Développement d’outils de plaidoyer pour la lutte contre le diabète de type 2 en Afrique subsaharienne à partir de l’estimation des coûts de l’inaction et de l’action

La présente thèse, organisée en trois volets, poursuivait trois objectifs : i) Estimer les coûts médicaux directs du traitement du DT2 dans 4 pays d’Afrique subsaharienne et dans le cas du Mali, rapprocher ces coûts médicaux directs estimés aux dépenses effectives des patients diabétiques ; ii) Examiner le coût-efficacité des interventions de prévention basées sur la modification du mode de vie chez les sujets à haut risque du DT2; iii) Cerner la perception et les attitudes des acteurs de la santé sur les outils de plaidoyer développés dans le cadre du projet DFN et leur potentiel d’impact sur les décideurs. Dans le premier volet, il s’est agi d’estimer les coûts du DT2 et de ses complications au moyen d’un calculateur et de le mettre à l’épreuve au Bénin, au Burkina- Faso, en Guinée et au Mali. Les composantes de soins pour le DT2 et ses complications avaient été définies au préalable par une équipe de spécialistes, sur la base de leur expérience clinique et des lignes directrices existantes. Les prix ont été relevés dans deux structures hospitalières du secteur public et deux du privé. Les coûts ont été estimés sur une base annuelle pour le DT2 avec ou sans complications chroniques puis par épisode pour les complications aiguës. Dans le cas du Mali, ces coûts ont été rapprochés des dépenses de patients diabétiques d’après une précédente enquête transversale dans ce pays. Cette enquête portait sur 500 sujets diabétiques sélectionnés au hasard dans les registres. Les dépenses pour les soins des trois derniers mois avaient été relevées. Les déterminants des dépenses ont été explorés. Il ressort des différences de coûts dans le même secteur puis entre le secteur privé et le secteur public. Le coût minimum du traitement du DT2 sans complications dans le secteur public représentait entre 21% et 34% de PIB par habitant, puis entre 26% - 47% en présence de la rétinopathie et au-delà de 70% pour la néphropathie, la complication chronique la plus coûteuse. Les dépenses des sujets diabétiques enquêtés au Mali, étaient en deçà des coûts minima estimatifs des différentes complications excepté la rétinopathie et le DT2 sans complication. Les facteurs comme l’insulinothérapie, le nombre de complications et la résidence dans la capitale étaient significativement associés aux dépenses plus élevées des patients. Dans le second volet, la revue systématique a consisté à recenser les études d’évaluation économique des interventions de prévention du DT2 dans des groupes à haut risque par l’alimentation et/ou l’activité physique. Les interventions de contrôle de l’obésité comme facteur de risque majeur de DT2 ont également été considérées. Les études ont été sélectionnées dans les bases de données scientifiques en utilisant les mots clés et des critères prédéfinis. Les études originales publiées entre janvier 2009 et décembre 2014 et conduites en français, anglais ou espagnol étaient potentiellement éligibles. La liste de contrôle de « British Medical Journal » a servi à évaluer la qualité des études. Des 21 études retenues, 15 rapportaient que les interventions étaient coût-efficaces suivant les limites d’acceptabilité considérées. Six études étaient non concluantes, dont quatre destinées à la prévention du DT2 et deux, au contrôle de l’obésité. Dans le troisième volet, les perceptions d’utilisateurs potentiels de ce calculateur et d’un autre outil de plaidoyer, à savoir, l’argumentaire narratif expliquant la nécessité de se pencher sur la lutte contre le DT2 en Afrique, ont été évaluées dans une étude qualitative exploratoire. Les données ont été collectées au cours d’entretiens individuels avec 16 acteurs de la santé de quatre pays d’Afrique subsaharienne et un groupe de discussion avec 10 étudiants de master de nutrition à l’issue d’un atelier de formation sur le plaidoyer faisant appel à ces outils, au Bénin. Les entretiens ont été enregistrés, transcrits et codés à l’aide du logiciel QDA Miner. Les participants ont souligné la pertinence des outils pour le plaidoyer et la convivialité du calculateur de coûts. Il demeure cependant que le contexte politique marqué par la compétition des priorités, l’absence de cohésion entre les décideurs et un défaut de données notamment sur le coût-efficacité des interventions sont des freins à la priorisation du DT2 dans les politiques de santé en Afrique subsaharienne que les répondants ont relevés. L’étude confirme que le traitement du DT2 est financièrement inabordable pour un grand nombre de patients. Elle souligne que les dépenses des patients sont en deçà des coûts estimés pour un traitement approprié avec quelques exceptions. La prévention du DT2 basée le mode de vie est coût-efficace mais devrait être étudiée en Afrique. On peut espérer que la pertinence des outils de ce travail telle que relevée par les acteurs de santé se traduise par leur utilisation. Ceci pour susciter des interventions de prévention afin d’infléchir l’évolution du DT2 et son impact économique en Afrique subsaharienne.

Description de l’évolution du profil socio-cognitif et clinique d’une cohorte d’adolescents diabétiques de type 1 ayant suivi un programme d’éducation thérapeutique

Thèse réalisée en cotutelle entre Aix-Marseille Université et l'Université de Montréal

Effects of fertilizer type and rate on partitioning of soil organic matter into pools of different stability

Type and rate of fertilizers influence the level of soil organic carbon (Corg) and total nitrogen (Nt) markedly, but the effect on C and N partitioning into different pools is open to question. The objectives of the present work were to: (i) quantify the impact of fertilizer type and rate on labile, intermediate and passive C and N pools by using a combination of biological, chemical and mathematical methods; (ii) explain previously reported differences in the soil organic matter (SOM) levels between soils receiving farmyard manure with or without biodynamic preparations by using Corg time series and information on SOM partitioning; and (iii) quantify the long-term and short-term dynamics of SOM in density fractions and microbial biomass as affected by fertilizer type and rate and determine the incorporation of crop residues into labile SOM fractions. Samples were taken from a sandy Cambisol from the long-term fertilization trial in Darmstadt, Germany, founded in 1980. The nine treatments (four field replicates) were: straw incorporation plus application of mineral fertilizer (MSI) and application of rotted farmyard manure with (DYN) or without (FYM) addition of biodynamic preparations, each at high (140 – 150 kg N ha-1 year-1; MSIH, DYNH, FYMH), medium (100 kg N ha-1 year-1; MSIM, DYNM, FYMM) and low (50 – 60 kg N ha-1 year-1; MSIL, DYNL, FYML) rates. The main findings were: (i) The stocks of Corg (t ha-1) were affected by fertilizer type and rate and increased in the order MSIL (23.6), MSIM (23.7), MSIH (24.2) < FYML (25.3) < FYMM (28.1), FYMH (28.1). Stocks of Nt were affected in the same way (C/N ratio: 11). Storage of C and N in the modelled labile pools (turnover times: 462 and 153 days for C and N, respectively) were not influenced by the type of fertilizer (FYM and MSI) but depended significantly (p ≤ 0.05) on the application rate and ranged from 1.8 to 3.2 t C ha 1 (7 – 13% of Corg) and from 90 to 140 kg N ha-1 (4-5% of Nt). In the calculated intermediate pool (C/N ratio 7), stocks of C were markedly higher in FYM treatments (15-18 t ha-1) compared to MSI treatments (12-14 t ha-1). This showed that differences in SOM stocks in the sandy Cambisol induced by fertilizer rate may be short-lived in case of changing management, but differences induced by fertilizer type may persist for decades. (ii) Crop yields, estimated C inputs (1.5 t ha-1 year-1) with crop residue, microbial bio¬mass C (Cmic, 118 – 150 mg kg-1), microbial biomass N (17 – 20 mg kg-1) and labile C and N pools did not differ significantly between FYM and DYN treatments. However, labile C increased linearly with application rate (R2 = 0.53) from 7 to 11% of Corg. This also applied for labile N (3.5 to 4.9% of Nt). The higher contents of Corg in DYN treatments existed since 1982, when the first sampling was conducted for all individual treatments. Contents of Corg between DYN and FYM treatments con-verged slightly since then. Furthermore, at least 30% of the difference in Corg was located in the passive pool where a treatment effect could be excluded. Therefore, the reported differences in Corg contents existed most likely since the beginning of the experiment and, as a single factor of biodynamic agriculture, application of bio-dynamic preparations had no effect on SOM stocks. (iii) Stocks of SOM, light fraction organic C (LFOC, ρ ≤ 2.0 g cm-3), light fraction organic N and Cmic decreased in the order FYMH > FYML > MSIH, MSIL for all sampling dates in 2008 (March, May, September, December). However, statistical significance of treatment effects differed between the dates, probably due to dif-ferences in the spatial variation throughout the year. The high proportion of LFOC on total Corg stocks (45 – 55%) highlighted the importance of selective preservation of OM as a stabilization mechanism in this sandy Cambisol. The apparent turnover time of LFOC was between 21 and 32 years, which agreed very well with studies with substantially longer vegetation change compared to our study. Overall, both approaches; (I) the combination of incubation, chemical fractionation and simple modelling and (II) the density fractionation; provided complementary information on the partitioning of SOM into pools of different stability. The density fractionation showed that differences in Corg stocks between FYM and MSI treatments were mainly located in the light fraction, i.e. induced by higher recalcitrance of the organic input in the FYM treatments. Moreover, the use of the combination of biological, chemical and mathematical methods indicated that effects of fertilizer rate on total Corg and Nt stocks may be short-lived, but that the effect of fertilizer type may persist for longer time spans in the sandy Cambisol.

A Virtual Machine for a Type-omega Denotational Proof Language

In this thesis, I designed and implemented a virtual machine (VM) for a monomorphic variant of Athena, a type-omega denotational proof language (DPL). This machine attempts to maintain the minimum state required to evaluate Athena phrases. This thesis also includes the design and implementation of a compiler for monomorphic Athena that compiles to the VM. Finally, it includes details on my implementation of a read-eval-print loop that glues together the VM core and the compiler to provide a full, user-accessible interface to monomorphic Athena. The Athena VM provides the same basis for DPLs that the SECD machine does for pure, functional programming and the Warren Abstract Machine does for Prolog.

Determinación de interleucina-10 (IL-10) en pacientes con cáncer en estadios III y IV tratados con dexametasona

La utilización de la dexametasona está asociada con la supresión de la respuesta inmune en pacientes con cáncer en estadíos III y IV, debido posiblemente a una acción inhibidora sobre las células dendríticas presentadoras de antígenos. Bajo la acción de la dexametasona, las células dendríticas secretan niveles muy bajos de IL-10, lo que a su vez disminuye, tanto la respuesta mediada por los linfocitos Th2 como la inducida por las células NK. La IL-10 tiene pues un efecto dual, si se tiene en cuenta que, en la mayoría de los modelos experimentales, aumenta en pacientes tratados con glucocorticoides tipo dexametasona e inhibe la respuesta mediada por los linfocitos Th1, con una consecuente exacerbación del proceso. Metodología: Se utilizó la prueba de ELISA para determinar IL-10 en pacientes con diferentes tipos de tumor en estadíos III y IV, sometidos a quimioterapia y tratados con dexametasona-metoclopramida como antiemético y en un grupo control de personas sanas. Resultados: En este modelo experimental, todos los pacientes con cáncer en estadíos III y IV presentaron niveles séricos de IL-10 muy bajos, comparados con los del grupo control. Además, IL-10 no aumentó su concentración en los pacientes tratados con dexametasona. Conclusión: IL-10 no provoca anergia de las células dendríticas ni disminución de la respuesta citotóxica mediada por Th1. Por tanto, se sospecha que es la dexametasona y no la IL-10 la responsable de la supresión en la respuesta inmune en pacientes con cáncer en estadíos III y IV, lo que podrá ser demostrado en posteriores estudios que complementen los resultados obtenidos.

Percepción de los trabajadores acerca del sistema de seguridad y salud en el trabajo en un hospital de III nivel, Bogotá-Colombia. 2014.

Objetivo: Evaluar la percepción que tienen los trabajadores acerca del sistema de seguridad y salud en el trabajo en la población asistencial y administrativa en un Hospital de III nivel de atención., Bogotá-Colombia. Materiales y métodos: Estudio de corte transversal en población de trabajadores asistenciales y administrativos. Se aplicó el “Cuestionario Nórdico Sobre Seguridad en el Trabajo NOSACQ 50 Spanish” validado. La muestra fue probabilística estratificada aleatoria, en 308 trabajadores (230 asistenciales y 78 administrativos). Resultados: El promedio de edad fue 39.5± 12 años, con mayor frecuencia de género femenino (74.68%), estado civil soltero (38.96%) y nivel educativo técnico (34.40%). La percepción que tienen los trabajadores acerca del sistema de seguridad y salud en el trabajo fue independiente de su tipo de actividad laboral administrativa y asistencial (p>0.05), la mayor percepción en ambos grupos fue la confianza de los trabajadores en la eficacia del sistema de seguridad (2.71 y 2.77), y las de menor percepción presentaron el empoderamiento de seguridad de gestión (2.35 y 2.46) y la seguridad como prioridad de los empleados y rechazo del riesgo (2.35 y 2.40). Conclusiones: Los trabajadores del Hospital tienen un nivel adecuado de buena percepción acerca de los aspectos de seguridad y salud en el trabajo donde se evidenció que la fortaleza es la confianza de los trabajadores en la eficacia del sistema y la debilidad del sistema se encuentra en la falta de empoderamiento y rechazo al riesgo.

A new look at stratospheric sudden warmings. Part III. Polar vortex evolution and vertical structure

The evolution of the Arctic polar vortex during observed major mid-winter stratospheric sudden warmings (SSWs) is investigated for the period 1957-2002, using European Centre for Medium-Range Weather Forecasts (ECMWF) ERA-40 Ertel’s potential vorticity (PV) and temperature fields. Time-lag composites of vertically weighted PV, calculated relative to the SSW onset time, are derived for both vortex displacement SSWs and vortex splitting SSWs, by averaging over the 15 recorded displacement and 13 splitting events. The evolving vertical structure of the polar vortex during a typical SSW of each type is clearly illustrated by plotting an isosurface of the composite PV field, and is shown to be very close to that observed during representative individual events. Results are verified by comparison with an elliptical diagnostic vortex moment technique. For both types of SSW, little variation is found between individual events in the orientation of the developing vortex relative to the underlying topography, i.e. the location of the vortex during SSWs of each type is largely fixed in relation to the Earth’s surface. During each type of SSW, the vortex is found to have a distinctive vertical structure. Vortex splitting events are typically barotropic, with the vortex split occurring near-simultaneously over a large altitude range (20-40 km). In the majority of cases, of the two daughter vortices formed, it is the ‘Siberian’ vortex that dominates over its ‘Canadian’ counterpart. In contrast, displacement events are characterized by a very clear baroclinic structure; the vortex tilts significantly westward with height, so that the top and bottom of the vortex are separated by nearly 180◦ longitude before the upper vortex is sheared away and destroyed.

Pollen ultrastructure in anther cultures of Datura innoxia. III. Incomplete microspore division

During the microspore division in Datura innoxia, the mitotic spindle is oriented in planes both perpendicular (PE) and oblique (OB) to the spore wall against which the nucleus is situated. However, irrespective of polarity, the usual type of hemispherical wall is laid down at cytokinesis and isolates the generative cell from the rest of the pollen grain (type A). In PE spores the vegetative nucleus initially occupies a central position in the pollen grain, whereas in OB spores the vegetative nucleus lies at the periphery of the grain close to the generative cell. In anther cultures initiated just before the microspore division is due to take place, no marked change can be observed in either orientation or symmetry of the mitotic spindle when the spores divide. In some, however, cytokinesis is disrupted and deposition of the hemispherical wall arrested. In the absence of a complete wall, differentiation of the generative cell cannot take place and binucleate pollen grains are formed having 2 vegetative-type nuclei (type B). The 2 nuclei in the B pollens are always situated against the pollen-grain wall, suggesting that the disruption phenomenon is related to the OB spores. The incomplete wall always makes contact with the intine on the intine-side of the spindle. Wall material may be represented merely as short stubs projecting out from the intine into the cytoplasm, in which event the 2 nuclei lie close to each other and are separated by only a narrow zone of cytoplasm. In other grains the wall is partially developed between the nuclei and terminates at varying distances from the tonoplast; in these, the nuclei are separated by a wider zone of cytoplasm. The significance of these binucleate grains in pollen embryogenesis is discussed.

An adaptive group sequential design for phase II/III clinical trials that select a single treatment from several

There is increasing interest in combining Phases II and III of clinical development into a single trial in which one of a small number of competing experimental treatments is ultimately selected and where a valid comparison is made between this treatment and the control treatment. Such a trial usually proceeds in stages, with the least promising experimental treatments dropped as soon as possible. In this paper we present a highly flexible design that uses adaptive group sequential methodology to monitor an order statistic. By using this approach, it is possible to design a trial which can have any number of stages, begins with any number of experimental treatments, and permits any number of these to continue at any stage. The test statistic used is based upon efficient scores, so the method can be easily applied to binary, ordinal, failure time, or normally distributed outcomes. The method is illustrated with an example, and simulations are conducted to investigate its type I error rate and power under a range of scenarios.

Uranyl(VI) and lanthanum(III) thio-diglycolamides complexes: synthesis and structural studies involving nitrate complexation

New tri-functional ligands of the type R2NCCCH2SCH2CCNR2 (where R = iso-propyl, n-butyl or iso-butyl) were prepared and characterized. The coordination chemistry of these ligands with uranyl and lanthanum(III) nitrates was studied by using the IR, (HNMR)-H-1 and elemental analysis methods. Structures for the compounds [UO2(NO3)(2)((Pr2NCOCH2SCH2CONPr2)-Pr-i-Pr-i)] [UO2(NO3)(2)((Bu2NCOCH2SCH2CONBu2)-Bu-i-Bu-i)(2)] [La(NO3)(3)((Pr2NCOCH2SCH2CONPr2)-Pr-i-Pr-i)(2)] and [La(NO3)(3)((Bu2NCOCH2SCH2CONBu2)-Bu-i-Bu-i)(2)] were determined by single crystal X-ray diffraction. These structures show that the ligand acts as a bidentate chelating ligand and bonds through both the carbamoyl groups to the uranyl and lanthanum(III) nitrate groups. Solvent extraction studies show that the ligand can extract the uranyl ion from the nitric acid medium but does not show any ability to extract the americium (III) ion. (C) 2009 Elsevier Ltd. All rights reserved.

Two pentacoordinate copper(II) complexes that display accessible Cu(III/II) couples

Two copper(II) complexes of the type CuL2.imidazole (1) and Cu2L4(4.4'-bpy).2H(2)O.C6H14 (2), where LH = 1-nitroso-2-naphthol and 4.4'-bpy = 4,4'-bipyridine, are characterised by X-ray crystallography. In 2, the two copper atoms are linked by 4,4'-bpy. In both the complexes, copper is found to have a distorted square pyramidal N3O2 coordination sphere. The axial position in I is occupied by an oxygen atom while those in 2 by the nitrogen atoms of 4.4'-bpy. The two complexes display quasireversible Cu(III/II) couples around 0.68 V vs. saturated calomel electrode in cyclic voltammetry in dichloromethane.

A new cyano-bridged one-dimensional (GdFeIII)-Fe-III coordination polymer with o-phenanthroline as the blocking ligand: synthesis, structure, and magnetic properties

Synthesis, structural characterization, and magnetic properties of a new cyano-bridged one-dimensional iron (III)-gadolinium (III) compound, trans-[Gd(o-phen)(2)(H2O)(2)(mu-CN)(2)Fe(CN)(4)], - 2no-phen (o-phen = 1,10-phenanthroline), have been described. The compound crystallizes in the triclinic P (1) over bar space group with the following unit cell parameters: a = 10.538(14) angstrom, b = 12.004(14) angstrom, c = 20.61(2) angstrom, alpha = 92.41(1)degrees, beta = 92.76(1)degrees, gamma = 11 2.72(1)degrees, and Z = 2. In this complex, each gadolinium (III) is coordinated to two nitrile nitrogens of the CN groups coming from two different ferricyanides, the mutually trans cyanides of each of which links another different Gd-III to create -NC-Fe(CN)(4)-CN-Gd-NC- type 1-D chain structure. The one-dimensional chains are self-assembled in two-dimensions via weak C-H center dot center dot center dot N hydrogen bonds. Both the variable-temperature (2-300 K, 0.01 T and 0.8 T) and variable-field (0-50 000 Gauss, 2 K) magnetic measurements reveal the existence of very weak interaction in this molecule. The temperature dependence of the susceptibilities has been analyzed using a model for a chain of alternating classic (7/2) and quantum (1/2) spins. (c) 2005 Elsevier B.V. All rights reserved.

Mononuclear single helices of lanthanum(III) and europium(III). Metal dependent diastereomeric excess

Using the 1: 2 condensate of benzildihydrazone and 2-acetylpyridine as a tetradentate N donor ligand L, LaL(NO3)(3) (1) and EuL(NO3)(3) (2), which are pale yellow in colour, are synthesized. While single crystals of 1 could not be obtained, 2 crystallises as a monodichloromethane solvate, 2 center dot CH2Cl2 in the space group Cc with a = 11.7099(5) angstrom, b = 16.4872(5) angstrom, c = 17.9224(6) angstrom and beta = 104.048(4)degrees. From the X-ray crystal structure, 2 is found to be a rare example of monohelical complex of Eu(III). Complex 1 is diamagnetic. The magnetic moment of 2 at room temperature is 3.32 BM. Comparing the FT-IR spectra of 1 and 2, it is concluded that 1 also is a mononuclear single helix. H-1 NMR reveals that both 1 and 2 are mixtures of two diastereomers. In the case of the La(III) complex (1), the diastereomeric excess is only 10% but in the Eu(III) complex 2 it is 80%. The occurrence of diastereomerism is explained by the chiralities of the helical motif and the type of pentakis chelates present in 1 and 2.

Carbon monoxide inhibits L-type Ca2+ channels via redox modulation of key cysteine residues by mitochondrial reactive oxygen species

Conditions of stress, such as myocardial infarction, stimulate up-regulation of heme oxygenase (HO-1) to provide cardioprotection. Here, we show that CO, a product of heme catabolism by HO-1, directly inhibits native rat cardiomyocyte L-type Ca2+ currents and the recombinant alpha1C subunit of the human cardiac L-type Ca2+ channel. CO (applied via a recognized CO donor molecule or as the dissolved gas) caused reversible, voltage-independent channel inhibition, which was dependent on the presence of a spliced insert in the cytoplasmic C-terminal region of the channel. Sequential molecular dissection and point mutagenesis identified three key cysteine residues within the proximal 31 amino acids of the splice insert required for CO sensitivity. CO-mediated inhibition was independent of nitric oxide and protein kinase G but was prevented by antioxidants and the reducing agent, dithiothreitol. Inhibition of NADPH oxidase and xanthine oxidase did not affect the inhibitory actions of CO. Instead, inhibitors of complex III (but not complex I) of the mitochondrial electron transport chain and a mitochondrially targeted antioxidant (Mito Q) fully prevented the effects of CO. Our data indicate that the cardioprotective effects of HO-1 activity may be attributable to an inhibitory action of CO on cardiac L-type Ca2+ channels. Inhibition arises from the ability of CO to promote generation of reactive oxygen species from complex III of mitochondria. This in turn leads to redox modulation of any or all of three critical cysteine residues in the channel's cytoplasmic C-terminal tail, resulting in channel inhibition.

Where theory meets practice: a critical comparison of research into identifying letters and craft knowledge of type design

This paper introduces scientific research findings and accounts of skilled design judgement to: (i) develop an interdisciplinary account of what affects our identification of letters when reading; (ii) analyse the relationship between the approaches of psychologists and designers to explaining how we identify letters; (iii) propose ways in which collaboration may work to make psychological research more relevant to typographic practice. The topics reviewed are addressed within each discipline and cover the contribution of letters and words to reading; letter features; essential or structural forms; uniformity within font design; and letter spacing. Analysis of the literature identifies possible means of reconciling different perspectives, points out some anomalies in interpretation of findings, and proposes how designers may contribute to research planning and dissemination.