Le sort des patients souffrant de troubles mentaux très graves et persistants lorsqu’il n’y a pas d’hôpital psychiatrique : étude de cas

L’Estrie est une région du Québec qui n’a jamais eu d’hôpital psychiatrique et s’avère donc un exemple extrême de désinstitutionnalisation. Comment parvient-on à y soigner et à héberger les personnes les plus gravement malades ? Ce système a-t-il des conséquences néfastes ? Les auteurs présentent ici une étude de cas jumelant des données qualitatives et quantitatives pour élucider ces questions. Ils ont repéré 36 patients souffrant de troubles mentaux très graves (prévalence 12,4/100 000). Cette région n’exporte pas ces cas les plus graves et parvient en général à les accueillir dans un réseau de petites et moyennes ressources d’hébergement. Par contre, les auteurs ont pu identifier une certaine dérive vers le réseau carcéral ; les cas à double ou triple diagnostics n’accèdent pas facilement aux soins ; faute d’alternative, les patients à potentiel chronique de violence stagnent parfois à l’hôpital dans des lits de courte durée (prévalence 1,6/100 000). Il semble donc possible d’éliminer le recours à un hôpital psychiatrique pour les patients souffrant de troubles mentaux très graves à condition de prévoir pour eux des milieux de vie très encadrés et de longue durée (besoin : 10-20 places/100 000).The Eastern Townships (Estrie) is an area of Québec which has never had a psychiatric hospital and is thus an extreme example of deinstitutionalization. How can people with the most severe mental illnesses be cared for ? Does this system have harmful consequences ? The authors present a case study with both qualitative and quantitative data to elucidate their questions. They found 36 patients with very severe mental illness (prevalence 12,4/100 000). This region does not send its most severely ill patients outside and generally succeeds in providing them with care and services in a network of small and medium size residential facilities. On the other hand, the authors have also been able to identify a certain drift of patients towards the correctional system ; cases with double or triple diagnosis do not easily have access to care ; through lack of an alternative, patients with potentially chronic violence often are stuck in a hospital in short stay beds (prevalence 1,6/100 000). It thus appears possible to eliminate the use of a psychiatric hospital for patients with very severe mental disorders as long as they are provided with supervised and long term care facilities (need : 10-20 places/100 000).Estrie es una región de Québec que nunca ha tenido hospital psiquiátrico y se reconoce entonces como un ejemplo extremo de desinstitucionalización. ¿Cómo se logra atender y alojar ahí a las personas más gravemente enfermas? ¿Tiene consecuencias nefastas este sistema? Los autores presentan aquí un estudio de caso que reune los datos cualitativos y cuantitativos para elucidar estas cuestiones. Se localizaron 36 pacientes que sufren de trastornos mentales graves (prevalencia 12.4/100,000). Esta región no exporta sus casos más graves y en general logra alojarlos en una red de recursos de alojamiento pequeños y medianos. En cambio, los autores pudieron identificar una cierta desviación hacia la red carcelaria; los casos de diagnóstico doble o triple no tienen fácil acceso a la atención; a falta de alternativas, los pacientes con un potencial crónico de violencia a veces se estancan en el hospital en las camas de corta duración (prevalencia 1.6/100,000). Parece entonces posible eliminar el tener que recurrir a un hospital psiquiátrico para los pacientes que sufren trastornos mentales graves, a condición de que para ellos se prevean medios de vida enmarcados y de larga duración (exigencia: 10-20 lugares/100,000).A Estrie é uma região do Quebec que nunca teve hospital psiquiátrico e revela-se um exemplo extremo de desinstitucionalização. Como conseguir atender e internar as pessoas mais gravemente enfermas? Este sistema tem conseqüências nefastas? Os autores apresentam, aqui, um estudo de caso que associa dados qualitativos e quantitativos para elucidar estas questões. Eles reconheceram 36 pacientes que sofrem de transtornos mentais graves (prevalência 12,4 por 100.000). Esta região não exporta estes casos mais graves e consegue, em geral, acolhê-los em uma rede de pequenos e médios recursos de internação. Entretanto, os autores puderam identificar uma certa deriva em direção à rede carcerária; os casos de duplo ou triplo diagnóstico não têm acesso fácil ao atendimento; sem alternativa, os pacientes com potencial crônico de violência ficam, às vezes, no hospital em leitos de curta duração (prevalência 1,6 por 100.000). Parece, então, que é possível eliminar o recurso a um hospital psiquiátrico para os pacientes que sofrem de transtornos mentais graves, com a condição de prever, para eles, meios de vida muito enquadrados e de longa duração (necessidade: 10-20 lugares por 100.000)

Maniabilité, uniformité et comportement structural du béton autonivelant à haute performance

Le béton autonivelant se caractérise par une mise en place ne nécessitant aucune vibration. Pour obtenir cette maniabilité élevée, le béton doit avoir une capacité de remplissage élevée et une excellente stabilité, c'est à dire pouvoir résister au ressuage, au tassement et à toute action extérieure risquant de détruire son homogénéité. Toutes ces qualités peuvent être atteintes à raison d'une optimisation poussée des formulations. Cette recherche vise à étudier, pour plusieurs formulations, la maniabilité, l'uniformité et le comportement structural du béton autonivelant. En premier lieu, l'apport des ajouts minéraux sur la maniabilité du béton autonivelant est étudié. Les qualités du béton à l'état frais sont évaluées pour des mélanges contenant un ou deux des ajouts suivants: fumée de silice, cendres volantes, laitier et filler calcaire. La com­paraison se fait par rapport à un béton ayant comme seul liant le ciment. Ces essais ont mis en évidence le caractère fluidifiant du laitier et la capacité de la fumée de silice à augmenter la stabilité du béton. Des combinaisons d'ajouts ont permis d'améliorer les qualités du béton autonivelant. Des essais ont montré également l'effet bénéfique de l'agent colloïdal sur la stabilité du béton frais. L'uniformité des caractéristiques du béton durci est ensuite examinée. Trois murs de 150 cm de hauteur, 95 cm de largeur et 20 cm de profondeur sont fabriqués avec du béton autonivelant de résistance spécifiée en compression variant de 60 MPa à 80 MPa. Quatre rangées de trois barres d'armatures horizontales sont fixées à des hauteurs variant de 7 cm à 142 cm au-dessus du sol. La résistance à l'arrachement de ces barres d'armature varie habituellement en fonction de la hauteur car elle est affectée par le ressuage et le tasse­ment. Les résultats montrent que le béton autonivelant, malgré un étalement deux fois plus élevé, a une uniformité supérieure à celle du béton témoin, non autonivelant. Des carottes prélevées à la même hauteur que les barres ont montré que la résistance à la compression, le module d'élasticité et la masse volumique varient peu en fonction de la hauteur. L'effet positif des ajouts minéraux sur la perméabilité aux ions chlore a aussi été mis en évidence. Enfin, le comportement structural du béton autonivelant a été analysé. Quatre poteaux densément armés ont été confectionnés avec du béton autonivelant, de résistance spécifiée à la compression de 60 MPa et 80 MPa. La quantité d'armature transversale était de 250% la quantité exigée par le Code ACI (318-1989). Le béton autonivelant s'est révélé apte à remplir des coffrages contenant autant d'armature. La qualité de parement était même améliorée, lorsque l'on compare à des poteaux de bétons de résistances similaires mais non autonivelants. Lors de leur écrasement, les poteaux ont atteint la résistance prévue et ont montré une ductilité égales ou supérieures aux poteaux de béton vibré. Le béton non autonivelant permet toutefois de mieux profiter du gain de résistance dû au confinement

Persistence and Progression of Masked Hypertension: A 5-Year Prospective Study

Objectives. To examine masked hypertension persistence over 5 years. Methods. White-collar workers were recruited from three public organizations. Blood pressure (BP) was measured using Spacelabs 90207. Manually operated BP was defined as the mean of the first three readings taken at rest. Ambulatory BP was defined as the mean of the next readings taken every 15 minutes and recorded during working hours. BP was assessed three times over 5 years. Masked hypertension was defined as manually operated BP less than 140 and less than 90 mmHg and ambulatory BP at least 135 or at least 85 mmHg. Sustained hypertension was defined as manually operated BP at least 140 or at least 90 mmHg and ambulatory BP at least 135 or at least 85 mmHg or being treated for hypertension. Results. BP measurements were obtained from 1669 participants from whom 232 had masked hypertension at baseline. Persistence of masked hypertension was 38% and 18.5%, after 3 and 5 years, respectively. Progression to sustained hypertension was 26% and 37%, after 3 and 5 years, respectively. Conclusion. Among baseline masked hypertensives, one-third progressed to sustained hypertension and about one out of five remained masked after 5 years, potentially delaying diagnosis and treatment

Assessment of the healthy worker survivor effect in the relationship between psychosocial work-related factors and hypertension.

OBJECTIVES: The healthy worker survivor effect (HWSE) usually leads to underestimation of the effects of harmful occupational exposures. HWSE is characterised by the concomitance of three associations: (1) job status-subsequent exposure, (2) job status-disease and (3) previous exposure-job status. No study has reported the coexistence of these associations in the relationship between psychosocial work-related factors and health. We assessed if HWSE is present when measuring the effects of cumulative exposure to psychosocial work-related factors on the prevalence of hypertension in white-collar workers. METHODS: Data were obtained from two timepoints (1991-1993 at baseline and 1999-2001 at follow-up) of a prospective cohort study. At baseline, the population was composed of 9188 white-collar employees (women: 49.9%) in Quebec City. Job strain as psychosocial work-related factor and blood pressure were measured using validated methods. Job status (retirees vs employees) at follow-up was self-reported. Multiple multilevel robust Poisson regressions were used to estimate prevalence ratios of hypertension and risk ratios of retirement separately by gender. We performed multiple imputations to control selection bias due to missing values. RESULTS: Retirement eliminated the subsequent exposure to job strain de facto and was associated with the reduction in the prevalence of hypertension in younger (-33%) and older (-11%) men and in older women (-39%). Job strain was associated with job status in younger men and in women of any age. CONCLUSION: Data showed the presence of HWSE in younger men and older women given the coexistence of the three structural associations

Cardiac anisotropy in boundary-element models for the electrocardiogram

The boundary-element method (BEM) is widely used for electrocardiogram (ECG) simulation. Its major disadvantage is its perceived inability to deal with the anisotropic electric conductivity of the myocardial interstitium, which led researchers to represent only intracellular anisotropy or neglect anisotropy altogether. We computed ECGs with a BEM model based on dipole sources that accounted for a “compound” anisotropy ratio. The ECGs were compared with those computed by a finite-difference model, in which intracellular and interstitial anisotropy could be represented without compromise. For a given set of conductivities, we always found a compound anisotropy value that led to acceptable differences between BEM and finite-difference results. In contrast, a fully isotropic model produced unacceptably large differences. A model that accounted only for intracellular anisotropy showed intermediate performance. We conclude that using a compound anisotropy ratio allows BEM-based ECG models to more accurately represent both anisotropies

Adding 6 months of androgen deprivation therapy to postoperative radiotherapy for prostate cancer: a comparison of short-course versus no androgen deprivation therapy in the RADICALS-HD randomised controlled trial

Background Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear. Methods RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy with 6 months of ADT (short-course ADT), using monthly subcutaneous gonadotropin-releasing hormone analogue injections, daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as distant metastasis arising from prostate cancer or death from any cause. Standard survival analysis methods were used, accounting for randomisation stratification factors. The trial had 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 80% to 86% (hazard ratio [HR] 0·67). Analyses followed the intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov, NCT00541047. Findings Between Nov 22, 2007, and June 29, 2015, 1480 patients (median age 66 years [IQR 61–69]) were randomly assigned to receive no ADT (n=737) or short-course ADT (n=743) in addition to postoperative radiotherapy at 121 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 9·0 years (IQR 7·1–10·1), metastasis-free survival events were reported for 268 participants (142 in the no ADT group and 126 in the short-course ADT group; HR 0·886 [95% CI 0·688–1·140], p=0·35). 10-year metastasis-free survival was 79·2% (95% CI 75·4–82·5) in the no ADT group and 80·4% (76·6–83·6) in the short-course ADT group. Toxicity of grade 3 or higher was reported for 121 (17%) of 737 participants in the no ADT group and 100 (14%) of 743 in the short-course ADT group (p=0·15), with no treatment-related deaths. Interpretation Metastatic disease is uncommon following postoperative bed radiotherapy after radical prostatectomy. Adding 6 months of ADT to this radiotherapy did not improve metastasis-free survival compared with no ADT. These findings do not support the use of short-course ADT with postoperative radiotherapy in this patient population

Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society

Effects of decarburization on the incipient melting temperature of AISI 4140 steel

The continuous heating to fracture test (CHF) developed at McGill was used to study the effect of decarburization on the incipient melting temperature. In the CHF test, a sample was deformed at a constant true strain rate, while its temperature is increased at a constant rate. This test allows the incipient melting temperature to be determined using a single test, instead of the several required by isothermal tensile testing. An isothermal decarburization step, to create a decarburized layer at the surface of the sample, was added prior to the CHF test.Analysis of the true stress vs temperature curves obtained by CHF testing allows the incipient melting temperature to be determined. Optical metallography was used to determine the effect of decarburization time on the observed depth of decarburization. The heat transfer characteristics of induction heating were studied, since this heating technique is known to create a significant temperature gradient at the surface of the piece being heated. Since the decarburized layer is in the high temperature zone, and also has a higher melting point due to its lower carbon content, it plays an important role in the melting process.A phenomenological model was derived to describe the melting process. It allows for both the temperature gradient due to induction heating and the melting point gradient due to decarburization. The hypothesis is advanced that melting takes place at the position, within the sample, where the temperature profile crosses the incipient melting temperature gradient. From this study, it appears that decarburization acts so as to limit the risk of hot shortness on a workpiece being forged at high temperatures. This is because decarburization raises the IMT, and in this way widens the temperature window of optimum workability