Les temporalités des médicaments : trajectoires en soins palliatifs à l'hôpital

A partir d'un terrain ethnographique réalisé au sein d'une équipe mobile de soins palliatifs d'un hôpital universitaire, cette thèse de doctorat porte sur les médicaments dans le contexte de la fin de vie. Au carrefour d'une socio-anthropologie de la maladie grave, du mourir et des médicaments, elle interroge les rapports à la morphine, ainsi qu'à certains psychotropes et sédatifs utilisés en soins palliatifs. Entre temporalité vécue et temporalité institutionnelle, les manières d'investir le temps lorsqu'il est compté, y sont centrales. Dans une dimension microsociale, les résultats montrent que l'introduction de certains médicaments comme la morphine et l'entrée en scène d'une équipe mobile de soins palliatifs sont des points de repère et peuvent sonner comme une annonce, sorte de sanction, dans la trajectoire incertaine de la personne malade. En outre, les médicaments permettent d'agir sur « le temps qui reste » en plus de soulager les symptômes lorsque la maladie grave bascule en maladie incurable. Ils font l'objet d'usages détournés du but initial de soulagement des symptômes pour repousser, altérer ou accélérer la mort dans une perspective de maîtrise de sa fin de vie. Dans une dimension mésosociale, ce travail considère les médicaments à la base d'échanges entre groupements professionnels sur fond d'institutionnalisation des soins palliatifs par rapport à d'autres segments de la médecine actifs dans la gestion de la fin de vie. Dans une médecine caractérisée par l'incertitude et les décisions -avec une teinte toute particulière en Suisse où le suicide assisté est toléré - les médicaments en soins palliatifs peuvent être considérés comme des instruments de mort, qu'ils soient redoutés ou recherchés. Interrogeant les risques de reproduire un certain nombre d'inégalités de traitements à l'approche de la mort, qui s'accentuent dans un contexte de plus en plus favorable aux pratiques euthanasiques, ce travail se propose, en définitive, de discuter le temps contraint de la mort dans les institutions hospitalo-universitaires, entre acharnement et abstention thérapeutique.¦-¦Based on ethnographie fieldwork conducted within a palliative care mobile team in an academic hospital, this doctoral thesis focuses on medicines used in end of life contexts. At the intersection of a socio-anthropology of illness, dying and pharmaceuticals, the relations to morphine, as well as to some psychotropic and sedative drugs used in palliative care are questioned. Between "lived" experiences of temporality and institutional temporality, the ways by which actors invest time when it is counted, appeared to be central. In a microsocial dimension, the results showed that introducing drugs such as morphine, as well as the arrival of a palliative care mobile team, are landmarks and sound like an announcement, a sort of sanction, during the uncertain trajectory of the ill person. In addition, medicines can act on "the remaining time" when severe illness shifts into incurable illness. Indeed, medicines are being diverted from the initial aim of symptom relief in order to defer, alter or hasten death in a perspective of control over one's death. In a mesosocial dimension, pharmaceuticals are seen as core to professional exchanges and to palliative care institutionalisation compared to other active medical segments in end of life care. In a medical context characterised by uncertainty and decision-taking-with a special shade in Switzerland where assisted suicide is tolerated - palliative medicines can be seen as instruments of death, whether sought or feared. Questioning the risks of reproducing treatment inequalities at the approach of death, which are accentuated in a context increasingly favorable to euthanasia practices, this study aims, ultimately, at discussing death's constrained time in academic hospitals, between therapeutic intervention and abstention.

Outcome of patients with acute coronary syndrome in hospitals of different sizes. A report from the AMIS Plus Registry.

To assess the impact of admission to different hospital types on early and 1-year outcomes in patients with acute coronary syndrome (ACS). Between 1997 and 2009, 31 010 ACS patients from 76 Swiss hospitals were enrolled in the AMIS Plus registry. Large tertiary institutions with continuous (24 hour/7 day) cardiac catheterisation facilities were classified as type A hospitals, and all others as type B. For 1-year outcomes, a subgroup of patients admitted after 2005 were studied. Eleven type A hospitals admitted 15987 (52%) patients and 65 type B hospitals 15023 (48%) patients. Patients admitted into B hospitals were older, more frequently female, diabetic, hypertensive, had more severe comorbidities and more frequent non-ST segment elevation (NSTE)-ACS/unstable angina (UA). STE-ACS patients admitted into B hospitals received more thrombolysis, but less percutaneous coronary intervention (PCI). Crude in-hospital mortality and major adverse cardiac events (MACE) were higher in patients from B hospitals. Crude 1-year mortality of 3747 ACS patients followed up was higher in patients admitted into B hospitals, but no differences were found for MACE. After adjustment for age, risk factors, type of ACS and comorbidities, hospital type was not an independent predictor of in-hospital mortality, in-hospital MACE, 1-year MACE or mortality. Admission indicated a crude outcome in favour of hospitalisation during duty-hours while 1-year outcome could not document a significant effect. ACS patients admitted to smaller regional Swiss hospitals were older, had more severe comorbidities, more NSTE-ACS and received less intensive treatment compared with the patients initially admitted to large tertiary institutions. However, hospital type was not an independent predictor of early and mid-term outcomes in these patients. Furthermore, our data suggest that Swiss hospitals have been functioning as an efficient network for the past 12 years.

Delirium: guidelines for general hospitals.

OBJECTIVE: Delirium is highly prevalent in general hospitals but remains underrecognized and undertreated despite its association with increased morbidity, mortality, and health services utilization. To enhance its management, we developed guidelines covering all aspects, from risk factor identification to preventive, diagnostic, and therapeutic interventions in adult patients. METHODS: Guidelines, systematic reviews, randomized controlled trials (RCT), and cohort studies were systematically searched and evaluated. Based on a synthesis of retrieved high-quality documents, recommendation items were submitted to a multidisciplinary expert panel. Experts scored the appropriateness of recommendation items, using an evidence-based, explicit, multidisciplinary panel approach. Each recommendation was graded according to this process' results. RESULTS: Rated recommendations were mostly supported by a low level of evidence (1.3% RCT and systematic reviews, 14.3% nonrandomized trials vs. 84.4% observational studies or expert opinions). Nevertheless, 71.1% of recommendations were considered appropriate by the experts. Prevention of delirium and its nonpharmacological management should be fostered. Haloperidol remains the first-choice drug, whereas the role of atypical antipsychotics is still uncertain. CONCLUSIONS: While many topics addressed in these guidelines have not yet been adequately studied, an explicit panel and evidence-based approach allowed the proposal of comprehensive recommendations for the prevention and management of delirium in general hospitals.

Market Potential and Demand Drivers for a Special Laminating Paper: Implementation of Market Research

Tutkimuksen tavoitteena oli selvittää raaka-aineena käytettävän paloa hidastavan laminaattipaperin markkinapotentiaali sekä kysyntä Euroopassa. Näiden kehitystä arvioitiin analysoimalla kysyntään vaikuttavia tekijöitä. Tutkimusmetodologiassa yhdistyivät useat lähestymistavat, pääasiassa käytettiin kuvailevaa ja ennustavaa tutkimusotetta. Tutkimus perustui sekä primaari että sekundaaritietoon. Primaaritietoa hankittiin tuotteen käyttäjiltä, myyntiedustajilta sekä haastattelemalla tuottajayrityksen henkilökuntaa. Sekundaaritietoa kerättiin myös, mutta tutkimuksen tavoitteisiin liittyviä lähteitä ei ollut runsaasti saatavilla. Tästä syystä primaaritiedolla oli tutkimuksessa hieman tärkeämpi rooli kuin sekundaaritiedolla, mikä on yleistä teollisessa markkinatutkimuksessa. Tuotteen tulevaisuuden näkymät vaikuttavat melko hyviltä. Teoreettinen markkinapotentiaali on suuri verrattuna nykyiseen myyntimäärään, myyntimäärän kasvattaminen vaatii kuitenkin tiettyjä toimenpiteitä. Tulevaisuudessa huomiota tulisi kiinnittää tuotekuvaan, hinnoitteluun ja laadun kokonaisvaltaiseen maksimointiin. Tutkimuksessa havaittiin suuntauksia kysynnän kasvusta tulevien parin vuoden aikana. Myös teoreettinen markkinapotentiaali voisi kasvaa, koska paloa hidastavien laminaattien kysyntä vaikuttaa kasvavan Euroopassa erityisesti rakennusalalla.

Special charta öfver kusten från Söderhamn til Stockholm

Graverad af Fr. Akrel

The surficial geology, sedimentology and geochemistry of the late glacial sediments and Paleozoic bedrock in the Campbellford area, Ontario, with special reference to the Dummer Complex /

The Dummer Complex extends 180 km along the Precambrian - Paleozoic contact from Tamworth to Lake Simcoe. It is composed of coarse, angular Paleozoic clasts in discontinuous, pitted, hummocky deposits. Deposits are usually separated by bare or boulder strewn bedrock, but have been found in the southern drumlinized till sheet. Dummer Complex deposits show rough alignment with ice-flow. Eskers cross-cut many of the deposits. Dummer sediment subfacies are defined on the basis of dominant coarse grain size and lithology, which relate directly to the underlying Paleozoic formation. Three subglacial tills are identified based on the degree of comminution and distance of transport; the immature facies of the Dummer Complex; the mature facies of the drumlinized till sheet and; the submature facies which is transitional. Carbonate geochemistry was used for till-bedrock correlation in various grain sizes. Of the 3 Paleozoic formations underlying the Dummer Complex, the Gull River Fm. is geochemically distinctive from the Bobcaygeon and Verulam Formations using Ca, Mg, Sr, Cu, Mn, Fe and Na. The Bobcaygeon Fm. and Verulam Fm. can be differentiated using Ca and the Sr/Ca ratio. The immature facies from 1.0 phi and finer is dominated by the non-carbonate, long distance transported component which decreases slightly downice. The submature till facies contains more long distance material than the immature facies. Sr and Mn can be used to correlate the Gull River immature till facies to the underlying bedrock the other subfacies could not be distinguished from each other or their respective source formation. This method proved to be ineffective for sediments with greater than 35% non-carbonate component, due to leaching of elements by the dissolving acid.The Dummer Complex is produced subglacially , as the compressional ice encounters the permeable Paleozoic carbonates. The increased shear strength of the ice and pore pressures in the carbonates results in the basal ice zones becoming debris ladden. Cleaner ice overrides the basal debris . laden dead ice which then acts as the glacier bed. During retreat, the Simcoe lobe stagnates as flow is cut-off by the Algonquin Highlands.

Amino acid transport : the special case of a H/L-glutamate cotransport system in Asparagus sprengeri mesophyll cells /

The addition of L-Glutamate (L-GLU) and L-Hethionine ~ulfoximine (L-HSO) to mechanically isolated. photosynthetically competent, Asparagus sprengeri mesophyll cells ~u~pended in 1mM CaS04 cau~ed an immediate transient alkalinization of the cell su~pension medium in both the light and dark. The alkalinization response was specific and stereospecific as none of the L-isomers of the other 19 protein amino acids tested or D-GLU gave this response. Uptake of 14C-L-GLU was stimulated by the light. The addition of non-radioactive L-GLU. or L-GLU analogs together with 14C-L-GLU showed that only L-GLU and L-HSO stimulated alkalinization whilst inhibiting the uptake of 14C-L-GLU. Both the L-GLU dependent alkalinization and the upt~ke of 14C-L-GLU were stimulated when the external pH was decreased from 6.5 to 5.5. Increasing external K+ concentrations inhibited the uptake of 14C-L-GLU. Fusicoccin (FC) stimulated uptake. The L-GLU dependent alkalinization re~ponse exhibited monophasic saturation kinetics while the uptake of 14C-L-GLU exhibited biphasic saturation kinetics. In addition to a saturable component. the uptake kinetics also showed a linear component of uptake. Addition of L-GLU and L-MSO caused internal acidification of the cell as measured by a change in the distribution of 14C-DMO. There was no change in K+ efflux when L-GLU was added. A H+ to L-GLUinflux stoichiometry of 3:1 wa~ mea~ured at an external I.-GLU concentration of O.5mM and increased with increasing external 13 L-QLU concentration. Metabolism of L-GLU was detected manometrlcally by observing an increase in COa evolution upon the addition of L-QLU and by detection of i*C02 evolution upon the addition of »*C-L-GLU. »*C02 evolution was higher in the dark than in the light. The data are consistent with the operation of a H+/L-QLO cotransport system. The data also show that attempts to quantify the stoichlometry of the process were complicated by the metabolism of L-GLU.

Special report of New York State Survey on the preservation of the scenery of Niagara Falls ; and fourth annual report on the triangulation of State. For the Year 1879 /

Notes by F. L. Olmsted.

At a special session of the General Assembly of the State of Connecticut, held at Hartford, on the twenty third day of February, A.D. 1809 ... An address of the General Assembly, to the people of Connecticut. --

Caption title.

Notice to Half Pay Officers and Out Pensioners of Chelsea and Kilmainham Hospitals- 1821

Discusses the half pay and pensions of Officers living within His Majesty's Dominions. At the bottom, there is also a comment made by Robert Morrogh to Daniel Shannon concerning the above notice.

Report of the Committee of the General Assembly, at their special session, August 25, 1812, on that part of His Excellency the Governor's speech which relates to his correspondence with the Secretary of War, andc

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