobroma cacao) à podridão-parda (Phytophthora palmivora). Foram estudados os métodos escala de notas, índice de intensidade de infecção e índice de doença. Discos foliares de 103 genótipos receberam 0,2 mL de uma suspensão com 3x10(5) zoósporos de P. palmivora por mililitro, e os sintomas foram avaliados pelos três métodos. Foram realizadas três avaliações (repetições) por genótipo, cada uma composta por 20 discos. O método do índice de doença foi o mais eficiente em caracterizar a resistência de genótipos de cacaueiro a P. palmivora.

Second-line status epilepticus treatment: comparison of phenytoin, valproate, and levetiracetam.

Purpose:  Phenytoin (PHT), valproic acid (VPA), or levetiracetam (LEV) are commonly used as second-line treatment of status epilepticus (SE), but comparative studies are not available. Methods:  Among 279 adult SE episodes identified prospectively in our tertiary care hospital over 4 years, we retrospectively identified 187 episodes in which PHT, VPA, or LEV were given after benzodiazepines. Patients with postanoxic SE were not included. Demographics, clinical SE features, failure of second-line treatment to control SE, new handicap, and mortality at hospital discharge were assessed. Uni- and multivariable statistical analyses were applied to compare the three agents. Key Findings:  Each compound was used in about one third of SE episodes. VPA failed to control SE in 25.4%, PHT in 41.4%, and LEV in 48.3% of episodes in which these were prescribed. A deadly etiology was more frequent in the VPA group, whereas SE episodes tended to be more severe in the PHT group. After adjustment for these known SE outcome predictors, LEV failed more often than VPA [odds ratio (OR) 2.69; 95% confidence interval (CI) 1.19-6.08]; 16.8% (95% CI: 6.0-31.4%) of second-line treatment failures could be attributed to LEV. PHT was not statistically different from the other two compounds. Second-line treatment did not seem to influence new handicap and mortality, whereas etiology and the SE Severity Score (STESS) were robust independent predictors. Significance:  Even without significant differences on outcome at discharge, LEV seems less efficient than VPA to control SE after benzodiazepines. A prospective comparative trial is needed to address this potentially concerning finding.

Pontificale parisiense [Pontifical dit de Poitiers ou de Vierzon].

Sur le feuillet de garde A, cette note autographe de Mabillon : « Hic codex optimae notae scriptus est ante annos circiter octingentos. Multa scitu digna continet, maxime in triduo ante Pascha. In litaniis sabbati sancti fit supplicatio pro congregatione S. Petri, quem patronum habet Pictavensis ecclesia. Invocantur etiam in iisdem sanctus Hilarius et sancta Radegundis, qui praecipue ad ecclesiam Pictavensem pertinent ; sed nulla mentio de aliis sanctis ejusdem dioecesis. Haec scripsi XI kal. decembris an. 1695. — F. J. M. » Fol. 1 : « Benedictio episcoporum. — Consecratio ». Fol. 2 : « Oratio ad ordinandum praesbiterum. — Consecratio. ». Fol. 3 : « Oratio ad ordinandum diaconum. — Consecratio. » Fol. 4 : « Ordo qualiter in Romana ecclesia praesbiteri, diaconi, subdiaconi ordinandi sunt. » Fol. 5 : « Ordinatio subdiaconi ». Fol. 5v° : « Ordinatio ostiarii. » Fol. 6 : « Ordinatio lectoris ». Fol. 6v° : « Ordinatio exorcistae ». Fol. 7 : « Ordinatio acoliti ». Fol. 7v° : « Incipit ordo qualiter publice vel specialiter agitur modus paenitentiae secundum censuram ecclesiasticam, quod quarta feria quinquagesime inchoatur ». Fol. 8v° : « Confessio pura coram Deo et angelis et coram omnibus sanctis » : — de superbia (fol. 12) ; de inani gloria (fol. 13) ; de invidia (fol. 13 vo) ; de ira (fol. 14 vo) ; de tristitia (fol. 15) ; de avaricia (fol. 16) ; de ventris ingluvie (fol. 20) ; de luxuria (fol. 23). Fol. 40v° : « Missa pro paenitentibus et confitentibus, sive unus sive plures fuerint ». Fol. 43 : « Denunciatio scrutinii quod tertia ebdomada in quadragesima secunda feria iniciatur ». Fol. 43v° : « Oratio super electos ad catecuminum faciendum ». Fol. 44 : « Benedictio salis dandi caticuminis. » — Prières et exhortations aux catéchumènes. Explication des évangiles. Fol. 54-56 : Le Credo, en grec avec traduction latine au-dessus. La traduction est faite de mot à mot. Pour l'article grec, le traducteur s'est contenté de mettre au-dessus, dans le texte latin, ces lettres ar. (articulus). Fol. 58v° : Explication du Pater. Fol. 60v° : « Incipit missa primi scrutinii ». Fol. : 63 : « Alia missa de secundo scrutinio ». Fol. 66v° : « Missa de tertio scrutinio ». Fol. 70 : « Sabbato ante diem Palmarum ». Fol. 72 : « Dominica indulgentiae quae est dies Palmarum ». Fol. 73 : Les 36 premiers vers de la pièce Gloria, laus de Théodulfe, évêque d'Orléans (Henry Martin signale l'éd. qu'en a fait Duemmler dans les Poetae latini aevi carolini, t. I, p. 558 : « Gloria, laus et honor tibi sit, Christe redemptor, Cui puerile decus promsit osanna pium. Israhel es tu rex Davidis et inclita proles, Nomine qui in Domini, rex benedicte, venis... » Fol. 95 :« Feria II post Palmas ». Fol. 98v° : « Feria tertia ». Fol. 130 : « Feria V, quae est cena Domini ». Fol. 141v° : « Alia missa eodem die, si plures ad reconciliandum venerint ». Fol. 154 : « Missa chrismalis ». Fol. 160 : Litanies. A noter : SS. Denys, Quentin, Julien, Géréon, Hilaire, Martin, Aignan, Benoît, Cloud [Clodoald], Ste Geneviève. Fol. 170v° : « Benedictio chrismatis principalis ». Fol. 171 : « Exorcismus olei ad baptizandos ». Fol. 173v° : In cena Domini de Flavius, évêque: « Versus Flavii episcopi ad mandatum in cena Domini ». « Tellus a cethra jubilent in magni cena principis, Que protoplasti pectora vite purgavit ferculo ; Hac nocte factor omnium potenti sat mysterio Carnem suam cum sanguine in escam transfert anime. — Tellus. » Fol. 174 : « Item versus Bedae » (Bède). « Fuit Domini dilectus languens a Bethania Lazarus beatus sacris olim cum sororibus quas Jhesus eternus Amor diligebat plurimum Martham simul et Mariam, felices per secula. » Fol. 174v° : « Feria VI quae est Parasceve ». Fol. 192v° : « Pange lingua gloriosi Proelium certaminis ». Fol. 193 : « Incipit de sabbato sancto. — Ordo baptisterii ». Fol. 200v° : Litanies. A noter : SS. Quentin, Cucuphat, Julien, Lucien, Hilaire, Martin, Benoît, Germain, Columban, Samson ; SStes Geneviève, Brigitte, Colombe, Radegonde, Aldegonde. — A noter aussi (fol. 201 vo) : « Ut exercitum Francorum conservare digneris. — Ut illum abbatem et cunctam congregationem sancti illius in tuo apto servitio conservare digneris... » Fol. 202 : « Benedictio cerei. — Exultet jam angelica turba coelorum. Exultent divina mysteria... », avec neumes. Fol. 208 : Litanies. A noter : SS. Hilaire, Martin, Ambroise, Maur, Maurille, Lezin, évêque d'Angers ; SStes Blandine, Nathalie. Fol. 210 : « Inde canitur hic versus : »« Urbs beata Hierusalem, dicta pacis visio, que construitur in celis vivis ex lapidibus... » Fol. 210v° : « Benedictio fontis ». Fol. 213 : vers « Tibi laus perennis auctor baptismatis... » Fol. 213v° : Litanies. A noter : SS. Martin, Brice, Médard, Vaast, Germain, Marcel, Hilaire ; SStes Reine, Julienne, Gertrude, Colombe, Geneviève, Afre, Radegonde, Aldegonde, Darie, Brigitte, Paule. — A noter (fol. 215) : « Ut exercitum Francorum conservare digneris. — Ut congregationem sancti Petri in tuo apto servitio conservare digneris ». Fol. 223 : « Finit ordo baptisterii ». Fol. 227 : Le jour de Pâques. Fol. 230v° : « Feria II ». Fol. 241 : « Feria quinta ». Fol. 245v° : « Feria VI ». Fol. 248 : « Sabbato ». Fol. 252v° : « In octavis Paschae ». Fol. 256v° : « Missa in octavis Paschae pro baptizatis ». Fol. 257v° : « Missa pro parroechias in diebus paschalibus... ». Fol. 258v° : « Fides catholica continens credulitatem... » Fol. 269 : « Missa pro conjugibus sterilitate infecundis in procreatione prolis ». Fol. 273v° : « Orationes ad benedicendam aquam aspergendam in domo. — Exorcismus salis ». Fol. 274 : « Benedictio salis. — Exorcismus aque. — Benedictio aque ». Fol. 274v° : « Benedictio salis et aquae... » etc. Fol. 275 : « Exorcismus salis et aquae contra fulgura ». Fol. 276 : « Benedictio salis ad pecora. — Orationes ad clericum faciendum ». Fol. 276v° : « Benedictio putei ». Fol. 277 : « Benedictio frugum novarum ». Fol. 277v° : « Benedictio panis. — Oratio ad capillarum (sic). — Alia ad tonsorandum puerum ». Fol. 278 : « Oratio post tonsionem. — Oratio ad barbas tondendas ». Fol. 278 : « lncipit actio pontificalis ad... » . Le verso du feuillet 279 est tout à fait effacé. Neumes français, du IXe s., aux f. 202-204 (l'Exultet) ; addition du Xe s. au f. 203 v° (Bernard).

Incidence and risk factors for chronic elevation of alanine aminotransferase levels in HIV-infected persons without hepatitis b or c virus co-infection.

BACKGROUND: Chronic liver disease in human immunodeficiency virus (HIV)-infected patients is mostly caused by hepatitis virus co-infection. Other reasons for chronic alanine aminotransferase (ALT) elevation are more difficult to diagnose. METHODS: We studied the incidence of and risk factors for chronic elevation of ALT levels (greater than the upper limit of normal at 2 consecutive semi-annual visits) in participants of the Swiss HIV Cohort Study without hepatitis B virus (HBV) or hepatitis C virus (HCV) infection who were seen during the period 2002-2008. Poisson regression analysis was used. RESULTS: A total of 2365 participants were followed up for 9972 person-years (median age, 38 years; male sex, 66%; median CD4+ cell count, 426/microL; receipt of antiretroviral therapy [ART], 56%). A total of 385 participants (16%) developed chronic elevated ALT levels, with an incidence of 3.9 cases per 100 person-years (95% confidence interval [CI], 3.5-4.3 cases per 100 person-years). In multivariable analysis, chronic elevated ALT levels were associated with HIV RNA level >100,000 copies/mL (incidence rate ratio [IRR], 2.23; 95% CI, 1.45-3.43), increased body mass index (BMI, defined as weight in kilograms divided by the square of height in meters) (BMI of 25-29.9 was associated with an IRR of 1.56 [95% CI, 1.24-1.96]; a BMI 30 was associated with an IRR of 1.70 [95% CI, 1.16-2.51]), severe alcohol use (1.83 [1.19-2.80]), exposure to stavudine (IRR per year exposure, 1.12 [95% CI, 1.07-1.17]) and zidovudine (IRR per years of exposure, 1.04 [95% CI, 1.00-1.08]). Associations with cumulative exposure to combination ART, nucleoside reverse-transcriptase inhibitors, and unboosted protease inhibitors did not remain statistically significant after adjustment for exposure to stavudine. Black ethnicity was inversely correlated (IRR, 0.52 [95% CI, 0.33-0.82]). Treatment outcome and mortality did not differ between groups with and groups without elevated ALT levels. CONCLUSIONS: Among patients without hepatitis virus co-infection, the incidence of chronic elevated ALT levels was 3.9 cases per 100 person-years, which was associated with high HIV RNA levels, increased BMI, severe alcohol use, and prolonged stavudine and zidovudine exposure. Long-term follow-up is needed to assess whether chronic elevation of ALT levels will result in increased morbidity or mortality.

Protection of Structural Concrete Substructures, Construction Report, HR-220, 1981

It is the objective of this project to determine, via field tests, the long term effectiveness of several available systems as their ability to protect concrete surfaces against the intrusion of chloride ions. Early concepts of this project included utilizing personnel from several offices within the Highway Division of the Iowa Department of Transportation. Cooperation and coordination with regularly scheduled activities were considered imperative. A meeting for this purpose was held on April 16, 1980. This meeting was attended by the investigators, Mr. Bernard C. Brown, Office of Materials, Mr. Richard Merritt, District 6 Materials Engineer, Mr. John Saunders, District 6 Maintenance Engineer, and Mr. James Phinney, Resident Maintenance Engineer.