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.

Faut-il avoir peur du libéralisme ?

Avec The Liberalism of Fear, Judith N. Shklar s’inscrit en marge des postulats classiques du libéralisme politique. La croyance propre au libéralisme traditionnel, selon Shklar, doit faire place à une conscience historique de la cruauté. La charge institutionnelle du politique est dès lors appelée à se déplacer, et c’est cette « peur » même de l’avenir qu’il s’agit d’institutionnaliser en s’appuyant, de manière paradoxale, sur la peur de l’institution elle-même. Conscience historique d’un cycle à freiner, ce retournement du politique contre lui-même prône la cessation des modes d’exercice traditionnels du pouvoir. Si la nouvelle formulation d’un libéralisme minimal rejoint plusieurs de nos intuitions morales, l’impératif d’une politique immobiliste – sinon régressive – en appelle à beaucoup plus de prudence. Ce court essai entend examiner les conséquences d’un plaidoyer politique en faveur de la peur. Le libéralisme de Shklar est-il un appel à la passivité ? Doit-on y lire le désaveu de l’Histoire – et, le cas échéant, quelles en sont les parentés avec les penseurs de la fin de l’histoire (Fukuyama, 1989) et de la privatisation de l’existence (Rorty, 1989) ?

Different coordination modes for disulfoxides towards diorganotin(IV) dichlorides. X-ray crystal structures of 1,2-cis-bis-(phenylsulfinyl)ethene (rac-,cis-cbpse) and adducts [{Ph2SnCl2(meso-bpse)}n] and [{n-Bu2SnCl2(pdtd)}2]

The reactions of meso-1,2-bis(phenylsulfinyl)ethane (meso-bpse) with Ph2SnCl2, 2-phenyl-1,3-dithiane trans-1-trans-3-dioxide (pdtd) with n-Bu2SnCl2 and 1,2-cis-bis-(phenylsulfinyl)ethene (rac-,cis-cbpse) with Ph2SnCl2, in 1:1 molar ratio, yielded [{Ph2SnCl2(meso-bpse)}n], [{n-Bu2SnCl2(pdtd)}2] and [{Ph2SnCl2(rac,cis-cbpse)}x] (x = 2 or n), respectively. All adducts were studied by IR, Mössbauer and 119Sn NMR spectroscopic methods, elemental analysis and single crystal X-ray diffractometry. The X-ray crystal structure of [{Ph2SnCl2(meso-bpse)}n] revealed the occurrence of infinite chains in which the tin(IV) atoms appear in a distorted octahedral geometry with Cl atoms in cis and Ph groups in trans positions. The X-ray crystal structure of [{n-Bu2SnCl2(pdtd)}2] revealed discrete centrosymmetric dimeric species in which the tin(IV) atoms possess a distorted octahedral geometry with bridging disulfoxides in cis and n-butyl moieties in trans positions. The spectroscopic data indicated that the adduct containing the rac,cis-cbpse ligand can be dimeric or polymeric. The X-ray structural analysis of the free rac-,cis-cbpse sulfoxide revealed that the crystals belong to the C2/c space group.

Quasinormal modes of black holes in anti-de Sitter space: A numerical study of the eikonal limit

Using series solutions and time-domain evolutions, we probe the eikonal limit of the gravitational and scalar-field quasinormal modes of large black holes and black branes in anti-de Sitter backgrounds. These results are particularly relevant for the AdS/CFT correspondence, since the eikonal regime is characterized by the existence of long-lived modes which (presumably) dominate the decay time scale of the perturbations. We confirm all the main qualitative features of these slowly damped modes as predicted by Festuccia and Liu [G. Festuccia and H. Liu, arXiv:0811.1033.] for the scalar-field (tensor-type gravitational) fluctuations. However, quantitatively we find dimensional-dependent correction factors. We also investigate the dependence of the quasinormal mode frequencies on the horizon radius of the black hole (brane) and the angular momentum (wave number) of vector- and scalar-type gravitational perturbations.

Brittle and ductile removal modes observed during diamond turning of carbon nanotube composites

Ultraprecision diamond turning was used to evaluate the surface integrity of a carbon nanotube (CNT) composite as a function of the cutting conditions and the percentage of CNT in the epoxy matrix. The effects of cutting conditions on the chip morphology and surface roughness were analysed. The results showed that an increase in the percentage of CNT may influence the mechanism of material removal and consequently improve the quality of the machined surface. When smaller quantities of CNT (0.02 and 0.07 wt %) are present in the matrix, microcracks form within the cutting grooves (perpendicular to the cutting direction). This indicates that the amount of CNT on the epoxy matrix may have a direct influence on the mechanical properties of these materials. Chips removed from the CNT composite samples were analysed by scanning electron microscopy in order to correlate the material removal mechanism and the surface generation process. The area average surface roughness Sa was influenced by the material removal mechanism (Sa ranging from 0.28 to 1.1 mu m).

Kinetic ion effect on geodesic acoustic Alfven modes in tokamaks

Using a quasitoroidal set of coordinates with coaxial circular magnetic surfaces, the Vlasov equation is solved for collisionless plasmas, and the dielectric tensor is found for large aspect ratio tokamaks in a low frequency band. Taking into account q-profile and charge separation parallel electric field, it is found that the Alfven wave continuum is deformed by ion geodesic effects producing continuum minimum at the rational magnetic surfaces. Low frequency geodesic ion induced Alfven waves are found below the continuum minimum where collisionless damping has a gap for Maxwell distribution. In kinetic approach, the ion thermal motion defines the geodesic effect but the mode frequency is strongly corrected due to parallel motion of electrons.

Localized modes of binary mixtures of Bose-Einstein condensates in nonlinear optical lattices

The properties of the localized states of a two-component Bose-Einstein condensate confined in a nonlinear periodic potential (nonlinear optical lattice) are investigated. We discuss the existence of different types of solitons and study their stability by means of analytical and numerical approaches. The symmetry properties of the localized states with respect to nonlinear optical lattices are also investigated. We show that nonlinear optical lattices allow the existence of bright soliton modes with equal symmetry in both components and bright localized modes of mixed symmetry type, as well as dark-bright bound states and bright modes on periodic backgrounds. In spite of the quasi-one-dimensional nature of the problem, the fundamental symmetric localized modes undergo a delocalizing transition when the strength of the nonlinear optical lattice is varied. This transition is associated with the existence of an unstable solution, which exhibits a shrinking (decaying) behavior for slightly overcritical (undercritical) variations in the number of atoms.

Stability, causality, and quasinormal modes of cosmic strings and cylinders

In this work we consider the evolution of a massive scalar field in cylindrically symmetric space-times. Quasinormal modes have been calculated for static and rotating cosmic cylinders. We found unstable modes in some cases. Rotating as well as static cosmic strings, i.e., without regular interior solutions, do not display quasinormal oscillation modes. We conclude that rotating cosmic cylinder space-times that present closed timelike curves are unstable against scalar perturbations.

Looking at the Gregory-Laflamme instability through quasinormal modes

We study evolution of gravitational perturbations of black strings. It is well known that for all wave numbers less than some threshold value, the black string is unstable against the scalar type of gravitational perturbations, which is named the Gregory-Laflamme instability. Using numerical methods, we find the quasinormal modes and time-domain profiles of the black string perturbations in the stable sector and also show the appearance of the Gregory-Laflamme instability in the time domain. The dependence of the black string quasinormal spectrum and late-time tails on such parameters as the wave vector and the number of extra dimensions is discussed. There is numerical evidence that at the threshold point of instability, the static solution of the wave equation is dominant. For wave numbers slightly larger than the threshold value, in the region of stability, we see tiny oscillations with very small damping rate. While, for wave numbers slightly smaller than the threshold value, in the region of the Gregory-Laflamme instability, we observe tiny oscillations with very small growth rate. We also find the level crossing of imaginary part of quasinormal modes between the fundamental mode and the first overtone mode, which accounts for the peculiar time domain profiles.

Quasinormal modes of brane-localized standard model fields in Gauss-Bonnet theory

We study the massless scalar, Dirac, and electromagnetic fields propagating on a 4D-brane, which is embedded in higher-dimensional Gauss-Bonnet space-time. We calculate, in the time domain, the fundamental quasinormal modes of a spherically symmetric black hole for such fields. Using WKB approximation we study quasinormal modes in the large multipole limit. We observe also a universal behavior, independent on a field and value of the Gauss-Bonnet parameter, at an asymptotically late time.

Gravitational quasinormal modes of AdS black branes in d spacetime dimensions

The AdS/CFT duality has established a mapping between quantities in the bulk AdS black-hole physics and observables in a boundary finite-temperature field theory. Such a relationship appears to be valid for an arbitrary number of spacetime dimensions, extrapolating the original formulations of Maldacena`s correspondence. In the same sense properties like the hydrodynamic behavior of AdS black-hole fluctuations have been proved to be universal. We investigate in this work the complete quasinormal spectra of gravitational perturbations of d-dimensional plane-symmetric AdS black holes (black branes). Holographically the frequencies of the quasinormal modes correspond to the poles of two-point correlation functions of the field-theory stress-energy tensor. The important issue of the correct boundary condition to be imposed on the gauge-invariant perturbation fields at the AdS boundary is studied and elucidated in a fully d-dimensional context. We obtain the dispersion relations of the first few modes in the low-, intermediate- and high-wavenumber regimes. The sound-wave (shear-mode) behavior of scalar (vector)-type low- frequency quasinormal mode is analytically and numerically confirmed. These results are found employing both a power series method and a direct numerical integration scheme.

Friction coefficient and abrasive wear modes in ball-cratering tests conducted at constant normal force and constant pressure-Preliminary results

The micro-scale abrasive wear test by rotative ball has gained large acceptance in universities and research centers, being widely used in studies on the abrasive wear of materials. Two wear modes are usually observed in this type of test: ""rolling abrasion"" results when the abrasive particles roll on the surface of the tested specimen, while ""grooving abrasion"" is observed when the abrasive particles slide; the type of wear mode has a significant effect on the overall behaviour of a tribological system. Several works on the friction coefficient during abrasive wear tests are available in the literature, but only a few were dedicated to the friction coefficient in micro-abrasive wear tests conducted with rotating ball. Additionally, recent works have identified that results may also be affected by the change in contact pressure that occurs when tests are conducted with constant applied force. Thus, the purpose of this work is to study the relationship between friction coefficient and abrasive wear modes in ball-cratering wear tests conducted at ""constant normal force"" and ""constant pressure"". Micro-scale abrasive wear tests were conducted with a ball of AISI52100 steel and a specimen of AISIH10 tool steel. The abrasive slurry was prepared with black silicon carbide (SiC) particles (average particle size of 3 mu m) and distilled water. Two constant normal force values and two constant pressure values were selected for the tests. The tangential and normal loads were monitored throughout the tests and their ratio was calculated to provide an indication of the friction coefficient. In all cases, optical microscopy analysis of the worn craters revelated only the presence of grooving abrasion. However, a more detailed analysis conducted by SEM has indicated that different degrees of rolling abrasion have also occurred along the grooves. The results have also shown that: (i) for the selected values of constant normal force and constant pressure, the friction coefficient presents, approximately, the same range of values and (ii) loading conditions play an important role on the occurrence of rolling abrasion or grooving abrasion and, consequently, on the average value and scatter of the friction coefficient in micro-abrasive wear tests. (C) 2009 Elsevier B.V. All rights reserved.

Effect of multiple transverse modes in self-mixing sensors based on vertical-cavity surface-emitting lasers

We investigate the effect of coexisting transverse modes on the operation of self-mixing sensors based on vertical-cavity surface-emitting lasers (VCSELs). The effect of multiple transverse modes on the measurement of displacement and distance were examined by simulation and in laboratory experiment. The simulation model shows that the periodic change in the shape and magnitude of the self-mixing signal with modulation current can be properly explained by the different frequency-modulation coefficients of the respective transverse modes in VCSELs. The simulation results are in excellent agreement with measurements performed on single-mode and multimode VCSELs and on self-mixing sensors based on these VCSELs.

How to be a chaste species pluralist-realist: the origins of species modes and the synapomorphic species concept

The biological species (biospecies) concept applies only to sexually reproducing species, which means that until sexual reproduction evolved, there were no biospecies. On the universal tree of life, biospecies concepts therefore apply only to a relatively small number of clades, notably plants and animals. I argue that it is useful to treat the various ways of being a species (species modes) as traits of clades. By extension from biospecies to the other concepts intended to capture the natural realities of what keeps taxa distinct, we can treat other modes as traits also, and so come to understand that the plurality of species concepts reflects the biological realities of monophyletic groups. We should expect that specialists in different organisms will tend to favour those concepts that best represent the intrinsic mechanisms that keep taxa distinct in their clades. I will address the question whether modes of reproduction such as asexual and sexual reproduction are natural classes, given that they are paraphyletic in most clades.

Conditional variance reduction by measurements on correlated field modes

We consider the case of two cavity modes of the electromagnetic field, which are coupled via the action of a parametric amplifier. The fields are allowed to leak from the cavity and homodyne measurement is performed on one of the modes. Because of the correlations between the modes, this leads to a reduction of the variance in a quadrature of the other mode, although no measurement is performed on it directly. We discuss how this relates to the Einstein-Podolky-Rosen Gedankenexperiment.