La théorie décisionnelle appliquée à l'orientation: Le modèle PIC comme outil complémentaire

L'approche décisionnelle met l'accent sur la manière dont l'individu aborde et négocie les décisions à différents moments de son parcours. Le modèle PIC propose un outil qui permet d'accompagner le processus décisionnel systématiquement. Souvent les conseillers ont tendance à le suivre de manière intuitive. Cependant, un suivi structuré pourrait améliorer l'efficacité de leurs interventions.

Stroke initial severity and outcome relative to insurance status in a universal health care system in Switzerland

Contexte et but de l'étude :Le statut socio-économique est suspecté d'avoir une influence significative sur l'incidence des attaques cérébrales (AVC), sur les facteurs de risque cardio-vasculaire, ainsi que sur le pronostic. L'influence de ce statut socio-économique sur la sévérité de l'AVC et sur les mécanismes physiopathologiques sous-jacents est moins connue.Méthode :Sur une période de 4 ans, nous avons collecté de manière prospective (dans un registre) des données concernant tous les patients avec AVC aigus admis à l'Unité Cérébrovasculaire du CHUV. Les données comprenaient le statut assécurologique du patient (assurance privée ou générale), les données démographiques, les facteurs de risque cérébrovasculaires, l'utilisation de traitements aigus de recanalisation vasculaire, le délai avant l'admission à l'hôpital, ainsi que la sévérité et le pronostic de l'AVC en phase aiguë, à 7 jours et à 3 mois des symptômes. Les patients avec assurance privée ont été comparés à ceux avec assurance générale.Résultats :Sur 1062 patients avec AVC, 203 avaient une assurance privée et 859 avaient une assurance générale. Il y a avait 585 hommes et 477 femmes. Les deux populations étaient similaires en âge. Les facteurs de risque cardio-vasculaire, la médication préventive, le délai d'arrivée à l'hôpital, l'incidence du taux de thrombolyse et l'étiologie de l'AVC ne différaient pas dans les deux populations. Le score de gravité de l'AVC en phase aiguë, mesuré par le NIHSS, était significativement plus élevé chez les patients avec assurance générale. Un pronostic favorable, mesuré par le score de Rankin modifié (mRS), était plus fréquemment obtenu à 7 jours et à 3 mois chez les patients avec assurance privée.Commentaires :Un statut socio-économique bas est associé à une incidence plus élevée de maladies cérébrovasculaires ainsi qu'à un plus mauvais pronostic, comme cela a été démontré dans différents pays. Il a été suspecté que l'accès à une prise en charge spécialisée en phase aiguë ou en rééducation soit différent selon le statut socio-économique. Comme la Suisse a un système de santé universel, avec une couverture assécurologique obligatoire pour chaque habitant, il y a là une occasion unique de comparer l'influence de l'aspect socio-économique sur la sévérité et le pronostic de l'AVC. De plus, les patients ont été admis dans la même Unité Cérébrovasculaire et pris en charge par la même équipe médicale.Conclusion et perspectives :Le lien entre le statut assécurologique et le statut socio-économique a déjà été prouvé par le passé dans d'autres pays. Nous avons mis en évidence une sévérité plus importante et un plus mauvais pronostic chez les patients avec assurance générale dans la population étudiée. L'étiologie de cette différence dans un système de santé à couverture universelle comme celui de la Suisse reste peu claire. Elle devrait être étudiée à plus grande échelle.

Does lamotrigine use in pregnancy increase orofacial cleft risk relative to other malformations?

OBJECTIVE: To investigate whether first trimester exposure to lamotrigine (LTG) monotherapy is specifically associated with an increased risk of orofacial clefts (OCs) relative to other malformations, in response to a signal regarding increased OC risk. METHODS: Population-based case-control study with malformed controls based on EUROCAT congenital anomaly registers. The study population covered 3.9 million births from 19 registries 1995-2005. Registrations included congenital anomaly among livebirths, stillbirths, and terminations of pregnancy following prenatal diagnosis. Cases were 5,511 nonsyndromic OC registrations, of whom 4,571 were isolated, 1,969 were cleft palate (CP), and 1,532 were isolated CP. Controls were 80,052 nonchromosomal, non-OC registrations. We compared first trimester LTG and antiepileptic drug (AED) use vs nonepileptic non-AED use, for mono and polytherapy, adjusting for maternal age. An additional exploratory analysis compared the observed and expected distribution of malformation types associated with LTG use. RESULTS: There were 72 LTG exposed (40 mono- and 32 polytherapy) registrations. The ORs for LTG monotherapy vs no AED use were 0.67 (95% CI 0.10-2.34) for OC relative to other malformations, 0.80 (95% CI 0.11-2.85) for isolated OC, 0.79 (95% CI 0.03-4.35) for CP, and 1.01 (95% CI 0.03-5.57) for isolated CP. ORs for any AED use vs no AED use were 1.43 (95% CI 1.03-1.93) for OC, 1.21 (95% CI 0.82-1.72) for isolated OC, 2.37 (95% CI 1.54-3.43) for CP, and 1.86 (95% CI 1.07-2.94) for isolated CP. The distribution of other nonchromosomal malformation types with LTG exposure was similar to non-AED exposed. CONCLUSION: We find no evidence of a specific increased risk of isolated orofacial clefts relative to other malformations due to lamotrigine (LTG) monotherapy. Our study is not designed to assess whether there is a generalized increased risk of malformations with LTG exposure.

Effective exposure to solar UV in building workers: influence of local and individual factors.

Excessive exposure to solar UV light is the main cause of skin cancers in humans. UV exposure depends on environmental as well as individual factors related to activity. Although outdoor occupational activities contribute significantly to the individual dose received, data on effective exposure are scarce and limited to a few occupations. A study was undertaken in order to assess effective short-term exposure among building workers and characterize the influence of individual and local factors on exposure. The effective exposure of construction workers in a mountainous area in the southern part of Switzerland was investigated through short-term dosimetry (97 dosimeters). Three altitudes, of about 500, 1500 and 2500 m were considered. Individual measurements over 20 working periods were performed using Spore film dosimeters on five body locations. The postural activity of workers was concomitantly recorded and static UV measurements were also performed. Effective exposure among building workers was high and exceeded occupational recommendations, for all individuals for at least one body location. The mean daily UV dose in plain was 11.9 SED (0.0-31.3 SED), in middle mountain 21.4 SED (6.6-46.8 SED) and in high mountain 28.6 SED (0.0-91.1 SED). Measured doses between workers and anatomical locations exhibited a high variability, stressing the role of local exposure conditions and individual factors. Short-term effective exposure ranged between 0 and 200% of ambient irradiation, indicating the occurrence of intense, subacute exposures. A predictive irradiation model was developed to investigate the role of individual factors. Posture and orientation were found to account for at least 38% of the total variance of relative individual exposure, and were also found to account more than altitude on the total variance of effective daily exposures. Targeted sensitization actions through professional information channels and specific prevention messages are recommended. Altitude outdoor workers should also benefit from preventive medical examination.

Conditioning of stochastic 3-D fracture networks to hydrological and geophysical data

The geometry and connectivity of fractures exert a strong influence on the flow and transport properties of fracture networks. We present a novel approach to stochastically generate three-dimensional discrete networks of connected fractures that are conditioned to hydrological and geophysical data. A hierarchical rejection sampling algorithm is used to draw realizations from the posterior probability density function at different conditioning levels. The method is applied to a well-studied granitic formation using data acquired within two boreholes located 6 m apart. The prior models include 27 fractures with their geometry (position and orientation) bounded by information derived from single-hole ground-penetrating radar (GPR) data acquired during saline tracer tests and optical televiewer logs. Eleven cross-hole hydraulic connections between fractures in neighboring boreholes and the order in which the tracer arrives at different fractures are used for conditioning. Furthermore, the networks are conditioned to the observed relative hydraulic importance of the different hydraulic connections by numerically simulating the flow response. Among the conditioning data considered, constraints on the relative flow contributions were the most effective in determining the variability among the network realizations. Nevertheless, we find that the posterior model space is strongly determined by the imposed prior bounds. Strong prior bounds were derived from GPR measurements and helped to make the approach computationally feasible. We analyze a set of 230 posterior realizations that reproduce all data given their uncertainties assuming the same uniform transmissivity in all fractures. The posterior models provide valuable statistics on length scales and density of connected fractures, as well as their connectivity. In an additional analysis, effective transmissivity estimates of the posterior realizations indicate a strong influence of the DFN structure, in that it induces large variations of equivalent transmissivities between realizations. The transmissivity estimates agree well with previous estimates at the site based on pumping, flowmeter and temperature data.

Dissociation of allocentric and egocentric orientation: Effect on hippocampal place cells and place navigation

Navigation by means of cognitive maps appears to require the hippocampus; hippocampal place cells (PCs) appear to store spatial memories because their discharge is confined to cell-specific places called firing fields (FFs). Experiments with rats manipulated idiothetic and landmark-related information to understand the relationship between PC activity and spatial rotation. Rotating a circular arena in the caused a discrepancy between these cuse. This discrepancy caused most FFs to disappear in both the arena and room reference frames. However, FFs persisted in the rotating arena frame when the discrepancy was reduced by darkness or by a card in the arena. The discrepancy was increased by "field clamping" the rat in a room-defined FF location by rotations that countered its locomotion. Most FFs disspared and reappeared an hour or more after the clamp. Place-avoidance experiments showed that navigation uses independent idiothetic and exteroceptive memories. Rats learned to avoid the unmarked footshock region within a circular arena. When acquired on the stable arena in the light, the location of the punishment was learned by using both room and idiothetic cues; extinction in the dark transferred to the following session in the light. If, however, extinction occured during rotation, only the arena-frame avoidance was extinguished in darkness; the room-defined location was avoided when the light were turned back on. Idiothetic memory of room-defined avoidance was not formed during rotation in light; regardless of rotation with a randomly dispersed pellet. The resulting behaviour alternated between random pellet searching and target-directed navigation, making it possible to examine PC correlates of these two classes of spatial behaviour. The independence of idiothetic and exteroceptive spatial memories and the disruption of PC firing during rotation suggest that PCs may not be necessary for spatial cognition; this idea can be tested by recording during place-avoidance and preference tasks.