An interdisciplinary HIV-adherence program combining motivational interviewing and electronic antiretroviral drug monitoring.

To ensure successful treatment, HIV patients must maintain a high degree of medication adherence over time. Since August 2004, patients who are (or are at risk of) experiencing problems with their HIV antiretroviral therapy (ART) have been referred by their physicians to an interdisciplinary HIV-adherence program. The program consists of a multifactorial intervention along with electronic drug monitoring (MEMS(TM)). The pharmacists organize individualized semi-structured motivational interviews based on cognitive, emotional, behavioral, and social issues. At the end of each session, the patient brings an adherence report to the physician. This enables the physician to use the adherence results to evaluate the treatment plan. The aim of this study was to retrospectively analyze this on-going interdisciplinary HIV-adherence program. All patients who were included between August 2004 and the end of April 2008 were analyzed. One hundred and four patients were included (59% women, median age 39 (31.0, 46.0) years, 42% black ethnicity). Eighty (77%) patients were ART-experienced patients and 59% had a protease inhibitor-based treatment. The retention rate was high (92%) in the program. Patient inclusion in this HIV-adherence program was determined by patient issues for naive patients and by nonadherence or suboptimal clinical outcomes for ART-experienced patients. The median time spent by a subject at the pharmacy was 35 (25.0, 48.0) minutes, half for the medication handling and half for the interview. The adherence results showed a persistence of 87% and an execution of 88%. Proportion of undetectable subjects increased during study. In conclusion, retention and persistence rates were high in this highly selected problematic population.

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

The efficiency of antigen recognition by CD8+ CTL clones is determined by the frequency of serial TCR engagement.

Using H-2Kd-restricted CTL clones, which are specific for a photoreactive derivative of the Plasmodium berghei circumsporozoite peptide PbCS(252-260) (SYIPSAEKI) and permit assessment of TCR-ligand interactions by TCR photoaffinity labeling, we have previously identified several peptide derivative variants for which TCR-ligand binding and the efficiency of Ag recognition deviated by fivefold or more. Here we report that the functional CTL response (cytotoxicity and IFN-gamma production) correlated with the rate of TCR-ligand complex dissociation, but not the avidity of TCR-ligand binding. While peptide antagonists exhibited very rapid TCR-ligand complex dissociation, slightly slower dissociation was observed for strong agonists. Conversely and surprisingly, weak agonists typically displayed slower dissociation than the wild-type agonists. Acceleration of TCR-ligand complex dissociation by blocking CD8 participation in TCR-ligand binding increased the efficiency of Ag recognition in cases where dissociation was slow. In addition, permanent TCR engagement by TCR-ligand photocross-linking completely abolished sustained intracellular calcium mobilization, which is required for T cell activation. These results indicate that the functional CTL response depends on the frequency of serial TCR engagement, which, in turn, is determined by the rate of TCR-ligand complex dissociation.

Swiss Interdisciplinary Management Programme for Heart Failure (SWIM-HF): a randomised controlled trial study of an outpatient inter-professional management programme for heart failure patients in Switzerland.

PRINCIPLES: International guidelines for heart failure (HF) care recommend the implementation of inter-professional disease management programmes. To date, no such programme has been tested in Switzerland. The aim of this randomised controlled trial (RCT) was to test the effect on hospitalisation, mortality and quality of life of an adult ambulatory disease management programme for patients with HF in Switzerland.METHODS: Consecutive patients admitted to internal medicine in a Swiss university hospital were screened for decompensated HF. A total of 42 eligible patients were randomised to an intervention (n = 22) or usual care group (n = 20). Medical treatment was optimised and lifestyle recommendations were given to all patients. Intervention patients additionally received a home visit by a HF-nurse, followed by 17 telephone calls of decreasing frequency over 12 months, focusing on self-care. Calls from the HF nurse to primary care physicians communicated health concerns and identified goals of care. Data were collected at baseline, 3, 6, 9 and 12 months. Mixed regression analysis (quality of life) was used. Outcome assessment was conducted by researchers blinded to group assignment.RESULTS: After 12 months, 22 (52%) patients had an all-cause re-admission or died. Only 3 patients were hospitalised with HF decompensation. No significant effect of the intervention was found on HF related to quality of life.CONCLUSIONS: An inter-professional disease management programme is possible in the Swiss healthcare setting but effects on outcomes need to be confirmed in larger studies.

Le mouvement peut-il guérir? : histoire de l'engagement des médecins français dans l'élaboration de l'éducation physique (1741-1888)

Résumé : Cette recherche doctorale analyse l'engagement des médecins français autour de l'éducation physique entre 1741 et 1888. Basé sur un travail prosopographique d'identification des médecins qui ont participé à l'élaboration de l'éducation physique, ce travail repose sur une mise en dialogue de leurs prises de position respectives. Pour réaliser cette enquête, nous avons compulsé un large corpus de sources primaires, composé des ouvrages consacrés à la gymnastique médicale mais aussi une très large portion de la production d'imprimés touchant à l'anatomie, l'hygiène, la thérapeutique, la physiologie, l'orthopédie, etc. Le corpus contient également des articles des principaux dictionnaires médicaux de la période et des principales revues médicales du XIXe siècle. Avec une approche critique de l'historiographie et à partir de ce corpus, nous avons travaillé dans le cadre de contextes définis pour saisir au plus près les logiques sociales et scientifiques amenant les médecins auprès de l'éducation physique. Trois conjonctures successives structurent l'engagement médical. Entre 1741 et 1817, la thèse retrace l'émergence d'un questionnement ; les années 1817-1847 constituent un « moment orthopédique » dans la formulation de la gymnastique ; et finalement entre 1847 et 1888, on observe une diversification des voies de légitimation médicale des exercices du corps. Ces trois moments de l'histoire des « discours gymniques médicaux » proposent un certain nombre de convergences : la prégnance de l'orthopédie, une certaine concentration autour de la santé des corps féminins, l'inclusion dans un « projet hygiéniste » ; mais aussi des divergences et des singularités : relatives à la progressive structuration en cours du champ médical, à l'implication progressive du politique (surtout après 1845/1850), aux transformations des pathologies/doctrines médicales « dominantes », ainsi qu'à l'importance plus ou moins forte de l'une ou l'autre des facettes de l'éducation physique (militaire, athlétique, « médicinale » ou pédagogique). Le processus est aussi celui de l'expérimentation de la curation de certaines pathologies (scolioses, affections nerveuses), dans des configurations idéologiques/scientifiques marquées par la « dégénération » (XVIIIe siècle), l'anatomie pathologique (début du XIXe siècle) et plus tard la « dégénérescence » et les affections nerveuses (après 1850). Dans le cadre d'une dynamique d'inspiration « foucaldienne », ces recommandations évoluent d'une anatomopolitique - caractérisée par un essor de discours empreints d'anatomie au XVIIIe siècle - vers une biopolitique - caractérisée par l'engagement de l'Etat qui fait de la gymnastique une discipline d'enseignement, pensée à des fins hygiéniques dans la seconde moitié du XIXe - où le processus réside en fait dans une biologisation progressive des recommandations pratiques. Observée à l'aune de la formulation médicale de l'éducation physique, la biopolitique n'est pas réalisée dans la seconde moitié du XVIIIe, elle se compose lentement aux marges de l'institution scolaire et des gymnastiques pédagogico-militaires pour constituer un projet thérapeutique et hygiénique plus construit après 1850. Abstract : This dissertation analyzes French doctor's involvement in debates and initiatives concerning physical education between 1741 and 1888. Based on a prosopographic inventory of those physicians who participated in the development of physical education, it explores the variety of their discourses with respect to the practice of physical exercises. This investigation relies on a large selection of primary sources: works devoted to medical gymnastic, but also medical treatises related to anatomy, hygiene, therapeutics, physiology, orthopedics, etc. The sources also include articles from the major medical dictionaries and journals of the nineteenth century. These documents are used to explore the socio-scientific mechanisms that underlay physicians' commitment to physical education. Three chronological periods structure medical engagement in the area of physical education. Between 1741 and 1817 the thesis traces the emergence of a questioning; the years 1817 to 1847 represent an « orthopedic moment » in the development of gymnastics; finally between 1847 and 1888, one witnesses a diversification of the legitimation process between medicine and gymnastics. These three moments in the history of « medical and gymnastic discourses » offer a number of similarities: the weight of orthopedics, the ongoing focus on the health of the female body, and the association of these discourses with a « hygienic project ». But differences also distinguish these periods as the medical field became more structured and new medical doctrines became dominant, with the increasing involvement of politics (especially after 1850), and with the changing weight of priorities within physical education (military, athletic, « medical » or pedagogic). Medical discourses centered on the curing of certain diseases (scoliosis or nervous disorders) are analyzed within an ideological configuration marked by the idea of « degeneration » (in the eighteenth century), « pathological anatomy » (in the early nineteenth century) and later « dégénérescence » associated with nervous disorders (after 1850). The dissertation draws on Foucault's historical epistemology to understand how medical recommendations evolve from an anatomopolitics - characterized by a surge in anatomical discourses - toward a biopolitics - characterized by the commitment of the State to introduce gymnastics for hygienic purposes into schools in the second half of the nineteenth century. This process reveals a progressive "biologization" of practical recommendations. The medical discourses about physical education show that Foucault's biopolitical power is not achieved in the second half of the eighteenth century, but develops slowly at the margins of the school system and of pedagogical and military gymnastic, becoming a veritable hygienic and therapeutic project only after 1850.