Complexité, médecine générale et réformes des systèmes de santé [Complexity, general practice and reforms of health systems].

The family doctor facing complexity must decide in situations of low certainty and low agreement. Complexity is in part subjective but can also be measured. Changes in the health systems aim to reduce health costs. They tend to give priority to simple situations and to neglect complexity. One role of an academic institute of family medicine is to present and promote the results of scientific research supporting the principles of family medicine, taking into account both the local context and health systems reforms. In Switzerland the new challenge is the introduction of managed care.

Bureaucracy and the flypaper effect : Evidence from intercommunal fiscal equalisation in the canton of Vaud

Unlike classical theoretical expectations, our empirical study shows that financial transfers to decentralised governments increase local public expenditures much more than would be triggered by an equivalent rise in local income. This empirical evidence of the presence of a flypaper effect is achieved using panel data from 375 municipalities located in the Swiss canton of Vaud covering the period 1994 to 2005. During that time there was a major change in the financial equalisation scheme. Furthermore, our study confirms the analysis of the public choice theory: the effect depends partly on the degree of complexity of the municipal bureaucracy. These results show that local bureaucratic behaviour may impede the effectiveness of a financial equalisation scheme that aims to reduce disparities in local tax.

Evolving from inferences to decisions in the interpretation of scientific evidence

Le travail d'un(e) expert(e) en science forensique exige que ce dernier (cette dernière) prenne une série de décisions. Ces décisions sont difficiles parce qu'elles doivent être prises dans l'inévitable présence d'incertitude, dans le contexte unique des circonstances qui entourent la décision, et, parfois, parce qu'elles sont complexes suite à de nombreuse variables aléatoires et dépendantes les unes des autres. Etant donné que ces décisions peuvent aboutir à des conséquences sérieuses dans l'administration de la justice, la prise de décisions en science forensique devrait être soutenue par un cadre robuste qui fait des inférences en présence d'incertitudes et des décisions sur la base de ces inférences. L'objectif de cette thèse est de répondre à ce besoin en présentant un cadre théorique pour faire des choix rationnels dans des problèmes de décisions rencontrés par les experts dans un laboratoire de science forensique. L'inférence et la théorie de la décision bayésienne satisfont les conditions nécessaires pour un tel cadre théorique. Pour atteindre son objectif, cette thèse consiste de trois propositions, recommandant l'utilisation (1) de la théorie de la décision, (2) des réseaux bayésiens, et (3) des réseaux bayésiens de décision pour gérer des problèmes d'inférence et de décision forensiques. Les résultats présentent un cadre uniforme et cohérent pour faire des inférences et des décisions en science forensique qui utilise les concepts théoriques ci-dessus. Ils décrivent comment organiser chaque type de problème en le décomposant dans ses différents éléments, et comment trouver le meilleur plan d'action en faisant la distinction entre des problèmes de décision en une étape et des problèmes de décision en deux étapes et en y appliquant le principe de la maximisation de l'utilité espérée. Pour illustrer l'application de ce cadre à des problèmes rencontrés par les experts dans un laboratoire de science forensique, des études de cas théoriques appliquent la théorie de la décision, les réseaux bayésiens et les réseaux bayésiens de décision à une sélection de différents types de problèmes d'inférence et de décision impliquant différentes catégories de traces. Deux études du problème des deux traces illustrent comment la construction de réseaux bayésiens permet de gérer des problèmes d'inférence complexes, et ainsi surmonter l'obstacle de la complexité qui peut être présent dans des problèmes de décision. Trois études-une sur ce qu'il faut conclure d'une recherche dans une banque de données qui fournit exactement une correspondance, une sur quel génotype il faut rechercher dans une banque de données sur la base des observations faites sur des résultats de profilage d'ADN, et une sur s'il faut soumettre une trace digitale à un processus qui compare la trace avec des empreintes de sources potentielles-expliquent l'application de la théorie de la décision et des réseaux bayésiens de décision à chacune de ces décisions. Les résultats des études des cas théoriques soutiennent les trois propositions avancées dans cette thèse. Ainsi, cette thèse présente un cadre uniforme pour organiser et trouver le plan d'action le plus rationnel dans des problèmes de décisions rencontrés par les experts dans un laboratoire de science forensique. Le cadre proposé est un outil interactif et exploratoire qui permet de mieux comprendre un problème de décision afin que cette compréhension puisse aboutir à des choix qui sont mieux informés. - Forensic science casework involves making a sériés of choices. The difficulty in making these choices lies in the inévitable presence of uncertainty, the unique context of circumstances surrounding each décision and, in some cases, the complexity due to numerous, interrelated random variables. Given that these décisions can lead to serious conséquences in the admin-istration of justice, forensic décision making should be supported by a robust framework that makes inferences under uncertainty and décisions based on these inferences. The objective of this thesis is to respond to this need by presenting a framework for making rational choices in décision problems encountered by scientists in forensic science laboratories. Bayesian inference and décision theory meets the requirements for such a framework. To attain its objective, this thesis consists of three propositions, advocating the use of (1) décision theory, (2) Bayesian networks, and (3) influence diagrams for handling forensic inference and décision problems. The results present a uniform and coherent framework for making inferences and décisions in forensic science using the above theoretical concepts. They describe how to organize each type of problem by breaking it down into its différent elements, and how to find the most rational course of action by distinguishing between one-stage and two-stage décision problems and applying the principle of expected utility maximization. To illustrate the framework's application to the problems encountered by scientists in forensic science laboratories, theoretical case studies apply décision theory, Bayesian net-works and influence diagrams to a selection of différent types of inference and décision problems dealing with différent catégories of trace evidence. Two studies of the two-trace problem illustrate how the construction of Bayesian networks can handle complex inference problems, and thus overcome the hurdle of complexity that can be present in décision prob-lems. Three studies-one on what to conclude when a database search provides exactly one hit, one on what genotype to search for in a database based on the observations made on DNA typing results, and one on whether to submit a fingermark to the process of comparing it with prints of its potential sources-explain the application of décision theory and influ¬ence diagrams to each of these décisions. The results of the theoretical case studies support the thesis's three propositions. Hence, this thesis présents a uniform framework for organizing and finding the most rational course of action in décision problems encountered by scientists in forensic science laboratories. The proposed framework is an interactive and exploratory tool for better understanding a décision problem so that this understanding may lead to better informed choices.

Partitioning of reproduction in mother-daughter versus sibling associations : a test of optimal skew theory

A critical feature of cooperative animal societies is the reproductive skew, a shorthand term for the degree to which a dominant individual monopolizes overall reproduction in the group. Our theoretical analysis of the evolutionarily stable skew in matrifilial (i.e., mother-daughter) societies, in which relatednesses to offspring are asymmetrical, predicts that reproductive skews in such societies should tend to be greater than those of semisocial societies (i.e., societies composed of individuals of the same generation, such as siblings), in which relatednesses to offspring are symmetrical. Quantitative data on reproductive skews in semisocial and matrifilial associations within the same species for 17 eusocial Hymenoptera support this prediction. Likewise, a survey of reproductive partitioning within 20 vertebrate societies demonstrates that complete reproductive monopoly is more likely to occur in matrifilial than in semisocial societies, also as predicted by the optimal skew model.

Compensation for environmental damages under international law

ABSTRACT The purpose of this research is to clarify the contribution of international dispute adjudication mechanisms in regard to environmental protection. Most specifically, the study aims to identify and develop the criterion adopted by the international judge in relation to the compensation for environmental damages. In this perspective, the study identifies some gaps between international responsibility and environmental protection interests. The premise sustained all along the study is that compensation is determinant to conciliate environmental prerogatives with mechanisms of international adjudication, in particular the system of international responsibility. Supported by the analysis of treaties, international decisions and secondary sources, the thesis defends the idea that some elements of international law allow the adjudicator to adapt the compensation to attend certain environmental interests, creating a new approach which was entitled 'fair compensation'. The antithesis of this approach is the idea that compensation in international law is limited exclusively to the strict reparation of the material losses incurred by the victim. As a synthesis, the study defends the specificity of environmental damages in relation to other kind of damages that are subject to compensation under international law. The measure upon which compensation for environmental damages could be classified as a specific type of damage under international law remains to be determined. The main conclusion of the study is that the existing standard of compensation defined by the theory and practice of international law is impossible to be strictly respected in cases involving environmental damages. This limitation is mainly due to the complexity of the notion of environment, which is constantly conflicting with the anthropologic view of legal theory. The study supports the idea that the establishment of a 'fair compensation' which takes into account the political, legal and technical context of the environmental damage, is the best possible approach to conciliate internationally responsibility and environmental interests. This could be implemented by the observance of certain elements by the international judge/arbitrator through a case-by-case analysis.

The genetical theory of social behaviour.

We survey the population genetic basis of social evolution, using a logically consistent set of arguments to cover a wide range of biological scenarios. We start by reconsidering Hamilton's (Hamilton 1964 J. Theoret. Biol. 7, 1-16 (doi:10.1016/0022-5193(64)90038-4)) results for selection on a social trait under the assumptions of additive gene action, weak selection and constant environment and demography. This yields a prediction for the direction of allele frequency change in terms of phenotypic costs and benefits and genealogical concepts of relatedness, which holds for any frequency of the trait in the population, and provides the foundation for further developments and extensions. We then allow for any type of gene interaction within and between individuals, strong selection and fluctuating environments and demography, which may depend on the evolving trait itself. We reach three conclusions pertaining to selection on social behaviours under broad conditions. (i) Selection can be understood by focusing on a one-generation change in mean allele frequency, a computation which underpins the utility of reproductive value weights; (ii) in large populations under the assumptions of additive gene action and weak selection, this change is of constant sign for any allele frequency and is predicted by a phenotypic selection gradient; (iii) under the assumptions of trait substitution sequences, such phenotypic selection gradients suffice to characterize long-term multi-dimensional stochastic evolution, with almost no knowledge about the genetic details underlying the coevolving traits. Having such simple results about the effect of selection regardless of population structure and type of social interactions can help to delineate the common features of distinct biological processes. Finally, we clarify some persistent divergences within social evolution theory, with respect to exactness, synergies, maximization, dynamic sufficiency and the role of genetic arguments.

Revising the Cannabis Use Disorders Identification Test (CUDIT) by means of Item Response Theory.

Cannabis use among adolescents and young adults has become a major public health challenge. Several European countries are currently developing short screening instruments to identify 'problematic' forms of cannabis use in general population surveys. One such instrument is the Cannabis Use Disorders Identification Test (CUDIT), a 10-item questionnaire based on the Alcohol Use Disorders Identification Test. Previous research found that some CUDIT items did not perform well psychometrically. In the interests of improving the psychometric properties of the CUDIT, this study replaces the poorly performing items with new items that specifically address cannabis use. Analyses are based on a sub-sample of 558 recent cannabis users from a representative population sample of 5722 individuals (aged 13-32) who were surveyed in the 2007 Swiss Cannabis Monitoring Study. Four new items were added to the original CUDIT. Psychometric properties of all 14 items, as well as the dimensionality of the supplemented CUDIT were then examined using Item Response Theory. Results indicate the unidimensionality of CUDIT and an improvement in its psychometric performance when three original items (usual hours being stoned; injuries; guilt) are replaced by new ones (motives for using cannabis; missing out leisure time activities; difficulties at work/school). However, improvements were limited to cannabis users with a high problem score. For epidemiological purposes, any further revision of CUDIT should therefore include a greater number of 'easier' items.

What kind of relationships between the evolution of pain, beliefs and bio-psycho-social complexity after a locomotor traumatism?

Introduction: Pain and beliefs have an influence on the patient's course in rehabilitation, pain causes fears and fears influence pain perception. The aim of this study is to understand pain and beliefs evolutions during rehabilitation taking into account of bio-psycho-social complexity.Patients and methods: 631 consecutive patients admitted in rehabilitation after a musculoskeletal traumatism were included and assessed at admission and at discharge. Pain was measured by VAS (Visual Analogical Scale), bio-psycho-social complexity by Intermed scale, and beliefs by judgement on Lickert scales. Four kinds of beliefs were evaluated: fear of a severe origin of pain, fear of movement, fear of pain and feeling of distress (loss of control). The association between the changes in pain and beliefs during the hospitalization was assessed by linear regressions.Results: After adjustment for gender, age, education and native language, patients with a decrease in pain during rehabilitation have higher probability of decreasing their fears. For the distress feeling, this relationship is weaker among bio-psycho-socially complex patients (odds-ratio 1.22 for each decreasing of 10mm/100 VAS) than among non-complex patients (OR 1.47). Patients with a pain decrease of 30% or more during hospitalization have higher probability of seeing their fears decrease, this relationship being stronger in complex patient for fear of a severe origin of pain.Discussion: The relationships between evolution of pain and beliefs move in the same direction. The higher a patient feels pain, the less they could be able to modify their dysfunctional beliefs. When the pain diminishes of 30% or more, the probability to challenge the beliefs is increased. The prognostic with regard to feeling of distress and fear of a severe origin of pain, is worse among bio-psycho-socially complex patients.