Étude du suivi conjoint par un médecin spécialiste chez les adultes avec maladies chroniques suivis en première ligne

Contexte : Les médecins spécialistes peuvent participer aux soins ambulatoires des personnes atteintes de maladies chroniques (MCs) et comorbidité comme co-gestionnaire ou consultant selon qu’ils sont responsables ou non du suivi du patient. Il y a un manque d’évidences sur les déterminants et l’impact du type d’implication du médecin spécialiste, ainsi que sur la façon optimale de mesurer la comorbidité pour recueillir ces évidences. Objectifs : 1) déterminer chez les patients atteints de MCs les facteurs associés à la cogestion en spécialité, dont les caractéristiques des organisations de première ligne et la comorbidité; 2) évaluer si le type d’implication du spécialiste influence le recours à l’urgence; 3) identifier et critiquer les méthodes de sélection d’un indice de comorbidité pour la recherche sur l’implication des spécialistes dans le suivi des patients. Méthodologie : 709 adultes (65 +/- 11 ans) atteints de diabète, d’arthrite, de maladie pulmonaire obstructive chronique ou d’insuffisance cardiaque furent recrutés dans 33 cliniques de première ligne. Des enquêtes standardisées ont permis de mesurer les caractéristiques des patients (sociodémographiques, comorbidité et qualité de vie) et des cliniques (modèle, ressources). L’utilisation des services de spécialistes et de l’urgence fut mesurée avec une base de données médico-administratives. Des régressions logistiques multivariées furent utilisées pour modéliser les variables associées à la cogestion et comparer le recours à l’urgence selon le type d’implication du spécialiste. Une revue systématique des études sur l’utilisation des services de spécialistes, ainsi que des revues sur les indices de comorbidité fut réalisée pour identifier les méthodes de sélection d’un indice de comorbidité utilisées et recommandées. Résultats : Le tiers des sujets a utilisé les services de spécialistes, dont 62% pour de la cogestion. La cogestion était associée avec une augmentation de la gravité de la maladie, du niveau d’éducation et du revenu. La cogestion diminuait avec l’âge et la réception de soins dans les cliniques avec infirmière ayant un rôle innovateur. Le recours à l’urgence n’était pas influencé par l’implication du spécialiste, en tant que co-gestionnaire (OR ajusté = 1.06, 95%CI = 0.61-1.85) ou consultant (OR ajusté = 0.97, 95%CI = 0.63-1.50). Le nombre de comorbidités n’était pas associé avec la cogestion, ni l’impact du spécialiste sur le recours à l’urgence. Les revues systématiques ont révélé qu’il n’y avait pas standardisation des procédures recommandées pour sélectionner un indice de comorbidité, mais que 10 critères concernant principalement la justesse et l’applicabilité des instruments de mesure pouvaient être utilisés. Les études sur l’utilisation des services de spécialistes utilisent majoritairement l’indice de Charlson, mais n’en expliquent pas les raisons. Conclusion : L’implication du spécialiste dans le suivi des patients atteints de MCs et de comorbidité pourrait se faire essentiellement à titre de consultant plutôt que de co-gestionnaire. Les organisations avec infirmières ayant un rôle innovateur pourraient réduire le besoin pour la cogestion en spécialité. Une méthode structurée, basée sur des critères standardisés devrait être utilisée pour sélectionner l’indice de comorbidité le plus approprié en recherche sur les services de spécialistes. Les indices incluant la gravité des comorbidités seraient les plus pertinents à utiliser.

Social rejection of minority groups and its impacts on the individual's identity and perception of the self : exploring homosexual and racial identities in James Baldwin's Giovanni's room and Just above my head

Ce mémoire examine la question de la formation de l'identité en tant que procédure compliquée dans laquelle plusieurs éléments interviennent. L'identité d'une personne se compose à la fois d’une identité propre et d’une autre collective. Dans le cas où l’identité propre est jugée sévèrement par les autres comme étant déviante, cela poussera la personne à, ou bien maintenir une image compatible avec les prototypes sociaux ou bien résister et affirmer son identité personnelle. Mon travail montre que l'exclusion et la répression de certains aspects de l'identité peuvent causer un disfonctionnement psychique difficile à surmonter. Par contre, l'acceptation de soi et l’adoption de tous les éléments qui la constituent conduisent, certes après une longue lutte, au salut de l’âme et du corps. Le premier chapitre propose une approche psychosociale qui vise à expliquer le fonctionnement des groupes et comment l'interaction avec autrui joue un rôle décisif dans la formation de l'identité. Des éléments extérieurs comme par exemple les idéaux sociaux influencent les comportements et les choix des gens. Toutefois, cette influence peut devenir une menace aux spécificités personnelles et aux traits spécifiques. Le deuxième chapitre examine la question des problèmes qu’on risque d’avoir au cas où les traits identitaires franchiraient les normes sociales. Nous partons du problème épineux de la quête de soi dans Giovanni's Room de James Baldwin. L'homosexualité de David était tellement refusée par la société qu’elle a engendrée chez lui des sentiments de honte et de culpabilité. Il devait choisir entre le sacrifice des aspects de soi pour satisfaire les paradigmes sociaux ou bien perdre ce qu’il a de propre. David n'arrive pas à se libérer. Il reste prisonnier des perceptions rigides au sujet de la masculinité et de la sexualité. Mon analyse se focalise essentiellement sur l'examen des différents éléments théoriques qui touchent la question du sexe et de la sexualité. Le résultat est le suivant : plus les opinions dominantes sont rigides et fermes, plus elles deviennent une prison pour l’individu. Par contre, plus elles sont tolérantes et flexibles, plus elles acceptent les diversités de l'identité humaine. Dans le dernier chapitre, j'examine la question de la représentation des relations entre les caractères masculins dans Just Above My Head. L'homosexualité est présentée comme un moyen sacré pour exprimer l'amour. Les caractères révèlent leurs sentiments implicitement à travers les chants spirituel tel que le gospel ou bien explicitement à travers la connexion physique. Dans ce roman, Baldwin montre que c'est seulement grâce à la sincérité et à l'amour que l'individu peut atteindre la libération du soi.

Utilization of biodiesel-derived glycerol or xylose for increased growth and lipid production by indigenous microalgae

The use of industrial wastes rich in mineral nutrients and carbon sources to increase the final microalgal biomass and lipid yield at a low cost is an important strategy to make algal biofuel technology viable. Using strains from the microalgal collection of the Université de Montréal, this report shows for the first time that microalgal strains can be grown on xylose, the major carbon source found in wastewater streams from pulp and paper industries, with an increase in growth rate of 2.8 fold in comparison to photoautotrophic growth, reaching up to µ=1.1/day. On glycerol, growth rates reached as high as µ=1.52/day. Lipid productivity increased up to 370% on glycerol and 180% on xylose for the strain LB1H10, showing the suitability of this strain for further development for biofuels production through mixotrophic cultivation.

L'histoire de l'art mise en pièces : analyse matérielle, spatiale et temporelle de la period room comme dispositif muséal

Dans cette thèse, nous étudions la period room présentée dans le musée d’art. À travers un examen de sa spécificité matérielle, spatiale et temporelle, nous analysons les mécanismes propres à cette stratégie de mise en exposition et nous identifions ses principales conditions de possibilité. Ce faisant, nous étudions les différents savoirs qui sont sollicités par la period room, leurs interactions ainsi que l’apport réciproque de cette stratégie de mise en exposition à la construction de ces savoirs et ce, de manière à établir les fondements d’une épistémologie de la period room. Nous montrons ainsi quelle est sa contribution particulière à l’élaboration et à la médiation de l’histoire dans l’espace muséal. Grâce à cette étude, nous posons des assises conceptuelles qui permettent de repenser le rôle de la period room pour la discipline de l’histoire de l’art, déjouant par le fait même les apories de l’historicisme et de l’authenticité en vertu desquelles la period room est le plus souvent discréditée. Nous procédons par études de cas à partir d’un corpus principalement composé de period rooms ayant pour référents des intérieurs français de la seconde moitié du 18ième siècle et qui sont présentées dans des musées d’art américains (Frick Collection, Metropolitan Museum of Art, Philadelphia Museum of Art) et dans un musée canadien d’histoire naturelle et culturelle (Royal Ontario Museum). Dans la première partie de la thèse, nous établissons la typologie muséographique de la period room et nous envisageons les enjeux, notamment idéologiques, associés à la question de son « authenticité » à travers une analyse de son double statut de pastiche et de simulacre. Nous posons en outre l’un des fondements théoriques de notre étude en montrant que, parce qu’elle est formée de l’articulation entre pouvoirs et savoirs, la period room est un dispositif au sens où l’entendent Michel Foucault (1977) et Giorgio Agamben (2007). Dans la seconde partie, nous examinons la spécificité matérielle de la period room en démontrant comment elle est simultanément une réunion d’objets et un « tout », c’est-à-dire un objet muséographique en elle-même. Nous étudions les implications épistémologiques de cette idée pour la représentation de l’histoire proposée au moyen de la period room, tout en portant une attention particulière aux enjeux politiques qui informent cette représentation dans l’espace muséal. Dans la troisième partie, nous nous concentrons sur les particularités spatiales et temporelles de cette stratégie de mise en exposition et nous démontrons que, en dépit de son apparente unité de lieu et de temps, la period room est composée de plusieurs espaces et concentre plusieurs temps. En puisant dans la spécificité même de ce dispositif, nous élaborons des outils théoriques et méthodologiques inédits qui contribuent à repenser la fonction de la period room pour la mise en forme et la transmission de l’histoire. En conclusion, nous présentons une dernière étude de cas qui, examinant l’intervention de Valerie Hegarty dans trois period rooms du Brooklyn Museum (2013), synthétise les principaux enjeux traités dans la thèse et défend la valeur d’actualité de la period room.

Mental health service utilization among students and staff in 18 months following Dawson College shooting

The aim of this study was to investigate service utilization by students and staff in the 18 months following the September 13, 2006, shooting at Dawson College, Montreal, as well as the determinants of this utilization within the context of Canada’s publicly managed healthcare system. Methods A sample of 948 from among the college’s 10,091 students and staff agreed to complete an adapted computer or web-based standardized questionnaire drawn from the Statistics Canada 2002 Canadian Community Health Survey cycle 1.2 on mental health and well-being. Results In the 18 months following the shooting, there was a greater incidence and prevalence not only of PTSD, but also of other anxiety disorders, depression, and substance abuse. Staff and students were as likely to consult a health professional when presenting a mental or substance use disorder, with females more likely to do so than males. Results also indicated that there was relatively high internet use for mental health reasons by students and staff (14% overall). Conclusions Following a major crisis event causing potential mass trauma, even in a society characterized by easy access to public, school and health services and when the population involved is generally well educated, the acceptability of consulting health professionals for mental health or substance use problems represents a barrier. However, safe internet access is one way male and female students and staff can access information and support and it may be useful to further exploit the possibilities afforded by web-based interviews in anonymous environments.

How Could Emergency Modify our Normal Ethics Standards? A Brief Review of Selected Chapters in Emergency Ethics

Compte-rendu / Review

Caractérisation des unités de soins aigus chirurgicaux au sein des départements de chirurgie générale au Canada

Introduction : The acute care surgery (ACS) units are dedicated to the prompt management of surgical emergencies. It is a systemic way of organizing on-call services to diminish conflict between urgent care and elective obligations. The aim of this study was to define the characteristics of an ACS unit and to find common criteria in units with reported good functioning. Methods : As of July 1st 2014, 22 Canadian hospitals reported having an ACS unit. A survey with questions about the organization of the ACS units, the population it serves, the number of emergencies and trauma cases treated per year, and the satisfaction about the implementation of this ACS unit was sent to those hospitals. Results : The survey’s response rate was 73%. The majority of hospitals were tertiary or quaternary centers, served a population of more than 200 000 and had their ACS unit for more than three years. The median number of surgeons participating in an ACS unit was 8.5 and the majority were doing seven day rotations. The median number of operating room days was 2.5 per week. Most ACS units (85%) had an estimated annual volume of more than 2500 emergency consultations (including both trauma and non-trauma) and 80% operated over 1000 cases per year. Nearly all the respondents (94%) were satisfied with the implementation of the ACS unit in their hospital. Conclusion : Most surgeons felt that the implementation of an ACS unit resulted in positive outcomes. However, there should be a sizeable catchment population and number of surgical emergencies to justify the resulting financial and human resources.

The Utilization of Waste Latex Products in Styrene-Butadiene Rubber

Waste latex products are converted to a processabto material by a novel economical process developed in our laboratory , It contains rubber hydrocarbon of very high quality and Is lightly cross -linked. Styrene-butadlene rubber is mixed with latex reclaim In different proportions . The mechanical properties are found to be improved up to 60 percent replacement of styrene-butadlene rubber by latex reclaim . The curing of styrene-butadiene rubber Is found to be accelerated by the addition of latex reclaim. The processablllty study shows that the blends can be processed similar to SBRINR blends.

Phase transitions in lithium ammonium sulfate below room temperature: An ultrasonic study

A detailed ultrasonic study of the elastic properties of lithium ammonium sulfate ~LiNH4SO4! or LAS has been carried out below room temperature. The elastic constants of LAS at room temperature are reported. The discrepancy present in earlier elastic constant data associated with the different choice of axes for this orthorhombic system are clarified. The results of the temperature variation study down to 220 K confirm the ferroelastic phase transition at 285 K and establish a thermal hysteresis of about 2.5 K between the cooling and heating cycles. Results of the investigation on the suspected weak phase transition at 256 K suggest that this transition occurs at 242 K on cooling and at 256 K on heating, thus having a thermal hysteresis of about 14 K. However, since the observed elastic anomaly for this transition is very small, the nature of this transition still remains unclear

OPTIMAL UTILIZATION OF SERVICE FACILITY FOR A k-OUT-OF-n SYSTEM WITH REPAIR BY EXTENDING SERVICE TO EXTERNAL CUSTOMERS IN A RETRIAL QUEUE

In this paper, we study a k-out-of-n system with single server who provides service to external customers also. The system consists of two parts:(i) a main queue consisting of customers (failed components of the k-out-of-n system) and (ii) a pool (of finite capacity M) of external customers together with an orbit for external customers who find the pool full. An external customer who finds the pool full on arrival, joins the orbit with probability and with probability 1− leaves the system forever. An orbital customer, who finds the pool full, at an epoch of repeated attempt, returns to orbit with probability (< 1) and with probability 1 − leaves the system forever. We compute the steady state system size probability. Several performance measures are computed, numerical illustrations are provided.

Application of Fermentation Techniques in the Utilization of Prawn Shell Waste

The present study aimed at the utlisation of microbial organisms for the production of good quality chitin and chitosan. The three strains used for the study were Lactobacillus plantarum, Lactobacililus brevis and Bacillus subtilis. These strains were selected on the basis of their acid producing ability to reduce the pH of the fermenting substrates to prevent spoilage and thus caused demineralisation of the shell. Besides, the proteolytic enzymes in these strains acted on proteinaceous covering of shrimp and thus caused deprotenisation of shrimp shell waste. Thus the two processes involved in chitin production can be affected to certain extent using bacterial fermentation of shrimp shell.Optimization parameters like fermentation period, quantity of inoculum, type of sugar, concentration of sugar etc. for fermentation with three different strains were studied. For these, parameters like pH, Total titrable acidity (TTA), changes in sugar concentration, changes in microbial count, sensory changes etc. were studied.Fermentation study with Lactobacillus plantarum was continued with 20% w/v jaggery broth for 15 days. The inoculum prepared yislded a cell concentration of approximately 108 CFU/ml. In the present study, lactic acid and dilute hydrochloric acid were used for initial pH adjustment because; without adjusting the initial pH, it took more than 5 hours for the lactic acid bacteria to convert glucose to lactic acid and during this delay spoilage occurred due to putrefying enzymes active at neutral or higher pH. During the fermentation study, pH first decreased in correspondence with increase in TTA values. This showed a clear indication of acid production by the strain. This trend continued till their proteolytic activity showed an increasing trend. When the available sugar source started depleting, proteolytic activity also decreased and pH increased. This was clearly reflected in the sensory evaluation results. Lactic acid treated samples showed greater extent of demineralization and deprotenisation at the end of fermentation study than hydrochloric acid treated samples. It can be due to the effect of strong hydrochloric acid on the initial microbial count, which directly affects the fermentation process. At the end of fermentation, about 76.5% of ash was removed in lactic acid treated samples and 71.8% in hydrochloric acid treated samples; 72.8% of proteins in lactic acid treated samples and 70.6% in hydrochloric acid treated samples.The residual protein and ash in the fermented residue were reduced to permissible limit by treatment with 0.8N HCI and 1M NaOH. Characteristics of chitin like chitin content, ash content, protein content, % of N- acetylation etc. were studied. Quality characteristics like viscosity, degree of deacetylation and molecular weight of chitosan prepared were also compared. The chitosan samples prepared from lactic acid treated showed high viscosity than HCI treated samples. But degree of deacetylation is more in HCI treated samples than lactic acid treated ones. Characteristics of protein liquor obtained like its biogenic composition, amino acid composition, total volatile base nitrogen, alpha amino nitrogen etc. also were studied to find out its suitability as animal feed supplement.Optimization of fermentation parameters for Lactobacillus brevis fermentation study was also conducted and parameters were standardized. Then detailed fermentation study was done in 20%wlv jaggery broth for 17 days. Also the effect of two different acid treatments (mild HCI and lactic acid) used for initial pH adjustment on chitin production were also studied. In this study also trend of changes in pH. changes in sugar concentration ,microbial count changes were similar to Lactobacillus plantarum studies. At the end of fermentation, residual protein in the samples were only 32.48% in HCI treated samples and 31.85% in lactic acid treated samples. The residual ash content was about 33.68% in HCI treated ones and 32.52% in lactic acid treated ones. The fermented residue was converted to chitin with good characteristics by treatment with 1.2MNaOH and 1NHCI.Characteristics of chitin samples prepared were studied and extent of Nacetylation was about 84% in HCI treated chitin and 85%in lactic acid treated ones assessed from FTIR spectrum. Chitosan was prepared from these samples by usual chemical method and its extent of solubility, degree of deacetylation, viscosity and molecular weight etc were studied. The values of viscosity and molecular weight of the samples prepared were comparatively less than the chitosan prepared by Lactobacillus plantarum fermentation. Characteristics of protein liquor obtained were analyzed to determine its quality and is suitability as animal feed supplement.Another strain used for the study was Bacillus subtilis and fermentation was carried out in 20%w/v jaggery broth for 15 days. It was found that Bacillus subtilis was more efficient than other Lactobacillus species for deprotenisation and demineralization. This was mainly due to the difference in the proteolytic nature of the strains. About 84% of protein and 72% of ash were removed at the end of fermentation. Considering the statistical significance (P

Studies on Some Aspects of Landings,Utilization and Export of Commercially Important Cephalopods

In the present study two aspects of cephalopod fishery such as (i) landings and (ii) utilization including export of cephalopods from Indian are dealt with. Under the topic landings, craft, both traditional and mechanized and fishing techniques employed for capturing cephalopods are discussed. General trend in cephalopod landing in India and particularly south west coast, species composition, description and geographic distribution of important species of cuttle fishes, squids and octopus and the distribution and abundance of cephalopods along the continental shelf of the south west coast are also discussed. Some biological aspects like population parameters, maturation and spawning, food and feeding of the two representive species of cuttle fishes and squid viz, Sepia pharaonis and Loligo duvauceli are studied.Under utilization, general handling and processing of various frozen cephalopods products for exports and commercial operation in a typical plant are studied. The export of cephalopod products since its commencement is studied in detail and market strategy for enhancing the export are suggested.

Characterization of Wastes from Natural Rubber and Rubber Wood Processing Industries and Their Utilization for Biomethanation

The research work which was carried out to characterization of wastes from natural rubber and rubber wood processing industries and their utilization for biomethanation. Environmental contamination is an inevitable consequence of human activity. The liquid and solid wastes from natural rubber based industries were: characterized and their use for the production of biogas investigated with a view to conserve conventional energy, and to mitigate environmental degradation.Rubber tree (flevea brasiliensis Muell. Arg.), is the most important commercial source of natural rubber and in india. Recently, pollution from the rubber processing factories has become very serious due to the introduction of modern methods and centralized group processing practices.The possibility of the use of spent slurry as organic manure is discussed.l0 percent level of PSD, the activity of cellulolytic, acid producing,proteolytic, lipolytic and methanogenic bacteria were more in the middle stage of methanogenesis.the liquid wastes from rubber processing used as diluents in combination with PSD, SPE promoted more biogas production with high methane content in the gas.The factors that favour methane production like TS, VS, cellulose and hemicellulose degradation were favoured in this treatment which led to higher methane biogenesis.The results further highlight ways and means to use agricultural wastes as alternative sources of energy.

lntemet utilization and academic activities of faculty members in the universities of Kerala : an analytical study

This thesis Entitled Internet Utilization and Academic Activities of Faculty Members in the Universities of kerala: an analytical study. Today, scientific research is throwing up new discoveries, inventions and vistas by the hour. We are witnessing a veritable knowledge explosion. It is important for members of university faculty members to keep abreast of it for giving up-t-date information to their students about the new development in the subject of their study. The internet is an invaluable tool for achieving it. Most of the universities have sufficient internet facility, but the accessibility to all the faculty members is not adequate. University Libraries also provides standard supplementary service in the internet area. This study indicates differential level of awareness and utilization of the internet services by the faculty members in the areas of teaching, research and publication. However the overall impression is that the awareness and utilization is inadequate. This point to the urgent need to devise programs and schemes to promote internet utilization among the faculty members. The suggestions indicate the key areas that deserve attention by policy makers and administrators. Thanks to the internet, every new development in every field of study is just a click away for faculty members, research scholars and students.

Studies on the utilization of selected species of Sharks

This thesis Entitled Studies on the Utilization of selected Species of sharks. The present study is the result of work carried out for 5 years, during the period from April, 1983 to March 1988. The materials were collected from the catches of the Government of India vessels, operated along the south west coast of India and landed in the Integrated Fisheries Project, Cochin—16. The sharks were caught by different types of gears such as bottom trawls, pelagic trawls, long line etc. A number of species of sharks were landed during this period and three species were selected for the present study namely Scoliodon palasorra (bleeker 1853, grey Shark), Carcharhinus limbatus (valenciennes 1839,black tip shark ) and centrophorus granulosus (bloch and schneider 1801 ,spiny shark). During this study period the quantity of shark utilized was 12,55,942 kg out of which 9.71% used for the production of Dressed shark; 36.21% for the production of Fillets; 49.09% converted into Dried shark and 4.99% was domesticallyy marketed as whole form. Besides this 526 kg of dried shark fin and 289.25 kg of shark fin rays were produced.The effect of Smoking of shark fillets and minced meat at different temperature were also studied during this period. Canning of cooked shark meat, smoked fillets and fish balls were carried out in media like brine, vegetable oil, tomato sauce etc. The quality of smoked fillets in vegetable oil was found superior to other canned products from shark meat.During this study an attempt was also made to evaluate the commercial processing of shark resources and found feasible.