La violence ou le traumatisme médical dans une consultation pluridisciplinaire spécialisée [Violence our medical trauma in specialized multidisciplinary consultation].

In this article a particular patient/physician relationship is described and analyzed: The described interaction between patient and physician during a consultative investigation by several specialists differs markedly from the common trustful relation between a patient and his family doctor. In this context the term and phenomenon pain is discussed and the necessity for an understandable, patient-oriented presentation of diagnosis and hypotheses considering the patient's individual bio-psycho-social dimension is stressed. Consequences for student education are mentioned.

Lethargic crab disease: multidisciplinary evidence supports a mycotic etiology

Although lethargic crab disease (LCD) is causing massive mortalities in populations of the mangrove crab Ucides cordatus of Northeastern Brazil, the identity of its etiological agent was hitherto unknown. In this study we provide robust evidence suggesting that LCD is caused by an anamorph Ascomycota (Fungi). We examined specimens of U. cordatus collected from stocks affected by LCD. Histological and TEM methods detected the presence of hyphae, conidia, and condiophores in several host tissues. Moreover, the abundance of fungal stages is negatively associated with crab health. Finally, DNA was isolated from the fungus and a region of its 18S ribosomal gene was sequenced. Phylogenetic analyses not only confirm the diagnosis of the LCD fungus in crab tissues as an ascomycete, but also suggest a close relationship with members of the subphylum Pezizomycotina.

Intérêt d'une Consultation spécialisée multidisciplinaire en neuro-urologie et urologie fonctionnelle [Benefit of a specialized multidisciplinary clinic in neuro-urology and functional urology].

Functional disorders encounter for a large amount of the medical activity, including in urology. The decreased quality of life due to lower urinary tract symptoms requires a prompt management, with primary assessment undergone in community. Referral to a specialist is required when simple management has failed, and whenever any of these coexists: hematuria, recurrent urinary infection, and neurological condition. The specialized clinic in neurourology and functional urology aim at further investigating the underlying disorder responsible for the urinary symptoms and preventing urinary tract complications. A multidisciplinary team is the key to accurately assess patients with regards to their bother and handicap, therefore offering the most appropriate conservative, medical or surgical management.

Supply-side risk adjustment and outlier payment policy

In most health care systems where a prospective payment system is implemented, an outlier payment is used to cover the hospitals' unusually high costs. When the hospital chooses its cost reduction effort before observing a patient's severity, we show that the best outlier payment is based on the realized cost when the hospital exerts the first best level of effort, for any level of severity. [Authors]

Information seeking activity and adherence to therapy: Findings from the Swiss Inflammatory Bowel Disease Cohort Study

Background: In spite of the relapsing nature of inflammatory bowel diseases (IBD), on average, 40% of IBD patients are nonadherent to treatments. On the other hand, they are often actively seeking information on their disease. The relationship between information seeking behaviour and adherence to treatment is poorly documented. The main aim of this study was to examine this association among IBD patients. Methods: We used data from the Swiss IBD cohort study. Baseline data included questions on adherence to ongoing treatments. A survey was conducted in October 2009 to assess information sources and themes searched by patients. Crude odds ratio (OR) and 95% CI were calculated for the association between adherence and information seeking. Adjustment for potential confounders and main known risk factors was performed using multivariate logistic regression. Differences in the proportions of information sources and themes were compared between adherent and non-adherent patients. Results: The number of patients eligible was 488. Nineteen percent (N = 99) were non-adherent to treatment and one third (N = 159) were active information seekers. Crude OR for being non-adherent was 69% higher among information seekers compared to non-seekers (OR = 1.69; 95%CI 0.99 2.87). Adjusted OR for non-adherence was OR = 2.39 (95%CI 1.32 4.34) for information seekers compared to non-seekers. Family doctors were 15.2% more often consulted (p = 0.019) among patients who were adherent to treatment compared to those who were not, as were books and TV (+13.1%; p = 0.048). No difference was observed for internet or gastroenterologists as sources of information. Themes of information linked to tips for disease management were 14.2% more often searched among non-adherent patients (p = 0.028) compared to adherent. No difference was observed for the other themes (research and development on IBD, therapies, basic information on the disease, patients' experiences sharing, miscellaneous). Conclusions: Active information seeking was shown to be strongly associated with non-adherence to treatment in a population of IBD patients in Switzerland. Surprisingly themes related to therapies were not especially those on which nonadherent patients focused. Indeed, management of symptoms and everyday life with the disease seemed to be the most pressing information concerns of patients. Results suggest that the family doctor plays an important role in the multidisciplinary care approach needed for IBD patients.

Réduction de volume pulmonaire dans l'emphysème sévère: importance d'une prise en charge multidisciplinaire [Lung volume reduction (LVR) in severe emphysema: a multidisciplinary approach].

Most cases of emphysema are managed conservatively. However, in severe symptomatic emphysema associated with hyperinflation, lung volume reduction (LVR) may be proposed to improve dyspnea, exercice capacity, pulmonary functions, walk distance and to decrease long-term mortality. LVR may be achieved either surgically (LVRS) or endoscopically (EVLR by valves or coils) according to specific clinical criteria. Currently, the optimal approach is discussed in a multidisciplinary setting. The latter permits a personalized evaluation the patient's clinical status and allows the best possible therapeutic intervention to be proposed to the patient.

When do we dare to stop biological or immunomodulatory therapy for Crohn's disease? Results of a multidisciplinary European expert panel.

BACKGROUND: Safety and economic issues have increasingly raised concerns about the long term use of immunomodulators or biologics as maintenance therapies for Crohn's disease (CD). Despite emerging evidence suggesting that stopping therapy might be an option for low risk patients, criteria identifying target groups for this strategy are missing, and there is a lack of recommendations regarding this question. METHODS: Multidisciplinary European expert panel (EPACT-II Update) rated the appropriateness of stopping therapy in CD patients in remission. We used the RAND/UCLA Appropriateness Method, and included the following variables: presence of clinical and/or endoscopic remission, CRP level, fecal calprotectin level, prior surgery for CD, and duration of remission (1, 2 or 4 years). RESULTS: Before considering withdrawing therapy, the prerequisites of a C-reactive protein (CRP) and fecal calprotectin measurement were rated as "appropriate" by the panellists, whereas a radiological evaluation was considered as being of "uncertain" appropriateness. Ileo-colonoscopy was considered appropriate 1 year after surgery or after 4 years in the absence of prior surgery. Stopping azathioprine, 6-mercaptopurine or methotrexate mono-therapy was judged appropriate after 4 years of clinical remission. Withdrawing anti-TNF mono-therapy was judged appropriate after 2 years in case of clinical and endoscopic remission, and after 4 years of clinical remission. In case of combined therapy, anti-TNF withdrawal, while continuing the immunomodulator, was considered appropriate after two years of clinical remission. CONCLUSION: A multidisciplinary European expert panel proposed for the first time treatment stopping rules for patients in clinical and/or endoscopic remission, with normal CRP and fecal calprotectin levels.

Vocational rehabilitation: a multidisciplinary intervention

Vocational rehabilitation is by definition a multidisciplinary intervention in a process linked to the facilitation of return to work or to the prevention of loss of the work. Clinical staff in contact with a person who has lost his job (general practitioner, specialized physician) must promote vocational rehabilitation. Medical rehabilitation for those with disabilities, whether new or old, has to be followed without delay by vocational rehabilitation. It is even better if these two intertwined processes are overlapping. They involve many professionals including physiotherapists, occupational therapists, psychologists, vocational trainers, job counsellors, teachers, case-managers, job placement agencies. Vocational rehabilitation has a financial cost, borne by many state organizations (security, social system, social affairs) as well as by employers and private insurances, which are in case of accident, concerned by this process. However, the evidence suggests that this is recouped 2- to 10-fold as suggested by the British Society of Rehabilitation Medicine

Changing paradigms--an update on the multidisciplinary management of malignant glioma.

Treatment of malignant glioma requires a multidisciplinary team. Treatment includes surgery, radiotherapy, and chemotherapy. Recently developed agents have demonstrated activity against recurrent malignant glioma and efficacy if given concurrently with radiotherapy in the upfront setting. Oligodendroglioma with 1p/19q deletions has been recognized as a distinct pathologic entity with particular sensitivity to radiotherapy and chemotherapy. Randomized trials have shown that early neoadjuvant or adjuvant administration of procarbazine, lomustine, and vincristine chemotherapy prolongs disease-free survival; however, it has no impact on overall survival. Temozolomide, a novel alkylating agent, has shown modest activity against recurrent glioma. In combination with radiotherapy in newly diagnosed patients with glioblastoma, temozolomide significantly prolongs survival. Molecular studies have demonstrated that the benefit is mainly observed in patients whose tumors have a methylated methylguanine methyltransferase gene promoter and are thus unable to repair some of the chemotherapy-induced DNA damage. For lower-grade glioma, the use of chemotherapy remains limited to recurrent disease, and first-line administration is the subject of ongoing clinical trials. Irinotecan and agents like gefitinib, erlotinib, and imatinib targeting the epidermal growth factor receptor and platelet-derived growth factor receptor have shown some promise in recurrent malignant glioma. This review summarizes recent developments, focusing on the clinical management of patients in daily neuro-oncology practice.