La pratique médicale des omnipraticiens : influence des contextes organisationnel et géographique

L’utilisation des services de santé est au centre de l’organisation des soins. La compréhension des processus qui déterminent cette utilisation est essentielle pour agir sur le système de santé et faire en sorte qu’il réponde mieux aux besoins de la population. L’objectif de cette thèse est de comprendre le phénomène complexe qu’est l’utilisation des services de santé en s’intéressant à la pratique des médecins omnipraticiens. En nous appuyant sur le cadre théorique de Donabedian, nous décomposons les déterminants de l’utilisation des services de santé en trois niveaux : le niveau individuel, le niveau organisationnel, et le niveau environnemental. Pour tenir compte de la complexité des phénomènes de cette étude nous proposons de nous appuyer sur l’approche configurationnelle. Notre question de recherche est la suivante : dans quelle mesure le mode d’exercice des omnipraticiens influence-t-il la prestation des services et comment l’environnement géographique et la patientèle modulent-ils cette relation ? Nous avons utilisé des bases de données jumelées du Collège des médecins du Québec, de la Régie d’assurance maladie du Québec et de la banque de données iCLSC. Notre échantillon est constitué des médecins omnipraticiens de l’année 2002, ayant satisfait aux critères d’inclusion, ce qui représente près de 70% de la population totale. Des analyses de correspondances multiples et des classifications ascendantes hiérarchiques ont été utilisées pour réaliser la taxonomie des modes d’exercice et des contextes géographiques. Nous avons construit des indicateurs d’utilisation des services de santé pour apprécier la continuité, la globalité, l’accessibilité et la productivité. Ces indicateurs ont été validés en les comparant à ceux d’une enquête populationnelle. Nous présentons tout d’abord les modes d’exercice des médecins qui sont au nombre de sept. Deux modes d’exercice à lieu unique ont émergé : le mode d’exercice en cabinet privé d'une part, caractérisé par des niveaux de continuité et productivité élevés, le mode d’exercice en CLSC d'autre part présentant un niveau de productivité faible et des niveaux de globalité et d'accessibilité légèrement au-dessus de la moyenne. Dans les cinq autres modes d’exercice, les médecins exercent leur pratique dans une configuration de lieux. Deux modes d’exercice multi-institutionnel réunissent des médecins qui partagent leur temps entre les urgences, les centres hospitaliers et le cabinet privé ou le CLSC. Les médecins de ces deux groupes présentent des niveaux d’accessibilité et de productivité très élevés. Le mode d’exercice le moins actif réunit des médecins travaillant en cabinet privé et en CHLSD. Leur niveau d’activité est inférieur à la moyenne. Ils sont caractérisés par un niveau de continuité très élevé. Le mode d’exercice ambulatoire regroupe des médecins qui partagent leur pratique entre le CLSC, le cabinet privé et le CHLSD. Ces médecins présentent des résultats faibles sur tous les indicateurs. Finalement le mode d’exercice hospitaliste réunit des médecins dont la majorité de la pratique s’exerce en milieu hospitalier avec une petite composante en cabinet privé. Dans ce mode d’exercice tous les indicateurs sont faibles. Les analyses ont mis en évidence quatre groupes de territoires de CSSS : les ruraux, les semi-urbains, les urbains et les métropolitains. La prévalence des modes d’exercice varie selon les contextes. En milieu rural, le multi-institutionnel attire près d’un tiers des médecins. En milieu semi-urbain, les médecins se retrouvent de façon plus prédominante dans les modes d’exercice ayant une composante CLSC. En milieu urbain, les modes d’exercice ayant une composante cabinet privé attirent plus de médecins. En milieu métropolitain, les modes d’exercice moins actif et hospitaliste attirent près de 40% des médecins. Les omnipraticiens se répartissent presque également dans les autres modes d’exercice. Les niveaux des indicateurs varient en fonction de l’environnement géographique. Ainsi l’accessibilité augmente avec le niveau de ruralité. De façon inverse, la productivité augmente avec le niveau d’urbanité. La continuité des soins est plus élevée en régions métropolitaines et rurales. La globalité varie peu d’un contexte à l’autre. Pour pallier à la carence de l’analyse partielle de l’organisation de la pratique des médecins dans la littérature, nous avons créé le concept de mode d’exercice comme la configuration de lieux professionnels de pratique propre à chaque médecin. A notre connaissance, il n’existe pas dans la littérature, d’étude qui ait analysé simultanément quatre indicateurs de l’utilisation des services pour évaluer la prestation des services médicaux, comme nous l’avons fait. Les résultats de nos analyses montrent qu’il existe une différence dans la prestation des services selon le mode d’exercice. Certains des résultats trouvés sont documentés dans la littérature et plus particulièrement quand il s’agit de mode d’exercice à lieu unique. La continuité et la globalité des soins semblent évoluer dans le même sens. De même, la productivité et l’accessibilité sont corrélées positivement. Cependant il existe une tension, entre les premiers indicateurs et les seconds. Seuls les modes d’exercice à lieu unique déjouent l’arbitrage entre les indicateurs, énoncé dans l’état des connaissances. Aucun mode d’exercice ne présente de niveaux élevés pour les quatre indicateurs. Il est donc nécessaire de travailler sur des combinaisons de modes d’exercice, sur des territoires, afin d’offrir à la population les services nécessaires pour l’atteinte concomitante des quatre objectifs de prestation des services. Les modes d’exercice émergents (qui attirent les jeunes médecins) et les modes d’exercice en voie de disparition (où la prévalence des médecins les plus âgés est la plus grande) sont préoccupants. A noter que les modes d’exercice amenés à disparaître répondent mieux aux besoins de santé de la population que les modes d’exercice émergents, au regard de tous nos indicateurs. En conclusion, cette thèse présente trois contributions théoriques et trois contributions méthodologiques. Les implications pour les recherches futures et la décision indiquent que, si aucune mesure n’est mise en place pour renverser la tendance, le Québec risque de vivre des pénuries dans la prestation des services en termes de continuité, globalité et accessibilité.

Dynamic graphics of parametrically linked multivariate methods used in compositional data analysis

Many multivariate methods that are apparently distinct can be linked by introducing one or more parameters in their definition. Methods that can be linked in this way are correspondence analysis, unweighted or weighted logratio analysis (the latter also known as "spectral mapping"), nonsymmetric correspondence analysis, principal component analysis (with and without logarithmic transformation of the data) and multidimensional scaling. In this presentation I will show how several of these methods, which are frequently used in compositional data analysis, may be linked through parametrizations such as power transformations, linear transformations and convex linear combinations. Since the methods of interest here all lead to visual maps of data, a "movie" can be made where where the linking parameter is allowed to vary in small steps: the results are recalculated "frame by frame" and one can see the smooth change from one method to another. Several of these "movies" will be shown, giving a deeper insight into the similarities and differences between these methods

Factores asociados a mortalidad en pacientes colombianos con enfermedades autoinmunes en la unidad de cuidado intensivo, de un hospital de tercer nivel en Bogotá Colombia

Antecedentes: El interés en las enfermedades autoinmunes (EA) y su desenlace en la unidad de cuidado intensivo (UCI) han incrementado debido al reto clínico que suponen para el diagnóstico y manejo, debido a que la mortalidad en UCI fluctúa entre el 17 – 55 %. El siguiente trabajo representa la experiencia de un año de nuestro grupo en un hospital de tercer nivel. Objetivo: Identificar factores asociados a mortalidad particulares de los pacientes con enfermedades autoinmunes que ingresan a una UCI, de un hospital de tercer nivel en Bogotá, Colombia. Métodos: El uso de análisis de componentes principales basado en el método descriptivo multivariado y análisis de múltiple correspondencia fue realizado para agrupar varias variables relacionadas con asociación significativa y contexto clínico común. Resultados: Cincuenta pacientes adultos con EA con una edad promedio de 46,7 ± 17,55 años fueron evaluados. Los dos diagnósticos más comunes fueron lupus eritematoso sistémico y esclerosis sistémica, con una frecuencia de 45% y 20% de los pacientes respectivamente. La principal causa de admisión en la UCI fue la infección seguido de actividad aguda de la EA, 36% y 24% respectivamente. La mortalidad durante la estancia en UCI fue del 24%. El tiempo de hospitalización antes de la admisión a la UCI, el choque, soporte vasopresor, ventilación mecánica, sepsis abdominal, Glasgow bajo y plasmaféresis fueron factores asociados con mortalidad. Dos fenotipos de variables fueron definidos relacionadas con tiempo en la UCI y medidas de soporte en UCI, las cuales fueron asociadas supervivencia y mortalidad. Conclusiones: La identificación de factores individuales y grupos de factores por medio del análisis de componentes principales permitirá la implementación de medidas terapéutica de manera temprana y agresiva en pacientes con EA en la UCI para evitar desenlaces fatales.

On the variability of the surface environment response to synoptic forcing over complex terrain: a multivariate data analysis approach

Synoptic climatology relates the atmospheric circulation with the surface environment. The aim of this study is to examine the variability of the surface meteorological patterns, which are developing under different synoptic scale categories over a suburban area with complex topography. Multivariate Data Analysis techniques were performed to a data set with surface meteorological elements. Three principal components related to the thermodynamic status of the surface environment and the two components of the wind speed were found. The variability of the surface flows was related with atmospheric circulation categories by applying Correspondence Analysis. Similar surface thermodynamic fields develop under cyclonic categories, which are contrasted with the anti-cyclonic category. A strong, steady wind flow characterized by high shear values develops under the cyclonic Closed Low and the anticyclonic H–L categories, in contrast to the variable weak flow under the anticyclonic Open Anticyclone category.

Análises espaciais na identificação das áreas de risco para a esquistossomose mansônica no município de Lauro de Freitas, Bahia, Brasil

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Seasonality of macroalgal communities in a subtropical drainage basin in Paraná state, southern Brazil

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Analysis of floristic composition and structure as an aid to monitoring protected areas of dense rain forest in southeastern Brazil

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Statistical methods applied to the analysis of blasting vibrations in a diabase quarry in the city of Campinas, (SP) Brazil

Statistical methods of multiple regression analysis, trend surface analysis and principal components analysis were applied to seismographic data recorded during production blasting at a diabase quarry in the urban area of Campinas (SP), Brazil. The purpose of these analyses was to determine the influence of the following variables: distance (D), charge weight per delay (W), and scaled distance (SD) associated with properties of the rock body (orientation, frequency and angle of geological discontinuities; depth of bedrock and thickness of the soil overburden) in the variation of the peak particle velocity (PPV). This approach yielded variables with larger influences (loads) on the variation of ground vibration, as well as behavior and space tendency of this variation. The results showed a better relationship between PPV and D, with D being the most important factor in the attenuation of the ground vibrations. The geological joints and the depth to bedrock have a larger influence than the explosive charges in the variation of the vibration levels, but frequencies appear to be more influenced by the amount of soil overburden.

Analysis of rain quality data from the South African interior

Rain acidity may be ascribed to emissions from power station stacks, as well as emissions from other industry, biomass burning, maritime influences, agricultural influences, etc. Rain quality data are available for 30 sites in the South African interior, some from as early as 1985 for up to 14 rainfall seasons, while others only have relatively short records. The article examines trends over time in the raw and volume weighted concentrations of the parameters measured, separately for each of the sites for which sufficient data are available. The main thrust, however, is to examine the inter-relationship structure between the concentrations within each rain event (unweighted data), separately for each site, and to examine whether these inter-relationships have changed over time. The rain events at individual sites can be characterized by approximately eight combinations of rainfall parameters (or rain composition signatures), and these are common to all sites. Some sites will have more events from one signature than another, but there appear to be no signatures unique to a single site. Analysis via factor and cluster analysis, with a correspondence analysis of the results, also aid interpretation of the patterns. This spatio-temporal analysis, performed by pooling all rain event data, irrespective of site or time period, results in nine combinations of rainfall parameters being sufficient to characterize the rain events. The sites and rainfall seasons show patterns in these combinations of parameters, with some combinations appearing more frequently during certain rainfall seasons. In particular, the presence of the combination of low acetate and formate with high magnesium appears to be increasing in the later rainfall seasons, as does this combination together with calcium, sodium, chloride, potassium and fluoride. As expected, sites close together exhibit similar signatures. Copyright © 2002 John Wiley & Sons, Ltd.

Relação entre o desempenho e período de recuperação após enfermidades ósseas do membro torácico distal de cavalos puro sangue inglês

It is well established in the literature that musculoskeletal injuries are important compromising agents in the performance of Thoroughbred horses. In Brazil, there are no studies on the interrelation between lay-up period post-injury and retirement of racehorses due to musculoskeletal injures. The aim of this study is to determine the relationship between rehabilitation times of track injures and variables of prior race performance and later return to competitions. The radiographic reports and athletic history of 416 thoroughbreds during the period between 2003 and 2006 were examined; they were selected based on continued presentations after injury diagnosis. The temporal variables (post-injury rehabilitation time) and performance variables (race score before and after injury) were evaluated by multivariate correspondence analysis of the data and represented in perceptual maps. Correspondence was observed between most of the animals that had a short lay-up post-injury and variables that denote decline in subsequent performance. Considering the integrity of the bone healing process as crucial for the horse to be able to handle later training routines and competitions, shortening this period could lead to an imbalance of the bone repair metabolism, thus resulting in performance decline and compromise of the horse athletic career.

A comunidade de borboletas frugívoras de áreas em processo de restauração, fragmentos de floresta estacional semidecidual e pastagens

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Desenvolvimento local e capital social: uma análise interdisciplinar do processo de indução do DLIS no Estado de Roraima

Uma nova tendência em termos de ações para o desenvolvimento vem se configurando. Trata-se de ações que levam em conta o território e seus atores. Nesse âmbito, insere-se a metodologia de indução do Desenvolvimento Local Integrado e Sustentável (DLIS). Esse Programa de política pública se constitui uma estratégia participativa de indução do desenvolvimento, pela qual se mobilizam recursos das comunidades, que em parceria com o Estado (em seus três níveis) e o mercado, realizam diagnósticos, identificam potencialidades e vocações, elaboram planos integrados de desenvolvimento, na perspectiva de envolvimento dos sujeitos como proponentes e protagonistas da ação social em seus territórios. Com este trabalho, buscou-se compreender a multidimensionalidade do processo de DLIS, no estado de Roraima, procurando, ao mesmo tempo, o estabelecimento de um nexo causal entre as trajetórias sócio-econômicas (resultados) do DLIS e o capital social. A pesquisa se enquadrou na modalidade qualitativa. Adotou-se como estratégia metodológica o estudo de caso, envolvendo os municípios de Rorainópolis, Uiramutã, Baliza e Pacaraima. Três dimensões analítico-contextuais foram adotadas, quais sejam: conceitual, de implementação e de impacto. Na avaliação do capital social, as variáveis participação, confiança, cooperação e redes foram consideradas. Na interpretação dos dados, as seguintes abordagens foram utilizadas: análise contextual, análise descritiva, análise das diferenças de proporções e análise de correspondência. Os resultados da pesquisa revelaram que alguns conceitos e categorias adotados pelo Programa, embora relevantes, apresentam alguma ordem de problema. Dois municípios, Rorainópolis e Uiramutã, foram considerados municípios de bons resultados. Isso porque atenderam a um conjunto de questões que expressavam condições desejáveis para que o desenvolvimento local integrado e sustentável, em suas múltiplas dimensões, se efetivasse. Por seu turno, os municípios de Baliza e Pacaraima foram classificados como municípios de maus resultados. Os resultados do DLIS em Rorainópolis e Uiramutã estão associados ao capital social (relação positiva). A despeito da extensa literatura que trata da relevância desse tema, não se têm, ainda, instrumentos satisfatórios para medir capital social. Nesse contexto, entendese que estes resultados representam, de fato, uma aproximação.

Analysis of cardiopulmonary and metabolic variables measured during laboratory and sport-specific incremental tests for table tennis performance prediction

Purpose. - The purposes of this study were: i) to compare the physiological responses measured during a specific table tennis incremental test with the physiological responses measured during cycling, arm cranking, and treadmill running tests; and ii) to verify the accuracy of table tennis performance prediction based on the physiological responses from these tests.Methods. - Eleven national level male table tennis players participated in the study and undertook incremental tests using ergometers. Table tennis performance was defined as the ranking obtained during a simulated tournament between the participants.Results. - In general, peak values for physiological variables (e.g., (V) over dotO(2PEAK) and [La]PEAK) were significantly lower (P < 0.05) in the specific test (e.g., (V) over dotO(2PEAK) = 39.9 +/- 1.5 ml.kg(-1) per minute and [La]PEAK = 6.4 +/- 0.5 mmol.L-1) than during cycling (e.g., (V) over dotO(2PEAK) = 41.3 +/- 1.4 ml.kg(-1) per minute and [La]PEAK = 10.2 +/- 0.7 mmol.L-1) or running (e.g., (V) over dotO(2PEAK) = 43.9 +/- 1.5 ml.kg(-1) per minute and [La]PEAK = 10.0 +/- 0.7 mmol.L-1), but higher than during arm cranking (e.g., (V) over dotO(2PEAK) = 26.6 +/- 1.6 ml.kg(-1) per minute and [La]PEAK = 8.9 +/- 0.6 mmol.L-1). At respiratory compensation point intensity (RCP), only the variables measured on arm cranking were lower (P < 0.05) than on the other ergometers. Stepwise multiple regression analysis showed significant correlation between table tennis performance and lactate concentration ([La]) and also rate of perceived effort (RPE) at RCP during cycling (r = 0.89; P < 0.05).Conclusion. - In conclusion, the significant differences obtained between the specific and laboratory ergometers demonstrate the need to use a specific test to measure physiological parameters in table tennis and the physiological parameters measured, independent of the ergometer used, are unable to predict table tennis performance. (C) 2013 Elsevier Masson SAS. All rights reserved.

Multiple-trait genomic evaluation for milk yield and milk quality traits using genomic and phenotypic data in buffalo in Brazil

The use of markers distributed all long the genome may increase the accuracy of the predicted additive genetic value of young animals that are candidates to be selected as reproducers. In commercial herds, due to the cost of genotyping, only some animals are genotyped and procedures, divided in two or three steps, are done in order to include these genomic data in genetic evaluation. However, genomic evaluation may be calculated using one unified step that combines phenotypic data, pedigree and genomics. The aim of the study was to compare a multiple-trait model using only pedigree information with another using pedigree and genomic data. In this study, 9,318 lactations from 3061 buffaloes were used, 384 buffaloes were genotyped using a Illumina bovine chip (Illumina Infinium (R) bovineHD BeadChip). Seven traits were analyzed milk yield (MY), fat yield (FY), protein yield (PY), lactose yield (LY), fat percentage (F%), protein percentage (P%) and somatic cell score (SCSt). Two analyses were done: one using phenotypic and pedigree information (matrix A) and in the other using a matrix based in pedigree and genomic information (one step, matrix H). The (co) variance components were estimated using multiple-trait analysis by Bayesian inference method, applying an animal model, through Gibbs sampling. The model included the fixed effects of contemporary groups (herd-year-calving season), number of milking (2 levels), and age of buffalo at calving as (co) variable (quadratic and linear effect). The additive genetic, permanent environmental, and residual effects were included as random effects in the model. The heritability estimates using matrix A were 0.25, 0.22, 0.26, 0.17, 0.37, 0.42 and 0.26 and using matrix H were 0.25, 0.24, 0.26, 0.18, 0.38, 0.46 and 0.26 for MY, FY, PY, LY, % F, % P and SCCt, respectively. The estimates of the additive genetic effect for the traits were similar in both analyses, but the accuracy were bigger using matrix H (superior to 15% for traits studied). The heritability estimates were moderated indicating genetic gain under selection. The use of genomic information in the analyses increases the accuracy. It permits a better estimation of the additive genetic value of the animals.

Infecção por Cryptosporidium em bezerros e humanos de assentamentos rurais na região de Araçatuba, São Paulo

Pós-graduação em Medicina Veterinária - FCAV